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Based on interview and record review, the facility failed to ensure one of one sampled patient (Pt 2) grievance (a written or verbal complaint) was resolved in a timely manner when the facility did not respond to Pt 2 in writing of the resolution to Pt 2's grievance in accordance with the facility's policy and procedure.

This failure resulted in Pt 2's unresolved grievance and placed other patients at risk for their grievances to be unresolved, violating their rights.

Findings:

During a review of Pt 2's "Face Sheet" (document containing patient demographic information and medical diagnosis), undated. The Face Sheet indicated Pt 2 was a 97-year-old, Caucasian, retired, female who came to the facility's Emergency Department (ED) by ambulance on 10/10/20 at 6:25 p.m. The face sheet indicated Pt 2 was admitted to the facility on 10/11/20 at 8:05 a.m., and was discharged to an Assisted Living facility on 10/16/21 at 4:21 p.m.

During a review of Pt 2's "Discharge Instruction", dated 10/16/21, no instructions for care of Pt 2's bed sore was documented.

During a review of Pt 2's "Patient Belongings" form, dated 10/16/21, the form indicated Pt 2 had come to the facility with "Clothing, other valuables, Pants, shirt, footwear, socks, and blanket". The form indicated Pt 2's belongings were left at bedside. The form did not have staff signature indicating Pt 2's belongings had been transferred with the patient on discharge.

During a review of Pt 2's "Transfer Form", dated 10/16/21, the form indicated Pt 2 was being discharged with a "Stage II [sic] Coccyx" (stage 2- pressure sore- the skin breaks open, wears away, which is usually tender and painful) indicating a bed sore on the patient's tail bone.

During a review of the "Grievance" letter sent by Pt 2 Health Care Agent/Power of Attorney (HCA/POA), dated 4/12/21, the Grievance letter indicated the HCA/POA received a bill for $1,500 for Pt 2 hospital stay 10/10/20-10/16/20 and the HCA/POA is requesting this bill be waived due to lack of treatment her aunt received. The HCA/POA states in the letter she was not contacted about the Pt 2's development of a bed sore nor was she informed of this bed sore upon the patients discharge and it was not addressed and no orders given for treatment of the bed sore. The HCA/POA states in the letter Pt 2 was discharged to her assisted living in a hospital gown with no underwear, no disposable adult brief or other disposable incontinence product. Once Pt 2 arrived to board and care home the facility staff saw that Pt 2 had a bowel movement on the ambulance gurney that had smeared all over Pt 2's legs. The Board and care staff discovered the bed sore when they were cleaning her up. The HCA/POA states in the letter that Pt 2 arrived at the hospital on 10/10/20 fully clothed including socks and slippers. The HCA/POA states in the letter, "Due to above facts, [name of patient] received negligence in care- bed sore- and was subjected to elder abuse, was disrespected, and suffered loss of dignity. Please waive all charges you are seeking from her associated with this hospital visit ..."

During a review of the hospital's response letter to Pt 2's HCA/POA "Grievance" letter, dated 7/2/21, the response letter states, "Dear [name of HCA/POA], Thank you for taking the time to provide feedback regarding your aunt's recent stay at [name of hospital]. We are sorry that your expectations were not met during her [name of department] visit on October 10th, 2020. Every complaint received is taken very seriously and diligently reviewed. Be assured that your complaint was forwarded to my management team for review and appropriate action. At [name of hospital], we encourage and value feedback from our patients and their families. Our goal is for each patient to have a positive experience with our services. Should you have any further questions or concerns please contact Patient and Family Relations at [phone number provided]. Again, I apologize for your recent experience. If you or a member of your family has a future need for health care services, we hope to be your provider of choice. Sincerely, [name] VP [Vice President] of Operations."

During an interview on 1/13/21 at 3 p.m., with the Director of Patient Experience (DPE) and the Director of Inpatient Services (DIS), the DPE stated when the hospital receives a grievance by phone or letter, they respond with a letter within 7 business days to let them know the facility received their complaint or grievance. The grievance is then inputted into the IRIS (Incident Reporting & Investigation System) system and the appropriate leadership is contacted to address the grievance. The facility will then send a response letter within 30 days to help solidify the resolution. The DIS stated the hospital placed Pt 2's grievance into the IRIS system on 4/16/21. The DPE stated the hospital would have contacted the HCA/POA within 7 business days by phone to see if there was any additional information but, "We do not have documentation for this patient, we normally do have documentation when this is done. I don't know why it wasn't and don't know if it was done". The DPE stated response letter to the grievance was sent on 7/2/21, not within the 30 days per facility policy. The DIS stated he received the grievance when "We were heavy into COVID [coronavirus disease 2019- an infectious disease current cause of world pandemic] and I was responsible for a lot of the disaster planning in our facility. It impacted the normal speed for our investigations. I remember looking into this investigation ... it was later than we usually do it ... There were pictures that were taken in the ED [emergency department]. I saw they [referring to the bed sore] were there prior to the admit ... the patient was very incontinent, the clothing was saturated in urine in a bag, when the patient went back we put the patients in a paper gown transport gown, they are fully covered with a blanket and pillow that is covered ... In my report I put in my investigation I did not feel it was appropriate to write off the charge. At this time, I did not call them [the HCA/POA] back up. The communication part is what got missed at the end ..." The DPE and DIS both stated the facility does not track the amount of time it takes to resolve a grievance. The DIS stated, "I think patients and family need to know that we care about their complaints and concerns, all of us know it is important," so that it does not happen to someone else.

During a review of the hospital's policy and procedure (P&P) titled, "Patient and Patient's Family Complaint & Grievance," dated 1/27/20, the P&P indicated, "I. PURPOSE ... B. To meet patients' reasonable expectations of care and services in a timely, reasonable, and consistent manner. C. To establish a mechanism to receive, investigate, evaluate and respond to written or verbal complaints or grievances concerning patient care or hospital practice for the population served. II. DEFINITIONS ... B. Patient grievance: a formal or informal, written or verbal complaint that is made to the hospital by a patient or patient's representative when a patient issue cannot be resolved promptly by staff present. All written complaints shall be treated as grievances. III. POLICY ... D. The Point of Service (POS) leadership or designee will contact the complainant within seven business days to acknowledge receipt of the complaint. A written response will be sent within thirty business days of the date [name of hospital] received the written or verbal grievance. This response will be communicated to the patient or patients' representative in a language that is understood and will include: 1. Name of the hospital contact person. 2. The steps taken on behalf of the patient to investigate the grievance. 3. The results of the grievance process. 4. The date of completion of the grievance process ..."

Based on interview and record review, the facility failed to provide personal privacy and dignity to one of 3 sampled closed record patients (Pt) 2 when the hospital allowed Pt 2 (an elderly female pt incontinent of bowel and bladder (a problem holding in urine or stool) to be transported by EMS back to her Board and Care facility in only a hospital gown and with no incontinence protection.
This failure resulted in emotional harm in the form of embarrassment and shame when Pt 2 arrived at the board and care home exposed and, on a soiled gurney, after she had a bowel movement while in transport to the board and care home.

Findings:

During a review of Pt 2's "Face Sheet" (a document containing Pt 2's demographic information and medical diagnosis), (undated), the Face Sheet indicated Pt 2 was a 97-year-old, Caucasian, retired, female who came into the facility's Emergency Department (ED) by ambulance on 10/10/20 at 6:25 p.m. She was admitted to the hospital on 10/11/20 at 8:05 a.m., and was discharged to an board and care facility on 10/16/21 at 4:21 p.m.

During an interview on 10/20/21, at 2:02 p.m., with Family Member (FM1), FM 1 stated Pt 2 had been sent to the ED wearing a nightgown, socks, slippers, and underwear over her brief but was discharged to the board and care home wearing only a hospital gown and the rest of her belongings were not sent with her. FM 1 stated Pt 2 had a bowel movement on the way back to the board and care facility and when she arrived, there was feces all over the gurney and Pt 2's back side and legs.

During an interview on 12/15/21, at 12:40 p.m., with the Board and Care Manager (BCM), BCM stated Pt 2 was discharged from the ED and sent home in a hospital gown with no brief and no underwear. BCM stated Pt 2 had a bowel movement in the ambulance on the way to the board and care home. BCM stated Pt 2 was "very messy." She stated Pt 2 was very upset and confused over the incident.

During a concurrent interview and record review on 1/12/22, at 9:25 a.m., with Registered Nurse Informaticist (RNI), Pt 2's medical record was reviewed. Pt 2's "Face Sheet" [undated], indicated, Pt 2 was admitted to the hospital on 10/10/21 and discharged to the board and care home on 10/16/20. Pt 2's "Default Flowsheet Data", dated 10/10/20 through 10/16/20, indicated, Pt 2 was incontinent of bowel and bladder.

During a concurrent interview and record review on 1/13/22, at 9:24 am, with Clinical Supervisor of Med/Surg (CS 1), Pt 2's clinical record was reviewed. CS 1 stated, a patient being discharged to a board and care is treated like a regular transfer home and the hospital's expectation is that a patient being discharged by Emergency Medical Services (EMS) is dressed back into their clothing before EMS arrives. She stated, if the patient was incontinent, the nurse should have sent Pt 2 in a brief. CS 1 reviewed the electronic record and stated, Pt 2 was incontinent of bladder and bowel, and should have been discharged wearing a brief or chux (incontinent pad). CS 1 reviewed Pt 2's "Patient Belongings" form and stated, the patient had come into the hospital wearing clothing and should have been discharged dressed in her clothing.
During a review of the facility's policy and procedure (P&P) titled Transfer of Patients - Outbound", dated 2/11/21, indicated, "Transfer of a Non-emergent patient to Skilled Nursing or Intermediate Care Facilities [board and care home] ...5. Ensure patient is prepared for transfer ..."

Based on observation, interview, and record review, the hospital failed to ensure the rights of patients to receive adequate care in a safe environment according to maintenance standards of practice when:
1. One of four blood pressure machines in the infusion center (location where patients receive intravenous [vein] fluids and/or medications) had an expired maintenance service date of September 2021,
2. Two of two vein finders in the infusion center had expired maintenance service dates of September 2021,
3. One of one Harmonic scalpel (is a surgical instrument used to simultaneously cut and cauterize [burn] tissue) in the operating room had an expired maintenance service date of November 2021, and
4. One of one examination light had an expired plant maintenance service sticker for electrical safety check dated of 6/19/14.

These failures had the potential for staff to use equipment on patients that may show inaccurate readings or failure to work properly when needed thus, putting patients at risk of delayed care or misdiagnosing the patient's health status.

Findings:

During a concurrent observation and interview on 1/10/22, at 3:50 p.m., with the Wound Clinic Clinical Supervisor (WCS) and the Manager of Outpatient Services (MOS), the Outpatient Wound Clinic was toured. One of 4 blood pressure machines was observed to have expired maintenance sticker dated 9/21. One of 1 examination light had a plant maintenance sticker with electrical safety check dated 6/19/14. The WCS and MOS stated the blood pressure machine must have been missed and not services. She stated, "We have been moving between buildings and sharing equipment. We will take it out of service and send a message to our maintenance department to get it serviced." The WCS stated the facility does not regularly use the examination light. She stated, "I don't think we have looked at the date on that light, but we should." The WCS and MOS stated equipment with expired maintenance stickers should not be used, they could possibly cause inaccurate readings and not work properly when needed.

During a concurrent observation and interview on 1/10/22, at 3:30 p.m., with the Nurse Manager (NM) of the Outpatient Infusion Clinic, the Outpatient Infusion Clinic was toured. Two Accuvein devices (machine used to locate a vein to draw blood or place an IV) were observed to have expired maintenance service stickers dated 9/21. The NM took the Accuvein devices out of service and stated he would be contacting the Biomed (service) department to follow up with the inspection of these devices. The NM stated nurses should not use equipment with expired stickers, this could lead to inaccurate readings and diagnosis could occur if the preventive maintenance was not performed.

During a concurrent observation and interview on 1/11/22, at 10:04 a.m., with the Operating Room (OR) Manager (ORM), the Outpatient OR department was toured. One Harmonic Scalpel machine was observed with a maintenance sticker which indicated it was due for a maintenance servicing on 11/21. ORM stated the machine should have been serviced by November 2021 at the latest. ORM stated she was not sure how the machine's maintenance had been missed.

During an interview on 1/13/22, at 2:13 p.m., with the Director of Clinical Engineering (DCE) and the Supervisor of Clinical Engineering (SCE), the DCE stated, "The Blood Pressure machine should be checked by maintenance every year, it is a low-risk Priority 2 machine but if not done could give incorrect readings thus has the potential for a patient to be misdiagnosed." The DCE stated the BP machine must have been missed, the service team has a master list of all machines in the facility, and they are required to look for them when it is their time to be serviced. If the services department are unable to locate the machine at the end of the month, they send an email to the Manager of the department the equipment it is missing in and ask them to look for it and get back to them when they find it so that they can go service the equipment. The DCE stated if the service department are not able to find a machine after two years, the hospital will retire it. The DCE stated servicing was missed for the two Accuvein. The DCE stated, "Our goal at the hospital is to get 90 percent of the equipment serviced every year." The DCE stated the exam light was maintained by Plant Maintenance.

During an interview on 1/14/22, at 9:57 a.m., with the Director of Plant Services (DPS), the DPS stated when the hospital acquires new equipment, it is added to the hospitals Preventive Maintenance (PM) software so they can track when equipment was last serviced and when it is due for its twice a year service check. The DPS stated the service department found that the exam light never made it into the PM software, therefore service staff did not know to look for it and thus it has not been maintained by the service department. The DPS stated the non-service of the exam light risk to the patient was very low because it does not touch the patient. The DPS stated PM's are necessary to make sure the equipment was properly functioning for staff.

During an interview on 1/14/22, at 10 a.m., with the DCE, the DCE stated, "We did not send an email out to the manager for the missing Accuvein devices. We did not follow our process." The DCE stated the BP machine was serviced per the PM software, staff just did not change the sticker on it. The DCE stated they were unable to look up when Harmonic device was serviced because they did not have the identification number from the device, but they are correcting the error.

During a review of the hospital's policy and procedure (P&P) titled, "Medical Equipment Management Plan" dated 11/16/21, the P&P indicated, " ... I. POLICY The management of medical equipment is a shared effort of the clinical and non-clinical departments and services, with the primary objective being to provide safe, operational efficiency and reliability of medical equipment used on our patients ... V. RESPONSIBILITIES Leadership, directors, managers, and staff have varying levels of responsibility relating to the Medical Equipment Plan and Program as follows: ... F. Clinical Engineering Director: 1. The Clinical Engineering Director or designee oversees the work of the bio-medical engineers, who are responsible for the management of clinical equipment in patient care areas ... The hospital maintains a written inventory of all medical equipment. The hospital inspects, tests and maintains medical equipment ... B. ... all high risk equipment ... equipment identified as life support will be placed on a semi-annual preventive maintenance schedule (unless a more stringent maintenance schedule is required by the product manufacturer) ... C. ... Non-high risk equipment ... Clinical Engineering will achieve 90 percent completion rate on all Non-Life support equipment. It is the responsibility of each technician to monitor and perform the required preventative maintenance duties within their assigned areas. In the event that a technician is unable to locate a piece of equipment during their rounding process. The technician will then notify the department manager for assistance on locating the equipment. The communication method will be via email by the end of month. The email will include a complete list of equipment requiring preventive maintenance and to contact Clinical Engineering once equipment has been located. In the event the equipment is still unable to be located the technician will send out a second email before the end of the 20-day grace ..."

During a review of the hospital's P&P titled, "Preventive Maintenance" dated 4/8/19, the P&P indicated, " ... I. PURPOSE Plant Services will provide the maintenance necessary to ensure a safe comfortable environment for patients staff and visitors. To attain this objective, the program will include regular routine inspections and maintenance procedures ranging from daily, through weekly, monthly, quarterly, semi-annually and yearly intervals to comply with applicable codes and regulations ..."

Based on interview and record review, the facility failed to ensure adequate nursing services were provided for three of 34 sampled patients (Pt) 1, Pt 2, and Pt 3 when:
1. Nursing staff did not complete a comprehensive assessment, review medical history and current medications, or conduct on-going physical assessments in the Emergency Department (ED) and did not follow policy and procedure for provider notification of Pt 1's declining health status throughout her 5-hour ED stay. This failure resulted in Pt 1 not being admitted to the hospital, discharged home, not receiving ED care, and being pronounced deceased at another hospital less than two hours after being discharged.

2. Nursing staff did not report Pt 2's pressure injury (PI) to a Medical Doctor (MD) during her hospital stay. This failure resulted in Pt 2 not receiving Home Health orders for the PI, and placed Pt 2 at risk for PI worsening.


3. Nursing staff did not complete an initial assessment on admission for Pt 3 as an ED Hold (a patient admitted and waiting for an open bed on a medical floor) patient. This failure had the potential to result in Pt 3 not receiving appropriate and prompt medical care due to lack of nursing assessments.

Findings:

1. During a review of Pt 1's "Face Sheet" (a document containing Pt 1's demographic information and diagnosis), undated, the Face Sheet indicated Pt 1 was a 34-year-old, unemployed, uninsured Hispanic female who came to the hospital's ED by private transportation on 10/23/21 at 6:58 p.m., and was discharged to home on 10/24/21, at 6:25 a.m.
During a review of Pt 1's Electronic Medical Record (EMR), the nursing clinical record indicated Pt 1 arrived at the facility's ED on 10/23/21 at 6:58 p.m. and was discharged on 10/24/21 at 12:20 a.m. The clinical record indicated the triage documentation was incomplete, and there was missing documentation for physical assessment, pain assessment, and safety screenings. The clinical record indicated Pt 1's medical history, emergency contact information, and medication history had not been updated.
During a review of the Emergency Medical Service (EMS) Report, dated 10/24/2021, the EMS report indicated, EMS arrived at Pt 1's home at 1:35 a.m. to find Pt 1 with no pulse (heartbeat), not breathing and fire department already on scene doing Cardiopulmonary resuscitation (CPR- is a lifesaving technique useful in emergencies, when the person us not breathing or heartbeat has stopped). EMS continued CPR, placed Pt 1 on cardiac monitor which showed asystole (no heart activity), placed an intravenous (IV- an apparatus used to administer a fluid [as of medication, blood, or nutrients] in the vein), gave two doses of epinephrine (heart medication), and transported Pt 1 to the ED at hospital B.
During a review of Pt 1's Code Blue Documentation from hospital B, dated 10/24/2021, the Code Blue (CPR) Documentation from hospital B indicated, Pt 1 was "Found pulseless at home at 1:15 a.m. [less than 1 hour after discharge from the hospital A's ED]. Time of death was pronounced at 2:03 a.m."

During an interview on 11/10/21, at 2:25 p.m., with MD 4, MD 4 stated, he was an emergency room physician at the hospital A. MD 4 stated, he had treated Pt 1 in the emergency room and at 12:13 a.m., he received a secure text message from one of hospital A's Licensed Vocational Nurses (LVN) 3 stating Pt 1's current vital signs (VS- obtaining heart rate, temperature, blood pressure, and oxygen level to detect or monitor medical problems) and asking him if he still wanted to discharge Pt 1. MD 4 replied to LVN 3's text, informing LVN 3 not to discharge Pt 1, and informed LVN 3 to admit Pt 1 to the hospital. MD 4 stated he received a call from Register Nurse (RN) 1 stating Pt 1 had already been discharged from the ED. MD 4 stated he received another secure text from LVN 3 also stating Pt 1 had already been discharged from the ED. MD 4 stated, his expectation was for the nurse to wait for his reply when there was a change of condition for a patient before discharging, his patient. MD4 stated, if he could have done things differently, he would have admitted Pt 1.

During an interview on 11/12/21, at 1:20 p.m., with LVN 3, LVN 3 stated, he had worked in the ED at the hospital for about two months. LVN 3 stated he was assigned to Pt 1 on 10/23/21. He stated prior to discharging Pt 1, he obtained Pt 1's vital signs and they were not normal. LVN 3 stated he attempted to reach MD 4 via secure voice system, but he was unable to get the secure voice system devise to work. LVN 3 stated after the failed attempt to notify MD 4, he informed the RN of the abnormal VS and was told to discharge Pt 1. LVN 3 stated he attempted to contact MD 4 using a secure messaging system within the electronic medical record (EMR) informing MD 4 of the abnormal VS and asked him if he should still discharge the patient. LVN 3 stated he waited a few minutes to see if MD 4 would reply and when MD 4 did not respond to the message he then discharged Pt 1 home. LVN 3 stated he did not consider using any other method of communication to notify MD 4 of Pt 1's abnormal VS status. LVN 3 stated he did not think to notify another RN, ED supervisor, or ED charge nurse of Pt 1's abnormal VS.

During a concurrent interview and record review, on 11/15/21, at 3:16 p.m., with the Emergency Department Manager (EDM), Pt 1's EMR was reviewed. He stated Pt 1's EMR indicated her oxygen saturations had been around 88-92% on room air (normal level of oxygen is usually 95% or higher). The EMR stated MD 4 should have been notified of Pt 1's oxygen levels but there was no documentation in Pt 1's chart that MD 4 had ever been notified except a late entry note documentation by LVN 1 at 3:48 a.m. with incident time of 12:30 a.m. EDM confirmed that a limited triage assessment was the only assessment completed for Pt 1's ED stay. EDM stated the expectation was that an RN complete a minimum of a focused assessment on every ED patient but that did not occur.

During a concurrent interview and record review on 1/12/22, 9 a.m., with Registered Nurse Informatics (RNI), Pt 1's EMR was reviewed. RNI stated no nursing assessment was completed in the ED for Pt 1 on 10/23/21 and 10/24/21.

During a review of the facility's policy and procedure (P&P) titled "Triage - EMS ", dated 8/2/21, the P&P indicated, " ...Policy: A. All persons requesting treatment in the Emergency Department will be triaged by a Registered Nurse who has completed triage orientation and has documented competency ...Procedure ...B. Patients that do not require immediate lifesaving interventions will be assessed including 1. Chief complaint and history of present illness, including physical findings and care before arrival. 2. Travel History. 3. Pertinent past medical history. 4. Complete vital signs - temperature, pulse, respiration, blood pressure, O2 saturation and pain assessment. 5. Medication allergies - place allergy arm band when appropriate. 6. Tetanus history, when appropriate/immunization status. 7. Name of private physician if known...C. RN will assign priority using the Emergency Severity Index (ESI)..."

During a review of the facility's P&P titled, "Critical Results Communication and Documentation", dated 5/9/2019, the P&P indicated, " ...Critical results: Results that require rapid clinical attention to avert significant patient morbidity or mortality ...must be communicated within defined time frames to the Registered Nurse (RN) caring for the patient or the physician. Documentation of the call including date, time and who received the critical result(s) must be made as a permanent part of the patient's electronic health record ...If the RN makes the decision that the patient's condition is very unstable, he or she follows existing unit and/or corporate policies for Physician Notification Regarding Patient Status and/or Code Blue."

During a review of the facility's P&P titled, "Chain of Command - Patient care issues", dated 2/11/2021, the P&P indicated, " ... Questions involving patient care or policies and procedures are pursued via the staff to the unit-specific Charge Nurse of Clinical Supervisor ...B. Nurse to Physician Chain of Command - Reporting of Medical Information, 1. Nursing personnel are responsible for reporting pertinent patient information to the patient's designated attending physician or to the resident assigned to the patient ..."

2. During a review of Pt 2's "Face Sheet", (undated), the Face Sheet indicated Pt 2 was a 97-year-old, Caucasian, retired female who came into the facility's ED by ambulance on 10/10/20 at 6:25 p.m. Pt 2 was admitted to the facility on 10/11/20 at 8:05 a.m., and was discharged to an Assisted Living facility on 10/16/21 at 4:21 p.m.

During a concurrent interview and record review on 1/12/22, 9:25 a.m., with RNI, Pt 2's EMR was reviewed. RNI stated there was documentation of a wound to Pt 2's sacrum (a triangular bone in the lower back between the two hipbones of the pelvis). Pt 2's "Flow Sheet" (a patient care records that documents interventions) indicated the wound was first assessed on 10/10/20 at 9:00 p.m., and a picture of the wound was uploaded into Pt 2's clinical record on 10/11/20. RNI stated Pt 2's clinical record did not contain nursing notes indicating notification to an MD regarding the wound. RNI validated that there was documentation in the clinical recpord indicating Pt 2 had a stage 2 pressure injury (PI - an injury that happens when pressure is applied to the surface of the skin. At stage 2, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful). Pt 2's "Transfer Form" dated 10/16/20 at 3:00 p.m. RNI validated there were no MD orders for PI and no mention of the PI in any of the MD notes, "History and Physical", or "Discharge Instructions". RNI stated the "Dietary Note", dated 10/11/20, at 8:02 a.m., indicated a dietary referral was initiated by the RN for a stage 2 PI. The dietitian reviewed Pt 2's chart, but there was no documentation of a stage 2 PI "only redness to buttocks noted", and a dietary consult was not provided.

During a concurrent interview and record review on 1/13/22, at 9:24 a.m., with the Clinical Supervisor of Med/surg (CS 1), Pt 2's EMR was reviewed. CS 1 stated the hospital process when discovering a patient with a PI, was to notify the MD, get a treatment plan from the doctor, take a picture for base line assessment, create a care plan, take measurements, and request a consult for a wound nurse if the PI was beyond the floor nurses' scope of practice. She stated documentation of the PI would be as a wound documented in "Doc Flow Sheets" and to put in a nursing note. CS 1 was unable to find any documentation in Pt 2's EMR indicating any of Pt 2's nurses had notified the MD of the pressure ulcer. She stated, the ED MD note indicated the MD was focusing on cardiac and respiratory issues and did not mention a PI at all. She stated, the nutrition consult, on 10/11/22 was not completed because after a review of the chart, the dietician did not think patient had a PI. So, the dietician deemed Pt 2 did not need a nutritional consultation. CS 1 validated when Pt 2 was discharged from the hospital that there were no discharge orders relating to the care of Pt 2's PI. CS 1 stated there was no indication in Pt 2's chart that nurses ever notified the MD of Pt 2's PI which did not follow the hospital's P&P for PIs.

During an interview on 1/13/22, at 3 p.m., with MD 3, he indicated he was not aware Pt 2 had a PI. MD 3 stated he wrote an order for Home Health on 10/22/20 after the patient had been discharged and later became aware of the PI. MD 3 stated his expectation was for nurses to tell him if his patient had a PI so he could assess the wound himself, write notes, and write wound treatment orders.

During a concurrent interview and record review, on 1/13/22, at 3:30 p.m., with the Director of Care Coordination (CSS), the Clinical Nutrition Manager (CNM), and the Registered Dietitian (RD), Pt 2's EMR was reviewed. RD stated when she received a patient consult, she reviewed the patient's chart to see if it was an appropriate consult and if she did not see a pressure ulcer documented, she would wait and consult on the fourth day of admission. CNM stated Pt 2's Flow Sheet did not indicate a "Stage II pressure ulcer" so it was appropriate for the dietitian to follow up on the fourth day. DCC stated, consultants relied on other clinical staffs' documentation to determine appropriate consultations. She stated, "if there was a wound, we would function off the physician order for a wound follow up, but there was no physician order indicating a wound" for Pt 2.

During a review of the facility's policy and procedure (P&P) titled "Pressure Injury Risk Assessment, Prevention, Staging and Treatment", dated 2/14/2019, the P&P indicated, " ...Policy ...A. All patients shall be assessed upon admission, then every shift, and with condition changes ...F. Notify the physician of any skin breakdown and of any significant changes to the pressure injury. G. All pressure injury treatment requires a physician order ...Procedure A. Risk Assessment 1. Use the Braden Scale Risk Assessment tool to identify patients at risk for pressure injury as part of the initial assessment within 4 hours of admission. Subsequent skin assessments are completed every 12 hours ...the initial skin assessment upon admission and/or transfer from another unit will be conducted with 2 licensed staff members ...Documentation ...D. Document the following upon recognition and with every dressing change on the KDA associated with the anatomic location of the wound ...
1. Dressing status.
2. Wound bed assessment.
3. Condition of the surrounding tissue.
4. Dimensions of wound in centimeters (cm) x length (head to toe) x width (side to side) x depth upon recognition and at least weekly thereafter
5. Presence of undermining, sinus tracts or tunneling.
6. Exudate description
7. Pain assessment and interventions.
8. Typo of solution used for irrigation and dressing change as appropriate.
9. Type and amount of dressing material used in the dressing treatment section.
10. Patient tolerance to procedure.
11. Physician notification of any changes.
12. Patient/family education.
13. Upload images of the patient's wounds into the EHR ..."

During a review of Pt 3's "Face Sheet", (undated), the Face Sheet indicated Pt 3 was a 63-year-old, single, disabled, Hispanic female who came to the facility's ED by ambulance on 7/25/21, at 2:08 p.m. Pt 3 was admitted to the facility on 7/26/21, at 8:46 a.m., and was not discharged from the facility.

During a concurrent interview and record review on 1/11/22, at 2:45 p.m., with MD 1, MD 1 reviewed Pt 3's EMR and stated, he expected nurses to provide the same care in the Emergency Department (ED) for ED hold (a patient admitted and waiting for an open bed on a medical floor) patients as they would for a patient on a medical floor.

During a concurrent interview and record review on 1/12/22, at 9:45 a.m., with RNI, Pt 3's EMR was reviewed. RNI stated there was no nursing assessment completed while Pt 3 was in the ED. RNI stated the first patient assessment was completed when Pt 3 was in the Intensive Care Unit (ICU- unit for patients with critical care needs) where a PI was first documented on Pt 3's coccyx (tail bone). RNI stated Pt 3's first nursing assessment was documented on 7/28/21, at 3:21 a.m. when Pt 3 was transferred to the ICU.

During a concurrent interview and record review on 1/12/22, at 3 p.m., with the RN Wound Nurse (RNWN), Pt 3's EMR was reviewed. RNWN stated, Pt 3's PI was discovered on 7/28/21, when she saw the patient on 7/29/21. RNWN stated she staged (severity of wound identification) the PI as a Deep Tissue Injury (DTI- when a wound is purple or maroon in color and localized area of discolored on intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear (force generated when the skin or tissue is moved against a bony skeleton moving in an opposite direction to the surface skin) and became an Unstageable PI (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) on 8/15/21. RNWN reviewed the photographs of Pt 3's PI dated, 7/28/21, 7/29/21, 8/16/21, and 8/23/21 and stated despite aggressive wound care, Pt 3's PI never got better, it only worsened.

During a concurrent interview and record review on 1/12/22, at 3:35 p.m., with RN 15, Pt 3's EMR was reviewed. RN 15 stated she was Pt 3's nurse when the MD ordered Pt 3 to be admitted to the hospital on 7/26/21 and afterwards until 7:00 p.m., on 7/26/21. RN 15 stated, a full assessment must be completed on an ED patient when they become an admission hold patient. RN 15 stated she did not remember if she had completed a full assessment on Pt 3. RN 15 stated, she did not remember if she had looked at Pt 3's skin when Pt3 was assigned to her care. The EMR indicated RN 15 did not complete either assessment. RN 15 stated during handoff, she could have given report to the next nurse if a task had not been completed but she did not recall doing that. RN 15 stated she was unclear of the P&P on assessments for ED but believed nurses had 24 hours to complete the full patient assessment. RN 15 stated she did not remember if she had told the nurse taking over care of Pt 3 the assessment still needed to be completed.

During a phone interview on 1/12/22, at 3:50 pm, with RN 16, RN 16 stated she was the admitting RN for Pt 3 in the ICU and had found and documented Pt 3's PI. She stated the policy for patients being admitted was for them to have a full body assessment, but Pt 3 did not have any of the assessments completed when she received Pt 3.

During a review of the facility's P&P titled, "Patient Assessment", dated 8/8/2019, the P&P indicated, " ...The initial assessment using the nursing process will be initiated by the Registered Nurse (RN) within two hours of the patient's admission ...and a complete admission and plan of care will be documented within 24 hours ..."

During a review of the facility's P&P titled "Admission Initial Assessment (Nursing)", dated 4/13/19, the P&P indicated, " ...Policy A. Admission ...4. The initial nursing admission assessment is to be documented by the RN and/or admission team completing the admission. A. The information will be entered into the electronic health record (HER) and a complete admission and plan of care will be documented within 24 hours ...5. At a minimum, include in the initial assessment ...b. A focused system assessment and stability of patient condition ...Procedure ...D. The RN ...2. Performs a head-to-toe assessment on the patient as appropriate to his/her diagnosis, condition, and age ...5. Assesses patient's skin and risk for impairments in skin integrity upon admission. (Refer to the Pressure Injury Risk Assessment, Prevention, Staging and Treatment policy) ..."

Based on interview and record review the hospital failed to ensure licensed nurses adhered to the hospital policies and procedures (P&P) when:
1. Three of 34 sampled patients (Pt) 10, 11 and 17 were administered pain medication without conducting an initial pain assessment and/or reassessment in a timely manner per the hospital's P&P titled "Pain Management Guidelines". These failures had the potential for Pt 10, 11 and 17 to continue to be in pain and to not have their pain needs met and reassessed in a timely manner.
2. One of one sampled patient (Pt 33) was not assessed prior to receiving wound dressing change for pain for a procedure that had the potential to cause pain. This failure resulted in Pt 33 experiencing undo pain when her wound dressing was removed.
3. One of four sampled patients (Pt 16), Consent for Transfusion of blood was not completed by Registered Nurse (RN) 1. This failure had the potential for patient 16 to receive or not receive blood per his consent.

Findings:

1. During a review of Pt 10's Face Sheet (document containing demographic information and medical diagnosis), undated, the Face Sheet indicated Pt 10 was admitted to the hospital on 12/26/21 at 7:32 p.m., with " ... Admit Reason (s): Failure to Thrive in Adult (a decline seen in older adults - typically those with multiple chronic medical conditions - resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression and decreasing functional ability) ..."

During a review of Pt 10's Medication Administration Report (MAR- medications given during hospital stay), dated 12/27/21 through 1/5/22, the MAR indicated Pt 10 had orders for the following pain medications:

-"Hydromorphone (Dilaudid- pain medication for severe pain) injection 1 mg (milligram- unit of measure) Dose: 1 mg Freq (Frequency): Every 3 hours PRN (as needed) PRN Route: IV (intravenous- in a vein) PRN Reason: Severe pain Start: 12/27/21 3:32 p.m. End: 1/10/22 8:56 p.m. Admin Instructions: For IV administration give slowly over 2-3 minutes.
-Hydromorphone (Dilaudid) injection 1 mg Dose: 1 mg Frequency: Every 3 hours PRN Route: IV PRN Reason: Severe pain Start: 12/27/21 8:35 a.m. End: 12/27/21 3:32 p.m. Admin Instructions: For IV administration give slowly over 2-3 minutes.
-Morphine (MSir- breakthrough pain medication) tablet 15 mg Dose: 15 mg Freq: every 4 hours PRN Route: Oral PRN Reason: Breakthrough Pain Start: 12/27/21 3:30 p.m. End: 1/10/22 8:56 p.m. Admin Instructions: Do not crush or chew
-Morphine (MS Contin-extended release medication is used to help relieve severe ongoing pain) 12 hr (hour) tablet 15 mg Dose: 15 mg Freq: 2 times Daily Route: Oral Start: 12/27/21 9 a.m. End: 12/27/21 3:32 p.m. Admin Instructions: Do not crush or chew
-Morphine (MS Contin) 12 hr tablet 15 mg Dose: 15 mg Freq: 3 times Daily Route: Oral Start: 12/27/21 9 p.m. End: 12/28/21 12 p.m. Admin Instructions: Do not crush or chew
-Morphine (MS Contin) 12 hr tablet 30 mg Dose: 30 mg Freq: 3 times Daily Route: Oral Start: 12/28/21 1 p.m. End: 1/3/22 11:21 a.m. Admin Instructions: Do not crush or chew
-Morphine (MS Contin) 12 hr tablet 15 mg Dose: 15 mg Freq: Every 12 hours Scheduled Route: Oral Start: 1/3/22 9 p.m. End: 1/10/22 8:56 p.m. Admin Instructions: Do not crush or chew."

During a concurrent interview and record review on 1/11/22, at 10:50 a.m., with the Registered Nurse Informaticist (RNI) and the Director of Clinical Practice and Development (DCPD), Pt 10's Pain Accordion (PA) for 12/26/21-1/10/22, undated was reviewed. RNI and the DCPD validated Pt 10's PA indicated Pt 10 was administered 1 mg (milligram- unit of measurement) of (hydromorphone) [generic pain medication name] IV (intravenous- given through the vein) on 12/27/21 at 9:37 a.m. The RNI and the DCPD validated Pt 10's PA indicated no pain score was documented for this administration of hydromorphone, the DCPD stated a pain score should have been documented when pain medication was given to see if the pain medication alleviated the pain. The patient receiving oral pain medication should be reassessed (done after pain medication given to see if pain medication alleviated the pain) within 1 hour after administration and if pain medications are given IV pain medication, they should be reassessed within 30 minutes of administration for effectiveness. The PA indicated the next reassessment pain score after the hydromorphone was on 12/27/21 at 10:30 a.m. The PA indicated:

-On 12/27/21 at 8:45 p.m. 15 mg of Morphine oral tablet was given, no pain score documented and no pain reassessment score,
-On 12/28/21 at 4:11 a.m. 15 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
-On 12/29/21 at 12:42 p.m. 30 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
- On 12/29/21 at 9:10 p.m. 30 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
- On 12/30/21 at 5:23 a.m. 30 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
- On 12/30/21 at 9:17 p.m. 30 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
- On 12/31/21 at 4:04 a.m. 30 mg of Morphine oral tablet was given, no reassessment score within the one hour of administration,
- On 12/31/21 at 1:09 p.m. 30 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
- On 12/31/21 at 9:23 p.m. 30 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
- On 1/1/22 at 5:11 a.m. 30 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
- On 1/1/22 at 8:54 p.m. 30 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
- On 1/4/22 at 8:56 p.m. 15 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
- On 1/5/22 at 9:09 p.m. 15 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
- On 1/6/22 at 8:43 a.m. 15 mg of Morphine oral tablet was given, no pain reassessment score,
- On 1/6/22 at 9:18 a.m. 15 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
- On 1/7/22 at 8:37 a.m. 15 mg of Morphine oral tablet was given, no pain reassessment score,
- On 1/7/22 at 9:47 p.m. 15 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
- On 1/8/22 at 10:16 a.m. 15 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
- On 1/8/22 at 8:55 p.m. 15 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
- On 1/9/22 at 8:49 a.m. 15 mg of Morphine oral tablet was given, no reassessment score,
- On 1/9/22 at 9:39 p.m. 15 mg of Morphine oral tablet was given, no pain score was documented and no pain reassessment score,
- On 1/10/22 at 8:34 a.m. 15 mg of Morphine oral tablet was given, no pain reassessment score.

During a concurrent interview and record review, on 1/13/22, at 10:32 a.m., with Registered Nurse (RN) 12, Pt 10's Pain Accordion (PA) for 12/26/21-1/10/22, (no date) was reviewed. RN 12 stated Pt 10's PA indicated on 12/28/21 she administered Morphine oral tablet to Pt 10 and no pain assessment score was documented and no pan reassessment score was documented. RN 12 stated when administering pain medication, it is the nurse's responsibility to assess the pain level and document. If it is oral pain medication to reassess pain level within 30 minutes of administration to make sure the pain medication was effective.

During an interview on 1/13/22, at 10:40 a.m., with the Director of Inpatient Services (DIS), the DIS stated he was not the manager at the time Pt 10 was in this department, but he is the interim manager now due to the manager being out on leave. The DIS stated the expectation when nurses give IV pain medication was that they chart a pain level at the time of giving the medication and reassess the patients pain level within 30 minutes of administration and document the pain level, if giving oral pain medication document the current pain level and reassess within 1 hour after administration and document the pain level. The DIS stated their computer system EPIC (Electronic Health Records- where staff chart in patient records) sees PRN pain medication different from routine pain medication and does not give a reminder to report pain level after the routine pain medication is given but after a PRN pain medication it alerts the nurse to reassess the patients pain level.

During a review of Pt 11's Face Sheet, (no date), the Face Sheet indicated Pt 11 was admitted to the hospital on 1/5/22 at 5:02 p.m., with " ... Admit Reason (s): Acute Cerebrovascular Accident (CVA) (Stroke- Damage to the brain from interruption of its blood supply.) ..."

During a review of Pt 11's Medication Administration Report (MAR- medications given during hospital stay), dated 1/6/22 through 1/12/22, the MAR indicated Pt 10 had orders for the following pain medications:

During a concurrent interview and record review on 1/11/22, at 11:24 a.m., with the RNI and the DCPD, Pt 11's Pain Monitoring, dated 1/4/22 through 1/7/22 was reviewed. The RNI and DCPD confirmed Pt 11's Pain Monitoring indicated:

-On 1/6/22 at 4:10 p.m. 1 mg of Morphine IV was given; no pain score was documented, and no reassessment pain score was documented.
-On 1/7/22 at 5:22 p.m. 1 mg of Morphine IV was given; no pain score was documented, and no reassessment pain score was documented.
The DCPD stated when a patient receives IV pain medication the patient should be reassessed within 30 minutes after administration.

During a concurrent interview and record review, on 1/12/22, at 3:45 p.m., with RN 13, Pt 11's Pain Monitoring, dated 1/4/22 through 1/7/22 was reviewed. RN 13 confirmed the Pain Monitoring form for Pt 11 indicated that RN 13 administered 1 mg of Morphine to Pt 1 on 1/6/22 at 4:10 p.m. RN 13 stated, "My initial assessment is missing [for her pain medication]," and there is "No[pain] reassessment ..." RN 13 stated IV pain medication should be reassessed within 30 minutes after administration.

During an interview on 1/12/22, at 3:50 p.m. with the Interim Emergency Department Manager (IEDM), the IEDM stated the expectation when a patient has pain is for the nurse to assess the patient's pain level and when they medicate the patient to reassess their pain level per our policy. The IEDM stated it is important to reassess the pain level of the patient afterwards for patient comfort and make sure the pain is managed and the patient is safe.

During a review of Pt 17's Face Sheet, (no date), the Face Sheet indicated Pt 17 was admitted to the hospital on 1/3/22 at 1:37 p.m., with " ... Admit Reason (s): Metastatic [which cancer cells spread to other parts of the body] Colon Cancer to Liver ..."

During a review of Pt 17's MAR, dated 1/8/22 through 1/11/22, the MAR indicated Pt 17 had an order for "Morphine 2-4 [milligrams-mg-unit of measurement], Dose 2-4 mg, [frequency]: EVERY 2 HOURS [PRN-as needed] Route [IV-intravenous-administered into a vein], PRN reason: SEVERE pain." The MAR indicated, Patient 17 received Morphine Sulfate 2 mg IV on 1/9/22 at 11:06 p.m., on 1/10/22 at 1:07 a.m., on 1/10/22 at 3:22 a.m., and on 1/10/22 at 5:29 a.m.

During a concurrent interview and record review, on 1/13/22, at 11:33 a.m., with RN 10 and the Cardiac Progressive Care Unit Manager (CM), Pt 17's MAR dated 1/8/22 to 1/11/22 was reviewed. RN 10 stated she assessed Pt 17's pain after administering each dose of Morphine on 1/10/22 at 12 a.m. at a level of 7 out of 10, on 1/10/22 at 1:37 a.m. at a level of 4 out of 10, on 1/10/22 at 2 a.m. at a level of 4 out of 10, on 1/10/22 at 4 a.m. a level of 9 out of 10, and 1/10/22 at 6 a.m. at a level of a 6 out of 10. RN 10 stated she assessed Pt 17's pain level prior to administering the morphine medication but failed to document the pain level. CM read the P&P, "Pain Assessment & Management (PAM) - Patients 14 and Older" dated 4/8/2021, the PAM indicated " ... If pain is identified as an issue, the initial assessment will include pain intensity (0-10), verbal pain descriptors, or the behavioral pain score, patient's acceptable level of pain, location, quality, duration, and any associated symptoms ...". RN 10 stated the P&P was not followed and the RN 10 failed to document the assessments. The CM stated the expectation is that nurses will follow the P&P's.

During an interview on 1/13/22, at 2:25 pm, with the Interim Vice President of Nursing (IVPN), the IVPN stated the expectation when pain medication is given to a patient is for the nurse to reassess all pain medications given, document it, and follow the hospitals policy and procedure.

During an interview on 1/13/22, at 2:28 pm, with the Chief Nursing Officer (CNO), the CNO stated there is a policy for pain management of a patient and "I would expect staff to follow the policy and procedures."

2.During a review of Pt 33's Face Sheet, (no date), the Face Sheet indicated Pt 17 was admitted to the hospital on 1/3/22 at 8:31 p.m., with " ... Admit Reason (s): Left Leg Cellulitis [A common and potentially serious bacterial skin infection that causes redness, swelling and pain to the affected area] ..."

During a review of Pt 33's document titled, "Wound Care Advanced Left Lower Extremity (Order 32041129), dated 1/4/22, the order indicated, " ... Order Date/Time 01/04/22 11:10 [a.m.] ... Order Details Frequency EVERY 2 DAYS ... Priority Routine ... Comments Place a wound sized piece of Xeroform [Non-stick primary dressing used to maintain a moist wound environment, made of fine-mesh gauze impregnated with a petrolatum blend] to the areas of open tissue. Cover with loose gauze or an ABD pad. Secure dressing to the left lower extremity with a Kerlix gauze and tape. Change dressing every 2 days and as needed for soilage and /or dislodgement ..."

During a review of Pt 33's MAR dated 1/13/22, the MAR indicated Pt 33 had an order for "acetaminophen (Tylenol) tablet 650 mg Dose: 650 mg Freq: EVERY 4 HOURS PRN Route: Oral PRN Reasons: Pain, MODERATE pain, MILD pain, Fever, Other ... Start: 01/04/22 0935 [a.m.] End: 01/14/22 0026 [12:26 a.m.] ..."

During a concurrent observation and interview on 1/13/22, at 4:07 p.m., with RN 14 and the CM, Pt 33's dressing change was observed at the patient's bedside. RN 14 was observed removing Pt 33's dressing to her left lower leg, when RN 14 pulled the dressing away from Pt 33's skin the patient immediately cringed/ grimaced and made a face that looked like she was in pain. Pt 33 stated she was in pain, and the pain level was an 8 out of 10 (severe pain). RN 14 continued to change the dressing, clean the open site on her inner leg with normal saline and reapplied the dressing per the order and asked the patient how her pain was. Pt 33 stated the dressing was not too tight and she had very little pain. RN 14 then asked if Pt 33 wanted anything for the pain and Pt 33 replied that it had stopped hurting. RN 14 stated, "I did not offer [pain medication prior]. She has not been having pain until now [after the dressing was removed]." RN 14 stated she should have asked the patient prior to the dressing change if she would like pain medication to prevent or lessen the pain that may be caused by the dressing change.

During an interview on 1/13/22, at 4:20 p.m., with the CM, the CM stated the expectation when a nurse is going to do a dressing change is to determine if the patient will need to be premedicated prior to the dressing change to help prevent the patient from having pain during the dressing change. The CM stated RN 14 did not do that prior to Pt 33's wound dressing change.

During the review of the facility's Policy and Procedure (P&P) titled, "Pain Assessment & Management- Patients 14 and Older," dated 4/8/21, this P&P indicated, "I. PURPOSE A. To demonstrate [name of hospital] commitment to a patient's right to effective pain management. B. To establish standards of nursing care and practice that defines the role and responsibilities of the Registered Nurse (RN) to provide pain management at all facilities within the [name of hospital] hospital system C. To promote the use of a developmentally based, individualized, multidisciplinary, pain management care plan in order to: q. Minimize the incidence and severity of acute and chronic pain, and promote patient comfort ... III. PROCEDURE A. Data Collection and Assessment ... 5. Assess and reassess pain using one of the following scales as appropriate. a. 0-10 pain intensity scale (adolescents to adults who do not have cognitive disorders). The appropriate pain rating scale is used to determine an appropriate pain management modality ... 7. Assume pain is present for conditions or procedures that are known to cause pain. 8. Pain screening will be conducted on admission and continue throughout hospitalization as determined by unit specific guidelines of care and individual patient needs such as before and after any known pain producing procedure ... D. Evaluation/Reassessment of Pain Management 1. Clinicians assess patients with pain as frequently as necessary to provide adequate pain relief and ensure patient safety. 2. Patients receiving oral pain medication are reassessed within 60 minutes after administration of oral pain medication, and patients receiving intravenous pain medication are reassessed within 30 minutes after administration of intravenous pain medication. 3. Compare post-intervention pain level to acceptable level of pain to determine intervention effectiveness and/or additional interventions for patients able to provide a self-report ... 5. Evaluate and reassess for side effects of treatment and risk factors for adverse events caused by treatment. Notify the physician and pharmacist if an adverse drug reaction occurs ... IV. DOCUMENTATION A. Document the following in the appropriate section of the electronic health record (EHR): 1. If pain is identified as an issue, the initial assessment will include pain intensity (0-10), verbal pain descriptors, or the behavioral pain score, patient's acceptable level of pain, location, quality, duration, and any associated symptoms. 2. Subsequent reassessments should include the following: intensity, location, response to treatment modalities, and type of pain assessment scale used ..."

During a review of the facility's P & P titled, "Medications - High Alert & Hight Risk for Patients 14 and Older," dated 10/14/21, the P & P indicated, "I. PURPOSE To provide guidelines to ensure patient safety for the safe selection, storage, ordering, transcribing, preparation, monitoring, administration, use, and medication system evaluation of medications which have been identified as "High Alert/High Risk". II. DEFINITIONS A. High Alert/High Risk: Medications and/or administration techniques are defined as those that have been shown to actually or potentially cause significant harm to the patient, even when used as intended. This may be determined through retrospective review of practice; recommendations from organizations, such as the Institute for Safe Medication Practices (ISMP); or prospective analysis ..."

During a review of the facility's document titled, "[Name of Hospital] High Alert & High Risk Medication List (as of 1/12/22), it indicated it was a Reference for "Policy # 16492 Medications - High Alert & High Risk Medications for Patients 14 and Older Policy # 25716 Medications - Hight Alert & High Risk Medications for Patients Under 14 ... HYDROMORPHONE (PF-prefilled) 1 MG/ML INJECTION SYRINGE ... MORPHINE (PF) 1 MG/ML INJECTION SOLUTION ... MORPHINE 2 MG/ML INJECTION SYRINGE ... MORPHINE ER 15 MG TABLET, EXTENDED RELEASE MORPHINE ER 30 MG TABLET, EXTENDED RELEASE ..."

During a concurrent interview and document review on 1/14/22 at 11:15 a.m., with Registered Nurse (RN) 10, RN 10 provided document titled, "NURSING SKILL Changing a Wet-to-Dry Dressing," undated, and stated the hospital does not have a P&P on dressing changes the nurse just follows the orders but if they need to refresh on their skills the hospital uses this reference. The reference indicates, "Purpose Wet-to-Dry (WTD) dressing are used to provide wound protection, absorb exudate, and promote mechanical debridement ... Procedure SUPPLIES * Sterile/nonsterile gloves ... *Facility-approved pain assessment tool *Prescribed analgesic [pain medication] and means for its delivery ... PREPROCEDURE STEPS ... 3. Prior to performing a dressing change, assess the patient for pain using a facility-approved pain scale 4. Administer prescribed analgesia 30 minutes before the procedure to allow the therapeutic level to be reached ..."

3. During a review of Pt 16's Face Sheet, (no date), the Face Sheet indicated Pt 16 was admitted to the hospital on 1/7/22 at 3:42 p.m., with " ... Admit Reason (s): Severe Anemia [a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues] ..."

During a concurrent interview and record review, on 1/12/22, at 10 a.m., with RN 9, the Nurse Manager (NM) and the Clinical Supervisor (CS) 1, Patient 16's "Consent of Transfusion of Blood and/or Blood Components (CTBBC)" dated 1/7/22 at 10:31 p.m., and the hospitals policy and procedure (P&P) titled, "Blood Consent" dated 12/12/19 were reviewed. The CBBTC indicated the signatures of the patient, witness, and provider were present. The CTBBC had a box that indicated, "I give consent to receive blood and/or blood components as determined to be necessary" and another box that indicated, "I refuse to consent for a transfusion of blood and/or blood components. I fully understand that the possible result of such refusal includes the potential loss of life". The NM 1 read the sections for consent aloud for RN 9 over the telephone. RN 9 stated, "I forgot to check the box" and patient 16's CTBBC did not indicate he consented to have blood products. The CS 1 read out loud the P&P Blood Consent and stated: "If the patient agrees to accept the transfusion, ensure that the patient checks the "I give consent to receive blood and/or blood components as determined to be necessary" box. RN 9 stated the P&P was not followed, and RN 9 failed to ensure the box was checked off.

During a concurrent interview and record review on 1/13/22, at 9:50 a.m. with Pt 16, Pt 16's CTBBC, dated 1/7/22 at 10:31 p.m. was reviewed. The CTBBC indicated, on 1/7/22 at 10:31 p.m., the signatures of the patient, witness and provider were present. The two boxes were blank. Pt 16 reviewed the CTBBC dated 1/7/22 and recognized his signature. Pt 16 stated he had consented for blood transfusions and failed to check the box indicating his preference.

During a review of the hospital's P&P titled, "Blood Consent" dated 12/12/19, Section, "III. Procedure ... D. Consent ..." indicates "If the patient agrees to accept the transfusion, ensure that the patient checks the 'I give consent to receive blood and/or blood components as determined to be necessary" box.

Based on interview and record review, the facility failed to maintain a complete and accurate clinical record for one of 34 patients (Pt 3) when the Medical Doctor (MD) did not document physician assessment notes for the12 hours MD provided medical care to Pt 3.

This failure resulted in an incomplete and inaccurate clinical record for Pt 3 and places Pt 3 at risk for inaccurate health professionals' communication of medical changes or response to medications and services which could compromise the effectiveness and evaluation of Pt 3's medical treatments.

Findings:

During a review of Pt 3's "Face Sheet" (document containing Pt demographic information and medical diagnosis), undated, the Face Sheet indicated Pt 3 was a 63-year-old, single, disabled, Hispanic female who came to the facility's Emergency Department (ED) by ambulance on 7/25/21, at 2:08 p.m. Pt 3's face sheet indicated she was admitted to the facility on 7/26/21 at 8:46 a.m.

During a concurrent interview and record review on 1/11/22, at 2:45 p.m., with the Medical Doctor (MD) 1, MD 1 reviewed Pt 3's electronic medical record (EMR) and stated, MD 2 was caring for Pt 3 on 7/21/21. MD 1 validated several orders from MD 2 on 7/21/21 but was unable to find a documented MD assessment note in Pt 3's EMR. He stated, there should have been an MD note documented from MD 2 regarding Pt 3's care. MD 1 stated every patient was supposed to have a note documented by the treating physician every day. MD 1 stated it was not okay for a patient not to have a physician note addressing the patient's response to medical treatment.

During a concurrent interview and record review on 1/13/22, at 10:30 a.m., with MD 2, MD 2 reviewed Pt 3's EMR, MD 2 stated he remembered Pt 3 and confirmed he was the physician caring for her in the Emergency Department on 7/21/21. MD 2 stated his MD note was not in Pt 3's EMR. MD 2 stated, the expectation was that upon treating patients, the physician should document the encounter and leave the documentation in the chart. He stated he couldn't explain why there was no progress note on the chart documenting the encounter. He stated he intended to be more careful in future patient encounters regarding required documentation.
The facility did not provide the policy and procedure for MD documentation of patient treatment when requested.

Based on observation, interview and record review, the facility failed to maintain a system for controlling sources of infection and communicable disease in accordance with internal policies and procedures, nationally recognized infection control practices, and guidelines and regulations, when:

1.Patients and visitors were not screened at the entry of the hospital for COVID-19 (a disease, caused by a novel (new) corona virus spread primarily through droplets of saliva or discharge from the nose when an infected person talks, coughs, or sneezes) in accordance with Centers for Disease Control and Prevention's (CDC-the nation's health protection agency) nationally recognized infection and communicable disease control guidelines.

2. Four of four staff (Respiratory Therapist (RT 1), Patient Care Assistant (PCA 1), Registered Nurse (RN 1), and COVID-19 Screener (S2) wore procedure masks over their fitted N95 filtering facepiece respirator (FFR- particulate filtering mask) which was not in accordance with hospital policy and procedure, State, and national guidelines for proper use of FFRs.

3.One of one vendor (V1) was not instructed on the hospital's policy for personal protective equipment (PPE- respirator, eye protection, gown, and gloves) use in patient care areas.

These failures increased the risk of transmission of communicable diseases to patients, staff, and visitors.

Findings:

1.During an observation on 1/10/22, at 8:50 a.m., at the main entry of the hospital, the COVID-19 screening process was observed. The screener (first in-person point of contact for the hospital responsible for ensuring COVID-19 health and safety measures are being adhered to when entering the hospital) asked patients and visitors to stand in front of a digital thermometer stand. The digital thermometer emitted an audible "Okay" when temperature levels were within preset parameters. The screener did not validate the temperature readings by checking the digital screen. A "COVID-19 Symptom Check Board" sat on the floor of the screening area, obscured by the digital thermometer stand. The screener asked visitors, "Do you have any symptoms?" The screener did not prompt visitors to read the "COVID-19 Symptom Check Board" when the question was asked. Visitors were not prompted perform hand hygiene prior to entry.

During a concurrent observation and interview on 1/12/22, at 8:30 a.m., at the main entry of the hospital, with S2, S2 reviewed COVID-19 symptoms (sore throat, difficulty breathing, unexplained muscle aches, new cough, loss of taste or smell, headaches, diarrhea, vomiting, runny nose, or congestion) with patients and visitors. S2 stated as screener, the main responsibility was to check temperatures and recite every COVID-19 symptom when screening patients and visitors so that potential infectious persons did not enter the hospital. S2 stated screening was not complete if temperatures and symptoms were not addressed.

During an interview on 1/13/22, at 5:15 p.m., with the Infection Preventionist (IP), the IP stated all patients and visitors must be screened prior to entry into the hospital. The IP stated patient and visitors were screened to keep patients, staff, and visitors safe and prevent the transmission of COVID-19. The IP stated the screener did not follow hospital protocol when she did not review COVID-19 symptoms with the patients and visitors.

During a review of the of the hospitals document titled "Screening Process Guide- Patients/ Visitors", undated, the document indicated, "Symptoms Check- Review Outpatient Screening Form with patients asking each question listed on the form OR ... Reading questions from on the large signs ... In the last 10 days have you experienced ... Fever at or above 100° F [Fahrenheit] ... Sore throat ... Difficulty breathing ... Unexplained muscle aches ... New cough ... loss of taste or smell ... headaches ... Diarrhea (3 or more loose stools in 24 hours) ... Pink eye ... Vomiting ... Runny nose or congestion... to pass screening, temperature must be less than 100 degrees F ..."

2. During a concurrent observation and interview on 1/10/22, at 3:25 p.m., in the fifth- floor medication room, with RT 1, RT 1 wore a procedure mask (breathable disposable mask) over her fitted FFR. RT 1 stated she was "fit- tested" (test to verify that a respirator provides the expected protection) for the FFR upon hire and was provided adequate FFRs to perform her job duties. RT 1 stated she wore a procedure mask over her FFR for added respiratory protection during COVID-19 pandemic. RT 1 stated she routinely administered nebulizing treatments (respiratory treatment to improve breathing) to patients. RT 1 stated she double masked each shift and was uncertain if it followed hospital policy.

During a concurrent observation and interview on 1/10/22, at 4:00 p.m., in the hallway, with PCA 1, PCA 1 wore a procedure mask over her FFR. PCA 1 stated she felt "safer" double masking during the COVID-19 pandemic. PCA 1 stated the hospital provided adequate PPE supplies (personal protective equipment- respirator, mask, gown, gloves, and eye protection and/ or face shield) to routinely change FFRs if needed but decided to double mask for safety purposes.

During a concurrent observation and interview on 1/10/22, at 4:30 p.m., in the nurse's station, with RN 1, RN 1 wore a procedure mask over her FFR. When asked why she double masked, RN 1 stated, "cause it's what I do [to] feel safer." RN 1 stated hospital administration did not stipulate whether a procedure mask could be worn over an FFR.

During an interview on 1/11/22, at 4:00 p.m., with the Respiratory Therapy Director (RTD), the RTD stated, "I don't see a problem" with wearing a procedure mask over a FFR and stated he was not aware of any concerns with this practice.

During a concurrent observation and interview on 1/12/22, at 8:30 a.m., at the main entry of the hospital, with S2, S2 wore a procedure mask over her FFR. S2 stated some staff, including herself, wore a procedure mask over a FFR for added respiratory protection. S2 stated she was not trained by the hospital to "double-up" but did it anyway for safety purposes. S2 stated she was uncertain if this practice followed hospital policy and procedure. S2 stated "supervisors" were aware and did not instruct her to change the method in which she wore face PPE (personal protective equipment- eye protection, respirator and/ or mask).

During an interview on 1/12/22, at 11:00 a.m., with the IP, the IP stated hospital administration allowed staff to wear a procedure mask over their FFRs if staff preferred to do so. The IP stated she was not aware of any professional literature indicating this practice was unsafe.

During an interview on 1/12/22, at 11:55 a.m., with the Director of Occupational Services and Safety (DOS), the DOS stated the hospital followed the California Division of Occupational Safety and Health (CAL/OSHA- state program that is responsible for protecting the health and safety of workers) and Federal (Fed-OSHA) regulations. The DOS stated although CAL/ OSHA and industry standard did not recommend employees wear a procedure mask over FFRs, but there were no conclusive studies published to indicate a procedure mask worn over a FFR was unsafe. The DOS stated he ran his own test sample and found the procedure mask did not disrupt the fit of the FFR, rather, it improved the filtration of the FFR. The DOS stated he would like to see employees stop this practice because of industry standards but did not prevent it since it provided employees an added sense of security during the COVID-19 pandemic.

During a review of the hospital's "Pandemic Response Plan", 4/2021, the "Pandemic Response Plan" indicated, " ... [hospital] Infection Prevention (IP) sets and implements the standards for infection prevention protocols to protect patients, staff, and visitors, and the overall facility. Infection Prevention bases its standards and practices from well -renowned organizations like the Centers for Disease Control [CDC- a national health protection agency] World Health Organization [WHO- a specialized agency responsible for international public health] and other Public Health agencies or organizations ..."

During a review of the CDC document "Clinical Questions About COVID-19: Questions and Answers", dated 11/17/21, the document indicated, " ... Infection Control ... Facemasks [procedure masks] commonly used during surgical procedures will provide barrier protection against droplet sprays contacting mucous membranes of the nose and mouth, but they are not designed to protect wearers from inhaling small particles. N95 and equivalent or higher-level respirators, such as other disposable filtering facepiece respirators ... provide both barrier and respiratory protection because of their fit and filtration characteristics ..."

During a review of the CDC document "Types of Masks and Respirators", dated 1/21/22, the document indicated, " ... NIOSH [The National Institute for Occupational Safety- federal agency] approves many types of filtering facepiece respirators. The most widely available are N95 respirators ... When worn consistently and properly, they provide the highest level of protection from particles, including the virus that causes COVID-19. Additionally, they contain your respiratory droplets and particles so you do not expose others ... Do NOT wear NIOSH-approved respirators ... With other masks or respirators ..."

During a review of the California Department of Public Health's guidance document "Get the Most Out of Masking", dated 1/14/2022, the document indicated, " ... it is not recommended to wear two medical masks, or to wear a medical mask on top of a KN95, KF94, or N95 [FFRs] ... If you wear an N95 respirator, you should not wear an additional face covering over or under the respirator, as it can interfere with the seal to the face ..."

During a review of the Federal Occupational Safety and Health Administration (OSHA) document "Understanding Compliance with OSHA's Respiratory Protection Standard During the Coronavirus Disease 2019 (COVID-19) Pandemic", dated 8/2020, the document indicated, " ... It is important for employers to understand that deviations from normal respirator use come with increased risk for workers ..."

During a review of the hospital's policy and procedure "Respiratory Protection", dated 9/2/19, the policy and procedure indicated, "To prevent illnesses resulting from exposure to air contaminated with ... biological agents ... identified by infection control as causing airborne disease ... Responsibilities ... Safety Officer ... Act as a general resource for sites for any matter concerning this program including education and training ... Department Head Supervisors ... Assure that all employees who perform a job where respirators are required use the appropriate respiratory protection ... Employees ... Use respirators as required ... Report any non- routine use of a respirator to a supervisor ..."

3. During an interview on 1/10/22, at 11:15 a.m., with the Patient Quality & Regulatory Specialist (PQRS), the PQRS stated all staff and visitors were required to wear eye protection and N95 respirator in patient care areas due to the COVID-19 surge in the hospital and community.

During concurrent observation and interviews on 1/11/22, at 11:20 a.m., in the hallway, with V1 and the Director Inpatient Services (DIS) and Intensive Care Unit Manager (MICU), V1 was observed inside Patient (Pt) 22's room handling equipment. V1 wore a respirator, glasses, and gloves. The glasses did not have side shields. V1 stated the glasses were his personal safety glasses which he wore when providing services in patient care areas. V1 stated he was screened for COVID-19 symptoms upon entering the hospital but was not informed of the hospital's COVID-19 surge status and current PPE requirements (respirator and eye protection). The DIS and MICU acknowledged the use of eye protection was required in the patient's room and the V1's personal safety glasses did not provide adequate eye protection. The MICU acknowledged hospital staff should have provided V1 with PPE instructions prior to his entry into the hospital and patient room.

During a review of the hospital's policy and procedure "Universal Masking and Eye Protection", dated 11/16/20, the policy and procedure indicated, "To ensure [hospital name] is in compliance with masking and eye protection guidelines set by the Centers for Disease Control and Prevention (CDC) as well as the [city] County Department of Public health recommendation for universal masking and eye protection ... eye protection: Physical barrier to protect the wear's eyes from potential splashes and sprays of infectious materials from others. Appropriate eye protection includes full face shield, surgical masks with attached eye shields, and goggles. Personal eyeglasses do not provide adequate eye protection ... Eye protection shall be worn in all patient care areas and for all direct patient care services ..."

During a review of the hospital's policy and procedure "COVID-19 Vendor Policy", dated 11/2/21, the policy and procedure indicated, "To ensure that Vendors entering [hospital] locations are compliant with COVID restrictions and requirements ... wear personal protective equipment as required by [hospital] ... Vendors are required to adhere to [hospital] PPE requirements at all times ..."