Huntington Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Patients’ Rights was met as evidenced by: 1. The facility failed to ensure the timely completion of one of 31 sampled patient’s (Patient 10) Condition of Admission (COA, a contract that outlines the patient’s obligations to the hospital, such as paying for services, providing informed consent (A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment), and understanding the hospital’s arrangements) form, in accordance with the facility’s policy and procedure regarding “Condition of Admission.” This deficient practice had the potential for Patient 10 and/or Patient 10’s designated representative not being able to fully understand and exercise their rights as patient, which may lead to Patient 10’s and/or Patient 10’s designated representative’s inability to effectively make decisions regarding own care and treatment in the facility. (Refer to A-0117) 2. The facility failed to ensure one of 31 sampled patients (Patient 13) was involved in the development and implementation of his (Patient 13) plan of care (a structured document that outlines the actions and interventions needed to address a patient’s health or personal care needs) to ensure that Patient 13 received adequate pain management during repositioning (moving a patient into a different position to redistribute pressure from a particular part of the body) activities, in accordance with the facility’s “Pain Management” and “Interdisciplinary Plan of Care” policy and procedure. This deficient practice caused Patient 13 to feel unnecessary pain during routine repositioning and had the potential to increase anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), sensitivity to pain, and mistrust in caregivers. This deficient practice also had the potential for untreated pain that could worsen Patient 13’s existing conditions, slow recovery, hinder mobility (the ability to move freely), and worsen bedsores (also known as pressure ulcers, are areas of skin damage that develop when pressure is applied to the same area of the body for an extended period) and reduced quality of life. (Refer to A-0130) 3. The facility failed to ensure its staff verified that the informed consent process (a process in which a health care providers educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) was completed for one of 31 sampled patients (Patient 3), in accordance with the facility’s policy and procedure regarding informed consent prior to a surgical procedure (Incision and Drainage [I&D, a minor surgical procedure that releases pus or pressure that builds up under the skin]), when there was no informed consent form obtained and signed by Patient 3 for a bedside procedure performed on 12/16/2024. This deficient practice had the potential to result in the physician not providing necessary information including the risks and benefits of a surgical procedure to Patient 3 and allows Patient 3 to make the informed decision. (Refer to A-0131) 4. The facility failed to provide physical privacy for one of 31 sampled patients (Patient 4) in accordance with the facility’s policy and procedure regarding patient’s rights, when the facility did not provide a privacy curtain in Patient 4’s room. This deficient practice resulted in Patient 4’s privacy rights not being respected as people could see Patient 4’s activities such as dressing, receiving medical treatment and nursing treatments. (Refer to A-0143) 5. The facility failed to ensure patient safety when the facility did not document a patient’s adverse drug reaction (unintended, harmful events attributed to the use of medicines) to the medication Ativan (a benzodiazepine, commonly prescribed for anxiety [characterized by excessive fear, worry, and nervousness] and sedation [a state of drowsiness and relaxation]) for one of 31 sampled patients (Patient 27) during their (Patient 27’s) first admission at the facility on December 2020, in accordance with the facility’s policy and procedure regarding “Adverse Drug Reactions.” This deficient practice in documentation resulted in Patient 27 receiving Ativan again during a subsequent admission in December 2023. Consequently, Patient 27 experienced another negative adverse drug event associated with Ativan, including excessive sedation, further compromising Patient 27’s health and recovery. (Refer to A-0144) 6. The facility failed to ensure one of 31 sampled patients (Patient 5), had proper documentation regarding the use of four siderails or evidence indicating that Patient 5 specifically requested all four side rails to be raised while in bed. There was also no physician order indicating the use of all four siderails. This deficient practice had the potential to restrict Patient 5’s freedom of movement and increase the risk of injury or harm due to potential entrapment, entanglement, or falls from a greater height should Patient 5 attempt to exit the bed. (Refer to A-0161) 7. The facility failed to ensure nursing staff obtained a physician order (orders written by physicians to direct care and treatment) for restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), in a timely manner, for one of 31 sampled patients (Patient 7), in accordance with the facility’s policy and procedure regarding restraints, when four (4) side rails were raised to prevent Patient 7 from getting out of bed. This deficient practice had the potential for increased risk of injury or harm due to potential entrapment, entanglement, or falls from a greater height should Patient 7 attempt to exit the bed. (Refer to A-0168) 8. The facility failed to ensure nursing staff performed and documented restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) monitoring every two (2) hours for one of 31 sampled patients (Patient 2), in accordance with the facility’s policy and procedure regarding restraints, when there was no documented restraints monitoring for eight (8) hours on 12/17/2024 from 6 a.m. to 2 p.m. This deficient practice had the potential to put Patient 2 at risk for skin breakdown (damage to the skin and underlying tissue, usually caused by prolonged pressure which restricts blood flow to the area) and needs including hydration (the process of ensuring a patient has enough fluids in their body by drinking water and consuming foods with high water content) not being met while under restraints. (Refer to A-0175) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment, potentially placing patients at risk for a delay in care and treatment, injury, and/or death.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to provide a competent Registered Nurse (trained in accessing a central line) for one of 31 sampled patients (Patient 1), to access Patient 1’s Hickman central line (a type of central venous catheter [long, flexible tube inserted into a large vein to provide access to the heart] inserted into vein under the collarbone and tunneled under the skin of the chest wall) in a timely manner, in accordance with the facility’s policy and procedure regarding central venous catheter and access devices, when there was a physician order to access Patient 1’s Hickman central line on 11/25/2024. This deficient practice resulted in Patient 1’s Hickman central line not accessed until the next day 11/26/2024 and caused delay in medication administration which included an ordered Dilaudid (type of opioid to treat severe pain) Patient Controlled Analgesia (PCA, a pain management method that allows patients to control when they receive pain medication by pressing a button from a machine). (Refer to A-0392) 2. The facility failed to: 2.a. Ensure one of 31 sampled patients (Patient 13), had a consistent wound care documentation and assessment completed and the appropriate wound region identified and documented correctly, in accordance with the facility’s policy and procedure regarding “Wound Care Assessment & Treatment” and “Documentation.” This deficient practice could result in improper wound care management for Patient 13, potentially causing delayed healing, an increased risk of infection, a worsening of the wound condition, and subsequent health complications. (Refer to A-0395) 2.b. Ensure the PICC (Peripherally Inserted Central Venous Catheter, nurses who are specialized in central line care) team performed proper assessment and accessed the central line catheter (CVC, long, flexible tube inserted into a large vein to provide access to the heart), in a timely manner, for one of 31 sampled patients (Patient 1) per physician’s order. This deficient practice resulted in the delay of care when Dilaudid (type of opioid to treat severe pain) PCA (PCA, a pain management method that allows patients to control when they receive pain medication by pressing a button from a machine), was not administered on time due to delay in accessing and utilizing Patient 1’s central line catheter. (Refer to A-0395) 3. The facility failed to: 3.a. Ensure Nursing staff developed and maintained a current nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 31 sampled patients (Patient 29), for Influenza A (a contagious viral infection of the respiratory tract that can cause fever, cough, sore throat, and potentially severe complications in vulnerable populations) and dialysis (dialysis, a medical procedure to remove waste products and excess fluids from the blood when the kidneys are no longer functioning adequately), in accordance with the facility’s policy regarding nursing care plans. This deficient practice had the potential for Patient 29’s needs, risks and treatment goals not being met, negatively affecting Patient 29’s effectiveness of care and treatment outcomes. (Refer to A-0396) 3.b. Implement and revise interventions in the pain care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 31 sampled patients (Patient 13), in accordance with the facility’s “Interdisciplinary Plan of Care” policy and procedures. This deficient practice resulted in Patient 13 experiencing pain when being repositioned every two hours, leading to heightened discomfort and emotional distress. This persistent pain can also limit Patient 13’s ability to move and refusal to be moved, resulting in decreased physical activity and potential complications such as muscle atrophy (wasting or thinning of muscle mass) and worsening pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time), negatively impacting Patient 13’s quality of life. (Refer to A-0396) 4. The facility failed to ensure that the clinical alarms for telemetry monitor (a medical device that continuously monitors the heart activity, and/or oxygen saturations [the amount of oxygen in the blood]) were appropriately set, according to the facility’s “Cardiac Monitoring Guidelines and Clinical Alarm Management” policy and procedure, for two of 31 sampled patients (Patients 14 and Patient 15). This deficient practice had the potential to delay the detection of life-threatening changes. For Patient 14, this could have led to uncontrolled high blood pressure, increasing the risk of stroke (occurs when blood flow to the brain is interrupted and causing brain cells to die) or other cardiac (relating to the heart) emergencies. For Patient 15, improper oxygen monitoring can lead to undetected hypoxia (low oxygen levels), which can cause brain damage or death. (Refer to A-0398) 5. The facility failed to ensure Nursing personnel reported a suspected adverse drug reaction (unintended, harmful events attributed to the use of medicines) to Ativan (Ativan, a benzodiazepine [class of medication] used to treat anxiety) and/or Benadryl (Benadryl, an antihistamine [class of medication] used to treat allergic reactions, reduce itching, and provide sedation) for one of 31 sampled patients (Patient 27), in accordance with the facility’s policy and procedure regarding adverse drug reaction reporting. This deficient practice had the potential to compromise Patient 27’s health and recovery due to delayed recognition and management of adverse drug reactions and repeated exposure to medications that Patient 27 may be allergic to. (Refer to A-0398) 6. The facility failed to ensure Nursing personnel entered the isolation precautions (infection control measures designed to prevent the spread of contagious diseases, such as placing the patient in a designated isolation room and using protective equipment like masks and gowns) information for Influenza A (a contagious viral infection of the respiratory tract that can cause fever, cough, sore throat, and severe complications in vulnerable populations) into the Patient Care System (PCS, an electronic system used to document and communicate patient care needs and treatment plans) for one of 31 sampled patients (Patient 29), in accordance with the facility’s policy and procedure regarding “Initiation of Infection Control Precautions for Staff and Visitors.” This deficient practice had the potential to delay the implementation of infection control measures for Patient 29, thereby increasing the risk of spreading Influenza A to other patients, visitors, and staff due to uncommunicated isolation precautions. (Refer to A-0398) 7. The facility failed to implement complete seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness [a state where a person is not aware of their environment or themselves]) precautions for one of 31 sampled patients (Patient 21), when there was no readily available suction set-up (a medical device that essentially acts like a vacuum cleaner for a person’s airway, removing excess mucus, saliva, blood, or other fluids that they can’t clear on their own, helping them breathe properly, especially when they are unconscious or unable to cough effectively) for Patient 21 in the event of a seizure episode, in accordance with the facility’s policy and procedure regarding “Seizure Precautions and Guidelines.” This deficient practice had the potential for Patient 21 to aspirate (inhale) during a seizure activity, which may result in complications such as aspiration pneumonia (infection of the lung) and may prolong Patient 21’s recovery. (Refer to A-0398) 8. The facility failed to ensure side rails were padded for one of 31 sampled patients (Patient 2) for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness) precaution, in accordance with the facility’s policy and procedure regarding “Seizure Precaution and Guidelines.” This deficient practice had the potential to result in Patient 2 getting injured when having seizures. (Refer to A-0398) 9. The facility failed to ensure Nursing staff completed the pre-procedure check list (steps taken to verify the patient, procedure, and consent form) and follow the time-out (a pause before a medical procedure to confirm that the correct patient, procedure, and site are being used) process for two of 31 sampled patients (Patient 2 and Patient 3), in accordance with the facility’s policy and procedure regarding “Universal Protocol (a set of standardized procedures in healthcare, primarily used in surgical settings, designed to prevent wrong-site, wrong-procedure, and wrong-patient surgeries by requiring a pre-procedure verification process, surgical site marking, and a “time-out” before starting the procedure). This deficient practice had the potential to result in Patient 2 and Patient 3 having the wrong procedure, wrong site and/or having the procedure without informed consent (a process in which a health care providers educates a patient about the risks, benefits, and alternatives of a given procedure or intervention). (Refer to A-0398) 10. The facility failed to ensure Nursing staff followed the chain of command (provides a clear structure for reporting concerns, escalating issues, and making decisions related to patient care) to manage one of 31 sampled patient’s (Patient 1) pain, in accordance with the facility’s policy and procedure regarding “Chain of Command.” This deficient practice resulted in Patient 1 remaining in severe pain for 3.5 hours on 12/3/2024 and had the potential to result in Patient 1 not being able to move, talk or perform activities of daily living (basic self-care tasks that people perform everyday such as hygiene) due to severe pain. (Refer to A-0398) 11. The facility failed to ensure one of 31 sampled patient’s (Patient 13) prescribed medication, Desitin (medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and skin irritations), was administered in accordance with prescribed instruction. This deficient practice could result in improper wound care management for Patient 13, potentially causing delayed healing, an increased risk of infection, a worsening of the wound condition, and subsequent health complication. (Refer to A-0405) 12. The facility failed to ensure nursing staff gave pain medications, per physician order, for one of 31 sampled patients (Patient 3), in accordance with the facility’s policy and procedure regarding “Medication Use, Administration, Routes and High Alert Medications,” when Norco (opioid medication to treat and relieve pain) 5/325 milligrams (mg, a unit of measure) by mouth and Morphine (opioid medication to treat and relieve moderate to severe pain) 2 mg intravenous (IV - administered into a vein), were administered to Patient 3 at the same time. This deficient practice had the potential to overmedicate Patient 3 and put Patient 3 at risk for oversedation (excessive drowsiness) and respiratory distress (difficulty breathing). (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 31993 Based on interview, and record review, the facility failed to ensure the timely completion of one of 31 sampled patient’s (Patient 10) Condition of Admission (COA, a contract that outlines the patient’s obligations to the hospital, such as paying for services, providing informed consent [A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment], and understanding the hospital’s arrangements) form, in accordance with the facility’s policy and procedure regarding “Condition of Admission.” This deficient practice had the potential for Patient 10 and/or Patient 10’s designated representative not being able to fully understand and exercise their rights as patient, which may lead to Patient 10’s and/or Patient 10’s designated representative’s inability to effectively make decisions regarding own care and treatment in the facility. Findings: During a review of Patient 10’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/15/2024, the H&P indicated Patient 10 was admitted on 12/15/2024 for Acute Respiratory Failure (inadequate gas exchange in the lungs) and septic shock (a life-threatening medical condition where a severe infection causes a dangerously low blood pressure, leading to potential organ failure and requiring immediate medical attention). During a review of Patient 10’s Social Worker Notes, dated 12/15/2024, the notes indicated that Patient 10 had a Power of Attorney (a legal document that gives someone the authority to act on the patient’s behalf). During an interview on 12/16/2024 at 3:00 p.m. with Patient 10’s designated representative, Patient 10’s representative confirmed that she (Patient 10’s designated representative) had not signed Patient 10’s Condition of Admission (COA, a contract that outlines the patient’s obligations to the hospital, such as paying for services, providing informed consent [A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment], and understanding the hospital’s arrangements). During a concurrent interview and record review on 12/20/2024 at 12:15 p.m. with the Manager for Quality and Training Patient Access (MQTP), MQTP stated he (MQTP) reviewed Patient 10’s medical record and did not see a documentation regarding attempts to contact Patient 10’s representative or designated family member regarding completion of the COA when Patient 10 was admitted on 12/15/2024. During the same interview on 12/20/2024 at 12:15 p.m. with the Manager for Quality and Training Patient Access (MQTP), MQTP stated that Patient 10’s representative’s contact information was in Patient 10’s record on admission since Patient 10 came from a Skilled Nursing Facility (SNF, a place where people can temporarily live and receive medical treatment and rehabilitation after an injury or illness). MQTP said the Patient Access staff should have contacted Patient 10’s designated representative upon admission on 12/15/2024 regarding the COA. The COA was only completed on 12/19/2024 at 11:55 a.m. During a review of the facility’s policy and procedure (P&P) titled, “Conditions of Admission,” effective date 3/20/2021, the P&P indicated the Facility was “committed to informing each patient or appropriate authorized patient representative of the patient’s rights and obtain their consent to care and services in the conditions of admission (COA).” The P&P also indicated, “it is the responsibility of the patient access representative (PAR) to communicate with the patient or their representative when appropriate, to obtain an authorized consent evidenced by the patient signature on the condition of admission form.””

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure one of 31 sampled patients (Patient 13) was involved in the development and implementation of his (Patient 13) plan of care (a structured document that outlines the actions and interventions needed to address a patient’s health or personal care needs) to ensure that Patient 13 received adequate pain management during repositioning (moving a patient into a different position to redistribute pressure from a particular part of the body) activities, in accordance with the facility’s “Pain Management” and “Interdisciplinary Plan of Care” policy and procedure. This deficient practice caused Patient 13 to feel unnecessary pain during routine repositioning and had the potential to increase anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), sensitivity to pain, and mistrust in caregivers. This deficient practice also had the potential for untreated pain that could worsen Patient 13’s existing conditions, slows recovery, hinders mobility (the ability to move freely), and worsens bedsores (also known as pressure ulcers, are areas of skin damage that develop when pressure is applied to the same area of the body for an extended period) and reduced quality of life. Findings: During a review of Patient 13’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/7/2024, the “H&P” indicated Patient 13 had “past medical history of alcoholism (a chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking) and bedbound state (when someone is unable to get out of bed independently, requiring assistance to move around or change positions) who presents to the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) for evaluation of back pain ... He (Patient 13) reports pain localized to his back and reports a history of sciatica (pain that radiates into one or both legs).” The H&P further indicated Patient 13 had osteomyelitis (an infection in a bone) with extensive cellulitis (a deep infection of the skin caused by bacteria) to the back, limbs, and right heel with visible bone exposure. During an observation on 12/16/2024 at 3:41p.m., at the entrance hallway to 4 East (surgical unit, an area in the hospital where patients are cared for and treated before or after the surgery), screaming was heard from room ABC (Patient 13’s room). Inside, two staff members (Certified Nursing Attendant [CNA], an entry-level role that provides vital support to both patients and nurses) 1 and Registered Nurse [RN], nurse who has graduated from a college’s nursing program or from a school of nursing and has passed a national licensing exam) 4 were repositioning (moving a patient into a different position to redistribute pressure from a particular part of the body) Patient 13, who continued to scream during the procedure. During an interview on 12/16/2024 at 3:50 p.m., Patient 13 stated, “I have pain in both legs when they move me.” Patient 13 reported pain levels of 8/10 (on a scale of 0-10, with 0 representing no pain and 10 being the worst pain) to the legs and back during repositioning and cleaning. During an interview on 12/16/2024 at 3:45 p.m. with Registered Nurse (RN) 8 outside the corridor of Patient 13’s room, RN 8 stated that Patient 13 screamed each time staff repositioned Patient 13 due to pain. RN 8 indicated that Norco (a prescribed medication, a combination of hydrocodone [a drug used to treat moderate to severe pain] and acetaminophen [a drug used to relieve mild or chronic pain and to reduce fever] for pain relief) was administered five hours prior. RN 8 confirmed that since the medication for pain (Norco) was administered five hours ago, it (Norco) will not relieve Patient 13’s pain during repositioning. RN 8 further stated that repositioning should have been paused when Patient 13 exhibited signs of pain. RN 8 stated Patient 13 may be aware of the pain medication ordered for him, but RN 8 confirmed that intervention for pain management was not discussed with Patient 13. During a concurrent interview and record review on 12/16/2024 at 4:00 p.m. with the Nurse Manager (NM) 3, Patient 13’s Electronic Medical Record (EMR, a digital version of the paper charts in hospitals) titled, “Medication Administration Report (MAR, a report detailing the drugs administered to a patient),” dated 12/8/2024 through 12/16/2024, was reviewed. NM 3 confirmed that Patient 13 had orders for pain medication as follows: -Norco 10/325 mg (milliliters, a unit of measurement). one tablet every six hours as needed for severe pain (7-10). -Tylenol 650 mg. tablet as needed for any pain level greater than zero when the patient refused other analgesics (also called painkillers, are medications that relieve different types of pain). During the same interview on 12/16/2024 at 4:00 p.m. with the Nurse Manager (NM) 3, NM 3 stated that RN 8 administered one dose of the Norco 10/325 mg on 12/16/2024 at 10:02 a.m. (5 hours and 58 minutes) prior to repositioning Patient 13. NM 3 stated giving pain medication more than five hours before repositioning Patient 13 was not an adequate pain management. NM 3 stated that pain management should also align with patient-reported pain level. NM 3 stated, “Pain is what the patient says the pain is.” NM 3 further stated it was important to follow prescribed orders, and if the prescribed order was not adequate for pain relief, the physician should be consulted for better pain management prior to repositioning Patient 13. During a concurrent interview and record review on 12/19/2024 at 10:23 a.m. with the charge nurse (CN 1) for the 4 East unit, Patient 13’s wound photos in the “Emergency Department Provider Notes,” documented by MD 5, dated 12/7/2024, were reviewed. The ED provider notes of Patient 13’s wounds with photos were as follows: - A photo of the left foot and ankle showing denuded skin (a condition that results from the removal of the skin’s surface layers), reddened skin, and an open wound at the heel with bone exposure. The photo was labeled: Multiple wounds of the left lower extremity as well as the right heel. - A photo of the left hip and left back was labeled: Patient has raised erythematous (redness of the skin) rash on the left back. During the same interview on 12/19/2024 at 10:23 a.m. with Charge Nurse (CN) 1, CN 1 confirmed that Patient 13 also had a pressure injury (a localized damage to the skin and underlying soft tissue) to the sacral region (region at the bottom of the spine that lies between the spine and tailbone) that required turning and repositioning to provide wound care and application of medication twice a day. CN 1 stated Patient 13 must be repositioned and turned every two hours to prevent worsening of the wound. CN 1 stated the physician should be called to advocate for the patient (Patient 13) to have IV (medication administered directly into the vein) pain medication to effectively relieve pain as the patient (Patient 13) required repositioning every two hours. During an interview on 12/20/2024 at 10:40 p.m. with Medical Doctor (MD) 4, MD 4 stated that because the patient had multiple wounds and experienced pain during repositioning, nursing staff should assess the patient’s level of pain and preferences for pain relief and make the provider aware so IV medication for pain could be ordered, as IV medication can provide faster pain relief. MD 4 also confirmed that IV pain medication was appropriate for Patient 13. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care (IPOC),” dated September 2020, the P&P indicated, “Ensure that the nursing staff develops, and keeps current, a nursing plan of care for each patient. The nursing plan of care is part of the interdisciplinary plan of care (lPOC). Each patient will receive care based on an individualized lPOC in collaboration with the interdisciplinary team. Ensure the patient’s (or patient’s representatives) right to participate in the development and implementation of his or her plan of care, inpatient treatment/care plan, outpatient treatment/care plan, and/or discharge plan. Aspects of patient care, such as, teaching, interventions, referrals, discharge planning, follow-up, changes in plan, etc. are linked with the interdisciplinary plan of care. Planning care includes planning the patient’s care while in the hospital as well as planning for discharge to meet post-hospital needs. A nursing IPOC is developed based on assessing the patient’s needs upon admission from all available sources of assessment to develop a comprehensive picture of the patients’ condition (not solely those needs related to the admitting diagnosis) and develop-appropriate nursing interventions in response to those needs. Those sources may include: The Patient, the Patient’s family, other patient caregivers as applicable ...” During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated November 2022, the P&P indicated, “Pain is highly individual and variable and is one of the most feared aspects of illness, and one of the most common reasons for seeking healthcare interventions. The purpose of this policy is to provide guidelines for a collaborative interdisciplinary approach to pain management. The goals of pain management are: Relief from physical suffering Preservation or restoration of function Sustained quality of life Prevention of addiction Pain management is a shared responsibility between the patient, providers, and nursing ... B. Initial and ongoing assessment of pain ...An initial pain assessment is done on admission. It includes: Pain Goal: This is set by the patient as is developmentally appropriate ... Continuing Pain Assessment (after Admission/Arrival Pain Assessment): Shift Assessment, Type of Assessment {Assessment or Post-Intervention Reassessment, Pain Goal (required each shift and pm any changes), Sedation Score (required), Location (required each shift and pm any change), Pain Rating (required) ...” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights,” dated November 2023, the P&P indicated, “To identify each client’s rights while under treatment. Each client has all rights given to all citizens unless relieved of these rights by court action. Specifically, staff needs to assist in maintaining the client’s rights to confidentiality, privacy, and dignity. Individualized treatment that is appropriate to the client’s problems and needs ... Each client receives individualized treatment, including at least the following: ...The provision of an individualized treatment plan. The periodic review of the treatment plan. The active participation of the client and/or conservator in the planning of treatment. The provision of an adequate number of competent, qualified, and experienced professional clinical staff to implement the treatment plan and provide care ...” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for the Provision of Patient Care Services,” dated 9/1/2020, the P&P indicated, “Overview of Discipline-Specific Policies for Assessment and Reassessment ... Nursing; Assessment time frame: Demographic, physical assessment, and care planning assessment within 2 hours of admission in critical care areas and 8 hours of admission in non-critical care areas. RN analyzes data/prioritizes care. Re-Assessment Time Frame: Every shift and/or unit-specific, as well as pre- and post-treatment, including diagnosis, pre- & post-treatment, and response to treatments ...””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure its staff verified that the informed consent process (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention), was completed for one of 31 sampled patients (Patient 3), in accordance with the facility’s policy and procedure regarding informed consent prior to a surgical procedure (Incision and Drainage [I&D, a minor surgical procedure that releases pus or pressure that builds up under the skin]), when there was no informed consent form obtained and signed by Patient 3 for a bedside procedure performed on 12/16/2024. This deficient practice had the potential to result in the physician not providing necessary information including the risks and benefits of a surgical procedure to Patient 3 and allows Patient 3 to make the informed decision. Findings: During a concurrent observation and interview on 12/16/2024 at 3:58 p.m. with Registered Nurse (RN) 13 at Patient 3’s room, Patient 3 had a dressing covering the right lower leg. RN 13 stated Patient 3 had a bedside procedure earlier. During a review of Patient 3’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/15/2024, the H&P indicated, Patient 3 was admitted to the facility with diagnoses of diabetes (high blood sugar), right lower leg abscess (a pocket of pus formed in any part of the body) with cellulitis (an infection of the deeper layers of skin and the underlying tissue). The H&P also indicated Patient 3 required surgical evaluation for possible debridement (a medical procedure that removed damaged, dead or infected tissue) and drainage (the process of removing fluid from a wound). During a review of Patent 3’s “Incision and Drainage (I&D, a minor surgical procedure that releases pus or pressure that builds up under the skin) Procedure Note (procedure note, operative report completed by a surgeon),” dated 12/16/2024, the procedure note indicated, physician (MD 8) performed right leg necrotizing (dead) soft tissue infection with abscess incision and drainage. During an interview on 12/18/2024 at 10:28 a.m. with the Process Excellence Specialist (SRN), SRN stated there was no informed consent (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) form for the incision and drainage procedure done on 12/16/2024. SRN stated informed consent was required for every surgical procedure. During an interview on 12/19/2024 at 10:29 a.m. with the Nurse Manager (NM 1) of Surgical Units (a hospital ward where patients are cared and treated before and after surgery) 1 and 2, NM 1 stated informed consent was the process to make sure patient was aware of what procedure he or she was having and understand its risk and benefits. NM 1 said patient was required to sign the informed consent form when he or she was agreeable with the procedure. During an interview on 12/20/2024 at 8:33 a.m. with the Surgery Residency Program Director (MD 7), MD 7 stated MD 8 should have obtained an informed consent for the bedside incision and drainage procedure done on Patient 3 on 12/16/2024. MD 7 stated the team should make sure Patient 3 signed the informed consent form with the name of the procedure prior to the procedure. During a review of the facility’s policy and procedure (P&P) titled, “Informed Consent,” dated 10/2021, the P&P indicated, “the ‘Informed Consent’ ... the patient’s physician is responsible for providing the information the patient needs in order to make an informed decision and for obtaining the patient’s informed consent or refusal for the recommended procedure ... the hospital’s role in the informed consent process is to verify that the physician obtained the patient’s informed consent before the physician is permitted to perform the procedure ... the doctors will provide the procedures to be performed ... so the ‘Authorization for and Consent to Surgery, Care, Treatment, Special Diagnostic or Therapeutic Procedures’ consent form can be completed ... If the ‘Authorization and Consent to Surgery, Care, Treatment, Special Diagnostic or Therapeutic Procedure’ consent form has not been completed or the informed consent attestation is not documented in the medical record prior to the procedure, the nurse must contact the physician providing the service to obtain documentation. Non-emergency procedures will be delayed or canceled until the informed consent process had been completed ... Nursing verifies that an executed ‘Authorization for and Consent to Surgery, Care, Treatment, Special Diagnostic or Therapeutic Procedures’ form is in the record or completes the form using information provided by doctors in his or her orders and has the patient or a surrogate decision-maker sign the form. Any doubt or confusion expressed by the patient regarding the procedure or operation must be immediately referred to the treating physician. The patient will not be asked to sign the form until satisfactory clarification is supplied by the physician.””

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to provide physical privacy to one of 31 sampled patients (Patient 4) in accordance with the facility’s policy and procedure of patient’s rights when the facility did not provide a privacy curtain to Patient 4’s room. This deficient practice had resulted in Patient 4’s privacy rights not being respected as people could see Patient 4’s activities such as dressing, receiving medical treatment and nursing treatments. Findings: During a review of Patient 4’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/11/2024, the H&P indicated, Patient 4 was admitted to the facility with diagnoses of suicide (killing self) attempt and diabetes (high blood sugar). During a concurrent observation and interview on 12/16/2024 at 4:02 p.m. with Registered Nurse (RN) 13 outside Patient 4’s room in Surgical Unit (a hospital ward where patients are cared and treated before and after surgery) 1, the door was closed, and there was a glass window on the door. Through the glass window, Patient 4 was observed sitting in bed holding two pillows. There was a bedside sitter with the door closed. RN 13 stated Patient 4’s privacy was not respected because everyone passing by could see through the window to see what Patient 4 was doing. RN 13 also stated the staff should cover the window on the door to give Patient 4 some privacy. During an interview on 12/16/2024 at 4:10 p.m. with the Nurse Manager (NM 1) of Surgical Unit 1 and 2, NM 1 stated there should be a privacy curtain in Patient 4’s room to provide privacy for Patient 4. During a review of the facility’s policy and procedure (P&P) titled, “Patient Non-Discrimination, Rights and Responsibilities,” dated 8/2021, the P&P indicated, “You have the right to have your personal privacy respected.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure patient safety when the facility did not document a patient’s adverse drug reaction (unintended, harmful events attributed to the use of medicines) to the medication Ativan (a benzodiazepine, commonly prescribed for anxiety [characterized by excessive fear, worry, and nervousness] and sedation [a state of drowsiness and relaxation]) for one of 31 sampled patients (Patient 27) during their (Patient 27’s) first admission to the facility in December 2020, in accordance with the facility’s policy and procedure regarding “Adverse Drug Reactions.” This deficient practice in documentation resulted in Patient 27 receiving Ativan again during a subsequent admission in December 2023. Consequently, Patient 27 experienced another negative adverse drug event associated with Ativan, including excessive sedation, further compromising Patient 27’s health and recovery. Findings: During a review of Patient 27’s History and Physical (H&P, a comprehensive medical document that summarizes a patient’s medical history, current symptoms, and physical examination findings upon admission), dated 12/04/2020, the H&P indicated that Patient 27 was admitted due to hypertensive urgency (a medical condition characterized by a severe and sudden increase in blood pressure that requires prompt medical attention to prevent organ damage) and visual hallucinations (visual hallucinations, seeing objects, people, or shapes that are not actually present). The H&P further indicated Patient 27 had a Past Medical History (PMH, a record of a patient’s previous health conditions) of possible memory impairment (refers to difficulties in remembering information), white coat hypertension (a phenomenon where a patient’s blood pressure readings are elevated in a clinical setting but remain normal in other environments, often due to anxiety experienced during medical visits), and possible depression (a mental health disorder characterized by persistent feelings of sadness, loss of interest in activities, and a range of emotional and physical problems that can affect a person’s daily functioning). During a review of Patient 27’s medical record (MR) titled, “History and Physical (H&P),” dated 12/04/2020, the MR indicated that Patient 27 had no known medication allergies documented in the H&P. During further review of Patient 27’s medical record (MR) titled, “Medication Administration Record (MAR, a document that tracks all medications administered to a patient),” dated 12/05/2020, the MR indicated that on 12/05/2020, Patient 27 received 1 milligram (mg, a unit of measurement) of Ativan (lorazepam [Ativan], a medication used to treat anxiety [a feeling of fear and uneasiness) at 6:16 p.m. prior to undergoing a Magnetic Resonance Imaging (MRI, a medical imaging procedure that uses magnetic fields and radio waves to create detailed images of the brain) ordered by a neurologist (neurologist, a medical doctor specializing in the diagnosis and treatment of disorders of the nervous system, including the brain, spinal cord, and nerves) on 12/04/2020 for sedation (induces a state of drowsiness or relaxation) to be administered prior to the procedure. During further review of Patient 27’s medical record (MR) titled, “Nursing Note,” dated 12/05/2020, the MR indicated the following: -At 8:00 p.m. - “Patient (Patient 27) was disoriented, not making sense, and experiencing visual hallucinations (sensing things such as visions, sounds, or smells that seem real but are not). Registered Nurse (RN) expressed to Medical Doctor (MD) that Patient 27 was not safe for discharge. MD agrees to keep Patient 27 overnight.” -At 8:30 p.m. - “It was decided to move patient (Patient 27) closer to the nurses’ station for safety ... Patient (Patient 27) got tangled in a cord and fell. This incident was witnessed by an RN who was walking in patient’s (Patient 27) room to assist. Patient (Patient 27) was assessed, and no injury was noted. MD and patient’s (Patient 27) family were notified.” -At 10:50 p.m. - “Patient (Patient 27) was disoriented, agitated (feeling of restlessness and irritability), wandering the halls, unsteady at times, attempting to enter other patients’ rooms, and trying to find the exit ... Patient (Patient 27) was placed on 4-point soft restraints (4-point soft restraints, a type of physical restraint that secures a patient’s arms and legs to limit movement). MD was consulted, and an order for restraints was received.” During a review of Patient 27’s medical record (MR) titled, “Initial Psychiatric Consultation (an evaluation conducted by a psychiatrist to assess a patient’s mental health status), dated 12/06/2020, the MR indicated the following: -“ ...Per the nurse on duty this evening, the patient (Patient 27), post (after)-Ativan for MRI, became more psychotic (a mental state characterized by a loss of contact with reality, including delusions (false beliefs that are firmly held despite clear evidence to the contrary) and hallucinations), experiencing sundowning (a pattern of increased confusion and agitation that occurs in the late afternoon and evening hours), and confused. This condition is slowly resolving; however, in the evening, Patient 27 appears to sundown and become confused ...” -“Diagnosis of MDD (Major Depressive Disorder, a mood disorder characterized by persistent feelings of sadness and loss of interest), single severe, with psychotic features, with recent delirium (an acutely disturbed state of mind characterized by restlessness, illusions, and incoherence) secondary to Ativan, with 12-24 hours of confusion/agitation/wandering that is now resolved.” During a review of Patient 27’s medical record (MR) titled, “Discharge Summary,” dated 12/07/2020, the MR indicated that the discharging physician (MD 1) documented that Patient 27 “was agitated by Lexapro (Lexapro, an antidepressant used to treat depression and anxiety disorders) and the Ativan made them (Patient 27) worse.” During a review of Patient 27’s History and Physical (H&P), dated 11/30/2023, the H&P indicated that Patient 27 was admitted to the facility on 11/30/2023 (second admission after 12/04/2020) due to a fall (an incident in which a person unintentionally comes to rest on the ground or a lower level) at home and elevated troponin (elevated troponin, an increased level of troponin in the blood indicative of heart muscle injury) with no symptoms. The H&P further indicated that Patient 27 had a Past Medical History (PMH) of Alzheimer’s (Alzheimer’s, a progressive disease that causes memory loss and cognitive decline), depression, white coat hypertension, and anxiety. During a review of Patient 27’s medical record (MR) titled, “Allergy Review History (a detailed record of a patient’s known allergies and adverse reactions to medications), dated 11/30/2023, the MR indicated that on 11/30/2023, an allergy to Xanax (a medication containing alprazolam, used to treat anxiety and panic disorders) with a recorded unspecified reaction (unspecified reaction, an allergic response where the specific symptoms or type of reaction are not documented or unavailable) was documented in Patient 27’s electronic medical record (EMR, digital version of paper charting). During a review of Patient 27’s medical record (MR) titled, “Physician’s Orders,” dated 12/02/2023, the MR indicated that 1 mg of Ativan IV push (Ativan IV push, an intravenous administration of lorazepam given rapidly through a vein to provide immediate relief) was ordered for Patient 27 on 12/02/2023 at 6:36 p.m., to be administered every 12 hours as needed for agitation and anxiety. During a review of Patient 27’s medical record (MR) titled, “Allergy Review History,” dated 12/2/2023, the MR indicated that Patient 27’s primary nurse reviewed Patient 27’s allergy record on 12/2/2023 at 6:35 p.m. During a review of Patient 27’s medical record (MR) titled, “Warning Override History for Lorazepam (Ativan) injection 1 mg,” dated 12/02/2023, the MR indicated that on 12/02/2023 at 6:36 p.m., the warning for allergy/contraindication (a condition in which a medication should not be used due to a documented allergy or other medical reason) for administration of Ativan (Ativan, a benzodiazepine medication used to manage anxiety and seizures) due to a documented allergy to alprazolam (Xanax, a benzodiazepine used to treat anxiety and panic disorders) was overridden (bypass a warning) by a primary nurse (Patient 27’s nurse) by the order of a physician (MD 1). The MR contained the following comment: “Physician (MD 1) aware [of an allergy/contraindication], Benadryl (an antihistamine medication used to treat allergic reactions and provide sedation) ordered.” During a review of Patient 27’s Medical Administration Record (MAR), dated 12/2/2023, the MAR indicated that on 12/2/2023 Patient 27 was administered 1 mg of Ativan at 7:57 p.m. During a review of Patient 27’s medical record (MR) titled, “Physician-Internal Medicine Progress Note,” dated 12/03/2023, the MR indicated that the physician (MD 1) documented the following: “[Patient 27] agitated last night, got Ativan, and now over-sedated” (a condition where a patient experiences excessive sedation, potentially causing decreased responsiveness, slowed breathing, and impaired motor function). “Discontinue Ativan.” During a review of Patient 27’s medical record (MR) titled, “Physician-Internal Medicine Progress Note,” dated 12/04/2023, the MR indicated that the physician (MD 1) documented the following: “[Patient 27] more awake. Nearer at baseline. It’s Ativan ...” During a review of Patient 27’s medical record (MR) titled, “Discharge Summary,” dated 12/05/2023, the MR indicated the following: Patient (Patient 27) had an allergy to Xanax on the MAR (Medication Administration Record, a document that tracks all medications administered to a patient) but was given a small amount of Ativan due to agitation. The patient was agitated and almost fell out of bed. The agitation caused by benzodiazepines (a class of psychoactive drugs used to treat anxiety, insomnia (difficulty sleeping), seizures (a temporary episode of abnormal electrical activity in the brain that causes physical and mental changes), which can also cause side effects like sedation, confusion, and agitation) is quite severe, leading to confusion, agitation, and almost comatose-like symptoms (a state of deep unconsciousness). No benzodiazepines whatsoever ...” During an interview on 12/18/2024 at 10:15 a.m. with the Medication Safety Pharmacy Compliance officer (MSPC, a pharmacist responsible for ensuring compliance with pharmacy regulations, medication safety, and adherence to organizational policies), the MSPC reviewed Patient 27’s “Warning Override History for Lorazepam (Ativan) injection 1 mg” and stated the following: -The ordering user for 1 mg of Ativan was [Patient 27’s] registered nurse (RN), and the ordering provider was medical doctor (MD 1). It was a telephone order with readback, signed on 12/02/2023. The allergy/contraindication warning was overridden by the nurse due to a comment: “MD 1 aware, PRN (PRN, an abbreviation for “pro re nata,” meaning “as needed”) Benadryl ordered.” Every medication ordered comes into a queue (a system where medication orders are temporarily held for review by the pharmacy before being dispensed) for the pharmacy to review. There was an allergy contraindication alert, but it was bypassed because of what the physician said and as documented by the nurse. The pharmacist released the order for 1 mg Ativan after reviewing the order and the comment. During the same interview on 12/18/2024 at 10:15 a.m. with the Medication Safety Pharmacy Compliance Officer (MSPC), the MSPC reviewed Patient 27’s medical records and stated the following: Patient 27’s adverse reaction to Ativan administration in December 2020 was not entered under the Allergy section in the patient’s (Patient 27) electronic medical record. Had this information been entered, it would have transitioned to the new electronic medical record platform when the patient (Patient 27) was admitted (back) to the facility in 2023. During an interview on 12/18/2024 at 3:20 p.m. with medical doctor (MD 1), MD 1 stated the following after reviewing Patient 27’s records from the first admission to the facility in 2020 [11/30/2020]: “In the discharge summary, I documented that the patient (Patient 27) got worse after receiving Ativan. The patient (Patient 27) was not allergic to Ativan then [in 2020].” MD 1 also stated, “Documentation of allergies and drug reactions should be done by nurses. It’s their job to document this information. I don’t typically document reactions to medications [in the allergy section] in medical records.” During the same interview on 12/18/2024 at 3:30 p.m. with medical doctor (MD 1), MD 1 stated the following: “Since the facility transitioned to a different platform for electronic medical records a few years ago, there is no way to read previous records. The information available for review is only what is accessible through the new platform. I reviewed the allergy for Xanax (during Patient 27’s admission on 11/30/2023), but there was no reaction documented for Ativan. I ordered Benadryl to be administered in case there is a reaction. I think the patient (Patient 27) was very agitated when the nurse called me for orders, and I wanted to use the least restrictive measures (interventions that limit a patient’s freedom as minimally as possible while ensuring safety and addressing clinical needs) possible, so I ordered Ativan and Benadryl.” The MD 1 also stated, “If there was a documented allergy to Ativan and it was flagged, I would have tried a different medication [not Ativan].” During an interview on 12/19/2024 at 1:02 p.m. with the Chair of Medicine (COM), the COM stated the following: “Everybody in the facility should be aware of the process of assessing a patient’s allergies. It starts with the emergency room; the intake person pulls up the information and clarifies it. Nurses perform medication reconciliation (the process of comparing a patient’s current medications to their medication orders to identify and resolve discrepancies), and as part of that process, they assess allergies. Once this is done, the physician would also clarify if there is a significant issue with any medications. Before I perform a procedure, ‘allergy’ would be the first question I ask. I would ensure that what the patient says matches what the chart indicates. As far as documentation of allergies or reactions in patients’ records, anybody can document an allergy in the chart when they identify a reaction.” During a review of the facility’s policy and procedure (P&P) titled, “Adverse Drug Reaction Reporting,” dated 3/2018, the P&P indicated the following: An adverse drug reaction (ADR) is defined as one which is noxious and unintended, and which occurs in doses normally used in humans for the prophylaxis, diagnosis, or therapy of disease or for modification of physiological functions. An ADR reaction is an unexpected, unintended, undesired, or excessive response to a drug that prolongs a stay in a health care facility, requires changing the drug therapy, or requires discontinuing the drug. Verified drug reactions shall be entered into the patient’s chart in the Allergy section of the electronic medical record (EMR).”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(C) A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort) This Standard is not met as evidenced by: 46238 Based on observation, interview, and record review, the facility failed to ensure one of 31 sampled patients (Patient 5), had proper documentation regarding the use of four siderails or evidence indicating that Patient 5 specifically requested all four side rails to be raised while in bed. There was also no physician order indicating the use of all four siderails. This deficient practice had the potential to restrict Patient 5’s freedom of movement and increase the risk of injury or harm due to potential entrapment, entanglement, or falls from a greater height should Patient 5 attempt to exit the bed. Findings: During a review of Patient 5’s History and Physical (H&P, a formal document summarizing the patient’s medical history and current condition), dated 12/9/2024, the H&P indicated that Patient 5 was admitted to the facility following a “robotic-assisted total gastrectomy reconstruction converted to open (a surgical procedure where the stomach is completely removed, initially performed using robotic assistance but later converted to an open surgery due to complexity or complications).” The H&P also indicated a past medical history (PMH, a record of previous diagnoses and medical treatments) of recurrent gastric cancer (a return of cancer in the stomach following prior treatment). During a review of Patient 5’s medical record (MR) titled, “Operative Report,” dated 12/9/2024, the MR indicated that Patient 5 underwent a partial transverse colectomy (a surgical procedure involving the removal of part of the ‘transverse’ colon, typically to treat conditions like cancer, polyps [small, non-cancerous (benign) growths that can develop on the lining of various body organs, such as the colon, uterus, bladder, and nose], or obstruction) and a total gastrectomy reconstruction on 12/9/2024. During a concurrent observation and interview on 12/16/2024 at 4:47 p.m. with Registered Nurse (RN 5), Patient 5 was observed in bed sleeping with all four side rails raised (positioned upright to provide a barrier). RN 5 stated that Patient 5 had walked the previous day with a walker and further indicated that Patient 5 was identified as high risk for falls (an unintentional event that results in a person coming to rest on the ground or a lower level). RN 5 confirmed that all four side rails were up at the time of observation (12/16/2024 at 4:47 p.m.) and stated that the patient (Patient 5) preferred to have all four side rails up. However, RN 5 was unable to demonstrate documentation or evidence of a safety assessment in the medical record regarding Patient 5’s preference and safety for having all four side rails raised. During a review of Patient 5’s medical record (MR) titled, “Flowsheets: Fall Prevention Intervention,” dated 12/16/2024, it was noted that all four bed side rails were documented as being raised. During a concurrent interview and record review on 12/18/2024 at 3:31 p.m. with the Professional Development Nurse (PDN), the PDN reviewed Patient 5’s nursing progress notes and nursing care plans (structured plans that outline the individualized nursing interventions, goals, and assessments to address a patient’s specific healthcare needs), dated 12/16/2024. The PDN stated that there was no record indicating that Patient 5 had expressed a preference to have all side rails raised on 12/16/2024. During a review of the facility’s policy and procedure (P&P) titled “Restraints and Seclusions (the involuntary confinement of a patient alone in a designated room or area, where they are physically prevented from leaving),” dated 2/2022, the P&P indicated the following: Side rails are considered a restraint (restraint, any device or intervention that restricts a patient’s voluntary movement to ensure safety or prevent harm) only when: A. Used to prevent a patient from getting out of bed. B. Used to create a barrier with other furniture to prevent a patient from voluntarily exiting the bed.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure nursing staff obtained a physician order (orders written by physicians to direct care and treatment) for restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) in a timely manner for one of 31 sampled patients (Patient 7), in accordance with the facility’s policy and procedure regarding restraints, when four (4) side rails were raised to prevent Patient 7 from getting out of bed. This deficient practice had the potential for increased risk of injury or harm due to potential entrapment, entanglement, or falls from a greater height should Patient 7 attempt to exit the bed. Findings: During a review of Patient 7’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/14/2024, the H&P indicated, Patient 7 was admitted to the facility with the diagnoses of right lower leg cellulitis (an infection of the deeper layers of skin and the underlying tissue), end stage renal disease (ESRD, a stage where the kidneys can no longer support the body’s needs for waste removal and fluid balance) and atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow, leading to blood clots, stroke [occurs when blood flow to the brain is interrupted and causing brain cells to die], or heart failure [a condition where the heart cannot pump enough blood to meet the body’s needs]). During an interview on 12/16/2024 at 3:12 p.m. with the Registered Nurse (RN) 7, RN 7 stated raising four (4) side rails up to prevent patient from getting out from bed would be considered as a form of restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body). During a concurrent observation and interview on 12/17/2024 at 10:31 a.m. with Registered Nurse (RN) 11 at Patient 7’s room, Patient 7 was observed in bed with all four (4) side rails up. RN 11 stated the following: Patient 7 had bilateral (both) ankles and mittens restraints due to being combative and pulling lines. Restraints were removed about twenty (20) minutes ago. She (RN 11) was keeping four (4) side rails up for now to monitor and prevent Patient 7 from getting out of bed. During a review of Patient 7’s “Nonviolent restraints flowsheet,” dated 12/17/2024, the “Nonviolent restraint flowsheet” indicated bilateral ankles and bilateral mittens were discontinued on 12/17/2024 at 10:08 a.m. The restraints flowsheet also indicated Patient 7’s orientation level as confused and disoriented. During a concurrent interview and record review on 12/17/2024 at 2:52 p.m. with the Process Excellence Specialist (SRN), Patient 7’s physician order for restraints dated 12/16/2024, was reviewed. The physician order indicated, primary restraint type with bilateral mittens and bilateral ankles with primary reason due to repeated attempts to remove/tamper with lines, tubes, equipment, dressing and unintentional behavior that could compromise self/medical treatment. SRN stated the following: there was no physician order for use of four (4) side rails. Using four (4) side rails as restraints could be a safety issue because patient might try to climb out of bed and hurt himself or herself. It was also violation of patient’s rights to restrain someone without a physician order. During an interview on 12/19/2024 at 10:55 a.m. with Nurse Manager (NM) 1 of Surgical Unit (a hospital ward where patients are cared and treated before and after surgery) 1 and 2, NM 1 stated there should be a physician order when using four (4) side rails up as a restraints to prevent patient from getting out of bed. During a review of the facility’s policy and procedure (P&P) titled, “Restraints and Seclusion,” dated 2/2022, the P&P indicated, “Side Rails are considered a restraint only when a. used to prevent a patient from getting out of bed ... restraint(s) is/are used in accordance with the order the of a physician or other licensed independent practitioner who is responsible for the care of the patient ... if the attending or treating physician did not order the restraint, the attending physician (or treating physician) is notified as soon as possible.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure nursing staff performed and documented restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) monitoring every two (2) hours for one of 31 sampled patients (Patient 2), in accordance with the facility’s policy and procedure regarding restraints, when there was no documented restraints monitoring for eight (8) hours on 12/17/2024 from 6 a.m. to 2 p.m. This deficient practice had the potential to put Patient 2 at risk for skin breakdown (damage to the skin and underlying tissue, usually caused by prolonged pressure which restricts blood flow to the area) and needs including hydration (the process of ensuring a patient has enough fluids in their body by drinking water and consuming foods with high water content) not being met while under restraints. Findings: During a review of Patient 2’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/3/2024, the H&P indicated, Patient 2 was admitted to the facility with diagnoses of acute intracranial (inside the brain) hemorrhage (bleeding). The H&P also indicated Patient 2 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) with mechanical ventilation (an appliance for artificial respiration). During an interview on 12/16/2024 at 3:12 p.m. with the Registered Nurse (RN) 7, RN 7 stated nursing staff needed to check restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) site for skin integrity (the state of the skin being intact or undamaged) and pulse, assess patients for hygiene and provide comfort measures while patients were being restrained. RN 7 stated the monitoring should have been done and documented every two (2) hours. During a concurrent interview and record review on 12/17/2024 at 2:39 p.m. with the Process Excellence Specialist (SRN), Patient 2’s “Nonviolent Restraints Flowsheet,” dated 12/17/20024, was reviewed. The “Nonviolent Restraints Flowsheet indicated, Patient 2 had right mitten (a large, soft glove that covers a patient’s hand to prevent them from dislodging medical equipment) and four (4) side rails as restraints. The “Nonviolent Restraints Flowsheet” also indicated last restraint monitoring was completed on 12/17/2024 at 6 a.m. SRN stated the following: nursing staff need to perform assessment every two (2) hours to monitor if patient still met criteria for restraints and check for skin integrity, pulse, offer hydration, toileting and allow range of motion while being restrained.The assessment should be documented every two (2) hours, and it should be real time charting. The last entry was made at 6 a.m. so there was eight (8) hours (from 6 a.m. to 2 p.m.) with no assessment/documentation of restraints monitoring. Patient 2 would be at risk for skin breakdown (damage to the skin and underlying tissue, usually caused by prolonged pressure which restricts blood flow to the area), not being fed, not being cleaned and at risk for circulation problem if the restraint applied was too tight. During a review of the facility’s policy and procedure (P&P) titled, “Restraints and Seclusion,” dated 2/2022, the P&P indicated, “monitoring is accomplished by observation, interaction with the patient, or related direct examination of the patient by qualified staff ...monitoring frequency and parameters ... c. monitor and document the following at least every two (2) hours as appropriate ...1. The licensed vocational nurse (LVN) may assist with the data collection of these components: a. restraints status/ evaluation of continued need, b. restraint site assessment, c. orientation/ level of consciousness, d. behavioral status ... the LVN or Patient Care Assistant (PCA) may assist with the data collection of these components: a. respiratory rate, b. nutrition/hydration, c. activity/position, d. toileting, e. range of motion (to restrained limbs).””

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to provide a competent Registered Nurse (trained in accessing a central line) for one of 31 sampled patients (Patient 1), to access Patient 1’s Hickman central line (a type of central venous catheter [long, flexible tube inserted into a large vein to provide access to the heart] inserted into vein under the collarbone and tunneled under the skin of the chest wall) in a timely manner, in accordance with the facility’s policy and procedure regarding central venous catheter and access devices, when there was a physician order to access Patient 1’s Hickman central line on 11/25/2024. This deficient practice resulted in Patient 1’s Hickman central line not accessed until the next day 11/26/2024 and caused delay in medication administration which included an ordered Dilaudid (type of opioid to treat severe pain) Patient Controlled Analgesia (PCA, a pain management method that allows patients to control when they receive pain medication by pressing a button from a machine). Findings: During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/25/2024, the H&P indicated, Patient 1 was admitted to the facility for left shoulder diagnostic arthroscopy (a minimally invasive surgical procedure that allows a surgeon to examine and treat the joint). The H&P also indicated Patient 1 had a Hickman central line (a type of central venous catheter [CVC, long, flexible tube inserted into a large vein to provide access to the heart] inserted into vein under the collarbone and tunneled under the skin of the chest wall). During a concurrent interview and record review on 12/19/2024 at 9:43 a.m. with the PICC (Peripherally Inserted Central Venous Catheter, nurses who are specialized in central line care) nurse (PICC 1), Patient 1’s “Physician Order,” dated 11/25/2024, was reviewed. The “Physician Orders (orders written by physicians to direct care and treatment)” indicated, “IV (Intravenous) Team Request to insert peripheral intravenous (IV, a thin, flexible that is inserted into a vein to administer fluid or medications) right arm only, also assess Hickman access.” PICC 1 stated the PICC nurse receiving this physician order should insert peripheral IV to Patient 1’s right arm and assess Patient 1’s Hickman central line including checking the site, getting a chest X ray (an imaging procedure that uses X-rays to create picture of the structures in the chest) to confirm placement, checking the ports for blood return, flushing the line and changing the dressing to make sure the central line was good to use. PICC 1 also stated the nursing staff could then follow up with the physician to obtain order for “okay to use” the central line. During a concurrent interview and record review on 12/19/2024 at 9:47 a.m. with PICC 1, Patient 1’s “Progress Note - Nursing (nurses notes),” dated 11/25/2024 at 3:17 p.m., was reviewed. The nurses notes indicated, “PICC team [name] Registered Nurse (RN) (PICC 2) inserted a right antecubital (the area on the front of the elbow joint) 20-gauge (G, a unit of measure) peripheral IV ... Placed an order got PICC team to assess Hickman central line. Per the PICC team, the PICC team does not evaluate or access the Hickman central line. PICC team stated that the Hickman central line is tunneled and sutured in the chest and does not need placement confirmation.” PICC 1 stated PICC 2 provided incorrect information. PICC 1 stated Patient 1’s Hickman central line needed to be assessed and accessed by PICC team. During a concurrent interview and record review on 12/19/2024 at 9:51 a.m. with PICC 1, Patient 1’s “LDA (line, drains and airways) Flowsheet,” dated from 11/25/2024 to 11/26/2024, was reviewed. The “LDA Flowsheet” indicated, Patient 1 had a double lumen central line at right subclavian (beneath the collarbone) present on admission (11/25/2024) and a peripheral IV 20 gauge to right antecubital (the area in front of the elbow joint) placed on 11/25/2024 at 3:15 p.m. PICC 1 stated the following: the PICC nurse (PICC 2) inserted a peripheral IV for Patient 1 only. PICC 2 did not follow physician order to assess Patient 1’s Hickman central line. The nursing staff would not be able to use the Hickman central line without being assessed and accessed by PICC team or other trained staff. Nurses from Oncology unit (a hospital ward that is specialized in providing care to patients with cancer) 1 were trained to access central lines (CVC) as well. PICC 1 stated Patient 1’s Hickman central line was accessed by another PICC nurse on 11/26/2024 at 11:45 a.m. During a review of Patient 1’s “Physician Orders,” dated 11/25/2024, the “Physician Orders” indicated the following: -Ketamine (name of medication to treat pain) 500 milligrams (mg, a unit of measure) in 0.9 percent (%, a unit of measure) Normal Saline (type of fluid) 250 milliliters (ml, a unit of measure) infusion with scheduled start date/time on 11/25/2024 at 11 p.m. and Dilaudid (type of opioid to treat severe pain) 1 mg/ml 30 ml adult standard Patient-controlled analgesia (PCA, a pain management method that allows patients to control when they receive pain medication by pressing a button from a machine) with scheduled start date/time on 11/25/2024 at 11 p.m. During a review of Patient 1’s “Pain Flowsheet (record of patient’s pain level, location, intervention and response to pain intervention),” dated from 11/26/2024, the “Pain flowsheet” indicated Patient 1 had aching left shoulder pain with the following pain rating: -12:11 a.m., 10/10 on numeric pain scale (0-10, a pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain) -1:47 a.m., 7/10 -3:14 a.m., 8/10 -3:44 a.m., 6/10 -4:30 a.m., 7/10 During a review of Patient 1’s “Medication Administration Record (MAR, record of medications given to patients),” dated 11/26/2024, the MAR indicated, Dilaudid 0.5 mg intravenous push (IVP, administered into a vein) was given on 11/26/2024 at 1:32 a.m., 3:14 a.m. and 3:44 a.m. During a review of Patient 1’s “Progress note - Nursing,” dated 11/26/2024 at 5:53 a.m., the nurses notes indicated, Patient 1 was transferred to Surgical Unit (a hospital ward where patients are cared and treated before and after surgery) 2 around 12:45 a.m. Registered Nurse (RN) 18 was told by Patient Flow Coordinator (charge nurse) and the house supervisor that on Surgical Unit 2, they were unable to use Patient 1’s Hickman central line. Patient 1 had one peripheral IV that was infusing Ketamine ... Patient 1 also wanted Dilaudid PCA ... Another IV was placed via ultrasound (no documented time when the second peripheral IV was started) ... Patient (Patient 1) repeatedly asked RN 18 if RN 18 could use Patient 1’s Hickman line ... RN 18 placed a PICC team consult for another line. During a review of Patient 1’s “Medication Administration Record,” dated from 11/25/2024 to 11/26/2024. The MAR indicated, Dilaudid 1mg/ml Adult Standard PCA was administered on 11/26/2024 at 5:17 a.m. through the second peripheral IV started by an Emergency Department (ED) nurse. During an interview on 12/19/2024 at 10:40 a.m. with the Nurse Manger (NM) 1 of Surgical Unit 1 and 2, NM 1 stated the following: there was miscommunication among the staff. They were under the impression that nurses on Surgical Unit 2 could not use Patient 1’s Hickman central line until nurses from Oncology Unit 1 access it. NM 1 stated he (NM1) did not know why the nursing staff from Surgical Unit 2 did not call nurses from Oncology Unit 1 to access the Hickman central line for Patient 1. NM 1 stated there was a delay in care in managing Patient 1’s pain due to delay in accessing Patient 1’s Hickman central line. Patient 1’s Hickman central line was accessed by another PICC line nurse on 11/26/2024 at 11:45 a.m. During an interview on 12/20/2024 at 9:06 a.m. with the Nurse Manager (NM) 5 of Post-Anesthesia Care Unit (PACU, a recovery area in hospital where patients are monitored after surgery), NM 5 stated the following: Hickman central line was a type of central venous catheter (CVC) in which only certain nurses at the facility could access. PACU nurses should refer to the facility’s policy and procedure to find out who the nurses were allowed to access the CVC. It was not acceptable to wait until the next morning for the PICC team to access Patient 1’s Hickman central line. During an interview on 12/20/2024 at 10 a.m. with the Director of Nursing Operation (DIR 3), DIR 3 stated all nursing staff was oriented with the facility’s policy and procedure regarding CVC including the nursing supervisor. The nursing supervisor should have made arrangement to have nurses from Oncology Unit 1 to come down to access Patient 1’s Hickman central line. It was not acceptable to wait for PICC team to access the Hickman central line in the morning. It was Patient 1’s right to receive pain medication and have pain managed in a timely manner. During a review of the facility’s policy and procedure (P&P) titled, “Central Venous Catheters and Access Devices Adult and Pediatrics,” dated 9/2023, the P&P indicated, “Accessing Subcutaneous Venous Access Ports (SCVAP, type of central venous catheter) 1. Must have a physician’s order to access the port 2. Registered Nurses (RNs) from 6 West/Oncology, Critical Care Unit, Definitive Observation Unit Patient Flow Coordinators, Emergency Room, Interventional Radiology, Endoscopy, and the PICC Team ... a consult to PICC Team is entered for all patients with an accessed port on any unit other than those listed in. If a patient with an accessed port from one of these areas is being transferred to another unit, the receiving unit is responsible for entering the PICC Team consult. The PICC Team will follow the patient and assure the needle and dressing are changed per policy ... Patients admitted to Central Venous Catheter (CVC) ... A. Patient may be admitted with a CVC in place B. Call the physician for a chest X ray (CXR) order to confirm placement before using or accessing the device C. Once the CXR is taken, confirm appropriate placement with the physician and obtain an order to access/use the device. D. Notify PICC team of any PICC, Midline or SCVAP.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to: 1. Ensure one of 31 sampled patients (Patient 13), had a consistent wound care documentation and assessment completed and the appropriate wound region identified and documented correctly, in accordance with the facility’s policy and procedure regarding “Wound Care Assessment & Treatment” and “Documentation.” This deficient practice could result in improper wound care management for Patient 13, potentially causing delayed healing, an increased risk of infection, a worsening of the wound condition, and subsequent health complications. 2. Ensure the PICC (Peripherally Inserted Central Venous Catheter, nurses who are specialized in central line care) team performed proper assessment and accessed the central line catheter (CVC, long, flexible tube inserted into a large vein to provide access to the heart), in a timely manner, for one of 31 sampled patients (Patient 1) per physician’s order. This deficient practice resulted in the delay of care when Dilaudid (type of opioid to treat severe pain) PCA (PCA, a pain management method that allows patients to control when they receive pain medication by pressing a button from a machine), was not administered on time due to delay in accessing and utilizing Patient 1’s central line catheter. Findings: 1. During a review of Patient 13’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/7/2024, the “H&P” indicated Patient 13 was admitted with “past medical history of alcoholism (a chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking) and bedbound state a (person is confined to their bed, unable to get up or move around without assistance, usually due to a significant health issue that limits their mobility, such as a severe injury) who presents to the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) for evaluation of back pain ... He (Patient 13) reports pain localized to his back and reports a history of sciatica (pain that radiates into one or both legs).” The H&P further indicated Patient 13 had osteomyelitis (an infection in a bone) with extensive cellulitis (a deep infection of the skin caused by bacteria) to the back, limbs, and right heel with visible bone exposure. During a concurrent interview and record review on 12/17/2024 at 3:10 p.m. with the Quality Coordinator (QC) 1, Patient 13’s “Medication Administration Report,” with a start date on 12/11/2024 indicated, “Zinc oxide-cod liver oil (Desitin, medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and skin irritations) 40% ointment, apply 2 times daily.” During a concurrent interview and record review on 12/18/2024 at 11:45 a.m. with the Quality Coordinator (QC) 1, Patient 13’s Electronic Medical Record (EMR, a digital version of the paper charts in hospitals) titled, “Skin/Wound/PI (pressure injury, a localized damage to the skin and underlying soft tissue),” dated 12/7/2024 through 12/16/2024, was reviewed. The record indicated as follows: -On 12/7/2024, the Skin/Wound/PI record indicated the wound’s location is at the “ischial tuberosity (an anatomical term for the V-shaped bone at the bottom of the pelvis that makes contact with a surface when a person is sitting down),” but the photo attached to the record showed the wound was actually located at the coccyx (the last bone at the base of the spine) area. QC 1 confirmed that the documentation was incorrect and stated the photo clearly indicated the wound was on the coccyx. -On 12/14/2024, the Skin/Wound/PI records indicated that for both an a.m. shift (7 a.m. to 7 p.m.) and a p.m. shift (7 p.m. to 7 a.m.), there was no wound assessment and wound care medication (Desitin) documented. QC 1 stated that Patient 13 remained on the unit on 12/14/2024. Thus, wound assessment and treatment should be completed and documented. OC 1 also confirmed that on 12/14/2024 there were no documentation indicating that Patient 13 refused wound assessment and treatment. -On 12/15/2024, the Skin/Wound/PI record indicated that for the a.m. shift (7 a.m. to 7 p.m.), there was no assessment and wound care medication (Desitin) documented. QC 1 stated that Patient 13 remained on the unit on 12/15/2024. Thus, wound assessment and treatment should be completed and documented. OC 1 also confirmed that on 12/15/2024, there were no documentation indicating that Patient 13 refused wound assessment and treatment. During an interview on 12/19/2024 at 12:15 p.m. with Nursing Supervisor and Wound Care (NSW), NSW stated skin and wound assessment must be completed every shift especially for Patient 13, who had a pressure injury that required wound treatment two (2) times a day. During a review of the facility’s policy and procedure (P&P) titled, “Wound Care Assessment & Treatment,” dated February 2021, the P&P indicated, “Patient Assessment: All patients admitted to [Name of Facility] will have their skin integrity assessed by a RN within eight (8) hours of admission. Skin integrity assessment will be performed by an RN at least once a shift ...” During a review of the facility’s policy and procedure (P&P) titled, “Documentation,” dated January 2023, the P&P indicated, “To establish general guidelines for documentation in the medical record. The medical record facilitates communication between members of the health care delivery team. Documentation is to be concise and pertinent to the clinical condition of the patient ... Filing an electronic document signifies that you have reviewed the information contained within the fields and that all information is accurate and up to date for your patient ...” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for the Provision of Patient Care Services,” dated 9/1/2020, the P&P indicated, “Overview of Discipline-Specific Policies for Assessment and Reassessment ... Nursing; Assessment time frame: Demographic, physical assessment, and care planning assessment within 2 hours of admission in critical care areas and 8 hours of admission in non-critical care areas. RN analyzes data/prioritizes care. Re-Assessment Time Frame: Every shift and/or unit-specific, as well as pre- and post-treatment, including diagnosis, pre- & post-treatment, and response to treatments ...” 2. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/25/2024, the H&P indicated, Patient 1 was admitted to the facility for left shoulder diagnostic arthroscopy (a minimally invasive surgical procedure that allows a surgeon to examine and treat the joint). The H&P also indicated Patient 1 had a Hickman central line (a type of central venous catheter [CVC, long, flexible tube inserted into a large vein to provide access to the heart] inserted into vein under the collarbone and tunneled under the skin of the chest wall). During a concurrent interview and record review on 12/19/2024 at 9:43 a.m. with the PICC (Peripherally Inserted Central Venous Catheter, nurses who are specialized in central line care) nurse (PICC 1), Patient 1’s “Physician Order,” dated 11/25/2024, was reviewed. The “Physician Orders (orders written by physicians to direct care and treatment)” indicated, “IV (Intravenous) Team Request to insert peripheral intravenous (IV, a thin, flexible that is inserted into a vein to administer fluid or medications) right arm only, also assess Hickman access.” PICC 1 stated the PICC nurse receiving this physician order should insert peripheral IV to Patient 1’s right arm and assess Patient 1’s Hickman central line including checking the site, getting a chest X ray (an imaging procedure that uses X-rays to create picture of the structures in the chest) to confirm placement, checking the ports for blood return, flushing the line and changing the dressing to make sure the central line was good to use. PICC 1 also stated the nursing staff could then follow up with the physician to obtain order for “okay to use” the central line. During a concurrent interview and record review on 12/19/2024 at 9:47 a.m. with PICC 1, Patient 1’s “Progress Note - Nursing (nurses notes),” dated 11/25/2024 at 3:17 p.m., was reviewed. The nurses’ notes indicated, “PICC team [name] Registered Nurse (RN) (PICC 2) inserted a right antecubital (the area on the front of the elbow joint) 20-gauge (G, a unit of measure) peripheral IV ... Placed an order, got PICC team to assess Hickman central line. Per the PICC team, the PICC team does not evaluate or access the Hickman central line. PICC team stated that the Hickman central line is tunneled and sutured in the chest and does not need placement confirmation.” PICC 1 stated PICC 2 provided incorrect information. PICC 1 stated Patient 1’s Hickman central line needed to be assessed and accessed by PICC team. During a concurrent interview and record review on 12/19/2024 at 9:51 a.m. with PICC 1, Patient 1’s “LDA (line, drains and airways) Flowsheet,” dated from 11/25/2024 to 11/26/2024, was reviewed. The “LDA Flowsheet” indicated, Patient 1 had a double lumen central line at right subclavian (beneath the collarbone) present on admission (11/25/2024) and a peripheral IV 20 gauge to right antecubital placed on 11/25/2024 at 3:15 p.m. PICC 1 stated the following: the PICC nurse (PICC 2) inserted a peripheral IV for Patient 1 only. PICC 2 did not follow physician order to assess Patient 1’s Hickman central line. The nursing staff would not be able to use the Hickman central line without being assessed and accessed by PICC team or other trained staff. Nurses from Oncology unit (a hospital ward that is specialized in providing care to patients with cancer) 1 were trained to access central lines (CVC) as well. PICC 1 stated Patient 1’s Hickman central line was accessed by another PICC nurse on 11/26/2024 at 11:45 a.m. During a review of Patient 1’s “Physician Orders,” dated 11/25/2024, the “Physician Orders” indicated the following: -Ketamine (name of medication to treat pain) 500 milligrams (mg, a unit of measure) in 0.9 percent (%, a unit of measure) Normal Saline (type of fluid) 250 milliliters (ml, a unit of measure) infusion with scheduled start date/ time on 11/25/2024 at 11 p.m. and Dilaudid (type of opioid to treat severe pain) 1 mg/ml 30 ml adult standard Patient-controlled analgesia (PCA, a pain management method that allows patients to control when they receive pain medication by pressing a button from a machine) with scheduled start date/time on 11/25/2024 at 11 p.m. During a review of Patient 1’s “Pain Flowsheet (record of patient’s pain level, location, intervention and response to pain intervention),” dated from 11/26/2024, the “Pain flowsheet” indicated Patient 1 had aching left shoulder pain with the following pain rating: -12:11 a.m., 10/10 on numeric pain scale (0-10, a pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain) -1:47 a.m., 7/10 -3:14 a.m., 8/10 -3:44 a.m., 6/10 -4:30 a.m., 7/10 During a review of Patient 1’s “Medication Administration Record (MAR, record of medications given to patients),” dated 11/26/2024, the MAR indicated, Dilaudid 0.5 mg intravenous push (IVP, administered into a vein) was given on 11/26/2024 at 1:32 a.m., 3:14 a.m. and 3:44 a.m. During a review of Patient 1’s “Progress note - Nursing,” dated 11/26/2024 at 5:53 a.m., the nurses notes indicated, Patient 1 was transferred to Surgical Unit (a hospital ward where patients are cared and treated before and after surgery) 2 around 12:45 a.m. Registered Nurse (RN) 18 was told by Patient Flow Coordinator (charge nurse) and the house supervisor that on Surgical Unit 2, they were unable to use Patient 1’s Hickman central line. Patient 1 had one peripheral IV that was infusing Ketamine ... Patient 1 also wanted Dilaudid PCA ... Another IV was placed via ultrasound ... Patient (Patient 1) repeatedly asked RN 18 if RN 18 could use Patient 1’s Hickman line ... RN 18 placed a PICC team consult for another line. During a review of Patient 1’s “Medication Administration Record,” dated from 11/25/2024 to 11/26/2024. The MAR indicated, Dilaudid 1mg/ml Adult Standard PCA was administered on 11/26/2024 at 5:17 a.m. During an interview on 12/19/2024 at 10:40 a.m. with the Nurse Manger (NM) 1 of Surgical Unit 1 and 2, NM 1 stated the following: there was miscommunication among the staff. They were under the impression that nurses on Surgical Unit 2 could not use Patient 1’s Hickman central line until nurses from Oncology Unit 1 access it. NM 1 stated he (NM1) did not know why the nursing staff from Surgical Unit 2 did not call nurses from Oncology Unit 1 to access the Hickman central line for Patient 1. NM 1 stated there was a delay in care in managing Patient 1’s pain due to delay in accessing Patient 1’s Hickman central line. During a review of the facility’s policy and procedure (P&P) titled, “Central Venous Catheters and Access Devices Adult and Pediatrics,” dated 9/2023, the P&P indicated, “Accessing Subcutaneous Venous Access Ports (SCVAP) 1. Must have a physician’s order to access the port 2. Registered Nurses (RNs) from 6 West/Oncology, Critical Care Unit, Definitive Observation Unit Patient Flow Coordinators, Emergency Room, Interventional Radiology, Endoscopy, and the PICC Team ... a consult to PICC Team is entered for all patients with an accessed port on any unit other than those listed in. If a patient with an accessed port from one of these areas is being transferred to another unit, the receiving unit is responsible for entering the PICC Team consult. The PICC Team will follow the patient and assure the needle and dressing are changed per policy ... Patients admitted to Central Venous Catheter (CVC) ... A. Patient may be admitted with a CVC in place B. Call the physician for a chest X ray (CXR) order to confirm placement before using or accessing the device C. Once the CXR is taken, confirm appropriate placement with the physician and obtain an order to access/use the device. D. Notify PICC team of any PICC, Midline or SCVAP.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 46238 Based on observation, interview and record review, the facility failed to: 1. Ensure Nursing staff developed and maintained a current nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 31 sampled patients (Patient 29), for Influenza A (a contagious viral infection of the respiratory tract that can cause fever, cough, sore throat, and potentially severe complications in vulnerable populations) and dialysis (dialysis, a medical procedure to remove waste products and excess fluids from the blood when the kidneys are no longer functioning adequately), in accordance with the facility’s policy regarding nursing care plans. This deficient practice had the potential for Patient 29’s needs, risks and treatment goals not being met, negatively affecting Patient 29’s effectiveness of care and treatment outcomes. 2. Implement and revise interventions in the pain care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 31 sampled patients (Patient 13) in accordance with the facility’s “Interdisciplinary Plan of Care” policy and procedures. This deficient practice resulted in Patient 13 experiencing pain when being repositioned every two hours, leading to heightened discomfort and emotional distress. This persistent pain can also limit Patient 13’s ability to move and refusal to be moved, resulting in decreased physical activity and potential complications such as muscle atrophy (wasting or thinning of muscle mass) and worsening pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time), negatively impacting Patient 13’s quality of life. Findings: 1. During a review of Patient 29’s History and Physical (H&P, a formal document summarizing the patient’s medical history and current condition), dated 12/14/2023, the H&P indicated that Patient 29 had a past medical history (PMH, a record of prior diagnoses and treatments), including but not limited to end-stage renal disease (ESRD, a chronic condition where the kidneys fail to function effectively), currently on hemodialysis (HD, a treatment that filters waste and excess fluids from the blood), diabetes (a chronic disease that affects the body’s ability to regulate blood sugar levels due to insufficient insulin production [helps the body manage blood sugar levels] or utilization), and a history of cardiac transplant (a surgical procedure to replace a diseased heart with a healthy donor heart). The H&P further indicated that Patient 29 was admitted on 12/14/2023 due to respiratory failure (a serious condition where the lungs cannot adequately oxygenate the blood) and Influenza A (a contagious viral infection of the respiratory tract that can cause fever, cough, sore throat, and potentially severe complications in vulnerable populations). During a review of Patient 29’s medical record (MR) titled, “Care Plan (CP, a structured, individualized plan created by healthcare providers to address a patient’s specific medical and nursing needs),” dated 12/14/2023-12/18/2023, the MR indicated that the following CPs were initiated for Patient 29 during the admission stay [12/14/2023-12/18/2023]: i. Mobility-Impaired: A condition where physical movement or coordination is limited, impacting the patient’s ability to perform daily activities independently. ii. Risk for Falls: A state where a patient is at increased risk of falling due to factors like impaired balance, weakness, or medications. iii. Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, requiring management and intervention. iv. Ineffective Breathing Pattern: A condition where the patient’s respiratory rhythm, depth, or rate is insufficient to meet physiological needs. v. Risk for Pressure Injury: A situation where prolonged pressure on the skin may lead to tissue damage, especially in immobile patients. vi. Discharge Planning: A process that begins on admission and involves preparing the patient for a safe transition from the hospital to home or another care setting, ensuring continuity of care. vii. Impaired Skin Integrity-Pressure Injury: Damage to the skin or underlying tissues caused by sustained pressure, often seen in bedridden or immobile patients, requiring specialized care and prevention strategies. During a concurrent interview and record review on 12/18/2024 at 10:58 a.m. with Professional Development Nurse (PDN), the PDN reviewed Patient 29’s medical record (MR) titled, “Care Plan,” dated 12/14/2023-12/18/2023, and stated the following: Nurses did not develop a care plan to address Patient 29’s medical conditions of dialysis and Influenza A infection. During a concurrent interview and record review on 12/18/2024 at 10:58 a.m. with Professional Development Nurse (PDN), the PDN reviewed the available nursing care plans for patients with kidney and dialysis conditions and stated the following: A renal failure care plan and an excess fluid volume care plan could be added for Patient 29 to address the medical diagnoses of kidney disease [End-Stage Renal Disease (ESRD)] and dialysis. Additionally, a Risk/Management of Infection care plan could be added to Patient 29’s plan of care to address Patient 29’s needs associated with a diagnosis of Influenza A. During an interview on 12/19/2024 at 10:20 a.m. with the Nurse Manager (NM 1), the NM 1 stated that care plans (CPs) should be initiated for patients as soon as possible after admission. The NM 1 said the following: This [initiation of individualized care plans] allows the care team to assess what’s working, what is not, and how the patient is progressing. For dialysis patients, for example, the nurse can initiate a fluid and electrolyte (the regulation of and minerals with an electrical charge (electrolytes) within the body) imbalance CP (a care plan addressing imbalances in the body’s essential minerals and fluids that can affect organ function), which prompts nurses to perform daily weights and establish appropriate interventions to meet the treatment goals for the patient. It’s important to have a CP so we can track progress, check in with the patient, and determine if additional education is needed: what they already know and what they need to learn. During the same interview on 12/19/2024 at 10:20 a.m. with the Nurse Manager (NM 1), NM 1 said that for Influenza A, the nurse should initiate a respiratory CP (focused on managing breathing difficulties and lung health) and an infection control/management CP (designed to prevent the spread of infection and address specific patient needs). The patient should also be placed on droplet isolation precautions (infection control measures to prevent the spread of respiratory droplets). This is a nurse-driven intervention and does not require a physician’s order. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Care Plan (IPOC),” dated 9/20/2024, the P&P indicated that nursing staff is responsible for developing and maintaining a current nursing plan of care for each patient. Plan of care: A communication tool that identifies and prioritizes patient care and treatment needs, including outcomes, interventions, indicators, and goals. A nursing IPOC is developed by assessing the patient’s needs upon admission from all available sources, creating a comprehensive picture of the patient’s condition (not just those related to the admitting diagnosis) to establish appropriate nursing interventions. The Registered Nurse is responsible for setting mutually agreed-upon goals with the patient (or family/significant other) and the interdisciplinary team as needed. These goals align with the medical plan of care. 2. During a review of Patient 13’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/7/2024, the “H&P” indicated Patient 13 was admitted with “past medical history of alcoholism (a chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking) and bedbound state (when someone is unable to get out of bed independently, requiring assistance to move around or change positions) who presents to the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) via paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) for evaluation of back pain ... He (Patient 13) reports pain, localized to his back and reports a history of sciatica (pain that radiates into one or both legs).” The H&P further indicated Patient 13 had osteomyelitis (an infection in a bone) with extensive cellulitis (a deep infection of the skin caused by bacteria) to the back, limbs, and right heel with visible bone exposure. During an observation on 12/16/2024 at 3:41 p.m., at the entrance hallway to 4 East (surgical unit, an area in the hospital where patients are cared for and treated before or after the surgery) screaming was heard from room ABC (Patient 13’s room). Inside, two staff members (Certified Nursing Attendant [CNA], an entry-level role that provides vital support to both patients and nurses) 1 and Registered Nurse [RN], nurse who has graduated from a college’s nursing program or from a school of nursing and has passed a national licensing exam) 4 were repositioning (moving a patient into a different position to redistribute pressure from a particular part of the body) Patient 13, who continued to scream during the procedure. During an interview on 12/16/2024 at 3:50 p.m., Patient 13 stated, “I have pain in both legs when they move me.” Patient 13 reported pain levels of 8/10 (on a scale of 0-10, with 0 representing no pain and 10 being the worst pain) to the legs and back during repositioning and cleaning. During an interview on 12/16/2024 at 3:45 p.m. with Registered Nurse (RN) 8, outside the corridor of Patient 13’s room, RN 8 stated that patient (Patient 13) screamed each time staff repositioned them (Patient 13) due to pain. RN 8 indicated that Norco (a prescribed medication, a combination of hydrocodone [a drug used to treat moderate to severe pain] and acetaminophen [a drug used to relieve mild or chronic pain and to reduce fever for pain relief]), one dose of 10/325 mg (milligram, a unit of measurement) was administered five hours prior (to repositioning Patient 13). RN 8 confirmed that since the medication for pain (Norco) was administered five hours ago; it (Norco) will not relieve the Patient 13’s pain during repositioning. RN 8 further stated that repositioning should have been paused when Patient 13 exhibited signs of pain. RN 8 stated Patient 13 may be aware of the pain medication ordered for them (Patient 13), but RN 8 confirmed that intervention for pain management was not discussed with Patient 13. RN 8 stated Another intervention to relieve pain for Patient 13 was rest. During an interview on 12/16/2024 at 4:00 p.m. with the Nurse Manager (NM) 3, NM 3 stated that pain management should align with patient-reported pain level. NM stated, “Pain is what the patient says the pain is.” NM 3 further stated it was important to follow prescribed orders, and if the prescribed order was not adequate for pain relief, the physician should be consulted for better pain management prior to repositioning Patient 13. NM 3 verified that RN 8 did not notify the physician that Patient 13 is experiencing pain upon repositioning and may require changes to pain medication regimen or additional pain medication. During a concurrent interview and record review on 12/18/2024 at 10:45 a.m. with the Quality Coordinator (QC) 1, Patient 13’s Electronic Medical Record (EMR, a digital version of the paper charts in hospitals) titled, “Vascular Surgery (surgery that can be used to treat a wide range of heart and blood flow issues) Progress Note,” dated 12/17/2024, indicated Patient 13 underwent right above-knee amputation (surgically removing a body part, like a limb) on 12/10/2024. During a concurrent interview and record review on 12/18/2024 at 10:50 a.m. with the Quality Coordinator (QC) 1, Patient 13’s EMR titled, “Care Plan,” dated from 12/7/2024 through 12/16/2024, was reviewed. QC 1 confirmed that there was no revision to the care plan for pain’s interventions throughout Patient 13 length of stay (from 12/7/2024 through 12/16/2024). The care plan for pain indicated intervention were as follows: 1. Assessment and preservation of baseline functional status or physical 2. Assessment and preservation of baseline functional status or Psychosocial 3. Opioid analgesic side-effect assessment 4. Pain characteristic assessment 5. appropriate form of analgesia 6. Cognitive-emotional support 7. Comfort promotion. 8. Patient family participation promotion During a concurrent interview and record review on 12/18/2024 at 11:00 a.m. with the Quality Coordinator (QC) 1, Patient 13’s EMR titled, “Pain Assessment,” dated from 12/7/2024 through 12/16/2024, was reviewed. QC 1 confirmed that from 12/7/2024 through 12/16/2024 when pain rating was documented, there was no documentation of the characteristics of pain, such as quality of pain, pain onset, and pain duration. QC 1 confirmed that pain characteristic assessment is part of the intervention listed in Patient 13’s pain care plan. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care (IPOC),” dated September 2020, the P&P indicated, “Ensure that the nursing staff develops, and keeps current, a nursing plan of care for each patient. The nursing plan of care is part of the interdisciplinary plan of care (lPOC). Each patient will receive care based on an individualized lPOC in collaboration with the interdisciplinary team. Ensure the patient’s (or patient’s representatives) right to participate in the development and implementation of his or her plan of care, inpatient treatment/care plan, outpatient treatment/care plan, and/or discharge plan. Aspects of patient care, such as, teaching, interventions, referrals, discharge planning, follow-up, changes in plan, etc. are linked with the interdisciplinary plan of care. Planning care includes planning the patient’s care while in the hospital as well as planning for discharge to meet post-hospital needs. A nursing IPOC is developed based on assessing the patient’s needs upon admission from all available sources of assessment to develop a comprehensive picture of the patients’ condition (not solely those needs related to the admitting diagnosis) and develop-appropriate nursing interventions in response to those needs. Those sources may include: The Patient, the Patient’s family, other patient caregivers as applicable ... The IPOC is kept current by ongoing assessments of the patient’s needs and the patient’s response to goals or outcomes, interventions, and updating or revising the patient’s IPOC in response to assessments ...” During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated November 2022, the P&P indicated, “Pain is highly individual and variable and is one of the most feared aspects of illness, and one of the most common reasons for seeking healthcare interventions. The purpose of this policy is to provide guidelines for a collaborative interdisciplinary approach to pain management. The goals of pain management are: Relief from physical suffering Preservation or restoration of function Sustained quality of life Prevention of addiction Pain management is a shared responsibility between the patient, providers, and nursing ... B. Initial and ongoing assessment of pain ...An initial pain assessment is done on admission. It includes: Pain Goal: This is set by the patient as is developmentally appropriate ... Continuing Pain Assessment (after Admission/Arrival Pain Assessment): Shift Assessment, Type of Assessment {Assessment or Post-Intervention Reassessment, Pain Goal (required each shift and pm any changes), Sedation Score (required), Location (required each shift and pm any change), Pain Rating (required) ...” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights,” dated November 2023, the P&P indicated, “To identify each client’s rights while under treatment. Each client has all rights given to all citizens unless relieved of these rights by court action. Specifically, staff needs to assist in maintaining the client’s rights to confidentiality, privacy, and dignity. Individualized treatment that is appropriate to the client’s problems and needs ... Each client receives individualized treatment, including at least the following: ...The provision of an individualized treatment plan. The periodic review of the treatment plan. The active participation of the client and/or conservator in the planning of treatment. The provision of an adequate number of competent, qualified, and experienced professional clinical staff to implement the treatment plan and provide care ...” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for the Provision of Patient Care Services,” dated 9/1/2020, the P&P indicated, “Overview of Discipline-Specific Policies for Assessment and Reassessment ... Nursing; Assessment time frame: Demographic, physical assessment, and care planning assessment within 2 hours of admission in critical care areas and 8 hours of admission in non-critical care areas. RN analyzes data/prioritizes care. Re-Assessment Time Frame: Every shift and/or unit-specific, as well as pre- and post-treatment, including diagnosis, pre- & post-treatment, and response to treatments ...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 45743 Based on observation, interview, and record review, the facility failed to: 1. Ensure that the clinical alarms for telemetry monitor (a medical device that continuously monitors the heart activity, and/or oxygen saturations [the amount of oxygen in the blood]) were appropriately set, according to the facility’s “Cardiac Monitoring Guidelines and Clinical Alarm Management” policy and procedure, for two of 31 sampled patients (Patients 14 and Patient 15). This deficient practice had the potential to delay the detection of life-threatening changes. For Patient 14, this could have led to uncontrolled high blood pressure, increasing the risk of stroke (occurs when blood flow to the brain is interrupted and causing brain cells to die) or other cardiac (relating to the heart) emergencies. For Patient 15, improper oxygen monitoring can lead to undetected hypoxia (low oxygen levels), which can cause brain damage or death. 2. Ensure Nursing personnel reported a suspected adverse drug reaction (unintended, harmful events attributed to the use of medicines) to Ativan (Ativan, a benzodiazepine [class of medication] used to treat anxiety) and/or Benadryl (Benadryl, an antihistamine [class of medication] used to treat allergic reactions, reduce itching, and provide sedation) for one of 31 sampled patients (Patient 27), in accordance with the facility’s policy and procedure regarding adverse drug reaction reporting. This deficient practice had the potential to compromise Patient 27’s health and recovery due to delayed recognition and management of adverse drug reactions and repeated exposure to medications that Patient 27 may be allergic to. 3. Ensure Nursing personnel entered the isolation precautions (infection control measures designed to prevent the spread of contagious diseases, such as placing the patient in a designated isolation room and using protective equipment like masks and gowns) information for Influenza A (a contagious viral infection of the respiratory tract that can cause fever, cough, sore throat, and severe complications in vulnerable populations) into the Patient Care System (PCS, an electronic system used to document and communicate patient care needs and treatment plans) for one of 31 sampled patients (Patient 29), in accordance with the facility’s policy and procedure regarding “Initiation of Infection Control Precautions for Staff and Visitors.” This deficient practice had the potential to delay the implementation of infection control measures for Patient 29, thereby increasing the risk of spreading Influenza A to other patients, visitors, and staff due to uncommunicated isolation precautions. 4. Implement complete seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness [a state where a person is not aware of their environment or themselves]) precautions for one (Patient 21) of 31 sampled patients, when there was no readily available suction set-up (a medical device that essentially acts like a vacuum cleaner for a person’s airway, removing excess mucus, saliva, blood, or other fluids that they can’t clear on their own, helping them breathe properly, especially when they are unconscious or unable to cough effectively) for Patient 21 in the event of a seizure episode, in accordance with the facility’s policy and procedure regarding “Seizure Precautions and Guidelines.” This deficient practice had the potential for Patient 21 to aspirate (inhale) during a seizure activity, which may result in complications such as aspiration pneumonia (infection of the lung) and may prolong Patient 21’s recovery. 5. Ensure side rails were padded for one of 31 sampled patients (Patient 2) for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness) precaution, in accordance with the facility’s policy and procedure regarding “Seizure Precaution and Guidelines.” This deficient practice had the potential to result in Patient 2 getting injured when having seizures 6. Ensure Nursing staff completed the pre-procedure check list (steps taken to verify the patient, procedure, and consent form) and follow time-out (a pause before a medical procedure to confirm that the correct patient, procedure, and site are being used) process for two of 31 sampled patients (Patient 2 and Patient 3), in accordance with the facility’s policy and procedure regarding “Universal Protocol (a set of standardized procedures in healthcare, primarily used in surgical settings, designed to prevent wrong-site, wrong-procedure, and wrong-patient surgeries by requiring a pre-procedure verification process, surgical site marking, and a “time-out” before starting the procedure). This deficient practice had the potential to result in Patient 2 and Patient 3 having the wrong procedure, wrong site and/or having the procedure without informed consent (a process in which a health care providers educates a patient about the risks, benefits, and alternatives of a given procedure or intervention). 7. Ensure Nursing staff followed chain of command (provides a clear structure for reporting concerns, escalating issues, and making decisions related to patient care) to manage one of 31 sampled patient’s (Patient 1) pain, in accordance with the facility’s policy and procedure regarding “Chain of Command.” This deficient practice resulted in Patient 1 remaining in severe pain for 3.5 hours on 12/3/2024 and had the potential to result in Patient 1 not being able to move, talk or perform activities of daily living (basic self-care tasks that people perform everyday such as hygiene) due to severe pain. Findings: 1. During a review of Patient 14’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/16/2024, the “H&P” indicated, Patient 14s past medical history included hypertension (abnormally high blood pressure), and premature ventricular contractions (PVCs, are extra, abnormal heartbeats). The H&P further indicated Patient 14 was brought in by ambulance (a special vehicle used to take sick or injured people to the hospital) after “developing acute vertigo (a sensation of motion or spinning that is often described as dizziness), patient (Patient 14) also had nausea (a feeling of sickness with an inclination to vomit) and vomiting. She (Patient 14 was hypertensive (having high blood pressure) to 211 (systolic blood pressure, the pressure in the artery when the heart contracts and pumps blood out)/92 (diastolic blood pressure, the pressure in the arteries when the heart is relaxed between beats).” The H&P indicated the blood pressure of 211/92 was treated. During a concurrent observation and interview on 12/16/2024 at 3:00 p.m. with the registered nurse (RN) 3 in Patient 14’s room, the telemetry monitor was set to trigger systolic blood pressure (the top number in a blood pressure reading) alarms only if readings reached 170 or above and heart rate alarms only if readings were 170 beats per minute or higher. RN 3 stated they (the nursing staff) did not address and set the high limits alarm to go off for SBP and the heart rate. RN 3 further stated, “It is important to check the alarm settings.” RN 3 also stated they (the nursing staff) should follow policy and procedure to set the alarm in accordance with the default standard limits if the patient does not have a specific order for alarm setting. During a concurrent interview and record review on 12/16/2024 at 3:16 p.m. with the charge nurse (CN) 1, the facility’s policy and procedure (P&P) titled, Cardiac Monitoring Guidelines and Clinical Alarm management,” dated February 2021, was reviewed. CN 1 stated the default standard alarm setting for heart rate high limits was 120, and for SBP high limits was 150. CN 1 stated if the patient (Patient 14) does not have an order for a heart rate setting, then the HR high limits should be set to 120. During a concurrent interview and record review on 12/17/2024 at 2:16 p.m. with Quality Coordinator (QC) 1, Patient 14’s Electronic Medical Record (EMR, a digital version of the paper charts in hospitals) titled, “Medication Administration Record (MAR, report of patient’s medication including special instructions and date and time),” dated 12/16/2024 at 9:39 a.m. was reviewed. The MAR indicated that Patient 14’s medication order included hydralazine (a drug that lowers blood pressure) 10 mg (milligram, a unit of measurement) with instructions to “give for SBP greater than 150.” QC 1 confirmed that the appropriate high limits alarm setting for SBP should be set at 150 to activate the alarm and thus administer the hydralazine as ordered. During a concurrent interview and record review on 12/17/2024 at 2:20 p.m. with Quality Coordinator (QC) 1, Patient 14’s EMR titled, “Order Report,” was reviewed. The report indicated that on 12/16/2024 at 3:05 a.m., Patient 14 was ordered to start “48-Hour Cardiac Monitoring until discontinued.” QC 1 verified that Patient 14 does not have a specific heart rate high limit order by the physician; thus, the HR’s alarm setting should be set to the standard default setting, at 120 for the high limits. During a review of the facility’s policy and procedure (P&P) titled, “Cardiac Monitoring Guidelines and Clinical Alarm management,” dated February 2021, the P&P indicated, “In order to promote patient safety, this policy provides Guidelines for RNs related to cardiac monitoring ... Alarms are set and adjusted as described under Procedure in this policy. Default Alarm Settings: Determination of default settings is based on risk analysis and each area provides input to safe default settings. For current Defaults See Appendix C., Alarm Default Settings Adults: Heart rate high 120 and SBP high 150 ...” 2. During a review of Patient 15’s “History and Physical (H&P),” dated 12/16/2024, the “H&P” indicated, Patient 15 medical history included DM II (diabetes mellitus type 2, a disease that occurs when your blood sugar is too high), cerebral accident (CVA, or stroke; a loss of blood flow to part of the brain), and pulmonary embolism (PE, a blood clot in the lungs). During a concurrent observation and interview on 12/16/2024 at 2:20 p.m. with the charge nurse (CN) 2 in Patient 15’s room, the telemetry monitor displayed that the oxygen saturation alarm was set to activate only if levels dropped below 85%. CN 2 stated it should be set at default setting of 88 % unless the patient has an order by the physician for setting of 85%. During a review of Patient 15’s electronic medical record titled “Notify Physician Vitals,” dated 12/16/2024 at 7:00 a.m., a physician order indicated the need to notify the physician if oxygen saturation levels fell below 88%. During a review of the facility’s policy and procedure (P&P) titled, “Cardiac Monitoring Guidelines and Clinical Alarm management,” dated February 2021, the P&P indicated, “In order to promote patient safety, this policy provides Guidelines for RNs related to cardiac monitoring ... Alarms are set and adjusted as described under Procedure in this policy. Default Alarm Settings: Determination of default settings is based on risk analysis and each area provides input to safe default settings. For current Defaults See Appendix C., Alarm Default Settings Adults: 02 (oxygen) saturation low at 88.” 3. During a review of Patient 27’s History and Physical (H&P), dated 11/30/2023, the H&P indicated that Patient 27 was admitted to the facility on 11/30/2023 due to a fall (fall, an incident in which a person unintentionally comes to rest on the ground or a lower level) at home and elevated troponin (elevated troponin, an increased level of troponin in the blood indicative of heart muscle injury) with no symptoms. The H&P further indicated that Patient 27 had a Past Medical History (PMH) of Alzheimer’s (Alzheimer’s, a progressive disease that causes memory loss and cognitive decline), depression, white coat hypertension (blood pressure is higher at a healthcare professional’s office than in other settings, such as at home), and anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one’s daily activities). During a review of Patient 27’s medical record (MR) titled. “Allergy Review History (a detailed record of a patient’s known allergies and adverse reactions to medications), dated 11/30/2023, the MR indicated that on 11/30/2023, an allergy to Xanax (a medication containing alprazolam, used to treat anxiety and panic disorders) with a recorded unspecified reaction (unspecified reaction, an allergic response where the specific symptoms or type of reaction are not documented or unavailable) was documented in Patient 27’s electronic medical record (EMR). During a review of Patient 27’s medical record (MR) titled, “Physician’s Orders,” dated 12/02/2023, the MR indicated that 1 mg of Ativan IV push (Ativan IV push, an intravenous administration of lorazepam given rapidly through a vein to provide immediate relief) was ordered for Patient 27 on 12/02/2023 at 6:36 p.m., to be administered every 12 hours as needed for agitation (a feeling of restlessness and irritability) and anxiety. During a review of Patient 27’s medical record (MR) titled, “Allergy Review History,” dated 12/2/2023, the MR indicated that Patient 27’s primary nurse reviewed Patient 27’s allergy record on 12/2/2023 at 6:35 p.m. During a review of Patient 27’s medical record (MR) titled, “Warning Override History for Lorazepam (Ativan) injection 1 mg,” dated 12/02/2023, the MR indicated that on 12/02/2023 at 6:36 p.m., the warning for allergy/contraindication (a condition in which a medication should not be used due to a documented allergy or other medical reason) for administration of Ativan (Ativan, a benzodiazepine medication used to manage anxiety and seizures) was due to a documented allergy to alprazolam (Xanax, a benzodiazepine used to treat anxiety and panic disorders) was overridden (to bypass) by a primary nurse (Patient 27’s nurse) by the order of a physician (MD 1). The MR contained the following comment: “Physician (MD 1) aware [of an allergy/contraindication], Benadryl (an antihistamine medication used to treat allergic reactions and provide sedation) ordered.” During an interview on 12/18/2024 at 10:15 a.m. with Medication Safety Pharmacy Compliance officer (MSPC, a pharmacist responsible for ensuring compliance with pharmacy regulations, medication safety, and adherence to organizational policies), the MSPC reviewed Patient 27’s “Warning Override History for Lorazepam (Ativan) injection 1 mg” and stated the following: The ordering user for 1 mg of Ativan was [Patient 27’s] registered nurse (RN), and the ordering provider was medical doctor (MD 1). It was a telephone order with readback, signed on 12/02/2023. The allergy/contraindication warning was overridden by the nurse due to a comment: “MD 1 aware, PRN (PRN, an abbreviation for “pro re nata,” meaning “as needed”) Benadryl ordered.” Every medication ordered comes into a queue (a system where medication orders are temporarily held for review by the pharmacy before being dispensed) for the pharmacy to review. There was an allergy contraindication alert, but it was bypassed because of what the physician said and as documented by the nurse. The pharmacist released the order for 1 mg Ativan after reviewing the order and the comment. During a review of Patient 27’s Medical Administration Record (MAR), dated 12/2/2023, the MAR indicated that on 12/2/2023 Patient 27 was administered 1 mg of Ativan at 7:57 p.m. During a review of Patient 27’s medical record (MR) titled, “Nursing Note,” dated 12/03/2023, the MR indicated that on 12/03/2024 at 6:00 a.m., the night shift nurse (RN 1) documented the following: Benadryl IV (an intravenous (IV) formulation of diphenhydramine (Benadryl) given through a vein and used to treat allergic reactions and provide sedation) and Ativan (IV) given for agitation. Patient (Patient 27) started to have occasional jerky movements afterwards, which seem like restless leg syndrome (legs jerking) and whole-body myoclonus (myoclonus, a rapid, involuntary muscle jerk affecting the entire body). Severity and frequency decreased over this shift [12/02/23-12/03/23, 7 p.m.-7 a.m.], but still present intermittently. During a review of Patient 27’s medical record (MR) titled, “Physician Notification,” dated 12/2/2024 through 12/3/2024, the MR indicated that no record of physician notification was entered during the night shift (7 p.m. to 7 a.m.) regarding the observed occasional jerky movements following the administration of Ativan and Benadryl. During a review of Patient 27’s medical record (MR) titled, “Provider Notification,” dated 12/03/2023, the MR indicated that Patient 27’s primary RN (RN, Registered Nurse) documented the following on 12/03/2023 at 9:00 a.m.: “Incomprehensible speech (speech that cannot be understood by others), tongue swelling/dryness (tongue swelling/dryness, a condition where the tongue becomes enlarged and lacks moisture) and fatigue. MD (MD, Medical Doctor) putting in orders.” During an interview on 12/19/2024 at 1:50 p.m. with Medication Safety Pharmacy Compliance Officer (MSPC), the MSPC stated the following: “Anybody can go on the intranet and access the event reporting system for any unsafe event, including medication-related events. They can also call the hotline to report. The nurse should have reported the adverse event associated with the medication administration [Ativan and/or Benadryl]. The event was not reported. The night shift nurse should have documented the adverse reactions. Both nurses should have documented in the reporting system. They take care of the patient, and when they see something, they should say something. If it is not reported, there is no way to intervene and identify the issues.” During the same interview on 12/19/2024 at 1:50 p.m., the MSPC stated, “Adverse medication reactions are tracked. I maintain a spreadsheet, and I track reactions, then report them to the Medication Safety Committee. I would have investigated the incident right away, documented it in the allergy section, and ensured that the next time the physician orders the medication, if coded correctly with the severity, we could follow up with the physician. We could then put a hard stop on the medication or discuss it with the MD.” During an interview on 12/20/2024 at 7:46 a.m. with registered nurse (RN 1), regarding Patient 27’s documented response to administration of Ativan and Benadryl on 12/03/2023, RN 1 provided the following response: -RN 1 recalled observing jerky movements in Patient 27, describing them as resembling a seizure (uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, sensations, or consciousness) but not an actual seizure. RN 1 stated that she (RN 1) did not find the movements concerning at the time and considered them a potential side effect of Benadryl based on information looked up online. RN 1 said that if she (RN 1) had notified the physician about the movements, it would have been documented in the notification in the patient’s (Patient 27) medical record. However, she (RN 1) believed the movements were most likely a side effect of the medication and reported her observations to the oncoming nurse during the shift handoff instead of escalating them further. -RN 1 further said that, in cases of suspected adverse medication reactions, the usual practice would be to call the physician and document the event in the progress notes. RN 1 said that adverse reactions should also be reported in the facility’s adverse event reporting system but stated that she (RN 1) thought the jerky movements were an expected reaction to Benadryl, as the medication was ordered to address a potential reaction (to Ativan). RN 1 did not recall any instances of tongue swelling during her (RN 1) shift (12/2/2024 through 12/3/2024, 7 p.m. to 7 a.m. shift) and described the patient (Patient 27) as responsive, occasionally waking up to say a word before falling back asleep. During a review of the facility’s policy and procedure (P&P) titled, “Adverse Drug Reaction Reporting,” dated 3/2018, the P&P indicated the following: A. Nursing personnel play a critical role in adverse drug reaction (ADR) reporting, as they are often the first to observe a suspected drug reaction and are required to report it immediately. B. An adverse drug reaction (ADR) is defined as a reaction that is noxious and unintended and occurs in doses normally used in humans for prophylaxis, diagnosis, therapy, or modification of physiological functions. C. An ADR is further defined as an unexpected, unintended, undesired, or excessive response to a drug that prolongs a hospital stay, requires changing drug therapy, or necessitates discontinuing the drug. Procedure: A. There are three methods of reporting ADRs: 1. Internal Reporting System. 2. Federal Reporting System. 3. Hospital Adverse Drug Reaction Hotline. B. Reporting Process: 1. All suspected ADRs must be reported in the internal reporting system. 4. ADRs that result in insignificant or no harm to the patient must also be documented in the electronic health record (EHR) but do not require immediate physician notification. Documentation should be completed as soon as practical but without undue delay. C. The nurse and/or pharmacist must report any suspected ADRs to the physician for verification and initiate event reporting. D. Pharmacy tracks ADR data E. A physician, Medication Safety Committee, and the Pharmacy Therapeutics and Diet Committee review reports quarterly. F. Verified drug reactions must be entered into the patient’s chart in the Allergy section of the electronic medical record (EMR). 4. During a review of Patient 29’s History and Physical (H&P), dated 12/14/2023, the H&P indicated that Patient 29 had a past medical history (PMH, a record of prior diagnoses and treatments), including but not limited to end-stage renal disease (ESRD, a chronic condition where the kidneys fail to function effectively), currently on hemodialysis (HD, a treatment that filters waste and excess fluids from the blood), diabetes (a chronic disease that affects the body’s ability to regulate blood sugar levels due to insufficient insulin [helps to lower blood sugar level] production or utilization), and a history of cardiac transplant (a surgical procedure to replace a diseased heart with a healthy donor heart). The H&P further indicated that Patient 29 was admitted on 12/14/2023 due to respiratory failure (a serious condition where the lungs cannot adequately oxygenate the blood) and Influenza A (a contagious viral infection of the respiratory tract that can cause fever, cough, sore throat, and potentially severe complications in vulnerable populations). During a concurrent interview and record review on 12/18/2024 at 10:58 a.m. with the Professional Development Nurse (PDN), the PDN reviewed Patient 29’s medical record (MR), titled, “Care Plan (a structured, individualized plan created by healthcare providers to address a patient’s specific medical and nursing needs),” dated 12/14/2023-12/18/2023. The PDN stated that nurses did not develop a care plan to address Patient 29’s medical condition of Influenza A infection. During the same interview on 12/18/2024 at 10:58 a.m. with the Professional Development Nurse (PDN), the PDN reviewed Patient 29’s medical chart and stated that there was no record or documentation of isolation precautions (infection control measures implemented to prevent the spread of contagious diseases, including actions like placing the patient in a designated isolation room and using appropriate protective equipment such as masks and gowns) in Patient 29’s medical record. During a review of the facility’s built-in nursing care plans titled, “Infection - Risk/Management of,” the following interventions (actions or measures taken by nursing staff to address specific patient care needs and promote positive outcomes) were identified as part of standard nursing practices upon initiation of an Infection Management care plan: -Isolation Appropriateness Assessment: Evaluating whether isolation precautions are necessary based on the patient’s condition, diagnosis, and potential risk of infection transmission to others. -Patient Isolation: Implementing measures to physically separate the patient to prevent the spread of infection, which may include placing the patient in a designated isolation room and applying appropriate precautions such as droplet, contact, or airborne protocols. During an interview on 12/19/2024 at 10:20 a.m. with the Nurse Manager (NM 1), the NM 1 stated that care plans (CPs) should be initiated for patients as soon as possible after admission. The NM 1 said the following: For Influenza A, the nurse should initiate a respiratory CP (focused on managing breathing difficulties and lung health) and an infection control/management CP (designed to prevent the spread of infection and address specific patient needs). The patient should also be placed on droplet isolation precautions (infection control measures to prevent the spread of respiratory droplets) and document it (placement in droplet isolation precaution) in the Patient Care System (PCS, an electronic system used to document and communicate patient care needs and treatment plans). This is a nurse-driven intervention and does not require a physician’s order. During a review of the facility’s policy and procedure (P&P) titled, “Initiation of Infection Control Precautions for Staff and Visitors,” dated 11/2022, the P&P indicated the following: A registered nurse to place a patient on precautions without a physician’s order to minimize the spread of infection to the patient, staff, and the community at large. The P&P further stated that the registered nurse is responsible for educating the patient and visitors about the need for precautions and expectations and for entering the type of precautions into the Patient Care System (PCS, an electronic system used to document and communicate patient care needs and treatment plans) and TeleTracking (a software system designed to optimize hospital operations by monitoring and managing patient flow, bed assignments, and resource utilization). During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Care Plan (IPOC)” dated 9/20/2024, the P&P indicated that nursing staff is responsible for developing and maintaining a current nursing plan of care for each patient. Plan of care: A communication tool that identifies and prioritizes patient care and treatment needs, including outcomes, interventions, indicators, and goals. A nursing IPOC is developed by assessing the patient’s needs upon admission from all available sources, creating a comprehensive picture of the patient’s condition (not just those related to the admitting diagnosis) to establish appropriate nursing interventions. 5. During a review of Patient 21’s History and Physical (H&P), dated 11/22/2024, the H&P indicated that Patient 21 was admitted to the facility on 11/22/2024 for bilateral (both) lower extremity (legs) cellulitis (bacterial infection of the skin) and had a history of seizures (a sudden uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness [a state where a person is not aware of their surroundings or themselves]). During a review of Patient 21’s electronic medical record titled, “Precaution Orders,” dated 11/22/2024 at 5:56 p.m., a physician order indicated continuous seizure precautions (safety measures taken before someone experiences a seizure activity). During a concurrent observation and interview on 12/17/2024 at 10:23 a.m. with Registered Nurse (RN) 11 in Patient 21’s room, RN 11 stated that Patient 21 was on seizure precautions and that the side rails should be padded and a suction machine (a medical device that essentially acts like a vacuum cleaner for a person’s airway, removing excess mucus, saliva, blood, or other fluids that they can’t clear on their own, helping them breathe properly, especially when they are unconscious or unable to cough effectively) should be set up at bedside. RN 11 stated that Patient 21 does not have a suction set-up because Patient 21 was on a safety hold (when someone is involuntarily detained for up to 72 hours for evaluation and treatment) and no cords were allowed in the room for safety. RN 11 stated that suction set-up could be placed outside in the hallway as standby. RN 11 confirmed that there was no portable suction in the hallway for Patient 21. During an interview on 12/17/2024 at 2:12 p.m. with the Process Excellence Specialist (SRN), the SRN stated that nurses should make sure that side rails were padded for safety, preventing patients from injuring themselves during a seizure episode, and suction should be set up at bedside to prevent aspiration (the accidental inhalation of foreign materials, such as food, liquid, or other substances, into the lungs). During an interview on 12/19/2024 at 1:28 p.m., with Nurse Manager (NM) 4, NM 4 stated seizure precautions could be determined by the neurologist (physician who specializes in the diagnosis, treatment, and management of disorders affecting the brain and spinal cord) and entered as an order. It could also be nursing driven for patients who had history of or with active seizures. NM 4 said Seizure precaution interventions included: applying padded side rails, keeping head of bed at appropriate elevation to prevention aspiration and have suction set up in the room. During a review of the facility’s policy and procedure (P&P) titled, “Seizure Precautions and Guidelines,” dated 1/21, indicated seizure precautions guideline “to help protect the patient from injury and maintain a patent airway if a seizure should occur. Equipment includes padding for side rails, suction setup with yankauer (a medical tool used to remove secretions from the mouth and throat, oropharynx, to prevent aspiration and maintain an open airway) and to ensure oxygen and suction is set up.” 6. During a review of Patient 2’s History and Physical (H&P) dated 12/3/2024, the H&P indicated, Patient 2 was admitted to the facility with diagnoses of acute intracranial (inside the brain) hemorrhage (bleeding). The H&P also indicated Patient 2 had seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness) on 12/3/2024. During a review of Patient 2’s “Neurology Consult Note,” dated 12/6/2024, the “Neurology Consult Note” indicated, Neurology was consulted for seizure control with recommendation to continue Phenobarbital (medication to treat seizure), Lamictal (medication to treat seizure), and Vimpat (medication to treat seizure) and seizure precaution (safety measures taken before an individual experiences seizure). During a concurrent observation and interview on 12/16/2024 at 3:03 p.m. with Registered Nurse (RN) 6 at Patient 2’s room, Patient 2 was observed in bed with no padded side rails. There was a communication board in the room with written “Seizure Precaution and monitor for seizure.” RN 6 stated there was no padded side rails applied on Patient 2. During an interview on 12/16/2024 at 3:12 p.m. with RN 7, RN 7 stated seizure precaution was considered prophylaxis (to prevent) measures to protect the patient when he or she seized, there should be padded side rails. RN 7 also stated the seizure precaution measures should be uniform throughout the hospital. During an interview on 12/17/2024 at 10:23 a.m. with RN 11, RN 11 stated nursing staff should make sure bed side rails were padded and there was a suction set up (a medical device that essentially acts like a vacuum cleaner for a person’s airway, removing excess mucus, saliva, blood, or other fluids that they can’t clear on their own, helping them breathe properly, especially when they are unconscious or unable to cough effectively) for seizure precaution. During a concurrent interview and record review on 12/17/2024 at 2:12 p.m. with the Process Excellence Specialist (SRN), Patient 2’s “Daily Care Flowsheet,” dated 12/16/2024, was reviewed. The Daily Care Flowsheet indicated, Patient 2 was placed on seizure precaution and seizure precaution intervention with “suction set up” from 8 a.m. to 6 p.m. SRN stated there was no documentation that padded side rails was applied for Patient 2. SRN stated nursing staff should also make sure side rails were padded to prevent patients from injuring themselves during seizures. SRN stated suction should be set up at bedside to prevent aspiration (when something accidentally enters the lungs or airway). During a concurrent interview and record review on 12/19/2024 at 1:28 p.m. with Nurse Manager (NM) 4 at Critical Care Unit (CCU, specialist hospital wards that provide treatment and monitoring for people who are very ill), Patient 2’s “Head to Toe Flowsheet,” dated 12/5/2024, was reviewed. The Head-to-Toe Flowsheet indicated, Patient 2 had seizure activity on 12/5/2024 at 4 p.m. with right arm and eye twitching. NM 4 stated it would be appropriate to implement seizure precaution on Patient 2. NM 4 stated seizure precaution intervention would include applying padded side rails, keeping head of bed elevated and having suction set up at bedside. During a review of the facility’s policy and procedure (P&P) titled, “Seizure Precaution and Guidelines,” dated 1/2021, the P&P indicated, “Purpose: to establish seizure precaution guidelines to help protect the patient from injury and maintain a patent airway if a seizure should occur ... ‘seizure precaution’ should be implemented if ... nursing may implement seizure precautions if the patient has a known history oof a seizure disorder with or without recent seizure activity ... assess patient’s history of seizures, precipitating factors, and medications.,.. inspect patient’s environment for potential safety hazards. Prepare bed with padded side rails and keep bed in low position. Ensure oxygen and suction setup.” 7.a. During a review of Patient 2’s History and Physical (H&P) dated 12/3/2024, the H&P indicated, Patient 2 was admitted to the facility with diagnoses of acute intracranial (inside the brain) hemorrhage (bleeding). The H&P also indicated Patient 2 had seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness) on 12/3/2024. During a concurrent observation and interview and on 12/16/2024 at 3:03 p.m. with Registered Nurse (RN) 6 at Patient 2’s room, Patient 2 had a drain to the left forehead. RN 6 stated it was an external ventricular drainage to drain cerebrospinal fluid (a clear colorless liquid that circulates around the brain and the spinal cord) from the brain. During a review of Patient 2’s “Operative Report,” dated 12/4/2024, the Operative Report indicated, Patient 2 had right frontal ventriculostomy (a surgical procedure that involves inserting a tube (catheter) into one of the brain’s ventricles (fluid-filled cavities) to drain excess cerebrospinal fluid) insertion on 12/4/2024. During an interview on 12/19/2024 at 2 p.m. with the Nurse Manager (NM) 4 of Critical Care Unit, NM 4 stated the following: Patient 2 had the right frontal ventriculostomy insertion done at bedside in CCU on 12/4/2024. Nursing staff did not complete the “Pre-Procedure check list,” and did not document if time-out (a brief pause before a surgical procedure where the entire surgical team actively verifies and confirms critical patient information, including their identity, the planned procedure, and the surgical site, to prevent errors and ensure patient safety) was performed prior to procedure. NM 4 stated time-out is done before procedure to make sure it was the correct patient for correct procedure to ensure patient’s safety. During a review of the facility’s policy and procedure (P&P) titled, “Universal Protocol,” dated 9/2024, the P&P indicated, “Bedside Procedure Protocol ... prior to initiating the bedside procedure, the following verification will occur between the physician performing the procedure, bedside nurse, and will include the involvement of the patient when possible. 1. Order for consent of the procedure; 2. Verification of documentation of informed consent; 3. Signed consent; 4. Ensure the availability of the following information using the Pre-Procedure Checklist: a. pre procedure verification; b. pre-operation code status; c. other; d. documents/ consents; e. site marked; f. required equipment is available and functioning; g. signature upon completion of the pre-procedure checklist ... Before beginning sedation and prior to the skin puncture/incision, the bedside Registered Nurse (RN) is to verify the following information at the bedside with the physician performing the procedure, and all of the team members necessary for the procedure ... 2. Prior to performing the procedure, the team will take a moment (‘Time Out’), which must be performed immediately before starting the procedure after draping (if required) and just prior to skin incision, which activities being suspended to best extent possible in order to verify the following: a. patient name, Financial Identification Number (FIN, an internal number assigned by hospital for each patient encounter), procedure, consent, site/side and marking ...h. the ‘Time Out’ section is completed in the pre-procedure checklist.” 7.b. During a review of Patient 3’s History and Physical (H&P), dated 12/15/2024, the H&P indicated, Patient 3 was admitted to the facility with diagnoses diabetes (high blood sugar), right lower leg abscess (a pocket of pus formed any part of the body) with cellulitis (an infection of the deeper layers of skin and the underlying tissue). The H&P also indicated Patient 3 required surgical evaluation for possible debridement (a medical procedure that removed damaged, dead or infected tissue) and drainage (the process of removing fluid from a wound). During a concurrent observation and interview on 12/16/2024 at 3:58 p.m. with Registered Nurse (RN) 13, at Patient 3’s room, Patient 3 had a dressing covering the right lower leg. RN 13 stated Patient 3 had a bedside procedure earlier. During a review of Patent 3’s “Incision and Drainage (I&D, a minor surgical procedure that releases pus or pressure that builds up under the skin) Procedure Note (procedure note, operative report completed by a surgeon),” dated 12/16/2024, the procedure note indicated, physician (MD 8) performed right leg necrotizing (dead) soft tissue infection with abscess incision and drainage on 12/16/2024. During an interview on 12/18/2024 at 10:28 a.m. with the Process Excellence Specialist (SRN), SRN stated there was no informed consent (a process in which a health care providers educate a patient about the risks, benefits, and alternatives of a given procedure or intervention) form for the incision and drainage procedure done on 12/16/2024. SRN stated informed consent was required for every surgical procedure. During an interview on 12/19/2024 at 10:29 a.m. with the Nurse Manager (NM 1) of Surgical Unit (a hospital ward where patients are cared and treated before and after surgery) 1 and 2, NM 1 stated MD 8 performed the procedure at bedside on 12/16/2024 on Patient 3 but there was no time-out documented. NM 1 also stated the following: when there was a bedside procedure, patient’s primary nurse should make sure there was a procedure order, informed consent in the patient’s medical record, and perform time-out with the physician prior to the procedure. The purpose of time-out was to ensure there was an informed consent to indicate patient fully understand and agree with the procedure, and to verify the correct patient for the correct procedure. It was for patient’s safety and to avoid any error. Patient’s nurse should document when time-out was performed. During a review of the facility’s policy and procedure (P&P) titled, “Universal Protocol,” dated 9/2024, the P&P indicated, “Bedside Procedure Protocol ... prior to initiating the bedside procedure, the following verification will occur between the physician performing the procedure, bedside nurse, and will include the involvement of the patient when possible. 1. Order for consent of the procedure; 2. Verification of documentation of informed consent; 3. Signed consent; 4. Ensure the availability of the following information using the Pre-Procedure Checklist: a. pre procedure verification; b. pre-operation code status; c. other; d. documents/ consents; e. site marked; f. required equipment is available and functioning; g. signature upon completion of the pre-procedure checklist ... Before beginning sedation and prior to the skin puncture/incision, the bedside Registered Nurse (RN) is to verify the following information at the bedside with the physician performing the procedure, and all of the team members necessary for the procedure ... 2. Prior to performing the procedure, the team will take a moment (‘Time Out’), which must be performed immediately before starting the procedure after draping (if required) and just prior to skin incision, which activities being suspended to best extent possible in order to verify the following: a. patient name, Financial Identification Number (FIN, an internal number assigned by hospital for each patient encounter), procedure, consent, site/side and marking ...h. the ‘Time Out’ section is completed in the pre-procedure checklist.” 8. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/25/2024, the H&P indicated, Patient 1 was admitted to the facility for left shoulder diagnostic arthroscopy (a minimally invasive surgical procedure that allows a surgeon to examine and treat the joint). The H&P also indicated Patient 1 had a Hickman central line (a type of central venous catheter [CVC, long, flexible tube inserted into a large vein to provide access to the heart] inserted into vein under the collarbone and tunneled under the skin of the chest wall). During a review of Patient 1’s “Anesthesia Inpatient Pain Service Note,” dated 12/3/2024, the pain consult progress note indicated, Patient 1 had acute postoperative pain and chronic pain. The pain consult progress note also indicated decreasing Dilaudid (type of opioid to treat severe pain) 0.5 milligrams (mg, a unit of measure) intravenous (IV - administered into a vein) push from every six (6) hours to every eight (8) hours. During a review of Patient 1’s “Physician Order,” dated 12/3/2024, the physician order indicated, Dilaudid 0.5 mg intravenous push every right (8) hours as needed for breakthrough pain. During a concurrent interview and record on 12/20/2024 at 11:39 a.m. with the Nurse Manager (NM) 1 at Surgical Unit, Patient 1’s “Communication Flowsheet,” dated 12/3/2024, was reviewed. The “Communication Flowsheet” indicated the following: -On 12/3/2024 at 5:39 p.m.: Registered Nurse (RN) 16 informed physician (MD) 9 that patient (Patient 1) feels like pain is not properly managed even with help from pain specialist. Patient (Patient 1) would like to relay concern to the surgeon (MD 10). -On 12/3/2024 at 8:03 p.m.: RN 16 left voicemail to on -call consultant for pain management physician on answering device. Explained that patient (Patient 1) was having pain and feels pain not being managed. Would like to get assistance if possible. Endorsed to night shift Registered Nurse. -On 12/3/2024 at 8:15 p.m.: Registered Nurse (RN) 17 tried to reach physician (MD 9) regarding patient (Patient 1) complaining of pain and wants pain regimen to be adjusted. Also patient (Patient 1) would like to speak with surgeon (MD 10). Waiting for MD 9 to reach back. -On 12/3/2024 at 9:13 p.m.: RN 17 left message to on-call consultant for pain management physician regarding patient’s (Patient 1) complaining of pain and pain was not managed. Waiting for physician to call back. -On 12/3/2024 at 9:33 p.m.: RN 17 paged on-call consultant physician (MD 11) regarding patient’s (Patient 1) pain, waiting for MD 11 to call back. -On 12/3/2024 at 11:10 p.m.: RN 17 paged physician (MD 9) again regarding patient (Patient 1) in severe pain and wanted to speak with surgeon (MD 10). No call back from MD (MD 9). -On 12/3/2024 at 11:35 p.m.: RN 17 notified MD 11 regarding patient (Patient 1) in severe pain. RN 16 asked MD 11 if it was okay to switch back to the old pain regimen. Per MD 11, ok to switch back Dilaudid 0.5 mg every six (6) hours as needed for pain. NM 1 stated RN 16 and RN 17 should have escalated to the charge nurse and supervisor for help when the physicians were not calling back. NM 1 stated Patient 1 was left in pain for 3.5 hours (from 8:03 p.m. to 11:35 p.m.). During a concurrent interview and record review on 12/20/2024 at 11:48 a.m. with NM 1, Patient 1’s “Pain Flowsheet,” dated 12/3/2024 from 5 p.m. to 11:50 p.m., was reviewed. The “Pain flowsheet” indicated Patient 1 had aching left shoulder pain with the following pain rating: -5:09 p.m., 10/10 on numeric pain scale (0-10, a pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain) -6:15 p.m., 10/10 -6:20 p.m., 6/10 -9:29 p.m., 9/10 -10:19 p.m., 7/10 -11:50 p.m., 9/10 NM 1 stated Patient 1 was in severe pain during these above referenced times. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 11/2022, the P&P indicated, “Pain is highly individual and variable and is one of the most feared aspects of illness, and one of the most common reasons for seeking healthcare interventions. The purpose of this policy is to provide guidelines for a collaborative interdisciplinary approach to pain management. The goals of pain management are: 1. Relief from physical suffering 2. Preservation or restoration of function 3. Sustained quality of life 4. Prevention of addiction ... [the facility] standard pain ranges and relationship to functional ability: A. mild: Pain level 1-3: able to do normal activities (normal activity for this patient). Pain is barely there or can be ignored. B. moderate: Pain level 4-6: this patient can do normal activities, but it is hard. Pain is often there with work, housework, socializing and hobbies. C. severe: Pain level 7-10: unable to do normal activities (for this patient). Hard or unable to think, talk to move or do activities of daily living (ADLs). Hard or unable to enjoy life because of pain ... Collaboration with providers ... nursing contacts the provider if current orders/therapies are not effective at achieving an adequate reduction in pain. These actions are documented in the electronic health record.” During a review of the facility’s policy and procedure (P&P) titled, “Chain of Command,” dated 9/2018, the P&P indicated, “to ensure safe, timely and appropriate quality care for the patient when any aspect of patient care is in question. It applies to call members of the health care team, including physicians, nurses, clinical professional, technical or other hospital personnel ... employees and physicians are expected to utilize the chain of command in situations that may cause harm to the patient, or situations where the concern(s) is/are unresolved ... if the caregiver feels that the question/concern has not been satisfactorily resolved, he/she should initiate the chain of command as follows. If the resolution of the concern is not achieved, the progressive contact should be made at the next level. 1. Medical staff chain of command: a. contact the physician in charge, b. contact the department Medical Director, c. contact the Section Chair, d. contact the Department Chair, e. contact the Medical Staff President ... 2. Administrative chain of command: a. contact the Patient Flow Coordinator (charge nurse) or Lead b. contact the department manager, c. contact the department Director, d. contact Chief Nurse Executive, f. contact the President. Chief Executive Officer, g. During evening, weekend or holidays hours, contact the House Supervisor and/or the Administrator On Call (AOC) who will consult management as needed ... B. the steps taken to resolve a problem related to the clinical management of a patient shall be documented in an objective, non-critical, unbiased and accurate manner in the patient’s medical record.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to: 1. Ensure one of 31 sampled patient’s (Patient 13) prescribed medication, Desitin (medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and skin irritations), was administered in accordance with prescribed instruction. This deficient practice could result in improper wound care management for Patient 13, potentially causing delayed healing, an increased risk of infection, a worsening of the wound condition, and subsequent health complication. 2. Ensure nursing staff gave pain medications, per physician order, for one of 31 sampled patients (Patient 3), in accordance with the facility’s policy and procedure regarding “Medication Use, Administration, Routes and High Alert Medications,” when Norco (opioid medication to treat and relieve pain) 5/325 milligrams (mg, a unit of measure) by mouth and Morphine (opioid medication to treat and relieve moderate to severe pain) 2 mg intravenous (IV - administered into a vein), were administered to Patient 3 at the same time. This deficient practice had the potential to overmedicate Patient 3 and put Patient 3 at risk for oversedation (excessive drowsiness) and respiratory distress (difficulty breathing). Findings: 1. During a review of Patient 13’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/7/2024, the “H&P” indicated Patient 13 was admitted with “past medical history of alcoholism (a chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking) and bedbound state (when someone is unable to get out of bed independently, requiring assistance to move around or change positions) who presents to the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) for evaluation of back pain ... He (Patient 13) reports pain localized to his back and reports a history of sciatica (pain that radiates into one or both legs).” The H&P further indicated Patient 13 had osteomyelitis (an infection in a bone) with extensive cellulitis (a deep infection of the skin caused by bacteria) to the back, limbs, and right heel with visible bone exposure. During a concurrent interview and record review on 12/17/2024 at 3:10 p.m. with the Quality Coordinator (QC) 1, Patient 13’s “Medication Administration Report,” with a start date on 12/11/2024, indicated Zinc oxide-cod liver oil (Desitin, medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and skin irritations) 40% ointment. Instruction: Apply 2 times daily. QC verified that Desitin was not applied on 12/14/2024 for the a.m. shift (7 a.m. to 7 p.m.). QC stated if the medication was not given, there should be documentation of the reason that the medication was omitted. Additionally, QC confirmed that there was no documentation indicating the reason that the Desitin was not administered. On 12/14/2024, the Skin/Wound/PI (Pressure Injury, a localized damage to the skin and underlying tissue caused by prolonged pressure on a specific area of the body, usually over a bony prominence, which restricts blood flow and can lead to tissue breakdown and open sores if left untreated) records indicated that for both an a.m. shift (7 a.m. to 7 p.m.) and a p.m. shift (7 p.m. to 7 a.m.), there was No wound assessment and wound care medication (Desitin) documented. QC 1 stated that Patient 13 remained on the unit on 12/14/2024. Thus, wound assessment and treatment should be completed and documented. QC 1 also confirmed that on 12/14/2024 there were no documents indicating that Patient 13 refused wound assessment and treatment. During an interview on 12/19/2024 at 12:15 p.m. with Nursing Supervisor and Wound Care (NSW), NSW stated skin and wound assessment must be completed every shift especially for Patient 13, who had pressure injury that required wound treatment 2 times a day. During a review of the facility’s policy and procedure (P&P) titled, “Medication Use, Administration, Routes and High Alert Medications,” dated September 2024, the P&P indicated, “Provide guidelines to ensure the safe administration of medications to patients at [Name of Facility]. Ensure regulatory compliance in the prescribing, dispensing, administration, and documentation of medication by authorized [name of the facility] employees ... Medication Use, Administration and routes: Meds ordered more frequently than daily but no more frequently than every scheduled time 4 hours, Administer up to 1 hour before or after the scheduled time. During a review of the facility’s policy and procedure (P&P) titled, “Wound Care Assessment & Treatment” dated February 2021, the P&P indicated, “Patient Assessment: All patients admitted to [Name of Facility] will have their skin integrity assessed by a RN within eight (8) hours of admission. Skin integrity assessment will be performed by an RN at least once a shift ...” 2. During a review of Patient 3’s History and Physical (H&P), dated 12/15/2024, the H&P indicated, Patient 3 was admitted to the facility with diagnoses of diabetes (high blood sugar), right lower leg abscess (a pocket of pus formed any part of the body) with cellulitis (an infection of the deeper layers of skin and the underlying tissue). The H&P also indicated Patient 3 required surgical evaluation for possible debridement (a medical procedure that removed damaged, dead or infected tissue) and drainage (the process of removing fluid from a wound). During a review of Patient 3’s “Pain Flowsheet,” dated 12/15/2024, the pain flowsheet indicated, on 12/15/2024 at 8 p.m., Patient 3 had pain rating of six (6) on numeric pain scale (0-10, a pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain) at right ankle. During a concurrent interview and record review on 12/18/2024 at 10:57 a.m. with the Process Excellence Specialist (SRN), Patient 3’s “Medication Administration Record (MAR, record of medications given to patients),” dated 12/15/2024, was reviewed. The MAR indicated Norco (opioid medication to treat and relieve pain) 5/325 milligrams (mg, a unit of measure) 1 tablet by mouth was given on 12/15/2024 at 10:10 p.m. and Morphine (opioid medication to treat and relieve moderate to severe pain) 2 mg intravenous (IV - administered into a vein) was given on 12/15/2024 at 10:10 p.m. by Registered Nurse (RN) 14. SRN stated the two medications were given for Patient 3’s pain level 6/10. During a review of Patient 3’s “Physician orders,” dated 12/15/2024, the physician orders indicated the following: -Diabetic Diet (a special diet for patients with high blood sugar); -Norco 5/325 mg one tablet every four (4) hours as needed for moderate pain (6-10); -Morphine injection 2 mg intravenous push (IVP) every four (4) hours as needed for moderate pain (4-6) if NPO or patient cannot tolerate PO. During an interview on 12/19/2024 at 11 a.m. with the Nurse Manager (NM) 1 at Surgical Unit (a hospital ward where patients are cared and treated before and after surgery) 1 and 2, NM 1 stated RN 14 should only give either Norco 3/325 mg or Morphine 2 mg to Patient 3 but not both medications. NM 1 stated RN 14 did not follow physician order. NM 1 stated giving both medications could over medicate Patient 3 and could put Patient 3 at risk for over sedation (excessive drowsiness) and result in respiratory distress (difficulty breathing). During a review of the facility’s policy and procedure (P&P) titled, “Medication Use, Administration, Routes and High Alert Medications,” dated 9/2024, the P&P indicated, “Purpose: Provide guidelines to ensure the safe administration of medications to patients at [the facility] ... Six rights of medication administration ... the licensed caregiver reviews the six rights prior to administering medication: 1. Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time and/or frequency 6. Right reason/ indication and the right monitoring following administration.””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 46238 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1.a. The facility failed to follow State and Federal regulatory standards regarding nurse-to-patient ratios (number of patients a registered nurse can care for at one time) and safe patient care assignments when Registered Nurses (RNs) cover each other for meal breaks (30 minutes lunch break) in three (3) of three sampled units (Cardio- Thoracic unit [CTU, a unit that specializes in the care of patient with heart, lungs, and chest conditions], Surgical-Trauma unit [STU, 32 bed unit, specializing in the delivery of care to the general surgical patients and post-operatively], and the Direct Observation Unit [DOU, unit that provides the second-highest level of care]). The nurse-to-patient ratio in CTU and STU was either 1: 4 or 1: 5 (one nurse to 4 or 5 patients) while DOU was 1: 3 (one nurse to 3 patients). When covering meal breaks, each RN assumed the care of additional 3 or 4 patients aside from their own assigned 3, 4 or 5 patients. This deficient practice had the potential to result in patient needs not being met (Refer to A-0392) 1.b. The facility failed to ensure Patient Flow Coordinators (Charge Nurses) remained free of direct patient care duties that prevented charge nurses from fulfilling the functions of the Patient Flow Coordinator (PFC) or (Charge Nurse) role, when charge nurses were assigned as the PFC (PFC or Charge Nurse, oversee the operations of their specific nursing unit during a set period while working alongside the team) and had patient assignments of their own concurrently for one of 3 sampled Charge Nurses (CN 3). This deficient practice resulted in CN 3 being unable to fulfill assigned Charge Nurse duties and also had the potential to compromise the quality of care provided to patients. (Refer to A-0392) 2. The facility failed to ensure the registered nurse (RN 20) provided oversight over licensed vocational nurse’s (LVN1) assessments for one of 30 sampled patients (Patient 24), in accordance with the facility’s policy and procedure regarding assessment (in depth evaluation conducted by a registered nurse that evaluates a patient’s current physical, mental and emotional state) and reassessment and professional standards of practice. This deficient practice resulted in assessments documented by LVN1 without RN 20’s oversight and had the potential for an inaccurate assessment of Patient 24’s condition which may result in Patient 24’s care needs not being addressed. (Refer to A-0395) 3.a. The facility failed to ensure Nursing staff developed, maintained and nursing updated care plans (provides a framework for evaluating and providing patient care needs related to the nursing process) specific to infection control and diarrhea (frequent watery stools) for one of 30 sampled patients (Patient 8). This deficient practice had the potential to result in the delay of treatment by not identifying the patient’s (Patient 8) needs and risks, which may result in worsening of the patient’s (Patient 8) condition and prolonged hospitalization. (Refer to A-0396) 3.b. The facility failed to ensure nursing staff develop the nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for hemodialysis (a machine filters wastes, salts and fluid from the blood when kidneys are no longer functioning) management for one of 30 sampled patients (Patient 22). This deficient practice had the potential to result in Patient 22 not knowing how to manage hemodialysis including how to manage new dialysis catheter (device used during hemodialysis). (Refer to A - 0396) 4.a. The facility failed to ensure the dialysis nurse had dialysis (dialysis machine cleans blood and moves it back into the body) vascular access (an access point for the dialysis machine to connect to the blood stream) site and the blood line connections continuously visible throughout the dialysis treatment for one of 30 sampled patients (Patient 1) in accordance with the facility’s policy and procedure regarding dialysis monitoring. This deficient practice had the potential to compromise Patient 1’s well-being if an accidental disconnection of a line went undetected which may result in complications such as bleeding, etc. (Refer to A-0398) 4.b. The facility failed to ensure nursing staff followed infection precautions guidelines (example: hand hygiene, use of gloves and masks) for one of 30 sampled patients (Patient 8), when one of one Registered Nurse (RN 18) used a hand sanitizer (alcohol based gel or liquid used to kill some forms of germs or infectious bacteria) after coming out of an isolation precaution (used to reduce transmission of microorganisms in the healthcare setting) patient room (Patient 18) instead of washing hands with soap and water in accordance with the facility’s policy and procedure on infection control. This deficient practice had the potential to cross-contaminating (when bacteria or other microorganisms are unintentionally transferred from one object to another) other patients and staff with infectious micro-organisms, which may cause patients and staff to get sick. (Refer to A-0398) 4.c. The facility failed to label the administration set for Intravenous (IV) infusion (a method of putting fluids, including drugs, into the bloodstream) with the date, time hung, and personnel’s initials for one of 30 sampled patients (Patient 6) in accordance with the facility’s policy and procedure regarding labeling administration set for IV infusions after 72 hours from the time the IV tubing was used. This deficient practice had the potential to place Patient 6 at risk for phlebitis (inflammation of the walls of a vein) or contamination (growing microorganisms, that may cause infections) associated with catheter (a device used to draw blood and give treatments) related bloodstream complications. (Refer to A-0398) 4.d. The facility failed to discontinue an order for physical restraints (any physical or mechanical device material or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body or head freely, or prevent the patient from voluntary exiting the bed) and remove restraints from the room of one of 30 sampled patients (Patient 10) in accordance with the facility’s policy and procedure regarding the use of restraints. This deficient practice had the potential to compromise Patient 10’s safety due to unnecessary use of restraints, which may result in complications such as skin tear, etc. (Refer to A-0398) 4.e. The facility failed to complete a pain reassessment (a process where a nurse reevaluates a patient’s health information for new information or changes) for one of 30 sampled patients (Patient 13) after pain medications were given. This deficient practice had the potential for delayed medical care and treatment to Patient 13, when Patient 13’s response to medication is not reassessed on time thus preventing the use of other alternative methods to relieve Patient 13’s pain. (Refer to A-0398) 4.f. The facility failed to provide an interpreter and consent forms in a language the patient can understand for one of 30 sampled patients (Patient 14), during the informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) process in accordance with the facility’s policy and procedure regarding the use of translator/interpreter services (facilitates communication between healthcare providers and non-English speaking patients to provide the best possible quality of care). This deficient practice had the potential for Patient 14 to not understand the medical care and procedures Patient 14 was consenting to and may lead to unwanted medical care and procedures. (Refer to A-0398) 4.g. The facility failed to ensure staff followed the facility’s policy and procedure on proper intravenous tubing (IV tubing, used to deliver medications to the vein via a machine pump) labeling and handling for one of 30 sampled patients (Patient 25) as the IV tubing was not labeled and covered with sterile cap (cap to cover endling of the IV tubing to prevent infection). This deficient practice had to potential for Patient 25 to develop infection due to contaminated IV line. (Refer to A-0398) 4.h. The facility failed to ensure staff to use translator service (facilitates communication between healthcare providers and non-English speaking patients to provide the best possible quality of care) based on patient’s language preference in Spanish when obtaining for informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) for one of 30 sampled patients (Patient 22) in accordance with the facility’s policy and procedure regarding the use of translator/interpreter services. This deficient practice had the potential for Patient 22 not receiving accurate and current information in the language Patient 22 could understand which might result in Patient 22 not understanding information regarding his (Patient 22) treatment plan. (Refer to A-0398) 4.i. The facility failed to ensure nursing staff documented date and time when obtaining telephone informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) from the emergency contact for one of 30 sampled patients (Patient 27) in accordance with the facility’s policy and procedure regarding informed consents. This deficient practice had the potential to result in causing confusion and violate Patient 27’s rights as it was unknown if the informed consent obtained was before or after the procedure. (Refer to A-0398) 4.j. The facility failed to ensure nursing staff documented the type of restraints (a physical restraint is any manual method, material or equipment that is attached to patient’s body that cannot be easily removed and restricts freedom of movement) use and alternative interventions for one of 30 sampled patients (Patient 26) from 2/16/2024 to 2/18/2024, in accordance with the facility’s policy and procedure regarding restraints use and documentation. This deficient practice had the potential to result in unnecessary use of restraints on Patient 26 as it was lacking alternative intervention attempt and unclear what type of restraints being used on Patient 26 putting Patient 26 at risk for injury and delaying removal of restraints. (Refer to A-0398) 5. The facility failed to ensure nursing staff gave medications only ordered by a physician when a Registered Nurse (RN 17) gave insulin Lispro (insulin to treat control blood sugar) to one of 30 sampled patients (Patient 21) without a physician order. This deficient practice had the potential for Patient 21 not getting appropriate insulin (medication used to lower blood sugar via injection) dosage to manage the elevated blood glucose (blood sugar), which may result in complications such as excessively low blood sugar, coma (state of prolonged loss of consciousness) or death. (Refer to A-405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48186 Based on observation, interview, and record review, the facility failed to correctly and safely apply non-violent ankle restraints (soft restraint [any physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move freely] used to manage behaviors which interfere with medical care) for one of 30 sampled patients (Patient 11), in accordance with the facility’s policy and procedures regarding restraints use. This deficient practice had the potential to cause injury or death to Patient 11 such as skin tear, etc. Findings: During a review of Patient 11’s Face Sheet (a document that gives a patient’s information at a quick glance), dated 2/19/2024, the Face Sheet indicated Patient 11 was admitted to the facility on 2/19/2024 at 11:56 a.m. with diagnoses of alcohol withdrawal (reduction in alcohol use after a period of excessive use) and seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). During a concurrent observation and interview on 2/21/2024 at 11:25 a.m. with Nurse Manager 3 (NM 3), Patient 11 was observed in non-violent ankle restraints (soft restraint [any physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move freely] used to manage behaviors which interfere with medical care) to both ankles, a roll belt restraint (belt applied around the torso to protect the patient from rolling out of bed and falling to the floor), and a patient sitter, while lying flat on his (Patient 11’s) back. NM 3 said that ankle restraints were applied to Patient 11’s ankles because the patient kicked facility staff. When Patient 11’s blanket was removed by NM 3, observed Patient 11’s ankle restraint straps attached and clipped together. NM 3 stated that this is not the correct way to apply ankle restraints and that the restraints should be individually applied to the patient and not clipped or tied together. Observed NM 3 unclip Patient 11’s ankle restraints and apply the straps individually to each ankle restraint, so each leg was restrained individually. NM 3 checked each ankle restraint strap which was tied to the bed frame with a slipknot (knot that is secured, but can be easily released in an emergency, using one hand). NM 3 stated that the ankle restraints should be tied to the bed individually so the patient can move freely. During an observation on 2/21/2024 at 11:37 a.m. with Patient 11, observed Patient 11 reposition himself to lay on his (Patient 11’s) right side following ankle restraint readjustment by NM 3. During a concurrent observation and interview on 2/21/2024 at 11:32 a.m. with Registered Nurse 10 (RN 10), RN 10 stated that she (RN 10) was the primary nurse assigned to Patient 11. RN 10 was made aware NM 3 adjusted Patient 11’s ankle restraints because they were applied incorrectly, with the straps clipped together. RN 10 said that she (RN 10) was unaware Patient 11’s restraints were previously incorrectly applied, with the restraints clipped together, and she was unaware who applied them incorrectly. RN 10 stated that she (RN 10) last checked Patient 11’s restraints at 10 a.m., and that Patient 11’s ankle restraints were applied individually during her last assessment. Observed RN 10 demonstrate the application of ankle restraints with the restraints individually applied and strap tied to the bed frame with a slipknot. RN 10 said that if restraints were not applied correctly, there is not enough room for the patient to do range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point) and movement was restricted. During an interview on 2/21/2024 at 10:11 a.m. with Nursing Professional Development Specialist (EDU), EDU stated that if ankle restraints were incorrectly applied, this was a safety issue, and the patient can have problems with ROM. During a concurrent interview and record review on 2/23/2024 at 12:30 p.m. with Nurse Manager of Medical-Surgical (NM 2), RN10’s skilled validation checklist titled, “Restraints Application: Acute Care and Emergency Department,” dated 4/13/2023, was reviewed. NM 2 verified that there were no ankle restraints included in the skills validation checklist. NM 2 stated ankle restraints should have been included in the skills validation checklist because it was important for staff to know how to use and apply ankle restraints correctly, otherwise it could lead to patient injury. During a review of the facility’s Policy and Procedure (P&P), dated 2/2022, titled “Restraints and Seclusion (involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving),” the P&P indicated: “Purpose: To guide the appropriate and safe management of adult and pediatric patients who are restrained and/or in seclusion. To guide on appropriate utilization of alternatives to restraint and/or seclusion, as well as nonphysical interventions ... V. Restraint Category A. Non-Violent or Non-Self Destructive 1. Used to promote healing and improve the patient’s well-being ... II. Selecting the Least Restrictive Type: The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm ... G. Limb Holder (soft), wrist and/or ankle (1-4) points ... Safe Application of Restraints A. Restraints will be applied correctly and appropriately according to the manufacturer’s recommendation by competent, trained staff ... C. Soft restraint straps will be secured to the bed frame (not to side rails) using a quick-release buckle supplied with the restraint, or tied such that they can be released quickly and easily in an emergency ...””

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to: 1. Follow State and Federal regulatory standards regarding nurse-to-patient ratios (number of patients a registered nurse can care for at one time) and safe patient care assignments when Registered Nurses (RNs) cover each other for meal breaks (30 minutes lunch break) in three (3) of three sampled units (Cardio- Thoracic unit [CTU, a unit that specializes in the care of patient with heart, lungs, and chest conditions], Surgical-Trauma unit [STU, 32 bed unit, specializing in the delivery of care to the general surgical patients and post-operatively], and the Direct Observation Unit [DOU, unit that provides the second-highest level of care]). The nurse-to-patient ratio in CTU and STU was either 1: 4 or 1: 5 (one nurse to 4 or 5 patients) while DOU was 1: 3 (one nurse to 3 patients). When covering meal breaks, each RN assumed the care of additional 3 or 4 patients aside from their own assigned 3, 4 or 5 patients. This deficient practice had the potential to result in patient needs not being met. 2. Ensure Patient Flow Coordinators (Charge Nurses) remained free of direct patient care duties that prevented charge nurses from fulfilling the functions of the Patient Flow Coordinator (PFC) or (Charge Nurse) role, when charge nurses were assigned as the PFC (PFC or Charge Nurse, oversee the operations of their specific nursing unit during a set period while working alongside the team) and had patient assignments of their own concurrently for one of 3 sampled Charge Nurses (CN 3). This deficient practice resulted in CN 3 being unable to fulfill assigned Charge Nurse duties and also had the potential to compromise the quality of medical care delivered to patients. Findings: 1. During an interview on 2/22/2024 at 8:00 p.m. with the patient flow coordinator (charge nurse- CN 12) working at the Cardio-Thoracic Unit (CTU- a unit that specializes in the care of patients with heart, lungs, and chest conditions), CN 12 stated, the facility staffing grid (planning tools that assign the appropriate amount of staff to care for the number of patients in the unit) for the CTU required the Registered Nurses (RNs) are staffed at 1:5 or 1:4 (1 RN to 4 or 5 patient) ratios (number of patients a registered nurse can care for at one time), and should have a charge nurse, 8 nurses, 4 CNAs and a break nurse. CN 12 stated, when there was no break relief nurse (covers the 15 minutes and the 30 minutes meal break) on duty, if charge nurse was unable to cover staff RN for their breaks, nurses cover each other for break relief, and are forced to go out of ratio (when 1 RN who had 4 or 5 patients assumes the care of additional 4 or patients from another RN going on break) which may diminish the quality of patient care making it difficult to meet patient needs. During an interview on 2/22/2024 at 8:10 p.m. with Patient Flow Coordinator (Charge Nurse -CN 11) working at the Surgical Trauma Unit (STU- a 32 bed unit, specializing in the delivery of care to the general surgical patients and post-operatively), CN 11 stated, the STU assignments were made based on State Regulations, and Registered Nurses (RNs) are staffed at 1:5 (1 RN to 5 patients) for medical surgical patients and 1:4 (1 RN to 4 patients) for patients with telemetry (patients undergo continuous cardiac [heart] monitoring). CN 11 further stated, per facility’s staffing grid requirements, the unit should have a charge nurse, 8 RNs, 4 Certified Nursing Assistants or Patient Care Providers (PCPs), and ideally a break nurse to cover nurses for rest breaks and lunches. CN 11 further said, there were numerous shifts the facility did not provide a break nurse to cover breaks and lunches and nurses had to cover each other for their breaks, which forces them out of ratio when they cover each other during their 30 minutes lunch breaks and two 10-minute rest breaks. CN 11 further stated, when the unit was not sufficiently staffed, patient care delivery was compromised. During an interview on 2/22/2024 at 8:20 p.m. with the Patient Flow Coordinator (Charge Nurse- CN 13) working nights at the Direct Observation unit (DOU, a unit that provides the second-highest level of care), CN 13 stated, the facility’s DOU unit specializes in caring for very sick patients. CN 13 said, the facility’s staffing grid requires the DOU to be staffed with 11 RNs, 3 CNAs, and ideally there should be a break nurse provided. CN 13 further stated, “Lately, the facility is unable to provide break relief nurses for the unit.” CN 13 stated, when there was no break nurse relief to cover nurses on their breaks, nurses have to go out of ratio (DOU staffed at 1:3 (1 RN to 3 patients) when covering each other for breaks. CN 13 stated, the DOU unit had high acuity (means that patients’ condition is severe and imminently dangerous) patients and when the staffing grid was not met for the unit, patients may not be receiving the best quality care as they should. During an interview on 2/23/2024 at 11:53 a.m. with the Director of Clinical Resource (DCR), DCR stated, the facility provided staffing budget for break nurses but at times staffing the floors with break nurses can be difficult. DCR further stated, for the facility to meet the staffing grid requirements and supplement for adequate staffing, the facility brings registry nurses and hires traveler nurses, but staffing was not an easy task in the last couple of months. DCR also stated, charge nurses occasionally must take on patient assignments while also continuing to perform charge nurse’s duties on the assigned unit and nurses cover each other on their 30 minutes rest periods which places them briefly out of ratio while caring for their patients. During a concurrent interview and record review on 2/23/2024 at 11:58 a.m. with DCR, the Cardio-Thoracic unit’s Break Assignment Sheet (BAS) for the night shift (7 p.m.-7 a.m.), dated 2/18/2024, was reviewed. The BAS indicated, PFC (Charge Nurse) had 4 assigned patients while being assigned charge nurse (PFC) duties; all licensed nurses had 4 patients assigned to them, and all licensed nurses had to cover each other for breaks (two 15 min breaks, and 30-minute lunch). DCR stated, when nurses cover each other for their breaks, they are going out of ratio, because they must cover additional 4 patients during the entire break period. DCR further stated, when nurses are under- staffed, patients may not receive the proper care and may not be properly monitored. During an interview on 2/23/2024 at 12:23 p.m. with the nurse manager (NM 4) of the Surgical Trauma Unit (STU), NM 4 stated, nursing core staffing for the STU required 8 to 9 nurses to be scheduled daily. NM 4 also stated, nurses should not be covering each other for meal breaks, and should not take meal breaks if unable to, because the facility reimburses nurses for their missed meal breaks. During an interview on 2/23/2024 at 1:24 p.m. with Registered Nurse (RN) 11, working in DOU, RN 11 stated, the facility often was unable to staff the floor with a break nurse and nurses cover each other for lunches and rest breaks. RN 11 said, the RN’s staffing ratio in this unit was 1:3 (1 RN to 3 patients), and when nurses cover each other for their meal relief breaks, nurses go out of ratio, often overseeing 6 patients at a time. During an interview on 2/23/2024 at 1:35 p.m. with Registered Nurse (RN) 12, working in DOU, RN 12 stated, nurses do not have an option to miss their meal breaks, and when there was no break relief nurse, nurses cover each other for their breaks, caring for 6 patients while covering. During a review of the facility’s STU Unit Assignment Sheets (UAS), dated 2/17/2024 and 2/18/2024, night shift, the UAS indicated, on both dates, charge nurse was assigned charge nurse duties, while taking care of 4 patients. During a review of the facility’s CTU Unit Assignment Sheets (UAS), dated 2/16/2024, 2/17/2024, and 2/21/2024, night shift, nurses covered each other for break relief. During a review of the facility’s 5 CTU Unit Assignment Sheet (UAS), dated 2/20/2024, day shift, the assignment indicated, nurses covered each other for their meal breaks. During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for the Provision of Patient Care Services,” dated 9/1/2020, the P&P indicated, “Patient care is directed, organized, and staffed on the basis of the identified needs of the patient. Staffing a patient care unit with patient care personnel is guided by a patient classification system, patient acuity (measure of a patient’s severity of illness), and mandated staffing ratios (the maximum number of patients a nurse can be responsible for in a shift).” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for the Provision of Patient Care Services,” dated 9/1/2020, the P&P indicated, “Staffing is assessed and adjusted on an ongoing basis to provide optimal patient care. Schedules are adjusted on an ongoing basis to meet patient care demands and may include adding additional staff, re-assignment of staff, or modification of the care delivery model.” During a review of the facility’s policy and procedure (P&P) titled, “Meal and Rest Periods,” dated 1/22/23, the P&P indicated, “Managers are responsible for providing meal periods and authorizing and permitting rest periods to the staff in accordance with the policy. Managers and their designees may not impede or discourage employees from taking meal and or rest periods in accordance with the policy.” 2. During an interview on 2/22/2024, at 8:00 p.m., with patient flow coordinator (Charge Nurse- CN 12) working at the Cardio-Thoracic Unit (CTU, a unit that specializes in the care of patients with heart, lungs, and chest conditions), CN 12 stated, the facility staffing grid (planning tools that assign the appropriate amount of staff to care for the number of patients in the unit) for the unit required the Registered Nurses (RNs) are staffed at 1:5 or 1:4 (1 RN to 4 or 5 patients) ratios, and should have a charge nurse, 8 nurses, 4 CNAs and a meal break nurse. CN 12 stated, typically, the floor should have a charge nurse on duty, but often, the charge nurse must take on patients’ assignments while they continue performing charge nurse duties. During an interview on 2/22/2024 at 8:10 p.m. with the Patient Flow Coordinator (Charge Nurse -CN 11) working at the Surgical Trauma Unit (STU -32 bed unit, specializing in the delivery of care to the general surgical patients and post-operatively), CN 11 stated, the unit assignments were made based on State Regulations, and Registered Nurses (RNs) were staffed at 1:5 (1 RN to 5 patients) for medical surgical patients and 1:4 (1 RN to 4 patients) for patients with telemetry (patients undergo continuous cardiac [heart] monitoring). CN 11 further stated, per facility’s staffing grid requirements, the unit should have a charge nurse. CN 11 further stated, lately, the unit charge nurses working night shifts had to take on patient assignments in addition to performing charge nurse duties due to insufficient staffing. During an interview on 2/22/2024 at 8:20 p.m. with the Patient Flow Coordinator (Charge Nurse- CN 13) working nights at the Direct Observation unit (DOU- a unit that provides the second-highest level of care), CN 13 stated, the facility’s DOU specializes in caring for very sick patients. CN 13 said, the facility’s staffing grid required the DOU to be staffed with 11 RNs, 3 CNAs, and ideally there should be a break nurse provided. CN 13 further stated, “Lately, the facility is unable to provide break relief nurses for the unit and as a charge nurse, I often go into care myself, while continuously providing support for the unit as a charge nurse, carrying on the charge nurse’s duties because we have registry nurses, that often need help, we have nurses that need guidance, and we have orientees.” During an interview on 2/23/2024 at 11:53 a.m. with the Director of Clinical Resource (DCR), DCR stated, charge nurses occasionally must take on patient assignments while also continuing to perform charge nurse’s duties on their assigned units. During a concurrent interview and record review on 2/23/2024 at 11:58 a.m. with DCR, the Cardio-Thoracic Unit Break Assignment Sheet (BAS) for the night shift (7 p.m.-7 a.m.), dated 2/18/2024, was reviewed. The BAS indicated, PFC or Charge Nurse (CN 3) had 4 assigned patients while being assigned charge nurse (PFC) duties. During an interview on 2/23/2024 at 12:23 p.m. with the nurse manager (NM 4) of the STU, NM 4 stated, nursing core staffing for the unit required 8 to 9 nurses to be scheduled daily. NM 4 further stated, the goal was to always have a charge nurse (or also called Patient Flow Coordinator, PFC) present in the unit, but occasionally, PFCs needed to take patient assignments to maintain nurses in the ratio (Ratio of 1 RN to4 Patients or 1 RN to 5 Patients). During a review of the facility’s STU Unit Assignment Sheets (UAS), dated 2/17/2024 and 2/18/2024, night shift, the UAS indicated, on both dates, charge nurse was assigned charge nurse duties, while taking care of 4 patients. During an interview on 2/23/2024 at 1:24 p.m. with Registered Nurse (RN) 11, working in DOU, RN 11 stated charge nurses were expected to take patients assignments if necessary while continue performing charge nurse’s duties. During a review of a document titled, “Patient Flow Coordinator-Job description,” dated, 5/2023, the document indicated, “ Position of a Patient Flow Coordinator (PFC) entails the following responsibilities: coordination and management of patient flow operatives to meet department needs to ensure an efficient operation of the department by directing functions and activities: interpreting policies and procedures, standards, and regulation as applicable, provides clinical leadership of the unit’s patient care team; plans for the timely completion of intake and discharge care processes and utilizes the nursing process to provide population specific patient care; Initiation and supervision of discharge planning with the RN; ensures patients safety, performs all the responsibilities and duties required by the assigned Unit/Division to ensure that the unique needs of the patient are addressed; actively participates in the Code Blue Response Team” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for the Provision of Patient Care Services,” dated 9/1/2020, the P&P indicated, “Patient care is directed, organized, and staffed on the basis of the identified needs of the patient. Staffing a patient care unit with patient care personnel is guided by a patient classification system, patient acuity (measure of a patient’s severity of illness), and mandated staffing ratios (the maximum number of patients a nurse can be responsible for in a shift).””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure the registered nurse (RN 20) provided oversight over licensed vocational nurse’s (LVN1) assessments for one of 30 sampled patients (Patient 24), in accordance with the facility’s policy and procedure regarding assessment (in depth evaluation conducted by a registered nurse that evaluates a patient’s current physical, mental and emotional state) and reassessment and professional standards of practice. This deficient practice resulted in assessments documented by LVN1 without RN 20 oversight and had the potential for an inaccurate assessment of Patient 24’s condition which may result in Patient 24’s care needs not being addressed. Findings: During a review of Patient 24’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/16/2024, the H&P indicated, Patient 24 was admitted to the facility’s rehabilitation unit (assists patients recovering from a serious injury, illness or surgery to regain strength) for physical therapy (helps manage movement and reduce pain in people with various conditions) and occupational therapy (assists patients to improve the skills that are needed to live life as independently as possible) after sustaining a fall (an unplanned descent to the floor with or without injury to the patient) with multiple fractures (broken bones) at left leg and left hip. During an interview on 2/23/2024 at 1:10 p.m. with nurse manager (NM2) of the Medical-Surgical Unit (serves the general population hospitalized for various cases such as surgery, etc.), NM2 stated registered nurses in the rehabilitation unit were responsible to oversee licensed vocational nurse’s patients as assigned. The covering RN was required to co-sign and validate the findings documented by the LVN. During a review of the Rehabilitation unit’s Patient assignment sheet dated 2/19/2024, the Patient assignment sheet indicated LVN1 was the assigned primary nurse for Patient 24, while RN 20 would cover (to co-sign and validate assessments) LVN1 for Patient 24. During a concurrent interview and record review on 2/23/2024 at 2:38 p.m. with the nurse manager (NM2) of Medical-Surgical Unit, Patient 24’s “Shift Assessment (nursing assessment, documentation of nursing assessment for patient in Rehab),” dated 2/19/2024 was reviewed. The nursing assessment indicated LVN1 recorded the nursing assessment on 2/19/2024 at 8 a.m. NM2 verified that there was no RN sign off on the nursing assessment recorded by LVN1. NM2 stated assessment was considered not done if it was not signed off and validated by a RN. NM2 also said RN 20 should have co-signed and validated LVN1’s findings in the shift assessment for Patient 24 to ensure it was correct in order to identify patient’s change of condition and modify plan of care. During a review of the facility’s policy and procedure (P&P) titled, “Scope of Service,” dated 1/2024, the P&P indicated, “Patient Monitoring: Assessments are done every shift and as needed based on the patient’s medical status.” During a review of the facility’s job description for Licensed Vocational Nurse at Physical Rehab Care with no date, the job description indicated, “[LVN] are responsible for performing nursing services requiring technical and manual skills under the direction of the Registered Nurse or Physician.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure: 1. Nursing staff developed, maintained and nursing updated care plans (provides a framework for evaluating and providing patient care needs related to the nursing process) specific to infection control and diarrhea (frequent watery stools) for one of 30 sampled patients (Patient 8). This deficient practice had the potential to result in the delay of treatment by not identifying the patient’s (Patient 8) needs and risks, which may result in worsening of the patient’s (Patient 8) condition and prolonged hospitalization. 2. Nursing staff developed the nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for hemodialysis (a machine filters wastes, salts and fluid from the blood when kidneys are no longer functioning) management for one of 30 sampled patients (Patient 22). This deficient practice had the potential to result in Patient 22 not knowing how to manage hemodialysis including how to manage newl dialysis catheter (device used during hemodialysis). Findings: 1. During a review of Patient 8’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/18/2024, the H&P indicated, Patient 8 was admitted after a syncopal (fainting or passing out) episode and fall (an unplanned descent to the floor with or without injury to the patient). The H&P further indicated, Patient 8’s Past Medical History (PMH, the total sum of a patient’s health status prior to the presenting problem) included abdominal infections leading to multiple surgeries and a colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen) and ileostomy (an opening in the abdomen that’s made during surgery to divert a piece of the small intestines), diabetes mellitus (a disease of inadequate control of blood levels of sugar), hypertension (the pressure in the blood vessels is above normal limits; normal BP 120/90 millimeters of Mercury [mmHg- a unit of measurement]) and chronic anemia (a condition in which the body does not have enough healthy red blood cells to carry oxygen). During a review of Patient 8’s medical record (MR) titled, “Infectious Disease Consultation Note,” dated 2/20/2024, the MR indicated, Patient 8 had had diarrhea (a lot of loose stool output) and was ordered to have stool tested for the presence of gastrointestinal (GI, relating to the stomach and the intestines) pathogens (microorganism that can cause disease.)and C. difficile (Clostridioides difficile or C. difficile is a germ (bacterium) that causes diarrhea and inflammation of the colon). During a review of Patient 8’s medical record (MR) titled, “Order History,” dated 2/20/2024, the MR indicated, the physician placed a continuous (until specified otherwise) order for isolation for “Contact Plus Precautions (Contact precautions isolation is intended to prevent transmission of infectious agents, which are spread by direct and indirect contact with the patient or the patient’s environment and requires all staff interacting with the patient to wash hands with soap and water upon exiting the room instead of using alcohol rub because specific infectious organisms are not affected by the alcohol).” During a concurrent interview and record review on 2/22/2024 at 3:35 p.m. with informatics nurse specialist (INS), Patient 8’s medical record (MR) titled, “Care Plans-Encounter Problems,” dated 2/18/2024, last updated 2/22/2024, was reviewed. The MR indicated, nursing developed three care plans for Patient 8 to address risk for falls, pain, and impaired skin integrity. INS stated, no infection control and diarrhea care plans were developed, maintained, and updated by nursing for Patient 8. During an interview on 2/23/2024 at 12:18 p.m. with nurse manager (NM 4), NM 4 stated, nursing staff should develop and update care plans for their patients. NM 4 further stated, each patient care plan must be individualized, based on patients’ specific needs, because it allows nurses to plan for meeting patients’ goals and monitoring the progress toward achieving goals. NM 4 further stated, if a patient is in “Isolation” status, there should be a care plan for isolation precautions (used to reduce transmission of microorganisms in healthcare settings). During an interview on 2/23/2024 at 1:24 p.m, with Registered Nurse (RN 11), RN 11 stated, a patient’s care plan should be specific to the patient’s diagnosis and is developed upon admission with specific goals and should be updated every shift to be able to track patient’s progress toward meeting the goals. During an interview on 2/23/2024 at 1:35 p.m. with Registered Nurse (RN 12), RN 12 stated, patient care plan should be specific to the patient’s diagnosis. The RN 12 further stated, if patient for instance had dialysis ordered, the care plan should be developed for the fluid and electrolyte imbalances, pain, and breathing pattern. During a review of the facility’s policy and procedure (P&P) titled, Interdisciplinary Plan of Care (IPOC),” dated 9/2020, the P&P indicated, “Nursing staff must develop and keep current nursing care plan for each patient. Each patient should receive care based on individualized IPOC because aspects of patient care, such as teaching, interventions, referrals, discharge planning, follow up, changes in plan are linked with the interdisciplinary plan of care.” 2. During a review of Patient 22’s nephrology consultation (physician examination and recommendation completed by kidney specialist), dated 2/20/2024, the consultation note indicated Patient 22 was admitted to the facility with diagnoses of hyperkalemia (high level of the electrolyte potassium in blood), and kidney failure (a condition in which kidneys are not functioning). The consultation note also indicated Patient 22 would be undergoing his first hemodialysis (a machine filters wastes, salts and fluid from the blood when kidneys are no longer functioning) on 2/21/2024 as part of the treatment plan. During a concurrent interview and record review on 2/22/2024 at 10:35 a.m. with the Patient Safety Officer (PSO), Patient 22’s care plan (provides a framework for evaluating and providing patient care needs related to the nursing process), dated 2/20/2024, was reviewed. The care plan indicated nursing had identified acute pain and risk for fall for Patient 22 as active problems on care plan. PSO stated the care plan was not complete because it did not address Patient 22’s diagnosis and his (Patient 22) needs. PSO further stated Patient 22’s care plan should have addressed fluid imbalance (occurs when you lose more fluid or water than your body can take in), electrolytes imbalance (occurs when certain mineral levels in your blood get too high or too low), and hemodialysis so that nursing staff can provide proper intervention and education for Patient 22. PSO further stated, otherwise it (lack or absence of a specific care plan) could result in difficulty in continuum of care, inconsistency in documentation and difficulty in evaluating Patient 22’s response to care. During an interview on 2/23/2024 at 11:21 a.m. with the Clinical Nurse Specialist (CNS), CNS stated the care plan should address Patient 22’s diagnoses and chief complaint and identify problems by talking to Patient 22. Patient 22’s care plan should have at least addressed knowledge deficit related to hemodialysis because he (Patient 22) was new to hemodialysis so that nursing staff can provide teaching on what to expect during hemodialysis and how to take care of the new dialysis catheter (device used during hemodialysis). During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care,” dated 9/2020, the P&P indicated, “Each patient will receive care based on an individualized IPOC (interdisciplinary plan of care) in collaboration with the interdisciplinary team ...Plan of care: a communication tool that identifies and prioritizes patient care and treatment needs including outcomes, interventions, indicators and goals ... A nursing IPOC is developed based on assessing the patient’s needs upon admission from all available sources of assessment to develop a comprehensive picture of the patients’ condition.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 46238 Based on observation, interview, and record review, the facility failed to: 1. Ensure the dialysis nurse had dialysis (dialysis machine cleans blood and moves it back into the body) vascular access (an access point for the dialysis machine to connect to the blood stream) site and the blood line connections continuously visible throughout the dialysis treatment for one of 30 sampled patients (Patient 1) in accordance with the facility’s policy and procedure regarding dialysis monitoring. This deficient practice had the potential to compromise Patient 1’s well-being if an accidental disconnection of a line went undetected which may result in complications such as bleeding, etc. 2. Ensure nursing staff followed infection precautions guidelines (example: hand hygiene, use of gloves and masks) for one of 30 sampled patients (Patient 8), when one of one Registered Nurse (RN 18) used a hand sanitizer (alcohol based gel or liquid used to kill some forms of germs or infectious bacteria) after coming out of an isolation precaution (used to reduce transmission of microorganisms in the healthcare setting) patient room (Patient 18) instead of washing hands with soap and water in accordance with the facility’s policy and procedure on infection control. This deficient practice had the potential to cross-contaminating (when bacteria or other microorganisms are unintentionally transferred from one object to another) other patients and staff with infectious micro-organisms, which may cause patients and staff to get sick. 3. Label the administration set for Intravenous (IV) infusion (a method of putting fluids, including drugs, into the bloodstream) with the date, time hung, and personnel’s initials for one of 30 sampled patients (Patient 6) in accordance with the facility’s policy and procedure regarding labeling administration set for IV infusions after 72 hours from the time the IV tubing was used. This deficient practice had the potential to place Patient 6 at risk for phlebitis (inflammation of the walls of a vein) or contamination (growing microorganisms, that may cause infections) associated with catheter (a device used to draw blood and give treatments) related bloodstream complications. 4. Discontinue an order for physical restraints (any physical or mechanical device material or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body or head freely, or prevent the patient from voluntary exiting the bed) and remove restraints from the room of one of 30 sampled patients (Patient 10) in accordance with the facility’s policy and procedure regarding the use of restraints. This deficient practice had the potential to compromise Patient 10’s safety due to unnecessary use of restraints, which may result in complications such as skin tear, etc. 5. Complete a pain reassessment (a process where a nurse reevaluates a patient’s health information for new information or changes) for one of 30 sampled patients (Patient 13) after pain medications were given. This deficient practice had the potential for delayed medical care and treatment to Patient 13, when Patient 13’s response to medication is not reassessed on time thus preventing the use of other alternative methods to relieve Patient 13’s pain. 6. Provide an interpreter and consent forms in a language the patient can understand for one of 30 sampled patients (Patient 14), during the informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) process in accordance with the facility’s policy and procedure regarding the use of translator/interpreter services (facilitates communication between healthcare providers and non-English speaking patients to provide the best possible quality of care). This deficient practice had the potential for Patient 14 to not understand the medical care and procedures Patient 14 was consenting to and may lead to unwanted medical care and procedures. 7. Ensure staff followed the facility’s policy and procedure on proper intravenous tubing (IV tubing, used to deliver medications to the vein via a machine pump) labeling and handling for one of 30 sampled patients (Patient 25) as the IV tubing was not labeled and covered with sterile cap (cap to cover endling of the IV tubing to prevent infection). This deficient practice had to potential for Patient 25 to develop infection due to contaminated IV line. 8. Ensure staff to use translator service (facilitates communication between healthcare providers and non-English speaking patients to provide the best possible quality of care) based on patient’s language preference in Spanish when obtaining for informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) for one of 30 sampled patients (Patient 22) in accordance with the facility’s policy and procedure regarding the use of translator/interpreter services. This deficient practice had the potential for Patient 22 not receiving accurate and current information in the language Patient 22 could understand which might result in Patient 22 not understanding information regarding his (Patient 22) treatment plan. 9. Ensure nursing staff documented date and time when obtaining telephone informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) from the emergency contact for one of 30 sampled patients (Patient 27) in accordance with the facility’s policy and procedure regarding informed consents. This deficient practice had the potential to result in causing confusion and violate Patient 27’s rights as it was unknown if the informed consent obtained was before or after the procedure. 10. Ensure staff documented the type of restraints (a physical restraint is any manual method, material or equipment that is attached to patient’s body that cannot be easily removed and restricts freedom of movement) use and alternative interventions for one of 30 sampled patients (Patient 26) from 2/16/2024 to 2/18/2024, in accordance with the facility’s policy and procedure regarding restraints use and documentation. This deficient practice had the potential to result in unnecessary use of restraints on Patient 26 as it was lacking alternative intervention attempt and unclear what type of restraints being used on Patient 26 putting Patient 26 at risk for injury and delaying removal of restraints. Findings: 1. During a review of Patient 1’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/15/2024, the H&P indicated, Patient 1 had past medical history (PMH, a record of information about a person’s health) of End-stage renal disease (ESRD the final, permanent stage of chronic kidney disease), dialysis (the clinical filtering of blood as a substitute for the normal function of the kidney), and diabetes (elevated levels of blood glucose (or blood sugar) and was admitted due to increased shortness of breath (not being able to get enough air). During a further review of Patient 1’s medical record (MR) titled, “Physician’s Progress Note,” dated 2/20/2024, the MR indicated, Patient 1 required hemodialysis (kidney dialysis) treatment on 2/20/2024. During an observation on 2/20/2024 at 11:07 a.m. Patient 1 was observed in Patient 1’s room, alone, with dialysis machine performing hemodialysis treatment. The dialysis nurse was not in the room. During a concurrent observation and interview on 2/20/2024 at 11:07 a.m. with dialysis registered nurse (RN 1), in the hallway, RN 1 was observed charting at the nurse station, across from Patient 1’s room. Patient 1 and Patient 1’s dialysis access site was not within the view from the nurse’s station, and only the dialysis machine was observed from the nurse station where RN 1 was charting. RN 1 stated, “Patient 1 is in the room being dialyzed (treat [a patient] by means of dialysis) and the dialysis machine is within the RN 1’s view and the alarm can be heard from the nurse station and Patient 1 can be attended immediately if needed.” During an interview on 2/20/2024 at 11:19 a.m. with dialysis RN (RN 1), RN 1 stated, dialysis nurses should stay inside the room with patients during dialysis treatment to monitor the patient while receiving treatment. During an interview on 2/20/2024 at 12:35 p.m. with dialysis RN (RN 7), RN 7 stated, dialysis nurses should stay inside the room or right outside of the door to be able to always see patient and the dialysis machine because treatment changes may require an immediate action from the nurse at any time during the treatment. During an interview on 2/23/2024 at 2:56 p.m. with dialysis charge nurse (CN 10), CN 10 stated, dialysis nurses should stay inside the room with the patient, overseeing the treatment and the patient’s access sites and line connections, monitoring and obtaining vital signs (pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient’s essential body functions every at 15 minutes intervals, monitoring level of consciousness [a person’s awareness and understanding of what is happening in his or her surroundings]) and response to dialysis treatment. During a review of the facility’s policy and procedure (P&P) titled, “Intradialytic Treatment Monitoring,” dated 10/2023, the P&P indicated, “The patient’s vascular access site and the blood line connections needs to be continuously visible throughout the dialysis treatment. Allowing patients to cover access sites and line connections provides an opportunity for accidental needle dislodgement or a line disconnection to go undetected. The arterial and venous drip chamber levels should be observed and adjusted as needed.” 2. During an observation on 2/21/2024 at 11:41 a.m. in Station 31, a registered nurse (RN 18) was observed using hand sanitizer (alcohol hand rub) before leaving Patient 8’s room. The signage posted at the entry to Patient 8’s room indicated, “Contact Plus Precautions,” which read, “Wash hands with soap and water upon exiting the room; alcohol hand rub may be used upon entry.” During an interview on 2/21/2024 at 11:45 a.m. with registered nurse (RN 18), RN 18 stated, Patient 8 was placed in “Contact Plus Precautions,” isolation due to a suspected case of unexplained/infectious diarrhea (loose stools). RN 18 further admitted using hand sanitizer before leaving Patient 8’s room instead of washing hands with soap and water as per infection control policy. During a review of Patient 8’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/18/2024, the H&P indicated, Patient 8 was admitted status post (after) syncopal (fainting) episode and fall (an unplanned descent to the floor with or without injury to the patient). During a review of Patient 8’s medical record (MR) titled, “Infectious Disease Consultation Note,” dated 2/20/2024, the MR indicated, Patient 8 had past medical history (PMH, a record of information about a person’s health) of partial colectomy (surgical procedure to remove part of the colon) and small bowel resection (a surgery to remove part of the small intestine, large intestine or both) with creation of left ileostomy (a procedure in which the lumen of the ileum, part of the small bowel, is brought through the abdominal wall via a surgically-created opening) and a colostomy (an opening into the colon from the outside of the body). The MR further indicated, Patient 8 had a lot of loose stool output and was ordered to have stool tested for gastrointestinal pathogens (a variety of viruses, bacteria, and parasites can cause infections of the digestive system and C. difficile (Clostridioides difficile or C. difficile is a germ that causes diarrhea and inflammation of the colon). During a review of Patient 8’s medical record (MR) titled, “Order History,” dated 2/20/2024, the MR indicated, the physician placed a continuous (until specified otherwise) order for isolation with “Contact Plus Precautions (Contact precautions isolation is intended to prevent transmission of infectious agents, which are spread by direct and indirect contact with the patient or the patient’s environment and requires all staff interacting with the patient to wash hands with soap and water upon exiting the room instead of using alcohol rub because specific infectious organisms are not affected by the alcohol).” During a review of Patient 8’s medica record (MR) titled, “Progress Note-Infectious Disease Specialist,” dated 2/22/2024, the note indicated, Patient 8 continued to have persistent stool output; stool was positive for Yersenia enterecolitica (an infectious agent). During an interview on 2/22/2024 at 10:30 a.m. with Infection Prevention Director (IPD), the IPD stated, nurses should perform handwashing with soap and water to rub-off pathogens because alcohol is not effective against specific infectious agents such as C. Difficille or others. The IPD further stated, nursing should follow infection control policies and procedures to prevent spread of infectious micro-organisms and cross-contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During a review of the facility’s policy and procedure (P&P) titled, “Infection Prevention and Control,” dated 11/2022, the P&P indicated, “Any patient presenting with Candida auris, Clostridium difficile and Yersinia enterocolitica should be placed in Contact Plus Precautions which requires handwashing with soap and water upon exiting the room, wearing gloves and gown upon entering the room, and using bleach wipes for cleaning of equipment in between use.” 3. During a review of Patient 6’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/11/2024, the H&P indicated, Patient 6 was admitted on 2/10/2024 with a diagnosis of pulmonary embolism (when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung), pulmonary infarct (the portions of lung served by each blocked artery can’t get blood and may die), and pneumonia (lung inflammation caused by bacterial or viral infection). During a review of Patient 6’s electronic Medication Administration Record (eMAR, record of medications administered to the patient), dated 2/11/2024-2/22/2024, the eMAR indicated, Patient 6 last received intravenous (IV, medication delivered to bloodstream directly) linezolid (antibiotic, a medicine to destroy micro-organisms) on 2/21/2023. During a concurrent observation and interview on 2/21/2024 at 11:01 a.m., with the Clinical Director of Medical Surgical unit (DMS), at the Direct Observation Unit (DOU, a hospital unit provide second-highest level of care), inside Patient 6’s room, Patient 6’s linezolid IV administration set was observed to be infusing. The IV tubing set contained no label, with the date, time hung, and personnel’s initials when initiated. DMS stated, nursing should label all IV tubing with the date and time when initially hung, and the tubing should be changed in 72 hours per facility’s policy. During an interview on 2/21/2024 at 12:29 p.m. with charge nurse (CN3), CN 3 stated, nursing should change the IV tubing every 72 hours to prevent infection or other complications associated with IV catheter. CN 3 further stated, nursing should label the IV tubing with date and time hung, and initials of the registered nurse (RN) who hung the IV antibiotic. During a review of the facility’s policy and procedure (P&P) titled, “Medication Use, Administration, Routes and High Alert Medications,” dated 8/2023, the P&P indicated “Any tubing intermittently connected to/disconnected from the patient is changed every 24 hours. This includes practices such as IVPB (intravenous piggy bag, a small bag of solution attached to a primary infusion line or intermittent venous access device to deliver medication over a specified period of time) that are not left continuously connected to the patient’s primary IV tubing. Intermittent infusion sets are capped with a new sterile tubing cap after each use. If IV tubing is found without the sterile cap, or looped back onto one of its ports, it is discarded immediately and replaced. Secondary tubing connected continuously to another tubing in use continuously are changed every 7 days. If they are connected and disconnected from the patient, they are replaced every 24 hours.” 4. During an observation on 2/21/2024, at 1:17 p.m., in the Emergency Department (ED responsible for providing treatment to patients arriving in the facility who are in need of immediate care), Patient 10 was observed sleeping in the room. Four-point restraints (devices that limit a patient’s movement, and which restrain both arms and both legs) were observed to be attached to each corner of the bed, while Patient 10 was not physically restrained. During a review of Patient 10’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/20/2024, the H&P indicated, Patient 10 was brought in by the police due to suicidal behavior (self-injurious behavior) and possible opiate (narcotic) intoxication (a temporary and reversible condition that affects the central nervous system after a person ingests certain substances, such as alcohol or drugs) and was placed on a 5150 Hold (involuntarily detention for a 72- hour psychiatric (mental, emotional, and behavioral conditions) hospitalization when evaluated to be a danger to others, or self or gravely disabled [a condition in which a person, as a result of a mental disorder, is unable to provide for his or her personal care needs such as hygiene, etc.]) in the ED. During a review of Patient 10’s medical record (MR) titled, “Psychiatric Consult,” dated 2/21/2023, the MR indicated, Patient 10 was admitted to the ED on 2/20/2024, and placed on a 5150 Hold. The MR further indicated, Patient 10 became agitated in the ED, started punching windows and became aggressive with staff requiring Intramuscular (IM, administered into, a muscle) medication and physical restraints on 2/20/2024, until he calmed down and was released from restraints without injury. The MR indicated, Patient 10 continued to remain paranoid (obsessively anxious, suspicious, or mistrustful) with suicidal thoughts, and had to be hospitalized. During an interview on 2/21/2024, at 1:19 p.m., with Emergency Department Manager (EDM), EDM stated, Patient 10 was placed in four-point restraints on 2/20/2024 at 6:21 p.m., but the restraints were physically removed at 6:44 p.m. after patient (patient 10) received IM sedative (calming) medications and fell asleep. During a review of Patient 10’s medical record (MR) titled, “Physician’s Orders,” dated 2/20/2024, the MR indicated, Patient 10 was ordered to be placed into four-point restraints due to demonstrating violent behavior, presenting with immediate and significant danger to self and or others. The MR further indicated the primary registered nurse (RN) could discontinue the order for restraints upon determination that the patient no longer meets restraint criteria. During a concurrent interview and record review on 2/22/2024 at 4:00 p.m., with Informatics Nurse Specialist (INS), Patient 10’s medical record (MR) titled, “Physician’s Orders,” dated 2/20/2024 was reviewed. The MR indicated, the initial order for four-point restraints was placed on 2/20/2024 at 6 :21 p.m., and expired on 2/20/2024 at 10:20 p.m. INS stated, the order for restraints remained active for four hours, and expired without being discontinued. During a review of Patient 10’s medical record (MR) titled, “Nursing ED Note,” dated 2/20/2024 at 6:44 p.m., the MR indicated, primary nurse documented, Patient 10’s restraints were discontinued. During an interview on 2/23/2024 at 11:23 a.m. with Clinical Nurse Specialist (CNS 1), CNS 1 stated, as per facility’s policy and procedure (P&P), if a patient no longer requires to be restrained, the restraint order should be discontinued, and the restraints should not be kept at bedside and should be removed from the room. CNS 1 further stated, nursing should discontinue an order for restraints if restraints are not in use. During a review of the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion, “dated 2/2022, the P&P indicated, “All restraints orders are time limited, and restraints must be discontinued at the earliest possible time, regardless of the length of time identified in the order. Orders will not be accepted as a standing order or on an as needed basis.” During a review of the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion, “dated 2/2022, the P&P indicated, “Orders for Medication Administration against the patient’s wishes are found under the Violent/Self Destructive orders. It is considered a type of physical restraint. During a review of the facility’s policy and procedure (P&P) titled, “Suicide Risk Assessment, Precautions and Psychiatric Holds,” dated 10/2021, the P&P indicated, “When a patient has been identified as at risk for suicide ideation, all potentially harmful items, such as all detachable or unfixed equipment, must be removed from the room to deliver safe medical care.” 5. During a review of Patient 13’s Face Sheet (a document that gives a patient’s information at a quick glance), dated 2/7/2024, the Face Sheet indicated Patient 13 was admitted to the facility on 2/7/2024 at 4:01 p.m. with a diagnosis of arm pain. During a review of Patient 13’s care plan (provides a framework for evaluating and providing patient care needs related to the nursing process), dated 2/20/2024, the care plan indicated a problem of pain. A review of care plan goals indicated a pain characteristic assessment (a pain description that includes location, radiation, mode of onset, character, exacerbating [makes worse] and relieving factors, and intensity). During a concurrent interview and record review on 2/22/2024 at 11:10 a.m. with Process Excellence Specialist (PES), Patient 13’s medical record was reviewed. The medical record indicated Patient 13 was given Norco (a combination [hydrocodone and Tylenol] opioid [class of drug] medication used to manage pain) 10 milligrams (mg, a unit of measurement)/325 mg on 2/20/2024 at 2:59 p.m. for 7/10 (severe) pain. PES stated that the indication for the Norco order (instructions a physician has written for a patient’s treatment) was severe 7-10 pain. PES verified that a pain reassessment (a process where a nurse reevaluates a patient’s health information for new information or changes) was not documented in Patient 13’s medical record. Additionally, PES confirmed the pain assessment was missing the pain location. PES said that pain should be reassessed within 1 hour of administration to include a pain scale and location. PES said that if patient response to pain medication was not reassessed timely, it was unknown if the medication was effective and if other pain interventions were needed. PES further stated that if pain was not reassessed, the patient could have worsening pain. During an interview on 2/23/2024 at 12:15 p.m. with Nurse Manager 4 (NM 4), NM 4 stated that a pain assessment should include documentation of a pain scale, intensity, and location. NM 4 said pain scale of 7-10 indicates severe pain and pain should be reassessed within 75 minutes per policy. NM 4 stated that pain should be reassessed to identify if the patient got relief from medications. NM 4 further stated that if pain was not reassessed, the patient can suffer in pain affecting sleep. During a review of the facility’s Policy and Procedure (P&P), dated 2/2022, titled “Pain Management,” the P&P indicated: “Purpose: Pain is highly individual and variable and is one of the most feared aspects of illness, and one of the most common reasons for seeking healthcare interventions. The purpose of this policy is to provide guidelines for a collaborative interdisciplinary approach to pain management. The goals of pain management are: 1. Relief from physical suffering 2. Preservation or restoration of function 3. Sustained quality of life 4. Prevention of addiction Policy: Pain management is a shared responsibility between the patient, providers and nursing. Opioid sparing strategies including multimodal analgesia and non-pharmacologic therapies should be considered when it is reasonable to do so. Procedure: [the facility] Standard Pain ranges and relationship to functional ability) ... C. Severe: Pain levels 7-10: Unable to do normal activities (for this patient). Hard or unable to think, talk or move or do ADLs. Hard or unable to enjoy life because of pain ... C. Continuing Pain Assessment (after Admission/Arrival Pain Assessment): 1. Shift Assessment a. Type of Assessment (Assessment or Post-Intervention Reassessment) ... 3. Timing of reassessments (“Post-Intervention Reassessments”): a. The reassessment task fires immediately. This reassessment occurs within 75 minutes following administration. When documenting reassessment select “Post Intervention Reassessment ...” 6. During a review of Patient 14’s Face Sheet (a document that gives a patient’s information at a quick glance), dated 2/12/2024, the Face Sheet indicated Patient 14 was admitted to the facility on 2/12/2024 at 7:41 a.m. with a diagnosis of leg pain. Patient 14’s Face Sheet further indicated Patient 14’s preferred language was Spanish. During a review of Patient 14’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/12/2024, indicated Patient 14 had acute left lower extremity ischemia (inadequate blood supply) with occlusion (blockage) of left external iliac artery (provides blood to the legs, pelvis, reproductive organs and other organs in the pelvic area) and everything distal (away from a particular point in the body). Patient 14’s H&P further indicated Patient 14 underwent emergent revascularization (procedure that restores blood flow) and fasciotomies (procedure to relieve pressure in the muscle compartment). During a concurrent interview and record review on 2/22/2024 at 1:45 p.m. with Process Excellence Specialist (PES), Patient 14’s medical record (a record of a patient’s medical information) titled “Consent for Transfusion of Blood Components,” dated 2/12/2024 at 12:49 p.m. was reviewed. The medical record indicated staff did not document the interpreter’s name, identification number and language in Patient 14’s medical record. PES said that when a patient does not speak English as the primary language, communication should be in the patient’s primary language. PES said that the use of an interpreter should be documented by staff in the medical record. PES stated that when the patient is not consented in their primary language, the patient may not understand what they are consenting for. PES further stated that the medical care or procedure may go against the patient’s wishes due to miscommunication. During a concurrent interview and record review on 2/23/2024 at 12:15 p.m. with Patient Safety Officer (PSO) and Nurse Manager 4 (NM 4), Patient 14’s medical record, dated 2/12/2024 at 12:09 p.m., titled “Authorization for and Consent to Surgery, Care, Treatment, Special Diagnostic or Therapeutic Procedures,” indicated “Procedure(s): Left lower extremity thrombectomy (to remove a blood clot from inside an artery or vein), possible fasciotomy.” PSO confirmed the medical record indicated the physician did not document the interpreter’s name, identification number and language in Patient 14’s consent form or in the medical record. NM 4 confirmed Patient 14’s Face Sheet indicated the Patient’s primary language was Spanish. NM 4 said that Patient 14’s consent should have been in Spanish. NM 4 stated that the consent should be in a language that the patient understands so the patient knows what they are consenting for. During a review of the facility’s Policy and Procedure (P&P), titled “Patient Non-Discrimination, Rights and Responsibilities,” dated 8/2021, the P&P indicated: “Purpose: To articulate the hospital’s policy on patient non-discrimination, and the rights of patients and ethical obligations of Huntington Hospital (HH) to its patients and their families and visitors, community, employees, medical staff, volunteers and professional and business relationships. To articulate the responsibilities of patients to communicate their own vital health information, participate in their own care while hospitalized and respect hospital policies and property ... VII. The patient rights and responsibilities are as follows: Patient rights ... You have the right to receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery, end-of-life care options and outcomes of care (including unanticipated outcomes) in terms that you can understand ...” During a review of the facility’s Policy and Procedure (P&P), titled “Interpreter and Communication Services,” dated 6/28/2023, the P&P indicated: “Purpose ... Language and communication services aid in the delivery of culturally competent care to the diverse patient population we serve. These services facilitate access to equitable healthcare by increasing the patient’s ability to participate in their own care, health, and well-being fully and confidently ... N. Documentation: Documentation in the patient’s EMR when an interpreter is used. Document: Interpreter’s name and ID number when available, If an employee or other non-qualified interpreter was used, Patient’s preferred language ...” 7. During a review of Patient 25’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/12/2024, the H&P indicated Patient 25 was admitted to the facility with diagnoses of acute respiratory failure (condition in which blood does not have enough oxygen causing difficulty breathing), pulmonary edema (excess fluid in the lungs), congestive heart failure (condition in which the heart does not pump blood as well as it could) and end-stage renal failure (permanent stage of chronic kidney disease where kidneys can no longer function). During a review of Patient 25’s electronic Medication Administration Record (eMAR, record of medications administered for the patient), dated from 2/13/2024 to 2/22/2024, the eMAR indicated Patient 25 last received intravenous (IV, medication deliver to bloodstream directly) Zithromax (antibiotics, type of medication to treat infection) and IV Rocephin (antibiotics, type of medication to treat infection) on 2/17/2024. During a concurrent observation and interview on 2/20/2024 at 12:02 p.m. with the nurse manager (NM5) of Definitive Observation Unit (DOU, a hospital unit provide second-highest level of care) in Patient 25’s room, there were three intravenous tubing (IV tubing, used to deliver medications to the blood stream via a machine pump) hanging without label and the ending (ending is used to connect to patient when delivering the IV fluid or medication) of the IV tubing was wrapped in an opened alcohol prep pad wrapper (individual alcohol pad used to disinfect items). NM5 stated all IV tubing should be labeled with date and time when it was first used so that it could be changed every 72 hours per facility’s policy. NM5 further stated the ending of the tubing should not be covered by opened alcohol prep pad wrapper. During an interview on 2/20/2024 at 12:11 p.m. with Patient 25’s primary nurse (RN13), RN13 stated IV tubing without label should be discarded. RN13 stated the ending of IV should be covered with a sterile cap (cap to cover endling of the IV tubing to prevent infection) otherwise dirty IV ending could cause line infection for Patient 25 if it was connected to Patient 25. RN13 stated that she (RN 13) did not discard the IV tubing because she (RN 13) was too busy. During a review of the facility’s policy and procedure (P&P) titled, “Medication Use, Administration, Routes and High Alert Medications,” dated 8/2023, the P&P indicated “Any tubing intermittently connected to/disconnected from the patient is changed every 24 hours. This includes practices such as IVPB (intravenous piggy bag, a small bag of solution attached to a primary infusion line or intermittent venous access device to deliver medication over a specified period of time) that are not left continuously connected to the patient’s primary IV tubing. Intermittent infusion sets are capped with a new sterile tubing cap after each use. If IV tubing is found without the sterile cap, or looped back onto one of its ports, it is discarded immediately and replaced. Secondary tubing connected continuously to another tubing in use continuously are changed every 7 days. If they are connected and disconnected from the patient, they are replaced every 24hours.” 8. During a review of Patient 22’s nephrology consultation (consultation notes, physician examination and recommendation completed by kidney specialist), dated 2/20/2024, the consultation notes indicated Patient 22 was admitted to the facility with diagnoses of hyperkalemia (high level of the electrolyte potassium in blood) and kidney failure (a condition that kidneys not functioning). The consultation notes also indicated Patient 22 would be undergoing his (Patient 22) first hemodialysis (a machine filters wastes, salts and fluid from the blood when kidneys are no longer functioning) on 2/21/2024 as part of the treatment plan. During an interview on 2/21/2024 at 10:33 a.m. with Patient 22, Patient 22 stated the physician spoke in broken Spanish to him (Patient 22) when explaining hemodialysis procedure and nurses did not use translator service (facilitates communication between healthcare providers and non-English speaking patients to provide the best possible quality of care) when having him sign the informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention). Patient 22 stated his (Patient 22) preferred language was Spanish and preferred to have an interpreter to speak Spanish than broken Spanish so he (Patient 22) could understand better. During a concurrent interview and record review on 2/21/2024 at 10:43 a.m. with Patient 22’s primary nurse (RN 19), Patient 22’s informed consent with procedure of hemodialysis, dated 2/21/2024, at 12:43 a.m., was reviewed. The informed consent indicated the consent was in Spanish version and the translator service was left blank. RN 19 stated Patient 22’s preferred language was Spanish therefore a Spanish translator service should have been used and documented on the informed consent. RN 19 further stated it was important to use translator service when obtaining informed consent so that Patient 22 could fully understand the risks and benefits of the procedure. During a review of the facility’s policy and procedure (P&P) titled, “Informed Consent,” dated 10/2021, the P&P indicated, “Informed consent must be obtained for procedures that are “complex” in that they involve material risks that are not commonly understood by the average layperson ...Patients and surrogate decision-makers must be able to understand what they are being asked to authorize ...to give informed consent for a surgical or other procedure. If there’s a communication barrier, the hospital must arrange for communication in a language or mode that can be understood by the patient or surrogate decision-maker ... If the patient or surrogate decision-maker was asked to sign a consent form, the interpreter name, signature (if in person) and language shall be documented on the consent form.” During a review of the facility’s policy and procedure (P&P) titled, “Interpreter and Communication Services,” dated 06/2023, the P&P indicated, “[the facility] is committed to ensuring meaningful and equal access to care, services, and benefits for individuals who are non-English speaking, have limited English proficiency (LEP), and/or individuals who have disabilities that impact communication... Utilizing qualified medical interpreters supports quality, patient safety, and health equity.” 9. During a review of Patient 27’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 1/18/2024, the H&P indicated Patient 27 was admitted to the facility’s intensive care unit (ICU, hospital unit with most critical patients) with diagnoses of septic shock (life-threatening condition caused by infection that requires immediate medical attention), acute respiratory failure (condition in which blood does not have enough oxygen causing difficulty breathing), requiring ventilator (a machine provides mechanical ventilation by moving air into and out of the lungs to someone who cannot breath), perforated abdomen (a hole in the stomach) and anemia (a condition with low blood cells). During a concurrent interview and record review on 2/23/2024 at 11:08 a.m. with the Clinical Nurse Specialist (CNS), Patient 27’s informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) for procedure “Possible Diagnostic Laparoscopy (a procedure used to check the organs in the abdomen), Exploratory Laparotomy (a general surgical operation where the abdomen is cut opened and the abdominal organs are examined for injury or disease), Abdominal Washout ( a procedure to diagnose whether certain types of cancer are present in the abdomen), Possible Repair, Possible Resection, Possible Gastrojejunostomy (a surgical procedure in which a cross connection is created between the stomach and part of the small intestine), Possible Pyloric Exclusion (a procedure to treat complicated stomach ulcer injury),” with no date was reviewed. The informed consent indicated telephone consent from Patient 27’s emergency contact was obtained at 10 a.m. with no date. CNS stated the date and time were required on all informed consent to ensure it was obtained prior procedure being performed. CNS further stated without the date, it would be unclear whether the informed consent was obtained before or after the procedure. During a review of the facility’s policy and procedure (P&P) titled, “Informed Consent,” dated 10/2021, the P&P indicated, “The hospital’s role in the informed consent process is to verify that the physician obtain the patient’s informed consent before the physician is permitted to perform the procedure or that an exception (such as the emergency exception) applied that allows treatment to proceed ... When the physician stated that he or she has obtained consent to treat patient, the hospital employee should verify that the patient’ legal representative and physician have discussed the patient’s condition and the recommended treatment and the patient’s legal representative has, in fact, given consent. The telephone discussion between the patient’s legal representative and a hospital nurse should be witnessed by a second responsible licensed caregiver ... Both hospital licensed employees who participate in verifying that consent to medical treatment should sign and date the documentation of the phone call on the appropriate hospital consent form.” 10. During a concurrent observation and interview on 2/20/2024 at 12:28 p.m. with the Clinical Supervisor (CS2) in Patient 26’s room, CS2 verified Patient 26 was with bilateral wrists (right and left wrists), bilateral mittens, and bilateral ankles restraints (devices that limit a patient’s movement, and which restrain both arms and both legs). During a review of Patient 26’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/13/2024, the H&P indicated Patient 26 was admitted to the facility with management of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with agitation (a condition in which a person is unable to relax and be still). During a concurrent interview and record review on 2/22/2024 at 2:24 p.m. with the Patient Safety Officer (PSO), Patient 26’s “Restraints Flowsheet (restraints flowsheet, document by nursing staff to indicate type of restraints being used, reason for restraints and patient condition while under restraints),” dated from 2/13/2024 to 2/24/2024, was reviewed. The restraints flowsheet indicated Patient 26 had restraints starting 2/13/2024 due to repeated attempts to remove lines, tubing and equipment. The restraints flowsheet indicated Patient 26 had bilateral wrists, bilateral ankle and belt restraints on 2/16/2024 at 12 p.m. The restraints flowsheet indicated missing documentation regarding restraints type and site, and alternative interventions from 2/16/2024 at 8 p.m. to 2/18/2024 at 8 a.m. PSO stated it was unknown what type of restraints being used from 2/16/2024 at 8 p.m. to 2/18/2024 at 8 a.m. due to lack of documentation. PSO further stated documentation for type of restraints being used must be documented at least once per shift to indicate what type of restraint being applied on Patient 26 according to the facility’s policy, without proper documentation, it could delay removal of restraints. During a review of the facility’s policy and procedure (P&P) titled, “Restraints and Seclusion,” dated 2/2022, the P&P indicated, “alternatives and nonphysical interventions are less restrictive interventions and must be attempted or considered and determined to be ineffective to protect the patient and/or other from harm prior to the application of restraints. The Registered Nurse is responsible for reassessing and monitoring the patient in restraints. The following must be documented at least every shift and prn (as needed): restraints type and site, reason for restraints, alternative interventions and other actions to prevent restraints.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure nursing staff gave medications only ordered by a physician when a Registered Nurse (RN 17) gave insulin Lispro (insulin to treat control blood sugar) to one of 30 sampled patients (Patient 21) without a physician order. This deficient practice had the potential for Patient 21 not getting appropriate insulin (medication used to lower blood sugar via injection) dosage to manage the elevated blood glucose (blood sugar), which may result in complications such as excessively low blood sugar, coma (state of prolonged loss of consciousness) or death. Findings: During a review of Patient 21’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/17/2024, the H&P indicated Patient 21 was admitted to the facility with diagnoses of rectal (ending of the intestine) bleeding, anemia (a condition with low blood cells), and gastric outlet obstruction (mechanical obstruction or motility disorder interfering with gastric emptying). During an observation on 2/21/2024 at 10:51 a.m. in facility’s Medical Oncology (hospital unit which provides medical care for cancer patients) floor, observed Patient 21 sitting in chair receiving intravenously (IV, administered into bloodstream directly) total parenteral nutrition (TPN, IV administered nutrition for someone with impaired gastrointestinal function). During a concurrent interview and record review on 2/22/2024 at 9:32 a.m. with the Patient Safety Officer (PSO), Patient 21’s glucose (blood sugar) record on 2/20/2024 at 6:02 p.m. was reviewed. The glucose record indicated glucose level was 362 mg/dL (milligram per deciliter, normal range from 70 to 99 mg/dL [a unit of measurement]). PSO verified that glucose reading was completed by RN 17. During a concurrent interview and record review on 2/22/2024 at 9:32 a.m. with the Patient Safety Officer (PSO), Patient 21’s electronic Medication Administration Record (eMAR, record of medications administered for the patient) dated 2/20/2024 was reviewed. The eMAR indicated RN 17 administered eight (8) units (unit of measurement) of insulin Lispro (insulin to treat control blood sugar) for Patient 21 on 2/20/2024 at 6:12 p.m. The eMAR also indicated Lispro correction scale (a scale listed how much insulin would be given based on the glucose reading) initiated on 2/20/2024 at 3:30 p.m. with the following instruction: 70 - 140 mg/dL = no dose 141 - 180 mg/dL = 2 units 181 - 220 mg/dL = 4 units 221 - 260 mg/dL = 6 units 261 - 300 mg/dL = 8 units Greater than 300 mg/dL = call physician PSO stated that any glucose level above 300 mg/dL must be reported to the physician per correction scale in eMAR. PSO verified there was no documentation that RN 17 notified physician for glucose level of 362 mg/dL or a physician order to administer Lispro 8 units for Patient 21. PSO stated administering 8 units of Lispro was not enough based on the correction scale, RN 17 should have called the physician to obtain a one-time order for insulin coverage. PSO further stated giving insulin without physician order could lead to improper managing of Patient 21’s blood glucose level. During a review of the facility’s policy and procedure (P&P) titled, “Medication Use, Administration, Routes and High Alert Medications,” dated 8/2023, the P&P indicated, “An order by a [facility] credential prescriber, acting within the scope of his/her practice, is required for all medications orders. A physician must countersign a Nurse Practitioner’s or a Physician’s Assistant’s order as specified in the Allied Health Professional Rules and Regulations.””