HospitalInspections.org

Based on interview and administrative document review, the hospital failed to maintain an effective, comprehensive, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program when the program did not effectively identify, collect data, track data, develop, or implement performance improvement activities consistent with their own Plan of Correction dated 5/31/24 when:

1. Interpreters were not used to communicate with patients in their preferred languages. (Cross reference A-309, A-117.)

2. Pain assessment and reassessments were not corrected or monitored for ongoing compliance. (Cross reference A-309, A-398 finding 1.)

3. Infection control deficiencies were not corrected or monitored for ongoing compliance (cross reference A-309, A-750)

The cumulative effect of these systemic problems resulted in the facilities inability to comply with statutory requirements for Quality Assessment and Performance Improvement and placed all patients at risk of not receiving care in a safe setting.

The facility failed to meet the regulatory requirements for the Condition of Participation: §482.42 Infection Prevention and Control and Antibiotic Stewardship Programs as evidenced by the following:

Based on observation, interview, and record review, the hospital failed to have an active Infection Prevention and Control program which adhered to nationally recognized infection prevention and control guidelines for the surveillance, prevention, and control of HAIs (hospital acquired infections- infection one gets while receiving treatment in a healthcare facility) and other infectious diseases, when:

1. Multiple drawers in the food preparation areas of the kitchen had a build-up of crumbs, one drawer had a binder with food crusted and personal items. According to the FDA Federal Food Code all non-food contact surfaces of the kitchen should be kept clean. (Refer A-0750 Finding 1).

2. The floor underneath fixed equipment in the kitchen had a buildup of trash, food, grease, and black grime. There was a build-up of food in the floor drain that was under a reach- in refrigerator. According to the FDA Federal Food Code all non-food contact surfaces of the kitchen should be kept clean. (Refer A-0750 Finding 2).

3. Shelves in 3 reach-in refrigerators in the kitchen near the tray line area (where food is plated for the patients) were coated in metal chards and build-up of black dust like substance. The plate warmer had a build-up of food crumbs. A commercial food warmer (used to keep food warm prior to service) had a build-up of black and red grime and convection ovens had a build-up of red and black grime. According to the FDA Federal Food Code all non-food contact surfaces of the kitchen should be kept clean. (Refer A-0750 Finding 3).

4. Five (5) of 27 ice machines (IMs) on the facility main campus were observed to be visibly soiled, and were not maintained according to facility P&P and manufacturer instructions for use (IFU). (Refer A-0750 Finding 4).

The ice machine in the main kitchen [IM 1] and another in the 3 West unit nourishment room [IM 2] had a pink or black slime build-up. (Refer A-0750 Finding 4).

The ice machine in the 4 North Medical Surgical pantry room [IM 3], had a black residue in the water catch sink area of the machine. (Refer A-0750 Finding 4).

The ice machine in the CVICU [IM 4] had visible white-colored and textured splash stains on the stainless-steel surfaces and the water collection trays and black-colored debris was observed on white tissue after wiping the ice dispenser spout. (Refer A-0750 Finding 4).

The CCU ice machine [IM 5] had visible, pink-colored stains in the ice shoot and spray guard covering. (Refer A-0750 Finding 4).

5. One (1) of 1 surgical instrument tray was stored on a trash can, and not in accordance with standards published by the American National Standards Institute and the Association for the Advancement of Medical Instrumentation (ANSI/AAMI - a primary source for the development, management, and use of safe and effective health technologies for the medical device industry, as well as practical information, support, and guidance for healthcare technology and sterilization professionals). (Refer A-0750 Finding 5).

6. An Intravenous (IV) administration set (connects the bag of solution to the patient's IV access site) was not labeled with date and time of initiation for two of two patients (Pt 36 and Pt 45) in accordance with hospital policy and procedure. (Refer A-0750 Finding 6).

7. Expired formula and formula sterile water was found in the Emergency Department (ED) supply room according to Food Safety and Inspection Services (FSIS-part of a science-based national system to ensure food safety and food defense) standards. (Refer A-0750 Finding 7).

8. Four (4) of 4 sampled pill crushers (a device that turns pills into powder) were not cleaned per manufacturer recommendation in the CVICU and CCU. The pill crushers were observed to be visibly soiled with white-colored chalk-like residue, and brown and orange-colored stains to metal pieces and throughout the device. (Refer A-0750 Finding 8).

9. Licensed nurses (LNs) in the Emergency Department (ED) failed to discard sharps (medical devices like needles, scalpels, and other tools that cut or go into the skin) in a sharps container ( made from rigid puncture-resistant plastic or metal with leak-resistant sides and bottom, and a tight-fitting, puncture-resistant lid with an opening to accommodate depositing a sharp but not large enough for a hand to enter) when a used IV catheter insertion needle, a small plastic dark red fluid-filled container, and a binder with a red smudge was observed to be on top of a crash cart in an occupied patient room and an empty bag of IV fluids (liquids that are administered directly into a vein to replace water, sugar, and salt) was observed laying on the floor and not discarded in accordance with the expectations of the CNO, per facility P&P and nursing standard of practice. (Refer A-0750 Finding 9).

10. The hospital did not ensure staff in the CVICU followed manufacturer instructions when using specialized pouches for dirty surgical instruments. (Refer A-0750 Finding 10).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality patient care in a safe and sanitary environment.

Based on interview and record review, the hospital failed to ensure patient's rights were considered for two of five sampled patients (Pt 27 and Pt 28) when patients preferred language was other than English and there was minimal to no documentation an interpreter was used for either patient during their hospitalization.

These failures had the potential for patients whose preferred language was other than English to not receive and fully understand procedures and/or education provided to them and could result in negative health outcomes when the interpreting system was not utilized to communicate with Pt 27 and Pt 28 according to the hospital's Policy and Procedure.


Findings:

1. During a concurrent interview and record review on 9/12/24 at 10:20 a.m. with Registered Nurse (RN) 1, Pt 27's "History & Physical [H&P- an assessment from physician including medical history and exam]," dated 9/2/24 and the "Face Sheet [FS- a document that contains a summary of a patients' personal information]," dated 9/1/24, were reviewed. "The "H&P" indicated, Pt 27 was admitted to the hospital on 9/1/24 at 10:31 p.m. for hypercalcemia (high calcium level in the blood), and hypoxemic respiratory failure (low oxygen in the blood). RN 1 stated the "FS" indicated Pt 27's preferred language was Spanish.

During a concurrent interview and record review on 9/12/24 at 10:30 a.m. with RN1, Pt 27's "Interdisciplinary Patient Education SMART Template (Template)" dated 9/3/24 to 9/5/24 were reviewed. The "Template" indicated, six nurses documented, the "Barriers to Learning: -Language Barrier:" but did not document interpreter services were provided by a certified interpreter. RN 1 stated, LNs should use certified interpreters when patients had a language barrier.

During a concurrent interview and record review on 9/12/24 at 10:45 with RN 1, Pt 27's "Electronic Medical Record (EMR)" dated 9/3/24 to 9/5/24 was reviewed. RN 1 stated when an interpreter was used, LNs could document the information in the rounding comments and frequent assessments. The "EMR" indicated no documentation of interpreter use in the round's comments or frequent assessments. RN 1 stated the "EMR" indicated no interpreter documentation besides "Conditions of Admission (COA-patient's obligation with respect to hospital services they receive)" form.

During an interview on 9/16/24 at 2:20 p.m. with RN 3, RN 3 stated she cared for Pt 27 on 9/3/24, 9/4/24, and 9/5/24 during the a.m. shift. RN 3 stated she did not use the interpreter line to communicate with Pt 27. RN 3 stated Pt 27's daughter would interpret for her whenever she needed to communicate with Pt 27. RN 3 stated she did not document Pt 27's daughter interpreting education to the patient. RN 3 stated she knew how to use the interpreter tablets. RN 3 stated she should use the interpreter phone line or tablet when speaking to the patient.

During an interview on 9/16/24 at 4:40 p.m. with Director of Patient Care Services (DPCS) 2, DPCS 2 stated all units have tablets that provide language services by video to provide interpreter services to non-English speaking patients. DPCS 2 stated LNs could also call an interpreter line on the telephone for interpreter services. DPCS 2 stated her expectation was for LNs to utilize video or telephone interpreters for patient education, procedures, and any consents the patient needed to sign. DPCS 2 stated patients needed to understand the care they were receiving, in their preferred language. DPCS 2 stated LNs were supposed to document the interpreter identification number in the patient's medical record when using an interpreter.

During a concurrent interview and record review on 9/12/24 at 11:10 a.m. with RN 1, Pt 28's "H&P," and "FS" dated 9/7/24 were reviewed. The "H&P" indicated Pt 28 was admitted to the hospital on 9/7/24 at 7:30 p.m. for a pulmonary thromboembolism (blood clot in the lung), dyspnea (difficulty breathing), and a liver mass (abnormal growth of tissue). RN 1 stated the "FS" indicated Pt 28's preferred language was Spanish.

During a concurrent interview and record review on 9/12/24 at 11:15 a.m. with RN 1, Pt 27's "Template" dated 9/8/24 to 9/12/24 were reviewed. The "Template" indicated, seven nurses documented, the "Barriers to Learning: -Language Barrier:" but did not document interpreter services were provided by a certified interpreter. RN 1 stated, LNs should use certified interpreters when patients had a language barrier.

During a concurrent interview and record review on 9/12/24 at 11:20 with RN 1, Pt 28's "Electronic Medical Record (EMR)" dated 9/8/24 to 9/12/24 was reviewed. RN 1 stated when an interpreter was used, LNs could document the information in the rounding comments and frequent assessments. The "EMR" indicated no documentation of interpreter use in the round's comments or frequent assessments. RN 1 stated the "EMR" indicated no interpreter documentation besides the COA form.

During an interview with RN 1 on 9/12/24 at 11:30 a.m. RN 1 stated she cared for Pt 28 on 9/9/24 during the a.m. shift. RN 1 stated she did not utilize the interpreter tablet when completing her morning assessments on Pt 28. RN 1 stated she utilized a Spanish speaking LN to interpret information when Pt 28 asked her a question about pain medications. RN 1 stated she did not document the Spanish staff member interpreting for her in Pt 28's EMR. RN 1 stated she should have documented using a Spanish interpreter to communicate with Pt 28. RN 1 stated she should have used the certified interpreter tablet or phone line per hospital policy.

During an interview on 9/16/24 at 3:20 p.m. with DPCS 1, DPCS 1 stated all units have little green translator electronic tablets and LNs should use them for interpreter services for non-English speaking patients. DPCS 1 stated LNs should use interpreter services for purpose and side effects of medication, and to determine if medication was effective, bedside education, new treatments, invasive things, and any procedures. DPCS 1 stated LNs were supposed to get interpreter staff identification number and document the number in the patients EMR. DPCS 1 stated utilizing certified interpreters was important to ensure communication was appropriate for the patient, and to not have information translated incorrectly.

During an interview on 9/17/24 at 4:30 p.m. with the Chief Nursing Officer (CNO), the CNO stated, her expectation was for LNs to use the interpreter tablets for non-English speaking patients. The CNO stated her expectation was for LNs to utilize interpreters for new medication education, consents, procedures, and any consents patients needed to sign. The CNO stated LNs were expected to document the interpreter identification number in the patient chart.

During a review of the hospital's Policy and Procedure titled, "Language Assistance Services (Including Interpreters) Procedure," dated 7/24/24, indicated, " ...Prompt Call for Interpreters ... the need for Qualified Interpreters and other Auxiliary Aids and Services throughout the Patient's receipt of Facility services ... Determination of a Patient's medical history or description of ailment or injury; ...provision of Patient rights, informed consent or permission for treatment; ... explanation of procedures, tests, treatment, treatment options or surgery; ... explanation of medications prescribed including dosage as well as how and when the medication is to be taken and any possible side effects; ... explanation regarding follow -up treatment, therapy, test results or recovery; discharge instructions; ...blood and organ donation ... Video Remote Interpreting (VRI) Services ... the [hospital] will ensure that it provides (i) real-time, full-motion video and audio ... Restricted Use of Other Interpreters ... Except in the limited circumstances ... shall not rely on a family member ... to interpret communications between Facility Personnel and that Person ...".

During a review of the hospital's "Instructions for Use (IFU)" for the [brand name of tablet] Language Services on iOS, undated, the "IFU" indicated, " ... More than 200 languages are available over audio ... Web based tool ...".

During a review of professional reference titled, "Clinicians' Obligations to Use Qualified Medical Interpreters When Caring for Patients with Limited English Proficiency," dated 3/2017, (retrieved from https://journalofethics.ama-assn.org/article/clinicians-obligations-use-qualified-medical-interpreters-when-caring-patients-limited-english/2017-03) indicated, " ... Access to language services is a required and foundational component of care for patients with limited English proficiency (LEP) ... In the United States, patients with LEP have a legal right to access health care in their preferred language ...".

Based on interview and record review, the hospital failed to protect and promote each patient's rights for one of three patients (Pt 23) when the hospital policy and procedure (P&P) titled, "Restraints and Seclusion" was not followed. LNs did not document monitoring and assessment information according to hospital policy for Pt 23.
These failures had the potential for Pt 23 to go unmonitored for an extended period and violated Pt 23's right to care in a safe setting. (Refer A-0154 Finding 1)

Findings:

1. During a concurrent interview and record review on 9/11/24 at 3:32 p.m. with Registered Nurse Quality (RNQ) 1, Pt 23's "History and Physical (H&P)," dated 9/8/24, was reviewed. The "H&P" indicated, " ... Patient was brought in from her assisted living with severe shortness of breath, altered level of consciousness [change in state of awareness] and hypotension [blood pressure lower than normal] ... history of dementia [condition that causes loss of memory, thought, and reasoning] ... acute hypoxic respiratory failure [not enough oxygen in body's tissues]. ...". Pt 23 was admitted to the hospital on 9/8/24 at 10:15 a.m. with sepsis (serious infection that can lead to lead to tissue damage organ failure or death) and acute hypoxic respiratory failure.

During a concurrent interview and record review on 9/11/24 at 3:40 p.m. with Registered Nurse Quality (RNQ)1 Pt 23's "Physician Order (PO) 1," dated 9/8/24, was reviewed. The "PO 1" indicated, " ... Restraint [device that limits movement] Initiation Non-Violent ... Reason for Restraints: Interferes with Medical Device ... Soft limb ... All Extremities ... 4 Point Restraint ... Restraint location: ... All extremities ...". RNQ 1 stated 4-point restraints were soft material restraints that went around the patient's wrists and ankles and attached to the bed frame, to prevent movement of arms and legs.

During a concurrent interview and record review on 9/11/24 at 3:43 p.m. with RNQ 1 Pt 23's "Restraint Placement Monitoring (RPM)" dated 9/8/24 to 9/10/24, were reviewed. The RPM indicated Pt 23 was placed in restraints on 9/8/24 at 5:15 p.m. and no documentation was monitored until 8 p.m. RNQ 1 stated patients with non-violent restraints were to have restraint monitoring documented every 2 hours. RNQ 1 stated Pt 23 should have had monitoring documented at 7:15 p.m. RNQ 1 stated LNs monitored and documented reason for restraints, alternatives attempted, points of restrains, learner profile, and a patient assessment every two hours.

During an interview on 9/16/24 at 2:37 p.m. with Registered Nurse (RN) 2, RN 2 stated he was Pt 23's primary nurse on 9/8/24 during the a.m. shift. RN 23 stated his shift was from 7:00 a.m. to 7:30 p.m. RN 2 stated he applied Pt 23's 4-point restraints. RN 2 stated Pt 23 was pulling at medical equipment and kicking her IV pole. RN 2 stated he called the physician and obtained the order for restraints. RN 2 verified on the "RPM" he applied Pt 23's restraints at 5:15 p.m. RN 2 stated he should have monitored and documented Pt 23's restraints at 7:15 p.m. or reported to the ongoing night shift nurse to monitor and document at 7:15 p.m. RN 2 stated monitoring patients every two hours assured patients remained safe, and allowed LNs to determine if restraints were still needed.

During an interview on 9/16/24 at 3:45 p.m. with Director of Patient Care Services (DPCS) 2, DPCS 2 stated her expectation was for LNs to monitor patients and document according to hospital policy.

During an interview on 9/17/24 at 4:22 p.m. with the Chief Nursing Officer (CNO), the CNO stated her expectation was for LNs to assess restrained patients and document according to P&P. The CNO stated LNs needed to address the reason patients were in restraints to determine if they were in the least restrictive restraint, or if restraints were still needed. The CNO stated LNs needed to assess restrained patients to assure their needs were met, such as nutrition, hydration, pain, and bathroom needs.

During a review of the hospital's P&P titled, "Restraints and Seclusion," dated 4/24/24, indicated, " ... Non-violent/Medical Behavior: Behavior resulting from a non-psychiatric medical condition and/or does not jeopardize the immediate safety of others but may result in harm to self. ... Staff must discontinue Restraint or Seclusion at the earliest possible time, regardless of the scheduled expiration of the order. ... a patient in restraints is monitored at least every two hours or sooner according to the patient needs ... When restraint or Seclusion is used, there must be documentation in the patient's medical record of the following: ... The patient's response to the intervention(s) used including the rational for continued use of the intervention ... Individual patient assessments and reassessments ... All employees whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy ...".

During a review of professional reference titled, Patient Restraint and Seclusion," dated 11/14/22, (retrieved from https://www.ncbi.nlm.nih.gov/books/NBK565873/ f (nih.gov)) indicated, " ... Healthcare workers should know that restraint and seclusion can have significant adverse implications on patients and should be deemed a last resort. Healthcare professionals must follow the 4 basic ethical healthcare principles: autonomy, justice, beneficence, and non-maleficence. Per beneficence - the act of doing good - and non-maleficence - do no harm; healthcare providers must ensure the administration of restraint is implemented as a last resort ... Healthcare workers must also be sure to appropriately monitor the patient following restraint and seclusion to avoid deleterious [causing harm] effects such as pressure ulcers, skin breakdown, abrasions, asphyxia, strangulation, incontinence, depression, social isolation, and drug overdose or interaction ...".

Based on interview and record review, the hospital's governing body did not ensure the hospital-wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety and that all improvement actions are evaluated when issues identified in the previous survey in May 2024 related to Patient Rights, Nursing Services, and Infection Control were not corrected, tracked, and monitored for compliance

These failures resulted in avoidable negative outcomes to patients. Patients 27 and 28 did not receive information in a language they could fully understand, patients (Pt) Pt 5, Pt 10, Pt 26, Pt 27, Pt 38, Pt 45, and Pt 50 did not have their pain adequately controlled, and placed all patients, visitors, and staff at continued risk for transmission of and cross contamination and increased the potential for hospital acquired infections and illnesses.


Findings:

Review of the hospital document titled, "Plan of Correction," dated 5/31/24 indicated:
" ...CMS 2567 - A117- Patient Rights: Notice of Rights. Finding: Based on interview and record review, the hospital failed to ensure patient's rights were considered for two of three sampled patients (Pt 11 and Pt 12) when patients preferred language was other than English and there was minimal (for informed consents) to no documentation an interpreter was used for either patient during their hospitalization. These failures had the potential for patients whose preferred language was other than English to not receive and fully understand procedures and/or
education provided to them and could result in negative health outcomes when bilingual staff who were not competent interpreters communicated with patients and did not use the interpreting system to communicate with patients in accordance with the hospital's policies and procedures ..."

Record review of the Corrective Actions included: Beginning on 6/17/2024, education regarding the use of interpreter services was provided to the inpatient hospital staff working in direct patient care via huddles, which included a signed attestation of understanding. Monitoring: The DBHC (Doctors Behavioral Health Center) Director or designee conducts audits on all charts for consent compliance at DBHC. Monitoring is conducted for until three consecutive months of 100% compliance is achieved. Once 100% compliance is achieved random weekly audits will be conducted to ensure compliance with the policy. LEP Coordinator/Quality Department audits 5 charts per week to ensure that the language interpreter services are used and documented for translation per hospital policy and regulatory standards on 100% of audits completed. Weekly chart audits occur until 100% compliance is achieved for 3 concurrent months. The Quality Department will audit charts monthly to ensure sustainability. Data is reported to Quality Council, MEC, and BOG quarterly."


During a concurrent interview and record review on 9/12/24 at 10:20 a.m. with Registered Nurse (RN) 1, Pt 27's "History & Physical [H&P- an assessment from physician including medical history and exam]," dated 9/2/24 and the "Face Sheet [FS- a document that contains a summary of a patients' personal information]," dated 9/1/24, were reviewed. "The "H&P" indicated, Pt 27 was admitted to the hospital on 9/1/24 at 10:31 p.m. for hypercalcemia (high calcium level in the blood), and hypoxemic respiratory failure (low oxygen in the blood). RN 1 stated the "FS" indicated Pt 27's preferred language was Spanish.

During a concurrent interview and record review on 9/12/24 at 10:30 a.m. with RN1, Pt 27's "Interdisciplinary Patient Education SMART Template (Template)" dated 9/3/24 to 9/5/24 were reviewed. The "Template" indicated, six nurses documented, the "Barriers to Learning: -Language Barrier:" but did not document interpreter services were provided by a certified interpreter. RN 1 stated, LNs should use certified interpreters when patients had a language barrier.

During a concurrent interview and record review on 9/12/24 at 10:45 with RN 1, Pt 27's "Electronic Medical Record (EMR)" dated 9/3/24 to 9/5/24 was reviewed. RN 1 stated when an interpreter was used, LNs could document the information in the rounding comments and frequent assessments. The "EMR" indicated no documentation of interpreter use in the round's comments or frequent assessments. RN 1 stated the "EMR" indicated no interpreter documentation besides "Conditions of Admission (COA-patient's obligation with respect to hospital services they receive)" form.

During an interview on 9/16/24 at 2:20 p.m. with RN 3, RN 3 stated she cared for Pt 27 on 9/3/24, 9/4/24, and 9/5/24 during the a.m. shift. RN 3 stated she did not use the interpreter line to communicate with Pt 27. RN 3 stated Pt 27's daughter would interpret for her whenever she needed to communicate with Pt 27. RN 3 stated she did not document Pt 27's daughter interpreting education to the patient. RN 3 stated she knew how to use the interpreter tablets. RN 3 stated she should use the interpreter phone line or tablet when speaking to the patient.

During an interview on 9/16/24 at 4:40 p.m. with Director of Patient Care Services (DPCS) 2, DPCS 2 stated all units have tablets that provide language services by video to provide interpreter services to non-English speaking patients. DPCS 2 stated LNs could also call an interpreter line on the telephone for interpreter services. DPCS 2 stated her expectation was for LNs to utilize video or telephone interpreters for patient education, procedures, and any consents the patient needed to sign. DPCS 2 stated patients needed to understand the care they were receiving, in their preferred language. DPCS 2 stated LNs were supposed to document the interpreter identification number in the patient's medical record when using an interpreter.

During a concurrent interview and record review on 9/12/24 at 11:10 a.m. with RN 1, Pt 28's "H&P," and "FS" dated 9/7/24 were reviewed. The "H&P" indicated Pt 28 was admitted to the hospital on 9/7/24 at 7:30 p.m. for a pulmonary thromboembolism (blood clot in the lung), dyspnea (difficulty breathing), and a liver mass (abnormal growth of tissue). RN 1 stated the "FS" indicated Pt 28's preferred language was Spanish.

During a concurrent interview and record review on 9/12/24 at 11:15 a.m. with RN 1, Pt 27's "Template" dated 9/8/24 to 9/12/24 were reviewed. The "Template" indicated, seven nurses documented, the "Barriers to Learning: -Language Barrier:" but did not document interpreter services were provided by a certified interpreter. RN 1 stated, LNs should use certified interpreters when patients had a language barrier.

During a concurrent interview and record review on 9/12/24 at 11:20 with RN 1, Pt 28's "Electronic Medical Record (EMR)" dated 9/8/24 to 9/12/24 was reviewed. RN 1 stated when an interpreter was used, LNs could document the information in the rounding comments and frequent assessments. The "EMR" indicated no documentation of interpreter use in the round's comments or frequent assessments. RN 1 stated the "EMR" indicated no interpreter documentation besides the COA form.

During an interview with RN 1 on 9/12/24 at 11:30 a.m. RN 1 stated she cared for Pt 28 on 9/9/24 during the a.m. shift. RN 1 stated she did not utilize the interpreter tablet when completing her morning assessments on Pt 28. RN 1 stated she utilized a Spanish speaking LN to interpret information when Pt 28 asked her a question about pain medications. RN 1 stated she did not document the Spanish staff member interpreting for her in Pt 28's EMR. RN 1 stated she should have documented using a Spanish interpreter to communicate with Pt 28. RN 1 stated she should have used the certified interpreter tablet or phone line per hospital policy.

During an interview on 9/16/24 at 3:20 p.m. with DPCS 1, DPCS 1 stated all units have little green translator electronic tablets and LNs should use them for interpreter services for non-English speaking patients. DPCS 1 stated LNs should use interpreter services for purpose and side effects of medication, and to determine if medication was effective, bedside education, new treatments, invasive things, and any procedures. DPCS 1 stated LNs were supposed to get interpreter staff identification number and document the number in the patients EMR. DPCS 1 stated utilizing certified interpreters was important to ensure communication was appropriate for the patient, and to not have information translated incorrectly.

During an interview on 9/17/24 at 4:30 p.m. with the Chief Nursing Officer (CNO), the CNO stated, her expectation was for LNs to use the interpreter tablets for non-English speaking patients. The CNO stated her expectation was for LNs to utilize interpreters for new medication education, consents, procedures, and any consents patients needed to sign. The CNO stated LNs were expected to document the interpreter identification number in the patient chart.

During a review of the hospital's Policy and Procedure titled, "Language Assistance Services (Including Interpreters) Procedure," dated 7/24/24, indicated, " ...Prompt Call for Interpreters ... the need for Qualified Interpreters and other Auxiliary Aids and Services throughout the Patient's receipt of Facility services ... Determination of a Patient's medical history or description of ailment or injury; ...provision of Patient rights, informed consent or permission for treatment; ... explanation of procedures, tests, treatment, treatment options or surgery; ... explanation of medications prescribed including dosage as well as how and when the medication is to be taken and any possible side effects; ... explanation regarding follow -up treatment, therapy, test results or recovery; discharge instructions; ...blood and organ donation ... Video Remote Interpreting (VRI) Services ... the [hospital] will ensure that it provides (i) real-time, full-motion video and audio ... Restricted Use of Other Interpreters ... Except in the limited circumstances ... shall not rely on a family member ... to interpret communications between Facility Personnel and that Person ...".

During a review of the hospital's "Instructions for Use (IFU)" for the [brand name of tablet] Language Services on iOS, undated, the "IFU" indicated, " ... More than 200 languages are available over audio ... Web based tool ...".

During a review of professional reference titled, "Clinicians' Obligations to Use Qualified Medical Interpreters When Caring for Patients with Limited English Proficiency," dated 3/2017, (retrieved from https://journalofethics.ama-assn.org/article/clinicians-obligations-use-qualified-medical-interpreters-when-caring-patients-limited-english/2017-03) indicated, " ... Access to language services is a required and foundational component of care for patients with limited English proficiency (LEP) ... In the United States, patients with LEP have a legal right to access health care in their preferred language ...".

Review of the hospital document titled, "Plan of Correction", dated 5/31/24 indicated:
" ...CMS 2567 -A385 - Nursing Services ... Finding 5: One of two sampled patients did not have her pain assessed and documented while she was receiving epidural pain medication according to hospital policy. Policy & Procedures: Finding 4: The hospital Pain Management policy, vital sign guidelines and physician order sets were reviewed. There was a reference added for Elsevier for vital signs assessment frequency. Elsevier is the Tenet Healthcare approved clinical reference platform. Completion date: 06/17/2024 Finding 5: L&D (Labor and Delivery) Epidural Management of the Laboring Patient Guidelines was reviewed without changes. Other Corrective Actions: Finding 4: The Director and Assistant Director and respective leaders developed an education plan for staff responsible for taking and documenting vital signs regarding compliance with vital signs and standardization of measurements and documentation. Elsevier was confirmed to be accessible from all hospital pc desktops for ease of reference. Completion date: 06/17/2024. Finding 5: The Director and respective leaders developed an education plan for staff responsible for assessing, managing, and reassessing pain regarding compliance with pain assessment while receiving epidural pain medication and standardization of measurements and documentation. Assess fetal heart rate, uterine contractions, maternal vital signs, signs of high spinal or ascending block, perception and level of pain relief once regional analgesia or anesthesia is initiated. Then every 3 minutes for the first 15 minutes, then every 5 for the next 15 min, then every 15 minutes thereafter. The frequency of subsequent assessment should be based on maternal-fetal response to medication, maternal-fetal condition, and the stage of labor Completion date: 08/7/2024. Training: Finding 4: Labor and Delivery and Postpartum Staff responsible for taking and documenting vital signs were educated by nursing leadership regarding standardization of vital sign measurements, importance of documentation and references to Elsevier learning and reference platform. Staff verbalized understanding as competency and had no questions or concerns. Competency is validated by audits conducted by nursing leadership (see monitoring). Finding 5: Beginning the Week of August 5th, 2024, Labor and Delivery staff responsible for pain assessment, management and reassessment were educated by nursing leadership regarding standardization of pain assessment and reassessment, as well as the importance of accurate and timely documentation. Staff verbalized understanding as competency and had no questions or concerns. Competency is validated by audits conducted by nursing leadership (see monitoring). Completion date: 08/7/2024 ... Finding 5: 30 records per month will be audited for pain assessment and reassessment until three consecutive months of 100 % compliance is achieved. Results of audits will be reported to the Quality Committee, MEC and Board of Governors quarterly to ensure compliance. Completion date: Estimated 8/7/2024. Responsible Person(s): Finding 4: The Director of Women's and Children's Services, The Director of Neonatal and Pediatric Services, and the Chief Nursing Officer. Finding 5: The Director of Women's and Children's Services, The Director of Neonatal and Pediatric Services, and the Chief Nursing Officer ... One of two sampled patients (Pt 61) was not offered pain medication prior to the start of a large wound dressing according to the hospital's pain policy and hand hygiene was not performed per hospital policy. Policy & Procedures: On 5/27/2024, the policy for Pain Management PC.AS.1.24 was reviewed. No revisions were required ...On 5/27/2024, all nursing staff working were provided education in huddles regarding patients receiving adequate pain control prior to a wound care dressing change. All staff on leave of absence, vacation, or otherwise not working and new hires will complete education upon return and prior to return to work. Completion date: 5/27/2024. Monitoring: ...On 5/27/2024 Inpatient Nursing Directors began randomly auditing wound care dressing changes in real time to ensure patients received adequate pain control prior to a wound care dressing change. These audits will continue until 100% compliance is achieved for 3 consecutive months. The data are reported through the Performance Improvement structure to Infection Prevention & Quality Council, MEC, and BOG quarterly. Completion date: 05/27/2024. Responsible Person(s): Inpatient Nursing Directors and Chief Nursing Officer ..."

During a review of Pt 26's "History and Physical [H&P- complete patient assessment by physician]", dated 9/4/24, the "H&P" indicated, Pt 26 was admitted to the hospital as an inpatient on 9/4/24 at 7:24 p.m. for status post (after surgery) hardware infection. Pt 26 had a recent left tibia (long bone in lower leg) open reduction internal fixation (ORIF- a surgical procedure for repairing fractured bone using either plates, screws, or a rod) with an external (outside the body) frame attached to internal (inside the body) hardware (implant, such as a plate, rod, screw, or nail that is used to hold bones together).

During a concurrent observation and interview on 9/10/24 at 3:07 p.m. with Pt 26 in Pt 26's hospital room, Pt 26 was observed with his left leg elevated on a pillow. The top of Pt 26's left leg right below his knee had a round metal frame encircling his leg, with metal pins puncturing his skin. Pt 26 stated he was in the hospital due to an infection in his left leg from a recent surgery. Pt 26 stated his leg was very painful at times. Pt 26 stated, nursing staff must be "very busy" because they are slow to answer his call light and bring him his pain medication. Pt 26 stated, he received both oral and intravenous (IV- in the vein) scheduled and as needed pain medication. Pt 26 stated he had scheduled pain medication every four hours. Pt 26 stated when his pain medication was late it was hard to keep his pain controlled.

During a review of Pt 26's "MO 1", dated 9/5/24 at 10:05 a.m., the "MO 1" indicated, " ... morphine [narcotic medication used for moderate to severe pain] ... 2 milligrams, [mg- a unit of measurement] ... Injection [administering a liquid] ... IV Push [IVP -pushing into intravenous line] ... Q2hr [every 2 hours] ... PRN [as needed] ... Pain Breakthrough [pain not controlled with scheduled medications] ...".

During a concurrent interview and record review on 9/12/24 at 3:15 p.m. with Registered Nurse Quality (RNQ) 1, Pt 26's "Pain Assessment Flowsheet (PAF)", and "Medication Administration Record [MAR- an electronic record of medications that were given]", dated 9/9/24 were reviewed. The "PAF" indicated, Pt 26's pain was assessed on 9/9/24 at 10:53 a.m. as a nine (severe). RNQ 1 stated, a pain score of 1-3 was mild pain, 4-6 was moderate pain and 7-10 was severe pain. The "MAR" indicated 2 mg morphine IVP was administered at 10:53 a.m. RNQ 1 stated, Pt 26's pain was not reassessed until 9/9/24 at 1 p.m. and scored an eight. RNQ 1 stated, Pt 26 should have had a pain reassessment on 9/9/24 at 11:53 a.m. one hour after pain medication was administered.

During an interview on 9/16/24 at 2:37 p.m. with Registered Nurse (RN) 2, RN 2 stated nursing staff were supposed to reassess and document pain after administration of medication within one hour. RN 2 stated reassessment was important because some patients do not respond to certain types of medications. RN 2 stated patients also needed to be monitored for sedation after certain types of pain medication administration, respirations, and heart rate needed to be closely monitored for the safety of the patient.

During a review of Pt 27's "H&P, dated 9/2/24, the "H&P" indicated, Pt 27 arrived in the ED with intractable (hard to control) back and pelvic (basin-shaped complex of bones that connects the trunk and the legs) pain. Pt 27 had a past medical history of recurrent hypercalcemia (high blood calcium), severe osteoporosis (bone mass and strength decreases) with multiple thoracolumbar fractures (area of the back between the ribcage and the lower back). T4, T12, (mid back) L1, L3, L4 (lower back), and occlusive deep vein thrombosis (DVT-blood clots form in deep veins). Pt 27 was admitted to the hospital as an inpatient on 9/1/24 at 10:31 p.m. with hypoxemic respiratory failure (not enough oxygen in the blood).

During a concurrent interview and record review on 9/12/24 at 9:30 a.m. with RN 1, Pt 27's "PAF", and "MAR", dated 9/7/24 were reviewed. The "PAF" indicated Pt 27's pain was assessed on 9/7/24 at 5:32 a.m. as nine (severe). The "MAR" indicated, on 9/7/24 at 5:32 a.m. Pt 27 was administered 10 mg oxyCODONE by mouth. RN 1 stated Pt 27's pain was reassessed on 9/7/24 at 8 a.m. as zero. RN 1 stated, Pt 27 should have had a pain reassessment on 9/7/24 at 6:32 a.m. one hour after pain medication was administered. RN 1 stated pain reassessments were important to evaluate the effectiveness of administered medications.

During a review of Pt 27's "MO 1", dated 9/2/24 at 12:50 a.m., the "MO 1" indicated, " ... oxyCODONE [narcotic medication for moderate to severe pain] ... 10 mg ... 2 tab ... Oral ... Q4hr [every 4 hours] ... PRN [as needed] ... Pain Severe ...".

During a concurrent interview and record review on 9/12/24 at 10 a.m. with RN 1, Pt 27's "PAF", and "MAR", dated 9/7/24 were reviewed. The "PAF" indicated Pt 27's pain was assessed on 9/7/24 at 5:32 a.m. as nine (severe). The "MAR" indicated, on 9/7/24 at 5:32 a.m. Pt 26 was administered 10 mg oxyCODONE by mouth. RN 1 stated Pt 27's pain was reassessed on 9/7/24 at 8 a.m. as zero. RN 1 stated, Pt 26 should have had a pain reassessment on 9/7/24 at 6:32 a.m. one hour after pain medication was administered. RN 1 stated pain reassessments were important to evaluate the effectiveness of administered medications. During a review of Pt 27's "MO 1", dated 9/2/24 at 12:50 a.m., the "MO 1" indicated, " ... oxyCODONE [narcotic medication for moderate to severe pain] ... 10 mg ... 2 tab ... Oral ... Q4hr [every 4 hours] ... PRN [as needed] ... Pain Severe ...".

During a review of Pt 5's "H&P, dated 8/26/24, the "H&P" indicated, Pt 5 arrived in the Emergency Department (ED) on 8/25/24 at 6:33 p.m. with abdominal (stomach) pain. Pt 5 was admitted to the hospital as an inpatient on 8/25/24 at 11:58 p.m. with diverticulitis (small pouches in the intestines become inflamed or infected), with micro perforation (a very small hole/puncture), and sepsis (serious infection that can lead to lead to tissue damage organ failure or death).

During a review of Pt 5's "Medication Order (MO 1)", dated 8/25/24 at 6:54 p.m., the "MO 1" indicated, " ... Acetaminophen [a pain reliever medication] ... 1,000 milligrams [mg - a unit of measurement] ... 2 tab [tablets] ... Oral ... STAT [immediately] ...".
During a review of Pt 5's "MO 2", dated 8/25/24 at 7:42 p.m., the "MO 2" indicated, " ... oxyCODONE [narcotic medication for moderate to severe pain] ... 10 mg ... 2 tab ... Oral ... STAT ...".

During a concurrent interview and record review on 9/16/24 at 4:31 p.m. with RNQ 1, Pt 5's "PAF", and "MAR", dated 8/25/24 to 8/26/24 were reviewed. RNQ 1 stated Pt 5's pain was assessed on 8/25/24 at 6:40 p.m. as 10 (severe). RNQ 1 stated, a pain score of 1-3 was mild pain, 4-6 was moderate pain and 7-10 was severe pain. The "MAR" indicated, on 8/25/24 at 6:58 p.m. Pt 5 was administered 1,000 mg acetaminophen. RNQ 1 stated Pt 5's pain was reassessed on 8/25/24 at 8:13 p.m. as an eight (severe). RNQ 1 stated, Pt 5 should have had a pain reassessment on 8/25/24 at 7:58 p.m. one hour or less after pain medication was administered.

During a concurrent interview and record review on 9/16/24 at 4:40 p.m. with RNQ 1, Pt 5's "PAF", and "MAR" dated 8/25/24 to 8/26/24 were reviewed. RNQ 1 stated, on 8/25/24 at 8:10 p.m. Pt 5 was administered 10 mg oxyCODONE for a pain score of 8. The "PAF" indicated, pain or sedation level (level of drug-induced sleep) was not assessed again until 8/26/24 at 2:32 a.m. The pain reassessment was documented as "no actual pain present", no numerical score was associated with the pain reassessment. RNQ 1 stated a pain reassessment should have been completed on 8/25/24 at 9:10 p.m. one hour after administration of the narcotic medication. RNQ 1 stated pain reassessments were important to ensure patients were getting pain control as well as not being overly sedated by pain medications.

During a review of Pt 10's "H&P", dated 9/9/24, the "H&P" indicated, Pt 10 was admitted to the hospital as an inpatient on 9/9/24 at 7:20 p.m. with acute cholecystitis (redness and swelling of gallbladder [pouch like organ in upper right of stomach]) and presumed gallstone pancreatitis (swelling of pancreas [organ behind stomach that produces digestive juices and hormones]) Pt 10 was admitted for laparoscopic cholecystectomy (small holes in stomach for small instrument to remove gallbladder).
During a review of Pt 10's "MO 1", dated 9/13/24 at 6:06 p.m., the "MO 1" indicated, " ... acetaminophen - HYDROcodone [narcotic medication] ... 325 mg [acetaminophen] 5 mg [HYDROcodone] ... 1 tab ... Oral ... Q4hr [every 4 hours] ... PRN [as needed] ... Pain Mild ... [1-3] ...".

During a concurrent interview and record review on 9/17/24 at 9:15 a.m. with RNQ 1, Pt 10's "PAF", and "MAR" dated 9/13/24 were reviewed. RNQ 1 stated, on 9/13/24 at 5:48 p.m. Pt 10 was administered 325 mg-5 mg acetaminophen HYDROcodone for a pain score of 3. The "PAF" indicated, on 9/13/24 at 8 p.m. a pain reassessment of three was documented. Pt 10's "PAF" indicated a pain acceptable intensity score of 3. RNQ 1 stated a pain reassessment should have been completed on 9/13/24 at 6:48 p.m. one hour after administration of the narcotic medication.

During a concurrent interview and record review on 9/13/24 at 9 a.m. with the Director of Women and Children Services (DWC) and Registered Nurse (RN) 4, Pt 38's H&P was reviewed. The H&P indicated, Pt 38 was a 33-year-old, gravida (G- the total number of confirmed pregnancies) 4 para (P- the number of live births) 2 at 35.6 weeks gestation (the period of time when something is conceived and developed; normal gestation is 40 weeks). Pt 38 was admitted for severe preeclampsia (a serious blood pressure condition that develops during pregnancy) for a repeat cesarean section (C/S- the surgical delivery of a baby through a cut made in the birth parent's abdomen and uterus).

During a concurrent interview and record review on 9/13/24 at 9:05 a.m. with the DWC and RN 4, Pt 38's "Medication Administration Record (MAR)," dated 9/12/24, and "Pain Assessment Flowsheet (PAF)," dated 9/12/24 were reviewed. The MAR indicated, " ...acetaminophen-hydrocodone ... 325 [milligrams (mg-unit of measure)]-10 mg oral) ... 1 tab ... [every] 4 [hour] [as needed] ..." The MAR indicated Pt 38 was administered acetaminophen-hydrocodone 325 mg-10mg by mouth at 8:41 a.m. RN 4 stated the PAF indicated Pt 38 had a pain assessment at 8 a.m. and 2 p.m. which indicated Pt 38 had no pain. RN 4 stated Pt 38 did not have a pain assessment completed when Pt 38 was administered pain medication at 8:41 a.m. nor did Pt 38 have a pain reassessment within one hour of pain medication administration. The MAR indicated Pt 38 was administered acetaminophen-hydrocodone 325 mg-10mg by mouth at 3:35 p.m. with a pain score of 9 (severe) out of 10 (Mild Pain=score of 1-3, Moderate Pain=score of 4-6, Severe Pain=score of 7-10). RN 4 stated the PAF indicated Pt 38's pain was not reassessed until 9:44 p.m. (a lapse of 6 hours and 9 minutes). RN 4 stated pain medication administered by mouth should be reassessed within the hour. RN 4 stated a pain assessment before administering pain medication was to make sure the appropriate pain medication is administered for the patient's pain score. RN 4 stated there were different pain medications for different pain scores. RN 4 stated a pain assessment should have been reassessed within the hour after pain medication administration to make sure it was effective and there were no side effects (undesirable effect of a drug). The DWC stated she expected LNs to complete a pain assessment and/or reassessment when pain medication was administered.

During a concurrent interview and record review on 9/13/24 at 2:02 p.m. with Shift Manager (SM) 2, Pt 45's "Consult Note (CN)," dated 9/12/24 and "Face Sheet (FS-a document that contains a summary of a patients' personal information), dated 9/13/24, were reviewed. The CN indicated, " ... 77 [year-old] [female] [past medical history] [gastroesophageal reflex disease (GERD- a common condition in which the stomach contents move up into the esophagus)], [hypertension- when the pressure in your blood vessels is too high] ... epigastric [abdominal] pain 9/10/2024 ..." The FS indicated Pt 45 was admitted to the facility on 9/12/24 at 1:40 p.m. for a small bowel obstruction (a blockage in the small intestine that prevents food, liquid, gas, and stool from passing through normally).

During a review of Pt 45's physician "Medication Order (MO)", dated 9/11/24 at 11:15 a.m., the MO indicated, " ... morphine [narcotic medication used for moderate to severe pain] ... 4 mg ... Injection [administering a liquid] ... IV Push [IVP -pushing into intravenous line] ... Q4hr [every 4 hours] ... PRN [as needed] ... PRN reason ...Abdominal Pain ...".

During a concurrent interview and record review on 9/13/24 at 2:10 p.m. with SM 2, Pt 45's "MAR," dated 9/10/24 to 9/12/24, and "PAF," dated 9/10/24 to 9/12/24, were reviewed. The MAR indicated Pt 45 was administered morphine 4 mg IVP on 9/10/24 at 8:50 p.m. and 9/11/24 at 1:37 a.m. The PAF indicated Pt 45's had a pain assessment on 9/10/24 at 8:02 p.m. with a pain score of 5 (moderate) and the next pain assessment was 9/11/24 at 7:18 a.m. with no pain (a lapse of 11 hours and 16 minutes). SM 2 stated Pt 45 did not have a pain reassessment within 30 minutes to an hour to see if the pain medication was effective. SM 2 stated Pt 45 did not have a pain assessment before administering morphine 4 mg IVP on 9/11/24 at 1:37 a.m. and a pain reassessment was not completed within 30 minutes to an hour. The MAR on 9/11/24 at 11:18 a.m. indicated Pt 45 received morphine 4 mg IVP and a pain score of 9 (severe). SM 2 stated the PAF indicated Pt 45 did not have a pain reassessment within 30 minutes to an hour. The PAF indicated the next pain assessment was on 9/11/24 at 9:14 p.m. with no pain (a lapse of 9 hours and 56 minutes). The MAR on 9/11/24 at 8:14 p.m. indicated Pt 45 received morphine 4 mg IVP. SM 2 stated the PAF indicated Pt 45 did not have a pain assessment when morphine 4 mg IVP was administered on 9/11/24 at 8:14 p.m. The MAR indicated Pt 45 was administered morphine 4 mg IVP on 9/12/24 at 1:50 p.m. SM 2 stated the PAF indicated Pt 45 did not have a pain assessment when morphine 4 mg IVP was administered on 9/12/24 at 1:50 p.m. SM 2 stated the PAF indicated Pt 45 had a pain reassessment on 9/12/24 at 2:48 p.m. (a lapse of 58 minutes) with no pain.

During a concurrent interview and record review on 9/13/24 at 2:25 p.m. with SM 2, Pt 45's "MAR," dated 9/13/24 and "PAF," dated 9/13/24 were reviewed. The MAR at 6:16 a.m. indicated Pt 45 was administered hydromorphone (a medication to treat moderate to severe pain) 1 mg IVP with a pain score of 8 (severe). SM 2 stated the PAF indicated Pt 45 had a pain assessment at 9:50 a.m. (a lapse of 3 hours and 34 minutes) with a pain score of 5 (moderate). SM 2 stated Pt 45 did not have a pain assessment completed within 30 minutes to an hour after pain medication administration. The MAR at 10:45 a.m. indicated Pt 45 was administered hydromorphone 1 mg IVP with a pain score of 7 (severe). SM 2 stated the PAF indicated Pt 45 did not have a pain reassessment as of current time (2:33 p.m.). SM 2 stated Pt 45 did not have a pain reassessment completed within 30 minutes to an hour.

During a concurrent interview and record review on 9/17/24 at 1:48 p.m. with RN 5, Pt 50's "Emergency Department Note - Physician (EDNP)," dated 9/10/24 was reviewed. The EDNP indicated, " ...a 73-year-old female patient with no known past medical history ... was brought in by [ambulance] from [Name of Shelter] with complaints of nausea, vomiting and headache ..."

During a concurrent interview and record review on 9/17/24 at 1:48 p.m. with RN 5, Pt 50's "MAR," dated 9/10/24 and "PAF," dated 9/10/24 were reviewed. The MAR at 8:15 a.m. indicated Pt 50 received acetaminophen 1,000 mg by mouth. RN 5 stated the PAF indicated Pt 50 had a pain assessment at 7:29 a.m. with a pain score of 4 (moderate) and 11:21 a.m. with no pain. RN 5 stated Pt 50 should have had a pain reassessment completed within one hour after pain medication administration.

During an interview on 9/16/24 at 3:17 p.m. with Director of Patient Care Services (DPCS) 1, DPCS 1 stated, nursing staff were expected to reassess patients after pain medication was administered. DPCS 1 stated nursing staff were expected to complete a full pain assessment daily and with vital signs, every four hours. DPCS 1 stated nursing staff were expected to document pain assessments.

During an interview on 9/16/24 at 3:25 p.m. with DPCS 3, DPCS 3 stated, nursing staff were expected to reassess patients within one hour or sooner after administration of pain medications. DPCS 2 stated nursing staff were expected to complete comprehensive, complete pain asses

Based on interview and record review, the hospital failed to assign licensed nurses (LNs) to meet the needs of patients who presented to the Emergency Department (ED) for emergent care. ED patients were triaged (a medical process that involves sorting and prioritizing patients based on their medical needs and the available resources) then returned to the (ED) waiting room (WR), rather than be admitted to the main ED, due to practice of closing patient beds/rooms to free up a Registered Nurse (RN) to cover staff breaks.

This failure had the potential to result in delayed patient care and for ED patients to not receive ordered treatments and/or medications to address their emergent needs due to their placement in the WR where the patient's nurse cannot continually assess the patient's condition and obtain vital signs as the situation warrants and treatments are limited (e.g.: no IV, or IV medications may be given to the patient) to ensure the patient is not placed at risk for harm or injury while unattended by a RN in the WR.

Findings:

During a concurrent interview and record review on 9/17/24 at 9:17 a.m. of the 7/4/24 ED schedule with the ED Manager (EDM) and RNQ 3, the EDM stated she is "acting" or "interim" (there is no permanent manager currently) ED Manager, prior to this she was an ED Shift Manager. EDM stated she has taken over the staffing and scheduling for the ED. EDM explained her scheduling process, which includes staff self-schedule submissions, with the goal of an even number of staff assigned throughout the schedule (i.e.: high volume days are staffed with a greater number of staff to meet anticipated higher volume of patients coming to the ED for care). EDM stated her goal is to staff to a minimum of 10 RNs daily. EDM stated unanticipated leave of absences, sick calls and several open RN and ED Tech (ED Technician- main function is to support registered nurses in a hospital emergency department to provide the highest quality patient care.) positions have prompted her to submit four (4) "Traveler Requests" (nurses who are not employees of the hospital, but work for another agency and supply temporary help) to fill behind these open positions, however this process is not an immediate remedy due to the hiring and onboarding process can be approximately 4-6 weeks prior to being able to work in the ED. EDM stated that Central Staffing (department that manages the day-to-day staffing for patients admitted to the hospital) sometimes has staff available to float into the ED, as needed to supplement their nursing staff. EDM stated the nurse-to-patient ratio is 1 LN to 4 patients in the ED and they try to meet that requirement when scheduling LNs. EDM stated another goal is to staff a "break nurse" (a nurse whose primary job is to take over care for nurses so they can go on break). If a dedicated break nurse is not available, the nurses break each other (this means nurse A takes on nurse B's patient assignment (e.g.: nurse to patient ratio increases to 1:8 from 1:4) or the charge nurse covers breaks, or if trauma nurse (a registered nurse (RN) who specializes in providing life-saving care to patients with critical injuries or medical emergencies.) doesn't have patients in the trauma and higher acuity patient care areas (C and D pods) they can come over and help with breaks. EDM stated if a trauma patient presents for care, the trauma nurse must return to the trauma area to provide care. EDM stated "mid-shifters also help with covering breaks, as they arrive to work [at 9:00 a.m., 10:00 a.m., 11:00 a.m., 12:00 p.m., 3:00 p.m., and 3:00 a.m.] The EDM stated of the mid-shifters, "their assignments aren't fixed. There are days when staff do not get breaks, rarely happens." EDM stated D and C pods along with Express Care [of mental health patients] are always open. ED Tech assignments are based on area open in the ED, one ED Tech may be assigned to cover multiple areas such as in "B" pod- which is a "catch all area and doesn't always have an ED Tech assigned because aren't always open." EDM stated her expectation is that the ED Techs should be rounding, but it "doesn't always happen."

During a review of the facility P&P "Standard of Care Policy (ED.1.04) dated 10/23/22, the P&P indicated, " ...I. Purpose: These are the fundamental components of care that are to be applied to any patient presenting for treatment to the ED. This standard of care must be used in conjunction with more specific protocols that are relevant to the patient's chief complaint ...II. Policy: ...2. All patient conditions will be classified and prioritized utilizing the Emergency Severity Index [ESI] ...The patient's nurse is responsible for continually assessing the patient's condition and obtaining vital signs as the situation warrants . Patient acuity will determine the frequency of vital signs. Abnormal vital signs will be checked prior to discharge, and persistent abnormalities will be brought to the physician's attention ... 9 ....a. Documentation of any changes in patient status and physician notification when significant changes occur ..."

Based on interviews and record reviews, the facility failed to develop current nursing care plans for one of eight sampled patients (Pt 43) when Pt 43 was placed on non-violent restraints and the care plan for restraints was not initiated at placement.

This failure had the potential to result in necessary nursing care not being provided to the Pt 43 and potential for patient harm.

Findings:

During a review of Pt 43's "Face Sheet (FS-a document that contains a summary of a patients' personal information)," dated 9/9/24 and "History and Physical (H&P), dated 9/8/24, the FS indicated Pt 43 was admitted to the facility on 9/8/24 at 7:11 p.m. The H&P indicated, " ...62 year old female with history of bipolar disorder, work related [TBI] that presented to the [emergency room] with alter mental status ... She is not demonstrating weakness and is not able to follow commands or responding to questions ..."

During a concurrent interview and record review on 9/17/24 at 9 a.m. with Registered Nurse Quality (RNQ) 2, Pt 43's "Physician Orders (PO)," dated 9/8/24 was reviewed. The PO indicated, " ...ED Non-Violent/Non Self Destructive Restraint ... Indication for Restraint ... Impulsive. Observed disconnecting and/or removing Therapeutic devices (s) ... Observed trying to climb out of bed when instructed not to do so ... Restraint Device ...Soft Wrist Right ...Soft Wrist Left ... Additional Orders: Update patient's Care Plan ..." RNQ 2 stated the PO indicated the restraint order was placed at 6:30 p.m.

During a concurrent interview and record review on 9/17/24 at 9:05 a.m. with RNQ 2, Pt 43's "Electronic Medical Record (EMR-an electronic record of health-related information on an individual)," dated 9/8/24 to 9/10/24, and "Interdisciplinary Care Plans (ICP)," dated 9/8/24 to 9/9/24 were reviewed. RNQ 2 stated Pt 43 was transferred to an inpatient bed on 9/8/24 at 8:49 p.m. from the Emergency Department (ED) and remained on non-violent restraints until 9/10/24 at 8:30 a.m. RNQ 2 stated the ICP indicated a non-violent restraints care plan was initiated on 9/9/24 at 1:37 p.m. (a lapse of 16 hours and 28 minutes). RNQ 4 stated a non-violent restraints care plan should have been initiated when the non-violent restraints were applied. RNQ 4 stated a care plan allowed LNs to know what interventions were needed for the patient.

During an interview on 9/17/24 at 4:20 p.m. with the Chief Nursing Officer (CNO) and Quality Manager (QM) 1, QM 1 stated there was no policy on care plans. The CNO stated she expected a care plan for restraints to be initiated upon application.

During a review of the facility's policy and procedure (P&P) titled, "Restraints and Seclusion," the P&P indicated, " ...PURPOSE: To define [Name of Hospital] approach to the use of restraint and seclusion for patients in a way that protects the patient's health and safety, and preserves their dignity, rights, and well-being ... Non-violent/Medical Behavior: Behavior resulting from a non-psychiatric medical condition and/or does not jeopardize the immediate safety of others but may result in harm to self. Restraint: Any manual method: physical or mechanical device, material, or equipment that immobilizes or reduces the patient's ability to move their arms, legs, body, or head freely ... Procedure: ... Monitoring and Reassessment ...When Restraint or Seclusion is used, there must be documentation in the patient's medical record of the following: ... Use of Restraint or Seclusion in the Plan of Care ..."

During a review of a professional reference titled, "Nursing Process," dated 4/10/23, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499937/, the Nursing Process indicated, " ...Planning ...The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. Goals should be: 1. Specific; 2. Measurable or Meaningful; 3. Attainable or Action-Oriented; 4. Realistic or Results-Oriented; 5. Timely or Time-Oriented ..."

Based on observation, interview and record review, the facility failed to ensure all licensed nurses adhered to the hospital's policies and procedures (P&P), when:

1. Licensed Nurses (LNs) did not adhere to the hospital's P&P "Pain Management Policy" for seven of 29 patients (Pt), Pt 5, Pt 10, Pt 26, Pt 27, Pt 38, Pt 45, and Pt 50. LNs did not reassess pain timely after administration of pain medication according to hospital policy.

These failures placed Pt 5, Pt 10, Pt 26, Pt 27, Pt 38, Pt 45, and Pt 50 at risk for inadequate pain management or oversedation and could negatively affect the physical, emotional, and psychosocial (the influence of both physical and social factors on an individual) well-being of patients.

2. LNs did not adhere to P&P "Pressure Injury Prevention and Management Policy" for two of three patients (Pt 25 and Pt 49). LNs did not document turning patients every two hours per physician order.

This failure had the potential for Pt 25 and Pt 49 to have further skin breakdown and new pressure injuries.

3. One of four patients (Pt 36) did not have documented fundal (top of uterus), or lochia (vaginal discharge after birth, bleeding) assessments by LNs after delivery in the Labor and Delivery (L&D) unit according to facility procedure.

This failure placed Pt 36 at risk for uterine atony (loss of tone) and hemorrhage (dangerous complication of excessive bleeding).

4. Two of 13 patients (Pt 36 and Pt 38) did not have a head-to-toe assessment (complex multisystem assessment completed by the LN) completed in accordance with the facility's P&P titled, "Documentation Policy."

This failure resulted in Pt 36 and Pt 38's head to toe assessment to not be completed which had the potential for any changes to go undetected.

5. One of one patient (Pt 36) did not have vital signs (measurements are taken to help assess the general physical health of a person, give clues to possible diseases, and show progress toward recovery) assessments completed after an epidural (a procedure used to relieve pain during labor) placement in accordance with the facility's P&P titled, "Epidural Management for the Laboring Patient Nursing Guidelines."

This failure had the potential to result in hypotension (low blood pressure-occurs when blood flows through your blood vessels at a lower-than-normal pressure), infection, and cardiac arrest (when the heart stops beating) leading to clinical deterioration and/or death.

6. LNs did not enter a physician verbal order for one of one patient (Pt 38) when a verbal order to discontinue magnesium sulfate (medication indicated for the prevention and control of seizures in preeclampsia-a serious blood pressure condition that develops during pregnancy) infusion was given by the nurse practitioner.

This failure resulted in LNs not following physician orders and the potential for adverse outcomes for Pt 38.

7. Two of 11 patients (Pt 17 and Pt 20) did not have vital signs assessed and documented in accordance with hospital policy Standard of Care P&P, and Documentation P&P and/or professional standards .

This failure had the potential to result in a change in condition for Pt 17 and 20 to be missed and acted on by the LN.

8. One of 11 patients (Pt 17) refused medication ordered by the physician and the LN did not notifying and document a notification to the physician per the hospital's P&P titled "Documentation Policy."

This failure resulted in an ordered medication to not be administered, placing Pt 17 at risk for a missed change in Pt 17's medical condition.

Findings:

1. During a review of Pt 26's "History and Physical [H&P- complete patient assessment by physician]", dated 9/4/24, the "H&P" indicated, Pt 26 was admitted to the hospital as an inpatient on 9/4/24 at 7:24 p.m. for status post (after surgery) hardware infection. Pt 26 had a recent left tibia (long bone in lower leg) open reduction internal fixation (ORIF- a surgical procedure for repairing fractured bone using either plates, screws, or a rod) with an external (outside the body) frame attached to internal (inside the body) hardware (implant, such as a plate, rod, screw, or nail that is used to hold bones together).

During a concurrent observation and interview on 9/10/24 at 3:07 p.m. with Pt 26 in Pt 26's hospital room, Pt 26 was observed with his left leg elevated on a pillow. The top of Pt 26's left leg right below his knee had a round metal frame encircling his leg, with metal pins puncturing his skin. Pt 26 stated he was in the hospital due to an infection in his left leg from a recent surgery. Pt 26 stated his leg was very painful at times. Pt 26 stated, nursing staff must be "very busy" because they are slow to answer his call light and bring him his pain medication. Pt 26 stated, he received both oral and intravenous (IV- in the vein) scheduled and as needed pain medication. Pt 26 stated he had scheduled pain medication every four hours. Pt 26 stated when his pain medication was late it was hard to keep his pain controlled.

During a review of Pt 26's "MO 1", dated 9/5/24 at 10:05 a.m., the "MO 1" indicated, " ... morphine [narcotic medication used for moderate to severe pain] ... 2 milligrams, [mg- a unit of measurement] ... Injection [administering a liquid] ... IV Push [IVP -pushing into intravenous line] ... Q2hr [every 2 hours] ... PRN [as needed] ... Pain Breakthrough [pain not controlled with scheduled medications] ...".

During a concurrent interview and record review on 9/12/24 at 3:15 p.m. with Registered Nurse Quality (RNQ) 1, Pt 26's "Pain Assessment Flowsheet (PAF)", and "Medication Administration Record [MAR- an electronic record of medications that were given]", dated 9/9/24 were reviewed. The "PAF" indicated, Pt 26's pain was assessed on 9/9/24 at 10:53 a.m. as a nine (severe). RNQ 1 stated, a pain score of 1-3 was mild pain, 4-6 was moderate pain and 7-10 was severe pain. The "MAR" indicated 2 mg morphine IVP was administered at 10:53 a.m. RNQ 1 stated, Pt 26's pain was not reassessed until 9/9/24 at 1 p.m. and scored an eight. RNQ 1 stated, Pt 26 should have had a pain reassessment on 9/9/24 at 11:53 a.m. one hour after pain medication was administered.

During an interview on 9/16/24 at 2:37 p.m. with Registered Nurse (RN) 2, RN 2 stated nursing staff were supposed to reassess and document pain after administration of medication within one hour. RN 2 stated reassessment was important because some patients do not respond to certain types of medications. RN 2 stated patients also needed to be monitored for sedation after certain types of pain medication administration, respirations, and heart rate needed to be closely monitored for the safety of the patient.

During a review of Pt 27's "H&P, dated 9/2/24, the "H&P" indicated, Pt 27 arrived in the ED with intractable (hard to control) back and pelvic (basin-shaped complex of bones that connects the trunk and the legs) pain. Pt 27 had a past medical history of recurrent hypercalcemia (high blood calcium), severe osteoporosis (bone mass and strength decreases) with multiple thoracolumbar fractures (area of the back between the ribcage and the lower back). T4, T12, (mid back) L1, L3, L4 (lower back), and occlusive deep vein thrombosis (DVT-blood clots form in deep veins). Pt 27 was admitted to the hospital as an inpatient on 9/1/24 at 10:31 p.m. with hypoxemic respiratory failure (not enough oxygen in the blood).

During a concurrent interview and record review on 9/12/24 at 9:30 a.m. with RN 1, Pt 27's "PAF", and "MAR", dated 9/7/24 were reviewed. The "PAF" indicated Pt 27's pain was assessed on 9/7/24 at 5:32 a.m. as nine (severe). The "MAR" indicated, on 9/7/24 at 5:32 a.m. Pt 27 was administered 10 mg oxyCODONE by mouth. RN 1 stated Pt 27's pain was reassessed on 9/7/24 at 8 a.m. as zero. RN 1 stated, Pt 27 should have had a pain reassessment on 9/7/24 at 6:32 a.m. one hour after pain medication was administered. RN 1 stated pain reassessments were important to evaluate the effectiveness of administered medications.

During a review of Pt 27's "MO 1", dated 9/2/24 at 12:50 a.m., the "MO 1" indicated, " ... oxyCODONE [narcotic medication for moderate to severe pain] ... 10 mg ... 2 tab ... Oral ... Q4hr [every 4 hours] ... PRN [as needed] ... Pain Severe ...".

During a concurrent interview and record review on 9/12/24 at 10 a.m. with RN 1, Pt 27's "PAF", and "MAR", dated 9/7/24 were reviewed. The "PAF" indicated Pt 27's pain was assessed on 9/7/24 at 5:32 a.m. as nine (severe). The "MAR" indicated, on 9/7/24 at 5:32 a.m. Pt 26 was administered 10 mg oxyCODONE by mouth. RN 1 stated Pt 27's pain was reassessed on 9/7/24 at 8 a.m. as zero. RN 1 stated, Pt 26 should have had a pain reassessment on 9/7/24 at 6:32 a.m. one hour after pain medication was administered. RN 1 stated pain reassessments were important to evaluate the effectiveness of administered medications. During a review of Pt 27's "MO 1", dated 9/2/24 at 12:50 a.m., the "MO 1" indicated, " ... oxyCODONE [narcotic medication for moderate to severe pain] ... 10 mg ... 2 tab ... Oral ... Q4hr [every 4 hours] ... PRN [as needed] ... Pain Severe ...".

During a review of Pt 5's "H&P, dated 8/26/24, the "H&P" indicated, Pt 5 arrived in the Emergency Department (ED) on 8/25/24 at 6:33 p.m. with abdominal (stomach) pain. Pt 5 was admitted to the hospital as an inpatient on 8/25/24 at 11:58 p.m. with diverticulitis (small pouches in the intestines become inflamed or infected), with micro perforation (a very small hole/puncture), and sepsis (serious infection that can lead to lead to tissue damage organ failure or death).

During a review of Pt 5's "Medication Order (MO 1)", dated 8/25/24 at 6:54 p.m., the "MO 1" indicated, " ... Acetaminophen [a pain reliever medication] ... 1,000 milligrams [mg - a unit of measurement] ... 2 tab [tablets] ... Oral ... STAT [immediately] ...".
During a review of Pt 5's "MO 2", dated 8/25/24 at 7:42 p.m., the "MO 2" indicated, " ... oxyCODONE [narcotic medication for moderate to severe pain] ... 10 mg ... 2 tab ... Oral ... STAT ...".

During a concurrent interview and record review on 9/16/24 at 4:31 p.m. with RNQ 1, Pt 5's "PAF", and "MAR", dated 8/25/24 to 8/26/24 were reviewed. RNQ 1 stated Pt 5's pain was assessed on 8/25/24 at 6:40 p.m. as 10 (severe). RNQ 1 stated, a pain score of 1-3 was mild pain, 4-6 was moderate pain and 7-10 was severe pain. The "MAR" indicated, on 8/25/24 at 6:58 p.m. Pt 5 was administered 1,000 mg acetaminophen. RNQ 1 stated Pt 5's pain was reassessed on 8/25/24 at 8:13 p.m. as an eight (severe). RNQ 1 stated, Pt 5 should have had a pain reassessment on 8/25/24 at 7:58 p.m. one hour or less after pain medication was administered.

During a concurrent interview and record review on 9/16/24 at 4:40 p.m. with RNQ 1, Pt 5's "PAF", and "MAR" dated 8/25/24 to 8/26/24 were reviewed. RNQ 1 stated, on 8/25/24 at 8:10 p.m. Pt 5 was administered 10 mg oxyCODONE for a pain score of 8. The "PAF" indicated, pain or sedation level (level of drug-induced sleep) was not assessed again until 8/26/24 at 2:32 a.m. The pain reassessment was documented as "no actual pain present", no numerical score was associated with the pain reassessment. RNQ 1 stated a pain reassessment should have been completed on 8/25/24 at 9:10 p.m. one hour after administration of the narcotic medication. RNQ 1 stated pain reassessments were important to ensure patients were getting pain control as well as not being overly sedated by pain medications.

During a review of Pt 10's "H&P", dated 9/9/24, the "H&P" indicated, Pt 10 was admitted to the hospital as an inpatient on 9/9/24 at 7:20 p.m. with acute cholecystitis (redness and swelling of gallbladder [pouch like organ in upper right of stomach]) and presumed gallstone pancreatitis (swelling of pancreas [organ behind stomach that produces digestive juices and hormones]) Pt 10 was admitted for laparoscopic cholecystectomy (small holes in stomach for small instrument to remove gallbladder).
During a review of Pt 10's "MO 1", dated 9/13/24 at 6:06 p.m., the "MO 1" indicated, " ... acetaminophen - HYDROcodone [narcotic medication] ... 325 mg [acetaminophen] 5 mg [HYDROcodone] ... 1 tab ... Oral ... Q4hr [every 4 hours] ... PRN [as needed] ... Pain Mild ... [1-3] ...".

During a concurrent interview and record review on 9/17/24 at 9:15 a.m. with RNQ 1, Pt 10's "PAF", and "MAR" dated 9/13/24 were reviewed. RNQ 1 stated, on 9/13/24 at 5:48 p.m. Pt 10 was administered 325 mg-5 mg acetaminophen HYDROcodone for a pain score of 3. The "PAF" indicated, on 9/13/24 at 8 p.m. a pain reassessment of three was documented. Pt 10's "PAF" indicated a pain acceptable intensity score of 3. RNQ 1 stated a pain reassessment should have been completed on 9/13/24 at 6:48 p.m. one hour after administration of the narcotic medication.

During a concurrent interview and record review on 9/13/24 at 9 a.m. with the Director of Women and Children Services (DWC) and Registered Nurse (RN) 4, Pt 38's H&P was reviewed. The H&P indicated, Pt 38 was a 33-year-old, gravida (G- the total number of confirmed pregnancies) 4 para (P- the number of live births) 2 at 35.6 weeks gestation (the period of time when something is conceived and developed; normal gestation is 40 weeks). Pt 38 was admitted for severe preeclampsia (a serious blood pressure condition that develops during pregnancy) for a repeat cesarean section (C/S- the surgical delivery of a baby through a cut made in the birth parent's abdomen and uterus).

During a concurrent interview and record review on 9/13/24 at 9:05 a.m. with the DWC and RN 4, Pt 38's "Medication Administration Record (MAR)," dated 9/12/24, and "Pain Assessment Flowsheet (PAF)," dated 9/12/24 were reviewed. The MAR indicated, " ...acetaminophen-hydrocodone ... 325 [milligrams (mg-unit of measure)]-10 mg oral) ... 1 tab ... [every] 4 [hour] [as needed] ..." The MAR indicated Pt 38 was administered acetaminophen-hydrocodone 325 mg-10mg by mouth at 8:41 a.m. RN 4 stated the PAF indicated Pt 38 had a pain assessment at 8 a.m. and 2 p.m. which indicated Pt 38 had no pain. RN 4 stated Pt 38 did not have a pain assessment completed when Pt 38 was administered pain medication at 8:41 a.m. nor did Pt 38 have a pain reassessment within one hour of pain medication administration. The MAR indicated Pt 38 was administered acetaminophen-hydrocodone 325 mg-10mg by mouth at 3:35 p.m. with a pain score of 9 (severe) out of 10 (Mild Pain=score of 1-3, Moderate Pain=score of 4-6, Severe Pain=score of 7-10). RN 4 stated the PAF indicated Pt 38's pain was not reassessed until 9:44 p.m. (a lapse of 6 hours and 9 minutes). RN 4 stated pain medication administered by mouth should be reassessed within the hour. RN 4 stated a pain assessment before administering pain medication was to make sure the appropriate pain medication is administered for the patient's pain score. RN 4 stated there were different pain medications for different pain scores. RN 4 stated a pain assessment should have been reassessed within the hour after pain medication administration to make sure it was effective and there were no side effects (undesirable effect of a drug). The DWC stated she expected LNs to complete a pain assessment and/or reassessment when pain medication was administered.

During a concurrent interview and record review on 9/13/24 at 2:02 p.m. with Shift Manager (SM) 2, Pt 45's "Consult Note (CN)," dated 9/12/24 and "Face Sheet (FS-a document that contains a summary of a patients' personal information), dated 9/13/24, were reviewed. The CN indicated, " ... 77 [year-old] [female] [past medical history] [gastroesophageal reflex disease (GERD- a common condition in which the stomach contents move up into the esophagus)], [hypertension- when the pressure in your blood vessels is too high] ... epigastric [abdominal] pain 9/10/2024 ..." The FS indicated Pt 45 was admitted to the facility on 9/12/24 at 1:40 p.m. for a small bowel obstruction (a blockage in the small intestine that prevents food, liquid, gas, and stool from passing through normally).

During a review of Pt 45's physician "Medication Order (MO)", dated 9/11/24 at 11:15 a.m., the MO indicated, " ... morphine [narcotic medication used for moderate to severe pain] ... 4 mg ... Injection [administering a liquid] ... IV Push [IVP -pushing into intravenous line] ... Q4hr [every 4 hours] ... PRN [as needed] ... PRN reason ...Abdominal Pain ...".

During a concurrent interview and record review on 9/13/24 at 2:10 p.m. with SM 2, Pt 45's "MAR," dated 9/10/24 to 9/12/24, and "PAF," dated 9/10/24 to 9/12/24, were reviewed. The MAR indicated Pt 45 was administered morphine 4 mg IVP on 9/10/24 at 8:50 p.m. and 9/11/24 at 1:37 a.m. The PAF indicated Pt 45's had a pain assessment on 9/10/24 at 8:02 p.m. with a pain score of 5 (moderate) and the next pain assessment was 9/11/24 at 7:18 a.m. with no pain (a lapse of 11 hours and 16 minutes). SM 2 stated Pt 45 did not have a pain reassessment within 30 minutes to an hour to see if the pain medication was effective. SM 2 stated Pt 45 did not have a pain assessment before administering morphine 4 mg IVP on 9/11/24 at 1:37 a.m. and a pain reassessment was not completed within 30 minutes to an hour. The MAR on 9/11/24 at 11:18 a.m. indicated Pt 45 received morphine 4 mg IVP and a pain score of 9 (severe). SM 2 stated the PAF indicated Pt 45 did not have a pain reassessment within 30 minutes to an hour. The PAF indicated the next pain assessment was on 9/11/24 at 9:14 p.m. with no pain (a lapse of 9 hours and 56 minutes). The MAR on 9/11/24 at 8:14 p.m. indicated Pt 45 received morphine 4 mg IVP. SM 2 stated the PAF indicated Pt 45 did not have a pain assessment when morphine 4 mg IVP was administered on 9/11/24 at 8:14 p.m. The MAR indicated Pt 45 was administered morphine 4 mg IVP on 9/12/24 at 1:50 p.m. SM 2 stated the PAF indicated Pt 45 did not have a pain assessment when morphine 4 mg IVP was administered on 9/12/24 at 1:50 p.m. SM 2 stated the PAF indicated Pt 45 had a pain reassessment on 9/12/24 at 2:48 p.m. (a lapse of 58 minutes) with no pain.

During a concurrent interview and record review on 9/13/24 at 2:25 p.m. with SM 2, Pt 45's "MAR," dated 9/13/24 and "PAF," dated 9/13/24 were reviewed. The MAR at 6:16 a.m. indicated Pt 45 was administered hydromorphone (a medication to treat moderate to severe pain) 1 mg IVP with a pain score of 8 (severe). SM 2 stated the PAF indicated Pt 45 had a pain assessment at 9:50 a.m. (a lapse of 3 hours and 34 minutes) with a pain score of 5 (moderate). SM 2 stated Pt 45 did not have a pain assessment completed within 30 minutes to an hour after pain medication administration. The MAR at 10:45 a.m. indicated Pt 45 was administered hydromorphone 1 mg IVP with a pain score of 7 (severe). SM 2 stated the PAF indicated Pt 45 did not have a pain reassessment as of current time (2:33 p.m.). SM 2 stated Pt 45 did not have a pain reassessment completed within 30 minutes to an hour.

During a concurrent interview and record review on 9/17/24 at 1:48 p.m. with RN 5, Pt 50's "Emergency Department Note - Physician (EDNP)," dated 9/10/24 was reviewed. The EDNP indicated, " ...a 73-year-old female patient with no known past medical history ... was brought in by [ambulance] from [Name of Shelter] with complaints of nausea, vomiting and headache ..."

During a concurrent interview and record review on 9/17/24 at 1:48 p.m. with RN 5, Pt 50's "MAR," dated 9/10/24 and "PAF," dated 9/10/24 were reviewed. The MAR at 8:15 a.m. indicated Pt 50 received acetaminophen 1,000 mg by mouth. RN 5 stated the PAF indicated Pt 50 had a pain assessment at 7:29 a.m. with a pain score of 4 (moderate) and 11:21 a.m. with no pain. RN 5 stated Pt 50 should have had a pain reassessment completed within one hour after pain medication administration.

During an interview on 9/16/24 at 3:17 p.m. with Director of Patient Care Services (DPCS) 1, DPCS 1 stated, nursing staff were expected to reassess patients after pain medication was administered. DPCS 1 stated nursing staff were expected to complete a full pain assessment daily and with vital signs, every four hours. DPCS 1 stated nursing staff were expected to document pain assessments.

During an interview on 9/16/24 at 3:25 p.m. with DPCS 3, DPCS 3 stated, nursing staff were expected to reassess patients within one hour or sooner after administration of pain medications. DPCS 2 stated nursing staff were expected to complete comprehensive, complete pain assessments and to document the pain assessments according to hospital policy.

During an interview on 9/16/24 3:40 p.m. with DPCS 2, DPCS 2 stated, her expectation was for nursing staff to complete pain assessments every shift and within an hour after pain medications were administered. DPCS 3 stated, her expectation was for nursing staff to follow hospital policy for pain assessments.

During an interview on 9/17/24 at 4:20 p.m. with the Chief Nursing Officer (CNO), the CNO stated, nursing staff were expected to reassess patients within one hour after administration of pain medications. The CNO stated nursing staff could speak to physicians for additional or different medications when pain was not controlled. The CNO stated nursing staff were expected to document responses to pain medications timely.

During a review of the facility's "P&P" titled, "PC.AD.1.24 Pain Management Policy," dated 4/27/22, the "P&P" indicated " ... Conduct an appropriate assessment and/or reassessment of a patient's pain consistent with the scope of care, treatment, and service ... The 0-10 Numeric Rating scale shall be used to score pain as appropriate using the "Mild, Moderate, and Severe" pain indications referenced ... A focused reassessment for the presence and intensity of pain shall be performed as a component of the shift assessment ... and any intervention intended to lessen the patient's pain (e.g., administration of pain medications ...) ... ongoing and dynamic process which shall take place within a clinically appropriate time frame ...".

During a professional reference review titled, "Pain management in hospitals: patients' satisfaction and related barriers," dated 9/25/18, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207353/) indicated, " ... Suboptimal pain control has been frequently reported in healthcare settings and documented to negatively impact patients' health. Patients' perception regarding pain management may influence their satisfaction regarding treatment ...".

During a professional reference review titled, "Acute Pain Management Pearls: A Focused Review for the Hospital Clinician," dated 12/22/22, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9818465/) indicated, " ... Uncontrolled pain worsens patient outcomes ... Uncontrolled acute pain triggers a complex neurohormonal cascade that is toxic to nearly every organ system, as evidenced by increased rates of renal [kidney] and gastrointestinal [stomach and intestine] dysfunction, infection, cardiopulmonary [heart and lungs] and thrombotic [blood clot] complications, impaired wound healing, adverse psychological effects, and poorer functional recovery and quality of life ... Acute pain management in hospitalized patients should therefore be a clinician and intuitional priority as a key driver of patient outcomes ...".

2. During a concurrent interview and record review on 9/12/24 at 2:22 p.m. with RN 1, Pt 49's "H&P," dated 9/4/24, was reviewed. The "H&P" indicated Pt 49 was admitted to the hospital on 9/4/24 at 3:06 a.m. with a one-day history of being "found down [patient found on the ground]" Pt 49 was admitted for severe sepsis (life-threating infection), multiple pressure injuries (areas of damaged skin caused by prolonged pressure on the body), and metabolic encephalopathy (brain dysfunction caused by chemical imbalance, can cause confusion).

During a review of "Physician Order (PO)", dated 9/4/24, the "PO" indicated, " ... Turn Patient ... Q2hr [every two hours] ...".

During a concurrent interview and record review on 9/12/24 at 2:27 p.m. with RN 1 Pt 49's "Braden Assessment (Braden) [Braden Score - given to determine risk of PI, a score of less than 18 indicates a risk for PI]", dated 9/4/24 to 9/9/24 was reviewed. The "Braden" indicated on 9/4/24 LNs scored Pt 49 a 12 (high risk) of developing a PI. The "Braden" indicated Pt 49 had very limited mobility (makes occasional changes in body position but unable to make big changes independently), was bedfast (confined to bed), had slightly limited sensory perception (ability to respond to pressure related discomfort), and had poor nutrition (never/rarely ate a complete meal). RN 1 stated the lower the Braden score the higher the chances a patient may develop a PI. RN 1 stated a limited mobility patient had a higher potential for PIs unless repositioned by staff timely.

During a concurrent interview and record review on 9/12/24 at 2:35 p.m. with RN 1, Pt 49's "Adult ADLs (ADL) [ADL-activities of daily living]" flowsheet, dated 9/4/24 to 9/10/24 were reviewed. The "ADL" indicated, Pt 49 was positioned by staff on 9/9/24 at 4 a.m. and then not positioned (turned) again until 9/10/24 at 8:01 a.m., 28 hours later. RN 1 stated Pt 49's "ADL" had documentation on 9/9/24 at 8:05 a.m., and 9/9/24 at 8:30 p.m. indicating Pt 49 was on a low air loss mattress, but no turns were documented. RN 1 stated LNs documented Pt 49's activity status as complete bedrest (staying in bed most of the time). RN 1 stated LNs documented 49's activity assistance as "total assist [required full physical assistance for re-positioning, standing, turning, transfers, and/or mobility]". RN 1 stated Pt 49 should have been re-positioned every two hours. RN 1 stated skin breakdown and PI could occur when patients were not turned or repositioned.

During a concurrent interview and record review on 9/12/24 at 2:54 p.m. with RNQ 1, Pt 25's "H&P," dated 7/31/24, was reviewed. The "H&P" indicated Pt 25 was a 72-year-old patient admitted to the hospital on 7/31/24 at 4:15 p.m. for sepsis.
During a review of "Physician Order (PO)", dated 7/31/24, the "PO" indicated, " ... Turn Patient ... Q2hr [every two hours] ...".
During a concurrent interview and record review on 9/12/24 at 2:54 p.m. with RN 1 Pt 25's "Braden," dated 9/1/24, was reviewed. The "Braden" indicated on 9/1/24 LNs scored Pt 25 a 13 (moderate risk) of developing a PI. RN 1 stated Pt 25 was scored an 8 (severe risk) when admitted to the hospital on 7/31/24. The "Braden" indicated Pt 25 had "very limited mobility," was bedfast, had slightly limited sensory perception, and had inadequate nutrition (rarely ate a complete meal). RN 1 stated patients who had inadequate nutrition were at a higher risk for PI.

During a concurrent interview and record review on 9/12/24 at 2:35 p.m. with RN 1, Pt 25's "ADL" flowsheet, dated 9/1/24 to 9/10/24 were reviewed. The "ADL" indicated, Pt 25 was positioned by staff on 9/1/24, 9/3/24 and 9/9/24 at 6 p.m. and not repositioned again until 8 a.m. the following morning, 14 hours later. RN 1 stated Pt 25's "ADL" had documentation on 9/1/24, 9/3/24 and 9/9/24 at 8 p.m. indicating Pt 25 was on a low air loss mattress, but no turns were documented. The "ADL" indicated Pt 25 was positioned by staff on 9/2/24 at 6 p.m. and not repositioned again until midnight, six hours later. RN 1 stated Pt 25 should have been re-positioned every two hours. RN 1 stated LNs documented Pt 25's activity status as complete bedrest (staying in bed most of the time). RN 1 stated LNs documented Pt 25's activity assistance as "total assist [required full physical assistance for re-positioning, standing, turning, transfers, and/or mobility]". RN 1 stated skin breakdown and PIs could occur when patients were not turned or repositioned.

During an interview on 9/16/24 at 3:15 p.m. with DPCS, DPCS 1 stated patients who are bedridden and were total assist patients had a higher potential for PI. DPCS 1 stated her expectation was for LNs to protect patients' skin from PIs, by following the hospitals policy and procedure.

During an interview on 9/17/24 at 4:30 p.m. with the CNO, the CNO stated LNs were expected to assess patients' skin at least once per shift including under pressure reduction dressings. The CNO stated her expectation was for staff to reposition patients to prevent PIs.

During a review of the hospital's P&P titled, "Pressure Injury Prevention and Management Policy," dated 6/23/21, indicated, " ... RNs will complete a comprehensive skin assessment with each shift re-evaluating as needed ... Risk assessment includes determining a person's risk for pressure ulcer developing using the appropriate Braden scale; preventative interventions will target risk factors as determined by risk assessment. ... When a patient is identified as High Risk (Braden score of less than or equal to 18: Order and initiate "Tissue Skin Integrity Care" plan ... Attachments: ... Braden Pressure Reduction Measure ... Initiate a turn schedule ... Turn patients at least every 2 hours ...".

During professional reference review titled, "The Braden Scale and How it Predicts Pressure Injury Risk", dated 3/5/24, indicated, " ...19-23 equals no risk, 15-18 equals mild risk, 13-14 equals moderate risk, 10-12 equals high risk, < 9 [< - less than] equals severe risk ..." for pressure injury. Each assessment category was scored one through four, with six categories. Category one sensory perception, two moisture, three activity, four mobility, five nutrition, and category six friction and shear.
During a review of professional reference titled, "Turning and Repositioning Frequency to Prevent Hospital-Acquired Pressure Injuries Among Adult Patients: Systematic Review," dated 2023, indicated " ... Turning and repositioning is considered one of the strategies to reduce the incidence of pressure injuries (PI)s among hospitalized patients, as it helps to redistribute and minimize direct pressure on targeted skin and enhance blood perfusion in the affected areas ...".

3. During a concurrent interview and record review on 9/12/24 at 4:10 p.m. with the Director of Women and Children Services (DWC) and Registered Nurse (RN) 4, Pt 39's "History and Physical (H&P)," dated 9/6/24, was reviewed. The H&P indicated, " ...31-year-old female [gravida-the total number of confirmed pregnancies] 6 [para- the number of live births] 3 at 23 weeks 5 days. Patient presents to labor and delivery complaining of mild abdominal pain and leaking from the vagina. ... Ultrasound [a procedure that uses high-energy sound waves to look at tissues and organs inside the body] was performed and patient was found to have a collection [a collection of fluid] under the placenta. This has concerns for placental abruption [a serious complication that occurs when the placenta separates from the uterine wall before birth] ... a history of previous cesarean section [C/S- the surgical delivery of a baby through a cut made in the birth parent's abdomen and uterus] ..."

During a concurrent interview and record review on 9/12/24 at 4:15 p.m. with the DWC and RN 4, Pt 39's "Electronic Medical Record (EMR-an electronic record of health-related information on an individual)," dated 9/6/24, and "Fundal/Lochia (FL)" flowsheet, dated 9/6/24 were reviewed. RN 4 stated Pt 39 delivered at 10:04 a.m. The FL indicated, Pt 39 had fundal (top of uterus) and lochia (vaginal discharge after birth, bleeding) assessments at 10:37 a.m., 10:50 a.m., 11:09 a.m., 11:25 a.m., and 1 p.m. RN 4 stated Pt 39 should have received four more fundal and lochia assessments in the second hour after delivery. RN 4 stated fundal and lochia assessments after delivery were important to ensure the patient's bleeding was under control and the fundus was firm. RN 4 stated the patient could hemorrhage (a loss of blood) at any time. The DWC stated she expected LNs to complete fundal and lochia assessments according to the facility procedure.

During an interview on 9/17/24 at 10:10 a.m. with the DWC, the facility's document, "Vital Signs, Fetal and Uterine Assessments," undated, was reviewed. The document indicated, " ...Immediate Vaginal Delivery and Recovery ... [Blood Pressure], [Pulse], [Respiration Rate], Uterus Tone, Bladder, Lochia, Perineum ... [every] 15 [minutes] [for] minimum 2 [hours] ..." The DWC stated the facility used Elsevier standards of practice. The DWC stated this document was a "policy" LNs followed.

4. During a concurrent interview and record review on 9/12/24 at 10:43 a.m. with the Director of Wome

Based on interview and record review, the facility failed to ensure medications were administered in accordance with physician medication orders and the facility's policy and procedure (P&P) titled "Medication Administration Policy" when:

1. Licensed Nurses (LNs) did not administer dopamine (a medicine is used to treat low blood pressure) in accordance with physician orders for one of one sampled patient (Pt 42) when LNs administered dopamine continuous intravenous (IV) drip (the administration of a fluid into a blood vessel, usually over a prolonged period of time) for Pt 42 to treat hypotension (low blood pressure) and the dopamine dose rate was not titrated (the medication dose is either progressively increased or decreased in response to the patient's status) in accordance with the physician medication order.

This failure placed Pt 42 at risk of serious harm from fluctuating blood pressure.

2. LNs titrated an amino acids (used for nutritional support of newborn babies) IV infusion without a physician medication order for one of one sampled patient (Pt 41).

This failure placed Pt 41 at risk for harm of nutritional deficiencies.

Findings:

1. During a concurrent interview and record review on 9/13/24 a 10:36 a.m. with the Assistant Director of Women and Children Services (ADWC), Pt 42's "History and Physical (H&P)," dated 9/6/24, the H&P indicated, Pt 42 was born on 9/6/24 at 10:04 a.m. by cesarean section (C/S- the surgical delivery of a baby through a cut made in the birth parent's abdomen and uterus) at 23 weeks and 6 days gestation (the period of time when something is conceived and developed; normal gestation is 40 weeks). The ADWC stated Pt 42 was admitted to the Neonatal Intensive Care Unit (NICU- a hospital unit that provides specialized care for premature or sick newborn babies) due respiratory distress syndrome (RDS- a condition that makes it difficult for newborns to breathe due to immature lungs) and a premature baby (a baby born before 37 weeks of pregnancy).

During a concurrent interview and record review on 9/13/24 at 10:40 a.m. with (ADWC), Pt 42's physician "Medication Orders (MO)," dated 9/12/24, and "Medication Administration Record (MAR)," dated 9/12/24 were reviewed. The PO indicated, " ...NICU dopamine [intravenous (IV-into the vein)] additive 400 [milligrams (mg-unit of measure)] + NICU D5W [a type of IV fluid that contains a 5% solution of dextrose (glucose) in water)] Premix Diluent 250 [milliliters (mL-unit of measure)] ... 9/12/24 [8:44 p.m.] ... Indication: hypotension ...Start at 5 [micrograms (mcg-unit of measure)] / [kilogram (kg-unit of measure)] / min [minute] ... Titrate by 1 mcg/kg/min every 20 min ... Maximum dose: 10 mcg/kg/min ... [10:34 p.m.] ... Start at 5 mcg/kg/min ... Titrate by 1 mcg/kg/min every 20 min ... Maximum dose: 20 mcg/kg/min ..." The MAR indicated, " ... [9:40 p.m.] Begin Bag ...10 mcg/kg/min ... [10:35 p.m.] Rate Change ...20 mcg/kg/min ..." The ADWC stated the dopamine drip was not titrated by 1 mcg/kg/min every 20 minutes according to the MO. The ADWC stated the nurse practitioner was at bedside and instructed to change the rate to 10 mcg/kg/min instead of the ordered start rate of 5 mcg/kg/min. The ADWC stated the physician medication order should have been modified to reflect the start rate dose and not the maximum dose. The ADWC stated the physician medication order should reflect the administration of dopamine in the MAR.

During a review of the facility's P&P titled, "PC.AD.1.21 Medication Administration Policy," approved 7/24/24, the P&P indicated, " ...PURPOSE: Assure the safe and timely administration of medications throughout the organization ... POLICY ...Orders for Medications ...In accordance with standard practice, practitioner orders for the administration of drugs and biological must include at the least the following: Name of the patient; Age and weight of the patients, or other dose calculation requirements (e.g. titration parameters [how a medication dose is adjusted over time]), where applicable; Date and time of the order ... Drug name; Dose, frequency [the amount of times it should be completed or administered], and route [the location at which the drug is administered]; ... Exact strength [the amount of drug in a given dosage form] and concentration [the amount of active ingredient per total weight of a substance], when applicable; Quantity and/or duration, when applicable; Specific instructions for use, when applicable; and Name of the prescriber ... Basic Safe Medication Administration Practices ...Staff shall confirm the following prior to administering each medication: Patient identification ...The correct medication ...The correct dose: To ensure that the dosage matches the ordered dose and does not reflect an unsafe dosage level (i.e., a dose that is too high or too low); ...The correct route ...The appropriate time: To ensure adherence to the ordered frequency and time of administration ... All parts of the medication order shall be reviewed, including additional instructions and parameters for use ..."

2. During a review of Pt 41's "History and Physical (H&P)," dated 9/10/24, the H&P indicated Pt 41 was born on 9/10/24 at 2:55 p.m. at 35 weeks and 6 days gestation. Pt 41 was admitted to the NICU for respiratory distress and sepsis evaluation (involves a combination of laboratory tests, imaging tests, and clinical findings).

During a concurrent interview and record review on 9/13/24 at 11:35 a.m. with the Assistant Director of Women and Children Services (ADWC), Pt 41's physician "Medication Orders (MO)," dated 9/10/24 to 9/11/24, and "Medication Administration Record (MAR)," dated 9/10/24 to 9/11/24 were reviewed. The MO indicated, " ...Amino Acids ...glucose ...sterile water ...heparin ... ...9/10/24 [4:33 p.m.] Route of administration ...IV ... Rate ...9 ... Rate unit ... [milliliters (mL-unit of measure)] / hr [hour] ... 9/11/24 [5:28 p.m.] ... Rate ...3 ..." The MAR indicated Pt 41 was administered amino acid infusion on 9/10/24 at 4:57 p.m. at a rate of 9 mL/hr. The MAR indicated on 9/11/24 at 11:03 a.m. the rate was changed to 4 mL/hr. The ADWC stated there was no physician medication order to change the rate to 4 mL/hr. The MAR indicated on 9/11/24 at 2:03 p.m. the rate was changed to 3 mL/hr. The ADWC stated the MO indicated the rate change order was placed on 9/11/24 at 5:28 p.m. (a lapse of 3 hours and 25 minutes after the rate was changed). The ADWC stated the MO for amino acid infusion was not a titratable medication. The ADWC stated LNs should receive an order from the physician to modify the rate change each time.

During a review of the facility's P&P titled, "Medication Administration Policy," approved 7/24/24, the P&P indicated, " ...PURPOSE: Assure the safe and timely administration of medications throughout the organization ... POLICY ...Orders for Medications ...In accordance with standard practice, practitioner orders for the administration of drugs and biological must include at the least the following: Name of the patient; Age and weight of the patients, or other dose calculation requirements (e.g. titration parameters), where applicable; Date and time of the order ... Drug name; Dose, frequency, and route; ... Exact strength and concentration, when applicable; Quantity and/or duration, when applicable; Specific instructions for use, when applicable; and Name of the prescriber ... Basic Safe Medication Administration Practices ...Staff shall confirm the following prior to administering each medication: Patient identification ...The correct medication ...The correct dose: To ensure that the dosage matches the ordered dose and does not reflect an unsafe dosage level (i.e., a dose that is too high or too low); ...The correct route ...The appropriate time: To ensure adherence to the ordered frequency and time of administration ... All parts of the medication order shall be reviewed, including additional instructions and parameters for use ..."

Based on interview and record review, the hospital failed to ensure physician telephone orders were authenticated (verified and signed) in patient's medical records within 48 hours in accordance with approved hospital policy and procedures for one of one patient (Pt 36).

This failure resulted in unverified physician orders and had the potential for inappropriate treatment and/or care of Pt 36.

Findings:

During a concurrent interview and record review on 9/12/24 at 10:43 a.m. with the Director of Women and Children Services (DWC), Pt 36's "History and Physical (H&P)," dated 9/6/24, was reviewed. The H&P indicated, " ...28 year old [gravida-the total number of confirmed pregnancies] 1 [para- the number of live births] 0 at 41.0 weeks gestation [the period of time when something is conceived and developed] presenting for scheduled induction of labor [IOL- when a medical professional uses medication or other methods to start labor before it begins on its own] ..."

During a concurrent interview and record review on 9/12/24 at 10:50 a.m. with the DWC, Pt 36's "Orders," dated 9/6/24 was reviewed. The Orders indicated, " ...OB Antepartum - Intrapartum ... Initiated and Electronically Signed by [Registered Nurse (RN) 7]-09/06/2024 [8:16 a.m.], Phone Read Back-Authentication ..." The DWC stated there was no physician signature for the telephone order received by RN 7. The DWC stated physician telephone orders required physician authentication within 48 hours.

During a concurrent interview and record review on 9/12/24 at 10:55 a.m. with the DWC, Pt 36's "Orders," dated 9/9/24 was reviewed. The Orders indicated, " ...Original order entered and electronically signed by [RN 8] on 09/09/2024 at [3:16 a.m.]. Phone Read Back-Authentication Required order by [MD] ... oxytocin [a synthetic hormone that helps speed up delivery or controls bleeding after childbirth] [intravenous] additive ..." The DWC stated there was no physician signature of the telephone order received by RN 8.

During a review of the facility's "Medical Staff Rules & Regulations," dated 4/29/21, page 12 indicated, " ...ORDERS ... All verbal orders for medications shall be authenticated, including the date and time of authentication, by the responsible or covering Practitioner within forty-eight (48) hours ..."

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection when:

1. Multiple drawers in the food preparation areas of the kitchen had build-up of crumbs, one drawer had a binder with food crusts and personal items. According to the FDA Federal Food Code, all non-food contact surfaces of the kitchen should be kept clean.

2. The floor underneath the fixed equipment in the kitchen had a buildup of trash, food, grease, and black grime. There was a build-up of food in the floor drain that was under a reach- in refrigerator. According to the FDA Federal Food Code, all non-food contact surfaces of the kitchen should be kept clean.

3. Shelves in 3 reach-in refrigerators in the kitchen near the tray line area (where food is plated for the patients) were coated in metal chards and build-up of black dust like substance. The plate warmer had a build-up of food crumbs. A commercial food warmer (used to keep food warm prior to service) had a build-up of black and red grime and convection ovens had a build-up of red and black grime. According to the FDA Federal Food Code, all non-food contact surfaces of the kitchen should be kept clean.

4. Five (5) of 27 ice machines (IMs) on the facility main campus were observed to be visibly soiled and were not maintained according to facility P&P and manufacturer instructions for use (IFU)s .

The ice machine in the main kitchen [IM 1] and another in the 3 West unit nourishment room [IM 2] had a pink or black slime build-up.

The ice machine in the 4 North Medical Surgical pantry room [IM 3], had a black residue in the water catch sink area of the machine.

The Ice machines in the Cardiovascular Intensive Care Unit (CVICU) and Critical Care Unit (CCU) (two of two (2) sampled ice machines were visibly soiled and covered in white colored stains. The ice machine in the CVICU ice machine [IM 4] had visible white-colored and textured splash stains on the stainless-steel surfaces and the water collection trays and black-colored debris was observed on white tissue after wiping the ice dispenser spout.
The CCU ice machine [IM 5] had visible, pink-colored stains in the ice shoot and spray guard covering.

5. One of one surgical instrument trays was stored on a trash can, and not in accordance with standards published by the American National Standards Institute and the Association for the Advancement of Medical Instrumentation (ANSI/AAMI - a primary source for the development, management, and use of safe and effective health technologies for the medical device industry, as well as practical information, support, and guidance for healthcare technology and sterilization professionals).

6. An Intravenous (IV) administration set (connects the bag of solution to the patient's IV access site) was not labeled with date and time of initiation for two of two patients (Pt 36 and Pt 45) in accordance with hospital policy and procedure.

7. Expired formula and formula sterile water was found in the Emergency Department (ED) supply room.

8. Four (4) of 4 sampled pill crushers (a device that turns pills into powder) were not cleaned per manufacturer recommendation in the CVICU and CCU. The pill crushers were observed to be visibly soiled with white-colored chalk-like residue, and brown and orange-colored stains to metal pieces and throughout the device.

9. The hospital did not ensure two (2) "brand name" pouches (" ...consists of a layer of highly absorbent material sandwiched between two layers of water-proof film ...") used to "place individual instruments (soiled processable patient care equipment), or an entire instrument tray inside the "brand name" pack, add the specified amount of water to the absorbent layer, and seal with the peel away adhesive strip; this creates a water tight, moist atmosphere that will prevent organics (relating to or derived from living matter such as human skin and blood, and/or bacteria) from drying over an extended period of time ..." inside the red container were sealed as required per manufacturer instructions for use (IFUs).

This failure resulted in the fluids leaking and pooling inside and at the bottom of the red biohazard collection tray (a rigid plastic container with clasp shut lid) used to store pouches on the unit for pick-up by the Sterile Processing Department (SPD) had the potential to harm patients; pre-soak cleansing is one of many steps in the reusable patient equipment sterilization process and harm staff from splash of contaminants to staff handling the red tray(s).

10. Licensed nurses (LNs) in the Emergency Department (ED) failed to discard sharps (medical devices like needles, scalpels, and other tools that cut or go into the skin) in a sharps container ( made from rigid puncture-resistant plastic or metal with leak-resistant sides and bottom, and a tight-fitting, puncture-resistant lid with an opening to accommodate depositing a sharp but not large enough for a hand to enter) when a used IV catheter insertion needle, a small plastic dark red fluid-filled container, and a binder with a red smudge was observed to be on top of a crash cart in an occupied patient room and an empty bag of IV fluids (liquids that are administered directly into a vein to replace water, sugar, and salt) was observed laying on the floor and not discarded in accordance with the expectations of the CNO, after use of inserting an intravenous (IV) catheter (a flexible tube that is inserted into the body to inject or withdraw fluids, or to keep a passage open) and obtain blood sample(s) into the sharps container (rigid plastic container used to safely lock the contaminated sharps while awaiting proper disposal) per facility P&P and nursing standard of practice.

These failures had the potential to allow for the spread of infection to patients, visitors and staff coming to the hospital.

10. The hospital did not ensure staff in the CVICU followed manufacturer instructions when using specialized pouches for dirty surgical instruments.

These failures resulted in the possibility of hazardous liquid leaking from the specialized pouch and not properly pre-soaking surgical instrument for subsequent processing.

Findings:

1. During an observation in the kitchen on 9/10/24, at 2:44 p.m., a drawer in the food preparation area had food crumbs and a 3-ring binder with recipes was covered in a food spill and crusted with old food. A drawer on the station with the toaster had a build-up of food crumbs.

During an observation in the kitchen on 9/10/24, at 3:04 p.m., a drawer near the plate warmer had a build-up of food crumbs.

During an observation in the kitchen and concurrent interview with the Senior Director of Food and Nutrition (SDFN 1) on 9/10/24, at 3:14 p.m., a drawer near the food preparation station had personal items, a purse, and a cell phone. The SDFN stated that personal items should not be stored in the food production area.

During an interview with the Registered Dietitian (RD) on 9/12/24, at 2:40 pm,p.m., RD 1 stated the drawers in the kitchen should be kept clean, with no food particles or personal items.

During a review of the FDA Federal Food Code, dated 2022, 6-305.11 indicated, "Street clothing and personal belongings can contaminate food, food equipment, and food-contact surfaces. Proper storage facilities are required for articles such as purses, coats, shoes, and personal medications."

2. During an observation in the kitchen on 9/10/24, at 2:44 p.m., the floor under the reach-in refrigerator #210 had a build-up of miscellaneous trash.

During an observation in the kitchen on 9/10/24, at 2:52 p.m., there was a floor drain under 3 reach-in refrigerators and it had a build-up of food and trash.

During an observation in the kitchen, on 9/10/24, at 3:04 p.m., the floor under the equipment of the cooking line (two ranges) had a build-up of food, trash and black grime and grease.

During an interview with the SDFN 1, on 9/11/24, at 9:40 am, a.m., the SDFN 1 stated the floors under the equipment were not on the checklist that the RD uses when she inspects the kitchen, but it needs to be added. The RD stated the floor drain should be kept clean with no food build-up.

During an interview with the RD 1, on 9/12/24, at 2:40 p.m., RD 1 indicated the floor under the equipment should always be kept clean.

During a review of the facility policy titled "Cleaning of Food and Nonfood Contact Surfaces", dated 9/22/21, indicated, nonfood contact surfaces of equipment ... shall be cleaned as often as necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris."

During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, "The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted."

3. During an observation in the kitchen on 9/10/24, at 2:52 p.m., 3 reach-in refrigerators had a build-up of metal shards and black dust on the shelves.

During an observation in the kitchen on 9/10/24, at 3:04 p.m., the plate warmer had a build-up of food crumbs.

During an observation in the kitchen on 9/10/24, at 3:11 p.m., the commercial food warmer had a build-up of red and black grime.

During an observation in the kitchen on 9/10/24, at 3:14 p.m., 6 convection ovens had a buildup of red and black grime and food crumbs.

During an interview with the RD 1 on 9/12/24, at 2:40 p.m., RD 1 stated equipment should be clean and have no build-up and no food.

During an interview with the SDFN 1, on 9/12/24, at 4:51 p.m., SDFN 1 stated they do not currently have a deep cleaning schedule for equipment or the floors. They plan to include it on their current cleaning schedule.

4. During an observation in the kitchen and concurrent interview with the Maintenance Technician 1 (MT 1) on 9/11/24, at 10 a.m., inside the ice bin of ice machine number 1, around the ice chute, there was a brown build-up and calcium build-up. Inside the ice bin of ice machine number 2, there was a build-up of pink slime. Maintenance Technician (MT) 1 stated he empties the ice bins and cleans the inside of the bin with Clorox wipes.

During an observation and concurrent interview with the Nurse Manager (NM 1) in the 3 west nourishment room, on 9/11/24, at 10:18 am, a.m., the ice chute of the ice machine had a pink slime build-up that was wipeable with a paper towel. NM 1 stated the ice is used for water pitchers for the patients. He stated 3 west is a unit for stroke (occurs when blood flow to the brain is disrupted, causing brain cells to die) and trauma patients.

During an interview with MT 1, on 9/12/24, at 11:21 p.m., MT 1 stated he does not use any brushes to scrub the inside of the ice bin. MT 1 stated moving forward he plans to scrub them to remove the hard water stains and to ensure there is no build-up of any kind.

During an interview with the RD 1, on 9/12/24, at 2:40 p.m., RD 1 indicated the ice machine should be kept clean and not have build-up inside or any discoloration.

During a concurrent observation and interview on 9/10/24 at 3:46 p.m. in the 4 North Medical Surgical pantry room, the countertop water and ice dispensing machine was observed to have a black residue in the water catch sink area of the machine. The black residue was wipeable and felt slimy when touched with a white paper towel. The area around the water shoot had black flaky residue on the inside of the clear plastic housing for the water dispensing down spout. The Director of Patient Care Services (DPCS)2 stated, patients were given ice and water from the machine, and the black slimy residue could cause infection and/or illness. The DPCS 2 stated the machine was supposed to be cleaned by environmental services, but all staff were responsible to report unclean equipment. The DPCS 2 stated unclean equipment should not be used for patients.

During a concurrent observation and interview on 9/10/24 at 2:50 p.m., with the Director of Critical Care (DCC), the Assistant Director of Critical Care (ADCC), and Shift Manager (SM) 1 in the CVICU, one of one (1) ice machines had visible white-colored and textured splash stains on the stainless-steel surfaces and the water collection trays and black-colored debris was observed on white tissue after wiping the ice dispenser spout. Both the DCC and ADCC stated their expectation was that the responsible parties for ensuring cleanliness and maintenance of the ice machines (environmental services (EVS) and maintenance departments, respectively) were following P&Ps and IFUs and staff were to alert the appropriate team to attend to the machine. The DCC stated the machine should have been free of stains and debris to prevent harboring bacteria that can increase the risk for patient harm of infection.

During a concurrent observation and interview on 9/11/24 at 10:00 a.m., with DCC, ADCC and SM 2, one (1) of 1 ice machines on the Critical Care Unit (CCU) had visible, pink-colored stains in the ice shoot and spray guard covering. The DCC stated it was his expectation that the machines were maintained per facility P&Ps and manufacturer IFUs and that nursing staff would report the need for maintenance as needed. The DCC stated the ice machine should be free of any debris and be well maintained to prevent contamination and possible patient harm of infection.

According to the manufacturer's "Brand Name" 1, instruction manual, undated, page 11 indicated the ice machine in the CVICU required " ...Cleaning/descaling and sanitizing ...Periodic cleaning/descaling and sanitizing of "brand name" ice and water dispenser and ice machine system is required to ensure peak performance and delivery of clean, sanitary ice. The recommended cleaning procedures that follow should be performed at least as frequently as recommended and more often if environmental conditions dictate ..."

According to the manufacturer's "Brand Name" 2, instruction manual, dated May 2001, page 18 indicated " ...Maintenance and Cleaning should be scheduled at a minimum of twice per year. Sanitizing of the ice storage bin should be scheduled for a minimum of 4 times a year ..."

During an interview with the Director of Infection Control (DIC 1), on 9/12/24, at 2:11 p.m., the DIC 1 stated the Environmental Services (EVS-housekeeping staff) are responsible for cleaning the outer surfaces of the ice machines, daily and that any maintenance or cleaning of internal parts of the ice machine; ice and waterspouts included is done by the maintenance department. The DIC 1 stated the expectation was, "If the staff see an issue with the ice machine, they will report it to be looked at as if you were to notice an IV leaking."

During an interview on 9/17/24 at 4:20 p.m., with the Chief Nursing Officer (CNO), the CNO stated the expectation is that ice machines need to be cleaned on a regular basis. The CNO stated, "We have "opportunities [for improvement] there."

According to the Centers for Disease Control (CDC), undated, retrieved 9/19/2/24 from https://www.cdc.gov/infection-control/hcp/environmental-control/appendix-c-water.html, " Microorganisms have a tendency to associate with, and stick to surfaces ... These adherent organisms can initiate and develop biofilms (a thin layer of bacteria that adheres to the surface.)"

During a review of the facility policy titled "Cleaning of Food and Nonfood Contact Surfaces", dated September 22, 2021, indicated, nonfood contact surfaces of equipment ... shall be cleaned as often as necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris."

During a review of the FDA Federal Food Code, dated 2022, 4-602.11 indicated, " ...ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms."

5. During a concurrent observation and interview on 9/10/24 at 2:33 p.m., with the Sterile Processing Department Manager (SPDM), in the Sterile Processing Department (SPD) prep and pack area (an area of a health care facility where clean and disinfected devices are inspected, assembled into trays, and prepared for high-level disinfection and/or sterilization) there was a surgical instrument tray stored on a trash can. The SPDM validated the observation and stated a clean surgical instrument tray should not be stored on a trash can and was uncertain why it was there. The SPDM stated the hospital followed AAMI ST79 guidelines for instrument cleaning, disinfecting, sterilization, and storage, and the guidelines were not followed. The SPDM stated the potential for cross-contamination from the trash can to the surgical instrument tray was an infection risk and sent the surgical instrument tray back to the decontamination area for reprocessing. A policy was requested for cross-contamination reprocessing, the hospital did not provide a policy for this process.

During an interview on 9/11/24 at 11:25 a.m., with the Infection Prevention Director (IPD), in the Infection Control Department, the IPD confirmed the hospital followed AAMI standards for sterile processing and validated AAMI standards were not followed for instrument processing/storage. The IPD stated clean and disinfected instruments stored on a trash can created cross-contamination with potentially infectious elements in the trash can such as blood, dirt, and other infectious material.

6. During a concurrent observation and interview on 9/10/24 at 2:40 p.m. with the Director of Women and Children Services (DWC), in Pt 36's room, Pt 36 was observed to have oxytocin (a synthetic hormone that helps speed up delivery or controls bleeding after childbirth) continuous infusion through her peripheral intravenous line (IV-a soft, flexible tube placed inside a vein). The oxytocin administration set did not have a label containing the date and time of initiation. The DWC stated the oxytocin administration set did not have a label containing a date and time of initiation. The DWC stated each administration set should have a label with the date and time when the administration set was first used and when it expired. The DWC stated it was important to know when the administration set was hung and when it expired to not introduce any infection risk to the patient. The DWC stated she expected staff to label the administration set with the date and time it was hung and when it expired.

During a concurrent observation and interview on 9/11/24 at 3:40 p.m. with the Emergency Department Manager (EDM), in Pt 45's room, Pt 45 was observed to have a lactated ringer's (LR-used to replace water and electrolyte loss in patients) continuous infusion through her IV. The LR administration set did not have a label containing the date and time of initiation. The EDM stated the LR administration set did not have a label containing a date and time of initiation. The EDM stated there should be a label with the date and time of initiation on the LR administration set. The EDM stated when the same administration set is used for a prolonged period it can cause problems like infection.

During a review of the facility's policy and procedure (P&P) titled, "CO.GL.2.024 Venous Access Device: Prevention, Insertion and Maintenance Policy, Procedure, and Protocol," approved on 5/22/24, indicated " ... PROCEDURE ... Maintenance ... Label all IV infusions with hang date, time, nurse initials ... Primary and secondary continuous administration sets: ... Replace primary continuous administration sets at least every 96 hours and [as needed] if compromised ..."

7. During a concurrent observation and interview on 9/11/24 at 3:20 p.m. with the EDM, in Supply Room A, bottles of [brand name] sterile water had an expiration date of 7/1/24 and bottles of [brand name] infant formula had an expiration date of 8/1/24. The EDM stated the bottles of [brand name] sterile water and [brand name] infant formula were expired. The EDM stated she expected the person who re-stocked the supply room to bring the oldest expiration date forward so it would be used first and new stock behind it. The EDM stated the expiration dates should have been checked by the person who restocked the supply room should have checked. The EDM stated it was everyone's responsibility to check and remove expired formula. The EDM stated the facility staff should check the expiration date before giving to the patient for use.

During an interview on 9/13/24 at 2:28 p.m. with the Infection Control Director (ICD), the ICD stated formula stored beyond the expiration date could have organisms that are overpowering it, and a baby should not have it. The ICD stated he expected formula to be taken out when it is going to be expired. The ICD stated central supply is supposed to take out and rotate the stock. The ICD stated nursing staff should check dates prior to giving formula. The ICD stated he expected staff to change out the expired items and not use them.

During an interview on 9/17/24 at 4:20 p.m. with the CNO, the CNO stated there should not be expired formula in the supply room.

8. During an observation on 9/10/24 at 2:22 p.m., with the DCC, and the ADCC in the CVICU unit, two (2) of 2 pill crushers were observed to have white-colored, powder-like residue and orange and brown colored stains throughout the device.

During an observation on 9/11/24 at 9:06 a.m., with DCC, ADCC and Shift Manager (SM) 1, on the Surgical ICU (SICU) unit, 2 of 2 pill crushers were observed to have white-colored powder-like residue and orange and brown colored stains throughout the device.

During an interview on 9/10/24 at 2:22 p.m., with the DCC, on the unit, the DCC stated CVICU nurses were responsible to ensure the equipment used to crush medications for administration to patients are cleaned per facility policy and procedure (P&P). The DCC stated it was his expectation the pill crushers would be cleaned by the Licensed Nurses following the manufacturer's IFUs and facility P&P. The DCC stated the potential harm to patients was possible contamination of the medication being given, placing the patient at risk for infection.

According to Links Medical Products, undated, retrieved on 9/19/2024 from https://imgcdn.mckesson.com/CumulusWeb/Click_and_learn/IFU_Silent_Knight_Cleaning_Instructions.pdf indicated "(Brand Name) pill crusher cleaning and maintenance instructions ...is made entirely of non-rusting materials and may be cleaned regularly with a damp cloth. A facility approved disinfectant wipe may also be used when indicated. In instances when the Silent Knight Pill Crusher requires a more thorough cleaning, please follow the instructions below: ..."

During an interview with the DIC 1, on 9/12/24 at 2:11 p.m., DIC 1 stated pill crushers were used by the nursing staff so they were responsible for cleaning the pill crushers. DIC 1 stated, "If its nursing equipment, no one else should "touch that."

9. During a concurrent observation and interview on 9/10/24 at 2:22 p.m., with DCC, ADCC and SM 3, on the Surgical CVICU, in the biohazard room (room where potentially contaminated human blood and fluid soiled items are kept), the red, rigid plastic container had 2 "brand name" pouches containing cardiac pacer wires (wires used during open heart surgery to monitor heart rhythm and provide temporary pacing (a pacemaker is used to control or increase the heartbeat)) was inside the container and was unsealed. The water added by staff to activate the pre-cleaning soak leaked out of the unsealed pouches causing contaminated fluid to pool at the bottom of the red container and a used double A (AA) battery was observed floating in the fluid. SM 3 stated "brand name" pouches are to be sealed after fluid is added to pouch and after inserting the soiled reusable patient care equipment. The ADCC stated he and was not sure why the 2 pouches observed had not been sealed. The ADCC stated it was his expectation that staff follow facility P&P and manufacturer IFUs to ensure proper handling and initiation of the disinfection process and to prevent the risk of contamination to staff by accidental spill or spray of contaminated fluid when handling the red container. The ADCC stated the potential for harm to patients was that the sterilization process would be interrupted if the initial step in the process (pre-soak in the pouch) was not done properly and that used batteries were stored too close to the red container and possibly caused a battery to fall into the container.

According to the "brand name" IFU document, version six (6), undated, the IFU indicated " ...Instructions for Using Product ...Description of Use(s) ...Placing items into the "brand name" [pouch] after use will provide a humid environment delaying the drying of contaminants during transport prior to any required cleaning, disinfection, reprocessing and/or sterilization ...Steps for Use of Product ...4. Place items in the pouch. 5. Peel off the protective strip from the adhesive band. 6. Fold over the adhesive strip and press down firmly from the center outwards to ensure a watertight seal ..."

During a review of facility P&P titled " ...Surgical Instrument Point-of-Use and Pre-Cleaning" dated 8/23/23, the P&P indicated " ...II. Procedure: Staff will pre-clean surgical instruments at the Point-of-Use immediately after the procedure and transport them in an appropriate container ...C. Pre-Treatment ...2. Prepare instruments in a manner which will maintain moisture and prevent organic soils from drying by one of the following methods: a. Use pre-treatment product according to manufacturer's instructions, applying to all instruments ...b. Place items inside a package designed to maintain a moist atmosphere [(air that contains water vapor]DEFINE) (e.g., "brand name" pouch) ...D. Transport: Transport soiled instruments to the decontamination area in a closed rigid container with a tight-fitting and/or latching lid or enclosed transport cart. The container must be: 1. Leak proof 2. Puncture resistant ..."

10. During a concurrent observation and interview on 9/10/24 at 3:45 p.m., with Chief Nursing Officer/Interim Emergency Department (ED) Director and Quality Review RN (RNQ) 3, in ED section B (where lower acuity patients of Emergency Severity Index (ESI- is a 5-level emergency department triage algorithm that sorts patients into 5 groups from 1 (most urgent) to 5 (least urgent) Level 3 (urgent) are treated in section B. Three (3) patients were present in section B. The CNO stated this section has the capacity to take up to 4 patients. Neither the primary nurse assigned to patient care in section B or ED tech were present in section B during observation. A used IV catheter insertion needle, and a small plastic dark red fluid-filled container with a red smudge on a binder was observed to be on top of a crash cart (contains the equipment and medications that would be required to treat a patient in the first thirty minutes or so of a medical emergency) in an occupied room and IV tubing and empty bag of IV fluids (liquids that are administered directly into a vein to replace water, sugar, and salt) was observed to have tubing laying on the floor. The CNO stated the observations are not to her expectations. The CNO stated the sharps (IV catheter needle) should have been discarded in designated safe sharps containers immediately after use, the binder should have been cleaned using facility P&P for cleaning of possible blood contamination, and the IV tubing and IV fluid bag should not be used again and ideally, should have been discarded per facility P&P when infusion was complete.

During an interview with the DIC 1, on 9/12/24 at 2:11 p.m., DIC 1 stated the was "no reason for sharps, to have been left on the crash cart" staff should "get rid of it right away and wipe the visible soiling on the binder [possible blood, red colored-smudge]" DIC 1 stated it is "standard operating procedure and should have been discarded appropriately and IVF tubing once completed discard right away." DIC 1 stated the expectation is for staff to report and ensure the matter is resolved "If you see it, do something about it. Don't just see it and walk away because not attending to the matter can affect staff and patient safety and can harm the patient by contamination of the debris."