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Based on interview and record review, the Governing Body (GB) failed to provide adequate oversight to ensure safe and effective patient care for a universe of 139 patients admitted on February 12, 2024, when :

1.The GB did not ensure an effective quality improvement program (Refer to A-0049).

2.The GB did not ensure to have an effective oversight on medication order, medication administration, and implementation of transmission-based precaution (used to help stop the spread of germs from person to another). (Refer to A-0049).

The cumulative effects of these systemic problem resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on interview, and record review, the hospital failed to maintain an effective and on-going hospital wide, data driven Quality Assessment and Performance Improvement (QAPI) program for a universe of 139 patients admitted on February 12, 2024, as evidenced by:

1. The facility failed to monitor, collecting data and analyze the process of the medication administration. (Refer to A-0273)

2. The facility failed to identify the collected data of the issues regarding medication administration, implementation of transmission-based precaution (used to help stop the spread of germs from person to another), and the utilization of Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs). (Refer to A-0283)

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care and nursing services in a safe environment.

Based on interview, and record review, the facility failed to maintain an organized Nursing Services to patients for 36 sampled patients, as evidenced by:

1. For Patient 2, the nursing staff did not accurately document intake and output (I&O) as ordered. (Refer to A-0395)

2. For Patient 2, the nursing staff did not follow-up on a patient's report of unrelieved pain in a timely manner . (Refer to A-0395)

3. For Patient 13, the nursing staff did not follow up appropriately when patient reported pain. (Refer to A-0395)

4. For Patient 12, 13, and 14, the nursing staff did not document assessment and reassessment of patients' condition appropriately. (Refer to A-0395)

5. For Patient 1, the nursing staff of the Emergency Department (ED) did not document the code blue (a hospital emergency code used to describe the critical status of a patient) or the event leading to the cardiopulmonary resuscitation (CPR-emergency procedure as an effort to restore blood circulation in a person when heart stop) and any intervention provided. (Refer to A-0398)

6. For Patient 4, the nursing staff did not clarify with a physician for a discrepancy of target Richmond Agitation Sedation Scale (RASS-a medical score used to measure the sedation [response] level of a patient) between continuous fentanyl (medication used to relieve pain and induce temporary loss of sensation or awareness) and midazolam (versed-a medication to provide sedation) intravenous (IV-into the vein) infusion order. (Refer to A-0405)

7. For Patient 8, continuous vasopressin (medication that can help to increase blood pressure in patients) drip (slow infusion of medication or fluids into the vein) did not provide clear and precise interpretation between staff throughout the facility. (Refer to A-0405)

8. For Patient 1, the nursing staff did not start continuous versed IV drip as ordered in the ED. (Refer to A-0410)

9. For Patient 1, the nursing staff did not start continuous dopamine (a medication to improve blood pressure) IV drip as ordered in the ED. (Refer to A-0410)

10. For Patient 4, the nursing staff did not titrate (the process of adjusting the dose of medication for the maximum benefit without adverse effects) fentanyl and versed based on RASS as ordered in the Intensive Care Unit (ICU). (Refer to A-0410)

11. For Patient 8, the nursing staff did not document and assess patient appropriately while on continuous vasopressin drip in the ED. (Refer to A-0410)

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

Based on observation, interview, and record review, the facility failed to ensure the infection prevention control program demonstrate adherence and control the transmission of infectious diseases including Hospital Acquired Infections (HAIs) for 36 sampled patients, as evidenced by:

1. For Patient 7 and 8, the nursing staff did not clean or disinfect (kill germ) the medication preparation area before preparing or mixing patients' intravenous (IV-into the vein) medication and the computer on wheel (COW) between patients' use in the Intensive Care Unit (ICU). (Refer to A-0749)

2. For Patient 20, the nursing staff did not utilize an appropriate transmission-based precautions (used to help stop the spread of germs from person to another) in the Definitive Observation Unit (DOU-unit in hospital that provides second highest level of care). (Refer to A-0749)

3. For Patient 20, the nursing staff did not wear appropriate Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs). (Refer to A-0750)

4. For Patient 20, the nursing staff did not perform hand washing after leaving an isolation room (a special room that keeps patients separate from others while receiving medical care). (Refer to A-0750)

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure safe and quality infection control program.

Based on interview and record review, the Governing Body (GB) failed to ensure the quality of care was provided to patients for a universe of 139 patients admitted on February 12, 2024, when the GB did not have an effective oversight on medication order, medication administration, and implementation of transmission-based precaution (used to help stop the spread of germs from person to another).

This failure had resulted in the facility's failure to deliver care with the GB oversight and failure to provide safe medication administrations that could lead to medication errors and can jeopardize the health and safety of the patients and the potential of acquiring infections and prolonged hospitalizations.

Findings:

A review of the facility's document titled, "Governing Board Meeting September 13, 2023," indicated, there was 92 percent (%) for staff hand hygiene and isolation gown usage of 94% from the infection data of "2nd [second] quarter [April through May] 2023."

During an interview on February 16, 2024, at 9:25 AM, in the conference room, with the Director of Performance Improvement (DPI) and the Director of Operating Room (DOR), the DPI stated, there was no issues brought up from the collected data regarding intravenous (IV-into the vein) infusions titration (the process of adjusting the dose of medication for the maximum benefit without adverse effects), documentation, or Richmond Agitation Sedation Scale (RASS-a medical score from +4 (combative) to -5 (unarousable) used to measure the sedation [response] level of a patient). The DPI further stated, he was not aware of any issues related to infection control practices.

A review of the facility's document titled, "ICU [Intensive Care Unit]/Stepdown Dashboard Performance Indicator Tracker for 2023," undated, was reviewed. The "ICU/Stepdown Dashboard Performance Indicator Tracker for 2023" indicated, there was 95 % from 358 opportunities regarding IV infusions titration, documentation, and RASS.

During a concurrent interview and record review on February 16, 2024, at 11:25 AM, in the conference room, with the Chief Executive Officer (CEO), the facility's "ICU/DOU [Definitive Observation Unit-area in hospital that provides second highest level of care] Staff Meeting Minutes" (Meeting Minutes), dated November 17, 2023, was reviewed. The Meeting Minutes indicated, "Please adhere to the hospital policies when titrating all gtts [drip]. An order must be received if you are titrating outside of the protocols. When you are charting your RASS scores, your IV titrations should reflect an adjustment as needed per your RASS score. For example, if your RASS score is -2 [light sedation], you should be adjusting your sedation to obtain the appropriate RASS score of -3 according to MD order ..." The CEO verified and stated, this education was given out to all nursing staff in regarding to following a physician order and notification to a physician when needed to start or titrate medication outside of the original order.

During an interview on February 16, 2024, at 1:22 PM, in the conference room, with the facility administration, the CEO confirmed, the GB had the responsibility to oversee the overall operation of the facility. The survey team brought up issues identified during survey including a discrepancy between continuous fentanyl (medication used to relieve pain and induce temporary loss of sensation or awareness) and midazolam (versed-a medication to provide sedation) IV infusion order for two different target RASS on the same patient, an unclear continuous vasopressin (medication that can help to increase blood pressure in patients) infusion order, and implementation of an inappropriate transmission-based precautions for patient. The CEO stated, there was no significant issues discussed during the last GB meeting. The CEO further stated, the GB were not aware of the above-mentioned issues.

A follow-up interview on February 16, 2024, at 1:25 PM, the CEO stated, the issue regarding a discrepancy between medication orders for two different target RASS on the same patient should have been caught while the nursing staff conducted 12-hour chart check and corrected as soon as possible. The CEO further stated, she became aware of the different interpretation from staff in regarding vasopressin order. The CEO confirmed, the order should be cleared with the same interpretation throughout the facility.

A follow-up interview on February 16, 2024, at 1:30 PM, the CEO stated, the titratable medication infusion issues were an on-going project that the facility had been tracked. The CEO further stated, she realized the survey findings did not reflect the positive outcome to show staff's compliance to the education provided and the facility's expectation.

A follow-up interview on February 16, 2024, at 1:35 PM, the CEO stated, the infection control department oversaw culture results and ensure appropriate usage of transmission-based precaution. The CEO confirmed, there was an issue with the audit and the practice needed to be reviewed.

A review of the facility's document titled, "Amended & [and] Restated Governing Board Bylaws," dated December 13, 2023, indicated, " ... The Hospital is an acute-care hospital providing health care services to the community. The primary purpose of the Hospital is to provide quality of health care in a cost effective manner with the maintenance of high standards of care, the availability of resources, and the expectations of the Practitioners and the community served by the community served by the Hospital ..."

Based on interview and record review, the facility failed to follow the discharge process for two of 36 sampled patients (Patient 13 and 14) in the emergency department (ED) when:

1. For Patient 13, the nursing staff did not follow the process for patient who left against medical advice (AMA).

2. For Patient 14, the nursing staff did not follow the process for patient who eloped (person leaving the care area against medical advice).

These failures had the potential to place Patient 13 and 14 at risk for inadequately treated medical problems and risk for readmission to the hospital.

Findings:

1. During a review of Patient 13's "EDM Summary" (summary of emergency department treatment) dated December 24, 2023, the EDM Summary indicated, Patient 13 arrived at the emergency department with a complaint of "LLE (left lower extremity-left leg) injury S/P (status/post) fall off ladder".

During a review of Patient 13's "Emergency Department (ED) Report" dated December 24, 2023, the ED Report indicated, " ...female present to the ED with right leg pain. Patient states that earlier today she fell off a ladder and her right foot got caught in the ladder. Patient states that since then she has been experiencing pain to her right foot, ankle, and tib-fib (tibia and fibula- bones in the leg) ... x-ray of the right foot, ankle and tib-fib ordered and reviewed. Radiology report for the images were pending for a significant amount of time. Patient eloped prior to return of the radiology report ...Time of 1st reevaluation: 02:07 reevaluation 1st: unchanged ...".

During a review of Patient 13's "Emergency Department (ED) Notes" dated December 25, 2023, at 2:02 AM, the ED Note indicated, "Patient states that she is leaving due to long wait time".

During a concurrent interview and record review on February 14, 2024, at 9:34 AM, with License Vocational Nurse 1 (LVN 1), Patient 13's EDM Summary, ED Report, and ED Notes dated December 24-25, 2023, was reviewed. LVN 1 was unable to locate her documentation on Patient 13 leaving against medical advice. LVN 1 stated she should have documented more information on her notes, specifically notifying the physician.

During a concurrent interview and record review on February 14, 2024, at 9:35 AM, with LVN 1, the facility's policy and procedure (P&P) titled, "Discharge of Patients", dated March 8, 2023, was reviewed. The P&P indicated, " ...5. Patients discharged Against Medical Advice (AMA). ... 5.2 Staff shall ask patient reason for leaving AMA. 5.2.1 If patients desire to leave AMA, attempts shall be made to address patient's needs/concerns ... 5.3 If patient desires to leave AMA, the following actions shall be taken: ... 5.3.3. Notify the patient's physician ...5.3.6 After the provider has finished their explanation request the patient to sign the form and have one staff member witness the signature ... 5.3.8 If the patient refuses to sign the form, documentation shall be made in the Occurrence Report and electronic medical record ...5.3.9 Information specific to the incident shall be documented in the patient's medical record." LVN 1 stated the P&P was not followed.

2. During a review of Patient 14's "EDM Summary" dated July 5, 2022, the EDM Summary indicated, Patient 14 arrived at the emergency room at 7:08 AM, with a stated complaint of abdominal pain, nausea, and vomiting with a priority level of 3 (level of emergency to be seen by provider: 1 emergent to 5 non-urgent). A further review of the record indicated, Patient 14's "Triage Assessment" was conducted at 7:35 AM, and "Past Medical History" conducted at 8:05 AM. There were no other assessments conducted on Patient 14.

During a review of Patient 14's "Emergency Department (ED) Report" dated July 5, 2022, the ED report indicated," ...female who comes in with chief complaint of right and left lower quadrant abdominal pain ...states that the pain is 6 out of 10 ...time seen by MD (medical doctor): 7:25 AM ...time of 1st reevaluation 4:20 PM reevaluation 1st: unchanged ...Time of Disposition" 16:19 ...disposition: 01 Home/self/homeless ...".

During a review of Patient 14's "Emergency Department (ED) Notes" dated July 5, 2022, the ED Notes indicated there was no documented evidence of Patient 14's elopement.

During a concurrent interview and record review on February 14, 2024, at 9:48 AM, with the Director of Emergency Department (DED), Patient 14's "EDM Summary", "ED Notes", and "ED Report" were reviewed. The EDM Summary dated July 5, 2022, indicated, " ...1630 Elopement" (4:30 PM). The DED stated there should have been more documentation from the nurses about the elopement in Patient 14's medical record.

During a concurrent interview and record review on February 14, 2024, at 9:50 AM, with the DED, the facility's policy and procedure (P&P) titled, "Discharge of Patients", dated March 8, 2023, was reviewed. The P&P indicated, " ...6. Elopement: Patients that are evaluated and leave prior to treatment or disposition shall be considered an elopement ... 6.1 Documentation shall include: 6.1.1 Time of patient's elopement, if observed. 6.1.2 The time it is discovered the patient eloped. 6.1.3. Inability to obtain a signed AMA." The DED stated the P&P was not followed.

Based on interview and record review, the facility failed to ensure the family was notified in a timely manner when one of 36 sampled patients (Patient 1) was admitted in the emergency room in a critical condition requiring medical resuscitation (an emergency procedure used to restart a person's heart beat or breathing when one or both stopped).

This failure had the potential to result in delay of patient's care,with Patient 1's family not being abile to follow and participate in the treatment plan.

Findings:

During a review of Patient 1's "History and Physical" (H&P), dated September 8, 2021, the H&P indicated, Patient 1 presented to the Emergency Department (ED) for "evaluation of urinary complaints" with past medical history including hyperlipidemia (high level of fat in the blood), hypertension (high blood pressure), and urinary retention (inability to pass out all urine).

During a concurrent interview and record review on February 12, 2024, at 2:56 PM, in the conference room, with the Director of Operating Room (DOR), Patient 1's "Order" for admission, dated September 8, 2021, at 3:29 AM, was reviewed. The "Order" for admission indicated, Patient 1 was admitted for Urinary Tract Infection (UTI-an infection to a system of organs that make urine) with Sepsis (a serious condition of infection). The DOR verified and confirmed admission order.

A review of Patient 1's "Patient Notes," dated September 8, 2021, indicated the following information :

On September 8, 2021, at 6:20 PM: Patient 1 had "occasional confusion."
On September 8, 2021, at 4:37 PM: "code blue called "(medical emergency to alert the healthcare team to restart a person's heart beat or breathing when one or both stopped).
On September 8, 2021, at 4:39 PM: "ROSC [return of spontaneous circulation-return of heart function] at this time."

A continued interview and record review on February 12, 2024, at 3:04 PM, with the Director of Operating Room (DOR), Patient 1's "Patient Notes," dated September 9, 2021, at 4:10 PM, was reviewed. The "Patient Notes" indicated, "daughters updated on PT [patient] status ..." The DOR verified , this was the first documentation that family was notified about Patient 1's admission to the facility. The DOR stated, the nursing staff should attempt to contact the family as soon as possible to update them about Patient 1's critical condition. The DOR further stated, Patient 1's family contact information was available in Patient 1's chart at the start of admission.

During a concurrent interview and record review on February 15, 2023, at 2:10 PM, in the conference room, with Registered Nurse 4 (RN 4), in the presene of the Director of ED (DED), and the DOR, Patient 1's "Patient Notes," dated September 8, 2021, was reviewed. RN 4 confirmed, Patient 1 had the code blue with ROSC.

A follow-up interview on February 15, 2023, at 2:13 PM, with RN 4, the DED, and the DOR, RN 4 stated, the nursing staff should attempt to call Patient 1's family as soon as possible to update with any changes in condition such as code blue and intubation (a process that a breathing tube was inserted into patient's mouth to trachea to provide supplemental oxygen).

A review of the facility's policies and procedures (P&P) titled, "Patient Rights and Responsibilities," revised date April 2018, the P&P indicated, "Policy: [Hospital Name] shall identify each Patient's Rights and Responsibilities by doing the following: In addition, this information is included in the list of Patient Rights and Responsibilities ... You have the right to: ... 3. Have a family member (or other representative of your choosing) and your own physician notified promptly of your admission to the hospital [482.13 (b)(4) ... 5. Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in ethical questions that arise in the course of your care, including issues of conflict resolution, withholding resuscitative services, and forgoing or withdrawing life-sustaining treatment ..."

Based on interview and record review, the hospital did not ensure an effective and ongoing hospital wide program when the facility failed to monitor, collect data, and analyze the process of medication administration.

This failure resulted in the missed opportunities to identify issues and created changes to improve patients' health outcomes and had the potential to cause a preventable adverse patient outcome that could negatively affect patients' health and safety.

Findings:

During an interview on February 13, 2024, at 11:05 AM, in the conference room, with the Infection Control Preventionist (ICP), the survey team brought up some issues identified during survey including not cleaning or disinfecting (kill germs) the medication preparation area and computer on wheel (COW) in between patients' use. The ICP stated, the nursing staff were expected to clean the medication preparation area before and after mixing medications, and to clean equipment or environment area between patients' use to avoid the risk of cross contamination (transfer of harmaful bacteria from one person or substance to another).

During an interview on February 14, 2024, at 3:02 PM, in the conference room, with the Director of Pharmacy Department (DPD), the DPD stated, the department had not observed, tracked, or collected data regarding the "medication pass [med pass-a process of giving medication to patient]."

During an interview on February 15, 2024, at 4:05 PM, with the Director of Intensive Care Unit (DICU), the survey team brought up some issues identified during survey including not cleaning or disinfect the medication preparation area and not cleaning the COW in between patients' use. The DICU stated, he did not remember observing the nursing staff regarding infection control during the med pass, so he was not aware of the issues.

A review of the facility's document titled, "Performance Improvement Plan Year 2024," undated, indicated, "Statement of Purpose: The purpose of the Performance Improvement Plan is to establish the organizational duties and responsibilities, procedures, and process by which the Governing Board, Medial Staff, and Administrative staff may achieve and maintain high-quality patient care at [Hospital Name] ... Goal and Objective: The primary goal is to provide a comprehensive Performance Improvement Program that will coordinate and integrate ALL performance improvement activities to assure that the highest achievable safe quality of care is delivered throughout the organization ..."

Based on interview, and record review, the hospital failed to maintain an effective and ongoing hospital wide, data driven Quality Assessment and Performance Improvement (QAPI) program for a universe of 139 patients admitted on February 12, 2024, when the facility failed to identify the collected data of the issues regarding medication administration, implementation of transmission-based precaution (used to help stop the spread of germs from person to another), and the utilization of Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs).

This failure resulted in the hospital's inability to focus on problem prone areas to ensure the provision of quality nursing and patient safety and had the potential to cause adverse health outcomes which could interfere with patients' medical care and jeopardize the health and safety of the patients.

Findings:

A review of the facility's document titled, "Governing Board Meeting September 13, 2023," indicated, there was 92 percent (%) for staff hand hygiene and isolation gown usage of 94% from the infection data of "2nd [second] quarter [April through May] 2023."

During an interview on February 13, 2024, at 11:05 AM, in the conference room, with the Infection Control Preventionist (ICP), the survey team brought up some issues identified during the survey including the nursing staff not wearing Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs) appropriately and not performing hand washing after leaving an isolation room (a special room that keeps patients separate from others while receiving medical care). The ICP stated, hand washing, and PPE usage seemed to be an on-going issues.

A review of the facility's document titled, "ICU [Intensive Care Unit]/Stepdown Dashboard Performance Indicator Tracker for 2023," undated, was reviewed. The "ICU/Stepdown Dashboard Performance Indicator Tracker for 2023" indicated, there was 95 % from 358 opportunities regarding intravenous (IV-into the vein) infusions titration (the process of adjusting the dose of medication for the maximum benefit without adverse effects), documentation, and Richmond Agitation Sedation Scale (RASS-a medical score used to measure the sedation [response] level of a patient).

During a concurrent interview and record review on February 15, 2024, at 3:58 PM, in the conference room, with the Director of ICU (DICU), the facility's document titled, "Chart Audit," dated January 2024, was reviewed. The "Chart Audit" indicated, the audit conducted for IV infusion, including titration, documentation per order, the RASS, and vital signs (measurements of the body's most basic function such as heart rate and blood pressure), were six of 31 charts that were incorrect. The DICU stated, he did not get a chance to educate the nursing staff regarding the issues from January 2024 data; however, he educated one on one with a staff from December 2023 data. The DICU further stated, he did not follow up to determine the effectiveness or compliance from that education.

During an interview on February 16, 2024, at 9:25 AM, in the conference room, with the Director of Performance Improvement (DPI) and the Director of Operating Room (DOR), the DPI stated, there was no issues brought up from the collected data regarding IV infusions titration, documentation, or RASS. The DPI further stated, he was not aware of any issues related to infection control practices.

A follow-up interview on February 16, 2024, at 10:38 AM, in the conference room, with the Infection Control Preventionist (ICP), the ICP stated, he followed up on patients' culture results (tests to identify type of bacteria) every morning to ensure patients were placed on an appropriate transmission-based precaution. The survey team brought up an issue identified during survey including utilizing an inappropriate transmission-based precautions for patient with Escherichia Coli (E. Coli-one type of bacteria) - Extended Spectrum Beta Lactamase-enzyme (ESBL-one type of bacteria that resistant to some antibiotics) positive result. The ICP stated, he overlooked and missed to identify the inappropriate transmission-based precaution.

During a concurrent interview and record review on February 16, 2024, at 11:25 AM, in the conference room, with the Chief Executive Officer (CEO), the facility's "ICU/DOU [Definitive Observation Unit-area in hospital that provides second highest level of care] Staff Meeting Minutes" (Meeting Minutes), dated November 17, 2023, was reviewed. The Meeting Minutes indicated, "Please adhere to the hospital policies when titrating all gtts [drip]. An order must be received if you are titrating outside of the protocols. When you are charting your RASS scores, your IV titrations should reflect an adjustment as needed per your RASS score. For example; if your RASS score is -2 [light sedation], you should be adjusting your sedation to obtain the appropriate RASS score of -3 according to MD order ..." The CEO verified and stated, this education was given out to all nursing staff in regarding to following a physician order and notification to a physician when needed to start or titrate medication outside of the original order. The CEO further stated, she realized the survey findings did not reflect the positive outcome to show staff's compliance to the education.

A follow-up interview on February 16, 2024, at 1:22 PM, with the facility administration, the survey team brought up an issue identified during survey including utilizing an inappropriate transmission-based precautions for patient, the CEO stated, the infection control department oversaw culture results and ensure appropriate usage of transmission-based precaution were implemented. The CEO confirmed, there was an issue with the audit and the practice needed to be reviewed.

A review of the facility's document titled, "Performance Improvement Plan Year 2024," undated, indicated, "Statement of Purpose: The purpose of the Performance Improvement Plan is to establish the organizational duties and responsibilities, procedures, and process by which the Governing Board, Medial Staff, and Administrative staff may achieve and maintain high-quality patient care at [Hospital Name] ... Goal and Objective: The primary goal is to provide a comprehensive Performance Improvement Program that will coordinate and integrate ALL performance improvement activities to assure that the highest achievable safe quality of care is delivered throughout the organization ..."

Based on interview, and record review, the facility failed to ensure the nursing staff provided care for patients in accordance with the patients' need for four of 36 sampled patients (Patient 2, 12, 13, and 14) when:

1. For Patient 2, the nursing staff did not accurately document intake and output (I&O) as ordered.

2. For Patient 2, the nursing staff did not follow-up on a patient's report of unrelieved pain in a timely manner .

3. For Patient 13, the nursing staff did not follow up appropriately when patient reported pain.

4. For Patient 12, 13, and 14, the nursing staff did not document assessment and reassessment of patients' condition appropriately.

These failures had resulted in inaccurate tracking of patient's fluid status, unrelieved pain, and delayed in detecting of any changes in patients' condition which had the potential to negatively impact the treatment plan from inappropriate monitoring, assessment and reassessment which could jeopardize patients' health and safety, prolong hospitalization, leading up to actual harm and possible death.

Findings:

1. During a review of Patient 2's "History and Physical" (H&P), dated May 23, 2023, the H&P indicated, Patient 2 was admitted into the facility for increased abdominal pain and generalized weakness with a diagnosis of acute kidney injury (a condition in which the kidneys do not work properly).

A review of Patient 2's "Medication Administration" (MAR), for Furosemide (Lasix-medication that helps to get rid of water in the body), dated June 1, 2023, through June 3, 2023, indicated, Patient 2 received Lasix as follows:

On June 1, 2023, at 3:41 PM: 60 milligrams (mg-unit dosing medication)
On June 2, 2023, at 10:20 AM: 60 mg
On June 3, 2023, at 11:06 AM: 60 mg

During an interview on February 15, 2024, at 1:26 PM, in the conference room, with Registered Nurse 1 (RN 1), RN 1 stated, the strict I&O indicated the nursing staff had to record everything that patients consumed into their body and measure everything that patients passed out. RN 1 further stated all staff were educated about the strict I&O including certified nursing assistant (CNA).

A follow-up concurrent interview and record review on February 15, 2024, at 1:28 PM, with RN 1, Patient 2's "Order," dated June 3, 2023, at 3:08 PM, was reviewed. The "Order" indicated Patient A had an order for "strict I&O." RN 1 verified the order.

A follow-up interview and record review on February 15, 2024, at 1:30 PM, with RN 1, Patient 2's "Intake and Output" (I&O) flowsheet, dated June 3, 2023, through June 6, 2023, were reviewed. The I&O flowsheet indicated as follows:

On June 3, 2023: 23 counts of voids (urine)
On June 4, 2023: 19 counts of voids
On June 5, 2023: 11 counts of voids
On June 6, 2023: 23 counts of voids

RN 1 verified and stated, the urine output did not show the urine measurement. RN 1 confirmed, the nursing staff did not correctly documented urine output as ordered.

A review of the facility's policies and procedures (P&P) titled, "Documentation-Nursing," dated April 2021, the P&P indicated, "Documentation-Nursing" indicated as follow: "Policy: [Hospital Name] Nursing staff shall document assessments, reassessments, care rendered, nursing outcomes and responses to care in a timely, clear and concise manner ... Procedure: ... 1.7 Documentation shall be complete. 1.8 Documentation shall be accurate ..."

2. During a review of Patient 2's H&P, dated May 23, 2023, the H&P indicated, Patient 2 was admitted into the facility for increased abdominal pain and generalized weakness with a diagnosis of acute kidney injury.

During an interview on February 15, 2024, at 1:32 PM, in the conference room, with RN 1, RN 1 stated, the nursing staff should assess patients' pain after medication administration to determine the effectiveness of medication. RN 1 further stated, if patients reported unrelieved pain, the nursing staff should provide additional medication as appropriated or notified a physician for any additional or alternative medication. RN 1 stated, the nursing staff should also assess patients' pain goal or the level patients able to tolerate pain or acceptable pain level.

A follow-up concurrent interview and record review on February 15, 2024, at 1:34 PM, with RN 1, Patient 2's "Medication Detail: Morphine Sulfate [medication to treat pain] Injection," dated May 27, 2023, at 10:45 AM, was reviewed. The "Medication Detail: Morphine Sulfate Injection" indicated, morphine 4 mg intravenous (IV-into the vein) was ordered for severe pain level (pain scale to evaluate pain level of patients, 0 signifies no pain and 10 signifies the more severe pain) as needed (PRN) every four hours. RN 1 verified and confirmed the morphine order.

A continued concurrent interview and record review on February 15, 2024, at 1:36 PM, with RN 1, Patient 2's MAR for morphine, dated from May 28, 2023, and June 3, 2023, were reviewed. The MAR indicated, there was no pain goal documentation and the pain reassessment indicated as follow:

On May 28, 2023, at 5:22 PM: reassessment pain level of 7
On May 28, 2023, at 9:42 PM: reassessment pain level of 8
On June 3, 2023, at 3:35 PM: reassessment pain level of 10

RN 1 verified and confirmed the pain reassessment level. RN 1 stated, the nursing staff did not accurately follow-up and document any further intervention of unrelieved pain. RN 1 further stated, she was unable to see any documented evidence to show Patient 2's acceptable pain level.

A review of the facility's P&P titled, "Pain Management," dated April 2021, the P&P indicated, "Purpose: [Hospital Name] respects and supports the rights of patients to safe, timely, and effective pain management. We place emphasis on improving the outcomes of pain management including comfort, managing side effects and complications, and patient satisfaction ... Patient will define their goals for pain relief and participate in a plan of care to achieve these goals ... Procedure: ... 12. The goal is to maintain a pain rating of the patient's own comfort level goal ..."


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3. During a review of Patient 13's "EDM Summary," (summary of emergency department treatment) dated December 24, 2023, the EDM Summary indicated, Patient 13 arrived at the emergency department with a complaint of "LLE [left lower extremity-left leg] injury S/P [status/post[ fall off ladder."

During a review of Patient 13's "Vital Signs" dated December 24, 2023, the Vital Signs indicated Patient 13's pain intensity level was a 6 (1-little to no pain, 10 severe pain) at 8:35 PM.

During a review of Patient 13's "Pain Assessment" dated December 24, 2023 at 10:16 PM, the Pain Assessment indicated Patient 13's pain level was 6 out of 10 (One hour and forty-one minutes after the initial report of pain).

During a review of Patient 13's EDM Summary dated December 24, 2023, the Notes section of the Summary did not contain any notes from the nurse to the physician indicating Patient 13 had pain of 6/10 and no notes indicating what pain management interventions were conducted on Patient 13.

During a concurrent interview and record review on February 14, 2024, at 9:33 AM, with License Vocational Nurse 1 (LVN 1), Patient 13's EDM Summary dated December 24, 2023, was reviewed. LVN 1 stated she should have documented more information on her notes.

During a concurrent interview and record review on February 14, 2024, at 9:36 AM, with LVN 1, the facility's policy and procedure (P&P) titled, Pain Management, revised April 2021, was reviewed. The P&P indicated, " ...We place emphasis on improving the outcomes of pain management including comfort ...the single most reliable indicator of the existence and intensity of pain is the patient's self-report ...Procedure: ...1.5 After each pain management intervention once, sufficient time has elapsed for the treatment to reach peak effect, the goal is reassessment and documentation ...Documentation should include the patient's response to the intervention ...12. The goal is to maintain a pain rating of the patient's own comfort level goal. This may be documented with the pain intensity score, by indicating intervention effective, or by patient statement that they do not need treatment for pain." LVN 1 stated the P&P was not followed.

4a. During a review of Patient 12's "EDM Summary" dated November 20, 2023, the EDM Summary indicated, Patient 12 arrived at emergency room at 7:11 PM, with a stated complaints of near syncope (fainting) with a priority level 3 (level of emergency to be seen by provider: 1 emergent to 5 non-urgent).

During a review of Patient 12's EDM Summary dated November 20, 2023, the EDM Summary indicated, the Triage Assessment was conducted at 7:25 PM, Past Medical History Assessment was conducted at 7:25 PM, and Vital Signs were taken on November 21, 2023, at 3:00 AM.

During a review of Patient 12's Emergency Department (ED) Report dated November 20, 2023, the ED Report indicated, "49-year-old female came to ER for dizziness ...she was feeling dizzy and lightheaded ...Time of 1st reevaluation: 2221 ... reevaluation 1st: unchanged ...Time of 3rd reevaluation: 0247 ...reevaluation 3rd: improved ..."

During a review of Patient 12's Emergency Department (ED) Notes dated November 21, 2023 at 3:04 AM, the ED Note indicated "Discharge Note Discharge instructions discussed with [patient name] verbalizes understanding. Exit care discharge instructions given. Instructed to follow up with Primary Care Provider. Instructed to return to ER if symptoms become worse or new symptoms develop. Ambulated (walked) out of ER without incident."

During a concurrent interview and record review on February 14, 2024, at 9:45 AM, with the Director of Emergency Department (DED), Patient 12's EDM Summary, ED Report, and ED Notes were reviewed. The DED stated there was no additional assessments conducted for Patient 12 from November 20, 2023 at 7:25 PM to November 21, 2023, at 3:00 AM (seven hours and thirty five minutes after arriving to the emergency room).

During a concurrent interview and record review on February 14, 2024, at 9:50 AM, with the DED, the facility's policy and procedure (P&P) titled, Assessment -Reassessment of Patients Interdisciplinary, dated February 2021 was reviewed. The P&P indicated, "Patients admitted to [name of hospital] shall have an age-appropriate assessment performed by each discipline involved in his/her care ...ED ... initiates physical assessment within 30 minutes of arrival to the emergency department. Complete triage assessment within 1 hour of arrival ...Priority 3 (urgent): every 4 hours or more often until condition stabilizes ...". The DED stated the P&P was not followed.

4b. During a review of Patient 13's "EDM Summary" dated December 24, 2023, the EDM Summary indicated, Patient 13 arrived at the emergency room at 8:25 PM, with a stated complaints of LLE (left lower extremity) injury S/P(status/post) fall off ladder with a priority level 4.

During a review of Patient 13's EDM Summary dated December 24, 2024, the EDM Summary indicated, the Triage Assessment was conducted at 8:39 PM, Vital Signs conducted at 8:35 PM, Past Medical History conducted at 8:39 PM, Focal Data Collection Adult conducted at 10:16 PM, and Pain Assessment at 10:16 PM.

During a review of Patient 13's Emergency Department (ED) Report dated December 24, 2023, the ED Report indicated, " ...female present to the ED with right leg pain. Patient states that earlier today she fell off a ladder and her right foot got caught in the ladder. Patient states that since then she has been experiencing pain to her right foot, ankle, and tib-fib [tibia and fibula- bones in the leg] ... x-ray of the right foot, ankle and tib-fib ordered and reviewed. Radiology report for the images were pending for a significant amount of time. Patient eloped prior to return of the radiology report ...Time of 1st reevaluation: 02:07 reevaluation 1st: unchanged ...".

During a review of Patient 13's ED Notes dated December 25, 2023, at 2:02 AM, the ED Note indicated, "Patient states that she is leaving due to long wait time".

During a concurrent interview and record review on February 14, 2024, at 9:47 AM, with the Director of Emergency Department (DED), Patient 13's EDM Summary, ED Report, and ED Notes were reviewed. The DED stated there was no additional assessments conducted for Patient 13 from December 24, 2023, at 10:16 PM, until Patient 13 left against medical advice at 2:02 AM. The DED further stated there was no discharge assessment conducted nor documentation of an attempt to reassess the patient.

During a concurrent interview and record review on February 14, 2024, at 9:51 AM, with the DED, the facility's policy and procedure (P&P) titled, Assessment -Reassessment of Patients Interdisciplinary, dated February 2021 was reviewed. The P&P indicated, "Patients admitted to [name of hospital] shall have an age-appropriate assessment performed by each discipline involved in his/her care ...ED ... initiates physical assessment within 30 minutes of arrival to the emergency department. Complete triage assessment within 1 hour of arrival ...Priority 4 and 5 (non-urgent): if there is a change in their condition ...2.2 Reassessment ...c. at unit-specified intervals related to the care setting and course of treatment". The DED stated the P&P was not followed.

4c. During a review of Patient 14's "EDM Summary" dated July 5, 2022, the EDM Summary indicated, Patient 14 arrived at the emergency room at 7:08 AM, with a stated complaints of abdominal pain, nausea, and vomiting with a priority level of 3.

During a review of Patient 14's EDM Summary dated July 5, 2022, the EDM Summary indicated, Patient 14's Triage Assessment was conducted at 7:35 AM, and Past Medical History conducted at 8:05 AM. There were no other assessments conducted on Patient 14.

During a review of Patient 14's ED Report dated July 5, 2022, the ED report indicated," ...female who comes in with chief complaint of right and left lower quadrant abdominal pain ...states that the pain is 6 out of 10 ...time seen by MD (medical doctor): 7:25 AM ...time of 1st reevaluation 4:20 PM reevaluation 1st: unchanged ...".

During a review of Patient 14's ED Notes dated July 5, 2022 at 12:20 PM, the ED Note indicated, "Radiology call center called to expedite pt (patient) results".

During a concurrent interview and record review on February 14, 2024, at 9:48 AM, with the Director of Emergency Department (DED), Patient 14's EDM Summary, ED Report, and ED Notes were reviewed. The DED stated there was no additional assessments conducted for Patient 14 from July 5, 2022, at 8:05 AM, until Patient 14 eloped from the ER at 4:40 PM. The DED further stated there was no discharge assessment conducted nor documentation of an attempt to reassess the patient.

During a concurrent interview and record review on February 14, 2024, at 9:52 AM, with the DED, the facility's policy and procedure (P&P) titled, Assessment -Reassessment of Patients Interdisciplinary, dated February 2021 was reviewed. The P&P indicated, "Patients admitted to [name of hospital] shall have an age-appropriate assessment performed by each discipline involved in his/her care ...ED ... initiates physical assessment within 30 minutes of arrival to the emergency department. Complete triage assessment within 1 hour of arrival ... Priority 3 (urgent): every 4 hours or more often until condition stabilizes ...2.2 Reassessment ...c. at unit-specified intervals related to the care setting and course of treatment". The DED stated the P&P was not followed.

Based on interview and record review, the facility failed to ensure the nursing staff documented the emergency intervention appropriately during the cardiopulmonary resuscitation (CPR-emergency procedure as an effort to restore blood circulation in a person when heart stop) in accordance to the Advanced Cardiac Life Support (ACLS-a set of clinical guides for the urgent treatment of heart emergencies) guideline when the nursing staff of the Emergency Department (ED) did not document the event leading to the CPR and any intervention provided for one of 36 sampled patients (Patient 1).

This failure had the potential to result in an inaccurate assessment of Patient 1's condition from the incomplete documentation of the code blue (a hospital emergency code used to describe the critical status of a patient), which could negatively impact Patient 1's health and safety.

Findings:

During a review of Patient 1's "History and Physical" (H&P), dated September 8, 2021, the H&P indicated, Patient 1 was presented to the ED for "evaluation of urinary complaints" with past medical history including hyperlipidemia (high level of fat in the blood), hypertension (high blood pressure), and urinary retention (inability to pass out all urine).

During a concurrent interview and record review on February 12, 2024, at 2:50 PM, in the conference room, with the Director of Operating Room (DOR), Patient 1's "Patient Notes," dated September 8, 2021, was reviewed. The "Patient Notes" indicated as follows:

On September 8, 2021, at 4:37 PM: "code blue called."
On September 8, 2021, at 4:39 PM: Return of circulation after emergency code.

The DOR stated, the code blue could be documented electronically or on paper and scanned into patients' record to explain what happened during the code. The DOR further stated, the documentation only showed Patient 1 had the code blue and had return of spontaneous circulation (ROSC-return of heart function). The DOR was unable to find any documented evidence to show what happened or any intervention completed during the code blue.

During a concurrent interview and record review on February 15, 2023, at 2:10 PM, in the conference room, with Registered Nurse 4 (RN 4), in the presence of the Director of ED (DED), and the DOR, Patient 1's "Patient Notes," dated September 8, 2021, was reviewed. RN 4 verified , Patient 1 had the code blue with ROSC. RN 4 stated, a house supervisor or charge nurse would normally be responsible to document onto the code blue sheet. RN 4 further stated, Patient 1's medical record should have a document to show information about what happened involving the code blue. RN 4 was unable to find any code blue documentation.

A review of the facility's policies and procedures (P&P) titled, "Code: Blue-Adult Emergency", revised date October 2020, the P&P indicated, "Purpose: 1. To provide a standard and consistent method to initiate the process of artificial ventilation [a device to assist with breathing] and circulation to those patients/visitors/employees with sudden cardiovascular collapse or arrest [a condition when heart stops working] ...Policy: 1. All patients who have a respiratory or cardiac arrest shall be resuscitated unless there is a valid physician "Do Not Resuscitate/No Code" or modified code order in the patient's medical record. Licensed staff assisting with the code shall be ACLS certified ... Documentation: 1. Code Record. 1.1 Completed prior to the end of the shift including MD [Medical Doctor] signature/electronic signature. 1.2 After each code, the Code Record should be reviewed for completeness. 1.3 Code evaluation shall be completed per policy for review of process of care and to provide feedback to the providers for a job well done or improvement needed. 2. Patient Care Record includes but not limited to: 2.1 Events leading up to initiation of Code. 2.2 All the interventions that occur during the resuscitation. 2.3 Names of all Code team members present. 2.4 Patient disposition following the termination of the Code ..."

Based on interview, and record review, the facility failed to ensure the nursing staff maintained and implemented the medication administration standard of practices to prevent medication errors for two of 36 sampled patients (Patient 4 and 8) when:

1. For Patient 4, the nursing staff did not clarify with a physician for a discrepancy of target Richmond Agitation Sedation Scale (RASS-a medical score used to measure the sedation [response] level of a patient) between continuous fentanyl (medication used to relieve pain and induce temporary loss of sensation or awareness) and midazolam (versed-a medication to provide sedation) intravenous (IV-into the vein) infusion order.

2. For Patient 8, continuous vasopressin (medication that can help to increase blood pressure in patients) drip (slow infusion of medication or fluids into the vein) did not provide clear and precise interpretation between staff throughout the facility.

These failures had the potential to result in patients' safety from preventable medication errors with discrepancy and controversial medication orders which could cause adverse health outcomes such as inadequate or inappropriate therapy for treatment and could negatively affect patients' health, safety, prolonged hospitalization, and lead to actual harm or death.

Findings:

1. During a review of Patient 4's "History and Physical (H&P), dated January 27, 2024, the H&P indicated, Patient 4 was presented to the ED with "complaint of shortness of breath" with past medical history including congestive heart failure (CHF-a condition in which the heart does not pump blood as well to the body), hypertension (high blood pressure), and myocardial infarction (MI-or heart attack).

During a concurrent interview and record review on February 14, 2024, at 11:10 AM, in the conference room, with the Director of Intensive Care Unit (DICU), Patient 4's "Medication Detail: Fentanyl drip" (fentanyl order), dated January 28, 2024, at 6:00 PM, was reviewed. The fentanyl order indicated, target RASS -4 (deep sedation). The DICU verified the fentanyl order.

A follow-up interview and record review on February 14, 2024, at 11:30 AM, with the DICU, Patient 4's "Medication Detail: Midazolam drip" (versed order) dated January 28, 2024, at 6:45 PM, was reviewed. The versed order indicated, target RASS -3 (moderate sedation). The DICU verified and stated, there was a discrepancy between fentanyl and versed's target RASS order. The DICU further stated, he was unable to provide any documented evidence to show the nursing staff communicated to a physician regarding a discrepancy of medication orders.

During a concurrent interview and record review on February 15, 2024, at 2:30 PM, in the conference room, with Registered Nurse 5 (RN 5) and the DICU, Patient 4's fentanyl order, dated January 28, 2024, at 6:00 PM, and versed order dated January 28, 2024, at 6:45 PM, were reviewed.

The fentanyl order indicated, target RASS -4.
The versed order indicated, target RASS -3.

RN 5 verified and confirmed, there were two different target RASS ordered. RN 5 stated, she would start the medication as appropriate for patient; however, she would not "necessary" call and notify a physician. RN 5 further stated, she would notify a physician when she saw a physician at bedside only. RN 5 stated, she would report to the upcoming shift to follow up with a physician. RN 5 was unable to answer how the nursing staff would be able to follow physician's orders to achieve two different target RASS in the same hour for Patient 4.

During an interview on February 16, 2024, at 1:22 PM, in the conference, with the facility administration, the Chief Executive Officer (CEO), the CEO stated, she was aware of the issue regarding a discrepancy between medication orders for two different target RASS. The CEO further stated, the orders should have been caught while the nursing staff conducted 12-hour chart check and corrected as soon as possible.

A review of the facility's policies and procedures (P&P) titled, "Physician Orders," dated December 2023, the P&P indicated, "Policy: [Hospital Name] staff shall process physician orders in a timely manner. Procedure: ... 15. All orders shall be reviewed and verified every 24 hours. 15.1 An intervention of "12 Hour Chart Check Completed" shall be completed. 15.2. The RN shall follow up on any incomplete orders, exams, consults, etc. 15.3 Chart checks shall include: 15.3.1 Medications ..."

2. A review of Patient 8's H&P, dated February 4, 2024, the H&P indicated, Patient 8 was presented to the ED with complaint of "worsening shortness of breath with mild chest pressure" and a past medical history including CHF, hypertension, and dyslipidemia (abnormal fat or cholesterol in blood).

During a concurrent interview and record review on February 15, 2024, at 10:05 AM, in the conference room, with the DICU and the CEO, Patient 8's "Medication Detail: IV Medication" for vasopressin, dated February 7, 2024, at 11:45 AM, was reviewed. The "Medication Detail: IV Medication" for vasopressin indicated, "starting rate 0.03 units/min [unit per min-unit dosing medication] FOR SHOCK. Titrate To: 0.03 units/min. Text Titrate To: 0.03 units/min ##DO NOT TITRATE ABOVE 0.03 units/min## FOR SHOCK ...DECREASE BY 0.01 units/minutes Q [every] 30 minutes if MAP [mean arterial pressure-the average number of blood pressure] tolerates ..." The DICU and the CEO verified and stated, vasopressin was ordered to be titrated (the process of adjusting the dose of medication for the maximum benefit without adverse effects) by 0.01 units/min q 30 mins.

During a concurrent interview and record review on February 15, 2024, at 1:40 PM, with RN 4, in the presence of the Director of Emergency Department (DED), and the Director of Operating Room (DOR), Patient 8's "Medication Detail: IV Medication" for vasopressin, dated February 7, 2024, at 11:45 AM, was reviewed. The "Medication Detail: IV Medication" for vasopressin indicated, "starting rate 0.03 units/min [unit per min-unit dosing medication] FOR SHOCK. Titrate To: 0.03 units/min. Text Titrate To: 0.03 units/min ##DO NOT TITRATE ABOVE 0.03 units/min## FOR SHOCK ... DECREASE BY 0.01 units/minutes Q 30 minutes if MAP tolerates ..." RN 4 verified and stated, vasopressin was ordered for shock, and it was meant to be kept at a fixed rate and not to be titrated.

A follow-up interview on February 16, 2024, at 8:45 AM, in the conference room, with the CEO, the CEO stated, she became aware of the different interpretation from staff in regarding to Patient 8's vasopressin order. The CEO further stated, the order should be cleared with the same interpretation throughout the facility. The CEO confirmed, the issue needed to be corrected.

A review of the facility's policies and procedures (P&P) titled, "Physician Orders," dated December 2023, the P&P indicated, "Policy: [Hospital Name] staff shall process physician orders in a timely manner. Procedure: ... 15. All orders shall be reviewed and verified every 24 hours. 15.1 An intervention of "12 Hour Chart Check Completed" shall be completed. 15.2. The RN shall follow up on any incomplete orders, exams, consults, etc. 15.3 Chart checks shall include: 15.3.1 Medications ..."

Based on interview and record review, the facility failed to ensure the nursing staff administered and adjusted the continuous intravenous (IV-into the vein) medications appropriately and as ordered for three of 36 sampled patients (Patient 1, 4, and 8) when:

1. For Patient 1, the nursing staff did not start continuous midazolam (versed-a medication to provide sedation) intravenous (IV-into the vein) drip (slow infusion of medication or fluids into the vein) as ordered in the Emergency Department (ED).

2. For Patient 1, the nursing staff did not start continuous dopamine (a medication to improve blood pressure) IV drip as ordered in the ED.

3. For Patient 4, the nursing staff did not titrate (the process of adjusting the dose of medication for the maximum benefit without adverse effects) fentanyl (medication used to relieve pain and induce temporary loss of sensation or awareness) and versed based on Richmond Agitation Sedation Scale (RASS-a medical score used to measure the sedation [response] level of a patient) as ordered in the Intensive Care Unit (ICU).

4. For Patient 8, the nursing staff did not assess and document patient appropriately while on continuous vasopressin (medication that can help to increase blood patient in patients) drip in the ED.

These failures had resulted in an unsafe medication administration and monitoring of patients which could adversely affect patients' responses without proper dosing adjustment and monitoring and could jeopardize patients' health and safety, leading up to actual harm and possible death.

Findings:

1. During a review of Patient 1's "History and Physical" (H&P), dated September 8, 2021, the H&P indicated, Patient 1 presented to the ED for "evaluation of urinary complaints" with past medical history including hyperlipidemia (high level of fat in the blood), hypertension (high blood pressure), and urinary retention (inability to pass out all urine).

During an interview on February 15, 2024, at 1:50 PM, in the conference room, with Registered Nurse 4 (RN 4), in the presence of the Director of ED (DED), and the Director of Operating Room (DOR), RN 4 stated, excessive sedation might increase the risk of neurological deficit (abnormal function of a body area due to injury of the brain) and prolong the mechanical ventilation (a medical device that help to deliver oxygen to body) for patients.

A follow-up concurrent interview and record review on February 15, 2024, at 1:53 PM, with RN 4,in the presence of the DED, and the DOR, Patient 1's "Medication Detail: Midazolam drip," dated September 8, 2021, at 5:15 PM, was reviewed. The "Medication Detail: Midazolam drip" indicated, the medication was ordered to start at 1 milligram per hour (mg/hr-a dosing unit of medication) to keep RASS -3 (moderate sedation) with the maximum dosage of 15 mg/hr. RN 4 verified the administration order of versed.

A follow-up interview and record review February 15, 2024, at 1:58 PM, with RN 4, the DED, and the DOR, Patient 1's "Medication Administration" (MAR) for versed, dated September 8, 2021, at 5:23 PM, was reviewed. The MAR for versed indicated, the nursing staff started versed IV drip at 15 mg/hr. RN 4 verified and confirmed the started dose of versed. The DOR was unable to find any documented evidence to justify the reason of started versed at 15 mg/hr. RN 4 stated, the nursing staff did not follow a physician's order when started versed IV drip.

2. During a review of Patient 1's H&P, dated September 8, 2021, the H&P indicated, Patient 1 presented to the ED for "evaluation of urinary complaints" with past medical history including hyperlipidemia, hypertension, and urinary retention.

During an interview on February 15, 2024, at 1:50 PM, in the conference room, with RN 4, in the presence of the DED, and the DOR, RN 4 stated, excessive sedation might increase the risk of neurological deficit and prolong the mechanical ventilation for patients.

A follow-up concurrent interview and record review on February 15, 2024, at 2:00 PM, with RN 4, in the presence of the DED, and the DOR, Patient 1's "Medication Detail: Dopamine," dated September 8, 2021, at 7:15 PM, was reviewed. The "Medication Detail: Dopamine" indicated, the medication was ordered to start at 5 microgram per kilogram per minute (mcg/kg/min-a dosing unit of medication) to keep mean arterial pressure (MAP-the average blood pressure) greater than 65. RN 4 verified the administration order of dopamine.

A follow-up interview and record review February 15, 2024, at 2:05 PM, with RN 4, the DED, and the DOR, Patient 1's MAR for dopamine, dated September 8, 2021, at 9:12 PM, was reviewed. The MAR for dopamine indicated, the nursing staff started dopamine IV drip at 10 mcg/kg/min. RN 4 verified and confirmed the started dose of dopamine. The DOR was unable to find any documented evidence to justify the reason of started dopamine at 10 mcg/kg/min. RN 4 stated, the nursing staff did not follow a physician's order when started dopamine.

A review of the facility's P&P titled, "Medication Administration," dated May 2021, the P&P indicated, "Policy: 1. [Hospital Name] Clinical departments shall ensure all medications be administered and documented upon a written, telephone and/or written verbal order. Procedure: 1. The Licensed Staff shall be responsible for assuring that the "rights" of medication administration are employed at all times. 2. The Licensed Staff shall check the name, dose, route of administration and compatibility (if appropriate) of all medication to be administered to the patient with the physician order or the medication administration record ..."

3. During a review of Patient 4's H&P, dated January 27, 2024, the H&P indicated, Patient 4 presented to the ED with "complaint of shortness of breath" with past medical history including congestive heart failure (CHF-a condition in which the heart does not pump blood as well to the body), hypertension, and myocardial infarction (MI-or heart attack).

During an interview on February 15, 2024, at 2:20 PM, in the conference room, with RN 5 in the presence of the Director of ICU (DICU), RN 5 stated, the nursing staff needed to follow a physician's order with every medication administration. RN 5 further stated, a physician needed to be notified if the medication was given differently than originally ordered.

A follow-up concurrent interview and record review on February 15, 2024, at 2:30 PM, with RN 5, in the presence of the DICU, Patient 4's "Medication Detail: Fentanyl drip," dated January 28, 2024, at 6:00 PM, and "Medication Detail: Midazolam drip," dated January 28, 2024, at 6:45 PM, were reviewed. The "Medication Detail: Fentanyl drip" indicated, the medication was ordered to be administered as a continuous infusion started at 25 microgram per hour (mcg/hr-a dosing unit of medication) with target RASS -4 (deep sedation). The "Medication Detail: Midazolam drip" indicated, the medication was ordered to be administered as a continuous infusion started at 1 mg/hr with target RASS -3. RN 5 verified the administration order of fentanyl and versed.

A follow-up interview and record review February 15, 2024, at 2:40 PM, with RN 5, in the presence of the DICU, Patient 4's MAR for fentanyl and versed, dated February 1, 2024, from 7:00 AM, through 12:00 PM, and were reviewed.

The MAR for fentanyl indicated as follows:
At 7:00 AM: RASS -5 (unarousable)
At 8:00 AM: RASS -5 (unarousable)
At 9:00 AM: RASS -5 (unarousable)
At 10:00 AM: RASS -5 (unarousable)
At 11:00 AM: RASS -5 (unarousable)
At 12:00 PM: RASS -5 (unarousable)

The MAR for versed indicated as follows:
At 7:00 AM: RASS -5 (unarousable)
At 8:00 AM: RASS -5 (unarousable)
At 9:00 AM: RASS -5 (unarousable)
At 10:00 AM: RASS -5 (unarousable)
At 11:00 AM: RASS -5 (unarousable)
At 11:59 AM: RASS -5 (unarousable)

RN 5 verified fentanyl and versed were continuously infusing with RASS level outside of a physician's parameter order. The DICU was unable to find any documented evidence to show a physician was notified when the nursing staff kept Patient 4 in an unarousable state. RN 5 was not able to verify that she notified a physician when she kept Patient 4 in an unarousable state. RN 5 further stated, she did not necessary document her conversation with a physician to justify her action.

During a concurrent interview and record review on February 16, 2024, at 11:25 AM, in the conference room, with the Chief Executive Officer (CEO), the facility's "ICU/DOU Staff Meeting Minutes" (Meeting Minutes), dated November 17, 2023, was reviewed. The Meeting Minutes indicated, "Please adhere to the hospital policies when titrating all gtts [drip]. An order must be received if you are titrating outside of the protocols. When you are charting your RASS scores, your IV titrations should reflect an adjustment as needed per your RASS score. For example; if your RASS score is -2 [light sedation], you should be adjusting your sedation to obtain the appropriate RASS score of -3 according to MD order ..." The CEO verified and stated, this education was given out to all nursing staff in regarding to following a physician order and notification to a physician when needed to start or titrate medication outside of the original order. The CEO further stated, she realized the survey findings did not reflect the positive outcome or staff's compliance to the education.

A review of the facility's P&P titled, "Intravenous Medication Administration," dated December 2023, the P&P indicated, "Purpose: To delineate the policy and procedure for administrating medications through the intravenous route ... Procedure: 4. Prior to administration, verify; patient identification, medication name, dose, route, frequency, rate of administration, and compatibility. 5. Verify the physician's order. 6. Follow any other appropriate policies and procedures ..."


4. A review of Patient 8's H&P, dated February 4, 2024, the H&P indicated, Patient 8 presented to the ED with complaint of "worsening shortness of breath with mild chest pressure" and a past medical history including CHF, hypertension, and dyslipidemia (abnormal fat or cholesterol in blood).

During an interview on February 15, 2024, at 9:40 AM, in the conference room, with the DICU, the DICU stated, Patient 8 was admitted on February 4, 2024, and remined in ED until February 9, 2024, when Patient 8 transferred into ICU.

During an interview on February 15, 2024, at 1:25 PM, in the conference room, with RN 4, in the presence of the DED, and the DOR, RN 4 stated, patients, who was admitted into the ICU status but remained in the ED, should be treated with ICU level of care including assessment and documentation every one hour during continuous IV sedation and vasoactive (a group of medications that has the effect of either increasing or decreasing blood pressure and/or heart rate) infusion.

A follow-up concurrent interview and record review on February 15, 2024, at 1:40 PM, with RN 4, in the presence of the DED, and the DOR, Patient 8's "Medication Detail: IV Medication" for vasopressin, dated February 7, 2024, at 11:45 AM, was reviewed. The "Medication Detail: IV Medication" for vasopressin indicated, "starting rate 0.03 units/min [unit per min-unit dosing medication] FOR SHOCK. Titrate To: 0.03 units/min. Text Titrate To: 0.03 units/min ##DO NOT TITRATE ABOVE 0.03 units/min## FOR SHOCK ... DECREASE BY 0.01 units/minutes Q [every] 30 minutes if MAP [mean arterial pressure-the average number of blood pressure] tolerates ..." RN 4 verified and stated, vasopressin was ordered for shock, and it was meant to be kept at a fixed rate and not titrated.

A follow-up concurrent interview and record review on February 15, 2024, at 1:45 PM, with RN 4, the DED, and the DOR, Patient 8's MAR for vasopressin, dated February 7, 2024, at 12:49 PM, through February 8, 2024, at 7:00 AM, were reviewed. The MAR for vasopressin indicated Patient 8 was assessed as follows:

On February 7, 2024, at 12:49 PM
On February 7, 2024, at 7:30 PM (6 hrs and 41 mins from previous)
On February 7, 2024, at 11:29 PM (3 hrs and 59 mins from previous)
On February 8, 2024, at 7:00 AM (7 hrs and 31 mins from previous)

RN 4 verified and stated, the nursing staff did not document hourly assessment of Patient 8 as indicated for an ICU patient. The DOR stated, she was unable to provide any documented evidence to show Patient 8 was assessed every one hour while on continuous vasopressin IV infusion.

During an interview on February 16, 2024, at 1:05 PM, in the conference room, with the CEO, the CEO stated, ICU patients in the ED were expected to be assessed every one hour.

A review of the facility's P&P titled, "Assessment-Reassessment of Patients Interdisciplinary," dated February 2021, the P&P indicated, "Policy: Patients admitted to [Hospital Name] shall have an age appropriate assessment performed by each discipline involved in his/her care ... The scope and intensity of any further assessment or reassessment are based on the patient's diagnosis, the care setting, the patient's desire for care, and the patient's response to any previous care ... Procedure: ICU ... shift assessment within 1 hour of coming on duty and every 2 hours or as condition warrants ..."

A review of the facility's P&P titled, "Intravenous Medication Administration," dated December 2023, the P&P indicated, "Purpose: To delineate the policy and procedure for administrating medications through the intravenous route ... Procedure: 4. Prior to administration, verify; patient identification, medication name, dose, route, frequency, rate of administration, and compatibility. 5. Verify the physician's order. 6. Follow any other appropriate policies and procedures ..."

Based on observation, interview, and record review, the hospital failed to ensure the nursing staff implemented the prevention and control of infection for three of 36 sampled patients (Patient 7, 8, and 20) when :

1. For Patient 7 and 8, the nursing staff did not clean or disinfect (kill germ) the medication preparation area before preparing or mixing patients' intravenous (IV-into the vein) medication and the computer on wheel (COW) between patients' use in the Intensive Care Unit (ICU).

2. For Patient 20, the nursing staff did not utilize an appropriate transmission-based precautions (used to help stop the spread of germs from person to another) in the Definitive Observation Unit (DOU-unit in hospital that provides second highest level of care).

These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable bloodstream infection which can negatively affect patients' health, prolonged hospitalization, lead up to actual harm, or possible death.

Findings:

1a. A review of Patient 7's "History and Physical" (H&P,) dated January 24, 2024, the H&P indicated, Patient 7 was admitted into the facility for "generalized weakness" with the past medical history of atrial flutter (an abnormal heart rhythm).

A review of Patient 9's H&P, dated February 6, 2024, the H&P indicated, Patient 9 presented to the ED with complaints of low blood pressure while receiving dialysis (a procedure to remove waste products from the blood) and led to cardiopulmonary resuscitation (CPR-emergency procedure as an effort to restore blood circulation in a person when heart stop), with past medical history including end stage renal disease (ESRD-a condition that kidneys did not work permanently), diabetes (a condition that body cannot control blood sugar), and hyperlipidemia (high cholesterol or fat in blood).

During an observation on February 13, 2024, at 10:16 AM, with Registered Nurse 2 (RN 2), RN 2 entered in to Patient 9's room, brought the COW to Patient 7's room without cleaning or disinfecting the surface or scanner, placed insulin (medication to treat high blood sugar) syringe onto the COW, used alcohol based hand rub (ABHR) to clean her hands, donning (wearing) on gloves, picked up scanner from computer, scanned Patient 7's arm band, scanned medication, and administered medication. Observed RN 2 discarded all the used supplies, donning off gloves, used ABHR, touched the power cord to plug the COW, touched the surface and handled of the COW to move it to the side, exited the room without cleaning the COW, and went to the medication room to gather more medication.

A continuous observation on February 13, 2024, at 10:22 AM, in the medication room, RN 2 was observed pulling out medications from the Pyxis machine (an automated medication dispensing system) for Patient 7 including:

A vial of dexamethasone (decadron-medication to treat inflammation)
A vial of pantoprazole (protonix-medication to decrease stomach acid)
A vial of levothyroxine (synthroid-medication to treat thyroid problem)

RN 2 placed the medications onto the preparation counter without cleaning the area. RN 2 performed hand hygiene, donning gloves, and obtained supplies to mix medications. RN 2 mixed a vial of protonix with 10 milliliter (ml-unit measurement) normal saline (NaCl-salt water) and continue the process with mixing decadron and Synthroid with NaCl. RN 2 discarded used supplies, discarded gloves, performed hand washing, gather the medications, and exited the room without cleaning the area.

A continuous observation on February 13, 2024, at 10:35 AM, in Patient 7's room, RN 2 placed medication syringes and supplies onto the COW, used alcohol based hand rub (ABHR) to clean her hands, donning on gloves, picked up scanner from computer, scanned Patient 7's arm band, scanned medications, administered protonix, discarded used supplies, went over to the COW, grabbed Synthroid, administered Synthroid, discarded used supplies, went over to the COW, grabbed decadron, and administered decadron. Observed RN 2 discarded all the used supplies, donning off gloves, used ABHR, went over to the COW to finish her documentation, and returned the COW to Patient 9's room without cleaning.

A follow-up interview on February 13, 2024, at 10:55 AM, in the clean utility room, with RN 2, RN 2 verified and stated, she did not clean or disinfect the medication preparing area before mixing medications. RN 2 stated, she did not clean or disinfect the COW when she brought it over from Patient 9's room or after she finished using for Patient 7 and took it back to Patient 9's room.

During an interview on February 13, 2024, at 11:05 AM, in the conference room, with the Infection Control Preventionist (ICP), the ICP stated, the nursing staff were expected to clean the medication preparing area before and after mixing medications, and to clean equipment or environment area between patients' use to avoid the risk of cross contamination between patients.

1b. A review of Patient 8's H&P, dated February 4, 2024, the H&P indicated, Patient 8 presented to the ED with complaint of "worsening shortness of breath with mild chest pressure" and a past medical history including congestive heart failure (CHF-a condition in which the heart does not pump blood as well to the body), hypertension (high blood pressure), and dyslipidemia (abnormal fat or cholesterol in blood).

A review of Patient 9's H&P, dated February 6, 2024, the H&P indicated, Patient 9 presented to the ED with complaint of low blood pressure while receiving dialysis and led to CPR, with past medical history including ESRD, diabetes, and hyperlipidemia.

During an observation on February 13, 2024, at 9:51 AM, in the medication room of ICU, RN 3 was observed pulling out medications from the Pyxis machine for Patient 8 including:

A vial of cefipime (medication to treat infection)
A vial of protonix

RN 3 placed the medications onto the preparation counter without cleaning the area. RN 3 performed hand hygiene, donning gloves, and obtained supplies to mix medications. RN 3 mixed a vial of cefipime with 10 ml and continued the process of mixing protonix with NaCl. RN 3 discarded used supplies, discarded gloves, performed hand washing, gather the medications, and exited the room without cleaning the area.

A continuous observation on February 13, 2024, at 10:00 AM, in Patient 8's room, RN 3 placed medication syringes and supplies onto the COW, performed hand washing with soap and water, donning on gloves, picked up scanner from computer, scanned Patient 8's arm band, was unable to scanned medications. Observed RN 3 donning off gloves, used ABHR to clean his hands, exited the room, walked to Patient 9's room, brought the COW to Patient 8's room without cleaning or disinfecting the surface or scanner, transferred all medications to the COW, used ABHR to clean his hands, donning on gloves, picked up scanner from computer, scanned Patient 8's arm band, medications, and administered protonix, discarded used supplies, went over to the COW, grabbed cefipime, and administered cefipime. Observed RN 3 discarded all the used supplies, donning off gloves, used ABHR, went over to the COW to finish his documentation, and returned the COW to Patient 9's room without cleaning.

A follow-up interview on February 13, 2024, at 10:50 AM, in the clean utility room, with RN 3, RN 3 verified and confirmed, he did not clean or disinfect the medication preparing area before mixing medications. RN 3 stated, he did not clean or disinfect the COW when he brought it over from Patient 9's room or after he finished using for Patient 8 and took it back to Patient 9's room. RN 3 further stated, he did not realize he did not clean until now. RN 3 stated, the shared equipment should have been cleaned to decrease the risk of cross contamination between patients.

During an interview on February 13, 2024, at 11:05 AM, in the conference room, with the ICP, the ICP stated, the nursing staff were expected to clean the medication preparing area before and after mixing medications, and to clean equipment or environment area between patients' use to avoid the risk of cross contamination between patients.

A review of the facility's P&P titled, "Precautions: Standard and Isolation," dated August 2022, the P&P indicated, "Policy Transmission of infection within a hospital requires three elements: (1) host, (2) pathogen, and (3) environment ... Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in the hospital ... Procedure ... 1.6 Environmental control 1.6.1 Ensure that the hospital has adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedside equipment, and other frequently touched surfaces ..."


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2. During an observation on February 12, 2024, at 9:24 AM, in the DOU, RN 7 was observed to enter Patient 20's room who was under droplet isolation precaution (set of precautions used to reduce transmission of microorganisms in healthcare setting) without wearing the appropriate personal protective equipment (PPE- equipment worn to minimize exposure to hazards).

During an interview on February 12, 2024, at 9:28 AM, with RN 7, RN 7 stated, Patient 20 was on droplet precaution (use mask and goggles to prevent exposure of mucosal and respiratory fluids) for VRE (vancomycin resistant enterococci- bacteria that has become resistant to certain antibiotics).

During a review of Patient 20's "Sputum (mixture of saliva and mucus) Culture," dated January 31, 2024, the sputum culture indicated, " ...Rare Growth: Escherichia coli (rod shaped bacterium) - ESBL (extended spectrum beta lactamase-enzyme produced by some bacteria that makes them resistant to some antibiotics) ...left message to [redacted name] - Infection Control Department ...".

During a review of Patient 20's Nurse Notes dated February 3, 2024, indicated, "Reported ESBL e coli in Sputum to Dr. [name] through phone. Order provided for meropenem (type of antibiotic) 2g (gram-unit of measurement) q (q-every) 8 h (h-hours) scheduled. Order entered and pharmacist verified".

During a review of Patient 20's "Isolation Assessment" dated February 3, 2024, the Isolation Assessment indicated, " ...Reason for isolation present or previous. ESBL Ecoli. Isolation. Droplet. Sputum".

During an interview on February 16, 2024, at 9:35 AM with the ICP, the ICP stated Patient 20 should have been placed on contact precautions (gown and gloves used when there is a risk for contamination with touching patients), not droplet precautions. The ICP stated, he oversees all isolated patients every day and every day sends an email to all the directors of the hospital with the list of patients who are on isolation with the associated pathogen. The ICP further stated, he missed it, and the nurses would be educated on the correct isolation precautions.

During a concurrent interview and record review on February 16, 2024, at 9:36 AM, with the ICP, the facility's P&P titled, "Infection Control", dated August 31, 2022, was reviewed. The P&P indicated, "Transmission of infection within a hospital requires three elements: (1) host, (2) pathogen, and (3) environment ... Transmission-based Precautions are designed for patients documented or suspected to be infected with highly transmissible or epidemiologically important pathogens for which additional precautions beyond Standard Precautions are needed to interrupt transmission in the hospital..." The ICP stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to implement the policy and procedure (P&P) on the prevention and transmission of infection when one registered nurse did not perform hand hygiene and wear the appropriate personal protective equipment (PPE - protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) when entering to one of 36 sampled patients (Patient 20).

This failure had the potential to expose all six patients on the Definitive Observation Unit (DOU) result in cross-contamination (the transfer of harmful bacteria) which can negatively affect patients' health and prolonged hospitalization .

Findings:

During an observation on February 12, 2024, at 9:24 AM, in the DOU, Registered Nurse 7 (RN 7), entered to Patient 20's room who was under isolation precaution (set of precautions used to reduce transmission of microorganisms in healthcare setting) without wearing the appropriate personal protective equipment (PPE). Patient 20's entrance door had a signage indicated droplet precautions (patient will be placed on droplet precautions when he or she has an infection with germs that can be spread to others by speaking, sneezing, or coughing).

During a continued observation on February 12, 2024, at 9:26 AM, in the DOU, RN 7 came out of Patient 20's room and walked towards the nurses station without performing hand hygiene.

During an interview on February 12, 2024, at 9:28 AM, with RN 7, RN 7 stated Patient 20 was on droplet precaution (use mask and goggles to prevent exposure of mucosal and respiratory fluids) for VRE (vancomycin resistant enterococci- bacteria that has become resistant to certain antibiotics). RN 7 stated, for droplet precautions he should have worn the following PPEs: gown, gloves, mask and goggles when entering in to the room. RN 7 further stated he did not use PPE .

During an interview on February 12, 2024, at 9:32 AM, with RN 7, RN 7 stated the expectation was to wash hands or apply hand sanitizer immediately after leaving a room of droplet precaution. RN 7 further stated he did not apply hand sanitizer or wash his hands after entering an isolation precaution room.

During an interview on February 16, 2024, at 9:33 AM, with the Infection Control Preventionist (ICP), the ICP stated, the staffs are expected to enter an isolation precautuion room with approriate PPEs and perform hand wash when exiting the isolation room.

During a concurrent interview and record review on February 16, 2024, at 9:36 AM, with the ICP, the facility's policy and procedure (P&P) titled, "Infection Control", dated August 31, 2022, was reviewed. The P&P indicated, " ...1.1 Handwashing 1.1.1 wash hands after touching blood, body fluids ...and contaminated items, regardless of whether gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments ... 1.1.2 use soap and water or supplied hand sanitizer ...3.1 In addition to Standard Precautions, use Droplet Precautions, for a patient known or suspected to be infection with microorganisms transmitted by droplets ...3.3.1 ...wear a mask when entering the patient's room or working within 3 feet of the patient." The ICP stated the P&P was not followed.