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Based on record review and interview, the hospital failed to ensure patients received care in a safe setting (A115).

Based on record review and interview, the hospital failed to ensure patients received care in a safe setting for one of ten medical records reviewed (Patient #5). This could affect all patients receiving services from the facility. The census was 32.

Findings include:

Review of the policy and procedure titled, Incident Reports, policy number: QM 12, review date: July 2017, revision date 10/09/2020, original date: March 1997, revealed an incident report will be completed for any incident deemed to be inconsistent with the normal or routine operation of PAM hospital or the care of patients. PAM maintains an electronic occurrence reporting system for the reporting of incidents. The procedures revealed an incident report will be completed on any incident deemed to be inconsistent with the desired operation of the hospital or the care of patients. The incident report will be submitted through the incident reporting system. Paper form will only be utilized only if the incident reporting system is not available. Any employee who witnesses or has knowledge of an incident shall, as soon as possible, complete the report in the incident reporting system. Reports must be completed prior to the end of the shift for the employee completing the report. Failure to do so may result in disciplinary action. In general an incident report must be completed when one of the following has occurred, however this list is not considered to be all inclusive including a significant violation of established policy or procedure, any disturbance which does or may disrupt unit/hospital functions, and an event which does or may result in personal and/or bodily injury.

Review of the medical record for Patient #5 revealed an admission date of 06/05/2020 due to an infection to the right stump following an above the knee amputation. Review of physician documentation on 06/05/2020 at 10:55 PM revealed the patient to be alert and oriented times three. Review of nursing documentation revealed the patient remained alert and oriented throughout the course of the hospitalization.

An interview was conducted with Staff B on 10/15/2020 at 1:55 PM. He/she stated an agency nurse, Staff K, provided nursing care to the patient on 06/06/2020 and 06/07/2020 from 7:00 PM to 7:00 AM. The patient was discharged from the facility on 06/20/2020 following treatment and stabilization. Staff B was not involved with the incident.

Interview with Staff U on 10/13/2020 at 1:30 PM revealed he/she had heard that Staff K was "cuddled up" with Patient #5 in his/her bed.

Interview with Staff A on 10/13/2020 at 4:44 PM revealed that she was told that a night nurse, no name was provided, reported to a charge nurse, no name was provided, who called Staff I and stated that Staff K was cuddled up with Patient #5 in the patient's bed on four different occasions. There was no incident report that he/she was aware of. Two former employees Staff H, the Chief Nursing Officer, and Staff I, a nurse manager, both dealt with this incident.

Interview with Staff Q on 10/14/2020 at 2:49 PM revealed Staff K's contract was terminated on 06/22/2020.

There was no documented evidence of an incident report regarding Staff K being in bed with Patient #5. However, two statements were provided. One statement from Staff R revealed he/she was contacted on 06/22/2020 with respect to an incident involving Staff K and a patient. The statement revealed that Staff R was specifically told that Staff K, who was not on duty a the time, was discovered in bed with Patient #5. He/she was made aware that the patient could make informed decisions and that the patient indicated that he/she was involved in a consensual relationship with the nurse in question and did not want the police contacted. The statement also revealed it would have been inappropriate for the hospital to contact the police or any other agency since the hospital had no reason to believe that the relationship was not consensual. While such action would fall outside our internal policies, there were no criminal activities, nor any action that constituted abuse.

The second statement from Staff S revealed in June 2020 Staff S was serving as the interim CEO of the hospital. He/she was also contacted on 06/22/2020 regarding this same incident. His statement revealed that an investigation was undertaken and involved contacting Staff R. This statement revealed the same statement made by Staff R.

Based on record review and interview, the facility failed to ensure medications were administered in accordance with physician orders for one of ten patients reviewed (Patient #1). The patient census was 32.

Findings include:

Review of the hospital policy and procedure titled, Medication Administration Record and Medication Administration, policy number: nsg 29, revision date 07/19/19, revealed the purpose is to provide a quality controlled document for the dispensing and administering of medications. The medication administration record (MAR) will list all medications given for a 24 hour period. Upon administration of the medications, the nurse will document in the MAR at assigned time slots. Scheduled doses not given are circled and initialed in the MAR with the reason not given.

Review of the medical record for Patient #1 revealed orders for Ativan (anti-anxiety medication) 0.5 milligrams (mg), give two mg, four tablets by mouth daily, may have either intravenous (IV) or by mouth at 7:30 PM, not both. The MAR for 07/12/2020 at 7:30 PM revealed no documentation that a by mouth or IV dose of Ativan was given. The time slot was not circled to indicate it was not given and no reason was documented. There was an as needed dose of Ativan given at 3:58 AM.

This finding was confirmed with the administrative staff in an interview prior to the exit conference on 10/15/2020.