HospitalInspections.org

Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Nursing Services. The deficient practice is evidenced by:
1) failure to monitor telemetry patients #1, #2, #3, #R1, #R2, and #R3 per hospital policy and physician orders (See findings in A-0398);
2) failure of nursing staff to document vital signs per physician orders for 3 (#1-#3) of 3 (#1-#3) patient medical records reviewed (See findings in A-0395);
3) failure to ensure nursing staff documented patient assessment as per hospital policy in 1 (#1) of 3 (#1-#3) patient records reviewed (See findings in A-0398);
4) failure to ensure nursing staff repositioned as per hospital policy 1 (#1) of 3 (#1-#3) patients reviewed (See findings in A-0398); and
5) failure of the nursing staff to administer Patient #1's medications per physician order (See findings in A-0402).

Based on observation, record review and interview the hospital failed to ensure care in a safe setting as evidenced by:
1) failure of nursing staff to follow infection control guidelines and don the appropriate Personal Protective Equipment (PPE) before entering 1 (#3) of 1 (#3) patients observed on contact precautions; and
2) failure to ensure each employee's personnel file contained documented evidence they were free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II., for 1 (S2RN) of 1 (S2RN) contract nurse personnel files reviewed.
Findings:

1) Failure of nursing staff to follow infection control guidelines and don the appropriate Personal Protective Equipment (PPE) before entering 1 (#3) of 1 (#3) patients observed on contact precautions.

Review of hospital policy provided by S1ADM titled "Infection Control Plan", last approved 05/2023, revealed in part: "Policy: Infection Control Program: The infection Control Program allows for a systemic, coordinated and continuous approach and is accomplished by: 8. Providing education to employees, staff patients visitors, with particular emphasis on proper use of personal protective equipment (PPE).

Review of hospital policy provided by S1ADM titled "Guidelines for Transmission Based Isolation Precautions", last revised 04/2021, revealed in part: Procedure: "A. Contact Precautions: Use Contact Precautions for patients with known or suspected infections. Use of Personal Protective Equipment (PPE): Perform hand hygiene prior to applying PPE. 2. Gloves. 3. Gowns."

Review of hospital job description provided by S1ADM titled "RN", last revised 09/2016, revealed in part: "Job Description and Responsibilities", in part: 10) Follows infection control guidelines as per Sage nursing policy and procedure.

Observation on 04/14/2025 at 8:16 AM revealed room 'a' with a sign on the door stating the following: Contact Precautions, Do Not Enter, Perform appropriate hand hygiene before donning required PPE. Personnel Protective Equipment (PPE): When entering a Patient Room-You Must Wear, in part: Gown.

Continued observation revealed S5CN walked into room 'a' without donning a gown.

Review of Patient #3's medical record revealed admission date of 04/03/2025 with diagnoses of sepsis, pseudomonas pneumonia, and tracheostomy. On antibiotics, Meropenem 1 gram and Gentamicin 80 mg.

During an interview on 04/14/2025 at 8:18 AM, S5CN stated Patient #3 was in room 'a', was on contact precautions for tracheal aspirate and she should have donned a gown before entering the room, but she was unable to find one.

2) Failure to ensure each employee's personnel file contained documented evidence they were free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II., for 1 (S2RN) of 1 (S2RN) contract nurse personnel files reviewed.

Review of the Louisiana Public Health Sanitary Code, Title 51, Part II. The Control of Diseases - Health Examinations for Employees, Volunteers and Patients at Certain Medical Facilities, Section 503, Mandatory Tuberculosis Testing, revealed in part: "A. [formerly paragraph 2:022] All persons, including employees, students or volunteers, having no history of latent tuberculosis infection or tuberculosis disease, prior to or at the time of employment, beginning clinical rotations in the healthcare profession, or volunteering at any hospital or nursing home (as defined in Parts XIX and XX of the Sanitary Code, respectively, herein, and including intermediate care facilities for the developmentally disabled) requiring licensing by the Louisiana Department of Health or at any Louisiana Department of Health, Office of Public Health (LDH-OPH) parish health unit or an LDH-OPH outpatient health care facility, whose duties include direct patient care, shall be free of tuberculosis in a communicable state as evidenced by either:
1. a negative purified protein derivative skin test for tuberculosis, 5 tuberculin unit strength, given by the Mantoux method or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration;
2. a normal chest X-ray, if the skin test or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration is positive; or
3. All initial screening test results and all follow-up screening test results shall be kept in each employee's, Student's, or volunteer's health record or facility's personnel record.
D. Annually, but no sooner than 6 months since last receiving tuberculosis educational information (more fully described at the end of this sentence) or symptom screening, all employees, students in the healthcare professions, or volunteers at any medical or 24-hour residential facility requiring licensing by LDH or at any hospital or nursing home (as defined in Parts XIX and XX of the Sanitary Code, respectively, herein, and including intermediate care facilities for the developmentally disabled) requiring licensing by the LDH or at any LDH-OPH parish health unit or and LDH-OPH out-patient health care facility shall receive, at a minimum, educational information explaining the health concerns, signs, symptoms, and risks of tuberculosis."

Review of hospital policy provided by S1ADM titled "Infection Control Plan", last approved 05/2023, revealed in part: "Policy: Infection Control Program: The infection Control Program allows for a systemic, coordinated and continuous approach and is accomplished by: 8. emphasis is placed on educating staff regarding TB and TB Exposure Plan. 12. Collaborating with employee health to provide appropriate screening, counseling, follow-up, and guidelines for staff and others who have the potential for exposure to communicable infectious disease, or have been exposed to or have such a disease.
Risk Assessment and Prioritization Goals, in part: Characteristics of Population Served, in part: Louisiana State Office of Public Health, TB control is located within the geographic service area which serves patients with confirmed TB.

Review of the personnel file of S2RN failed to reveal evidence she free of TB (tuberculosis) in a communicable state.

During an interview on 04/15/2023 at 11:08 AM, S10HR confirmed S2RN employee's personnel file failed to reveal documented evidence she was free of TB (tuberculosis) in a communicable state.

Based on record review and interview, the hospital failed to ensure the patient's right to be free from all forms of neglect. This deficient practice was evidenced by failure of the facility to ensure wound care consults occurred in a timely manner to avoid delay in care in 1 (#3) of 2 (#2 and #3) patients reviewed for wound care consults.
Findings:

Review of hospital policy provided by S1ADM titled "Wound Care Management", last approved 05/2023, last revised 10/2012, revealed in part: "Purpose, in part: To identify responsibilities of the wound care team. Procedure, in part: 1. There must be physician order for wound care. 2. Each wound is documented by the registered nurse or designee on initial interdisciplinary assessment and plan of care at the initial assessment weekly, and prn to effectively maintain an accurate record of care. Wound Assessment, in part: 4. Within 24 hr of receipt of the consult order, the consulting physician will assess the wounds, design a plan of care, collaborate with the interdisciplinary team orders for wound care, and implementation.

Review of Patient #2's History and Physical dated 04/08/2025 revealed admission date of 04/08/2025 with diagnoses of Acute respiratory failure with hypoxia with tracheostomy and paraplegia. Patient was in a high-speed motor vehicle accident (MVA) with semi-truck. Status post C5-C6 Anterior Cervical Discectomy and Fusion (ACDF) on 03/03/2025. Arrived at hospital with acute traumatic pain, blood loss vertebral artery narrowing bilaterally, left wrist fracture left trapezoidal fracture, left 2nd metacarpal base fracture, left upper extremity levophed infiltration. Right hand laceration repaired. Incomplete tetraplegia/paraplegia. Dysphagia, obesity. Resolved pneumothorax. Neurogenic shock and pneumonia. Anemia. Right superficial cephalic clot 3/10. No movement beneath nipple line. 3-column fracture at c5-c6. Peg.
Review of Patient #2's admission orders dated 04/08/2025 revealed: Wound Care Consult.

Review of Patient #2's medical record on 04/15/2025 at 11:37 AM guided by S9DON, failed to reveal the wound consulting physician/provider assessed the wounds, designed a plan of care, collaborated with the interdisciplinary team orders for wound care, and implemented a plan of care.

During an interview on 04/15/2025 at 11:37 AM, S9DON confirmed the Wound Care Consulting provider had not assessed Patient #2 because she was out of town as of 04/15/2025 at 11:37 AM.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of nursing staff to document vital signs per physician orders for 3 (#1-#3) of 3 (#1-#3) patient medical records reviewed; and
Findings:

Patient #1
Review of physician orders dated 12/04/2024 and discontinued on 12/31/2024 revealed vital signs every six hours.

Review of Patient #1 document titled "Vital Signs-By Date and Type" dated 12/03/2024-12/31/2024 revealed the following vital signs were not assessed by nursing staff within the time-span indicated per physician orders:
12/30/24 at 3:34 PM Pulse 54, temperature 96.5. No retake or vitals until 12/31/24 at 5:23 AM.
12/29/24 at 7:00 PM temperature 96.2. No retake or vitals until on 12/30/24 at 5:22 AM.
12/28/24 vitals taken at 7:00 PM with no retake until 12/29/24 at 5:54AM.
12/27/24 vitals taken at 6:20 PM no retake until 12/28/24 at 5:33AM.
12/27/24 vitals taken at 7:12 AM, temperature 96.9 with no retake until 12/27/24 at 334 PM when Patient #1's temperature was 96.5.
12/26/24 vitals taken at 3:19 PM temperature "unable", pulse 100 with no retake until 12/27/24 at 4:57 AM when Patient #1's pulse was 100 beats per minute.
12/25/24 vitals taken at 8:33 PM with no retake until 12/26/24 at 5:38 AM.
12/25/24 vitals taken at 7:00 AM with no retake until 12/25/24 at 8:33 PM.
12/24/24 vitals taken at 7:11 PM with no retake until 12/25/24 at 5:06 AM.
12/23/24 vitals taken at 7:00 PM with no retake until 12/24/24 at 4:58 AM.
12/22/24 vitals taken at 8:09 PM with no retake until 12/23/24 at 4:51 AM.
12/21/24 vitals taken at 8:23 PM with no retake until 12/22/24 at 5:22 AM.
12/20/24 vitals taken at 9:40 PM with no retake until 12/21/24 at 5:02 AM.
12/19/24 vitals taken at 7:00 PM with no retake until 12/20/24 at 5:15 AM.
12/18/24 vitals taken at 7:30 PM with no retake until 12/19/24 at 5:37 AM.
12/17/24 vitals taken at 8:42 PM with no retake until 12/18/24 at 5:12 AM.
12/17/24 vitals taken at 7:00 AM with no retake until 12/17/24 at 4:07 PM.
12/16/24 vitals taken at 9:47 PM with no retake until 12/17/24 at 5:37 AM.
12/15/24 vitals taken at 3:38 PM with no retake until 12/16/24 at 5:41 AM.
12/15/24 vitals taken at 6:30 AM with no retake until 12/15/24 at 3:58 PM.
12/14/24 vitals taken at 3:18 PM with no retake until 12/15/24 at 6:30 AM.
12/13/24 vitals taken at 5:25 PM with no retake until 12/14/24 at 4:41 PM.
12/12/24 vitals taken at 7:00 PM with no retake until 12/13/24 at 10:18 AM.
12/11/24 vitals taken at 8:02 AM with no retake until 12/12/24 at 4:58 AM.
12/10/24 vitals taken at 3:14 PM with no retake until 12/11/24 at 5:22 AM.
12/09/24 vitals taken at 8:56 PM with no retake until 12/10/24 at 5:14 AM.
12/08/24 vitals taken at 9:08 PM with no retake until 12/09/24 at 4:53 AM.
12/07/24 vitals taken at 8:52 PM with no retake until 12/08/24 at 4:12 AM.
12/06/24 vitals taken at 6:49 PM with no retake until 12/07/24 at 7:12 AM.
12/05/24 vitals taken at 6:44 PM with no retake until 12/06/24 at 7:00 AM.
12/05/24 vitals taken at 7:54 AM with no retake until 12/05/24 at 4:50 PM.

Patient #2
Review of physician orders dated 04/08/2025 revealed vital signs every six hours.

Review of Patient #2 document titled "Vital Signs-By Date and Type" dated 04/08/2025-04/15/2025 revealed the following vital signs were not assessed by nursing staff within the time-span indicated per physician orders:
04/14/25 vitals taken at 9:24 PM with no retake until 04/15/25 at 5:41 AM.
04/13/25 vitals taken at 5:44 PM with no retake until 04/14/25 at 4:29 AM.
04/12/25 vitals taken at 9:24 PM with no retake until 04/13/25 at 5:40 AM.
04/11/25 vitals taken at 8:50 PM with no retake until 04/12/25 at 5:33 AM.
04/09/25 vitals taken at 8:53 PM with no retake until 04/10/25 at 5:34 AM.

Patient #3
Review of physician orders dated 04/03/2025 revealed vital signs every six hours.

Review of Patient #3 document titled "Vital Signs-By Date and Type" dated 04/03/2025-04/15/2025 revealed the following vital signs were not assessed by nursing staff within the time-span indicated per physician orders:
04/14/25 vitals taken at 11:04 AM with no retake as of 04/15/25 at 11:51 AM.
04/13/25 vitals taken at 6:30 PM with no retake until 04/14/25 at 11:04 AM.
04/12/25 vitals taken at 7:19 AM with no retake until 04/13/25 at 6:02 AM.
04/11/25 vitals taken at 8:41 PM with no retake until 04/12/25 at 5:29 AM.
04/10/25 vitals taken at 9:42 PM with no retake until 04/11/25 at 8:41 AM.
04/08/25 vitals taken at 8:14 PM with no retake until 04/09/25 at 5:45 AM.
04/08/25 vitals taken at 9:45 AM with no retake until 04/08/25 at 8:14 PM.
04/07/25 vitals taken at 9:26 AM with no retake until 04/07/25 at 6:30 PM.
04/06/25 vitals taken at 6:30 PM with no retake until 04/07/25 at 9:26 AM.
04/06/25 vitals taken at 8:15 AM with no retake until 04/07/25 at 4:47 PM.
04/05/25 vitals taken at 2:00 PM with no retake until 04/06/25 at 4:52 AM.
04/04/25 vitals taken at 6:30 PM with no retake until 04/05/25 at 9:38 AM.
04/03/25 vitals taken at 8:00 PM with no retake until 04/04/25 at 5:02 AM.

During an interview on 04/15/2025 at 11:04 AM, S9DON confirmed Patients #1, #2, and #3's vital signs were not assessed as per physician orders

Based on observation, record review and interview, the hospital failed to ensure licensed nurses adhered to policies and procedures of the hospital as evidenced by:
1) failure to monitor telemetry patients #1, #2, #3, #R1, #R2, and #R3 per hospital policy and physician orders;
2) failure to ensure nursing staff documented patient assessment as per hospital policy in 1 (#1) of 3 (#1-#3) patient records reviewed; and
3) failure to ensure nursing staff repositioned as per hospital policy 1 (#1) of 3 (#1-#3) patients reviewed.
Findings:

1) Failure to monitor telemetry patients #1, #2, #3, #R1, #R2, and #R3 per hospital policy and physician orders.
Review of hospital policy provided by S1ADM, titled "Telemetry Monitoring" last approved 05/2023, revealed in part: Policy: C. All Telemetry Patients will be monitored through a central monitor located at the Nurse's Station or via bedside monitor by a competency verified RN, LPN, or Monitor Tech. Procedure, I part: 1. Cardiac rhythms will be monitored by a qualified observer at all times. It is the responsibility of the assigned Monitor Technician to assure that a qualified observer covers in his/her absence during meal or break times. At no time is the central monitor to be left unattended. Any variance from this must be reported to the Charge Nurse or DON immediately. 2. A Physician's Order must be written for a Patient to be placed on Telemetry: The monitor alarms are turned on at all times. The Monitor Technician verifies that the alarms are on at the beginning of each shift. 1, Rhythm strips are printed every four hours on medical/surgical and High Observation Patients, or as ordered and in the event of an abnormal arrhythmia. The rhythm strip will be printed and include Patients Name, Date and Time, Heart Rate, PR interval, QRS width, regularity and rhythm interpretation.

Observation of nurses' station on 04/14/2025 at 8:08 AM revealed 1 unit clerk and one nurse in the medication room. Continued observation revealed an unattended telemetry monitor with a WOW (Workstation On Wheels) parked in front of the monitor. Flashing alarms on 5 (#2, #3, #R1, #R2, and #R3) of 5 (#2, #3, #R1, #R2, and #R3) patients on telemetry with no sound coming from the telemetry monitor. At 8:10 AM S5CN entered nurse station.

During an interview on 04/14/2025 at 8:10 AM, S5CN confirmed she was responsible for observing the monitor and that she was not aware the alarms were flashing. S5CN confirmed no alarm sound and did not know who silenced the alarms.

Observation of telemetry monitor on 04/14/2025 at 8:21 AM revealed monitor labeled Patient #2 flashing a red alarm icon without sound registering a heart rate of 54.

Observation of telemetry monitor on 04/14/2025 at 8:21 AM revealed monitor labeled Patient #R1 flashing a red alarm icon without sound registering "Check Electrodes".

Observation of telemetry monitor on 04/14/2025 at 8:21 AM revealed monitor labeled Patient #R2 flashing a red alarm icon without sound registering a heart rate of 61.

Review of Patient #R2's Alarm History Record on 04/14/2025 at 10:03 AM revealed heart rate of 120 with silenced alarms at the following times: 8:20:46 AM, 8:20:47 AM, 9:59:17 AM, 9:59:20 AM, and 10:02:30 AM.

Observation of telemetry monitor on 04/14/2025 at 8:21 AM revealed monitor labeled Patient #R3 flashing a red alarm icon without sound and no visible heart rate.

Observation of telemetry monitor on 04/14/2025 at 8:21 AM revealed monitor labeled Patient #3 flashing a red alarm icon and an icon of a battery with a red "X" struck through it registering "Check Electrodes".

During an interview on 04/14/2025 at 8:21 AM, S5CN confirmed the Patients #2, #3, #R1, #R2, and #R3 telemetry monitor alarms were silent and did not know why. S5CN stated she needed to assess the leads on all of the patients and determine why the alarms were flashing.

Review of Patient #1's physician orders revealed the following:
12/04/2024 at 2:00 AM Continuous Cardiac Monitoring every four hours.

Review of Patient #1's medical record for cardiac monitoring:
12/05/2024 failed to reveal cardiac monitoring between 6:01 AM - 22:00 PM.
12/06/2024 failed to reveal cardiac monitoring between 10:01 AM - 22:00 PM.
12/09/2024 failed to reveal cardiac monitoring between 10:01 AM - 22:00 PM.

During an interview on 04/14/2025 at 3:45 PM, S8QA confirmed cardiac monitoring was not implemented per physician orders and hospital policy for Patient #1.

2) Failure to ensure nursing staff documented patient assessment as per hospital policy in 1 (#1) of 3 (#1-#3) patient records reviewed.
Review of hospital policy provided by S1ADM titled "Nursing Assessment" last approved 05/2023, revealed in part: "Responsibilities and Procedures: Nursing Assessment, in part: Assessment of the patient care needs will include consideration of: Neurological; Safety Risk; Cardiovascular; Plumonary; Nutrition; Communication; Gastrointestinal; Genitourinary; Pain; Integumentary; Functional; Educational; Discharge Planning Factors; An other care needs indentified by the admission care nurse. Reassessment, in part: All patients admitted will be reassessed every nursing shift (12 hour shift) by the RN or LPN."

Review of Patient #1's History and Physical revealed an admission date of 12/03/2024 with diagnoses of chronic respiratory failure with hypoxia, toxic encephalopathy, Budd-Chairi syndrome, Paracoccidioidomycosis (PCM), pneumonia due to klebsiella, Vent weaning, gastronomy, acute kidney failure, chronic kidney disease, immunodeficiency due to drugs, deep vein thrombosis with emboli, Hypo-osmality and hyponatremia, ESBL resistance, tracheostomy, anticoagulants, Polycythemia Vera, malaise, and hyperkalemia. Of note, Patient #1 was being treated with anti-rejection medications, tacrolimus (Prograf) and mycophenolate (CellCept) following liver transplant in 2019.

Review of Patient #1's nursing assessment dated 12/05/2024 at 3:05 PM failed to reveal the following assessments were addressed:
Ambulatory Aid
Continuous IV infusion or Heplock
Gait
Mental Status
Morse Fall Scale Score
Sepsis Screening
Pain Goal
Able to verbalize pain
Neurological
Cardiovascular
Respiratory
Skin / Wounds
Braden Pressure Injury Risk
Genitourinary
Gastrointestinal
Musculoskeletal
Nursing Discharge Planning

During an interview on 04/14/2025 at 2:48 PM, S8QA confirmed the assessment was incomplete.

Review of Patient #1's medical record failed to reveal a nursing assessment completed on the day shift of 12/31/2024 as per hospital policy.

During an interview on 04/14/2025 at 9:10 AM, S8QA confirmed there was no evidence of a nursing assessment completed on 12/31/2024 before patient discharged at 9:35 AM.

3) Failure to ensure nursing staff repositioned as per hospital policy 1 (#1) of 3 (#1-#3) patients reviewed.
Review of hospital policy provided by S1ADM, titled "Turning and Repositioning" last approved 12/2024, revealed in part: Policy: It is our policy to implement turning and repositioning as part of our systematic approach to pressure injry prevention and management. This policy establishes responsibilities and protocols for turning and repositioning. Poly Explanation and Compliance Guidelines: 3. The facility has established routine turning and repositioning schedules consisting of every 2-4 hours, on the even hour. A maximum of thirty minutes before or after the scheduled time will be allotted for compliance with the schedule. 4. A routine turn schedule includes using both side-lying and back positions, alternating from the right, back, and left side. 5. The frequency of turning and repositioning will be documented in the resident's plan of care.

Review of Patient #1's Rounding & ADLs document dated 12/05/2024 revealed the following:
6:30 PM: positioning: supine/back
8:30 PM: positioning: supine/back
10:30 PM: positioning: supine/back
12:20 AM: positioning: supine/back
2:30 AM: positioning: supine/back
4:30 AM: positioning: supine/back

During an interview on 04/14/2025 at 2:54 PM, S8QA confirmed the medical record failed to reveal evidence that Patient #1 was repositioned/turned per hospital policy.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered according to the physician's orders. The deficient practice is evidenced by failure of the nursing staff to administer Patient #1's medications per physician order.
Findings:

Review of Patient #1's medical record revealed an admission date of 12/03/2024 with diagnoses of chronic respiratory failure with hypoxia, toxic encephalopathy, Budd-Chairi syndrome, Paracoccidioidomycosis (PCM), pneumonia due to klebsiella, Vent weaning, gastronomy, acute kidney failure, chronic kidney disease, immunodeficiency due to drugs, deep vein thrombosis with embolis, Hypo-osmality and hyponatremia, ESBL resistance, tracheostomy, anticoagulants, Polycythemia Vera, malaise, and hyperkalemia. Of note Patient #1 was being treated with anti-rejection medications, tacrolimus (Prograf) and mycophenolate (CellCept) following liver transplant in 2019.

Review of Patient #1's physician orders revealed the following in part:
-Order date 12/04/2024-Discontinue date 12/31/2024:
Tacrolimus 1 Mg (Prograf). Give 2.5 mg (2 ½ capsule(s)) per tube twice daily. Time critical at 8 AM and 6 PM: medication must be given within 30-minute window before or after the scheduled administration due time.
Order failed to reveal indication.

Review of Medication Administration Record dated 12/05/2024, 12/06/2024, 12/07/2024, 12/08/2024, 12/09/2024, 12/10/2024 and 12/31/2024 failed to reveal Tacrolimus 2.5 mg (2 ½ capsule(s)) per tube twice daily was administered per physician order.
-On 12/05/2024 administered at 8:55 AM, approximately 25 minutes outside the prescribed window for scheduled administration due time.
-On 12/06/2024 administered at 9:49 AM, approximately 1 hour and 20 minutes outside the prescribed window for scheduled administration due time.
-On 12/06/2024 Tacrolimus was not administered at 6:00 PM or during the night shift on the 6th. S9DON confirmed the medical record failed to reveal documentation the Tacrolimus was administered and failed to reveal documentation as to why the Tacrolimus was not administered as per physician order.
-On 12/07/2024 administered at 5:07 PM, approximately 23 minutes outside the prescribed window for scheduled administration due time.
-On 12/08/2024 administered at 10:10 AM, approximately 1 hour and 40 minutes outside the prescribed window for scheduled administration due time.
-On 12/08/2024 administered at 5:14 PM, approximately 15 minutes outside the prescribed window for scheduled administration due time.
-On 12/09/2024 administered at 9:55 AM, approximately 1 hour and 25 minutes outside the prescribed window for scheduled administration due time.
-On 12/31/2024 Tacrolimus was not administered. S9DON confirmed the medical record failed to reveal documentation the Tacrolimus was administered and failed to reveal documentation as to why the Tacrolimus was not administered as per physician order.

Review of Patient #1's physician orders revealed the following in part:
-Order date 12/04/2024-Discontinue date 12/31/2024
Mycophenolate mofetil. Give 200 mg per tube twice daily. Take 2.5 ml per PEG tube BID Indication: Liver Transplant.

Review of Medication Administration Record dated 12/05/2024-12/07/2024 failed to reveal Mycophenolate mofetil 200 mg per tube twice daily was administered per physician order.

During an interview on 04/15/2025 at 10:32 AM, S9DON verified the Mycophenolate mofetil was not administrated per physician order. S9DON stated that Mycophenolate was administered on 12/04/24 at 10:00 PM but the medication was not administered again until 12/07/2024 at 9:00 PM after the night shift nurse notified the pharmacy on 12/06/2024 at 8:00 PM that the Mycophenolate was not on the nursing unit.

Review of Patient #1's physician orders revealed the following in part:
-Order date 12/05/2024-Discontinue date 12/10/2024
Enteral Flush every four hours. Flush type: Water, Flush (in mLs): 100, Route: G-Tube. Indication: Ventilated, Malnutrition.

Review of Medication Administration Record dated 12/06/2024 and 12/09/2024 failed to reveal Enteral Flushes every four hours were administered per physician order.
-On 12/06/2024 at 2:00 PM and 6:00 PM, documentation failed to reveal the enteral flush was administered.
-On 12/09/2024 at 2:00 PM and 6:00 PM, documentation failed to reveal the enteral flush was administered.
During an interview on 04/15/2025 at 11:15 AM, S9DON verified the enteral flushes were not administrated per physician order.

Review of Patient #1's physician orders revealed the following in part:
-Order date 12/09/2024-Discontinue date 12/09/2024:
Kayexalate Suspension 15 G/ 60 mL, give 15 grams (60 mL) by mouth once.
Indication: Hyperkalemia

Review of Medication Administration Record dated 12/09/2024 failed to reveal the Kayexalate Suspension 15 G/ 60 mL, give 15 grams (60 mL) was administered per physician order.

During an interview on 04/15/2025 at 10:25 AM, S9DON verified the Kayexalate suspension was not administrated per physician order. S9DON confirmed the medical record failed to reveal documentation as to why the Kayexalate suspension was not administered.

Review of Patient #1's physician orders revealed the following in part:
-Order date 12/13/2024-Discontinue date 12/15/2024:
Furosemide 20 mg (2 ML) IV push daily.

Review of Medication Administration Record dated 12/14/2024 failed to reveal the Furosemide 20 mg was administered per physician order.

During an interview on 04/15/2025 at 10:20 AM, S9DON verified the furosemide was not administrated per physician order. S9DON confirmed the medical record failed to reveal documentation as to why the furosemide was not administered.

-Order date 12/13/2024-Discontinue date 12/13/2024:
Enteral Flush every four hours. Flush type: Water, Flush (in mLs): 250, Route: G-Tube. Comments: Flush G-Tube with Pedialyte not water.
Indication: Ventilated, Malnutrition.

-Order date 12/13/2024-Discontinue date 12/23/2024:
Enteral Flush every four hours. Flush type: Normal Saline, Flush (in mLs): 250, Route: G-Tube. Comments: Flush G-Tube with 1 gm saline tablet in 1000cc water after Pedialyte completes.
Indication: Ventilated, Malnutrition.

-Order date 12/23/2024-Discontinue date 12/24/2024:
Enteral Flush every four hours. Flush type: Normal Saline, Flush (in mLs): 250, Route: G-Tube. Comments: Flush G-Tube with Pedialyte only.
Indication: Ventilated, Malnutrition.

Review of provider note dated 12/23/2024 revealed the following:
Patient #1's sodium was back down to 119 due to her getting water as flushes instead of the pedialyte that was ordered.

During an interview on 04/15/2025 at 111:45 AM, S9DON confirmed the above findings.

Based on record review and interview, the hospital failed to provide re-evaluation of the patient's condition to identify changes that required modification of the discharge plan in 1 (#1) of 3 (#1-#3) patient records reviewed.
Findings:

Review of hospital policy provided by S1ADM titled "Discharge Planning and Transfers", last approved 05/2023, revealed in part: "Procedure: 5. Discharge planning will include the identification of the patient's continuing needs upon discharge from this facility. 7. The facility will re-evaluate the discharge plan regularly and update as needed to reflect any changes."

Review of Patient #1's medical record revealed an admission date of 12/03/2024 with diagnoses of chronic respiratory failure with hypoxia, toxic encephalopathy, Budd-Chairi syndrome, Paracoccidioidomycosis (PCM), pneumonia due to klebsiella, Vent weaning, gastronomy, acute kidney failure, chronic kidney disease, immunodeficiency due to drugs, deep vein thrombosis with embolis, Hypo-osmality and hyponatremia, ESBL resistance, tracheostomy, anticoagulants, malaise, and hyperkalemia. Of note Patient #1 was being treated with anti-rejection medications, tacrolimus (Prograf) and mycophenolate (CellCept) following liver transplant in 2019.

Review of Patient #1's provider note dated 12/30/2024 revealed patient was to continue Tacrolimus as per hepatology with a target range of 4-6 ng/mL.

Review of Laboratory report revealed the following liver enzyme reference values:
Aspartate aminotransferase (AST)=13-56 U/L.
Alanine Transaminase (ALT)=15-37 U/L.
Alkaline Phosphatase (Alk Phos)=45-117 U/L.

Review of Patient #1's laboratory results revealed the following liver enzyme values and tacrolimus (TAC) levels:
12/02/2024: AST 16 U/L, ALT=12 U/L, Alk phos=98 U/L. TAC=3.8 ng/mL.

12/05/2024: AST=15 U/L, ALT=22 U/L, Alk phos=112 U/L. No TAC level.

12/09/2024: AST=11 U/L, ALT=30 U/L, Alk phos=159 U/L. No TAC level.

12/12/2024: AST=11 U/L, ALT=30 U/L, Alk phos=159 U/L. No TAC level.

12/13/2024: TAC level 3.0 ng/mL.

12/16/2024: AST=21 U/L, ALT=32 U/L, Alk phos=120 U/L. TAC level 3.9 ng/mL.

12/23/2024: AST=26 U/L, ALT=41 U/L, Alk phos=141 U/L. No TAC level.

12/25/2024: AST=39 U/L, ALT=56 U/L, Alk phos=159 U/L. No TAC level.

12/30/2024: AST=129 U/L, ALT=209 U/L, Alk phos=200 U/L. No TAC level. (last labs before discharge on 12/31/2024).

Review of Patient #1's laboratory results revealed the following lab values in part with the White Blood Count (WBC), Hemoglobin (Hgb) and Hematocrit (Hct) reference values:

WBC=4.0-11.0 K/uL
Hgb=11.2-15.7 g/dL
Hct=34.1-44.9%

12/02/2024: Hgb=10 and hct=31.7

12/05/2024: WBC=11.58, Hgb=10.4, and Hct=33.6.

12/09/2024: WBC=17.38, Hgb=11.6, and Hct =35.7.

12/16/2024: WBC=12.69, Hgb =9.1, Hct =29.2.

12/23/2024: WBC=6.31, Hgb =9.9, Hct =30.1.

12/30/2024: WBC=1.41 Hgb=7.8, Hct=23.9. (last labs drawn before discharge on 12/31/2024).

Review of provider note dated 12/27/2024 at 10:16 AM stated provider spoke with the patient's mother and sister, who were at bedside, and provided an update on the clinical exam and findings. The patient was not yet ready to wean, as she was not showing progress towards weaning at this time. She had no muscle tone, not initiating spontaneous breaths on the ventilator, and lacked a gag reflex. Provider noted she addressed all their questions. The
Patient will be transferred to nursing home 'A' from LTAC. The family requested a neurology consult. Provider would ask the case manager to arrange a follow-up. However, it may take time to set up or may need to be coordinated with nursing home 'A'.
The provider note failed to reveal documentation regarding the rising liver enzymes or the TAC levels below therapeutic range.

Review of provider note dated 12/28/2024 revealed the following regarding liver transplant and long-term use of immunosuppressant medication: Liver transplant in 2019. Was stable up until August 2024 when she developed UTI. Continue mycophenaolate 200 mg BID and prograf 2.5 BID. Failed to reveal documentation of rising liver enzymes and TAC levels

Review of provider note dated 12/30/2024 at 10:00 AM revealed in part:
Weekly labs and tacrolimus level were pending.
Lab results listed for 12/05/2024-12/29/2024 revealed the rising liver enzymes and only one TAC level listed at 3.8 (below therapeutic level) on 12/05/2024.
Values for Vital signs listed a temperature of 96.9 and a pulse of 58.
The progress note stated vitals were stable, eyes and mouth were open but patient did not respond to verbal or tactile stimuli.
Non-Verbal.
Did not track with eyes.
Thin, ill appearing, female.
Flaccid extremities.
Bilateral hand edema.
Wasting muscle mass, temporal wasting, no energy reserves.
Peg in place with tube feedings.
Neurologically unresponsive, Glasgow Coma Scale=eye 4, verbal 1, motor 1.
The plan for Liver transplant recipient stated in part:
Liver transplant in 2019. Tacrolimus Management: Current therapeutic level.
Continue tacrolimus as per hepatolgy with a target range of 4-6 ng/mL.
The progress note failed to reveal documentation of rising LFTs and TAC level below therapeutic range. The note stated vital trends and labs would continue to be monitored. No changes in plan of care noted.

Review of physician orders dated 12/30/2024 at 1:34 PM stated discharge to nursing home 'A'. Diet as follow Jevity 1.5 at 45 mL/hr, give 2 tablets of sodium chloride mixed in 250 mL every 4 hours, flush peg tube with 600 mL of H2O.

Review of nursing note dated 12/31/2025 at 10:05 AM revealed patient discharged to Skilled Nursing 'A' via EMS at 9:35 AM. Patient with stable vitals, 0 signs of pain prior to discharge. AM meds given, oral and peri-care preformed, PICC line pulled and report called in by S3RN.

Review of nursing note dated 12/31/2025 at 2:58 PM revealed S3RN spoke with nursing home 'A' stated Patient #1 arrived at facility with eyes bulging. Told nursing home 'A' that when Patient #1 left the LTAC her eyes were not bulging. Nursing home 'A' would notify their MD of new onset eye bulging. Nursing home requested sputum culture to be faxed. Sputum culture and final report faxed at this time.

Of note, there was no evidence of a nursing assessment completed on 12/31/2024.

Review of discharge summary dated 12/31/2024 at 8:36 AM revealed the following in part:
The plan for status post liver transplant and long-term use of immunosuppressant medication stated liver transplant in 2019. Was stable up until August 2024 when she developed UTI. Continue mycophenolate 200 mg BID and Continue Prograf 2.5 BID.
The discharge summary failed to reveal documentation of rising liver enzymes and TAC levels below therapeutic range.

During an interview on 04/15/2025 at AM, S9DON stated she did not think the providers were aware of the laboratory values from 12/31/2025. S9DON verified Patient #1's medical record failed to reveal the hospital/provider contacted the nursing home or family regarding the abnormal laboratory values from 12/31/2025. S9DON confirmed there was no evidence of a nursing assessment completed on 12/31/2024 before discharge in order to identify changes that required modification of the discharge plan.