UCSF Health St. Mary’s Hospital

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 31794 Based on interviews and record reviews, the facility failed to ensure and promote Patient’s Rights to be “free from pain” for four (4) of 30 sampled patients (Patients 21, 25, 26, and 27) when, 1. For Patient 21, the Pain Assessment (an evaluation that measures the intensity, nature, duration, and location of pain) with the Numerical Pain Scale (NPS, screening tool that measures the intensity of pain, zero (0) is no pain and 10 is worse) of 4/10 (moderate pain) to 7/10 (severe pain) were not reported to the physician for appropriate pain treatment and management. 2. For Patient 25, Pain re-assessments (assessment performed to determine the effectiveness of the interventions) were not done after the patient received pain medications. 3. For Patient 26, Pain re-assessments were not done after the patient received pain medications. 4. For Patient 27, Pain re-assessments were not done after the patient received pain medications. These deficient practices had the potential to lead to inadequate pain management outcomes and can negatively impact the patient’s “quality of life” and the patient’s “physical”, “emotional”, and psychosocial well-being. FINDINGS: In an interview on10/10/24, at 3:04 PM, with the Unit Manger (UM 1), UM 1 stated, upon admission patients were notified of the Patient’s Rights and patients has the right to be “free from pain.” 1.Review of the undated Face Sheet (front page of the chart that contains a summary of basic information about the patient) indicated, Patient 21 was admitted to the facility on 7/30/23. Review of the admission History and Physical (H & P) dated 7/31/23 indicated, patient presented with nausea, vomiting, and bloody diarrhea. The diagnosis included sepsis (life-threatening blood infection) likely secondary to colitis (inflammation of the large intestine), hypokalemia (low blood level of potassium), and hypophosphatemia (low blood level of phosphorus). In a concurrent record review and interview on 10/9/24, at 1:38 PM, with the Registered Nurse /Clinical Informatics (RN/CI), the Pain Flowsheet was reviewed. The RN/CI stated, on 7/30/24 at 7:10 PM, the NPS was 5/10, and at 9:00 PM the NPS was 5/10. On 7/31/24 at 5:00 AM, the NPS was 6/10, and at 4:00 PM the NPS was 4/10. On 8/1/24 at 8:53 AM, the NPS was 6/10, and at 3:23 PM the NPS was 4/10. On 8/3/24 at 7:46 AM the NPS was 6/10, and at 4:00 PM the NPS was 7/10. The RN/CI searched the Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient) and stated, there was no pain medication administered for NPS of 4/10 up to 7/10 for those dates, and there was no documentation the Physician was notified of the pain scale. 2. Record review of the undated Face Sheet indicated Patient 25, was admitted to the facility on 9/25/24. Review of the admission H & P dated 9/24/24 indicated, Patient 25 had history of fracture (broken) left knee status post repair and chronic low back pain who presented to the facility with progressive and worsening back pain and was scheduled to undergo a laminectomy (surgery of the lower back to remove or most of the spinal bone or back bone). In a concurrent record review and interview on 10/10/24, at 12:45 PM, with the RN/CI, the Pain Flowsheet and the MAR were reviewed. The RN/CI stated, on 9/29/24 at 1:34 AM, the NPS was 4/10 and after searching the MAR stated, Oxycodone (pain medication) five (5) mg (milligrams) tablet was administered to the patient and the staff “did not do (pain) re-assessment”. The RN/CI stated, on 9/30/24 at 4:54 AM, the NPS was 7/10, Oxycodone 10 mg was administered, and “I don ’ t see (pain) re-assessment”. The RN/CI stated, on 10/3/24 at 6:21 PM the NPS was 5/10, Oxycodone five (5) mg was administered, there was “no (pain) re-assessment done.” The RN/CI stated, on 10/4/24 at 5:26 AM the NPS was 5/10, Oxycodone five (5 mg) was administered, “they (staff) did not re-assess the patient.” The RN/CI stated, on 10/4/24 at 11:36 PM the NPS was 10/10, Oxycodone 10 mg was administered, staff “did not do” the pain re-assessment. The RN/CI stated, on 10/8/24 at 3:05 PM, the NPS was 7/10, Oxycodone 10 mg was administered, and “no re-assessment” was done. When asked when pain re-assessment was supposed to be done, the RN/CI stated, per policy it should be done 30-60 minutes after the administration of the oral pain medication(s). 3. Review of the undated Face Sheet indicated Patient 26 was admitted to the facility on 9/26/24. Review of the admission H & P dated 9/27/24 indicated, the diagnoses that included acute respiratory failure (when the lungs can’t release enough oxygen into your blood and makes it difficult to breathe on your own), severe sepsis (a life-threatening blood infection), and community acquired pneumonia (lung infection that develops outside the hospital or other healthcare facility). In a concurrent record and interview on 10/10/24, at 1:50 PM, with the RN/CI, the pain Flowsheet and the MAR were reviewed. The RN/CI stated, on 9/27/24 at 9:34 PM the Numeric Pain Scale (NPS, a pain screening tool) was 10/10, Oxycodone (pain medication) 20 mg (milligrams) was given and there was no pain re-assessment done after the pain medication was administered. The RN/CI stated, on 9/30/24 at 1:02 PM, using the “Wong Baker (Face rating scale, a pain assessment tool)” the staff documented the pain scale was 7/10 and after searching the MAR, the RN/CI stated, Oxycodone 10 mg was given but there was no pain re-assessment done after the pain medication was administered. The RN/CI further stated, on 10/1/24 at 3:34 PM, the NPS scale was 8/10, Oxycodone 10 mg was administered, and no pain re-assessment after the pain medication was administered. The RN/CI stated, as per policy pain re-assessment should be done “30 to 60 minutes” after the oral pain medication was administered. 4. Record review of the undated Face Sheet indicated, Patient 27 was admitted to the facility on 9/21/24. Review of the admission H & P dated 9/21/24 indicated, Patient 27 had a history of hypertension (high blood pressure) and metastatic lung adenocarcinoma (lung cancer that has spread from the lungs to other parts of the body). The diagnosis included acute hypoxic respiratory failure (condition when the body does not have enough oxygen in the blood), shortness of breath, and chronic back and neck pain. In a concurrent record review and interview on 10/10/24, at 2:41 PM, with the RN/CI, the Pain Flow Sheet and the MAR were reviewed. The RN/CI stated, on 10/10/24 at 2:39 AM, the NPS was 10/10. The RN/CI searched the MAR and stated, Morphine Sulfate (pain medication) was administered and there was no pain re-assessment done. The RN/CI stated, on 10/10/24 at 6:39 AM the NPS was 8/10, Morphine Sulfate was administered as per the MAR, and there was no pain reassessment done. Review of the undated facility’s document (provided to patients upon admission) titled, “Patient Rights and Responsibilities” indicated, “(name of Hospital A) complies with applicable Federal civil rights laws ... Each patient is entitled to compassionate and professionally competent care delivered with respect for each individual. ... 10. Appropriate assessment and management of your pain, information about pain, and pain relief measures and to participate in pain management decisions. ... .” In an interview on 10/14/24, at 2:38 PM, with the Senior Director of Patient Care Services (SDPCS) with the UM 1 present, SDPCS stated, it was patient’s rights to be “free from pain”, pain could be “emotional” because the patient was “suffering”, it could be “physical”, and pain “affects the quality of life.” Review of the facility’s Policy and Procedure titled, “Patient’s Rights & (and) Responsibilities”, with the approval date of 12/22 indicated, “Policy: The organization believes that patients have certain rights and responsibilities while under our care and services. ... Purpose: To assure that a patient is informed of their rights and responsibilities upon receiving care and services from (name of Hospital A). To assure that staff, ... other healthcare providers are informed of these rights and responsibilities. ... INFORMING PATIENTS: Patients are to be informed of their rights and responsibilities upon admission to an inpatient setting. ... .””

“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: 31794 Based on observation, interview, and record review the facility failed to ensure patients were monitored while on Restraint (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely, as define in the facility’s policy) for one of 30 sampled patients (Patient 22) when, there was no documented evidence the monitoring and/or assessment for the use of Restraint were performed on 9/29/24 at 10:00 PM (evening) and on 9/30/24 at 12 MN (midnight), at 2:00 AM (morning) 4:00 AM and at 6:00 AM. Failure to perform the required monitoring of patients placed on Restraints had the potential to negatively affect the patient’s physical and emotional well-being, and his/her dignity and safety. FINDINGS: Review of the undated Face Sheet (front page of the chart that contains a summary of basic information about the patient) indicated, Patient 22 was admitted to the facility on 9/24/24 at 3:15 PM. Review of the admission History and Physical, dated 9/24/24 indicated, patient presented with the chief complaint of weakness and the Assessment/Plan indicated the diagnoses that included hypovolemia (low fluid volume or blood circulating in the body) with lactic acidosis (lactic acid build up in the bloodstream) acute kidney failure (sudden loss of kidney functions), and failure to thrive (decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). In an observation of the 7th West Nursing Unit and interview, on 10/9/24, at 11:27 AM, with the Registered Nurse (RN)/Clinical Informatics (CI), the Senior Director of Patient Care Services (SDPCS), and the Unit Manager (UM 1), the patient’s room was observed. The patient’s room had an empty bed, there was a pair of light blue colored soft wrist restraint on top of the counter table on the wall, and intravenous bags hanging in the intravenous pump machine next to the patient’s empty bed. The UM 1 stated, the patient went for a procedure earlier today and he expect the patient would be back soon. In an interview on 10/9/24, at 11:32 AM, with the Registered Nurse (RN 1), RN 1 stated, she was the primary nurse of Patient 22. The RN 1 stated, Patient 22 was “totally confused”, soft wrist restraint placed on patient’s both arms was applied because the patient was “pulling the intravenous (IV, fluids given directly into the blood stream) lines and foley catheter (device that drains urine from the urinary bladder)” and the last time the patient attempted pulling IV line was “yesterday”. The RN 1 stated, the order for Restraint was renewed every 24 hours. Record review of the Physician’s Order for “non-violent, non-destructive” Restraint, with the starting date of 9/29/24 at 11:25 AM and stop date of 9/30/29 at 11:19 AM indicated, “Monitor q (very) 2 (two) hours interval for 24 hr (hour) Soft Limb, bilateral wrist, Pulling at lines Tubes, or Dressings.” In concurrent record review and interview, on 10/9/24, at 2:28 PM, with the RN/CI, the Flow Sheet for Restraint, dated 9/29/24 to 9/30/24, was reviewed. The RN/CI verified, there was “no assessment” and/or monitoring of Restraint on 9/29/24 at 10:00 PM and on 9/30/24 at 12 MN (midnight), at 2:00 AM, at 4:00 AM, and at 6:00 AM, and the restraint assessment was resumed on 9/30/24 at 7:00 AM. The RN/CI searched the Electronic Health Record but did not find documentation of the assessment / monitoring or an explanation whether patient needed restraint or not. In a concurrent record review and interview, on 10/4/24, at 12:20 PM, with the NM 1, the SDPCS and the RN/CI, the Physician’s Order for Restraint, dated 9/29/24 to 9/30/24, was reviewed. The SDPCS stated, it was an “active order” for the use of Restraint on 9/29/24 and 9/30/24 and there was a “gap in assessment” on 9/29/24, night shift. The SDPCS stated, skin assessment and /or monitoring was needed to make sure there was no untoward impact from the use of Restraint, the patient’s level of consciousness needed to be assessed to make sure if patient was actively agitated and how the patient responded in the use of Restraints. The SDPCS stated, during assessment, fluids should be provided to the patient for hydration, toileting was important, it should be offered and when patient was on restraint, staff should ensure patient has toileting activities. When asked if there was a potential harm if assessment and/or monitoring was not done while patient was on restraint, the SDPCS stated, if there was no assessment and something happen at that point, when the patient was on restraint then, no way the staff could validate what happened, when it was not documented, it was not done, and it would be “hard to justify” if there was any action done. Review of the facility’s Policy and Procedure titled, “Restraint and Seclusion Use”, with the last approval dated of 12/22 indicated, “Procedure: ...1. The use of restraints is based on the assessed needs of the patient. ... B. General Requirements ... G. Monitoring the Patient in Restraint ... 2. At a minimum, patient in restraints shall be evaluated and monitored as follows: a. At least every two hours for all patients in medical restraint ... J. Documentation: For each episode of restraint, the patient’s medical records shall contain at least the following documentation: ... 2. A description of the patient’s behavior, interventions used, ... that warranted the use of the restraint ... 6. The patient’s response to the interventions used, including the rationale for continued use of the intervention. ... .””

“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: 17334 Based on observation, staff interview, record and policy review the rehab (rehabilitation) unit nursing staff failed to document that safety measures were implemented before transporting and transferring care to dialysis unit, for one of 30 patients reviewed (Patient 20). There was no documentation in the rehab unit notes that staff ensured appropriate mode of transfer and oxygen were provided for Patient 20 who needed extensive assistance and used oxygen. There was no policy or procedure presented for unit transfers communication such as SBAR (Situation, Background, Assessment, and recommendations) or other, as per hospital policy “Core Nursing Standards of Practice” effective 7/13/22. These failures presented potential risk for patient safety during transferring of care between care teams. Findings: The electronic medical record (EMR) review on 10/14/24 at 10:30 AM. with Informatic Manager (IM) showed Patient 20 was admitted to the rehabilitation unit on 9/10/24. Review of 9/10/24 History and Physical showed Patient 20 with a history of multiple medical problems. The 10/14/24 physician progress note indicated, the patient was admitted to acute rehab unit following cardiac (heart) and kidney (renal) transplants on 6/15/24 and 6/16/24 “complicated by delayed renal graft function and persistent volume overload requiring dialysis (hemodialysis, a procedure of removing body waste and extra fluids from blood) “. Review of nursing flow chart showed Patient 20 was stable on oxygen supplement via nasal canula, vital signs done every shift. It was noted that on 10/13/24 vital signs intervals increased to every 15 minutes at 9:45 AM. until 10/13/24 at 3:00 PM. The rehab unit nursing records showed no nursing notes to indicate the reason for the increased monitoring or any nursing note indicating any change of the patient status. Review of orders showed no order for vital signs to indicate the frequency. There was an order for hemodialysis by nephrologist documented on 10/13/24 at 9:17 AM. Further record review showed a note by dialysis RN (Registered Nurse) that the patient underwent dialysis on 2nd floor. The dialysis RN notes indicated the patient was sent from rehab unit on 4th floor for dialysis and the procedure lasted from 10/23/24 at 10:00 AM to 10/13/24 at 1:15 PM. Review of rehab unit nursing record with IM on 10/14/24 at 10:30 AM. did not contain any documentation by a RN reflecting the patient leaving the floor for dialysis, the patient overall condition, if the patient traveled with oxygen, or how the patient was transported to the dialysis location. During tour of the rehab unit on 10/14/24 at 12:10 PM., Patient 20 was observed in the rehab room assisted by a physical therapist (PT) teaching the patient to get into a rehab car. The patient was very slow, needing extensive assistance with transfer to a specialized wheelchair by the PT. The patient was using portable oxygen via nasal cannula. Review of record for Patient 20 and concurrent interview with the Rehab Unit Charge Nurse (RUCN) was conducted on/10/14/24 at 12:20 PM., at the unit nursing station. The RUCN confirmed there was no order for vital signs but stated, the vital signs were done routinely per unit policy approximately every 8 hours, unless the patient condition or orders required more frequent monitoring. The RUCN reviewed the nursing notes and handoff section of the flowchart for 10/13/24 and confirmed, there was no nursing documentation for Patient 20 showing that there was a communication with dialysis unit about the patient’s condition. The RUCN stated usually patients were transported via a transport team available hospital wide. The RUCN confirmed, the expectation at minimum would be to write a progress note, or document in the flow chart under handoff the patient condition, mode of transfer, and report to the receiving care provider. The RUCN stated, there was a ticket generated for patient transport, but it was not a part of the patient record. A request was made during survey form the leadership to present a policy that addressed the patient handoff or similar written procedure that would outline the process. In a follow up interview with Critical Care Services Director (CCSD) on 10/14/24 at 4:30 PM. she stated, there was no specific policy on handoff. She stated, there was no policy on SBAR or similar. SBAR did not occur on the floor. She presented a copy of “Ticket to Ride”, a document to transport team for Patient 20 on 10/13/24, stating this document would be scanned in the patient chart upon discharge. No ticket to ride was available for the return trip to the unit. She also presented a policy titled “Core Nursing Standards of Practice” effective 7/13/22. Review of the “Ticket to Ride” for Patient 20, dated 10/13/24, showed current patient location on 4th floor, indicating the ticket was for the patient to transport to dialysis. The ticket was not timed and only indicated patient code status “full”. The “Safety Risk & Precautions”, “Consideration for Safe Lift” infection control or “other” considerations were left blank. There was nothing showing the patients ambulatory status (extensive assistance) or need for oxygen. There was no authentication by any staff. Review of the policy “Core Nursing Standards of Practice” effective 7/13/22 indicated, it was applicable to units including Acute Rehab. The policy in part indicated, the registered nurse coordinates care delivery and “collaborates with ...interprofessional team ...to effect safe transitions in continuity of care” (page 5). Section on page 8 “Patient Handoff” indicated, “Patient handoff is completed using a standardized format according to policy, such as SBAR or ISHAPED (introduction, story, assessment, plan, error prevention, and dialogue) when patient transition from one caregiver to another.” Under Documentation Expectations it was noted, documentation is considered a communication tool, as such nursing documentation should reflect nursing assessment process and should inform the care team briefly of the patient’s status. On 10/14/24 at 5:00 PM Quality Director confirmed the findings, also confirmed there was no specific policy for SBAR or similar that would address a patient handoff.”

“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: 31794 Based on interviews and record reviews the facility failed to ensure a Care Plan was developed for one of 30 sampled patients (Patient 26) when there was no Care Plan developed to address the pain issue. This failure had the potential to negatively affect the delivery of care and services rendered to patients. FINDINGS: Review of the undated Face Sheet (front page of the chart that contains a summary of basic information about the patient) indicated Patient 26 was admitted to the facility on 9/26/24. Review of the admission History and Physical dated 9/27/24 indicated the diagnoses that included acute respiratory failure (when the lungs can’t release enough oxygen into your blood and makes it difficult to breathe on your own), severe sepsis (a life-threatening blood infection), and community acquired pneumonia (lung infection that develops outside the hospital or other healthcare facility). In a concurrent record and interview on 10/10/24, at 1:50 PM, with the Registered Nurse /Clinical Informatics (RN/CI), the Pain Flowsheet and the Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient) were reviewed. The RN/CI stated, on 9/27/24 at 9:34 PM the Numeric Pain Scale (NPS, a pain screening tool) was 10/10, Oxycodone (pain medication) 20 mg (milligrams) was given and there was no pain re-assessment done after the pain medication was administered. The RN/CI stated, on 9/30/24 at 1:02 PM, using the “Wong Baker (Face rating scale, a pain assessment tool)” the staff documented the pain scale was 7/10 and after searching the MAR, the RN/CI stated, Oxycodone 10 mg was given but there was no pain re-assessment done after the pain medication was administered. The RN/CI further stated, on 10/1/24 at 3:34 PM, the NPS scale was 8/10, Oxycodone 10 mg was administered, and no pain re-assessment after the pain medication was administered. The RN/CI stated, as per policy pain re-assessment should be done “30 to 60 minutes” after the oral pain medication was administered. In a concurrent record review and interview on 10/10/24, at 2:27 PM, with the RN/CI, the Care Plan was reviewed. The RN/CI searched the list of Care Plans and stated, there was no Care Plan developed for pain, “I don’t see anything”. Review of the facility’s Policy and Procedure (P & P) titled, Pain Management, with the last approval date of 3/23 indicated, “Procedure: ... Pain Management. ... 11) The Nurse will initiate a Pain Care Plan in the event the patient is experiencing pain. ... .” In an interview on 10/10/24, at 3:10 PM, with the Nurse Manager (NM 1) NM 1 stated, Care Plan should be developed to address the pain issue, staff should work with the patient, and the expectation was for them (staff) to reach patient’s goal, because “it’s patient’s rights”. Review of the facility’s P & P titled, “Core Nursing Standards of Practice”, with the effective date of 7/13/22 indicated, “Standard 1: Nursing Process. 1. ... 4. Plan of Care - The registered nurse develops a plan of care that prescribes strategies to attain expected, measurable outcomes. The registered nurse: a. partners with the patient to implement the plan in a safe, effective, efficient, timey, patient -centered, and equitable manner. ... .””

“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: 31794 Based on interviews and record reviews the facility failed A. To ensure the staff implemented its Policy and Procedure (P&P) on “Pain Management” for four (4) of 30 sampled patients (Patients 21, 25, 26, and 27) when: 1. For Patient 21, there was no documented evidence the Pain Assessment (an evaluation that measures the intensity, nature, duration, and location of pain) with the Numerical Pain Scale (NPS, screening tool that measures the intensity of pain from 0-10, zero (0) is no pain and 10 is worse pain) of 4/10 (moderate pain) to 7/10 (severe pain) was reported to the physician in order for the patient to receive the appropriate pain treatment and management. 2.For Patient 25, no Pain re-assessment (assessment performed to determine the effectiveness of the interventions) done after the patient received pain medication. 3.For Patient 26, no Pain re-assessment done after the patient received pain medication. 4.For Patient 27, no Pain re-assessment done after the patient received pain medication. These deficient practices had the potential to negatively impact the quality of life and the quality of care and services rendered to the patients. B. To ensure the staff implemented its P&P on “Critical Value Notification and Read Back” for one (1) of 30 sampled patients (Patient 30) when, the serum lactic acid (also known as lactate, is the amount of lactic acid in the blood) of 5.4 collected on 9/18/24, considered as Critical Value (means results or findings that require rapid communication because it indicates a life-threatening condition that needs to be corrected by appropriate and timely intervention [i.e. panic values] as per facility policy) was not reported to the Physician within the time frame as stated in the facility policy. It was reported to the physician about six (6) hours after it was called in to the Registered Nurse (RN 2) on 9/18/24. Failure to notify the Physician of the critical laboratory value had the potential to delay the care and treatment needed to prevent life threatening medical condition which could lead to harm and/or death. FINDINGS: A. 1. Review of the undated Face Sheet (front page of the chart that contains a summary of basic information about the patient) indicated, Patient 21 was admitted to the facility on 7/30/23. Review of the admission History and Physical (H & P) dated 7/31/23 indicated, patient presented with nausea, vomiting, and bloody diarrhea. The diagnosis included sepsis (a life-threatening blood infection)) likely secondary to colitis (inflammation of the large intestine), hypokalemia (low blood level of potassium), and hypophosphatemia (low blood level of phosphorus). In a concurrent record review and interview on 10/9/24, at 1:38 PM, with the Registered Nurse /Clinical Informatics (RN/CI), the Pain Flowsheet was reviewed. The RN/CI stated, on 7/30/24 at 7:10 PM, the NPS was 5/10, and at 9:00 PM the NPS was 5/10. On 7/31/24 at 5:00 AM, the NPS was 6/10, and at 4:00 PM the NPS was 4/10. On 8/1/24 at 8:53 AM, the NPS was 6/10, and at 3:23 PM the NPS was 4/10. On 8/3/24 at 7:46 AM the NPS was 6/10, and at 4:00 PM the NPS was 7/10. The RN/CI searched the Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient) and stated, there was no pain medication administered for NPS of 4/10 up to 7/10 for those dates, and there was no documentation the Physician was notified of the pain scale. In an interview on 10/14/24, at 2:10 PM with the Unit Manager (UM 1), UM 1 stated, for NPS of one (1) to three (3) it was considered mild, for NPS of four (4) to six (6), it was considered moderate, and for seven (7) to 10, it was considered severe. The UM 1 stated, for increased pain level he expected the staff to escalate the pain issue to the Physician for adequate pain management. Review of the facility’s Policy and Procedure (P &P) titled, “Pain Management”, with the approval date of 3/23 indicated, “Policy: ...1. Patients have a right to appropriate pain assessment and management. ... Procedure: Pain Management. ... 10) In the event a patient experiences unexplained or unexpected pain, the nurse will immediately notify the physician to facilitate further evaluation. The pain will be treated during the process. ... .” 2.Record review of the undated Face Sheet indicated Patient 25, was admitted to the facility on 9/25/24. Record review of the admission H&P dated 9/24/24 indicated, Patient 25 had history of fracture (broken) left knee status post repair and chronic low back pain who presented to the facility with progressive and worsening back pain and was scheduled to undergo a laminectomy (surgery of the lower back to remove or most of the spinal bone or back bone). In a concurrent record review and interview on 10/10 24 at 12:45 PM, with the Registered Nurse/Clinical Informatics (RN/CI), the Pain Flowsheet and the MAR were reviewed. The RN/CI stated, on 9/29/24 at 1:34 AM, the NPS was 4/10 and after searching the MAR stated, Oxycodone (pain medication) five (5) mg (milligrams) tablet was administered to the patient, the staff “did not do (pain) re-assessment”. The RN/CI stated, on 9/30/24 at 4:54 AM, the NPS was 7/10, Oxycodone 10 mg was administered, “I don’t see (pain) re-assessment”. The RN/CI stated, on 10/3/24 at 6:21 PM the NPS was 5/10, Oxycodone five (5) mg was administered, there was “no (pain) re-assessment done.” The RN/CI stated, on 10/4/24 at 5:26 AM the NPS was 5/10, Oxycodone five (5 mg) was administered, “they (staff) did not re-assess the patient.” The RN/CI stated, on 10/4/24 at 11:36 PM the NPS was 10/10, Oxycodone 10 mg was administered, staff “did not do” the pain re-assessment as per policy. The RN/CI stated, on 10/8/24 at 3:05 PM, the NPS was 7/10, Oxycodone 10 mg was administered, and there was “no re-assessment” done. When asked when pain re-assessment was supposed to be done, the RN/CI stated per policy, it should be done 30 -60 minutes after the administration of the oral pain medication(s). 3. Review of the undated Face Sheet indicated Patient 26 was admitted to the facility on 9/26/24. Review of the admission H&P dated 9/27/24 indicated, the diagnoses that included acute respiratory failure (when the lungs can’t release enough oxygen into your blood and makes it difficult to breathe on your own), severe sepsis (body’s extreme response to an infection), and community acquired pneumonia (lung infection that develops outside the hospital or other healthcare facility). In a concurrent record and interview on 10/10/24, at 1:50 PM, with the RN/CI, the Pain Flowsheet was reviewed. The RN/CI stated, on 9/27/24 at 9:34 PM the NPS was 10/10, Oxycodone (pain medication) 20 mg (milligrams) was given and there was no pain re-assessment done after the pain medication was administered. The RN/CI stated, on 9/30/24 at 1:02 PM, using the “Wong Baker (Face rating scale, a pain assessment tool)” the staff documented the pain scale was 7/10 and after searching the MAR, Oxycodone 10 mg was given but there was no pain re-assessment done after the pain medication was administered. The RN/CI further stated, on 10/1/24 at 3:34 PM, the NPS scale was 8/10, Oxycodone 10 mg was administered, and no pain re-assessment after the pain medication was administered. 4. Record review of the undated Face Sheet indicated, Patient 27 was admitted to the facility on 9/21/24. Review of the admission H&P dated 9/21/24 indicated Patient 27 had a history of hypertension (high blood pressure) and metastatic lung adenocarcinoma (lung cancer that has spread from the lungs to other parts of the body). The diagnosis included acute hypoxic respiratory failure (condition when the body does not have enough oxygen in the blood), shortness of breath, and chronic back and neck pain. In a concurrent record review and interview on 10/10/24, at 2:41 PM with the RN/CI, the Pain Flow Sheet was reviewed. The RN/CI stated, on 10/10/24 at 2:39 AM, the NPS was 10/10. The RN/CI searched the MAR and stated, Morphine Sulfate (pain medication) was administered and there was no pain re-assessment done. The RN/CI stated, on 10/10/24 at 6:39 AM the NPS was 8/10, Morphine Sulfate was administered as per the MAR, and there was no pain reassessment done. In an interview on 10/14/24, at 2:30 PM, with the UM, UM 1 stated, pain reassessment was important to determine if the pain medication was effective and how the patient was doing. Review of the facility’s P&P titled, Pain Management, with the last approval date of 3/23 indicated, “Procedure: Patient Assessment. ... (4) The patient’s pain intensity is assessed before and after pain management interventions. (a) reassess pain intensity ... 30-60 minutes after PO (oral) /IM (intramuscular)/ PR (per rectum) medication. ... .” B. Record review of the undated Face Sheet indicated, Patient 30 was admitted to the facility on 9/18/24. Review of the admitting H&P dated 9/18/24 indicated, patient presented with the chief complaint of generalized weakness and the diagnosis included acute lactic acidosis (lactic acid build up in the bloodstream), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and chronic protein calorie malnutrition (inadequate intake of food source rich in protein, calories, and other essential nutrients). In a concurrent record review and interview on 10/14/24, at 11:35AM, with the RN/CI, the laboratory results were reviewed. The RN/CI stated, on 9/18/24 at 5:10 PM, the serum lactic acid result was “5.4”, the normal range was from “0.5 up to 2.2”, it was a “critical value.” The RN/CI stated, the elevated level of lactic acid was indicative of “sepsis”. The RN/CI searched the Electronic Health Record (EHR) and stated, the Laboratory staff called in the critical value result of the serum lactic acid to the RN 2 on 9/18/24 at 5:40 PM. After searching the EHR, the RN/CI stated, the RN 2 did not document the Physician was notified of the critical value of the serum lactic acid, “I did not see it”, and the RN 2 should have notified the Physician. Further review of the EHR indicated, the RN 3 called the critical value of the lactic acid to the Physician at 11:15 PM on 9/18/24 (about six hours after it was first reported to RN 2), this was a “late call”. Review of the facility’s P&P titled, “Critical Value Notification and Read Back”, with the last approval date of 7/23 indicated, “Policy: All critical test results and values ... are to be verbally relayed to the patient’s attending physician or designee within 60 minutes from the time the critical value is first identified in the Laboratory, ... Procedure: Licensed staff receiving Value ... 2. All critical values received on the units will be reported to the attending physician or designee ... 3. If a patient’s test result is in the critical value range, it will be verbally relayed to the patient’s attending physician or designee within 60 minutes from the time the critical value is first identified ... . The result will be given with emphasis that the result is a “Critical value”. ... .””