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Based on interview and record review, the facility failed to ensure one of 30 Patients (Patient 19) was offered an opportunity to formulate an advance directive (a written statement of medical treatments to be carried out if patient is unable to communicate.) This failure had the potential for Patient 19's health care decisions to not be followed.

Findings:

During a review of Patient 19's "INPATIENT [IR]," record dated 9/2/25, the IR indicated Patient 19 was admitted to the facility on 9/2/25 as an in patient.

During an concurrent interview and record review on 9/8/25 with Registered Nurse (RN) 3, Patient 19's medical record was reviewed. RN was unable to provide documented evidence an Advance Directive was offered to patient 19. RN 3 stated, "They didn't do it."

During a review of the facility policy and procedure(P&P) titled, "Advance Directives," dated 10/26/22, the P&P indicated, "[facility name] honors the patient's advanced health care directives. . .Patients. . . will be asked if they executed an Advanced Directive designating their health care wishes and/or health care decision maker. Any patients desiring to formulate an Advance Directives with capacity to do so will be assisted by being given a choice of an approved Advance Directive form."

Based on concurrent interview and record review, the facility failed to develop and implement an individualized fall prevention plan of care (plan to meet patient health care goals and needs) for one of 30 sampled patients (Patient 6). This failure had the potential for Patient 6 to fall resulting in harm or death.

Findings:

During a review of Patient 6's "History and Physical Reports [H&P]," dated 8/27/25, the H&P indicated, Patient 6 was admitted to the hospital with an admission diagnosis of seizure disorder (uncontrolled jerking, loss of consciousness, or blank stares caused by abnormal electrical activity in the brain) and multiple falls.

During a concurrent interview and record review on 9/9/25 at 9:57 a.m. with Registered Nurse (RN) 2, Patient 6's "Plans of Care [POC]," dated 8/27/25 to 8/31/25 were reviewed. RN 2 stated she was unable to find documentation of a fall prevention POC. RN 2 stated Patient 6's admitting diagnosis was multiple falls. RN 2 stated a POC should have been developed and implemented for Patient 6's risk for fall.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Pt Assessment, Reassessment & Care Planning for the Acute Setting," dated 9/23/21, the P&P indicated, "D. Care Plan Development. . .The patient, their family, and/or their legal representative, whenever possible and appropriate, shall be included in all aspects of the development, review and revision of the care plan. The care plan shall be current and reflect all elements of the nursing process. . .The nursing process is. . .1. Assessment. . .2. Diagnosis (Nursing). . .3. Identification of outcomes (Goals). . .4. Planning. . .5.Implementation. . .6. Evaluation. . .7. Advocacy."

Based on interview, and record review, the facility failed to follow their policy and procedure (P&P) for the blood and blood components transfusion (whole blood or parts of blood are put into a patient's blood stream through a vein) for one of four sampled patients (Patient 9). This failure had the potential for suspected transfusion reactions to be missed, a delay interventions, and compromised patient safety during the blood transfusion process.

Findings:

During a review of Patient 9's "Physician Orders [PO]," dated 9/6/25, the PO indicated, one unit of red blood cells (RBC, blood) was ordered for transfusion on 9/6/25 at 2:07 a.m.

During a review of Patient 9's "Transfusion Medicine" Record (TMR), dated 9/6/25, the TMR indicated, Patient 9's blood transfusion started on 9/6/25 at 4:17 a.m. and was completed on 9/6/25 at 6:41 a.m.

During a review of Patient 9's "Vital Signs" Log (VSL), dated 9/6/25, the VSL indicated, Patient 9 had vital signs checked on 9/6/25 at 4:16 a.m., 4:31 a.m., 4:58 a.m., 5:27 a.m., 5:48 a.m., 6:18 a.m., 6:43 a.m., and at 3:29 p.m.

During a concurrent interview and record review on 9/9/25 at 10:55 a.m. with Registered Nurse (RN) 2, Patient 9's VSL dated 9/6/25 was reviewed. The VSL indicated, there were no vital signs obtained one hour after Patient 9's blood transfusion was completed. RN 2 stated she was unable to find documentation that Patient 9's vital signs were checked after the blood transfusion was completed. RN 2 stated Patient 9 should have had his vital signs check one hour after the blood transfusion was completed.

During a review of the facility's P&P titled, "IV Therapy: Transfusion of Blood & Blood Components," dated 11/1/24, the P&P indicated, "Licensed nursing staff who are competent in transfusion administration, identification of transfusion reactions, and/or complications associated with transfusion therapy and implementations of appropriate interventions, shall administer blood and blood components in accordance with the following procedures. . .C. Patient Monitoring for Routine and Emergency Transfusions: 1. The licensed nurse monitors for any change in VS [vital signs] and patient assessment throughout the transfusion. a) VS's are obtained immediately prior to initiation of the transfusion, once the transfusion is initiated, at 5 and 15 minutes after infusion start, then every 30 minutes until the transfusion is completed, and then 1 hour after transfusion is completed."