San Dimas Community Hospital

“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: 46333 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 follow regulatory standards (State and Federal_ and facility’s staffing and patient care plan regarding safe patient care assignments for six (6) of six sampled charge nurses (CN 4, 5, 6, 7, 8 and 9) by assigning the charge nurses to direct patients care (the first line supervision of direct patient care; the provision of health care services directly to individuals being treated for, or suspected of having, physical or mental illnesses. Direct patient care includes preventive care) and telemonitoring technician (health professionals who monitor heart rhythms and places a patient on the heart monitoring machine) duties. This deficient practice had the potential to result in patient needs not being met to assure patient safety especially during an emergency situation, and the charge nurse was not readily available to assist the staff (Registered Nurse). (Refer to A-0392) 2. The facility staff failed to complete assessments (a head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient’s overall condition) for three (3) of thirty (30) sampled patients (Patient 3, Patient 4, and Patient 27) within four hours of the start of the shift in accordance with the facility’s policy and procedure. This deficient practice has the potential to result for delayed assessment, to provide care, and treatment for changes of condition for Patient 3, Patient 4, and Patient 27. (Refer to A-0395) 3. The facility failed to develop and implement a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for four out of thirty (30) sampled patients (Patient 2, Patient 9, Patient 19, and Patient 22) in accordance with the facility’s policy and procedures regarding care plan development. This deficient practice had the potential to result in Patient 2, Patient 9, Patient 19, and Patient 22’s treatment and care goals not being met by not identifying their individualized patient care needs and risks. (Refer to A-0396) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“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: 46333 Based on observation, interview, and record review, the facility failed to follow regulatory standards (State and Federal) and facility’s staffing and patient care plan regarding safe patient care assignments for six (6) of six sampled charge nurses (CN 4, 5, 6, 7, 8 and 9). The six charge nurses were assigned direct patients care (the first line supervision of direct patient care; the provision of health care services directly to individuals being treated for, or suspected of having, physical or mental illnesses. Direct patient care includes preventive care) and telemonitoring technician (health professionals who monitor heart rhythms and places a patient on the heart monitoring machine) duties. This deficient practice had the potential to result in the unit without proper accountability on addressing patient needs and safety especially during an emergency because the charge nurse for the unit has multiple roles. Findings: During an interview with Charge Nurse 2 (CN 2) on 1/25/2024 at 3:23 p.m., CN 2 stated, “Here in the ICU (intensive care units, a unit in a hospital providing intensive care for critically ill or injured patients), the charge nurse would be assigned to care for one to two patients and will also be the charge nurse on the same shift.” CN 2 stated she was assigned as charge duties and was also assigned to direct patient care. CN 2 stated charge duties, she would check the crash cart (emergency supplies and medication cart), check the temperature for the warmer and medication refrigerator, complete acuity sheets, answer calls from the emergency department, assist in procedures if a patient condition became urgent, for example, intubation (the insertion of a tube into the windpipe to aid in breathing), and do a monitor technician job. CN 2 confirmed that she was assigned direct care of two patients and was the charge nurse for that shift. CN 2 stated she and the other registered nurses would not have time for a full meal, and she would take a quick bite in the back room. A record review of the ICU nursing assignment schedule’s record, “ICU Staffing Sheet,” dated 12/31/2023, indicated CN2 was assigned to charge nurse responsibilities and direct care of a patient in room 3. The record also indicated, “Charge Note: The charge nurse will be the Rapid Response Team leader (a lead for the team of medical emergency clinicians in the response to medical emergencies, provide rapid assessment, and deploy resources for patients who are experiencing acute clinical deterioration in the hospital) when called upon.” During a concurrent observation and record review, on 1/26/2024 at 1:22 p.m. on the ICU (Intensive care unit, is a part of a hospital that gives care to people who are critically ill), ten (10) patients were observed on the unit. A review of the unit assignment indicated CN 1 was assigned to direct patient care for a patient in Room 10 (Patient 30). CN 1 observed preparing medication to prepare for intubation (the process of inserting a tube into the airway [windpipe] to aid breathing) for another patient in Room 7. During an interview with Registered Nurse (RN) 2, who was one of the registered nurses working in the ICU, on 1/26/2024 at 1:22 p.m., RN 2 stated CN1 was assigned to direct patient care (Patient 30). RN 2 stated charge nurses in the ICU were assigned to direct patient care and function as charge nurses. RN 2 stated they (CNs) were also assigned to telemetry monitoring (a specially trained nurse monitors continuously transmitted data, such as the heart rate, breathing, and blood pressure, and can respond to any changes that signal a potential problem). A record review of the ICU nursing assignment schedule’s record, “ICU Staffing Sheet,” dated from 12/1/2023 through 12/13/2023, and 1/14/2024 through 1/20/2024, the “ICU Staffing Sheet” indicated, “Charge Note: The charge nurse will be the Rapid Response Team Leader when called upon.” The ICU Staffing Sheet indicated the following: 1. On 12/2/2023, day shift (7 p.m. - 7 a.m.), CN 6 was assigned charge duties and was also assigned direct care of two patients, who were patients in room 2 and room 7. 2. On 12/4/2023, day shift (7 a.m. - 7 p.m.), CN 7 was assigned charge duties and was also assigned direct care of two patients, who were patients in Room 2 and Room 6. 3. On 12/5/2023, day shift (7 a.m. - 7 p.m.), CN 7 was assigned charge duties and was also assigned direct care of two patients, who were patients in Room 2 and Room 9. 4. On 12/5/2023, night shift (7 p.m. - 7 a.m.), CN 6 was assigned charge duties and was also assigned direct care of a patient in Room 8. 5. On 12/8/2023, day shift (7 a.m. - 7 p.m.), CN 7 was assigned charge duties and was also assigned direct care of two patients, who were patients in Room 2 and Room 3. 6. On 12/9/2023, day shift (7 a.m. - 7 p.m.), CN 8 was assigned charge duties and was also assigned direct care of a patient in Room 2. 7. On 12/12/2023, night shift (7 p.m. - 7 a.m.), CN 6 was assigned charge duties and was also assigned direct care of a patient in Room 2. 8. On 12/13/2023, day shift (7 a.m. - 7 p.m.), CN 9 was assigned charge duties and was also assigned direct care of two patients, who were patients in Room 3 and in Room 7. 9. On 1/17/2023, night shift (7 p.m. - 7 a.m.), CN 6 was assigned charge duties and was also assigned direct care of a patient in Room 2. 10. On 1/18/2023, night shift (7 p.m. - 7 a.m.), CN 5 was assigned charge duties and was also assigned direct care of patients, who were in Room 6 (from 7 p.m. - 10:10 p.m.), patient in Room 7, and patient in Room 3 (from 4:10 a.m. - 6:05 a.m.). 11. On 1/19/2023, night shift (7 p.m. - 7 a.m.), CN 4 was assigned charge duties and was also assigned direct care of a patient in Room 9. 12. On 1/20/2023, night shift (7 p.m. - 7 a.m.), CN 4 was assigned charge duties and was also assigned direct care of two patients, who were patients in Room 9 and Room 10. During a concurrent interview and record review, on 1/26/2024 at 5:40 p.m. with the Chief Nursing Officer (CNO), the CNO stated, “The facility followed staffing ratios (maximum number of patients assigned to a Registered Nurse [RN] during one shift) as per Title 22, State Regulations.” The CNO reviewed the Barclays California Code of Regulations (current through 1/26/24 Register 2024), under Title 22, Division 5, Chapter 1, Article 3, Section (a), which indicated, “Nurse Administrators, Nurse Supervisors, Nurse Managers, and Charge Nurses, and other licensed nurses shall be included in the calculation of the licensed nurse-to-patient ratio only when those licensed nurses are engaged in providing direct patient care. When a nurse administrator, nurse supervisor, nurse manager, charge nurse, or other licensed nurse is engaged in activities other than direct patient care, that nurse shall not be included in the ratio.” The CNO stated, “We are not aware of this (the charge nurse will not be counted in the ratios if the charge nurse is engaged in activities other than direct patient care).” A record review of the facility’s policy and procedure (P&P) titled, “Staffing Plan,” dated January 2024, the P&P indicated, “Staffing patterns have been developed to include the base staffing requirements identified by Title 22 (Addendum 8) and acuity-based staffing standard ...The charge nurse will document the patient acuity level on the Patient Assignment Sheets. Patient Classification: Patient Classification will provide a method of determining nursing care needs of each individual patient based on the beside nurse assessment. Staffing will be determined on a shift-by-shift basis using the staff to patient ratio as determined in Title 22 section 70217. Patient Classification will be used to access the need for additional staff and in making balanced staff assignments ... The acuity will be called to the staffing office in preparation for the upcoming shift’s staffing ...” A record review of the facility’s policy and procedure (P&P) titled, “Plan for Provision of Patient Care,” dated October 2023, the P&P indicated the following: Staffing plans for patient care departments are based on the level and scope of care that needs to be provided, the frequency of care to be provided, and a determination of the level of staff that can most competently, comfortably confidently, and effectively provide the type of care needed. Minimum nurse patient ratios are based on the California Department of Health regulations ... Anticipated changes in the patient care delivery system may necessitate delegation of patient care planning, as indicated, to organizational departments with patient care responsibilities. These will include all disciplines involved in the type of services undergoing change ... Staffing Plans for Patient Care: Nursing: Principles underlying the plan for the provision of nursing care included the following: 1. A Registered Nurse (RN) plans, delegates, and coordinates nursing care provided in every area throughout the hospital 2. Consistent Standards of Patient care and Standards of Nursing Practice were used to monitor and evaluate the quality and relevance of nursing care provided 3. Charge Nurse - The Charge Nurse functions as the assistant to the Department Director/Manager. The Charge Nurse was responsible for unit activities and documentation for the duration of his/her shift. The Charge Nurse monitors activities on his/her shift and consults with the Department Director or Administrative House Supervisor as necessary. The Charge Nurse was accountable to the Department Director/Manager.”

“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 observation, interview, and record review, the facility staff failed to complete assessments (physical [a head to toe assessment] and psychosocial [an individual’s mind or behavior, and to the interrelation of behavioral and social factors] assessment) for three (3) of thirty (30) sampled patients (Patient 3, Patient 4, and Patient 27) within four hours of the start of the shift in accordance with the facility’s policy and procedure. This deficient practice has the potential to result in delayed assessment (physical and psychosocial), to provide care, and treatment for changes of condition for Patient 3, Patient 4, and Patient 27. Findings: a. A record review of Patient 3’s History and Physical (H&P, a physician’s examination record of a patient), dated 12/15/2023, indicated Patient 3’s medical history included alcohol abuse and hypertension (high blood pressure). The H&P indicated, Patient 3 was “Positive for recent fatigue (tired), confusion, but Patient 3 was appearing to be in mild withdrawals (the physical and mental symptoms that a person has when they suddenly stop or cut back the use of an addictive substance) “ The H&P indicted Patient 3’s blood pressure was 165/71 mmHg (millimeter of mercury, a unit of measurement, normal blood pressure between 90/60 mmHg and 120/80 mmHg), and Patient 3’s “Prognosis (likely outcome) is guarded (being an extremely serious condition).” During a concurrent interview with Wound Care Consultant and staff coordinator (Registered Nurse, RN 6) and record review of Patient 3’s Medical Surgical Telemetry (MST) Shift Assessment (a comprehensive physical examination and health evaluation of a patient’s entire body), on 1/24/2024 at 3:03 p.m., Patient 3’s Medical, Surgical, Telemetry (MST, unit for patient requiring medical, surgical, and [Telemetry, care in a hospital where patients undergo continuous heart monitoring) Shift Assessment indicated Patient 3’s shift assessment was completed on 12/16/2023 at 2:35 a.m. RN 6 stated, “The shift assessment should be completed within four hours after the shift started, and shift started at 7 p.m.” RN 6 stated the RN has four hours from the beginning of the shift to enter their assessment. RN 6 stated, Patient 3’s assessment was late (Start of shift was on 12/15/2023 at 7 p.m. and assessment was completed on 12/16/2023 at 2:35 a.m. [7 hours and 35 minutes]). During an interview, on 1/25/2024 at 2:34 p.m. with Charge Nurse (CN 1) of the Medical, Surgical (specialty that cares for patients with complex medical and surgical conditions in the hospital), and Telemetry (Patient with heart monitoring) Unit , CN 1 stated, “The start of the shift (start of nursing shift) is between 7:00 a.m. and 7 p.m., and assessments (physical and psychosocial), should be entered within 4 hours of the start of the shift.” During an interview on 1/25/2024 at 3:00 p.m. with Registered Nurse (RN) 5, RN 5 stated, “Assessment is important to enter prior to four hours, as we need to have a baseline (information or data gathered at the beginning of a period from which variations that subsequently develop are compared) of patient condition, and if there are changes, we will be able to know.” b. A record review of Patient 4’s “Face Sheet (one-page summary of important information about a patient),” undated, indicated Patient 4 was admitted on 12/13/23 at 9:44 p.m. to the medical surgical service. A record review of Patient 4’s “History and Physical,” dated 12/14/2023, indicated, Patient 4 medical history included diabetes mellitus (having high blood sugar level in the body), hypertension, left breast mass, and facial basal cell carcinoma (skin cancer on the face). The H&P indicated Patient 4, “Presented to the Emergency Room with generalized weakness, failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity) for cellulitis (bacterial skin infection that causes redness, swelling, and pain in the infected area) of the left side of the chest wall.” During a concurrent interview and record review, on 1/24/2024 at 3:03 p.m. with the Wound Care Consultant and staff coordinator (RN 6), Patient 4’s Medical Surgical Telemetry (MST) Shift Assessment (a comprehensive physical examination and health evaluation of a patient’s entire body), dated 12/15/2023 indicated Patient 4’s assessment was completed on 12/15/2023 at 2:11 a.m. RN 6 stated, “This assessment (Patient 4’s assessment) is over three hours late, it (Patient 4’s assessment) should be done within the four hours of shift start (Start of shift was on 12/14/2023 at 7 p.m. and shift assessment was completed at 12/15/2023 at 2:11 a.m. [7 hours and 11 minutes]).” During an interview on 1/25/2024 at 2:34 p.m. with charge nurse of the medical surgical and telemetry unit (CN) 1, CN 1 stated, “The shift is between 7:00 a.m. and 7 p.m., and assessments should be entered within 4 hours of the start of the shift.” c. A record review of Patient 27’s “Face Sheet,” undated, the face sheet indicated Patient 27 was admitted on 12/3/2023 at 00:03 (12a.m.) to the Medical and Surgical Unit and was discharge on 12/6/2023 at 3:35 p.m. A record review of Patient 27’s “History and Physical,” dated 12/3/2023, indicated, Patient 27’s presented to the ER for flu-like symptoms. The patient states he had been feeling sick since yesterday complaining of fever, muscle ache, generalized weakness, cough, congestion. Patient 27 had a fever of 102 degrees Fahrenheit (normal body range, from 97°F [Fahrenheit] to 99°F) on the morning of admission. Patient 27’s wife was concerned and called EMS (emergency medical service, a system that provides emergency medical care). The record indicated family reported that Patient 27 was so weak and tired, and Patient 27 could not stand up to walk. The record indicated Patient 27 denied any nausea, vomiting, abdominal pain, diarrhea, chest pain, shortness of breath, or difficulty breathing. During a concurrent interview, with RN 11, and record review of Patient 27’s Medical Surgical Telemetry (MST) Shift Assessment), on 1/25/2024 at 11:20 a.m., Patient 27’s “Medical Surgical Telemetry (MST) Shift Assessment,” indicated Patient 27’s shift assessment was completed, on 12/5/2023 at 11:21 a.m. RN 11 stated, “The shift assessment should be completed within four hours of shift start and shift start at 7 a.m.” RN 11 stated RN has four hours from the beginning of the shift to enter their shift assessment. RN 11 stated Patient 27’s shift assessment was late (Start of shift was on 12/5/2023 at 7 a.m. and shift assessment was completed on 12/5/2023 at 11:21 a.m. [4 hours and 11 minutes].” A record review of the facility’s policy and procedure (P&P) titled, “Assessment & Reassessment-Patient.” dated January 2024, the P&P indicated...A registered nurse assesses the patient’s needs for nursing care in all settings where nursing care is provided. Nurses will complete assessments on the inpatient units within four hours of patient arrival and/or within four hours of the start of their shift. Additional assessments will be determined from the initial assessment’s department-specific criteria for patient type, and/or by other discipline consultation.” A record review of the facility’s P&P titled, “Plan For Provision of Patient Care,” dated October 2023, indicated, “A complete physical and psychosocial assessment of the patient through interview, observation, inspection, auscultation, palpation and reports as performed by the RN within the time frame outlined in the Assessment/Reassessment Policy.””

“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: 46333 Based on interview and record review, the facility failed to develop and implement a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for four out of thirty (30) sampled patients (Patient 2, Patient 9, Patient 19, and Patient 22) in accordance with the facility’s policy and procedures regarding care plan development. This deficient practice had the potential to result in Patient 2, Patient 9, Patient 19, and Patient 22’s treatment and care goals not being met by not identifying their individualized patient care needs and risks. Findings: a. A record review of Patient 2’s “Face Sheet (one-page summary of important information about a patient),” undated, indicated Patient 2 was admitted on 12/15/2023 at 2:25 p.m. to the Telemetry service (specialty that cares a floor in a hospital where patients undergo continuous heart monitoring). A record review of Patient 2’s “History and Physical (H&P, a physician’s examination record of a patient),” dated 12/15/2023, indicated, Patient 2 medical history includes coronary artery disease (plaque buildup in the wall of the arteries that supply blood to the heart) and cardiac (relating to the heart) complaints along with hypertension (high blood pressure). The record indicated Patient 2 was brought in by EMS (emergency medical service, (emergency medical service, a system that provides emergency medical care) after becoming very dizzy while sitting at home and stated Patient 2 had some chest pressure. During a concurrent interview with the Wound Care Consultant and staff coordinator (Registered Nurse, RN 6), and record review of Patient 2’s Medication Administration Record (MAR), on 1/24/2024 at 2:43 p.m. with Patient 2’s “Medication Administration Record (MAR),” dated 12/15/2023 was reviewed and indicated, on 12/15/2023, Patient 2 was given 2 milligram (mg, unit of measurement) of an intravenous (IV, into the vein) Morphine (a pain medication) for head pain. The record indicated Patient 2’s pain level rate on a numeric pain rating scale (a 0 [zero] - 10 scale, with zero meaning “No pain,” and 10 meaning “The worst pain imaginable.”) was at 8 out of 10. The MAR indicated Patient 2 was given a dose of 2 mg IV Morphine. The record indicated the following day, on 12/16/2023, Patient 2 had a pain level rate was 7 out of 10. RN 6 stated the prescribed order for Morphine was a PRN (as needed) order. During a concurrent interview with RN 6, and record review of Patient 2’s Care Plan records, on 1/24/2024 at 2:45 p.m., Patient 2’s Care Plan, dated 12/18/2023 was reviewed by RN 6 and RN 6 show Patient 2’ care plan. The record indicated no care plan was developed to addressed Patient 2’ pain. RN 6 stated, “Patient 2 should have a pain care plan as she is on a PRN, Morphine.” During a review of the facility’s policy and procedure (P&P) titled, “Plan for Provision of Patient Care,” dated October 2023, the P&P indicated, “Standard of Care: Patient Care/Nursing Process: Patients are entitled to receive safe care which reflects an ongoing use of the Nursing process based on their specific care needs. All patients can expect to have their physiologic and psychosocial health status assessed upon admission for the purpose of formulating nursing diagnoses and development of a plan of care that describes nursing actions necessary to achieve patient goals. Systems assessments should also include mobility, rest, and pain management to facilitate a satisfactory level of comfort. This plan will be individualized, multidisciplinary, and continually evaluated and adapted as patient needs change ...Nursing interventions will be performed in response to identified problems/needs and referrals to other disciplines made as necessary ... Nursing diagnoses are derived from health status data, i.e., the patient’s health status is compared to the norm; capabilities and limitations are identified. The Registered Nurse will initially date and initial all problem lists ... Implementation of the plan of care is necessary to achieve desired outcomes ...” b. A record review of Patient 9’s “History and Physical (H&P),” dated 12/9/2023, indicated, Patient 9 presented to the emergency room accompanied by her daughter for evaluation of dysuria (painful or difficult urination). The H&P indicated, “Plan: admit, IV antibiotics (medicines that fight bacterial infections), and renal ultrasound (uses sound waves to examine the kidneys and bladder).” During a concurrent interview with Charge Nurse 1 (CN 1) and record review of Patient 9’s “Medication Administration Record,” on 1/25/2024 at 1:50 p.m., Patient 9’s “Medication Administration Record (MAR),” dated 12/9/2023,indicated that on 9/12/2023 at 12:20 a.m., Patient 9 received fifty (50) milliliters (mL, unit of measurement) of piperacillin and tazobactam (a medication used to treat many different infections) intravenous for a urinary infection. During a concurrent interview with CN 1 and record review of Patient 9’s medical records and “Care Plans,” on 1/24/2024 at 2:45 p.m. CN 1 showed the screen for Patient 9’s “Care Plan,” but the screen indicated there was no care plan initiated for Patient 9. CN 1 stated, “There should be a care plan initiated as soon as possible once the patient is admitted.” CN 1 confirmed that Patient 9 did not have care plans developed that reflect Patient 9’ care and needs. CN 1 also confirmed that it (care plan) was important for urinary infections, as it was evident that Patient 9 was receiving IV antibiotic medications to treat urinary infection. During a review of the facility’s policy and procedure (P&P) titled, “Plan for Provision of Patient Care,” dated October 2023, indicated, “Standard of Care: Implementation of the plan of care is necessary to achieve desired outcomes.” The policy and procedure indicated formulation of nursing actions to be taken were consistent with established interdisciplinary plan of care. The Registered Nurse plans and collaborates with other disciplines to ensure the patient will be able to demonstrate understanding of medical and nursing interventions associated with the patient’s diagnosis. The delivery of safe and quality nursing care included accurately reported, documented patient’s symptoms, and progress in the medical record. Nursing assigned responsibility for patients during the shift was to ensure that the basic needs of patients were met and notification of the physician of any unexpected changes in the patient’s condition. Nurses to initiate appropriate nursing intervention which might be required to stabilize a patient’s condition and/or prevent complications. Nurses to execute of all medical orders written by the physician. The nurse’s knowledge of the rationale for the effects of and the proper administration of the medications and/or treatments he/she administers. c. A record review of Patient 19’s “History and Physical (H&P),” dated 12/2/2023, indicated, Patient 19’ presented to the ER (Emergency Room) with hematemesis (vomiting of blood) for 2 days. Patient was just recently discharged from the Hospital for GI ([Gastrointestinal] relating to both stomach and intestine) bleeding. The H&P plan indicated monitoring of Hemoglobin (the protein contained in red blood cells that is responsible for delivery of oxygen to the tissues) and Hematocrit (test measures the proportion of red blood cells in the blood) every 12 hours. During a concurrent interview with RN 4and record review of Patient 19 medical records and Care Plan record, on 1/24/2024 at 2:00 p.m. Patient 19’s electronic medical record was reviewed with RN 4 and RN 4 verified Patient 19 had no care plan initiated for Patient 19 that addresses her bleeding on admission. RN 4 stated, “Patient came with a diagnosis of gastrointestinal bleed on admission 12/1/23, a care plan should be initiated and developed on 12/1/23.” RN 4 stated it (care plan) was important that a care plan was developed for GI bleed and stated Patient 9 was receiving blood transfusion to treat blood loss. d. A record review of Patient 22’s “History and Physical (H&P),” dated 12/6/2023, indicated, Patient 22 presented to the ER (Emergency Room) with a chief complaint of back pain. Patient 22 presented to the ER a day before (12/5/2023) admission with similar complaints and left without being seen. The record indicated Patient 22’s pain reportedly worsened on the morning of admission (12/6/2023), so she returned to the ER. The record indicated Patient 22 had not been seen for this problem and has not taken any medications. Patient 22’s husband reports the patient fell off the toilet day before. The record indicated the plan was to admit Patient 22to Medical/Surgical Unit and to obtain Magnetic Resonance Imaging ([MRI] a medical imaging technique that uses a magnetic field and computer-generated radio waves to create detailed images of the organs and tissue.) of lumbar spine (consists of the five bones vertebra in a person’s lower back). During a concurrent interview with RN 11 and record review Patient 22’s medical records and Care Plans, on 1/25/2024 at 10:28 a.m., Patient 22’s electronic medical record was reviewed by RN 11 and verified Patient 22 had no care plan initiated to address Patient 22’s pain. RN 11 stated, “Patient came with a chief complaint of back pain, a care plan should be initiated and developed immediately on admission.” RN 4 also confirmed that it (care plan) was important be developed for pain management. RN 11 stated Patient 22 was receiving pain medication for pain management. During a review of the facility’s policy and procedure (P&P) titled, “Plan for Provision of Patient Care,” dated October 2023, indicated, “Standard of Care: Implementation of the plan of care is necessary to achieve desired outcomes.” The policy and procedure indicated formulation of nursing actions to be taken were consistent with established interdisciplinary plan of care. The Registered Nurse plans and collaborates with other disciplines to ensure the patient will be able to demonstrate understanding of medical and nursing interventions associated with the patient’s diagnosis. The delivery of safe and quality nursing care included accurately reported, documented patient’s symptoms, and progress in the medical record. Nursing assigned responsibility for patients during the shift was to ensure that the basic needs of patients were met and notification of the physician of any unexpected changes in the patient’s condition. Nurses to initiate appropriate nursing intervention which might be required to stabilize a patient’s condition and/or prevent complications. Nurses to execute of all medical orders written by the physician. The nurse’s knowledge of the rationale for the effects of and the proper administration of the medications and/or treatments he/she administers.”

“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: 46333 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 assistance, ensure a patient was safe, and ensure the bed alarm (an alarm indicating a patient out of the bed) was functioning for one (1) of thirty (30) sampled patients (Patient 2). Patient 2 had used the call light requesting for assistance and had a tracheostomy (opening on the trachea [windpipe] and a tracheostomy tube [a curved hollow tube of rubber or plastic inserted into the trachea used to assist for breathing and or suctioning of secretions),a high risk of falling, and on seizure (a sudden, uncontrolled burst of electrical activity in the brain) precaution (padded rails and fall prevention with bed alarm). . This deficient practice resulted in Patient 2’s falling out of the bed, tracheostomy tube dislodged (knocked out of position), and suffered from severe hypoxic encephalopathy (a brain dysfunction caused by a lack of blood flow and oxygen to the brain). . (Refer to A-0395) 2. The facility failed to develop and implement a care plan (which provides a framework for evaluating and providing patient care needs related to the nursing process) for patients with high fall risk for one (1) of the thirty (30) sampled patients (Patient 2) in accordance with the facility’s policy and procedures regarding care plan development. This deficient practice has resulted in Patient 2’s treatment and care goals not being met by not identifying Patient 2’s needs and risks for falling. (Refer to A-0396) 3. The facility failed to adhere to intravenous (IV-administered through the vein) therapy guidelines for three (3) patients (Patient 6, Patient 9, and Patient 10) of the 30 sampled patients. Patients 6’ and 9’s peripheral (generally placed in the arm or hand) IV (in the vein) access site was not labeled (date and initial by staff who inserted the IV catheter), and Patient 10’s central catheter (a larger tube that is placed in a large (central) vein in the neck, upper chest, or groin) was not labeled as indicated by the facility’s IV Therapy policy and procedure. This deficient practice may result for the patients increasing their chances for intravascular (within the blood vessel) catheter related infections. (Refer to A - 0398) The cumulative effect of these systemic problems 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) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 36329 Based on record review and interview the facility failed to post the correct contact information (wrong phone number and no address) for the California Department of Public Health in the main front lobby of the facility. This deficient practice can lead to patients’ complaints not being addressed promptly by the CDPH. Findings: During an observation in the facility’s main front lobby, on 12/26/2023 at 1:00 PM, there was a notification board on the west wall of the main front lobby. On the west wall of the main front lobby, a board was posted indicating, “Patient Rights and Responsibilities.” The board identified what facility department may be contacted to address grievances against the facility. Also on the board was the phrase ‘You may also contact the California Department of Public Health (CDPH),” and included phone number without an address of CDPH. The CDPH phone number was incorrect. During an interview, on 12/26/2023 at 1:05 PM, Registered Nurse 6 (RN 6) verified and stated the contact information (phone number and no address) on the board for the CDPH was incorrect contact information to which patients can call to address complaints and would be corrected.”

“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 the interview and record review, the facility failed to provide assistance, ensure a patient was safe, and ensure the bed alarm (an alarm indicating a patient out of the bed) was functioning for one (1) of thirty (30) sampled patients (Patient 2). Patient 2 had used the call light requesting for assistance and had a tracheostomy (opening on the trachea [windpipe] and a tracheostomy tube [a curved hollow tube of rubber or plastic inserted into the trachea used to assist for breathing and or suctioning of secretions),a high risk of falling, and on seizure (a sudden, uncontrolled burst of electrical activity in the brain) precaution (padded rails and fall prevention with bed alarm). This deficient practice resulted in Patient 2’s falling out of the bed, tracheostomy tube dislodged (knocked out of position), and suffered from severe hypoxic encephalopathy (a brain dysfunction caused by a lack of blood flow and oxygen to the brain). On 12/29/2023 at 4:05 p.m., the survey team called an immediate jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Wound Consultant and Staffing Coordinator Registered Nurse 6 [RN 6]), Director of Medical Surgical and Telemetry (MST), Administrator Assistance (AA), Chief Nursing Officer (CNO), and Chief Executive Officer (CEO). The facility failed to ensure Patient 2, who required an oxygen supplement via a tracheostomy (a surgically created hole in the windpipe that provides an alternative airway) and was at high risk for falling, was provided adequate assistance when Patient 2 requested assistance and was protected from falling. On 12/29/2023 at 7:17 p.m., the IJ was removed while the survey team was onsite in the presence of the CNO and the CEO after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The IJ Removal Plan indicated the implement of a closed-loop communication escalation algorithm, with an initial bedside responder responding to a call light. If the first responder is unable to meet the patient’s needs, they escalate to the primary nurse, charge nurse, or house supervisor/unit director. The house supervisor or unit director will inform the CNO of any issues. Hourly rounding by staff will include high-risk fall interventions, bed alarms, and seizure precautions. Respiratory therapy rounds will be conducted every hour for patients with tracheaostomy(opening on the trachea [windpipe] and a tracheostomy tube, and signs for seizure and trach precautions will be placed in affected rooms. Implement the bed alarm escalation process for Monitor Tech and Unit Secretary. If the bed alarm is not responded to within 60 seconds, the monitor tech or unit secretary will initiate a rapid response. The charge nurse will identify patients who are high risk for fall during shift huddles. The Fall Prevention and Management Program Policy will be revised to reflect these changes. Findings: A review of Patient 2’s History and Physical (H&P, the initial clinical evaluation and examination of the patient.), dated 7/16/2023, the H&P indicated, Patient 2 was admitted to the facility on 7/16/2023 with medical history of respiratory failure (lungs cannot get enough oxygen into the blood) with tracheostomy and tonic-clonic seizure (uncontrolled, abnormal electrical activity of the brain that causes uncontrolled muscle twitching or jerking). During a concurrent interview and a record review of Patient 2’s Med (Medical) Surge (Surgery) Tele (Telemetry, unit where patients are on cardiac monitor) Shift Assessment (MST), dated 7/16/23, with Wound Consultant and Staffing Coordinator (RN 6), on 12/27/2023 at 1:20 p.m., Patient 2’s MST indicated Patient 2 was assigned a 45 Morse Score (fall risk indicator for fall, score of 45 and above indicates high risk for fall). RN 6 confirmed Patient 2’s 45 Morse Score indicated Patient 2 was at a high fall risk and was on seizure precaution status. During an interview, on 12/ 28/2023 at 1:30 p.m., RN 6 stated that for patients assigned seizure precaution status and with high fall risk, the bed alarm should be always on. During an interview on 12/28/23 at 1:30 p.m. with the Director of Medical, Surgical, and Telemetry (MST Director), MST Director stated Patient 2’s bed alarm was heard by a Licensed Vocational Nurse (LVN) 2. LVN 2 responded but was unable to figure out what Patient 2 needed at that time (7/17/2023 around 2055 [8:55 p.m.] to 2150 [9:50 p.m.]). Patient 2 was observed by LVN 2 attempting to communicate Patient 2’s needs. The LVN 2 left Patient 2 unattended to report to the primary RN (RN 12) regarding Patient 2 requesting assistance. DMS confirmed that RN 12 did not check on Patient 2 after RN 12 received the report from the LVN 2 regarding Patient 2’s needs. During an interview on 12/28/23 at 2:30 p.m., MST Director stated, “The facility had implemented fall risk prevention measures (bed alarm) but did not implement any measures specifically for this incident (Patient 2’s fall).” During an interview on 12/29/23 at 1:30 p.m. MST Director stated, “The bed alarm (Patient 2’s bed alarm) should have gone off; I did not know why it (bed alarm) didn’t.” During an interview on 12/29/23 at 2:10 p.m., RN 3, who found Patient 2 on the floor, on 7/17/23, confirmed there was no sound from the bed alarm was heard when RN entered Patient 2’s room. RN 3 stated Patient 2’s trach was on the floor. RN 3 called code Rapid Response (a team called when there is a change in patient condition from respiratory distress). A review of Patient 2’s Respiratory Therapist Note, dated 7/17/2023 at 11:19 p.m., indicated, “Rapid Response called then turned into Code Blue (patient requiring immediate medical attention due to respiratory or cardiac arrest) by the time the respiratory therapist reached the patient’s (Patient 2) room, Patient 2 trach (tracheostomy) was out.” A review of Patient 2’s Nursing Note, dated 7/18/2023 at 7:30 a.m. by RN 13, indicated, Patient 2 was transferred to ICU (Intensive Care Unit, unit that provides critical care and life support for acutely ill and injured patients), after Patient 2 was found on the floor and code was called. The note indicated, “Patient (Patient 2) has hematoma (a collection [or pooling] of blood outside the blood vessel) on the right side of face just above the right eye. Right eye completely swollen and shut.” A review of Patient 2’s Nursing Note by RN 1, dated 7/18/23 at 8:08 a.m. indicated at 10:18 p.m. (7/17/2023). “Patient 2 was found on the floor by (RN 3). Unresponsive and pulseless. Code blue was activated, and CPR (Cardiopulmonary Resuscitation, a way to save the life of someone who’s in cardiac arrest [when their heart can’t pump blood] by attempting to restart their heart) was performed. Patient (Patient 2) transferred to the ICU.” A review of Patient 2’s Emergency Department Code Blue Note, dated 7/17/2023 by the emergency room physician indicated, “I was called to treat this patient. I discussed the patient’s condition at bedside with the patient’s nurse ...patient (Patient 2) was found on the floor, compression in progress by primary RN team.” The note indicated there was a concern for possible seizure complicated by head trauma. Patient 2 required ICU level of care. A review of Patient 2’s Electroencephalogram (EEG, a medical test used to measure the electrical activity of the brain) Report, dated 8/16/2023, indicated “Extremely abnormal EEG due to the presence of slow activity, mostly over the left hemisphere (left side of the brain) with little activity if any over the right hemisphere (right side of the brain) consistent with severe hypoxic encephalopathy.” A review of the facility’s policy and procedure (P&P) titled, “Fall Prevention and Management Program,” dated 11/2023, indicated to reduce patient falls and injuries from falls through a Fall Prevention and Management Program, with the goal of reducing patient injuries related to falls and increasing staff awareness of patients at risk for falls; the interventions for ALL Patients at risk for falls included the following: 1. Intervention will be planned, implemented, and documented according to each patient’s risk level and individual needs. These will be documented within the interdisciplinary plan of care. 2. Individual Patient Interventions for all patients: “Orient to surroundings.” “Place personal items (telephone, ambulation devices, glasses, and hearing aids) within patient reach. “Use of fitted non-skid footwear.” “Secure handheld call light within easy patient reach. Instruct patients in use of bedside, handheld and bathroom call lights and confirm patient’s ability to use.” “Assure call light on bed is functional each shift by pressing call light on bed.” “Hourly rounding with particular attention to toileting.” “Eliminate environmental hazards (i.e., keep the floor clear, clean up spills) and monitor equipment that could be a fall hazard (i.e., IV [intravenous, medication given into the vein] and foley tubing [a medical device that helps drain urine from the bladder]). “Provide adequate lighting.” “For those patients in a bed, the bed should be in the lowest position except when providing direct care. Assure bed is plugged into wall.” “Identify inpatient as a 1-2 patient assist and communicate in hand off communication to include therapies to nursing. “Additional interventions for Patients at Moderate Risk” Indicated If a patient found out of bed without calling for assistance implement High Risk interventions and “Consider usage of Direct Observer ...” 3. Interventions for Patients at High Risk included implement all previous interventions listed above for low and moderate risk and additional interventions were the following: “Consider moving patients to a room for increase observation by staff. Consider using a direct observer.” “Do not leave patients unattended in the shower, bathroom or when on the bedside commode.” “Do not leave the patient alone if out of bed. Educate family/significant others to notify staff when leaving patient bedside.” “Institute yellow armband for patients with a previous fall or came into hospital after a fall.” “Yellow armband is to be removed at time of discharge.” “Activate the bed alarm, at zero second delay and verify sound is on whenever the patient is in the bed.” “If a high alert adult patient is found out of bed, stay with patient do not leave patient. Evaluate the need for a Direct Observer.””

“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: 46333 Based on interview and record review, the facility failed to develop and implement a care plan (which provides a framework for evaluating and providing patient care needs related to the nursing process) for patients with high fall risk for one (1) of the thirty (30) sampled patients (Patient 2) in accordance with the facility’s policy and procedures regarding care plan development. This deficient practice has resulted in Patient 2’s treatment and care goals not being identified and met in relation to the identified fall risk which led to Patient 2’s fall. Findings: A review of Patient 2’s History and Physical (H&P, the initial clinical evaluation and examination of the patient.), dated 7/16/2023, the H&P indicated, Patient 2 was admitted to the facility on 7/16/2023 with medical history of respiratory failure (lungs cannot get enough oxygen into the blood) with tracheostomy and tonic-clonic seizure (uncontrolled, abnormal electrical activity of the brain that causes uncontrolled muscle twitching or jerking). During a concurrent interview and record review of Patient 2’s Med (Medical) Surge (Surgery) Tele (Telemetry, unit where patients are on cardiac monitor) Shift Assessment (MST), dated 7/16/2023, with Wound Consultant and Staffing Coordinator (RN 6), on 12/27/2023 at 1:20 p.m., Patient 2’s MST indicated Patient 2 was assigned a 45 Morse Score (fall risk indicator for fall, score of 45 and above indicates high risk for fall). RN 6 confirmed Patient 2’s 45 Morse Score indicated Patient 2 was at a high fall risk and was on seizure precaution status. During a concurrent interview and record review of Patient 2’s Care Plan, on 12/28/2023 at 11:50 a.m., Registered Nurse (RN) 6, stated Patient 2 did not have a care plan for fall prevention, on 7/16/2023,date of Patient 2’s admission. RN 6 stated the care plan for the fall was started on 7/18/2023. RN 6 stated the care plan was started after the fall incident that occurred RN 6 stated a care plan for fall prevention should have been initiated for Patient 2, who was assigned a high fall risk level on admission. During a concurrent interview and record review of Patient 2’s Morse Fall Scale and Risk Screening, dated 7/16/2023, on 12/29/23 at 10:50 a.m., RN 5, verified Patient 2’s Morse Fall Risk Score Protocol indicated a score of 0-24 as minimal fall risk, a score of 25-44 as low fall risk, and a score of 45 or above as high fall risk. During an interview on 12/29/23 at 1:30 p.m. with the Director of Medical Surgical and Telemetry (MST Director), MST Director stated, “The bed alarm (Patient 2’s bed alarm) should have gone off; I did not know why it (bed alarm) didn’t.” During an interview on 12/29/23 at 2:10 p.m., RN 3, who found Patient 2 on the floor, confirmed there was no sound from the bed alarm when he entered the room. RN 3 further stated the trach was on the floor. RN 3 called the code Rapid Response (a team called when there is a change in patient condition from respiratory distress). A review of Patient 2’s Respiratory Therapist Note, dated 7/17/2023 at 11:19 p.m., the respiratory therapist (RT) note indicated, “Rapid Response called then turned into Code Blue (patient requiring immediate medical attention due to respiratory or cardiac arrest) by the time respiratory reached the patient’s (Patient 2) room, Patient 2’s tracheostomy (a surgically created hole in the windpipe that provides an alternative airway) tube was out.” A review of the RN 1 note dated 7/18/23 at 8:08 a.m. indicated that at 10:18 p.m. “Patient 2 was found on the floor by (name of another RN). Unresponsive and pulseless. Code blue was activated, and CPR was performed. Patient transferred to the ICU (Intensive Care Unit, unitthat provdes critical care and life support for acutely ill and injured patients).” A review of Patient 2’s “Emergency Department Code Blue Note” dated 7/17/2023, the note indicated, “I was called to treat this patient. I discussed the patient’s condition at bedside with the patient’s nurse. patient was found on the floor; compression is in progress by the primary RN team.” The note further indicates there is concern for a possible seizure complicated by head trauma. The patient will require ICU-level care. A review of the facility’s policy and procedure (P&P) titled, “Documentation Outcome Notes,” dated August 2020, the P&P indicated, “Outcome notes will be initiated in Meditech for all patients upon admission. Patient status will be reviewed at regular timeframes to ensure appropriate prioritization of care needs. Documentation of all assessment/reassessments that note a significant change will be included utilizing an assessment, intervention, and outcome format. In Meditech review care plan under Process Plan and Intervention work list. The plan of Care will be reviewed each shift and updated as patients progress indicates ...” A review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment Documentation,” dated February 2021, the P&P indicated, “The registered nurse is responsible for a Total System assessment on all patients on admission ... Any focus/problem identified needs to be documented in the Assessment and documented onto the multidisciplinary plan of care ...A falls assessment is done on all patients at the time of admission. The assessment identities those patients who are “At Risk” or at “High Risk” for falls.””

“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: 46333 Based on observation, interview, and record review, the facility failed to adhere to intravenous (IV-administered through the vein) therapy guidelines for three (3) patients (Patient 6, Patient 9, and Patient 10) of the 30 sampled patients. Patients 6’ and 9’s peripheral (generally placed in the arm or hand) IV (in the vein) access site was not labeled (date and initial by staff who inserted the IV catheter), and Patient 10’s central catheter (a larger tube that is placed in a large (central) vein in the neck, upper chest, or groin) was not labeled as indicated by the facility’s IV Therapy policy and procedure. This deficient practice may result for the patients increasing their chances for intravascular (within the blood vessel) catheter related infections. Findings: 1. During a review of Patient 6’s History and Physical (H&P, the initial clinical evaluation and examination of the patient), dated 12/25/2023, indicated that Patient 6 was admitted to the facility for altered mental status (a change in mental function). During a concurrent observation and interview on 12/26/2023 at 2:15 p.m. with Registered Nurse (RN) 9 in Patient 6’s room, Patient 6 had a gauze dressing wrapped around her left forearm. RN 9 pulled the dressing away to reveal the IV catheter site. Observed with RN 9, underneath the gauze dressing, the skin to the catheter site is swollen and reddening. There is no label on the IV catheter site. Patient 6 stated it is painful at her left forearm. RN 9 stated, “I will remove the IV catheter.” During an interview on 12/26/2023 at 2:20 p.m. with RN 6 outside of Patient 6’s room, RN 6 stated that she had checked Patient 6’s IV catheter site this morning at 8 a.m. RN 6 stated the IV site should be checked to see if it is properly labeled with the date the IV catheter was inserted and for any signs of redness or swelling that can lead to infection. RN 6 stated, “I forgot to check to see if there was a label.” RN 6 stated, “It is important to label the IV site because if the IV catheter is left in too long, it may lead to infection or infiltration (when some of the fluid leaks out into the tissues under the skin where the tube has been put into your vein).” During an interview on 12/26/2023 at 3:55 p.m. with the interim supervisor of ICU (SICU, supervisor of intensive care unit, unit that provides critical care and life support for acutely ill and injured patients), SICU stated, “The IV site should be assessed every shift to ensure it is patent and that there are no signs of infiltration. The dressing should be changed and label with the date to prevent an IV catheter infection.” During a concurrent interview and record review on 12/29/2023 at 4:50 p.m. with Registered Nurse (RN) 6, the facility’s policy and procedure (P&P) titled “Intravenous Therapy Timeframes,” dated February 2021, was reviewed. The P&P indicated, “To ensure that intravenous dressing changes and tubing changes are consistent with the Center for Disease Control recommendations, Peripheral intravenous catheter site rotation every 96 hours, depending on the site assessment and availability of venous sites... The central line dressing changes after 24 hours, then every 7 days. Refer to Lippincott Williams & Wilkins for nursing techniques and actual procedures.” RN 6 provided an attached document from Lippincott Williams & Wilkins and stated the facility follows Lippincott Williams. Review the attached documents titled “Nursing Skill: Insertion a Peripheral IV in Adults,” dated 2023, it indicated, “Label dressing with date or time of insertion per facility protocol. Evaluate the IV site every 8 hours or per facility protocol to detect signs or symptoms of CLABSI (Central Line-associated Bloodstream Infection) or infiltration, including redness, pain, swelling, or vein enlargement.” 2. During a review of Patient 9’s H&P, dated 12/23/2023, indicated that Patient 9 came into the emergency department for a complaint of abdominal (stomach) pain. The H&P indicated Patient 9 has a past medical history of diabetes (a chronic disease characterized by elevated levels of blood sugar) and hypertension (high blood pressure [140/90 mmHg or higher]). H&P further indicates the plan of treatment for patient 9 includes IVF (intravenous fluid) and pain control. During a concurrent observation and interview on 12/26/2023 at 2:55 p.m. with wound care consultant and staffing coordinator (RN) 6 in Patient 9’s room, Patient 9’s left forearm peripheral IV site had no label. RN 6 stated, “The IV site should have a label; the IV site should be checked every shift for a label with the date and for any signs of swelling or redness to prevent infection.” During a concurrent interview and record review on 12/29/2023 at 4:50 p.m. with registered nurse (RN) 6, the facility’s policy and procedure (P&P) titled “Intravenous Therapy Timeframes,” dated February 2021, was reviewed. The P&P indicated, “To ensure that intravenous dressing changes and tubing changes are consistent with the Center for Disease Control recommendations, peripheral intravenous catheter site rotation every 96 hours, depending on the site assessment and availability of venous sites... The central line dressing changes after 24 hours, then every 7 days. Refer to Lippincott Williams & Wilkins for nursing techniques and actual procedures.” RN 6 provided an attached document from Lippincott Williams & Wilkins and stated the facility follows Lippincott Williams. Review the attached documents titled “Nursing Skill: Insertion of a Peripheral IV in Adults,” dated 2023, it indicated, “Label dressing with date or time of insertion per facility protocol. Evaluate the IV site every 8 hours or per facility protocol to detect signs or symptoms of CLABSI (Central Line-associated Bloodstream Infection) or infiltration, including redness, pain, swelling, or vein enlargement.” 3. During a review of Patient 10’s H&P, dated 12/25/2023, indicated that Patient 10 presented to the emergency department with worsening of breathing and was found to have respiratory distress (having trouble breathing) and eventually require intubation (a tube placed in the airway to deliver oxygen) and ventilation (a machine that takes over the work of breathing when a person is not able to breathe enough on their own). During a concurrent observation and interview on 12/26/2023 at 4:45 p.m. with Registered Nurse (RN) 6 in Patient 10’s room, Patient 10’s central IV site at the jugular (neck) area did not have a label with a date, and Patient 10’s left forearm peripheral IV site did not have a label with a date. RN 6 stated, “It is important that the registered nurse assess these IV sites and assure that there are labels with dates.” During an interview on 12/26/2023 at 4:46 p.m. with Registered Nurse (RN) 11, RN 11 stated, “I have just changed the dressing for the central catheter (right jugular site), but I forgot to label it (IV site) with the date.” RN 11 also stated, “I forgot to check the left forearm IV site to see if it (the IV site) was dated.” During a concurrent interview and record review on 12/29/2023 at 4:50 p.m. with registered nurse (RN) 6, the facility’s policy and procedure (P&P) titled “Intravenous Therapy Timeframes,” dated February 2021, was reviewed. The P&P indicated, “To ensure that intravenous dressing changes and tubing changes are consistent with the Center for Disease Control recommendations, peripheral intravenous catheter site rotation every 96 hours, depending on the site assessment and availability of venous sites... The central line dressing changes after 24 hours, then every 7 days. Refer to Lippincott Williams & Wilkins for nursing techniques and actual procedures.” RN 6 provided an attached document from Lippincott Williams & Wilkins and stated the facility follows Lippincott Williams. Review the attached documents titled “Nursing Skill: Insertion of a Peripheral IV in Adults,” dated 2023, it indicated, “Label dressing with date or time of insertion per facility protocol. Evaluate the IV site every 8 hours or per facility protocol to detect signs or symptoms of CLABSI (Central Line-associated Bloodstream Infection) or infiltration, including redness, pain, swelling, or vein enlargement.””