HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital's Governing Body failed to ensure that:
- The Chief Executive Officer (CEO) effectively managed the hospital in order to meet applicable regulatory requirements. (A-0057)
- A doctor of medicine or osteopathy was on duty or on-call at all times. (A-0067)
- Contracted services furnished services that permitted the hospital to comply with all applicable conditions of participation. (A-0083)
- There was an effective, ongoing, hospital-wide, data driven Quality Assurance and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) program that worked in conjunction with the Governing Body and used data to monitor the quality, effectiveness and safety of care and services provided. (A-0273 and A-0283)
- The QAPI Committee reviewed incident reports when 21 out of 25 nursing department incident reports reviewed failed to be investigated and reviewed through QAPI. (A-0273)
- The QAPI Committee reviewed incident reports for thoroughness and completion when 16 out of 25 nursing department incident reports reviewed were incomplete and had missing data in high risk areas. (A-0273)
- All hospital departments and contracted services were included in a hospital-wide QAPI program where data was used to identify opportunities for improvement and actions were taken aimed at performance improvement, monitoring, and reporting, to provide patients with quality care and safety. (A-0283)
- The Medical Staff conducted periodic appraisals and re-appraisals of clinical practice for two staff physicians of two staff physicians reviewed and two staff nurse practitioners of two staff nurse practitioners reviewed. (A-0340)
- The Medical Staff performed peer review (evaluation of professional work by others working in the same field) for two staff physicians of two staff physicians reviewed. (A-0340)
- The Medical Staff maintained documentation of continuing education for two staff physicians of two staff physician credentialing files reviewed. (A-0340)
- The Medical Staff maintained current Bureau of Narcotics and Dangerous Drugs (BNDD) licensure for one staff physician of two staff physicians reviewed. (A-0340)
- Nursing staff followed physicians' orders for preventive care, which included pressure relief mattresses for one current patient (#4) of two current patients reviewed and one discharged patient (#14) of two discharged patients reviewed. (A-0395)
- Nursing staff followed wound care orders for daily dressing changes for one current patient (#1) of two current patients observed. (A-0395)
- Nursing staff followed physicians' orders to turn patients every two hours for eight current patients (#1, #4, #5, #6, #9, #10, #12, #13) of ten current patients reviewed and one discharged patient (#14) of two discharged patients reviewed. (A-0395)
- The acuity (severity of the patient's illness and the level of service needed) of the patients was included when planning for daily staffing in order to ensure sufficient numbers of licensed nursing staff were available to provide essential patient care. (A-0395)
- Nursing staff administered medications according to physicians' orders and medication administration policies for seven current patients (#2, #3, #4, #6, #7, #12 and #13) of seven current patients reviewed. (A-0405)

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

The severity and cumulative effect of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.12 Condition of Participation: Governing Body and resulted in the hospital's failure to ensure quality health care and safety.

The hospital census was 12.

Based on interview, record review and policy review, the hospital failed to have systemic practices in place to ensure that:
- There was an effective, ongoing, hospital-wide, data driven Quality Assurance and Performance Improvement program, (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) that worked in conjunction with the Governing Body and used data to monitor the quality, effectiveness and safety of care and services provided. (A-0273 and A-0283)
- The QAPI Committee reviewed nursing department incident reports when 21 (#8, #14, #15, #16, #17, #18, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #36, #37, #38 and #39) out of 25 nursing department incident reports reviewed failed to be investigated and reviewed through a QAPI program. (A-0273)
- The QAPI Committee reviewed nursing department incident reports for thoroughness and completion when 16 (#14, #15, #17, #18, #25, #26, #27, #28, #29, #30, #31, #32, #33, #37, #38 and #39) out of 25 nursing department incident reports reviewed were incomplete and had missing data in high risk areas. (A-0273)
- All hospital departments and contracted services were included in a hospital-wide QAPI program where data was used to identify opportunities for improvement, and actions were taken aimed at performance improvement, monitoring and reporting, to provide patients with quality care and safety. (A-0283)

These failures had the potential to adversely affect the quality of care, safety and care outcomes of all patients in the hospital.

The severity and cumulative effects of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.21 Condition of Participation: QAPI Program and resulted in the hospital's failure to ensure quality health care and safety.

The hospital census was 12.

Based on interview and record review, the hospital failed to ensure that:
- The Medical Staff conducted periodic appraisals and re-appraisals of clinical practice for two staff physicians (T and V) of two staff physicians reviewed and two staff nurse practitioners (U and GG) of two staff nurse practitioners reviewed. (A-0340)
- The Medical Staff performed peer review (evaluation of professional work by others working in the same field) for two staff physicians (T and V) of two staff physicians reviewed. (A-0340)
- The Medical Staff maintained documentation of continuing education for two staff physicians (T and V) of two staff physician credentialing files reviewed. (A-0340)
- The Medical Staff failed to ensure current Bureau of Narcotics and Dangerous Drugs (BNDD) licensure for one staff physician (T) of two staff physicians reviewed. (A-0340)

These deficiencies had the potential to permit physicians to provide patient care outside of acceptable professional standards as determined by the Medical Staff.

The cumulative effects of these systemic practices resulted in the overall non-compliance with 42 CFR 482.22 Condition of Participation: Medical Staff.

The hospital census was 12.

Based on observation, interview, record review, and policy review, the hospital failed to ensure that:
- Nursing staff provided adequate preventive care for eight current patients (#1, #4, #5, #6, #9, #10, #12 and #13) of 10 current patients reviewed and one discharged patient (#14) of two discharged patients reviewed with pressure ulcers (injury to the skin and/or underlying tissue, usually over a bony area). (A-0395)
- Nursing staff followed physicians' orders for preventive care, which included pressure relief mattresses for one current patient (#4) of two current patients reviewed and one discharged patient (#14) of two discharged patients reviewed. (A-0395)
- Nursing staff followed wound care orders for daily dressing changes for one current patient (#1) of two current patients observed. (A-0395)
- Nursing staff followed physicians' orders to turn patients every two hours for eight current patients (#1, #4, #5, #6, #9, #10, #12 and #13) of ten current patients reviewed and one discharged patient (#14) of two discharged patients reviewed. (A-0395)
- Nursing staff administered medications according to physicians' orders and medication administration policies for seven current patients (#2, #3, #4, #6, #7, #12 and #13) of seven current patients reviewed. (A-0405)
- Sufficient numbers of licensed nursing staff were available to provide essential nursing care when they failed to include patient acuity (the severity of the patient's illness and the level of service needed) when planning for daily staffing for the past six months. (A-0395)

These failures resulted in non-compliance with 42 CFR 482.23 Condition of Participation (COP): Nursing Services and placed all vulnerable patients within the hospital at risk for their health and safety and had the potential to lead to poor outcomes. The hospital census was 12.

Based on observation, interview, record review, and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital including accountability for the effective oversight of staff to comply with the requirements under 42 CFR 482.12 Condition of Participation (COP): Governing Body, 482.21 COP: Quality Assessment and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) Program, 42 CFR 482.22 COP: Medical Staff and 42 CFR 482.23 COP: Nursing Services. This failure had the potential to affect the quality of care and safety of all patients.

Findings included:

1. Review of the hospital's document titled, "Board of Managers (Governing Body) Bylaws," dated 12/2017, showed that the Governing Body appoints one CEO who is responsible for managing the entire hospital and keeping the board apprised of all necessary information.

The CEO failed to ensure compliance with the COP of Governing Body as evidenced by failure to ensure that:
- The CEO effectively managed the hospital in order to meet applicable regulatory requirements. (A-0057)
- A doctor of medicine or osteopathy was on duty or on-call at all times. (A-0067)
- Contracted services furnished services that permitted the hospital to comply with all applicable conditions of participation. (A-0083)

The CEO failed to ensure compliance with the COP of QAPI Program as evidenced by failure to ensure that:
- There was an effective, ongoing, hospital-wide, data driven QAPI program that worked in conjunction with the Governing Body and used data to monitor the quality, effectiveness and safety of care and services provided. (A-0273 and A-0283)
- The QAPI Committee reviewed incident reports when 21 out of 25 nursing department incident reports reviewed failed to be investigated and reviewed through QAPI. (A-0273)
- The QAPI Committee reviewed incident reports for thoroughness and completion when 16 out of 25 nursing department incident reports reviewed were incomplete and had missing data in high risk areas. (A-0273)
- All hospital departments and contracted services were included in a hospital-wide QAPI program where data was used to identify opportunities for improvement and actions were taken aimed at performance improvement, monitoring, and reporting, to provide patients with quality care and safety. (A-0283)

The CEO failed to ensure compliance with the COP of Medical Staff as evidenced by failure to ensure that:
- The Medical Staff conducted periodic appraisals and re-appraisals of clinical practice for two staff physicians of two staff physicians reviewed and two staff nurse practitioners of two staff nurse practitioners reviewed. (A-0340)
- The Medical Staff performed peer review (evaluation of professional work by others working in the same field) for two staff physicians of two staff physicians reviewed. (A-0340)
- The Medical Staff maintained documentation of continuing education for two staff physicians of two staff physician credentialing files reviewed. (A-0340)
- The Medical Staff maintained current Bureau of Narcotics and Dangerous Drugs (BNDD) licensure for one staff physician of two staff physicians reviewed. (A-0340)

The CEO failed to ensure compliance with the COP of Nursing Services as evidenced by failure to ensure that:
- Nursing staff followed physicians' orders for preventive care, which included pressure relief mattresses for one current patient (#4) of two current patients reviewed and one discharged patient (#14) of two discharged patients reviewed. (A-0395)
- Nursing staff followed wound care orders for daily dressing changes for one current patient (#1) of two current patients observed. (A-0395)
- Nursing staff followed physicians' orders to turn patients every two hours for eight current patients (#1, #4, #5, #6, #9, #10, #12 and #13) of ten current patients reviewed and one discharged patient (#14) of two discharged patients reviewed. (A-0395)
- The acuity (severity of the patient's illness and the level of service needed) of the patients was included when planning for daily staffing in order to ensure sufficient numbers of licensed nursing staff were available to provide essential patient care. (A-0395)
- Nursing staff administered medications according to physicians' orders and medication administration policies for seven current patients (#2, #3, #4, #6. #7, #12 and #13) of seven current patients reviewed. (A-0405)

During an interview on 03/03/21 at 5:00 PM, Staff S, CEO and interim Chief Clinical Officer (CCO), stated that she was responsible for the entire hospital and responsible for the oversight of the Governing Body, QAPI Program, Medical Staff and Nursing Services.

Based on observation, interview, record review and policy review, the hospital failed to ensure that a doctor of medicine or osteopathy was on duty or on-call at all times. This failure had the potential to cause delayed care and poor patient outcomes. The hospital census was 12.

Findings included:

1. Review of the hospital's policy titled, "Physician On-call Coverage," dated 04/2018, showed the following:
- The attending physician, or a privileged physician covering for the attending, must be available to address patient care issues.
- When the attending physician or his covering physician cannot be reached within 20 minutes of being called or paged, the Chief Medical Officer and/or the Administrator-On-Call shall be notified by the charge nurse.
- If another 10 minutes elapses without the attending physician or covering physician responding to the call or page, the charge nurse shall call any active medical staff member with like privileges to assume the care of the patient.
- An on-call physician is available 24 hours a day, seven days a week.
- All on-call physicians will be members of the medical staff and will be privileged according to the Medical Staff Bylaws.

Review of the hospital's document titled, "Medical Staff Bylaws," revised 11/2020, showed that an appointed member of the medical staff agreed to provide continuous care to his/her patients at the generally recognized professional level of quality and efficiency established by the hospital. The appointed medical staff member will delegate in his/her absence, the responsibility for diagnosis and/or care of his/her patients only to a Practitioner who is a member in good standing of the Medical Staff and who is qualified and approved by the hospital to undertake this responsibility by the granting of appropriate clinical privileges.

Review of the hospital's incident report regarding discharged Patient #24, dated 09/05/20, showed the following:
- On 09/06/20 at 1:00 AM, the patient had an irregular heart rhythm with a heart rate in the 130's (normal heart rate is 60 to 80 beats per minute). His blood pressure (BP, a measurement of the pressure of blood flow in two different parts of the heart, normal is approximately 90/60 to 120/80) was low at 92/48 and his temperature (degree of hotness or coldness of the body, normal is 98.6) was 99.4. He was very nauseated (a feeling of sickness with an inclination to vomit) even after administration of anti-nausea medication.
- At 1:00 AM, the Registered Nurse (RN) caring for the patient, called Staff U, Nurse Practitioner (NP) on-call; there was no answer so she left a message.
- The RN waited 15 minutes and called Staff T, Medical Director; there was no answer so she left a message.
- At 1:20 AM, the RN attempted to call Staff U again with no answer, she left a message.
- At 2:00 AM, the RN attempted to call Staff U without success.
- At 2:05 AM, Staff BB, Licensed Practical Nurse (LPN), attempted to call Staff T without success.
- Staff BB texted both Staff U and Staff T with no response.
- The patient remained in the fast, irregular heart rhythm in the 130's throughout the night.
- At 6:30 AM, the patient's BP was 96/63.

Review of Patient #24's medical record showed that on 09/07/20, he was transferred to another hospital for a computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail that a regular x-ray) of the abdomen to evaluate for possible sepsis (life threatening condition when the body's response to infection injures its own tissues and organs).

Review of the hospital's incident report dated 09/06/20, regarding discharged Patient #23, showed that on 09/06/20 from 11:00 PM through 09/07/20 at 2:00 AM, Staff BB, LPN, attempted to call Staff T, Medical Director, and Staff U, NP, without success. Staff BB wrote in the incident report that Patient #23 had been profusely vomiting since 11:00 PM on 09/06/20. She attempted multiple times to call Staff T and Staff U, they did not answer her calls or make any attempt to call back. Patient #23 continued to vomit profusely into the morning of 09/07/20.

During an interview on 03/01/21 at 10:03 AM, Staff I, RN, Charge Nurse, stated that the physician on-call schedule was not posted until this week.

During an interview on 03/01/21 at 10:22 AM, Staff W, LPN, stated that she didn't know where the physician on-call schedule was.

During an interview on 03/01/21 at 9:07 AM, Staff BB, LPN, stated that her experience had been that the physicians weren't returning calls on nightshift. She also stated that they didn't have up-to-date on-call schedules.

During an interview on 02/24/21 at 12:20 PM, Staff J, Quality Director, stated that there was confusion about which physician or nurse practitioner to call after hours.

During an interview on 03/01/21 at 2:20 PM, Staff T, Medical Director, stated that he didn't make the on-call schedule and that it had just been a verbal schedule that was made by the Chief Executive Officer (CEO).

During an interview on 03/03/21 at 4:35 PM, Staff S, CEO and interim Chief Clinical Officer, stated that the on-call schedule was a verbal process. She also stated that she should have posted one on the unit.





36473

Based on interview, record review and policy review, the hospital's Governing Body failed to ensure that contracted services furnished services that permitted the hospital to comply with all applicable conditions of participation. This failure had the potential to cause inadequate monitoring of services and poor patient outcomes.

Findings included:

1. Review of the hospital's policy titled, "Contract Evaluation and Review," dated 03/2012, showed the following:
- The purpose of contract evaluation and review was to ensure that the performance of contracted services reflect the hospital's principles of risk reduction, safety, staff competence and performance improvement; and to provide for the standardization of all contracts to ensure maximum protection and enforceability.
- All contracted services must provide quality control, assessment and improvement information; participate in hospital-wide clinical risk management and performance improvement programs; participate in providing/collaborating on individual performance improvement evaluations.
- The Quality/Risk Management Director, Chief Clinical Officer (CCO) and the Chief Executive Officer (CEO) will review all service contracts and evaluate the services provided.
- Evaluation will include, but not be limited to the following criteria: review of incident reports, collection of data that address the efficacy of the contracted services, review of performance reports based on indicators required in the contractual agreement, review of results of risk management activities, performance improvement standards and safety of services.
- The evaluation will be forwarded to the Medical Executive Committee and the Corporate Compliance Officer for review.
- The Medical Director and the CEO will sign the evaluation after the Medical Executive Committee's review and forward to the Governing Body.

Review of the hospital's document titled, "Board of Managers (Governing Body) Bylaws," dated 12/2017, showed that the Board of Managers had overall responsibility for operation of the hospital, including contract services. The Medical Staff and hospital leadership shall provide the Board of Managers with annual evaluations of the effectiveness of these contracts.

Review of the hospital's undated document titled, "Hospital Contracted Services," showed that the hospital contracted with 27 different services.

Review of the hospital's quarterly review of contracted services showed that in 2020, the only review of a contracted service was completed on 11/30/20, for Radiology and Linen Services. Even though requested, the hospital was not able to provide any other contracted services evaluations, reviews or involvement in hospital wide Quality Assessment and Improvement Performance (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) evaluations for the year 2020.

During an interview on 03/03/21 at 5:00 PM, Staff S, CEO and interim CCO, stated that all contracted services should participate in QAPI and be reviewed quarterly. She was not aware that the contracted services quarterly reviews were not completed for 2020.

Based on interview, record review and policy review, the hospital failed to ensure the Quality Assessment Performance Improvement program, (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) investigated 21 (#8, #14, #15, #16, #17, #18, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #36, #37, #38 and #39) out of 25 nursing department incident reports reviewed and also failed to ensure that staff completed 16 (#14, #15, #17, #18, #25, #26, #27, #28, #29, #30, #31, #32, #33, #37, #38 and #39) out of 25 nursing department incident reports reviewed to collect accurate data in a high risk area. Staff also failed to initiate incident reports for four falls documented for one discharged patient (#8) of one discharged patient reviewed. These failures of investigation and collection of accurate data failed to identify problems and provide a plan for performance improvement. This had the potential to affect all patient care received in the hospital to ensure that standards of care were met. The hospital census was 12.

Findings included:

1. Review of the hospital's policy titled, "Incident Reporting," last reviewed on 01/27/21, showed that:
- The department management should thoroughly investigate all incidents immediately and document their findings on the incident report.
- The Risk Manager should ensure reporting to designated agencies occurs promptly as defined by regulatory requirements.
- All staff should be educated on the incident reporting policy and process, the need for accurate and specific documentation of incidents, appropriate use of the incident report form and the open disclosure process.
- All applicable fields should be complete and legible on the incident reports.

Review of the hospital's document titled, "Employee Handbook," last reviewed on 10/2016, showed that after an incident occurs, staff should contact their immediate supervisor, complete a Confidential Incident Report and forward to the Risk Manager within 24 hours of the event.

Review of 21 nursing department incident reports for Patients #8, #14, #15, #16, #17, #18, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #36, #37, #38 and #39 dated between 08/22/20 and 02/22/21, showed that staff failed to perform an investigation on each of these incidents, with lack of follow-up to ensure all patient safety. These failures created a break in the systemic process placing all patients at risk.

During an interview on 03/01/21 at 11:30 AM, Staff X, Monitor Technician, stated that she had never received any follow-up on an incident report she had submitted.

During an interview on 02/24/21 at 2:16 PM, Staff Q, Pharmacy Technician, stated that they were instructed to pass all incident reports to the Chief Clinical Officer (CCO).

During an interview on 03/03/21 at 4:03 PM, Staff J, Quality Director, stated that she expected all incident reports to be investigated to identify failures, and for all incident reports to be reviewed through QAPI.

2. Review of 16 nursing department incident reports for Patients #14, #15, #17, #18, #25, #26, #27, #28, #29, #30, #31, #32, #33, #37, #38 and #39 dated between 08/22/20 and 02/22/21, showed that staff failed to complete each of these nursing department incident reports, which created a breakdown in identifying the failures, to include lack of contacting the physician; documenting witnesses, injuries and medications; and contacting the family members of changes in patients' conditions.

3. Review of Patient #8's medical record showed that the patient had four falls documented by the following staff:
- Staff H, Registered Nurse (RN), documented the patient had a fall on 12/27/21 at 5:30 PM, and failed to initiate an incident report.
- Staff M, RN, documented the patient had a fall on 12/28/21 at 7:45 PM, and failed to initiate an incident report.
- Staff M, RN, documented the patient had a fall on 12/29/21 at 2:37 AM, and failed to initiate an incident report.
- Staff KK, Licensed Practical Nurse (LPN), documented the patient had a fall on 01/09/21 at 2:41 AM, and failed to initiate an incident report.
These failures caused a lack of follow-up and accountability to ensure patients' safety.

During an interview on 03/01/21 at 2:20 PM, Staff T, Medical Director, stated that he was supposed to be notified of any medication errors and patient changes (to include falls) and that these failures were unacceptable.

During an interview on 03/03/21 at 4:03 PM, Staff J, Quality Director, stated that she expected all staff to fully complete all incident reports, and for all incident reports to be reviewed through the QAPI program.

During an interview on 03/03/21 at 4:35 PM, Staff S, Chief Executive Officer and interim CCO, stated that:
- They had a higher than normal use of agency staff and the incident report process was not part of the on-boarding with agency staff which led to these failures.
- The Quality Director (QD) was responsible for investigating the incident reports.
- She was aware that their recent QD was not fully present, communicative or organized and that he lacked follow-through.
- She was responsible for the QD oversight, but was so overwhelmed with their staffing challenges that she had not been as focused on his oversight.
- They had just recently made a change in the QD position.
- She expected all staff to complete the incident reports thoroughly, and for all incident reports to be reviewed through the QAPI program.

The former QD was reached out to by phone but he did not respond to call attempts.

Based on interview and record review, the hospital failed to have systemic practices in place to which all hospital departments and contracted services were included and showed active integration in a hospital-wide Quality Assessment and Performance Improvement program, (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) which assessed and identified opportunities for improvement, set priorities and took actions that were aimed at performance improvement, and showed evidence of measuring and tracking performance. These failures had the potential to put all patients at risk for sub-standard quality of health care and adverse outcomes. The hospital census was 12.

Findings included:

1. Review of the hospital's undated document titled, "QAPIC Charter," showed that the QAPI Committee is responsible to:
- Monitor and disseminate information related to quality and patient safety.
- Receive regular reports regarding hospital-wide issues and review ongoing reports to make recommendations for improvement.
- Identify organizational trends and opportunities for improvement and set priorities for process improvement.
- Assure that staff has appropriate training to facilitate process improvement.
- Review and distribute new and revised regulatory/accreditation standards.
- Recommend tools for achieving compliance with standards that affect multiple departments.

Review of the QAPI Committee meeting minutes for 08/2020 through 01/2021, showed:
- A sign-in sheet that listed the active QAPI Committee meeting participants was not completed and dated for five of the six months reviewed.
- The QAPI Committee meeting notes were not completed, thorough, typed and organized for six of six months reviewed.
- Data analysis to identify opportunities for improvement was incomplete and/or missing for six of six months reviewed.
- Clear expectations with tracking and trending evidence was incomplete and/or missing for six of six months reviewed.
- Performance improvement action steps with monitoring for sustained improvement was incomplete and/or missing for six of six months reviewed.
- Evidence of the hospital's departments' and contracted services' involvement was incomplete and/or missing for six of six months reviewed.

During an interview on 03/01/21 at 12:35 PM, Staff U, Clinical Nurse Specialist (CNS), stated that she had not been involved in QAPI meetings for at least the last six months and that sometimes information would be emailed to her from the meetings. Although requested by the surveyor, Staff U was not able to provide emails of previous QAPI-related communications.

During an interview on 03/01/21 at 2:17 PM, Staff T, Medical Director, stated that:
- He had previous experience on quality committees and the hospital's current QAPI program had not been functioning as it should be.
- He was supposed to be part of QAPI; however, the program had not been functional.
- The hospital was "consistently inconsistent" with processes, and that included the QAPI program.
- He had often turned things into the Quality Director (QD) for review and analysis through the QAPI program; however, he never received back a formal review.
- He did not get feedback from QAPI meetings.

During an interview on 03/03/21 at 9:10 AM, Staff BB, Licensed Practical Nurse (LPN), stated that she was not aware of QAPI meetings, and she had not received any information regarding performance improvement plans. She stated that she used to hear about QAPI when the former QAPI person was in place, about 18 months ago; however, the most recent (QD) had not communicated QAPI program details with her.

During an interview on 03/03/21 at 10:17 AM, Staff DD, Respiratory Therapy Manager, stated that she had not been a part of the QAPI program and she did not have any information shared with her from QAPI meetings. She stated that she would like to be a part of the QAPI program; however, she had not been asked to be in over a year.

During an interview on 03/03/21 at 1:09 PM, Staff GG, Family Nurse Practitioner (FNP) for wound care plus, stated that she was not involved in QAPI meetings, she had not been invited to attend them, and she had never had anything communicated to her regarding the QAPI program's plans and/or projects.

During an interview on 03/03/21 at 4:01 PM, Staff J, Registered Nurse (RN), stated that she was just recently placed into the QAPI role on 02/22/21, and due to staffing challenges, she had not yet been able to be active in that role. She stated that she was not asked to be involved in the QAPI program with the previous person in charge and shared that he was a really poor communicator and was unorganized with the QAPI program. She reported that she had never received communication verbally or via email regarding QAPI Committee meeting minutes and/or plans.

During an interview on 03/03/21 at 4:30 PM, Staff S, Chief Executive Officer (CEO) and interim Chief Clinical Officer (CCO), stated that
- She was aware that they did not have a good QAPI process.
- She was aware that their recent DQM was not fully present, communicative or organized and that he lacked follow-through.
- Their most recent QD had come into the position with great challenges as their QAPI program had to be completely rebuilt due to the failures of the DQM just prior to him.
- She was responsible for the QD oversight, but was so overwhelmed with their staffing challenges that she had not been focused on QAPI.
- She felt it was better to have someone doing a little versus having no one in that role at all.
- Their most recent QD had been in that role for approximately one year prior to his recent termination, and he never ran a solid QAPI during his tenure.
- They had just recently made the decision to make a change in the QAPI positon.
- She expected that QAPI meetings be multi-disciplinary and included all departments and contracted services.
- She expected QAPI meetings to analyze data, identify opportunities, have measureable goals, and monitor outcomes.
- She expected QAPI to be thorough and produce active plans that were communicated across all applicable disciplines.
- QAPI meeting minutes should always be shared with all clinical teams across all disciplines at all levels.

Based on interview and record review, the hospital failed to ensure the Medical Staff conducted periodic appraisals and re-appraisals of clinical practice for two staff physicians (T and V) of two staff physicians reviewed and two staff nurse practitioners (U and GG) of two staff nurse practitioners reviewed. The hospital also failed to perform peer review (evaluation of professional work by others working in the same field) and documentation of continuing education for two staff physicians (T and V) of two staff physician credentialing files reviewed and failed to ensure that one staff physician (T) of two staff physicians reviewed, had a current Bureau of Narcotics and Dangerous Drugs (BNDD) license. These deficiencies had the potential to permit physicians to provide patient care outside of acceptable professional standards as determined by the Medical Staff. The hospital census was 12.

Findings included:

1. Review of the hospital's document titled, "Medical Staff Bylaws," last revised on 11/2020, showed that all medical staff were expected to:
- Participate in peer review, quality assessment, performance improvement, and any review and improvement activities.
- Participate in continuing education to maintain clinical skills and current competencies.
- Notify and update the Medical Staff and hospital within one business day of any changes in qualifications or clinical privileges.
- Maintain a current registration for prescribing privileges through the BNDD.

Review of the hospital's policy titled, "Medical Staff Peer Review," last reviewed on 10/2020, showed that ongoing practice evaluation was ongoing data collected for the purpose of assessing a practitioner's clinical competence and professional behavior. Peer review was to ensure there was a process that evaluated and monitored an individual practitioner's quality of services and met professional standards of health care. Also, all types of evaluations was documented with minutes presented to the Medical Executive Committee reflecting the findings, conclusions, recommendations and actions taken. Review of the Medical Staff records for Staff T, Medical Director and Staff Physician, showed no evaluation of clinical practice, no continuing education, no peer review and an expired BNDD license.

During an interview on 03/01/21 at 2:20 PM, Staff T, Medical Director and Staff Physician, stated that he was unaware his BNDD license expired and that his continuing education was not on file.

Review of the Medical Staff records for Staff V, Staff Physician, showed no evaluation of clinical practice, no peer review and no continuing education on file.

Review of the Medical Staff records for Staff U, Nurse Practitioner (NP) and Staff GG, Wound Care NP, showed no evaluation of clinical practice on file.

During an interview on 03/03/21 at 4:35 PM, Staff S, Chief Executive Officer and interim Chief Clinical Officer, stated that it was her responsibility to ensure that the medical staff appraisals were completed and there had not been a structure in place to complete or track these and she expected all physicians to have peer review performed every two years, a current BNDD license, evaluations of clinical practice on all medical staff and she also expected that all employees would have their continuing education up-to-date.

Based on observation, interview, record review, and policy review the hospital failed to ensure that:
- Nursing staff provided adequate preventive care for eight current patients (#1, #4, #5, #6, #9, #10, #12 and #13) of 10 current patients reviewed and one discharged patient (#14) of two discharged patients reviewed with pressure ulcers (injury to the skin and/or underlying tissue, usually over a bony area).
- Nursing staff followed physicians' orders to turn patients every two hours for eight current patients (#1, #4, #5, #6, #9, #10, #12 and #13) of 10 current patients reviewed and one discharged patient (#14) of two discharged patients reviewed.
- Nursing staff followed physicians' orders for preventive care which included pressure relief mattresses for one current patient (#4) of 10 current patients reviewed and one discharged patient (#14) of two discharged patients reviewed.
- Nursing staff followed wound care orders for daily dressing changes for one current patient (#1) of two current patients observed.
- Sufficient numbers of licensed nursing staff were available to provide essential nursing care when they failed to include patient acuity (the severity of the patient's illness and the level of service needed) when planning for daily staffing for the past six months.

These failures resulted in non-compliance with 42 CFR 482.23 Condition of Participation (COP): Nursing Services and placed all patients within the hospital at risk for their health and safety and had the potential to lead to poor outcomes. The hospital census was 12.

Findings included:

1. Review of the hospital's policy titled, "Wound Care Scope of Services," reviewed 09/2020, showed:
- Wound care and procedures included specialty mattresses and frequent turning of the patient.
- The responsibilities also included implementing ongoing interventions for the prevention of skin breakdown, protect bony prominences (areas at high risk of developing pressure ulcers) by turning, positioning and padding areas as appropriate.
- Wound care practitioners were responsible for the initial assessment and orders, then the subsequent care was assigned to nursing staff to carry out.
- All wound care orders not completed by the patient's nurse were to be written up in an incident report.

Review of the hospital's policy titled, "Clinical Practice Guidelines," reviewed 12/2020, showed that a Braden Scale (an assessment tool for predicting the risk of pressure sores; scores of less than nine =Severe Risk, 10-12=High Risk, 13-14=Moderate Risk, and 15-18=Mild Risk) would be calculated and documented on the nursing flow sheet. All patients who were unable to turn or move themselves adequately, and those who were assessed as being moderate, high, and severe risk for pressure ulcer development would be turned and repositioned every two hours to help ensure skin integrity.

Review of Patient #1's physical therapy documentation dated 02/16/21 through 02/23/21, showed that the patient was identified as dependent (a person who needs another person to completely and totally perform a task for them) needing maximum assistance.

Review of Patient #1's Braden Scale scores dated 02/16/21 through 02/23/21, showed a range of scores from 13 (moderate risk for skin breakdown) through nine (severe risk for skin breakdown).

Review of Patient #1's Nursing Flowsheet dated 02/16/21 through 02/22/21, showed that staff failed to turn the dependent patient every two hours per physician's orders, five times on 02/16/21, 12 times on 02/17/21, 11 times on 02/18/21, eight times on 02/19/21, seven times on 02/20/21, 11 times on 02/21/21, and 11 times on 02/22/21. Since Patient #1's admission on 02/16/21, nursing staff failed to turn the patient a total of 65 times which created an environment that promoted and heightened her risk for pressure ulcers.

During an interview on 02/23/21 at 1:30 PM, Patient #1, stated that she was unable to turn herself and that nursing staff did not turn her every two hours and she was concerned about her wounds becoming worse. She also stated that one night she asked to be turned at 1:00 AM and didn't get turned until 5:00 AM.

Review of Patient #4's medical record showed:
- Patient #4 was admitted on 02/09/21, with a Braden Scale score of 12 (high risk for skin breakdown).
- On 02/10/20, the Nursing Assessment documented a Braden Scale score of nine (severe risk for skin breakdown).
- Patient #4 had no pressure wounds at the time of admission.
- On 02/20/21, a Certified Nursing Assistant (CNA) reported an open area on the patient's coccyx (tailbone area) and wound care was notified.
- On 02/22/21, the wound care assessment noted that the patient had three newly acquired pressure areas: right heel, coccyx, and right buttock.
- On 02/22/21, the wound care assessment noted that Patient #4 remained on a regular mattress.
- On 02/22/21, a low air loss mattress was obtained, 13 days after admission.

Review of Patient #4's Nursing Flowsheets dated 02/09/21 through 02/25/21, showed that staff failed to turn the dependent patient every two hours per physician's order six times on 02/09/21, 12 times on 02/10/21, 12 times on 02/11/21, 10 times on 02/13/21, 11 times on 02/14/21, nine times on 02/15/21, 10 times on 02/16/21, 12 times on 02/17/21, 12 times on 02/18/21, nine times on 02/19/21, seven times on 02/20/21, six times on 02/21/21, five times on 02/22/21, nine times on 02/23/21, 12 times on 02/24/21, and 12 times on 02/25/21. Since Patient #4's admission on 02/09/21, nursing staff failed to turn the patient a total of 154 times, which created an environment that promoted and heightened the patient's risk for pressure ulcers.

During an interview on 02/25/21 at 11:00 AM, Staff L, Rehabilitation Manager, stated that Patient #4 was dependent and required maximum assist with turning.

During an interview on 02/23/21 at 10:00 AM, Staff A, Licensed Practical Nurse (LPN), Wound Nurse, stated that Patient #4 had acquired pressure ulcers due to poor incontinent care and failure to get the correct mattress. She stated that the nursing staff didn't perform turns appropriately or provide pressure relief as ordered. She stated that pressure intervention orders were frequently not followed by nursing staff.

Review of Patient #5's Nursing Admission Assessment, dated 02/18/21, showed that he had a Braden Score of eight (severe risk for skin breakdown).

Review of Patient #5's Nursing Flowsheets dated 02/19/21 through 03/01/21, showed that staff failed to turn the dependent patient every two hours seven times on 02/19/21, five times on 02/20/21, six times on 02/21/21, five times on 02/22/21, and nine times on 03/01/21. Since the patient's admission on 02/18/21, nursing staff failed to turn the patient a total of 32 times, which created an environment that promoted and heightened the patient's risk for pressure ulcers.

During an interview on 02/25/21 at 11:00 AM, Staff L, Rehabilitation Manager, stated that Patient #5 was dependent and required maximum assist with turning.

Review of Patient #6's Nursing Admission Assessment, dated 02/19/21, showed that he had a Braden Score of 11 (high risk for skin breakdown).

Review of Patient #6's Nursing Flowsheets dated 02/20/21 through 03/01/21, showed that staff failed to turn the dependent patient every two hours eight times on 02/20/21, 11 times on 02/21/21, 11 times on 02/22/21, and 11 times on 03/01/21. From 02/20/21 through 03/01/21, nursing staff failed to turn the patient a total of 41 times, which created an environment that promoted and heightened the patient's risk for pressure ulcers.

During an interview on 02/25/21 at 11:00 AM, Staff L, Rehabilitation Manager, stated that Patient #6 was dependent and required assistance with turning.

Review of Patient #9's Nursing Admission Assessment, dated 02/15/21, showed that he had a Braden Score of 15 (low risk for skin breakdown) and a coccyx pressure wound.

Review of Patient #9's Nursing Flowsheets dated 02/19/21 through 03/01/21, showed that staff failed to turn the dependent patient every two hours eight times on 02/19/21, six times on 02/20/21, six times on 02/21/21, five times on 02/22/21, and 10 times on 03/01/21. From 02/19/21 through 03/01/21, nursing staff failed to turn the patient a total of 35 times, which created an environment that promoted and heightened the patient's risk for pressure ulcers.

During an interview on 02/25/21 at 11:00 AM, Staff L, Rehabilitation Manager, stated that Patient #9 was dependent and required maximum assistance with turning.

Review of Patient #10's Nursing Admission Assessment, dated 02/18/21, showed that she had a Braden Score of 12 (high risk for skin breakdown).

Review of Patient #10's Nursing Flowsheets dated 02/19/21 through 03/01/21, showed that staff failed to turn the dependent patient every two hours nine times on 02/19/21, six times on 02/20/21, six times on 02/21/21, seven times on 02/22/21, and 10 times on 03/01/21. From 02/19/21 through 03/01/21, nursing staff failed to turn the patient a total of 35 times, which created an environment that promoted and heightened the patient's risk for pressure ulcers.

During an interview on 02/25/21 at 11:00 AM, Staff L, Rehabilitation Manager, stated that Patient #10 was not independent with rolling and required minimum assistance with turning.

Review of Patient #12's Nursing Admission Assessment, dated 02/09/21, showed that she had a Braden Score of 14 (medium risk for skin breakdown) and a coccyx pressure wound.

Review of Patient #12's Nursing Flowsheets dated 02/19/21 through 02/22/21, showed that staff failed to turn the dependent patient every two hours eight times on 02/19/21, five times on 02/20/21, six times on 02/21/21, and five times on 02/22/21. From 02/19/21 through 02/22/21, nursing staff failed to turn the patient a total of 24 times, which created an environment that promoted and heightened the patient's risk for pressure ulcers.

During an interview on 02/25/21 at 11:00 AM, Staff L, Rehabilitation Manager, stated that Patient #12 was dependent and required moderate assistance with turning.

Review of Patient #13's Nursing Admission Assessment, dated 02/20/21, showed that he had a Braden Score of 10 (high risk for skin breakdown).

Review of Patient #13's Nursing Flowsheets dated 02/20/21 through 02/22/21, showed that staff failed to turn the dependent patient every two hours six times on 02/20/21, nine times on 02/21/21, and 12 times on 02/22/21. Since the patient's admission on 02/20/21, nursing staff failed to turn the patient a total of 27 times, which created an environment that promoted and heightened the patient's risk for pressure ulcers.

During an interview on 02/25/21 at 11:00 AM, Staff L, Rehabilitation Manager, stated that Patient #13 was dependent. He could participate in turning, but could not roll his whole body by himself.

Review of Patient #14's medical record showed:
- He was admitted on 09/25/20, with a Braden Scale score of 10 (high risk for skin breakdown).
- He had a pressure ulcer on his sacrum upon admission.
- On 09/25/20, the physician ordered for him to be turned every two hours.

Review of Patient #14's Nursing Flowsheets dated 09/26/20 through 10/09/20, showed that staff failed to turn the dependent patient every two hours six times on 09/26/21, eight times on 09/27/20, three times on 09/28/20, six times on 09/29/20, eight times on 09/30/20, 10 times on 10/01/20, nine times on 10/02/20, seven times on 10/03/20, four times on 10/04/20, three times on 10/05/20, 10 times on 10/06/20, 11 times on 10/07/21, 10 times on 10/08/20, and four times on 10/09/20. From 09/26/20 through 10/09/20, nursing staff failed to turn the patient a total of 99 times, which created an environment that promoted and heightened the patient's risk for pressure ulcers.

During an interview on 03/01/21 at 10:22 AM, Staff W, LPN, stated that she didn't have time to turn patients every two hours because the acuity was too high.

During an interview on 03/03/21 at 9:07 AM, Staff BB, LPN, stated that when the acuity was high, they had no time to turn the patients.

During an interview on 02/24/21 at 9:22 AM, Staff K, Physical Therapy Assistant (PTA), stated that she expected that when patients were identified as a dependent patient, they were to be turned every two hours.

During an interview on 02/24/21 at 11:40 AM, Staff L, Rehabilitation Manager, stated that they have communicated the need for patients to be turned every two hours with nursing staff and she expected that this was completed.

During an interview on 03/01/21 at 10:03 AM, Staff I, RN, Charge Nurse, stated that Staff J, Quality Director, made the staffing sheets and patient acuity was not took into consideration.

During an interview on 03/01/21 at 2:20 PM, Staff T, Medical Director, stated that he felt that they should have increased staffing or increased the competency in training for the nurses. He also stated that the acuity was high and he worried that his patients weren't turned every two hours and he expected the nurses to turn the patients every two hours.

During an interview on 03/03/21 at 4:03 PM, Staff J, Quality Director, stated that she expected all staff to be responsible for turning the patients every two hours and they don't take patient acuity into account and that they just looked at the numbers when they were staffing.

During an interview on 03/03/21 at 4:35 PM, Staff S, CEO and interim Chief Clinical Officer (CCO), stated that these were sicker patients and needed to be turned every two hours and she expected the charge nurses to look at the report sheets for acuity when staffing.

2. Review of Patient #4's medical record showed:
- Patient #4 was admitted on 02/09/21, with a Braden Scale score of 12 (high risk for skin breakdown).
- On 02/10/20, the Nursing Assessment documented a Braden Scale score of nine (severe risk for skin breakdown).
- Patient #4 had no pressure wounds at the time of admission.
- On 02/20/21, a Certified Nursing Assistant (CNA) reported an open area on the patient's coccyx (tailbone area) and wound care was notified.
- On 02/22/21, the wound care assessment noted that the patient had three newly-acquired pressure areas: right heel, coccyx, and right buttock.
- On 02/22/21, the wound care assessment noted that Patient #4 remained on a regular mattress.
- On 02/22/21, a low air loss mattress was obtained, 13 days after admission.

Review of Patient #14's medical record showed:
- He was admitted on 09/25/20, with a Braden Scale score of 10 (high risk for skin breakdown).
- He had a pressure ulcer on his sacrum upon admission.
- On 09/25/20, the physician ordered a low air loss mattress and to turn every two hours.
- On 09/30/20, documentation on a completed Incident Report showed that the patient was found on a standard mattress and the low air loss mattress was not in place.
- On 09/30/20, the physician wrote a second order which stated, "Please place patient on a low air loss mattress."
- On 09/30/20, a low air loss mattress was obtained, five days after admission and the physician's original order.

During an interview on 2/25/21 at 10:00 AM, Staff H, Registered Nurse (RN), stated that all nursing staff had been trained on preventative wound care, but despite training, they continued to do it incorrectly. The patients were not turned as they should be and wound treatments were often not done. She stated there was not enough people to take care of the very sick patients that were admitted, so the nurses relied on the nurse technicians, who also did not turn the patients and provide pressure relief as ordered.

During an interview on 2/25/21 at 10:00 AM, Staff GG, Nurse Practitioner (NP), Wound Care Plus, stated that there were times the nursing staff did not follow wound care and prevention directions appropriately. She stated the nursing staff seemed to fear wounds and preferred the wound nurse or wound care plus to do all treatments. She stated wound dressings were often off or the wrong dressing was in place. She stated that she had offered to do staff education, but the staff frequently changed and the education she offered had not been accepted by the hospital.

During an interview on 3/01/21 at 2:15 PM, Staff T, Medical Director, stated that he had ordered low air loss mattresses on two different patients and those orders were not followed by the nursing staff. He stated that his expectations were that wound care treatments would be done as ordered, pressure relief interventions would be followed as ordered, and patients would be turned at least every two hours.

During an interview on 3/03/21 at 4:05 PM, Staff J, RN, Quality Director, stated that her expectations were for patients who had a Braden Scale score that showed they were at risk for pressure ulcers should be turned at least every two hours and a low air loss mattress should be ordered immediately. She stated the physician should not even have to write orders for a low air loss mattress and/or turning a patient every two hours because that is the policy for all patients at risk.

3. Review of Patient #1's wound care practitioner's orders dated 02/18/21 at 5:50 PM, showed the direction for nursing staff to change the patient's abdominal dressing daily and as needed if soiled. Nursing flowsheets revealed that nursing staff failed to change the abdominal dressing on 02/19/21, 02/20/21 and 02/23/21.

During an interview on 02/23/21 at 1:30 PM, Patient #1 stated that the wound care team saw her twice per week and told her that the nurses were to change her abdominal dressing daily. She had informed nursing staff and she was told that they didn't change the dressings, wound care did that.

During an interview on 02/23/21 at 2:45 PM, Staff A, LPN, Wound Care Nurse, stated that nursing staff should have adhered to the dressing changes ordered since she only sees the patients two times per week. She also stated that she had addressed this with administration.

During an interview on 03/03/21 at 9:07 AM, Staff BB, LPN, stated that the acuity had been too high and she was unable to perform dressing changes.

During an interview on 03/01/21 at 2:20 PM, Staff T, Medical Director, stated that wounds should have been assessed by the Wound Care Nurse and then reassessed by the nursing staff daily.

During an interview on 03/03/21 at 4:35 PM, Staff S, CEO and interim CCO, stated that she felt there was a huge disconnect with wound care and dressing changes.





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39562

Based on interview, record review and policy review, the hospital failed to ensure staff administered medications according to physicians' orders and medication administration policies for seven current patients (#2, #3, #5, #6, #7, #12 and #13) of seven current patients reviewed. These failed practices had the potential to cause harm and/or ineffective medication therapy to patients admitted to the hospital.

Findings included:

1. Review of the hospital's policy titled, "Drugs Administration: General," dated 10/2014, showed the following:
- Medications ordered should be ordered to treat a patient's specific condition.
- Verify drugs to be administered with the physician's order.
- Review the medication administration record (MAR, a list of medications ordered for the patient by the physician, also where the nurse documents administration of medications) to ensure that the dose is correct and that the drug is not contraindicated by allergy, sensitivity or diagnosis.
- Be attentive to cautionary statements on the MAR and drug label.
- Monitor patient's response to the drug and if response is not what was expected, notify the prescriber.
- Before administering, inform the patient about potential clinically significant adverse drug reactions or other concerns regarding administration of a medication.

Review of the hospital's policy titled, "Nursing Standards of Patient Care," revised 06/2020, showed the following:
- Physician orders will be reviewed and checked for accuracy against the MAR at the beginning of each shift by the on-coming nurse and every 12 hours.
- Orders are transcribed by the unit secretary and reviewed for completeness and accuracy of transcription by the nurse.
- The nurse is ultimately responsible for the accurate transcription of orders.

Review of Patient #2's History and Physical (H&P, a document in a patient's medical record that contains the physician's initial assessment and treatment plan), physician orders and MAR showed the following:
- He was a 76-year-old male with a medical history of high blood pressure (BP, a measurement of the pressure of blood flow in two different parts of the heart, normal is approximately 90/60 to 120/80), high cholesterol, irregular heart rhythm and heart failure (a chronic condition in which the heart cannot pump or fill adequately).
- An order for Metoprolol (medication used to treat high blood pressure, chest pain and heart failure) 50 milligram (mg, unit of measure) tablet, twice a day; hold for systolic blood pressure (SBP) less than 100 or heart rate (HR, the number of times the heart beats within a certain time period, usually a minute) less than 55.
- From 02/13/21 through 03/03/21 (19 days), the patient's BP and HR were only documented four times on the MAR. Nursing staff failed to document 34 entries of the BP and HR before the medication Metoprolol was administered.
- An order for Amiodarone (medication used to treat and prevent an irregular heartbeat) 200 mg. tablet daily; hold for HR less than 55.
- From 02/14/21 through 03/03/21 (18 days), the patient's HR was only documented three times on the MAR. Nursing staff failed to document 15 entries of the HR before the medication Amiodarone was administered.

Review of Patient #3's H&P, physician orders and MAR showed the following:
- She was a 66-year-old female with a medical history of heart failure, high BP, irregular heart rhythm and respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).
- An order for Amiodarone 200 mg. tablet daily; hold for HR less than 55.
- From 02/09/21 through 03/01/21 (21 days), the patient's HR was not documented on the MAR. Nursing staff failed to document 21 entries of the HR prior to administration of the medication Amiodarone.
- On 02/27/21, a new physician order was written at 3:15 PM for Metoprolol 25 mg. tablet, twice a day; hold for SBP less than 100 or HR less than 55; first dose to be given on 02/27/21 at 9:00 PM.
- The first dose of Metoprolol was not given until 02/28/21 at 9:44 AM; there was no documentation of why the dose was not given as ordered and from 02/28/21 through 03/01/21, the patient's BP or HR was not documented on the MAR. Nursing staff failed to document four entries of the BP and HR before the medication Metoprolol was administered.

Review of Patient #5's H&P, physician orders and MAR showed the following:
- He was a 68-year-old male with a medical history of high BP, irregular heart rhythm and respiratory failure.
- An order for Metoprolol 25 mg. tablet, twice a day; hold for SBP less than 100 or HR less than 55.
- From 02/18/21 through 03/03/21 (14 days), the patient's BP and HR was only documented nine times on the MAR. Nursing staff failed to document 19 entries of the BP and HR before the medication Metoprolol was administered.
- An order for Diltiazem (medication used to treat high blood pressure and chest pain) 60 mg. tablet, three times a day; hold for SBP less than 100 or HR less than 55.
- From 02/18/21 through 03/03/21 (14 days), the patient's BP and HR was documented 14 times on the MAR. Nursing staff failed to document 28 entries of the BP and HR before the medication Diltiazem was administered.

Review of Patient #6's H&P, physician orders and MAR showed the following:
- He was a 60-year-old male with a medical history of heart transplant, high BP, high cholesterol, obesity and previous COVID-19 (highly contagious, and sometimes fatal, virus) infection.
- An order for Diltiazem 60 mg. tablet, three times a day; hold for SBP less than 100 or HR less than 55.
- From 02/20/21 through 03/03/21 (12 days), the patient's BP and HR was documented three times on the MAR. Nursing staff failed to document 33 entries of the BP and HR before the medication Diltiazem was administered.
- An order for Metoprolol 75 mg. tablet, twice a day; hold for SBP less than 100 or HR less than 55.
- From 02/20 through 03/03/21 (12 days), the patient's BP and HR was documented one time on the MAR. Nursing staff failed to document 23 entries of the BP and HR before the medication Metoprolol was administered.

Review of Patient #7's H&P, physician orders and MAR showed the following:
- He was a 64-year-old male with a medical history of stroke (occurs if the flow of oxygen-rich blood cannot reach a portion of the brain), heart disease, heart failure (a chronic condition in which the heart cannot pump or fill adequately) and high BP.
- An order for Metoprolol extended release 100 mg. tablet daily; hold for SBP less than 100 or HR less than 55.
- From 02/23/21 through 03/01/21 (seven days), the patient's BP and HR was documented one time on the MAR. Nursing staff failed to document six entries of the BP and HR before the medication Metoprolol was administered.
- An order for Furosemide (medication used to treat fluid retention and swelling caused heart failure) 80 mg. tablet, twice a day; hold for SBP less than 100.
- From 02/23/21 through 03/01/21 (seven days), the patient's BP was documented two times on the MAR. Nursing staff failed to document 12 entries of the BP before the medication Furosemide was administered.

Review of Patient #12's H&P, physician orders and MAR showed the following:
- She was a 71-year-old female with a medical history of heart valve disease, irregular heart rhythm and status post Covid-19 infection.
- An order for Metoprolol 50 mg. tablet, twice a day; hold for SBP less than 100 or HR less than 55.
- From 02/09/21 through 03/03/21 (23 days), the patient's BP and HR was documented 13 times on the MAR. Nursing staff failed to document 33 entries of the BP and HR before the mediccation Metoprolol was administered.

Review of Patient #13's H&P, physician orders and MAR showed the following:
- He was a 75-year-old male with a medical history of heart failure and high BP.
- An order for Amlodipine (medication used to treat high blood pressure and chest pain) 10 mg. tablet daily; hold for SBP less than 100.
- From 02/20/21 through 03/03/21 (12 days), the patient's BP was documented one time on the MAR. Nursing staff failed to document 11 entries of the BP before the medication Amlodipine was administered.
- An order for Lisinopril (medication used to treat high blood pressure and heart failure) 20 mg. tablet daily; hold for SBP less than 100.
- From 02/20/21 through 03/03/21 (12 days), the patient's BP was documented two times on the MAR. Nursing staff failed to document 10 entries of the BP before the medication Lisinopril was administered.

During an interview on 02/24/21 at 11:00 AM, Staff Y, Patient Care Technician (PCT), stated that vital signs (body temperature, blood pressure, heart rate, and breathing rate) were done once a shift in the morning and evening by the PCT anytime between 6:00 AM to 8:00 AM and 6:00 PM to 8:00 PM.

During an interview on 03/01/21 at 9:30 AM, Staff N, Registered Nurse (RN), stated that prior to giving a cardiac medication, she used the vital signs obtained from the PCT that morning. The patient's BP and HR should be documented in the comments on the MAR.

During an interview on 03/02/21 at 11:00 AM, Staff FF, Pharmacist, stated that vital signs should be documented if parameters were written on the medication order. Medications should be administered as ordered to prevent adverse patient outcomes.

During an interview on 03/03/21 at 4:30 PM, Staff S, Chief Executive Officer (CEO), stated that she was the interim Director of Nursing until a replacement was hired. Her expectation of nursing staff was to follow physician medication orders as specified. Nursing staff should obtain the patient's BP and HR prior to administration of a cardiac medication and document on the MAR as ordered.