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Based on interview and record review, the hospital failed to ensure the staff monitored the vital signs, nutrition, hydration, hygiene, and elimination needs as per the hospital's P&P for one of 18 sampled patients (Patient 6) when the patient was restrained or secluded. This failure had the potential to result in unsafe care and poor clinical outcomes to the patient.

Findings:

Review of the hospital's P&P titled Seclusion and Restraints dated October 2024 showed seclusion is the involuntary confinement and isolation of a person, alone in a room or an area, where the patient is physically prevented from leaving.

* The LIP/Trained RN section showed when less restrictive interventions fail, initiates the seclusion and restraints process when emergency situation continues:

- Places patient in seclusion or restraints and obtains telephone or written order from physician/provider/or LIP who is responsible for the care of the patient immediately following initiation of S and R or seclusion only. PRN or standing orders are not acceptable.

- Order includes the following information: date and time of order; specific behavior that led to S or R (Reason for seclusion or restraints).

- If order not immediately obtained from patient's attending physician or provider, continues to attempt to reach physician or provider follows escalation chain as necessary to obtain order as soon as possible. Escalation chain as follows: If attending physician or provider cannot be reached after two attempts (no more than 10 minutes apart), then the nurse will phone the physician or provider-on call for order; If physician or provider on-call cannot be reached after two attempts (no more than 10 minutes apart) nurse will call the facility medical director for order.

* The Clinical Staff section showed the following:

- MAB trained staff provides direct observation in close proximity to the patient for any patient in locked seclusion only (not restraints).

- Completes documentation on the S and R flow sheet. The following patient needs will be assessed on a continuous 1:1 basis and documented in the medical record every 15 minutes: vital signs every 15 minutes or as ordered; any signs of injury and over all skin integrity; nutrition and hydration need every 15 minutes; hygiene and elimination every 15 minutes.

On 1/21/25 at 1407 hours, an interview and concurrent review of Patient 6's medical record was conducted with the CNO.

Patient 6's medical record showed Patient 6 was admitted to the hospital on 12/3/24.

Review of Patient 6's Seclusion/Restraint Record showed Patient 6 was placed in seclusion on 12/8/24 at 0043 hours and ended on 12/8/24 at 0443 hours. There was no documentation in the Seclusion/Restraint Record to show the following patient needs were assessed and documented every 15 minutes as per the hospital's P&P: vital signs, nutrition, hydration, hygiene, and elimination needs.

The CNO was asked for the physician's order for seclusion. The CNO verified the physician's order for seclusion was dated 12/9/24 at 0535 hours. The CNO was asked for the monitoring of the patient's vital signs, nutrition, hydration, hygiene, and elimination needs every 15 minutes as per the hospital's P&P. The CNO stated there was no section on the Seclusion/Restraint Record for staff to document the assessment of patient needs (nutrition, hydration, hygiene, and elimination) every 15 minutes. The CNO also stated the patient refused for the vital signs to be taken. However, there was no documented evidence the patient refused for the vital signs to be taken.

The CNO verified the findings.

Based on interview and record review, the hospital failed to ensure the care plans were developed for eight of 18 sampled patients (Patients 1, 2, 3, 5, 8, 11, 12, and 13) as per the hospital's P&P. These failures created the increased risk of poor health outcomes to the patients in the hospital.

Findings:

Review of the hospital's P&P titled Master Treatment Plan dated October 2024 showed the following:

* Policy: Each patient admitted to the hospital shall have a written, individualized master treatment plan (MTP) that formulates a plan of care that meets the patient's objectives and needs. Treatment shall be planned, reviewed, and evaluated at regular intervals by a multidisciplinary treatment team. This team shall consist of the physician and representatives of each clinical discipline involved in the treatment as appropriate. Treatment planning will provide appropriate communication between team members that fosters consistency and continuity in the care of the patient. Ultimate responsibility for the development and implementation of the master treatment plan shall rest with the provider.

* Procedure:

- Within eight hours of admission, the RN will initiate the master treatment plan. This initial plan shall include high risk and critical medical problems, and appropriate physician and nursing interventions as determined by the initial assessments, the provider's treatment plan, and the provider's order.

- Within 72 hours of admission, member of the treatment team shall further develop the master treatment plan that is based on a comprehensive assessment of the patient's presenting problems, physical health, emotional and behavioral status. The team will consist of the provider, nursing staff, social services staff, adjunctive therapy staff, and other clinical disciplines, as appropriate.

- The treatment plan is developed and reviewed on the same day as the treatment team meeting.

- The Master Treatment Plan Review shall be reviewed within 7 days of completion with the exception of significant events which should be updated within 24 hours. This includes episodes of seclusion and restraints. The Treatment Plan review shall include treatment and discharge changes, modality or intervention change, new issues, updates to problems or goals as identified in Mater Treatment Plan Form.

- Additional Treatment Plan Components includes Active Problems. For each problem to be addressed during treatment, the treatment plan status will be deemed "active " , and a problem sheet will be completed. The problem statement will be in behavioral, medical, observable terminology, etc. Only medical problems should be stated in diagnostic terms (example hypertension) but should also include statement of current status of condition.

1. On 1/14/25 at 1425 hours, Patient 1's closed medical record was reviewed with the CNO.

Patient 1's medical record showed the patient was admitted to the hospital on 12/2/24, and discharged on 12/16/24.

On 1/21/25 at 1315 hours, Patient 1's medical record was reviewed with RN 7.

Review of the MAR showed the patient was given Flonase (a nasal steroid) one nasal spray on 12/12/24 at 1308 hours, for nasal congestion; and Bentyl (an anticholinergic) 20 mg po on 12/11 at 1418 hours and 12/12/24 at 1810 hours, for intestinal spasm.

Review of the MTP did not show a care plan for the use of the Flonase and Bentyl.

On 1/21/25 at 1315 hours, during an interview and concurrent review of Patient 1's medical record with RN 7, RN 7 verified the care plan was not updated.

2. On 1/15/25 at 0938 hours, Patient 2's closed medical record was reviewed with the CNO.

Patient 2's closed medical record showed the patient was admitted to the hospital on 11/30/24, and discharged on 12/12/24.

Review of Patient 2's Medical History & Physical Examination dated 12/2/24 at 0930 hours, showed the patient had a medical history of HTN.

Review of Patient 2's MAR showed amlodipine (a medication to treat high blood pressure) 5 mg 1 tablet po once a day at 0900, hold for SBP less than 100 mmHg, for HTN. The MAR showed Patient 2 received amlodipine daily from 12/2/24 to 12/12/24.

On 1/21/25 at 1530 hours, the CNO was interviewed. When asked about the care plan for HTN, the CNO verified there was no care plan for HTN.

3. On 1/15/25 at 1006 hours, Patient 3's closed medical record was reviewed with the CNO.

Patient 3's closed medical record showed the patient was admitted to the hospital on 12/2/24, and discharged on 12/17/24.

Review of the RN's Progress Note dated 12/6/24 at 0216 hours, showed Patient 3 complained of nausea and vomiting earlier during the day and was given Zofran (a medication to prevent nausea and vomiting) as needed.

Review of Patient 3's MAR showed the patient received Zofran 4 mg po on 12/5/24 at 2344 hours and 12/6/24 at 1251 hours as needed for nausea and vomiting.

On 1/21/25 at 1530 hours, the CNO was interviewed. When asked about the care plan for the use of Zofran, the CNO verified there no plan of care for the use of Zofran.

4. On 1/15/25 at 1107 hours, Patient 5's closed medical record was reviewed with the CNO.

Patient 5's closed medical record showed the patient was admitted to the hospital on 11/23/24, and discharged on 12/12/24.

Review of the Consultation Request to NP 1 dated 12/6/24 at 0043 hours, showed Patient 5 complained of nausea and vomiting since earlier during the day. NP 1's Consultation Reply dated 12/6/24 at 0748 hours, showed to give Zofran as needed for nausea and vomiting and recommended a liquid diet. The diagnosis was nausea and vomiting.

Review of Patient 5's Order showed an order for loperamide (a medication used to treat diarrhea) 2 mg 1capsule every 6 hours as needed for 3 days, for diarrhea.

Review of Patient 5's MAR showed the patient received Zofran 4 mg po as needed for nausea and vomiting on 12/5/24 at 1743 and 2300 hours, on 12/6/24 at 1152 hours, and on 12/7/24 at 0750, 0938, and 1628 hours. Patient 5 also received loperamide 2 mg po as needed for diarrhea on 12/6/24 at 1507 and 2130 hours, and on 12/7/24 at 0750, 0937, and 1631 hours.

On 1/21/25 at 1343 hours, the CNO was interviewed. When asked about the care plan for the use of Zofran and loperamide for nausea, vomiting and diarrhea, the CNO verified there was no care plan for the use of Zofran and loperamide.

5. On 1/22/25 at 0845 hours, Patient 8's closed medical record was reviewed with the Nurse Educator.

Patient 8's closed medical record showed Patient 8 was admitted to the hospital on 11/28/24, and discharged on 12/11/24.

Review of Patient 8's Medical History & Physical Examination dated 11/29/24 at 0000 hours, showed the patient had a history of HIV, fibromyalgia, scoliosis, rhabdomyolysis and was on multiple pain medication.

Review of Orders showed a written order for CIWA-B (Clinical Institute for Withdrawal Assessment for Benzodiazepine).

Review of the Patient 8's MTP did not show a care plan for CIWA and HIV.

The Nurse Educator verified there was no care plan for CIWA and HIV.

6. On 1/22/25 at 1103 hours, Patient 11's closed medical record was reviewed with the Nurse Educator.

Patient 11's closed medical record showed Patient 11 was admitted to the hospital on 12/2/24, and discharged on 12/11/24.

Review of RN's Progress Note dated 12/5/24 at 1045 hours, showed Patient 11 complained of nausea and vomiting. The patient at first wanted to take Zofran but changed her mind. The patient stated that the patient vomited after taking Zofran yesterday. The patient was offered warm water and crackers for nausea.

Review of RN's Consultation Request to IM showed the patient complained of constipation, not relieved by Colace (stool softener).

Review of Patient 11's MAR showed the patient received Zofran 4 mg po on 12/3/24 at 1807 hours and 12/4/24 at 1234 hours, for nausea and vomiting as needed. Patient 11 also received Colace 100 mg po on 12/3/24 at 1305 hours, and 12/4/24 at 1241 hours as needed for constipation.

Review of Patient 11's MTP did not show a care plan for constipation, nausea, and vomiting.

The Nurse Educator verified the findings.

7. On 1/22/25 at 1103 hours, Patient 12's closed medical record was reviewed with the Nurse Educator.

Patient 12's closed medical record showed Patient 12 was admitted to the hospital on 11/30/24, and discharged on 12/9/24.

Review of the RN's Progress Note dated 12/8/24 at 0914 hours, showed the patient refused gabapentin (a medication to relieve pain or treat seizures) and Lexapro (a medication that treats depression and anxiety) due to nausea and diarrhea.

Review of Patient 12's MAR showed the patient received Zofran 4 mg po on 12/7/24 at 1422 hours and 12/8/24 at 0912 hours for nausea and vomiting as needed.

Review of Patient 12's MTP did not show a care plan for nausea and vomiting.

The Nurse Educator verified the findings.

8. On 1/22/25 at 1345 hours, Patient 13's closed medical record was reviewed with the Nurse Educator.

Patient 13's closed medical record showed Patient 13 was admitted to the hospital on 12/1/24, and discharged on 12/9/24.

Review of the RN's Consultation Request to NP 1 dated 12/5/24 at 1819 hours, showed Patient 13 complained of mild diarrhea. NP 1's Consultation Reply dated 12/6/24 at 0752 hours, showed to give Imodium (same as loperamide) every 6 hours as needed and recommended clear liquid diet. The diagnosis was acute diarrhea.

Review of the Acute Nursing Progress Note (evening) dated 12/6/24 at 0556 hours, showed on the narrative update the patient was complaining of nausea and diarrhea and stated he had 3 to 4 stools today.

Review of the Orders showed an order dated 12/6/24 at 0752 hours, for loperamide 2 mg capsule every 6 hours as needed for 3 days for diarrhea.

Review of Patient 13's MAR showed the patient received loperamide 2 mg capsule po for diarrhea as needed.

Review of Patient 13's MTP did not show a care plan for diarrhea.

Based on interview and record review, the hospital failed to ensure the nursing staff implemented the hospital's P&P for eight of 18 sampled patients (Patients 1, 3, 5, 6, 9, 10, 13, and 14) as evidenced by:

1. For Patient 1, there was no written physician's order to transfer the patient to the acute hospital ED. In addition, there was no attending physician's order was obtained to consult with the IM provider for Patient 1's medical problem.

2. For Patient 6, there was no physician's order was written when placing the patient in contact isolation and when discontinuing the contact isolation for the patient.

3. For Patient 3, the diet recommendation was not clarified and was not transcribed as the order for the patient.

4. For Patient 5, the diet recommendation was not clarified and was not transcribed as the order for the patient.

5. For Patient 13, the diet recommendation was not clarified and was not transcribed as the order for the patient.

6. For Patient 9, there was no transcribed order for tiotropium (anticholinergic bronchodilator, a medication used to prevent the narrowing of the airways in the lungs).

7. For Patient 10, there was no transcribed order to transfer the patient to the ED for further evaluation.

8. For Patient 14, there was no transcribed order for a BRAT diet for the patient.

These failures had the potential to result in unsafe care and poor clinical outcomes to the patients.

Findings:

Review of the hospital's P&P titled Transcribing Provider Orders dated October 2024 showed in part:

* It is the policy to accept and carry out written and telephone orders for medication related orders and treatments.

* Telephone Orders:

- Telephone orders will be accepted only if the ordering provider is not present on the unit for admissions, unplanned, AMA discharges, STAT and emergency medications or treatments, denial of rights, or in response to an emergent situation.

- All telephone orders will be received by a licensed member of the nursing staff and written order as a Provider's Order.

- The licensed staff receiving a telephone order is to read the complete order back to the provider once it has been written for verification. After the order has been read back to the ordering provider the licensed staff will then complete the order.

-Telephone orders must be authenticated by the provider signature within 48 hours.

Review of the hospital's P&P titled Transcribing Provider Orders reviewed date 10/24 showed the following:

* Clarification of Orders:

- If the provider is present, the licensed staff will ask the provider to clarify the order. The provider will write the clarifications such as a provider's order.

- If the provider is not present, the licensed staff will call the provider for clarification if the order does not contain the listed requirement, anytime there is a question regarding any of the content of the order.

- The licensed staff calling the provider will write the clarification order as such as a provider's order.

- The provider will authenticate each clarification by signature within 48 hours.

* Transcribing other orders:

- Consults - notify the appropriate consultant or department by phone and/or on notification boards; indicate the time of the notification on the order (example notified date or time by name).

- Diet Orders - notify the dietary department and or registered dietician by phone and consult request; indicate the date and time of notification on the order.

Review of the hospital's Medical Staff Rules and Regulation (undated) showed in part:

* Consultations:

- Consultations must be requested by the attending provider by a written or telephone order.

- Medical Staff who are functioning as consulting may write orders for medication and treatment.

- Emergency Consultation must be requested by the attending provider directly to the consulting provider. A telephone order may be dictated in the case of emergency. A telephone order must be transcribed, dated, timed, and signed by the authorized recipient in the patient's medical record within the shift, whenever possible. Telephone order must be countersigned by the attending provider within 24 hours.

* Nursing Standards of Practice: A RN shall be considered to be competent when he or she consistently demonstrates the ability to transfer scientific knowledge from social, biological and physical sciences in applying the nursing process, as follows:

- Formulates a nursing assessment through observation of the client's physical condition and behavior, and through interpretation of information obtained from the client and others, including the health team.

- Formulates a plan of care in collaboration with the client, which ensures that direct and indirect nursing care services provide for the client's safety, comfort, hygiene, and protection, and for disease prevention and restorative measures.

- Acts as the client's advocate as circumstances require by initiating action to improve health care or to change decisions or activities which are against the interest or wishes of the client, and by giving the opportunity to make informed decisions about health care before it is provided.

1. On 1/14/25 at 1425 hours, Patient 1's closed medical record was reviewed with the CNO.

Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 12/2/24, and discharged on 12/16/24.

Review of the Nursing Progress Notes dated 12/4/24 at 1859 hours, showed Patient 1 had several episodes of watery light brown foul-smelling diarrhea during the late afternoon, Imodium was given with little effect. Patient 1 also complained of generalized abdominal pain, bloating, and some mild nausea. Patient 1's abdomen was distended but soft. NP 1 (IM provider) was notified, and Patient 1 would be sent out for medical evaluation. The Call Center was notified and BLS transportation would be arranged to the nearest ER.

a. Review of the Acute Nursing Progress Note dated 12/4/24 at 2000 hours, showed Patient 1 would be sent out to a hospital for assessment of uncontrolled diarrhea.

The CNO was asked about Patient 1's transfer to the hospital on 12/4/24. The CNO stated Patient 1 was sent out to the hospital's ED for several hours and came back to their hospital. The CNO was asked for the physician's order to transfer the patient to the hospital's ED. The CNO stated the RN wrote on her progress note.

On 1/16/25 at 1400 hours, an interview and concurrent review of Patient 1's closed medical record was conducted with the Nurse Manager. The Nurse Manager was asked for the order to transfer Patient 1 to the hospital on 12/4/24. The Nurse Manager stated the verbal order was written on the RN's progress note. However, when asked for the physician's written order, the Nurse Manager stated generally the order had to be written as a telephone order. The Nurse Manager verified there was no written physician's order for the patient to be transferred to the nearest hospital ED.

b. On 1/15/25 at 0900 hours, an interview was conducted with the Medical Director, CNO, and Director of Quality. The Medical Director was asked about the Medical Consultants. The Medical Director stated the Medical Consults were the IM physicians who would do the patient's H&P on admission. The IM physician would have NPs under their supervision. The H&P could be done by the NPs or IM physicians within 24 hours of the patient's admission.

On 1/16/25 at 0948 hours, an interview and concurrent review of Patient 1's closed medical record review was conducted with the Director of Quality. The Director of Quality was asked about Patient 1's H&P examination. The Director of Quality stated the NP who performed Patient 1's H&P examination was not the psychiatrist. The IM provider was consulted to do the H&P examination; and if they needed to consult the IM providers again, we would. The Director of Quality verified the attending physician was the psychiatrist. The Director of Quality was asked to show the physician's order to consult for the IM physician to perform the H&P examination on admission. The Director of Quality stated there was no order for the IM physician to conduct the H&P examination, it had been a practice of the hospital to have the patient's H&P examination to be done for medical clearance on admission.

On 1/16/25 at 1400 hours, an interview and concurrent review of Patient 1's closed medical record was conducted with the Nurse Manager. The Nurse Manager was asked if an order from the attending psychiatrist was needed to consult the IM physician for medical clearance and H&P examination. The Nurse Manager stated the IM physician knew when there were admissions. The IM physician would conduct the required medical clearance and H&P examination. The succeeding contact with the IM physician would be a consultation.

On 1/16/25 at 1510 hours, a telephone interview was conducted with NP 1. NP 1 was asked how the IM provider was involved with the care of the patients at the hospital. NP 1 stated they would conduct the patient medical clearance and H&P examination on admission. The IM provider would see the newly admitted patients medically, they would do physical examination for medical clearance; and if the patient was on chronic medications, they would continue the medication for continuity of care. NP 1 was asked if the nurse sent the consultation request for a patient who developed diarrhea, nausea and vomiting. NP 1 stated that was a medical consult when the nurse requested certain medications, if needed medically, or patient needed medical attention, and the IM provider was called.

On 1/22/25 at 1001 hours, a telephone interview was conducted with the Service Director for IM. The Service Director for IM was asked about the care provided for the patients in the hospital. The Service Director for IM stated when patients were admitted to the hospital, the IM provider was consulted. They got a list of the new patients admitted overnight who would need consultation for H&P examination, and they continued the consult if the nurse would call them for medical problems such as headache, HTN, or diarrhea. The IM provider would give orders if needed. However, there was no order for the IM physician for consultation. The findings were shared with the Service Director of IM.

2. On 1/15/25 at 1350 hours and 1/21/25 at 1512 hours, Patient 6's closed medical record was reviewed with the CNO. Patient 6's closed medical record showed Patient 6 was admitted to the hospital on 12/3/24 and discharged on 12/19/24.

Review of the RN's Progress Note dated 12/9/24 at 0800 hours, showed Patient 6 was experiencing diarrhea; and per the NP, Patient 6 was placed on contact precaution. The staff encouraged the patient to follow precautions and to stay in the room.

On 1/21/25 at 1512 hours, during the interview and concurrent review of Patient 6's closed medical record with the CNO, the CNO was asked about Patient 6's contact precaution. The CNO stated Patient 6 was placed on contact precaution for diarrhea as per the telephone order. The staff would put a sign on the door for specific type of isolation. Patient 6's contact isolation was the use of gown, gloves, and hand hygiene. However, there was no written order for the contact precaution.

The CNO was asked when the contact isolation was discontinued. The CNO stated per RN's Progress Note on 12/13/24 at 1200 hours, the RN spoke to the medical provider (NP 1) and discontinued the contact isolation as a telephone order. However, the order was not transcribed in Patient 6's medical record.

The CNO verified the findings.

3. On 1/15/25 at 1006 hours, Patient 3's closed medical record was reviewed with the CNO.

Patient 3's closed medical record showed Patient 3 was admitted to the hospital on 12/2/24, and discharged on 12/17/24.

Review of the RN's Consultation Request for the IM provider (NP 1) for Patient 3 dated 12/6/24 at 0038 hours, showed Patient 3 complained of nausea and vomiting since earlier in the day. NP 1's Consultation Reply dated 12/6/24 at 0812 hours, showed the treatment recommendations were to give Zofran every 6 hours along with Imodium every 6 hours PRN; and recommended clear liquid diet. The diagnosis for Patient 3 was acute nausea and vomiting, and acute diarrhea. The CNO was asked for the clear liquid diet recommendation. The CNO stated the medical provider did not write an order for the clear liquid diet.

On 1/15/25 at 1254 hours, an interview was conducted with RN 6 and the CNO. RN 6 was asked how she would address the patient's complaints of nausea, vomiting, and diarrhea. RN 6 stated she would communicate to the patient's physician (medical provider) through the consultation request, hydrate and assess the patient, check the vital signs, and wait for the physician's order. RN 6 stated she would notify the supervisor. RN 6 also said she would verbally endorse to the following nurse, update the change of shift report and the internal communication of the nurses anything related to the patient's change in the medical condition. The nurse would also write in the progress note what happened during the shift. RN 6 was asked about the medical provider's consultation reply. RN 6 stated the incoming nurse should check the Consultation Reply as the incoming nurse had been verbally informed and patient's information had been updated. RN 6 was asked about the medical provider ' s Consultation Reply with a diet recommendation. RN 6 stated the incoming nurse should check the consultation reply and communicate the diet recommendation to the dietician.

On 1/15/25 at 1335 hours, during an interview with the CNO, the CNO stated the patient's Kardex would be updated if there would be new orders; however, the consultation would not appear on the Kardex. The nurses updated the internal communication that used for reporting, but not all nurses updated it. The nurses would not see the consultation reply unless it was checked by nurse.

On 1/16/25 at 1510 hours, a telephone interview was conducted with NP 1. NP 1 was asked about his consultation reply for the diet recommendations for the patients. NP 1 stated he would speak and address the diet recommendation with the patient's nurse. The nurse should follow through, it was not transcribed as an order, the nurse should call him and if he gave the order, it would be a telephone order.

4. On 1/15/25 at 1107 hours, Patient 5's closed medical record was reviewed with the CNO.

Patient 5's closed medical record showed Patient 5 was admitted to the hospital on 11/23/24, and discharged on 12/12/24.

Review of Patient 5's Consultation Request to NP 1 dated 12/6/24 at 0043 hours, showed Patient 5 was complaining of nausea and vomiting since earlier in the day. The Consultation Reply from NP 1 dated 12/6/24 at 0748 hours, showed the treatment recommendations were to give Zofran as needed for nausea and vomiting; and recommend clear liquid diet for now. The CNO was asked for the order of clear liquid diet. The CNO stated there was no diet order for clear liquid.

Review of Patient 5's MAR showed Patient 5 was given Zofran 4 mg po as needed for nausea and vomiting on 12/6/24 at 1152 hours, 12/7/24 at 0150, 0938, and 1638 hours. Patient 5 was also medicated with loperamide 2 mg 1 capsule every 6 hours as needed for diarrhea on 12/6/24 at 1507 and 2130 hours and 12/7/24 at 0750, 0937, and 1631 hours.

On 1/21/25 at 1343 hours, a follow-up interview and concurrent review of Patient 5's closed medical record was conducted with the CNO. The CNO was asked about the treatment recommendation of clear liquid diet for Patient 5. The CNO stated the nurses would not get notification if there was a consultation reply. The nurse would not see the consultation reply unless the nurse looked at the consultation ' s requests. If the physician wanted to order the liquid diet, he should place it as an order.

5. On 1/22/25 at 1345 hours, Patient 13's closed medical record was reviewed with Nurse Educator.

Patient 13's closed medical record showed Patient 13 was admitted to the hospital on 12/1/24, and discharged on 12/9/24.

Review of Patient 13's Consultation Request to NP 1 dated 12/5/24 at 1819 hours, showed Patient 13 reported mild diarrhea since earlier in the day. The Consultation Reply from NP 1 dated 12/6/24 at 0725 hours, showed the treatment recommendations were to give Imodium every 6 hours PRN and recommend clear liquid diet. The Nurse Educator was asked for the order of clear liquid diet. The Nurse Educator stated there was no diet order for clear liquid diet. The Nurse Educator was asked about NP 1's recommendation of clear liquid diet written on the Consultation Reply. The Nurse Educator stated the nurse could call and ask the dietician for the diet recommendation. However, there was no documented evidence the nurse followed up on the diet recommendation.

The findings were shared with the CNO.


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6. On 1/22/25 at 0837 hours, on interview and concurrent review of Patient 9's medical record was conducted with the Director of Quality.

Patient 9's medical record showed Patient 9 was admitted to the hospital on 12/3/24.

Review of the Medical History & Physical Examination dated 12/4/24 at 0000 hours, showed Patient 9 had a history of asthma.

Review of Patient 9's Master Treatment Plan showed the medical problems of asthma and food sensitivities.

Review of Patient 9's NP progress note dated 12/8/24, showed the problem was gastroparesis, poor po intake, and asthma. The note showed to add ensure, increase Zofran dose per request and add tiotropium inhaler.

The Director of Quality verified the hospital's P&P transcribing the provider's orders did pertain to this patient. The Director of Quality was asked to show the transcribed order for the NP order in the progress note on 12/8/24. The Director of Quality reviewed the MAR, nursing progress notes, and provider's orders and verified the order had not been transcribed and no follow-up phone call or clarification had been documented by the nursing staff in Patient 9's chart.

On 1/22/25 at 0900 hours, an interview and concurrent record review was conducted with the Nurse Educator. The Nurse Educator stated the nursing staff was expected to read the provider's progress notes and act accordingly. The Nurse Educator stated if an order was unclear, the nurse was expected to call the provider who wrote the order and get clarification. The Nurse Educator stated the expectation was to follow the hospital's P&P. The Nurse Educator stated the rationale for calling the provider was to ensure the patient received the intended treatment.

On 1/22/25 at 0922 hours, an interview was conducted with the Director of Pharmacy. The Director of Pharmacy was asked to provide information about the medication, tiotropium. The Director of Pharmacy stated the medication was a bronchodilator and was used to treat both asthma and COPD.

On 1/22/25 at 1002 hours, an interview was conducted with the Service Director of IM. The Service Director of IM was asked what was expected to be done if an NP placed an order in the progress notes, but it was not transcribed into the patient's medical record as an order. The Service Director of IM stated all progress notes were to be reviewed by the nursing staff. The Service Director of IM stated if the NP did not place the order, but did place it in their progress notes, the nurse was expected to phone the provider and ask them if they wanted it. The Service Director of IM stated the nurses were expected to read the provider notes, follow-up, and call the provider.

7. On 1/22/25, Patient 10's medical record was reviewed and showed Patient 10 was admitted to the hospital on 12/1/24.

Review of Patient 10's Master Treatment Plan showed the medical problems including ulcerative colitis, anemia, and possible fistula on the perianal area.

Review of Patient 10's Consultation Request dated 12/06/24, showed a medical consultation. Patient 10 had reported a history of ulcerative colitis and a current flare up. The patient had loose stool and small amount of dried blood observed with redness to perinea area. An opening on the right perianal area stool of leaking loose stool was observed. The patient states she usually received injections of Stelara (a medication used to treat ulcerative colitis) for treatment.

Review of the NP's Consultation Reply dated 12/6/24, showed to recommend the patient to be seen in the ED for further evaluation to rule out fistula by means of CT abdomen/pelvis. The patient could "be sent BLS scheduled pick up."

On 1/22/25 at 1002 hours, an interview was conducted with the Service Director of IM. The Service Director of IM was asked if a recommendation was an order or simply a recommendation for care. The Service Director of IM stated the consultation reply was for orders, the providers did not recommend but gave orders for the nursing staff to follow. The Service Director of IM was asked what was expected to be done if a NP placed an order in the consultation reply note, but it was not transcribed into the patient's medical record as an order. The Service Director of IM stated all reply notes were to be reviewed by the nursing staff. The Service Director of IM stated if the NP did not place the order, but did place it in their reply note, the nurse was expected to phone the provider and ask them if they wanted it. The Service Director of IM stated the nurses were expected to read the reply notes to the nursing requests, follow-up, and call the provider if they had a concern about an order.

On 1/22/25 at 1104 hours, an interview and concurrent review of Patient 10's medical record was conducted with the Director of Quality. The Director of Quality verified the hospital's P&P related to transcribing the provider's orders did pertain to this patient. The Director of Quality was asked to show the transcribed order for the NP order in the consult reply note on 12/6/24, sending Patient 10 to the E) for further evaluation. The Director of Quality reviewed the nursing progress notes and provider's orders and verified the order had not been transcribed, no follow-up phone call or clarification had been documented by the nursing staff in Patient 10's medical record.

On 1/22/25 at 1130 hours, an interview and concurrent record review was conducted with the Nurse Educator. The Nurse Educator stated the nursing staff was expected to read the provider's consultation reply notes to the original concern and act accordingly. The Nurse Educator stated if an order was unclear, the nurse was expected to call the provider who wrote the order and get clarification, document the clarification, and act accordingly. The Nurse Educator stated the verbiage recommendation for the ED was confusing and required further follow up with the provider. The Nurse Educator stated the expectation was to follow the hospital's P&P. The Nurse Educator stated the rationale for calling the provider was to ensure the patient received the intended treatment, such as being sent to the ED.


8. On 1/22/25, Patient 14's medical record was reviewed and showed Patient 14 was admitted to the hospital on 12/2/24.

Review of Patient 14's Consultation Request dated 12/5/24, showed a medical consultation. Patient 14 complained of diarrhea. The patient came back from dinner early due to feeling dizzy and unwell.

Review of the NP's Consultation Reply dated 12/6/24, showed to recommend Imodium q 6 hours prn and BRAT diet for now.

On 1/22/25 at 1002 hours. an interview was conducted with the Service Director of IM. The Service Director of IM was asked what was expected to be done if an NP placed an order in the consultation reply note, but it was not transcribed into the patient's medical record as an order. The Service Director of IM was asked if a recommendation was an order or simply a recommendation for care. The Service Director of IM stated the consultation reply was for orders and providers did not recommend but gave orders for the nursing staff to follow. The Service Director of IM stated all reply notes were to be reviewed by the nursing staff. The Service Director of IM stated if the NP did not place the order, but did place it in their reply note, the nurse was expected to phone the provider and ask them if they wanted it. The Service Director of IM stated the nurses were expected to read the reply notes to the nursing requests, follow-up. and call the provider if they had a concern about an order.

On 1/22/25 at 1406 hours, an interview and concurrent review of Patient 14's medical record was conducted with the Director of Quality. The Director of Quality verified the hospital's P&P related to transcribing physician's orders did pertain to this patient. The Director of Quality was asked to show the transcribed order for the NP order in the consultation reply note on 12/6/24, ordering Patient 14 to be ordered Imodium every 6 hours as needed and to be placed on a BRAT diet. The Director of Quality reviewed the MAR, nutrition notes, nursing progress notes, and provider's orders and verified the order had only been transcribed with the Imodium being ordered, but not the BRAT diet. The Director of Quality verified no follow-up phone call or clarification had been documented by the nursing staff in Patient 14's medical record.

On 1/22/25 at 1408 hours, an interview and concurrent record review was conducted with the Nurse Educator. The Nurse Educator stated the nursing staff was expected to read the provider's consultation reply notes. The Nurse Educator stated if an order was unclear, the nurse was expected to call the provider who wrote the order and get clarification, document the clarification, and act accordingly. The Nurse Educator stated the verbiage recommendation for both the medication, Imodium and the BRAT diet was confusing and required further follow up with the provider. The Nurse Educator stated the expectation was to follow the hospital's P&P. The Nurse Educator stated the rationale for calling the provider was to ensure the patient received the intended treatment.

Based on interview and record review, the hospital failed to ensure the P&P for Infection Prevention and Control was implemented when the list of patients monitored for the reported signs and symptoms of nausea, vomiting, and diarrhea was not completed. This failure posed an increased risk for the spread of and exposure to communicable organisms to vulnerable patients and staff.

Findings:

Review of hospital's P&P titled Surveillance Methods dated October 2024 showed the following:

* There is a written plan describing the type of surveillance carried out to monitor the rates of hospital-acquired infections, the system used to collect and analyze data, and activities to prevent and control infection.

* Various methods used to identify infections of the patients include:

- Screening patients on admission.

- Chart review, including microbiology, serology, and radiology result, as well as the other diagnostic studies

- Review of laboratory results.

- Review of pharmacy reports.

- Review and input from physicians and other health care personnel.

- Information from admitting and census sheets.

* Approved criteria are used to determine whether infections identified are community acquired or hospital acquired.

* The Infection Preventionist gathers pertinent data when a hospital acquired infection is suspected from the diagnosis by the physician, physician order of antibiotics or antiviral, positive culture result, and or observation of signs and or symptoms by nursing staff.

- All pertinent data is recorded, including but not limited to date of admission, procedure performed, lab results, and date of onset of infection following the National Healthcare Safety Network (NHSN) and McGeer criteria in the absence of clear guidelines from NHSN.

- Summaries are reviewed at the ICC meetings.

- Any unusual pattern or trend specific infection that requires input from the ICC meeting will be brought to the meeting for review.

* Surveillance Method: Cluster or outbreak investigations will become the immediate top priority at any time an unexpected occurrence or frequency of infections become evident. Indicators for such increased incidence may include reports of a particular organism, service, site, or ward. Examples may be clustering of any infection from specific unit or even from all units.

Review of the hospital P&P titled Communication of Infection Control Information dated October 2024 showed in part:

- The Infection Control Preventionist is responsible for managing the infection control program. He or she is responsible for surveillance, monitoring and reporting of infection control issues, concerns, and information to appropriate individuals, departments, and or agencies.

- Disseminate information to staff results of surveillance, recommended changes, and enforcement of standards, through in-services, orientation, and education, posters, newsletters, email updates or personal counseling.

- The Department heads share infection control information, issues, concerns through their scheduled staff meeting, or personal counseling.

- Staff and personnel are responsible for bringing to infection control coordinator and their department heads, infection control issues of non-compliance to standard of care. They are responsible for reporting exposure incidents, possible outbreaks situation, personal illnesses or diseases that may constitute an infection or communicable condition. They are to inform Infection Control Department if a patient is placed in isolation precautions.

On 1/14/25 at 1345 hours, an interview was conducted with the CNO. The CNO was asked who the Infection Control Preventionist was. The CNO stated the hospital had contracted services for infection control and prevention and she was the Infection Control contact person for the hospital. The CNO was asked if there was reported outbreak of C-diff or food poisoning. The CNO stated there was no reported food poisoning; however, the staff had reported nausea, vomiting, and diarrhea. She did not remember specific date, but she remembered a specific person who was Patient 1.

a. On 1/14/25 at 1425 hours, Patient 1's closed medical record was reviewed with the CNO. Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 12/2/24 and discharged on 12/16/24.

Review of the Nursing Progress Notes dated 12/4/24 at 1859 hours, showed Patient 1 had several episodes of watery light brown foul-smelling diarrhea during the late afternoon. Imodium was given with little effect. Patient 1 also complained of generalized abdominal pain, bloating, and some mild nausea. Patient 1's abdomen was distended but soft. NP 1 was notified, and Patient 1 would be sent out for medical evaluation. The BLS transportation would be arranged for the patient to go to the nearest ER.

Review of the Acute Nursing Progress Note dated 12/4/24 at 2000 hours, showed Patient 1 would be sent out to a hospital for assessment of uncontrolled diarrhea.

b. Review of the medical records for Patients 2, 3, 4, 5, 6, and 7 showed the following:

* Patient 2 received Zofran 4 mg po once on 12/5/24 at 2027 hours. The RN Progress Note showed on 12/6/24 at 0037 hours, the patient complained of nausea and vomiting started earlier in the day. The Consultation Request to NP 1 showed on 12/6/24 at 0033 hours, the patient reported nausea and vomiting since earlier in the day. NP 1's consultation reply showed on 12/6/24, the NP recommended Zofran for nausea and vomiting and clear liquid diet; and the diagnosis was acute nausea and vomiting and acute diarrhea.

- Patient 3 received Zofran 4 mg po on 12/5/24 at 2344 hours and 12/6/24 at 1251 hours. On 12/6/24 at 0038 hours, the RN consulted NP 1 for the patient's complaint of nausea and vomiting since earlier in the day. NP 1 consultation reply showed on 12/6/24 at 0812 hours, to give the patient Zofran with Imodium every 6 hours as needed and recommended clear liquid diet and the diagnosis was acute nausea, vomiting, and acute diarrhea.

- Patient 4 received Zofran 4 mg po on 12/6/24 at 0013 hours. On 12/7/24 at 0017 hours, the RN consulted NP 1, the patient endorsed feeling bloated and experienced nausea and vomiting for the past 24 hours; however, there was no reply from NP 1.

- Patient 5 was given Zofran 4 mg po on 12/6/24 at 1152 hours, 12/7/24 at 0150, 0938, and 1628 hours; and loperamide 2 mg po on 12/6/24 at 1507 and 2130 hours and on 12/7/24 at 0750, 0937, and 1631 hours. The RN placed a consolation request to NP 1 on 12/6/24 at 0043 hours, for patient's complaint of nausea and vomiting since earlier in the day. NP 1's Consultation Reply dated 12/6/24 at 0748 hours, showed to give Zofran as needed for nausea and vomiting and recommend clear liquid diet and the diagnosis was acute nausea and vomiting.

- Patient 6's medical record showed on 12/4/24 at 0648 hours, the LVN placed a consultation request to a medical physician for patient's complaint of diarrhea. NP 1 consultation reply dated 12/4/24 at 0940 hours, showed to give Imodium 2 mg every 8 hours as needed for 3 days, and the diagnosis was acute diarrhea. On 12/9/24 at 0800 hours, RN's Progress Note showed Patient 6 was experiencing diarrhea and as per the NP, to place Patient 6 on contact Precaution. The staff encouraged the patient to follow precautions and to stay in the room. The CNO was asked about Patient 6's contact precaution. The CNO stated Patient 6 was placed on contact precaution for diarrhea as per the telephone order. The staff would put a sign on the door for specific type of isolation. For Patient 6's contact isolation was the use of gown, gloves, and hand hygiene. The CNO was asked when the contact isolation was discontinued. The CNO stated as per the RN's Progress Note on 12/13/24 at 1200 hours, the RN spoke to NP 1 and discontinued the contact isolation as a telephone order.

- Patient 7's medical record showed on 12/4/24 at 1242 hours, the patient was given Bentyl 20 mg for abdominal cramps. On 12/8/24 at 2043 hours, the RN sent the Consultation Request to a medical physician for the patient requested to be seen, experienced diarrhea as of today. However, there was no reply from the medical physician.

c. On 1/22/25 at 0845 hours, review of the medical records for Patients 11, 12, and 13 was conducted with the Nurse Educator.

- Patient 11's medical record showed on 12/5/24, the patient received Zofran 4 mg po at 0352 hours for nausea and refused at 1042 hours. The RN Progress note dated 12/5/24. showed the patient complained of nausea and vomiting; however, the patient refused Zofran as the medication made her vomit after she took the medication.

- Patient 12's medical record showed on 12/7/24 at 1422 hours, the patient was given Zofran 4 mg po for nausea and vomiting; and was reassessed as not effective. On 12/8/24 at 0914 hours, the RN Progress Note showed Patient 12 refused the 0900 hours medications, including Lexapro and gabapentin due to nausea and diarrhea.

- Patient 13's medical record showed on 12/5/24 at 1819 hours, the RN sent a consultation request to NP 1 for patient's complaint of mild diarrhea. On 12/6/24 at 1105 hours, the patient was given Imodium 2 mg po for diarrhea as needed. NP 1's Consultation Reply dated 12/6/24 at 0752 hours, showed to give the patient Imodium every 6 hours as needed and recommend clear liquid diet.

On 1/16/25 at 1308 hours, a telephone interview was conducted with the Infection Control Preventionist and Associate Infection Control Preventionist. The Associate Infection Control Preventionist was asked if the hospital had reported incidence of patients who had nausea, vomiting, and diarrhea during 12/4 to 12/9/24. The Associate Infection Control Preventionist stated there were patients reported during the 12/4 to 12/9/24 but could not recall the specific date. The Associate Infection Control Preventionist stated there was no outbreak but had clusters of patients who had the reported symptoms of nausea, vomiting, and diarrhea; there was no trends, no cohorting, no verifiable cause of symptoms. There was no test that turned out to verify it was an infectious outbreak. From the time they were informed, they started monitoring the symptoms and collaborating with the nursing team's report of symptoms. The Associate Infection Control Preventionist was asked what intervention was done during the monitoring. The Associate Infection Control Preventionist stated they had the EVS to monitor cleanliness of the environment, they used glogerm and immediately once they got the report, the EVS cleaned with bleach to prevent potential spread.

Review of the List of Patients monitored for the reported sign and symptom of nausea, vomiting. and diarrhea showed five patients exhibited the symptoms on 12/4/24 and one patient exhibited the symptom on 12/5/24. The surveillance report was undated and there was no documented evidence of the intervention or education provided to staff or the EVS.

On 1/16/25 1505 hours, interview was conducted with the Director of Quality. The Director of Quality was asked about the Infection Control Monitoring for the symptoms reported to the Infection Control. The Director of Quality stated there were only few patients listed on the monitoring sheet. The Director of Quality stated this happened when the staff did not report to the administration what was going on in their units.

On 1/21/25 at 0917 hours, a follow-up telephone interview was conducted with the Infection Control Preventionist and the Associate Infection Control Preventionist. The Associate Infection Control Preventionist was asked for the documentation of what was done during the visit at the hospital for monitoring and intervention for the six patients reported with nausea, vomiting, and diarrhea. The Associate Infection Control Preventionist stated the hand hygiene and PPE rounds was documented; if there was concern, it was corrected on the spot; if not corrected, they spoke to the staff. There was no clear cut with the patients ' reported symptoms. The EVS was educated about disinfection and contact time for the bleach. The Associate Infection Control Preventionist stated they checked with the nursing staff to follow up if there were other patients with reported symptoms and there were no additional cases reported. However, there was no documented evidence of the education and intervention performed during the visit. The Associate Infection Control Preventionist was informed there were patients with nausea, vomiting, and diarrhea with the same symptoms of nausea, vomiting and diarrhea; however, these patients were not included on their surveillance list. The Associate Infection Control Preventionist was asked if all the staff were informed of the purpose of their presence at the hospital and if they communicated with the physicians. The Associate Infection Control Preventionist stated they informed the supervisors and the staff; however, they did not meet with the night shift staff.

On 1/22/25 at 1430 hours, an interview was conducted with the Director of Quality and Nurse Educator. The Nurse Educator was asked if he was aware of the Infection Control's presence in the hospital for the patients reporting of nausea, vomiting, and diarrhea. The Nurse Educator stated he heard from the Nurse Manager that there was GI issue going around. The Nurse Educator stated he did not know the Infection Control was at the hospital to address the issue. The Director of Quality was asked how the staff would know the Infection Control's presence at the hospital. The Director of Quality stated the Infection Control reported to the CNO, the Nurse Educator would not know the Infection Control's presence at the facility. The Director of Quality was asked how the monitoring was done for one day on the list. The Director of Quality stated they did not have other reported patients; they had only what was on the list.

The findings were share with the CNO and Director of Quality.