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Based on record review, observations, and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

1.Failure to ensure an RN assessed patients who had a change in condition, who were assigned to LPNs, for 2 (#3, #6) of 2 sampled patients reviewed for an acute change in condition, from a total patient sample of 7. This deficiency was previously cited on 06/22/2022. (See findings tag A-0395);

2.Failure to ensure each patient was assessed at least every 24 hours by the RN, as required by the Louisiana State Board of Nurse's Practice Act. This deficient practice resulted in patient care provided by LPNs without documented evidence of an RN assessment at a minimum of every 24 hours for 2 (#2, #3) of 4 (#1, #2, #3, #6) sampled patient records reviewed for RN assessments (at main campus), from a total patient sample of 7. (See findings tag A-0397);

3.Failure to ensure staff skills competency evaluations for all skills performed were assessed for 10 (S6RN, S7LPN, S8LPN, S9LPN, S11RN, S12LPN, S13LPN, S14RN, S15LPN, S16RN) of 11 (S6RN, S7LPN, S8LPN, S9LPN, S10LPN, S11RN, S12LPN, S13LPN, S14RN, S15LPN, S16RN) sampled personnel records reviewed for skills competency evaluations. (See findings tag A-0397); and

4. Failure to ensure non-employee RNs working as charge nurses were supervised by an appropriately qualified hospital employed RN. This deficient practice is evidenced by staffing with non-employee RNs as the only RN on shift for 7 of 18 shift assignment schedules reviewed from 08/18/2022 - 09/01/2022. This deficiency was previously cited on 06/22/2022. (See findings tag A-0398).

Based on observation, record review, and interview, the hospital failed to ensure a patient ( #7) placed in a soft limb restraint for non-violent behavior /safety was assessed every 2 hours, while in a restraints, per hospital policy, for 1 ( #7) of 1 total sampled patient where a restraint was currently utilized.

Findings:

Review of the hospital policy titled,"Restraints" Policy Number: 12300659, revealed the following, in part:
Definitions: A restraint is: A. Any manual method, physical or mechanical device, material, or equipment that mobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely.
Procedure: A. Restraint used in acute medical and surgical care as a measure to prevent patient injury ( i.e. non-violent/non-self destructive behaviors). Indications: Prior to initiation of restraints in acute medical or surgical care as a measure to prevent patient injury, the patient must be assessed for need for restraints and risks associated with behaviors that indicate need for restraint such as confusion/disorientation, interference with medical treatment i.e attempting to remove medical treatment such as IV's tubes, catheters and trachs.
Patient Monitoring: Patients in restraint will be monitored by trained staff as follows:
a. Every 2 hours to assure safety and dignity and to attend to comfort needs. Patients will be observed at least every 2 hours to assure restraint remains indicated. Fluids will be offered, mental status assessed, assistance with toileting needs provided, circulation and integrity of restrained limb assessed, assessment that restraining devices remain safely applied, and that the patient remains as comfortable as possible.

Review of Patient #7's H&P revealed the patient had the following diagnoses: Anoxic Encephalopathy, Chronic Respiratory Failure, and is Trach/Vent dependent, requiring tube feedings per PEG tube for nutrition.

On 09/02/2022 at 11:45 a.m. Patient #7 was observed supine with his head turned to the left, his eyes were noted to be closed. The patient has a trach, was connected to the vent, and was noted to have a large, wrapped mitt on his right hand. Patient #7 is medically restrained daily to keep him from pulling out/pulling at his trach and his feeding tube.

Review of Patient #7's entire medical record, assisted by S2ADON, revealed no documented evidence of q 2 hour assessments of the restraint device being on, observation/assessment of the patient for release, assessment of the patient's mental status, assessment for exhibited behaviors, offer of fluids/nutrition, offer of toileting, assessment of skin/circulation checks, documentation of patient turning/position changes, performance of ROM, and performance of skin care from 08/02/2022 - 09/01/2022. S2ADON verified the above referenced findings after review of the patient's entire medical record.

Based on record review, observation, and interview, the hospital failed to ensure an order for non-violent restraint use for a patient (#7) placed in a soft limb restraint for non-violent behavior /safety was re-ordered every 24 hours, per hospital policy, for 1 ( #7) of 1 total sampled patient where a restraint was currently utilized.

Findings:

Review of the hospital policy titled,"Restraints", Policy Number: 12300659, revealed the following, in part:
Definitions: A restraint is: A. Any manual method, physical or mechanical device, material, or equipment that mobilizes or reduces the ability of a patient to move his/her arms, legs, body or head freely.
Procedure: A. Restraint use in acute medical and surgical care as a measure to prevent patient injury ( i.e. non-violent/non-self destructive behaviors). Indications: Prior to initiation of restraints in acute medical or surgical care as ameasure to prevent patient injury, the patient must be assessed and need for restraints and risks associated with behaviors that indicate need for restraint such as confusion/disorientation, interference with medical treatment i.e attempting to remove medical treatment such as IV's tubes, catheters and trachs.
Orders: Restraint use will be initiated upon the order of a Physician or other Licensed Independent Practitioner, who is responsible for the care of the patient and authorized to order restraints.
Continuation of restraint orders: The Attending or other Licensed Independent Practitioner, who is responsible for the care of the patient will perform in-person assessments of the restrained patient at least every 24 hours at which time either restraints will be re-ordered or discontinued as indicated.

Review of Patient #7's H&P revealed the patient had the following diagnoses: Anoxic Encephalopathy, Chronic Respiratory Failure, and is Trach/Vent dependent, requiring tube feedings per PEG tube for nutrition.

Review of a restraint order dated 08/10/2022 (the last documented restraint order at the time of the record review on 09/02/2022), revealed Patient #7's hand was restrained via a mitt on his right hand due to meeting the high risk criteria of attempting to remove his tracheostomy tube and feeding tubes (PEG tube) with the following alternatives having been tried: increased observation, re-taping/changing location of line/device, concealing devices/lines, and repositioning patient.

On 09/02/2022 at 11:45 a.m. Patient #7 was observed supine with his head turned to the left, his eyes were noted to be closed. The patient has a trach, was connnected to the vent, and was noted to have a large, wrapped mitt on his right hand. Patient #7 is medically restrained daily to keep him from pulling out/pulling on his trach and his feeding tube.

Review of Patient #7's MD orders revealed restraint renewal orders had not been obtained every 24 hours for the following dates: 08/06/2022, 08/07/2022 and 08/11/2022- 09/01/2022 (22 days without restraint renewal orders every 24 hours). S2ADON, who assisted with the restraint record review, verified restraints should be re-ordered every 24 hours per facility policy and further verified there were no new restraint orders obtained for the above referenced dates.

Based on record review and interview, the hospital failed to ensure the hospital wide QAPI program's performance improvement activities tracked medication errors and adverse patient events, analyzed their causes, and implemented preventive actions. This deficient practice is evidenced by failure to identify, analyze, and track inpatient overdoses requiring administration of Narcan/illicit drug related incidents and inaccurate documentation of scheduled medication counts as risks to patient safety/adverse events to be addressed in QAPI.

Findings:

In hospital illicit drug use related incidents/Drug overdoses requiring rescue doses of Narcan (medication used to rapidly reverse opioid overdose):

Review of Hospital provided incident reports revealed the following inpatient/in-hospital illicit drug use related incidents. There was a total of 6 documented incidents from 04/03/2022 - 09/01/2022. Three incidents requiring rescue doses of Narcan occurred in 04/2022 (04/03/2022 and 04/08/2022 - 6 days apart and from 04/08/2022 to 04/11/2022 - 4 days apart). There were 2 incidents in 08/2022 (08/13/2022 and 08/22/2022 - 9 days apart). There was also an incident that occurred while surveyors were onsite on 09/01/2022. This incident also required a rescue dose of Narcan.

Patient #R3
Incident report dated 09/01/2022 (this incident occurred while surveyors were present during an onsite complaint survey): Patient #R3 was found unresponsive in his room by CNA on duty. This nurse and staff suspect patient had an overdose from drugs that were possibly given to patient by his roommate (Patient #1). Patient #R3 was administered Narcan per report from nursing staff SL7PN and S6RN.

Patient #2
Incident report dated 08/22/2022: Patient #2 suspected of injecting substance in his arm. Pt. was found with syringe in his arm. Pt. responsive, very lethargic, somewhat irate and combative. CNA reported seeing syringe in Patient #2's arm. There was a foreign substance found in syringe. Pt. referred to Psychiatrist for consult and treatment for substance abuse.

Review of Patient #2's Psychiatric consult note, dated 08/23/2022, revealed the following, in part: Patient #2 was found by nursing with a syringe in his IV as a possible overdose in the hospital. The patient reportedly took the used syringe out of the garbage can, crushed up one of his pain pills, and injected it into himself.

Patient #R1
Incident report 08/13/2022 Event time 6:25 p.m.: Patient #R1 observed by CNA in bathroom with a male gentleman with orange needles. Pt. #R1 found sitting on toilet and male sitting on floor. When confronted by CNA male quickly denied drug use and packed backpack with needles. Staff also found an Edge razor blade in the trash. Police Department and EMS notified. Vitals within normal limits.

Patient #R5
Incident report dated 04/11/2022: Patient #R5 - Attending nurse notified by CNA of decreased blood pressure and responsiveness. Upon nurse entering room, found Patient #R5 slumped in bed. Verbal stimuli did not arouse patient. Upon sternal rub patient awakened briefly but fell back to sleep. Charge nurse notified and called to room. RT at bedside O2 SaO2's 88% and O2 given. Narcan administered by Charge Nurse with immediate results noted in responsiveness. Pt. moving and thrashing around in bed. Search of room conducted and a number of items found to include multiple syringes, a Jim Beam bottle with a cloudy substance in it, a syringe with a greenish substance in it and multiple empty medicine cups.

Patient #R6
Incident report dated 04/08/2022 at 01:00 a.m.: Patient #R6 - CNA reported to Charge Nurse that Pt. #R6 had a syringe in her right hand and was not easily arousable to verbal stimuli. Staff nurse obtained Narcan 0.4 mg IVP to give through Left upper arm PICC line. Pt. #R6 was immediately responsive to verbal commands and was awake, was more alert. Vital signs stable. Syringe was bagged and labeled.

Patient #R4
Incident report dated 04/03/2022 at 03:45 a.m.: Patient #R4 - Nurse summoned to Patient #R4's room per loud outbursts by Patient #R4's roommate exclaiming "Check on Patient #R4 in the bathroom". Pt. #R4 was found unresponsive on the toilet slouched over. Skin appeared cyanotic. Pt. was unresponsive. Radial and carotid pulses palpable. Pt. #R4's vital signs O2 75%, heartrate 75 beats/minute, Nurse and Charge Nurse observed syringe with 4 cc yellow tinted unknown substance via \PICC right upper arm port, near insertion site. 30 cc white cup of water and grey/brown powder like unknown substance observed near toilet on floor. Charge RN attempted sternal rub; however Pt. #R4 remained unresponsive. RT arrived and started O2 non-rebreather. Pt. #R4's SaO2 noted 98%. Charge RN administered Narcan 0.4 mg/ml via PICC. P. #R4 observed with eye flickering, jerking movements. Pt. #R4 stood up near toilet and stated," I'm fully conscious, I'm fully alert".

In an interview on 09/02/2022 at 9:30 a.m. with S1Adm, she confirmed there had been several incidents involving overdoses in the hospital, some of which required Narcan rescue doses. She reported the incidents appeared to occur in clusters. She further reported they make sure they keep needle boxes under filled because patients will go into needle boxes in any room, not just in their room, to get used needles to shoot up with.

In an interview on 09/02/2022 at 10:30 a.m. with S2ADON, she confirmed there had been several incidents involving overdoses in the hospital, some of which required Narcan rescue doses. She further confirmed patients will go into needle boxes in any room to get used needles to shoot up with. S2ADON also explained patients will take empty, used pre-filled normal saline flush syringes that had been discarded in the trash to inject themselves with. She said they also sometimes "cheek" their medications and stockpile them to crush them in order to inject them later.

Inaccurate documentation of scheduled medication counts

Review of documentation of receipt of scheduled drugs - Suboxone and Oxycontin and documentation of scheduled drug administration for Patients #2, #R7, #R8, #R9, and #R10. Review of multiple pages/dates of documentation revealed there was a failure of the hospital's nursing staff to keep accurate and complete documentation of receipt and administration of scheduled drugs and also a failure to maintain accurate narcotic dose administration counts for Oxycontin from the Cubex medication dispensing system.

Multiple instances for unexplained corrected counts for Suboxone were noted in the sampled records. Also noted was missing data for entries such as missing times and missing documentation regarding the number of doses administered. Also noted during the documentation review was an instance of 3 missing doses of Oxycontin in the Cubex documentation with no explanation documented in the record as to why the doses were unaccounted for.

In an interview on 09/02/2022 at 3:00 p.m. with S3DirComp, she confirmed, after review of the above referenced findings, that the inpatient overdoses requiring administration of Narcan/illicit drug use related incidents and inaccurate documentation of scheduled medication counts had not been identified as adverse patient events/patient safety events that needed to be analyzed, addressed, and tracked through the hospital's QAPI program. S3DirComp indicated the 3 incidents of overdose requiring rescue with Narcan should have been flagged for immediate PIPs and a root cause analysis should have been done. She had been unaware of the incidents at the time of the interview and had not realized there had actually been 6 incidents related to drug use/overdoses in the hospital. She further confirmed, after review of the narcotic documentation, that this too needed to be looked at in QAPI.

Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice is evidenced by:
1. failure to ensure an RN assessed patients who had a change in condition, who were assigned to LPNs, for 2 (#3, #6) of 2 sampled patients reviewed for an acute change in condition, from a total patient sample of 7. ;

2. failure to perform wound care as ordered for 1 (#3) of 3 (#3, #4, #5) sampled patients reviewed for skin breakdown/wounds from a total patient sample of 7.;

3. failure to ensure documentation of rounding every 2 hours, offer of toileting every 2 hours, and repositioning every 2 hours of patients at risk for skin breakdown, and failure to document IV site assessment every 4 hours for 1 (#3) of 3 (#3, #4, #5) patients reviewed for skin breakdown/wounds from a total patient sample of 7.; and

4. failure to document vent settings on daily shift nursing assessments for 1 (#3) of 3 (#3,#4,#5) patients sampled for being on vents from a total patient sample of 7. This deficiency was previously cited on 06/22/2022.

Findings:

1.Failure to ensure the RN assessed patients who had a change in condition, who were assigned to LPNs.

Patient #3
Review of Patient #3's medical record revealed the patient had a history of cardiac arrest secondary to asthma exacerbation resulting in anoxic brain injury. Further review revealed the patient had a tracheostomy and was vent dependent. The patient also has a PEG tube for nutrition.

Further review of Patient #3's medical record revealed the following nurses' note entries dated 08/29/2022:
02:30 a.m. This nurse notified Charge RN pt.'s SaO2's down to 70's %. Charge nurse notified RRT regarding findings. Upon observation patient observed with rapid breathing with use of accessory muscles via abdomen. Pt.'s O2 in 70% and tending down.

02:50 a.m. Heartrate elevated 150's and trending up. RRT arrived at bedside and implemented bagging with 100% FiO2. Pt.'s O2 SaO2's and heartrate trending and unstable. Assessed CBG 126 mg/dl noted. Vital sign assessment Blood pressure 117/72 mm/Hg, Pulse 140, O2 SaO2s 85%, Respiratory Rate 22 breaths per minute, Temperature 97.9 F. RRT maintained bagging.

Further review revealed no documented evidence that the patient was assessed by the RN when the patient decompensated and demonstrated a change in condition. Additional review revealed the RN failed to assume care of the patient after the patient's condition became unstable and unpredictable.

Patient #6
Review of an Incident Report, dated 8/13/2022, revealed Patient #6 had an unwitnessed fall, in his room. He was found on the floor face down. Further review revealed the following description of the adverse effect of the incident: Change in level of consciousness or seizures, change in vital signs, dislocation/fracture possible, swelling/edema at site.

Review of Patient #6's medical record revealed the following nurses' note entry 08/13/2022 at 5:13 a.m. Pt. found on floor at 4:58 a.m. by CNA, noted on floor face down, stupor at present time, rolled pt. over and pt. not answering questions, both hands noted tightly close. Pt. unable to open hands. Pupils not dilating at this time. Pt. unable to follow commands. Eyes noted open but not responding when patient spoken to. Tongue noted swollen and protruding from mouth at present time. Accu-check done at 5:00 a.m. 51. EMS contacted for send out. Initial assessment: Blood Pressure: 162/101, Pulse 80, O2 SaO2 95%, Temperature 97.6 F, Respirations 16. D50W - IVP at 5:10 am. Pt. PICC line intact, repeat CBG 115.

Further review of Patient #6's medical record revealed no documented evidence that the patient had been assessed by an RN after the above referenced change in condition.

In an interview on 09/02/2022 at 9:30 a.m. with S1Adm, she confirmed, after review of the documentation of the change in condition for Patient's #3 and #6, that there was no documented assessment by the RN after the patients' change in condition.

2. Failure to perform wound care as ordered.

Review of Patient #3's medical record revealed the patient had a Stage IV Sacral pressure wound with bone exposed and the patient also had a Stage IV pressure wound on his left ear.

Review of an incident report dated 08/22/2022 at 5:30 a.m., date of incident 08/21/2022, revealed the drainage sponge to the sacral wound was left in place without being removed for several days.

Review of a wound assessment record dated 08/15/2022 revealed Patient #3's Stage IV Sacral pressure wound measured 13 cm L x 14 cm W x 5 cm D. Additional review revealed the patient had a second Stage IV Pressure wound on his left ear.

Review of Patient #3's treatment administration record (TAR) wound care orders revealed the following: Sacrum - change dressing every day and PRN. Cleanse with wound cleanser, pat dry, Sure-prep to peri-wound. Place collagen powder plus hydrogel gauze to bone. Fill wound with Dakins 0.125% moistened gauze and cover with Opti-Foam dressing.

Further review of the TAR revealed there was no documented dressing change to the sacrum on 08/21/2022.

In an interview on 09/02/2022 at 1:30 p.m. with S4Wound, she reported Patient #3 had a wound on his ear and he also had a large Stage IV sacral wound with bone exposed that drained a lot. S4Wound explained one day of not doing wound care as ordered on a wound like Patient #3's can negate an entire week's work towards healing of the wound. She indicated patient wound orders can be found on the TAR and if anyone needed to verify wound treatment orders they could check the TAR or the MD's orders. S4Wound reported when she was not working dressing changes were not always being done as ordered. S4Wound further reported Administration is aware wound care is not being done as ordered and that wound care is rarely done on weekends. She said Administration told her they can't hold agency nurses, used to staff the hospital, accountable for not performing wound care as ordered. S4Wound reviewed Patient #3's TAR and verified there were no initials on 08/21/2022 to indicate wound care had been done. She also reported there was an issue where the sponge in the patient's wound vac was stuck to the tissue and instead of irrigating the sponge to loosen it, the staff left the sponge in place for several days without removal/placing a new sponge. She indicated there are instructions in a book on the unit for performing dressing changes, including wound vacs.

3. Failure to ensure documentation of rounding every 2 hours, offer of toileting every 2 hours, and repositioning every 2 hours of patients at risk for skin breakdown, and IV site assessment every 4 hours.

Review of Patient #3's medical record revealed the patient was in a vegetative state secondary to anoxic brain injury, was obese, had a tracheostomy, and was vent dependent. Further review revealed the patient had a Stage IV Sacral pressure wound with bone exposed and also had a Stage IV pressure wound on his left ear.

Further review of Patient #3's medical record revealed a wound consult by S17MD, wound specialist, for his opinion on how to manage the patient's wounds. Additional review of the consult revealed a section titled, " Patient Assessment and Chronic Contributing Conditions Increasing Risk of Wound Incidence" was due to the following factors: Impaired mobility, Decreased functional mobility, Co-morbid conditions, Incontinence, Malnutrition, and/or Dehydration.

Review of Patient #3's Daily Nursing Assessments revealed the following entries:
08/17/2022 section indicating Turn q 2 hours, IV site checks q 4 hours, purposeful rounding q 2 hours, HOB elevated, and skin care protocol had a straight line drawn through the entire sections from 7:00 a.m. -4:00 p.m. with no individual entries. ;
08/19/2022 section indicating Turn q 2 hours, IV site checks q 4 hours, purposeful rounding q 2 hours, HOB elevated, and skin care protocol had a straight line drawn through the entire sections from 7:00 p.m. - 6:00 a.m. with no individual entries.;
08/22/2022 section indicating Turn q 2 hours, IV site checks q 4 hours, purposeful rounding q 2 hours, HOB elevated, and skin care protocol had a straight line drawn through the entire sections from 7:00 a.m. -5:00 p.m. with no individual entries.; and
08/23/2022 section indicating Turn q 2 hours, IV site checks q 4 hours, purposeful rounding q 2 hours, HOB elevated, and skin care protocol had a straight line drawn through the entire sections from 7:00 a.m. -5:00 p.m. with no individual entries.

In an interview on 09/02/2022 at 9:30 a.m. with S1Adm, she verified, after review of the above referenced entries, that the entries had been lined through with no individual entries for the time frames referenced. She confirmed there was no explanation for what the lines drawn through the entries for the shift indicated. She further confirmed there should have been individual entries every 2 hours for purposeful rounding, skin checks, and repositioning and every 4 hours as indicated per the section regarding IV site checks.

4. Failure to document vent settings on daily shift nursing assessments.
Review of Patient #3's medical record revealed the patient had a tracheostomy and was vent dependent.

Review of Patient #3's Daily Nursing Assessments flowsheet revealed a section titled Vent Settings with spaces to document Trach/ETT size/location, Mode, Rate, PEEP/PS, Tidal Volume, FiO2, as well as spaces or O2 delivery via: NC @___LPM, VM (Venti Mask)____FiO2, NR ( non-rebreather) ____FiO2, and BiPap ___FiO2.

Further review revealed that section of the flowsheets was left blank on Day shifts of 08/17/2022, 08/19/2022, and Day and Night shifts on 08/18/2022, 08/22/2022, 08/23/2022, 08/25/2022, 08/26/2022, 08/28/2022, and 08/29/2022. Additional review of the narrative notes section of the flowsheets on the above referenced shifts revealed no documentation of the patient's Trach size/location, Vent Mode, Rate, PEEP/Pressure Support, Tidal Volume, and FiO2.

In an interview on 09/02/2022 at 9:30 a.m. with S1Adm, she confirmed the nurses had not documented the patient's Trach size/location, Vent settings, and FiO2. S1Adm reported the hospital's respiratory therapists documented this information on their flowsheets, but agreed the nurses should have documented the referenced settings on the nursing flowsheet as well.

Based on record review, interviews and observations, the hospital failed to ensure that the RN assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of nursing staff available. This deficient practice is evidenced by:

1.failure to ensure each patient was assessed at least every 24 hours by the RN, as required by the Louisiana State Board of Nurse's Practice Act. This deficient practice resulted in patient care provided by LPNs without documented evidence of a RN assessment at a minimum of every 24 hours for 2 (#2, #3) of 4 (#1, #2, #3, #6) sampled patient records reviewed for RN assessments (at main campus), from a total patient sample of 7.; and

2. failure to ensure staff skills competency evaluations for all skills performed were assessed for 10 (S6RN, S7LPN, S8LPN, S9LPN, S11RN, S12LPN, S13LPN, S14RN, S15LPN, S16RN) of 11 (S6RN, S7LPN, S8LPN, S9LPN, S10LPN, S11RN, S12LPN, S13LPN, S14RN, S15LPN, S16RN) sampled personnel records reviewed for skills competency evaluations.

Findings:

1. Failure to ensure each patient was assessed at least every 24 hours by the RN as required by the Louisiana State Board of Nurse's Practice Act.

Review of the LSBN's Practice Act revealed that RNs may delegate select nursing interventions to the LPN provided the patient is assessed by an RN every 24 hours.
Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part,
"3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems.
The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required.
a. Any situation where tasks are delegated should meet the following criteria: i. the person has been adequately trained for the task; ii. the person has demonstrated that the task has been learned; iii. the person can perform the task safely in the given nursing situation; iv. the patient's status is safe for the person to carry out the task; v. appropriate supervision is available during the task implementation; vi. the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all.
b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification..."

Review of the hospital policy titled, "Assessment/Reassessment" Policy Number: 11399753, revealed the following, in part: A RN will perform and document the initial admission assessment and thereafter, a head to toe assessment in every 24 hour period.

Patient #3
Review of Patient #3's medical record revealed the patient had a history of cardiac arrest secondary to asthma exacerbation resulting in an anoxic brain injury. Further review revealed the patient had a tracheostomy, was vent dependent, and had a PEG tube for nutrition due to dysphagia secondary to the tracheostomy.

Review of Patient #3's nursing assessment documentation revealed the patient's care was assigned to LPNs on both the day and night shifts for the following dates: 08/17/2022, 08/18/2022, 08/19/2022, 08/22/2022, 08/23/2022, 08/26/2022, 08/27/2022, and 08/29/2022. Further review revealed there was no documented RN assessments performed every 24 hours, prior to delegating patient care to LPNs, on the above referenced days.

Patient #2
Review of Patient #2's medical record revealed the patient was admitted on 08/09/2022 for persistent infection of the left olecranon since sustaining a fracture of the same area on 03/03/2022. Further review revealed a psychiatric consult note indicating Patient #2 was found by nursing with a syringe in his IV as a possible overdose in the hospital. The patient reportedly took the syringe out of the garbage can, crushed up one of his pain pills, and injected it into himself.

Review of Patient #2's nursing assessment documentation revealed the patient's care was assigned to LPNs on both the day and night shifts on 08/22/2022. Further review revealed there was no documented RN assessment performed every 24 hours, prior to delegating patient care to LPNs, on 08/22/2022.

In an interview on 09/02/2022 at 9:30 a.m. with S1Adm, she confirmed it was the hospital's policy that all patients were to be assessed by an RN every 24 hours. She also confirmed the assessment should be documented in the patient's records. She verified there were no RN assessments documented on the above referenced records.

2. Failure to ensure staff skills competency evaluations for all skills performed were assessed.

Review of requested personnel records for the refernced nursing staff listed below revealed the following:
S6RN - Charge Nurse (agency) - no documented evidence of skills competency evaluations.;
S7LPN - no documented evidence of skills competency evaluations for all skills performed.;
S8LPN - no documented evidence of skills competency evaluations for all skills performed.; ;
S9LPN - no documented evidence of skills competency evaluations for all skills performed.;
S11RN - Charge Nurse (agency) - no documented evidence of skills competency evaluations for all skills performed.;
S12LPN - no documented evidence of skills competency evaluations for all skills performed.;
S13LPN - no documented evidence of skills competency evaluations for all skills performed.;
S14RN - Charge Nurse (agency) - no documented evidence of skills competency evaluations except for restraints and PPE. Further review revealed no skills competency evaluations for Vents, Tracheostomies, or Suctioning.;
S15LPN - no documented evidence of skills competency evaluations for all skills performed.; and
S16RN - no documented evidence of skills competency evaluations for all skills performed.

In an interview on 09/02/2022 at 3:00 p.m. with S1Adm, she confirmed there were no documented skills competencies for the above referenced requested personnel records. S2ADON, present during the interview with S1Adm, reported she tries to perform skills competency evaluations but it is difficult with the agency staff because the same nurses do not always report for assigments from the agencies used for staffing.

Based on record review, observation, and interview, the hospital failed to ensure non-employee RNs working as charge nurses were supervised by an appropriately qualified hospital employed RN. This deficient practice is evidenced by staffing with non-employee RNs as the only RN on shift for 7 of 18 shifts assignment schedules reviewed from 08/18/2022 - 09/01/2022. This deficiency was previously cited on 06/22/2022.

Findings:

Review of hospital's staffing assignment documentation from 08/18/2022 - 09/01/2022 revealed on 08/20/2022 (weekend day shift), 08/21/2022 (weekend day shift), and 09/01/2022 an Agency RN was the hospital's Charge RN. Further review revealed the Agency RN's were the only RNs working on those days.

Further review revealed an Agency RN was the hospital's Charge RN on the following night shifts: 08/18/2022, 08/23/2022, 08/24/2022, and 08/25/2022. Further review revealed the Agency RNs were the only RNs working on those shifts.

On 09/01/2022 at 10:00 a.m. S6RN was observed on the inpatient care unit. S1Adm, present during the observation, verified S6RN was the hospital's RN Charge Nurse on this shift. She also verified S5IntDON and S2ADON were not working on the day shift of 09/01/2022. S1Adm further verified S6RN was the only RN working on this shift.

In an interview on 09/02/2022 at 9:30 a.m. with S1Adm, she confirmed the above referenced findings regarding staffing with Agency RNs as Charge Nurses. She reported the hospital frequently relied upon multiple staffing agencies to provide both RN and LPN staff to cover shifts in the hospital.

Based on record review and interview, the hospital failed to ensure drugs, biologicals, and ordered oral nutritional supplements were administered in accordance with accepted standards of practice, the orders of the practitioner responsible for the patient's care, and hospital policy. This deficient practice was evidenced by failure to administer and document medication administration or reason for not administering medications , for all ordered medications on the patient's MAR for 1(#2) of 5 (#1 - #5) sampled patient medical records reviewed for medication administration from a total patient sample of 7. This defiency was previously cited on 06/22/2022.

Findings:

Review of the hospital policy titled, "Administration of Medication", Policy Number: K.11.31, effective date: 09/2017, revealed the following, in part:
Documentation: A. The individual administering the medication(s) must document all medications immediately after administration in the patient's MAR.
C. Following the dispensing of drugs from pharmacy, medications are to be administered by the practitioner who prepares them. D. Documentation of administration of medication on the MAR: There are 2 methods for documenting administered medications: The hospital may require the administrator to initial next to the time to indicate the medication has been administered or the hospital may use a single slash mark ( \ ) through the time of the administered dose. If a medication is not administered (held for example due to blood pressure parameters, patient refused, etc.), the appropriate documentation on the MAR, including the reason, must be recorded. The physician must also be notified. Further review of the policy revealed no guidance on time-frames for administration of medications ordered as "give NOW."

Review of Patient #2's medical record revealed an admission date of 08/09/2022 for persistent infection of the left middle finger abscess since sustaining a fracture of the same area on 03/03/2022. Patient #2 has Co-morbid conditions including Hepatitis C, COPD, HTN, and Arthritis.

Further review revealed Aerobic cultures grew Staphylococcus aureus and gram negative rods. Patient #2 was admitted due to needing one month of IV antibiotic therapy.

Review of Psychiatric consult, dated 08/23/22, revealed the following, in part: History of heroin use in the past. Currently at Sage LTAC for IV antibiotics. Patient was found by nursing with a syringe in his IV. The patient reportedly took the syringe out of the garbage can, crushed up one of his pain pills, and injected it into himself. The patient reports he has been using heroin for years, stopped 13 years ago but still has a craving for opioids. Pt. has recently been abusing pain pills, crushing them and injecting crushed up pain meds into his veins. Pt. last used heroin 9 years ago. Pt. states he has been on Suboxone before and it has helped him stay off opioids.

Review of Patient #2's MAR revealed the following medications were left blank with no indicators of whether the medications had been administered or not administered with no reason for why medication may not have been administered.

09/01/2022 - Cipro tablet 500 mg - take 1.5 tablets (750 mg) by mouth every 12 hours for 42 days. Further review revealed the dose was not documented as given 9:00 a.m. on 09/01/2022. The time entry was not circled (indicating dose not given) or lined out (indicating dose given) by staff.

09/01/2022- Vancomycin 1 gram ordered every 12 hours at 4:00 a.m. and 4:00 p.m. Further review revealed the doses at 4:00 a.m. and 4:00 p.m. on 09/01/2022 were circled with no documentation to indicate reason for why medication may not have been administered.

09/01/2022 - Lasix ordered 40 mg - 1 tablet by mouth 2 times a day at 7:00 a.m. and 1:00 p.m. On 09/01/2022 the time entries for both 7:00 a.m. and 1:00 p.m. doses were not circled (indicating dose not given) or lined out (indicating dose given) by staff.

09/01/2022 - Gabapentin 40 mg - 2 capsules 3 times a day, by mouth, at 9:00 a.m., 3:00 p.m., and 9:00 p.m. Further review revealed on 09/01/2022 the time entries for both 9:00 a.m. and 3:00 p.m. doses were not circled (indicating dose not given) or lined out (indicating dose given) by staff.

09/01/2022 - Buprenorphine/Naloxone (Suboxone) 8 mg/2 mg ordered to place film under tongue and dissolve 3 times a day at 9:00 a.m., 3:00 p.m., and 9:00 p.m. Further review revealed on 09/01/2022 the time entry for the 3:00 p.m. dose was not circled (indicating dose not given) or lined out (indicating dose given) by staff.

08/31/2022 - Pantoprazole tablet 40 mg by mouth every day at 06:00 a.m. On 08/31/2022 the time entry for the 06:00 a.m. dose was circled with no explanation as to why the dose was not given by staff.

08/30/2022 - Lasix ordered 40 mg - 1 tablet by mouth 2 times a day at 7:00 a.m. and 1:00 p.m. On 08/30/2022 the time entry for 1:00 p.m. dose was not circled (indicating dose not given) or lined out (indicating dose given) by staff.

08/30/2022 - Lotrisone apply to affected area twice a day for 7 days - rash - times 09:00 a.m. and 9:00 p.m. On 08/30/2022 the 09:00 a.m. dose was not circled (indicating dose not given) or lined out (indicating dose given) by staff.

In an interview on 09/02/2022 at 9:30 a.m. with S1Adm, she confirmed, after review of the above referenced MAR, that medications had not been documented as administered, held, or refused. She further confirmed the referenced entries had been left blank with no explanation for not being marked as administered or held.

Based on record review, observation, and interview, the hospital failed to ensure the accurate disposition of all scheduled drugs as evidenced by nurses failing to keep accurate and complete documentation of receipt and administration of scheduled drugs for 5 ( #2, #R7, #R8, #R9, and #R10) of 5 sampled patients' records reviewed for documentation of scheduled drug administration and failure to maintain accurate narcotic dose administration counts from the cubex automated medication dispensing system.

Findings:

Review of Patient #2's first sampled individual controlled medication log for Suboxone 8 mg/2mg, ordered 1 BID, revealed the following entries:

Entry 08/30/2022 09:00 p.m. Amount on hand: 4 , amount given 1, amount remaining 3.
Entry 08/31/2022 09:00 a.m. Amount on hand; 12, amount given 1, amount remaining: 11
Entry 09/01/2022 09:00 a.m. Amount on hand 9, amount given 1, amount rmeaining 8

Review of a second individual controlled medication log for Suboxone 8 mg/2mg revealed on 08/29/2022 at 9:00 p.m. the quantity received from pharmacy was documented as 6 with the amount remaining documented as 6 ( the amount remaining should have been 0)

Review of a third individual controlled medication log for Suboxone 8 mg/2mg on 08/31/2022 at 9:00 p.m. revealed the quantity received from pharmacy was 9 and the remaining count was documented as 6.

Follow-up review of the first sampled individual controlled medication log for Suboxone revealed there was no entry on this log for an updated count after receipt of 9 Suboxone from the pharmacy at 9:00 p.m. on 08/31/2022. The remaining count at that time had been 6 which would have made the current count 15.

Furtther review of the first sampled individual controlled medication log for Suboxon revealed on 09/01/2022 at 09:00 a.m. the remaining count was 9, amout given was 1 and the amount remaining was 8.
At this time an actual count of the drawer was performed with S7LPN and S8RN and the count correlated with the 09:00 a.m. count documented on 09/01/2022.

In an interview at the time of the observation of the automated medication dispensing system, the secured medication cart where the Suboxone was stored, S7LPN verified the above referenced documentation had not been accurate because the remaining counts had not been accurately documented when medications were received from the pharmacy.

Patient #R7
Review of Patient #R7's sampled individual controlled medication log for Buprin/Naloxone (Suboxone) 8 mg/2mg revealed the following entries:

08/05/2022 at 09:00 a.m. Amount on hand 6, amount given was blank, and amount remaining was 5.
08/06/2022 at 09:00 a.m. Amount on hand 4, amount given was blank, and amount remaining was 3.

Patient #R8
Review of Patient #R8's sampled individual controlled medication log for Suboxone 8 mg/2mg - 1 sublingual BID. revealed the following entries:

07/02/2022 at 9:00 p.m. Amount on hand 28, amount given was 1, and amount remaining was 27.
07/02/2022 at - No time documented - handwritten notation: correct count 26. Further review revealed there was no dose documented after 9:00 p.m. on 07/02/2022 and no explanation documented for the corrected count.

07/10/2022 at 09:00 a.m. Amount on hand: 43, amount given 1, amount remaining 42
07/10/2022 at 8:45 p.m. Corrected count 41.Further review revealed there was no dose documented prior to the 8:45 p.m. entry on 07/10/2022 and no explanation for the corrected count.

07/24/2022 at 09:00 a.m. Amount on hand 14, amount given 1, amount remaining 13
07/24/2022 at 9:00 p.m. Notation - not signed out, entry not signed by staff, amount remaining 12 which left one dose unaccounted for or previous count was incorrect.

Patient #R9
Review of Patient #R9's sampled individual controlled medication log for Suboxone 2 mg/0.5 mg TID revealed the following entries:

07/29/2022 at 9:15 p.m. Amount on hand 11, amount given 1, amount remaining 10
07/30/2022 at 9:00 p.m. Shift count - Amount on hand 8, corrected count 7. No entries on the record documenting the administration of the doses between the two entries.

08/01/2022 at 8:51 p.m. Amount on hand 3, amount received 48, amount remaining 51
08/01/2022 at 9:30 p.m. Amount on hand 53, amount given 1, remaining count 52.
08/02/2022 at 8:55 a.m. Count corrected 50 on hand on a.m. shift count. Further review revealed no other documented doses noted between the two entries.

08/08/2022 at 9:00 p.m. amount on hand 60, amount given 1, amount remaining 59.
08/09/2022 - No time documented, Corrected count 57. Further review revealed no documentation of 2 doses unaccounted for and if they were administered or if it was an inaccurate count.

Patient #R10
Review of Patient #R10's sampled individual controlled medication log for Buprin/Nalox (Suboxone) - 1 film on tongue TID revealed the following entries:

07/29/2022 at 08:30 a.m. Amount on hand 16, amount given 1, amount remaining 15
07/29/2022 - No time documented - Corrected count 14 . No entries on the record documenting the administration of the dose unaccounted for that resulted in a corrected count or if the previous count was inaccurate.

08/01/2022 at 3:00 p.m. Amount on hand 8, amount given 1, amount remaining 7.
08/01/2022 at 9:00 p.m. shift count - Count corrected amount remaining 8. Further review revealed no notation/explanation for the count having to be corrected.

Review of Cubex count documentation for Oxycodone 10/325 revealed the following notation: Quantity received 3. Further review revealed a Post-it note was attached to the form, dated 08/25/2022 indicating there had been 3 missing doses of Oxycodone. Additional review revealed no explanation had been documented for the missing doses.

Review of a second Cubex count documentation record for Oxycodone 10/325 revealed on 08/04/2022
3 doses of Oxycodone 10/325 had been administered to 3 different patients and the amount administered was not documented for any of the 3 doses administered.

In an interview on 09/01/2022 at 10:00 a.m. with S1Adm, present during review of the above referenced narcotic record reviews, she verified the counts were not accurately documented and medication administration documentation was also not accurate. S1Adm confirmed, based upon review of the referenced narcotic dose administration records, that there was a need for education of staff as to the correct way to document narcotic counts and medication administration.







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