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Based on document review and interview, it was determined that for 1 of 5 patients' (Pt. #1) clinical record reviewed, the hospital failed to ensure that the patient's representative/caregiver was provided information regarding Pt. #1's treatment plan, including the disposition of care.

Findings include:

1. On 11/13/2024, the clinical record for Pt. #1 was reviewed. On 5/27/2024, Pt. #1 was brought to the hospital's ED (emergency department) due to shortness of breath. The clinical record included:

- On 5/27/2024 at 1:53 AM, the ED physician's note indicated, "(Pt. #1) with dementia (memory problem) with known history of COPD (chronic obstructive pulmonary disease/respiratory illness), very poor historian.." At 3:27 AM, the ED nurse's note included name of two daughter's as contacts for Pt. #1.

- On 5/27/2024 at 11:48 AM, E #7's (Telemetry RN) progress note indicated, " ... (At 9:00 AM), received (Pt. #1) from ER (emergency room) via cart ... alert and oriented to self ... unaware of day date, or time ... (Pt. #1) came to (the) ER with increased (shortness of breath) ... (E #2/Nurse Practitioner/Hospitalist) notified, no new orders received ..."

- On 5/28/2024 at 12:58 PM, E #2's (Nurse Practitioner/Hospitalist) progress note indicated, " ... (Pt. #1) seen and assessed at bedside this morning. Oriented to self and place, but not date. ...Denies any medical complaints at this time including headache, cough, (shortness of breath), (chest pain) ... abdominal pain ... O2 sat (oxygen saturation) 100% on 3 liter's nasal cannula (NC) ... Exam ... Awake, (no acute distress), on NC at 3 Liters ... Assessment and Plan... Diet ...(Disposition)... " At 3:08 PM, E #2 placed an order to discharge Pt. #1. There was no documentation regarding discussion of Pt. #1's treatment/care plan with Pt. #1 or Pt. #1's daughter.

2. On 11/13/2024, the hospital's policy titled, "Patient's Rights and Responsibilities" (October 2021), was reviewed and included, "... Information: The patient has the right to obtain from the practitioner responsible for coordinating their care complete and current information concerning their diagnosis... treatment, and any known prognosis..."

3. On 11/13/2024 at approximately 10:00 AM, an interview was conducted with E #2 (Hospitalist/Nurse Practitioner). E #2 stated that E #2 was the practitioner coordinating the care for Pt. #1. E #2 stated that Pt. #1 had memory issue and the daughters were the caregivers and contacts. E #2 stated that with Pt #1's condition, there should have been a documentation regarding discussion of the treatment plan, including the disposition, with the patient's daughter.

Based on document review and interview, it was determined that for 1 of 2 patient care units (4B/Telemetry) staffing schedules/assignments reviewed, the hospital failed to ensure that adequate number of registered nurses and/or personnel were available to meet patient care needs. This can potentially affect the delivery of safe patient care on the unit.

Findings include:

1. On 11/13//2024, the hospital's staffing policy titled, "Acuity Levels and Patient Classification" (dated September 2022) was reviewed and included, "... Procedures... 7. The Charge Nurse assigns patients based on patient acuity, competency of the staff, and available personnel..."

2. On 11/13/2024, the staffing assignments/records for 4 B/Telemetry Unit were reviewed for May 27, 2024, May 28, 2024, November 11, 2024, and November 12, 2024. The records indicated the following:

- 05/27/2024, Day Shift (7:00 AM through 7:00 PM), short of one RN/Registered Nurse;
- 05/27/2024 Night Shift (7:00 PM through 7:00 AM), short of two RNs and one CNA (Certified Nurse Assistant);
- 05/28/2024, Day Shift, short of one RN and one CNA;
- 05/28/2024, Night Shift, short of one RN;
-11/11/22024, Night Shift, short of two RNs;
-11/12/2024, Day Shift, short of two RNs and one CNA.

3. On 11/13/2024 at approximately 2:00 PM, findings were discussed with E #11 (Nurse Manager). E#11 confirmed that based on the unit's grid and acuity level, the unit was short staffed on the above dates because of call-offs. E #11 stated that the hospital uses agency but could not get anyone.

4. At approximately 12:15 PM, interviews were conducted with Pt #11 and Pt. #12. Pt. #11 and Pt. #12 stated that it takes a while before staff respond to call lights. Pt. #12 stated, "I have been here and came back from surgery and nobody has been here."

A. Based on document review and interview, it was determined that for 1 of 5 patients' (Pt. #1) clinical records reviewed regarding assessment, the hospital failed to ensure that a fall risk assessment was conducted, as required.

Findings include:

1. On 11/13/2024, the hospital's policy titled, "Fall Prevention Program, Adult" (April 2024) was reviewed and included, "... Procedures... A. Inpatient Assessment using Morse Fall Scale... Upon admission..."

2. On 11/13/2024, the clinical record for Pt. #1 was reviewed. On 5/27/2024, Pt. #1 was brought to the hospital's ED (emergency department) due to shortness of breath. On 5/27/2024 at 9:00 AM, Pt. #1 was admitted to the telemetry unit with a diagnosis of COPD (chronic obstructive pulmonary disease). There was no fall risk assessment completed for Pt. #1 upon admission to the unit.

3. On 11/13/2024 at approximately 2:00 PM, findings were discussed with E #12 (Vice President of Quality). E #12 stated that there was no fall risk assessment performed during Pt. #1's admission to the unit. E #12 stated that a fall risk assessment should have been completed.

B. Based on document review and interview, it was determined that for 1 of 2 patient care units (4B Telemetry) reviewed for hourly rounding, the hospital failed to ensure that the documentation of hourly rounding was performed.

Findings include:

1 On 11/13/2024, the hourly monitoring logs for 4B Telemetry Unit for 11/12/2024, was reviewed. The logs did not include documentation of hourly rounding at 8:00 AM; 10:00 AM; and 11:00 AM for Room 427 Bed 1 and 2; Room 429 Bed 1 and 2; Room 433 Bed 1 and 2; and Room 435 Bed 1.

2. On 11/13/2024, the hospital's document regarding "Purposeful Hourly Rounding" (undated) was reviewed. The document included, "Definition: A structured process where nurses or staff check on patients at regular intervals to address key needs... Hourly Rounding Log... Documentation of Hourly Rounding: Keep accurate records of each round..."

3. On 11/13/2024 at approximately 11:30 AM, an interview was conducted with E #11 (4B Telemetry Unit Manager). E #11 stated that the nurses and nursing assistant alternately make hourly rounds on each patient. E #11 stated that documentation of the rounding is completed on the log posted by the patient's door. E #11 stated that documentation on the log should be completed when hourly rounding was made.

4. On 11/13/2024 at approximately 12:15 PM, interviews were conducted with Pt. #12. When asked about the staff making rounds, Pt. #12 stated that sometimes, nobody comes for three hours.

Based on document review and interview, it was determined that for 1 of 5 patients' (Pt. #1) clinical records reviewed for nursing care plan, the hospital failed to ensure that an individualized plan of care was developed based on Pt. #1's needs.

Findings include:

1. On 11/12/2024, the hospital's policy titled, "Interdisciplinary Plan of Care" (March 2022) was reviewed and included, "... Definition... an individualized plan of care that is formulated... with the patient outcomes in mind and is based on... patient's needs and goals... Procedure: 1. The plan of care is initiated during the admission process based on the assessed needs of the patient..."

2. On 11/13/2024, the clinical record for Pt. #1 was reviewed. On 5/27/2024, Pt. #1 was brought to the hospital's ED (emergency department) due to shortness of breath. The clinical record included:

- On 5/27/2024 at 1:53 AM, the ED physician's note indicated, "(Pt. #1) with dementia with known history of COPD (chronic obstructive pulmonary disease/respiratory illness), very poor historian according to the daughter, (Pt #1) removed ... oxygen at home... Assessment and Plan: Acute Exacerbation of COPD with Asthma ... oxygen ..."

- On 5/27/2024 at 5:28 AM, MD #1's (Hospitalist) progress note indicated, " ... (Pt. #1) ... on 3 (L/liters) nasal cannula/NC, dementia, (hypertension/high blood pressure) ... arrived in the ED ... for shortness of breath ... began at 1:00 AM this morning ... found unattached to ... oxygen ... done multiple times due to (Pt. #1's) dementia, per (Pt. #1's daughter). (Pt. #1) began becoming hypoxic and was unable to catch ... breath, before arriving to the hospital... Will admit to telemetry ... as inpatient ..."

- On 5/27/2024 at 11:48 AM, E #7's (Telemetry RN) progress note indicated, " ... (At 9:00 AM), received (Pt. #1) from ER (emergency rom) via cart ... alert and oriented to self ... unaware of day date, or time ... (Pt. #1) came to (the) ER with increased (shortness of breath) ..." From 5/27/2024 through 5/28/2024, there was no nursing care plan developed for Pt. #1's respiratory need/problem, including behavior of removing oxygen.

3. On 11/13/2024 at approximately 2:00 PM, findings were discussed with E #11 (4B Telemetry Nurse Manager). E #11 stated that there should have been nursing care plan developed to address Pt. #1's respiratory needs and behavior of removing the oxygen.