La Palma Intercommunity Hospital

“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: 45560 Based on interview and record review, the hospital failed to develop the individualized nursing care plan related to shortness of breath and risk of bleeding due to the administration of continuous IV heparin (blood thinning medication) infusion for one of five sampled patients (Patient 2). This failure created the risk of not meeting Patient 2’s care needs. Findings: Review of the hospital’s P&P titled Multidisciplinary Plan of Care dated September 2023 showed each admission will have a written multidisciplinary plan of care utilized by all disciplines. Expected outcomes/goals will be based on assessment and will be realistic, measurable, and consistent with the therapy prescribed by the patient’s physician and other clinical disciplines. Patient education and patient/family knowledge of self-care will be given special consideration in the nursing plan. Review of Patient 2’s closed medical record was initiated on 4/16/25. The medical record showed Patient 2 was admitted on 1/3/25. Review of Patient 2’s H&P examination dated 1/3/25, showed Patient 2 was admitted to the hospital with a chief complaint of increasing shortness of breath over the last several days and was diagnosed with acute pulmonary embolus. Review of Patient 2’s physician’s order dated 1/3/25, showed an order to start heparin, 25000 units in D5W (Dextrose 5% in water, an IV solution) 250 mL, continuous IV infusion On 4/16/25 at 1401 hours, an interview and concurrent review of Patient 2’s closed medical record was conducted with Nursing Director 1. Nursing Director 1 stated the nursing care plans should be individualized to reflect the patient’s current health conditions and care needs. However, Nursing Director 1 was unable to find the care plans developed to address Patient 2’s shortness of breath and risk of bleeding related to continuous IV heparin infusion. Nursing Director 1 acknowledged Patient 2’s care plan was not individualized to address their specific needs. On 4/16/25 at 1215 hours, the Chief Nursing Officer and Performance Improvement Director were notified and acknowledged the above findings.”

“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: 45560 Based on observation, interview, and record review, the hospital’s failed to implement their P&Ps and physician’s orders for one of five sampled Patients (Patient 5) as evidenced by: 1. RN 5 did not perform hand hygiene prior to administering the medications as required by the hospital’s P&P. 2. RN 5 did not access Patient 5’s central line device as per the hospital’s P&P. 3. There was no documentation to show RN 5 notified the physician before administering insulin glargine (a long-acting insulin used to manage blood sugar levels in people with diabetes) to Patient 5 while the patient was on NPO as per the physician’s order. These failures had the potential to increase the risk of substandard healthcare outcomes and safety to the patient. Findings: 1. Review of the hospitals P&P titled Medication Administration dated September 2024 showed aseptic technique, IV, and infection control practices will be adhered to in the preparation and administration of medications. On 4/17/25 at 0845 hours, a medication pass observation was conducted with RN 5. RN 5 was observed exiting the nursing station and holding Patient 5’s medications. RN 5 then pushed a workstation on wheels and a mobile computer cart into Patient 5’s room, and donned the gloves. RN 5 did not perform hand hygiene before donning the gloves. RN 5 then accessed Patient’s 5 electronic medical record and administered one medication via subcutaneous injection and one medication via IV push to Patient 5. On 4/17/25 at 0854 hours, an interview was conducted with RN 5. RN 5 acknowledged hand hygiene was not performed before administering medication to Patient 5 or before donning gloves. On 4/17/25 at 1003 hours, an interview was conducted with the Infection Preventionist. The Infection Preventionist confirmed hand hygiene should always be performed immediately before administering medication to a patient. 2. Review of the hospital’s P&P titled Care of Central Venous Catheters dated March 2020 showed the hospital adopts the recommendations provided by the CDC and the IHI for the prevention and reduction of CR BSI. Review of the CDC’s Guidelines for the Prevention of Intravascular Catheter-Related Infections dated 2011 showed the recommendations for needleless intravascular catheter systems include to minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices. On 4/17/25 at 0845 hours, RN 5 was observed scrubbing Patient 5’s CVC access port with a 70% alcohol prep pad. However, after scrubbing the access port of the CVC, RN 5 was observed placing the access port on Patient 5’s right shoulder allowing the port to come into contact with Patient 5’s pillow and gown. RN 5 was then observed to administer a medication via the CVC port to Patient 5. On 4/17/25 at 0854 hours, an interview was conducted with RN 5. RN 5 stated the CVC port had come into contact with Patient 5’s pillow and gown, and this practice could increase the risk of a catheter-related bloodstream infection. On 4/17/25 at 1003 hours, an interview was conducted with the Infection Preventionist. The Infection Preventionist stated when working with central lines, once the injection port was cleaned with alcohol, it should be not placed where it could be re-contaminated prior to the administration of IV medications. 3. Review of the hospital’s P&P titled Medication Administration dated September 2024 showed prior to administration, the practitioner will review the medication administration record (MAR) for any special considerations that would influence the administration of medications, including but not limited to clinical parameters, NPO status, medications at odd hours, one time only medications, or medications that must be given with food. On 4/17/25 at 0845 hours, a medication pass observation was conducted with RN 5. RN 5 was observed administering 10 units of insulin glargine to Patient 5. Review of Patient 5’s physician’s orders showed the following orders: - The physician’s order dated 4/13/25 at 1316 hours, showed insulin glargine 10 units subcutaneous, every 12 hours, notify MD if the patient is NPO for procedure when there are no IV fluids with dextrose (an IV fluid used to treat low blood sugar) running or no orders for temporary decrease of insulin glargine - The physician’s order dated 4/16/25 at 1858 hours, showed NPO after midnight. On 4/17/25 at 0946 hours, an interview and concurrent review of Patient 5’s medical record was conducted with Nursing Director 1 and RN 5. RN 5 stated Patient 5 was scheduled for a procedure and was NPO, RN 5 also confirmed Patient 5 did not have an order for IV fluids with dextrose or any order for a temporary decrease of insulin glargine. RN 5 stated the physician was not notified, and Patient 5 received 10 units of insulin glargine without the required physician’s notification. Nursing Director 1 was unable to locate documentation in Patient 5’s electronic medical record showing the physician was notified as required prior to the administration of the insulin glargine. On 4/16/25 at 1215 hours, the Chief Nursing Officer and Performance Improvement Director were notified and acknowledged the above findings.”

“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: 38660 Based on interview and record review, the hospital failed to ensure the nursing staff monitored one of four sampled patients (Patient 1) every two hours for the use of non violent behavior restraint as per the hospital’s P&P. This failure posed the risk of injury and inappropriate care and treatment for the patient. Findings: Review of the hospital’s P&P titled Restraints: Non Violent Behavior dated March 2023 showed the following: * A patient in restraints is monitored at least every two hours or more often as applicable to the patient. * Monitoring is accomplished by observation, interaction with the patient, or related direct examination of the patient by qualified staff. * Monitoring includes: - Assessing the patient’s physical and emotional well-being. - Maintaining the patient’s rights, dignity, and safety. - Determining if less restrictive methods are possible. - Assessing for changes in the patient’s behavior or clinical condition needed to initiate the removal of restraint - Confirming the proper restraint application, remove and reapplication. * Care includes toileting, positioning, circulation checks, range of motion, food/fluids offered. On 9/11/24 at 1000 hours, an interview and concurrent review of Patient 1’s medical record was conducted with the Director of Performance Improvement and Director of Medical Surgical and Telemetry. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 9/5/24. Review of the physician’s order dated 9/10/24 at 1013 hours, showed the physician’s order of soft restraint to bilateral wrists and the restraint reason was interference with medical treatment. Review of the nursing flowsheet dated 9/10 and 9/11/24, failed to show documented evidence showing the nursing staff conducted the initial assessment applied the restraints on Patient 1; and monitored the patient every two hours on 9/10/24, from 1000 to 1800 hours as per the hospital’s P&P. When asked about the process of using restraint, the Director of Medical Surgical and Telemetry stated when the patient was danger to self or removed the lines used for medical interventions, the nurses provided the alternative interventions before applying restraints on the patient. If the alternative interventions were not effective, the nurse obtained the physician’s order for restraint, applied the restraint on the patient, assessed the patient, documented the patient monitoring every two hours, and initiated the plan of care. The Director of Performance Improvement and Director of Medical Surgical and Telemetry confirmed the above findings.”

“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: 38660 Based on interview and record review, the hospital failed to ensure the nursing staff developed the individualized nursing care plan to address the use of restraint for one of four sampled patients (Patient 1). This failure posed the risk of patient care and treatment were not being provided appropriate to the patient. Findings: Review of the hospital’s P&P titled Restraints - Non Violent Behavior dated March 2023 showed to use Electronic Medical Record Restraint Flow Sheet, restraint order forms, and narrative notes to document all pertinent information in the medical record including but not limited to plan of care/ treatment plan, including criteria for discontinuation when applicable. On 9/11/24 at 1000 hours, an interview and concurrent review of Patient 1’s medical record was conducted with the Director of Performance Improvement and Director of Medical Surgical and Telemetry. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 9/5/24. Review of the physician’s order dated 9/10/24 at 1013 hours, showed the physician’s order of soft restraint to bilateral wrists and the restraint reason was interference with medical treatment. Patient 1’s medical record failed to show documented evidence the nursing staff developed the plan of care related to the use of restraints for Patient 1. The Director of Performance Improvement and Director of Medical Surgical and Telemetry confirmed the above findings.”

“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: 22553 Based on interview and record review, the hospital failed to ensure the five-minute EKG strip was obtained for one of four sampled patients (Patient 1) as per the hospital’s P&P. This failure had the potential for miscommunication among hospital staff. Findings: Review of the hospital ’ s P&P titled Code Blue-Adult Cardiac/Pulmonary Arrest dated December 2020 showed the purpose is to provide an accurate chronological record of all data pertaining to the arrest and resuscitation efforts. The post CPR responsibilities include the Nursing Supervisor will complete code blue sheet with assistance of primary nurse, the Code Blue critique must be completed. The House Supervisor must obtain a five-minute strip print out from the Charge Nurse or Monitor Tech and make sure it is scanned into the Electronic Healthcare System. The Nursing Supervisor obtains the input from Code Blue team members for completion of the Code Blue Evaluation. A five-minute cardiac monitoring strip prior to code blue must be obtained and be included with the completed critique form. An interview and concurrent review of Patient 1’s closed medical record was conducted with the CNO on 8/28/24 at 1602 hours. Patient 1 ’ s medical record showed on 7/16/24 at 1310 hours, RN 4 noticed the patient’s heart rate went from 90 to 75 beats per minute. The patient was unresponsive, pale, and agonal breathing. The Code Blue was called. At 1313 hours, the patient had no pulse and the chest compressions started. At 1319 hours, the Code Blue ended. The patient was intubated with a breathing tube and returned to a spontaneous circulation. However, Patient 1 ’ s medical record did not include the EKG strip. The CNO stated she was the recorder for Patient 1’s Code Blue and responsible to retain the EKG strips, but she went to help another patient immediately and was not able to retrieve Patient 1’s EKG strips for the CPR record.”

“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: 39796 Based on interview and record review, the hospital failed to ensure the nursing staff accurately conducted the integumentary assessment and took a wound photograph for one of four sampled patients (Patient 4) as per the hospital’s P&P. This failure had the potential to result in poor clinical outcomes to the patient. Findings: Review of the hospital’s P&P titled Skin Integrity dated December 2020 showed Photographed alterations in skin integrity and open wound are to be posted on the Wound Photograph Documentation Form in the patient’s medical record or uploaded to the electronic medical record. Wounds are to be photographed upon discovery of a new wound. Any change in conditions on skin integrity will be reported to the primary physician and will be documented. On 8/28/24 at 1455 hours, a medical record review for Patient 4 was initiated with the CNO, Director of Performance Improvement, and Director of Behavioral Unit. Review of Patient 4’s closed medical record showed Patient 4 was admitted on 8/20/24. Review of the Nursing Note dated 8/22/24 at 1545 hours, showed Patient 4 was walking around unit in underwear and asked by the MHW to return to the room. The patient started to become agitated and yelling back on his way to his room “I can do whatever I want!” The patient was educated on the way back to his room of the unit rules, non-acceptant of the teaching. The patient was able to be escorted back to the room. About a minute later, the patient exited room yelling “Where is he” “Lets go then!” The patient rushed at the MHW swinging arms. The MHW and LVN were able to hold and restraint the patient. The unit staff was notified and the code gray was called. The staff notified the NP and the emergency medications were ordered. Review of the Progress Notes dated 8/23/24 at 0945 hours, showed an event yesterday involved Patient 4, requiring to be physically restrained and code gray being called. Patient 4 hit the ground during the event, but no LOC. Patient 4 suffered a minor laceration to the forehead. Review of the Default Flowsheet Data dated 8/22/24 at 2000 hours and 8/23/24 at 0900 hours, showed the RN had performed the integumentary assessment. The integumentary assessment showed “WDL.” Review of Patient 4’s medical record failed to show documented evidence of the photograph was taken for the patient’s minor laceration to the forehead as per hospital’s P&P. On 8/28/24 at 1506 hours, an interview and concurrent medical record review was conducted with the RN 4 in the presence of the Director of Behavioral Unit, Director of Performance Improvement, and CNO. RN 4 stated he was the primary RN for Patient 4 on 8/22/24. RN 4 stated he witnessed the incident that happened to Patient 4 at that time. RN 4 stated Patient 4 attacked the staff. RN 4 stated Patient 4 sustained injury from the incident, a small skin opening on his right eyebrow. RN 4 stated he performed an assessment of Patient 4’s injury. RN 4 stated there was no documentation of the assessment of the wound, it should have been documented, but it was missed. On 8/29/24 at 0912 hours, an interview and concurrent review of Patient 4’s medical record was conducted with the Director of Behavioral Unit. The Director of Behavioral Unit stated it was not necessary to document the wound assessment. The Director of the Behavioral Unit stated the assessment of Patient 4’s integumentary system was not accurate. The Director of the Behavioral Unit stated there was no photograph taken for Patient 4’s laceration. The Director of Behavioral Unit reviewed the hospital’s P&P and acknowledged the findings. On 8/29/24 at 1300 hours, the CNO, Director of Performance Improvement, Director of ICU, and Director of Behavioral Unit were informed and acknowledged the findings.”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure a grievance was reviewed and completed timely for one of two sampled patients (Patient 1). This failure created the increased risk of a failed grievance process. Findings: Review of the hospital’s P&P titled Grievance/Complaint Process dated 9/2022 showed if an issue is unable to be resolved on the spot, within seven days following the submission, the patient will be provided with a written notice. If a prolonged investigation is anticipated, the patient will be informed of this fact and the anticipated length of the investigation. On 7/15/2024, a review of Patient 1’s grievance was conducted. Review of Patient 1’s complaint form showed a complaint was submitted on 7/2/24 (no time) for an event on 7/1/24, of a patient care concern regarding the patient and MD 1 for unprofessionalism and harassment. Review of the document showed the complaint was referred to the Medical Director for ED. Documentation showed the Executive Assistant forwarded the grievance by email to the Medical Director of ED on 7/2/24 at 1127 hours. On 7/12/24 at 1347 hours, the Executive Assistant sent another email to the Medical Director of ED stating Patient 1 had yet to receive any resolution actions from the hospital. On 7/12/24 at 1422 hours, the Medical Director of ED sent an email stating MD 2 called Patient 1 four times with no response. On 7/15/2024 at 1211 hours, an interview was conducted with MD 2. MD 2 stated he was made aware via email of Patient 1’s grievance on 7/2/24. MD 2 stated however, the attempts to call Patient 1 did not occur until 7/12/24. On 7/15/2024 at 1330 hours, the above findings for the grievance to not be reviewed and completed timely were shared and acknowledged by the CMO, CNO, and Director of Performance Improvement.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to provide a written notice of the resolution of the grievance as per the hospital’s P&P for one of two sampled patients (Patient 1). This failure had the potential to result in the increased risk of a failed grievance process. Findings: Review of the hospital’s P&P titled Grievance/Complaint Process dated 9/2022 showed a patient concern is defined as an expression of displeasure or dissatisfaction with service received. A resolution is achieved at the time of the concern by the staff. A patient grievance is a written or verbal concern by a patient regarding care, abuse, or neglect. The Grievance Committee will assure the grievance is investigated timely. If an issue is unable to be resolved on the spot within seven days following the submission, the patient will be provided with a written notice of: - The name and number of the hospital contact person should further information be required. - The steps taken on behalf of the patient to investigate the grievance. - The results of the grievance process. - The date of the investigation was completed. On 7/15/24 at 1040 hours, an interview and concurrent review of Patient 1’s grievance was conducted with the CNO. Review of Patient 1’s complaint form showed a complaint was submitted on 7/2/24 (no time) for an event on 7/1/24, of a patient care concern regarding the patient and MD 1 for unprofessionalism and harassment. However, further review of hospital records failed to show a written notice of the grievance was sent to Patient 1 according to the hospital’s P&P. When asked, the CNO stated the CNO was part of the grievance committee. The CNO stated the hospital treated Patient 1’s care issue as an ongoing concern which initially started as a complaint. However, the CNO stated the issue was not resolved and acknowledged the grievance process was not implemented according to the hospital’s P&P.”

“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: 29558 Based on interview and record review, the hospital failed to ensure one of two sampled patients (Patient 1) was informed of the AMA discharge as per the hospital’s P&P. This failure had the potential for the patient to not be allowed to make medical care decisions. Findings: Review of the Medical Staff General Rules dated 12/2018 showed should a patient leave the hospital against the advice of the attending physician, every effort will be made to have the patient sign the hospital AMA form. The patient will be informed of the risks of leaving the hospital AMA. Review of the hospital’s P&P titled Discharge of Patients Against Medical Advice dated 9/2022 showed the patient’s physician should attempt to provide the patient with information as to why the continued treatment is recommended and the potential consequences of the action so the patient can make an informed decision on whether to leave the hospital. The patient’s signature (or refusal to sign) must be witnessed by a hospital employee. Review of the hospital’s P&P tiled Aftercare Instructions dated 9/2022 showed each patient who is discharged from the ED will receive a written After Care Instruction form. The ED MD will generate a computer set of instructions specific to the patient’s diagnosis including what treatment was provided and what follow-up care is needed. The After Care Instruction form must be verbally explained to the patient and a signature from the patient obtained. A copy of the After Care Instruction form will be given to the patient and the original signature sheet must be returned to the medical records department staff to be scanned into the patient’s EMR. On 7/15/24, Patient 1’s medical record review was initiated. Patient 1 visited the ED on 7/1/24, with a complaint of back pain. Review of the ED Provider Notes dated 7/1/24 at 1226 hours, showed MD 1 provided an MSE for Patient 1 regarding back pain. The section to determine the medical decision showed the severity of Patient 1’s back pain was mild, and Patient 1 was discharged AMA. However, further review of the patient’s medical record failed to show MD 1 had discussed the risks and benefits of leaving AMA with Patient 1. Review of Patient 1’s medical record failed to show evidence of the completed AMA form. Additionally, review of the After Visit Summary form dated 7/1/24, showed no documented evidence Patient 1 had signed and acknowledged receiving the discharge instructions and advisements to return to the ED for worsening symptoms. The After Visit Summary form failed to include the specific details related to Patient 1’s chief complaint of back pain. On 7/15/24 at 1330 hours, the CMO, CNO, and Director of Performance Improvement were informed and acknowledged the above findings.”