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Based on interview and record review, the hospital failed to ensure the hospital's P&P for the delivery of patient care, treatment, and services was implemented for the patients in Telemetry and Med/Surg units. This failure posed the increased risk of substandard health outcomes to the patients.

Findings:

Review of the hospital's Organizational Plan for the Delivery of Patient Care, Treatment, and Services dated 3/23/2024, showed the following:

* Nursing Service: the goal is to provide quality patient care in an acute long-term health care environment. This is achieved by facilitating and coordinating the members of the healthcare team to meet patient needs, assist in the rehabilitation process, and support the patient in the dying process, as recognized by the standards for the practice of nursing.

* Staffing:

- Licensed RN/LVN: for Med/Surg, 1 licensed nurse: 5 patients; for Telemetry, 1 licensed nurse: 4 patients.

- CNA: 1 CNA: 10 patients for Med/Surg and Telemetry.

On 2/3/25 at 1545 hours, an interview and record review was conducted with the COO/CCO and House Supervisor. The House Supervisor was asked for the nurse-to-patient ratio in the Med/Surg and Telemetry units. The House Supervisor stated the hospital practiced team nursing which included RN and LVN. The nurse to patient ratio was one nurse to 5 patients for Med/Surg unit and one nurse to four patients for Telemetry unit.

1. Review of the Shift Assignments dated 12/26/24 for 7 A to 7 P, showed the following:

- There was a total of 41 patients, including eight patients in Telemetry, 29 patients in Med/Surg, and four patients in ICU.

- Team A's RN and LVN were assigned to 13 Med/Surg patients.

- Team B's RN and LVN were assigned to eight Med/Surg patients and four Telemetry patients (a total of 12 patients).

- Team C's RN and LVN were assigned to eight Med/Surg patients and four Telemetry patients (a total of 12 patients).

- Team D had a LVN with nine Med/Surg patients.

The House Supervisor verified the nurse patient ratio was out of ratio.

2. Review of the Night Shift Assignment dated 2/2/25 for 7 P to 7 A, showed the following:

- There were eight Telemetry patients and 34 Med/Surg patients (total of 42 patients).

- There were four CNAs for 42 patients.

The findings were shared with the COO/CCO and verified the findings.

Based on observation, interview, and record review, the hospital failed to ensure one of five sampled patients' (Patient 2) plan of care was developed to reflect the use of restraints during their hospitalization. This failure created the risk of substandard outcomes to the patient.

Findings:

Review of the hospital's P&P titled Physical Restraints (Violent and Non-Violent Behavior) and Seclusion dated June 2023, showed the RN will create and modify the patient's plan of care. Elements of the Plan of Care includes the following:
- The safety issue resulting in restraint use.
- Desired measurable outcome-oriented goals.
- Alternative interventions to minimize restraint use.
- Ongoing evaluation to assess potential use of less restrictive alternatives.
- Patient/family education regarding assessment of the need for restraints, including the condition or symptoms that pose harm to the patient; alternatives attempted; monitoring safe use of a restraint, including the patient's response to the restraint.

On 2/3/25 at 1434 hours, a tour of ICU was conducted with the Director of Quality Management and RN 2. Patient 2 was observed on bilateral wrist restraints. RN 2 stated the bilateral soft restraint were initiated when Patient 2 pulled off his trach.

On 2/4/25 at 1305 hours, medical record review for Patient 2 was conducted with the Director of Quality Management. Patient 2's medical record showed the patient was admitted on 1/30/25.

Review of the Restraint Initiation/Order (Non-Violent Non-Self Destructive Behavior) showed the following:

* On 2/2/25 at 0500 hours, the right and left wrists restraints were applied for Patient 2.

* The nursing assessment or the reason for the use of restraint included the risk of injury to self-due to inability to understand or remain oriented, disturbing monitoring equipment or necessary treatment modality (pulling at lines/tubes/drains), and lack of safety awareness/did not seek assistance.

Further review of Patient 2's medical record did not show Patient 2's plan of care was developed to reflect the use of restraints. The Director of Quality Management verified the findings.

Based on interview and record review, the hospital failed to ensure their P&Ps were implemented as evidenced by:

1. The physician's verbal order was not entered to the patient's EMR for one of five sampled patients (Patient 4) as per the hospital's P&P. This failure posed the increased risk for substandard health outcomes to the patient.

2. The hospital failed to ensure the performance evaluation was conducted annually for CNA 1 as per the hospital's P&P.

These failures posed the increased risk for substandard health outcomes to the patients.

Findings:

1. Review of the hospital's P&P titled Core: Ordering of Medications dated June 2022 showed the policy of the hospital is to ensure all medication orders must be entered into the patient's medical record (computerized or manual) and must include: drug name, form, route, dosage, frequency, date, time of order, and name of prescribing licensed practitioner. In addition, indications for the medication should either be included as part of the medication order or documented elsewhere in the medical record. Verbal order and telephone orders will be minimized and must follow differentiation between verbal and written policy. All verbal and telephone orders will be read back to the physician or LIP and verified. Verification should include the spelling of the product and all the pertinent information. The authorized personnel transcribing the Verbal Order or Telephone Order is responsible for entering the order into the patient's EMR.

On 2/4/25 at 1425 hours, an interview and concurrent record review was conducted with RN 1 and the Director of Quality Management. RN 1 was asked about the verbal orders. RN 1 stated Patient 4's physician was here for the patient this morning. Patient 4's physician gave a verbal order for Lasix (diuretic) IVP. RN 1 stated he entered the physician's verbal order of Lasix IVP for Patient 4. RN 1 was asked to show the physician's verbal order that he entered in Patient 4's EMR. RN 1 stated he wrote the verbal order as the telephone order because he could not enter the physician's order as the verbal order.

Review of Patient 4's medical record was conducted with RN 1. Patient 4's medical record showed the patient was admitted to the hospital on 1/29/25.

Review of the Chronological Retrieval for Furosemide (same as Lasix) Data showed a physician's telephone order dated 2/4/25 at 0749 hours, showing to give Lasix 40 mg IV times one dose. The physician's order was read back to the provider. RN 1 acknowledged the order on 2/4/25 at 1418 hours.

On 2/4/25 at 1510 hours, the Director of Quality Management was asked about entering the verbal orders. The Director of Quality Management stated there was an option in the EMR to place a verbal order. The Director of Quality Management showed how to enter a verbal order on the EMR. When asked, the Director of Quality Management stated RN 1 should have entered the above physician's order as the verbal order.


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2. Review of the hospital's P&P titled Core: Evaluation & Verification of Competency dated June 2023 showed the purpose of this policy includes to provide a method to measure the employee's performance based on the objective data and to validate competency on an ongoing basis. A summary of the employee's initial and ongoing competency validation is maintained in the employee's education file. The annual competency validation section showed the competency is an ongoing process and is achieved at least annually or more frequently if the needs indicate or are required by the regulatory agency. Annual skills are ongoing and should be completed throughout the given year.

On 2/4/25 at 1550 hours, an interview and concurrent record review was conducted with the Education Manager. Review of the personnel's files for CNA 1 showed CNA 1's DOH was 12/10/10, and the Employee Annual Performance Appraisal Form was completed on 6/21/22. CNA 's personnel file failed to show documented evidence the performance evaluation was conducted for the year 2023 as per the hospital's P&P.

The Education Manager acknowledged the above finding and stated the Annual Performance Appraisal was supposed to be performed every year.

On 2/4/25 at 1600 hours, a follow-up interview was conducted with the COO/CCO and the Director of Quality Management. They acknowledged the finding and stated all employees were required to have performance evaluation every year.