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Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P), for two of 31 sample patients (Patients 4 and 18), when Patients 4, and 18's soft wrist restraints were not monitored every two hours.

These failures had the potential to impact the health and treatment of the patients and may cause harm to the patient.

Findings:

1. On January 27, 2025, at 9 a.m., a tour of the Medical/Surgical unit was conducted with the Interim Director of Quality Management (DQM).

During the tour of the Medical/Surgical Unit with the DQM, in Patient 4's room, Patient 4 was observed with soft wrist restraints on both wrists. During a concurrent interview on January 27, 2025, at 9:45 a.m., the Licensed Vocational Nurse (LVN) 1 stated the soft wrist restraints were placed on Patient 4's wrists because Patient 4 was pulling the trach (surgical opening in the trachea (windpipe) to provide an airway for breathing) and tubing and nasogastric tube (NGT, a feeding tube).

A review of Patient 4's medical record was conducted on January 27, 2025, at 2:15 p.m., with the Education Manager (EM). The facility document titled, "History and Physical" dated December 26, 2024, indicated, "...Date of Admission: December 26, 2024...Diagnosis...Acute and Chronic Respiratory failure, unspecified with hypoxia [not enough oxygen to the body] or hypercapnia [excessive carbon dioxide in the blood].

The facility document titled, "[Facility Name] Restraint Monitoring (Non-Violent, Non-Self Destructive Behavior)." The document indicated, "...Restraint Episode Began: 1/20/25 [January 20, 2025] Episode Day # [number] 7 [seven]...Safety Checks and Monitoring (at least Q [every] 2 [two] hours)...Daily Assessment to Determine Need for Restraint(s)...timed 08:00 a.m....dated 1/26/25 [January 26, 2025]." There was no documented evidence the RN completed the Daily Assessment to determine the need for restraint(s) and signed the Restraint Monitoring (Non-Violent, Non-Self Destructive Behavior).

During further review of Patient 4's medical record, the facility document titled, "[Facility Name] Restraint Monitoring (Non-Violent, Non-Self Destructive Behavior)" indicated, "...Restraint Episode Began: Episode Day # [number]...Safety Checks and Monitoring (at least Q 2 hours)...Range of motion offered/provided...food/fluids offered/provided...Toileting offered/provided...Dignity/comfort/hygiene maintained...managed safety/no injury...mental status unchanged...skin integrity unchanged...temporary release during care giving...circulatory status of restrained extremities unchanged RN ONLY...Pain managed per policy RN ONLY...08 [8 a.m.] signed...10 [10 a.m.] signed...Daily Assessment to Determine Need for Restraint(s)...RN signature..." There was no documented evidence of the RN Episode Began date, identified episode number, assessed the patient every two hours, and completed the daily assessment from 12 p.m. to 2 p.m., to determine need for restraints.

An interview was conducted on January 27, 2025, at 2:17 p.m., with RN 1. RN 1 stated she did not complete the 2 hour assessment and document per the facility policy. RN 1 further stated she should have completed the assessment.

An interview was conducted on January 27, 2025, at 2:30 p.m., with the EM. The EM stated the nurse did not assess the patient and document the assessment every two hours. The EM stated there is no documentation the nurse monitored the patient between 12 p.m. and 2 p.m. The EM further stated the nurse is to visibly assess the patient every two hours.

2. A tour of the Medical Surgical Unit was conducted on January 27, 2025, at 9:30 a.m., with the Director of Radiology (DOR).

During the tour of the Medical surgical Unit, in Patient 18's room, Patient 18 was observed having bilateral wrist restraints on. The DOR stated Patient 18 had been pulling on the tubes and lines, and needed the restraints for safety.

On January 27, 2025, at 2:45 p.m., a review of Patient 18's record was conducted with the DOR.

The facility document titled, "History and Physical ( H&P)", dated January 15, 2025, indicated Patient 18 was admitted on January 15, 2025, for Acute and Chronic Respiratory Failure with hypoxia or hypercapnia. Patient 18 had a medical history of diabetes (a chronic disease that occurs when the body can't produce or use insulin properly), acute renal failure (a sudden decrease in kidney function) with hemodialysis (a medical procedure that filters waste products and excess fluid from the blood when the kidneys are no longer able to do so), and hypertension (elevated blood pressure).

On January 27, 2025, at 3:15 p.m., a review of the facility document titled, "Restraint Care Plan," indicated, "Type of Restraint - limb/soft...location...left wrist...right wrist...restraint initiation...risk of injury to self due to inability to understand or remain oriented...disturbing monitoring equipment or necessary treatment modality (i.e. Pulling at Lines/Tubes/Drains)...lack of safety awareness/doesn't seek assistance...unsuccessful attempts to redirect behavior..." The document further indicated a signature from the physician on January 27, 2025, at 8 a.m.

On January 27, 2025, at 3:30 p.m., a review of the facility document titled, "Safety Checks and Monitoring," dated January 27, 2025, was conducted, and there was no documented evidence Patient 18's restraint assessment was conducted at 12 p.m. and 2 p.m.

On January 27, 2025, at 3:35 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she should have assessed and documented the restraints. She further indicated she did not complete the documentation for 12 p.m. and 2 p.m.

On January 27, 2025, at 4 p.m., an interview was conducted with the House Supervisor (HS). The HS stated, "...the documentation and assessment should have been completed with today's information at the time of assessment and it was not done..."

On January 28, 2025, a review of the facility's P&P titled, "Core: Physical Restraints [Violent and Non-Violent Behavior] and seclusion," dated June 2023, was conducted. The policy indicated, "...Ongoing safety checks & [and] monitoring at least every two hours or as noted on the designated forms by the patient's clinical team of the patient's response to the restraint, including any condition changes...visually observe the patient at least every 2 hours for safety needs....all documentation of the patient's status should be in real time..."

Based on observation, interview and record review, the facility failed to follow their policies and procedures (P&P), for six of 31 patients (Patients 2, 3, 6, 7, 10 and 31) when:

1. For Patient 10, did not receive a CHG bath daily,

2. For Patient 10, tracheostomy care was not completed,

3. For Patient 2, foley catheter care was not provided once per shift,

4. For Patient 2 and 3, central line tubing was not changed,

5. For Patient 31, facility did not ensure proper personal protective equipment was worn while providing patient care;

6. For Patient 6, staff did not maintained a sterile field for a sterile procedure,

7. For Patient 7, facility failed to notify provider when an occult blood lab was canceled.

The cumulative effects of these failures had the potential to impact the health and treatment of the patients and may cause delays in the provision of patient care.

Findings:

1. On January 29, 2025, at 1:24 p.m., Patient 10's medical record was reviewed with the Director of Radiology (DOR). The facility document titled, "History and Physical," dated December 7, 2024, was reviewed and indicated Patient 10 was admitted for Acute (less than 6 months) and Chronic (longer than 6 months) Respiratory failure, unspecified with hypoxia (not enough oxygen to the body) or hypercapnia (excessive carbon dioxide in the blood).

A review of the facility's untitled, and undated document was conducted on January 29, 2025, at 2:05 p.m., with the DOR. It indicated Patient 10 did not receive a chlorhexidine bath (CHG, special bath to prevent infection) on the below dates and shifts:

December 8, 2025, a.m. (6:30 a.m. to 7:00 p.m.) and p.m.(7:00 p.m. to 6:30 a.m.) shifts,
December 9, 2025, a.m. and p.m. shifts,
December 10, 2025, a.m. and p.m. shifts,
December 15, 2025, a.m. and p.m. shifts,
December 17, 2025, a.m. and p.m. shifts,
December 26, 2025, a.m. and p.m. shifts; and
January 3, 2025, a.m. and p.m. shifts.

The DOR indicated, there was no documented evidence a CHG bath was given to Patient 10 on the dated and shift listed above.

An interview was conducted on January 30, 2025, at 9:40 a.m., with the Infection Prevention (IP). The IP stated the facility does not have a policy for giving the patient a CHG bath. The facility uses a tool for guidelines or suggestions for the use of a CHG Bath. The IP further stated currently the CHG bath is given daily to every patient to reduce the Multidrug-Resistant Organisms (MDRO, a drug resistant microorganism) transmission. The IP stated the nurses will document the CHG bath in the electronic medical record under the hygiene section.

A review of the facility's resource titled, "Procedure-Chlorhexidine Bathing and Decolonization," dated June 2023 was conducted. It indicated, "...CHG bathing should be considered part of the hospital's risk reduction strategy in infection prevention...CHG bathing as part of quality improvement...Patient's plan of care is updated to reflect the CHG bath..."

2. On January 29, 2025, at 1:24 p.m., Patient 10's medical record was reviewed with the DOR. The facility document titled, "History and Physical," dated December 7, 2024 indicated Patient 10 was admitted for Acute (less than 6 months) and Chronic (longer than 6 months) Respiratory failure, unspecified with hypoxia (not enough oxygen to the body) or hypercapnia (excessive carbon dioxide in the blood).Acute and Chronic Respiratory failure, unspecified with hypoxia or hypercapnia.

A review of the facility document titled, "Flowsheet's," dated December 27, 2024, was conducted. The document indicated, "...Physician orders...Tracheostomy Care...Start 12/8/24 [December 8, 2024], 7:01 a.m. q [every] 12 h [hour]..." A concurrent interview was conducted with the DOR. The DOR stated there was no documented evidence Patient 10 received tracheostomy care on the following dates and shifts:

December 28, 2024, a.m., (6:30 a.m. to 7:00 p.m.) and p.m. (7:00 p.m. to 6:30 a.m.) shifts,
December 29, 2024, a.m. shift,
January 6, 2025, a.m. shift; and
January 11, 2025, a.m. shift.

An interview with the Respiratory Therapy Manager (RTM) on January 30, 2025, at 10:52 a.m., was conducted. The RTM stated there is currently no policy in place for providing respiratory care. The practice of the facility is to perform respiratory care/Tracheostomy care once per shift. The Respiratory Therapist (RT) is expected to document the care provided. The RTM further stated, if the RT did not document the care, it was not done.

An interview with the Chief Operating Officer (COO) on January 30, 2025, at 11:03 a.m., was conducted. The COO stated they do not have a policy for tracheostomy care. The tracheostomy care is part of the scope of practice just like nursing care. The RT should know when and how to perform the care.

3. On January 28, at 2:20 p.m., Patient 2's medical record was reviewed with the Educator Manager (EM). The facility document titled, "History and Physical," dated December 7, 2024, indicated Patient 2 was admitted for Respiratory failure, unspecified with hypoxia or hypercapnia.

A facility document titled, "Kardex," dated January 28, 2025, was reviewed. The document indicated, "...foley catheter [tube inserted in the bladder]...start 12/9/2024 (December 9, 2024)...days to date...50...Present on admission..."

An untitled facility document, dated January 28, 2025, was reviewed. The document indicated, "...Foley catheter...16FR [french, size of catheter]...Start 12/9/2024 (December 9, 2024) at 8:16 (8:16 a.m.)..."

An untitled, facility document, dated January 1, 2025, was reviewed. The document indicated no foley catheter care was provided to Patient 2 on the below dates and shifts:

December 28, 2024, a.m., (7 a.m. to 7:30 p.m.) and p.m., (7:30 p.m. to the 7 a.m.) shifts; and
January 1, 2025, for a.m., and p.m., shifts.

A concurrent interview was conducted with the EM. The EM stated there was no documented evidence Patient 2 received foley catheter care on the dates and shifts listed above. The EM further stated foley catheter care is required once a shift or every 12 hours. The EM further stated that if the nurses did not document the foley catheter care, it was not done.

A review of the facility Policy and Procedure titled, "Core: Indwelling Urinary Catheter Standards and Practice," dated June 2022, was conducted. The document indicated, "...The insertion of an indwelling urinary catheter requires a physician order...All patients admitted to the hospital with an existing indwelling urinary catheter will be assessed...Patients with urinary catheter will be assessed daily..."

4 a. A tour of the Medical/Surgical unit was conducted with the Interim Director of Quality Management (DQM) on January 27, 2025, at 9 a.m.

During the tour, while in Patient 2's room, Patient 2's Intravenous (IV, administering in the veins) tubing was observed with a pink sticker that indicated to change on Sunday and was dated January 25, 2025.

A concurrent interview was conducted on January 27, 2025, at 9:12 a.m., with Registered Nurse (RN) 2. RN 2 stated the IV tubing that is used for the Total Parenteral Nutrition (TPN, providing all the necessary nutrients directly into the bloodstream through a catheter) should be changed each time the TPN is changed. RN 2 further stated the IV tubing should have been changed on Sunday, and tubing for a central line is changed daily.

On January 28, 2025, at 2:20 p.m., Patient 2's medical record was reviewed with the EM. The facility document titled, "History and Physical," dated December 7, 2024, was reviewed. The document indicated, Patient 2 was admitted for Respiratory failure, unspecified with hypoxia or hypercapnia.

A facility document titled "History and Physical," dated December 7, 2024, indicated,"...history and physical performed...impression...14...TPN dependent...continue TPN..."

A facility document titled, "Kardex," dated January 28, 2025, was reviewed. The document indicated, "...CV Line [Central venous catheter, thin flexible tube inserted into a large vein]..RT [Right] upper arm PICC [peripherally inserted central catheter] line...present on admission..."

b. A tour of the Medical/Surgical unit was conducted with the Interim Director of Quality Management (DQM) on January 27, 2025, at 9 a.m.

During the tour, while in Patient 3's room, Patient 3's Intravenous (IV, administering in the veins) tubing was observed with a pink sticker that indicated to change on Sunday and was dated January 25, 2025.

A concurrent interview was conducted on January 27, 2025, at 9:22 a.m., with the DQM. The DQM stated the IV tubing used for Total Parenteral Nutrition (TPN, providing all the necessary nutrients directly into the bloodstream through a catheter) should be changed each time the TPN is changed. The DQM further stated the IV tubing should have been changed on Sunday.

On January 29, 2025, at 9:33 a.m., Patient 3's medical record was reviewed with the DQM. The facility document titled, "History and Physical," dated January 12, 2025, was reviewed. The document indicated, Patient 3 was admitted for unspecified anemia (low red blood cell count) with a history of liver cirrhosis (scarring of the liver), hypertension (elevated blood pressure), concerns of Gastrointestinal (stomach) bleed.

A facility document titled, "IV administration set (tubing) change," dated August 19, 2024, was reviewed. The document indicated, "...Change administration sets, including in-line and add-on filters used for parenteral nutrition (with or without lipids), at least every 24 hours. Change the set with each new parenteral nutrition container..."

5. During a tour of Patient 31's room, on January 27, 2025, at 9:30 a.m., Registered Nurse (RN) 3 was observed in Patient 31's room with no gloves on. Registered Nurse (RN) 3 was observed in Patient 31's room pulling the curtain between bed A and bed B, and around bed A, and began to work on the dialysis machine. A concurrent interview was conducted with RN 3. RN 3 stated he was aware he was in an isolation room. RN 3 stated Patient 31 is in contact isolation. RN 3 stated he removed his gloves and did not put new ones on when closing the curtains. RN 3 further stated he should have put new gloves on and should keep gloves on while in Patient 31's room.

An interview with the DQM on January 27, 2024, at 9:35 a.m., was conducted. The DQM stated Patient 31 is on contact isolation and the nurse should have gloves on while in the room.

On January 29, 2025, at 9:03 a.m., Patient 31's medical record was reviewed with the DQM. The facility document titled, "History and Physical," dated January 12, 2025, was reviewed. The document indicated, Patient 31 was admitted for Respiratory failure, unspecified with hypoxia or hypercapnia, sepsis (life threatening infection) secondary to Extended spectrum Beta-Lactamase (ESBL, an enzyme that makes bacteria resistant to some antibiotics), and MRSA (Methicillin Resistant Staphylococcus Aureus).

A facility Policy and Procedure titled, "Procedure-Donning and Doffing Personal Protective Equipment," dated June 2022, was reviewed. The document indicated, "...Personal Protective Equipment (PPE) when there is a potential for contamination from the skin-to-skin contact...PPE will be donned (put on) upon entering the patients room...PPE will be doffed (removed) upon exiting the patients room..."

6. During the tour of the Medical Surgical unit on January 27, 2025, at 9: 55 a.m., conducted with the DQM, RN 1 was observed in Patient 6's contact isolation room preparing for a central line dressing change. RN 1 placed the central line dressing change kit on the foot of Patient 6's bed. RN 1 began to open the package and pulled out two green packages. RN 1 began to open both green packages and place on the foot of the bed. RN 1 pulled out white folded package and chlora prep pad. RN 1 opened the sterile package and put on the gloves and touched the outside of the package and the front of her PPE gown with the sterile gloves. RN 1, with sterile gloves on, grabbed the chlora prep pad and the towel, shook the towel with the sterile gloves on, then RN 1 shook the prep towel two times and walked to the head of Patient 6's bed. RN 1 shook the towel again and put it on the patient's chest. RN 1 set down the chlora prep pad and proceeded to begin the process of removing the previous central line dressing on the patient. When asked about shaking the towel and contaminating the gloves, RN 1 stated she would get new gloves. When asked about the sterile field, RN 1 stated she had broken the sterile field and contaminated her gloves and would start over with a new kit. The House Supervisor (HS) put on PPE and came into the room to assist RN 1 with the central line dressing change. The HS brought in a new Central line dressing kit and pack of size 7.5 sterile gloves. RN 1 began to open the new sterile package and again broke sterility by touching her gloves with her PPE.

On January 27, 2025, at 10:15 a.m., an interview with the HS was conducted. The HS stated RN 1 broke the sterile field and she came into Patient 6's room to help guide and educate the nurse with the central line dressing change. The HS redirected RN 1 during the central line dressing change multiple times.

On January 28, 2025, at 9:30 a.m., Patient 6's medical record was reviewed with the DQM. The facility document titled, "History and Physical," was reviewed. The document indicated, Patient 6 was admitted to the facility for acute or chronic respiratory failure, unspecified with hypoxia or hypercapnia and ESBL in the urine.

On January 30, 2025, at 2:10 p.m., an interview with the Director of Nursing Clinical Services (DNCS) was conducted. The DNCS stated it is expected for the nurses to maintain the sterile field while performing the sterile procedure of central line dressing changes. The DNCS further stated the nurse is expected to clean the area where they plan to work to ensure they are working on a clean surface.

A facility Policy and Procedure titled, "[Facility Name] Core: Central Line Placement, Maintenance and Dressing Change," dated June 2023, was reviewed. The document indicated, "...the procedure for central line dressing changes will be performed under strict aseptic technique (sterile gloves and mask)..."

7. On January 30, 2025, a review of Patient 7's record was conducted with Director of Pharmacy (DOP).
A review of the facility document, titled, "History and Physical," dated December 26, 2024, indicated Patient 7 was admitted for Respiratory failure, unspecified with hypoxia or hypercapnia,

On January 30, 2025, a review of the facility untitled document, dated December 26, 2024, at 1:47 a.m., indicated an order was placed for a stool specimen for occult blood.

On January 30, 2025, a review of the facility document titled, "Laboratory Results," dated January 5, 2025, at 10:47 a.m., indicated the occult blood lab was not done and cancelled on January 8, 2025, at 11:35 p.m., by lab.

On January 30, 2025, an interview was conducted with the Chief Operating Officer (COO). The COO stated, "...there was no note placed by lab as to why the test was cancelled. It was not caught by medical or nursing staff. The physician or RN should have been notified and the test should have been reordered. There should have been a phone call and documentation to the RN of why it was cancelled. Policy was not followed..."

On January 30, 2025, a review of the facility document titled, "Criteria For Acceptance of Microbiology Specimens," dated August 2, 2022, indicated, "Guidelines for Rejection of Specimens...Specimen without requisition/order: Call the nursing station and have a requisition sent to the laboratory or ordered...If there are questions about the order, the nurse must clarify with the physician before the specimen is processed...Specimen unlabeled or mislabeled...Reject specimen. Call the nursing station and have a new specimen collected and sent, along with a new requisition..."