Valley Children’s 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: 45929 Based on interview and record review, the hospital failed to ensure Licensed Nurses (LNs) followed policies and procedures (P&Ps) in developing, maintaining current, and patient (Pt) specific nursing care plans (NCP- a process through which the nurse identifies, documents, and keeps track of a patient’s state or condition, needs, and risks) for two of thirty (30) sampled patients (Pt 13 and Pt 26) when a NCP for Pt 13 and Pt 26 had not been updated or changed to reflect the active use of bilateral (having or relating to two sides; affecting both sides) restraints. This failure resulted in LNs providing care without an assessment and development of a patient specific NCP to guide the LN in the management of Pt 13’s and Pt 26’s care needs and had the potential to result in their care needs going unmet and/or possibly an unnecessary extended time in restraints. Findings: During a review of Pt 13’s “Face Sheet (FS-a document that contains a summary of a patient’s personal information),” dated 3/16/25 and “History and Physical (H&P)”, dated 3/17/25, the “FS” indicated Pt 13 was admitted to the hospital on 3/17/25 at 3:51 a.m. The “H&P” indicated, “ ...5-month-old female ... with no reported past medical history ... History of Present Illness: unvaccinated ... is being admitted to the PICU (Pediatric Intensive Care Unit) for respiratory failure (a serious condition that makes it difficult to breathe on your own) in the setting of RSV (Respiratory syncytial virus (RSV) causes infections of the lungs and respiratory tract) and COVID (is a disease caused by a virus named SARS-CoV-2. It can be very contagious and spreads quickly) ...” During a concurrent interview and record review on 3/18/25 at 9:51 a.m. with Registered Nurse (RN) 9, Pt 13’s “Electronic Medical Record (EMR-an electronic record of health-related information on an individual),” 3/16/25 to 3/18/25, and “Flow Sheet (DEFINE)” dated 3/17/25 at 1700 (5:00 p.m.) to 3/18/25 at 0000 (midnight) were reviewed. RN 9 stated Pt 13 had restraints in place, this problem should be care planned by the nurse to make sure everyone is on the same page with the patient’s care needs and progress. During a review of Pt 26’s “H&P”, dated 3/12/25, the “H&P” indicated Pt 26 was 13-year-old with a bowel obstruction and significant autism (a neurodevelopmental condition characterized by significant challenges in social communication/interaction and restricted or repetitive behaviors of interests). During a review of Pt 26’s “Restraint Orders (RO)”, dated 3/12/25, 3/13/25, 3/14/25, 3/16/25, 3/17/25, and 3/18/25, the “RO” indicated, Patient 26 had bilateral (left and right) soft wrist restraints due to interference with medical treatment. During a review of Pt 26’s “Restraint Flowsheet (RF)”, dated 3/12/25 to 3/19/25, “RF” indicated Pt 26 was in left and right soft wrist restraints from 3/12/25 at 7:45 p.m. to 3/14/25 at 1:05 p.m. and from 3/16/25 at 12:00 p.m. to 3/19/25 at 9:00 a.m. The “RF” indicated documentation if the restraint device was intact, secured to bed frame, if maximum movement is allowed, if call light was within reach, if the restraint was continued, a visual check of patient, check patient’s circulation, range of motion, if fluids or foods were offered, and if elimination (of bladder /bowel) was addressed. During a concurrent interview and record review on 3/20/25 at 10:20 a.m. with Registered Nurse (RN) 8, Pt 26’s “Care Plan (CP, an individualized plan for the patient’s care, goals and interventions to reach those goals is documented and revised)”, dated 3/12/25 to 3/19/25 was reviewed. RN 8 stated the care plan did not contain a plan of care for restraint use. RN 8 stated she was unsure if the [brand name of electronic medical record] had a care plan for restraint use available. During an interview on 3/21/25 at 10:24 a.m. with Clinical Education Specialist (CES) 1, CES 1 stated she checked the in [brand name of electronic medical record] and a plan of care for restraint use was available in the electronic record. During an interview on 3/21/25 at 11:07 a.m. with hospital Chief Nursing Officer (CNO), CNO stated she would have to would have to look at the policy on this [Restraints and Care Planning], heard directors talking about this, and how it is set up in “brand name EMR software.” Violent vs. non-violent restraints would require education and ensuring that NCP follows suit with interventions. CNO stated the purpose of the interdisciplinary NCP is to coordinate care where the whole team sees the plan. During a review of the hospital policy and procedure (P&P) titled, “Restraints and Seclusion (RS)”, dated 2/2025, “RS” indicated, “ ... restraint will be utilized in the least restrictive manner possible, and will be discontinued at the earliest possible time ... Documentation ... Nursing documentation will be reflected in the restraint flowsheet, this is inclusive of the Pre-restraint Application Assessment and ongoing restraint monitoring and assessment documentation as well as interventions ... routine clinical documentation relating to the patient overall condition will be reflected in the physical assessment and patient safety interventions. Goals, planned interventions, and desired outcomes will be identified and documented either electronic or paper ...”. During a review of the hospital’s policy and procedure (P&P) titled, “Interdisciplinary Care Planning” dated 4/23, the P&P indicated, “ ... Policy Patient and family care is defined in policies, Standardized Procedures, Interdisciplinary Care Plans, patient care conferences and individualized treatment plans. These mechanisms are used for planning, providing, monitoring and coordinating interdisciplinary care across the continuum... Mechanisms for Ensuring Interdisciplinary Care 1. Patient and family Plan of Care...2. ...the Registered Nurse will initiate a Plan of Care based upon the above named sources. All disciplines will participate in the development and updating of the interdisciplinary plan of care within their scope of practice... a. All patients will have a Plan of Care developed and implemented within 24 hours after the admission assessment. b. The Plan of Care is the basis for continuity and consistency in documentation and evaluation of care... d. Plans are reviewed and/or revised every shift, based upon reassessment data by Nursing. Consulting disciplines will update the plan of care weekly. Nursing will coordinate care with consulting disciplines to regularly to plan for discharge... E. The patient’s plan of care will include: 1. Problems/Diagnosis(es) 2. Expected outcomes 3. Reference to intervention resources: a. Treatments b. Diagnostic Testing c. Education d. Referral/Consultation e. Follow-Up 4. Newly identified issues...” During a review of a professional reference titled, “Nursing Process,” dated 4/10/23, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499937/, the Nursing Process indicated, “ ...Planning ...The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP (Evidence-based Practice- recommendations for nursing care that are based on scientific evidence) guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. Goals should be: 1. Specific; 2. Measurable or Meaningful; 3. Attainable or Action-Oriented; 4. Realistic or Results-Oriented; 5. Timely or Time-Oriented ...”.”

“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: 47205 Based on observation, interview, and record review, the hospital failed to follow their policies and procedures (P&P) when: 1. Licensed Nurses (LNs) did not reassess two (2) of 30 patients’ (Pt 9, and Pt 24) pain level A. after administration of pain medication(s) within the expected timeframe and B. at specified intervals. These failures placed Pt’s 9 and 24 at risk to receive inadequate pain management and had the potential for LNs to not recognize a change in condition. 2. LNs did not ensure a central line (a central venous catheter (CVC) is a long, flexible tube your provider inserts into a vein in your neck, chest, arm or groin) cart was left unattended and unlocked. This failure had the potential to result in unauthorized access and use of sharps (any medical device that can puncture or cut the skin, like needles, scalpels, and lancets, requiring special handling and disposal to prevent injuries and infections) and potential harm or injury to staff, patients and/or visitors. Findings: 1. A. During a review of Pt 9’s “Electronic Health Record (EHR- a digital version of a patient’s medical history)”, Pt 9’s “Face Sheet (FS-a document that contains a summary of a patient’s personal and demographic (all of the non-clinical data about a patient [name, date of birth, address, etc.] information),” (undated) was reviewed. The FS indicated, “... admit: 3/18/25 ... Spontaneous Pneumothorax (the sudden onset of a collapsed lung without any apparent cause) ...” During a review of Pt 9’s “EHR”, Pt 9’s “History and Physical (H&P- a formal assessment of a patient’s health that includes a medical history and physical exam)” dated 3/18/25, was reviewed. The “H&P” indicated Pt 9 was a “... 17-year-old ... with a recurrent spontaneous pneumothorax on the left side ...” During concurrent interview and record review on 3/18/25 at 9:15 a.m. with the Director of the Emergency Department (DED), Pt 9’s “EHR” and “Medication Administration Report (MAR)” dated 3/19/25 was reviewed. The “MAR” indicated, Pt 9 received a dose of morphine as ordered at “ ... 0744 [7:44 a.m.] ...” The DED stated LN documented pain level at 7 out of 10 (7/10- Strong pain, keeps you from doing normal activities) on the numerical pain scale (a tool that uses numbers (typically from 0 to 10 to help people describe and quantify their pain intensity, with 0 representing no pain and 10 representing the worst possible pain.) The DED stated documentation of a pain reassessment was not done within the expected timeframe (pain was reassessed at 9:03 a.m., with documented pain level of 7/10). The DED stated the expectation was that pain be reassessed about 30 minutes after administration of pain medication, about that and the hour mark (or for Pt 9 by 8:44 a.m.). During a concurrent interview and record review on 3/18/25 at 9:25 a.m. with the DED, Pt 9’s “EHR” and “ED Timeline” dated 3/18/25 was reviewed. The “ED Timeline” indicated, an order at “ ... 0837 [8:37 a.m.] ... morphine ... 4 mg/ml [milligrams per milliliter- the amount of one substance dissolved in a specific volume of a liquid] ... injection 4 mg; morphine 2 mg/ml injection 2 mg ...” was written. Pt 9’s pain reassessment indicated “... 3/18 0903 [9:03 a.m.], Pain Screening/Assessment Scale Pain Assessment Scales: 0-10 Pain Score: 7 ... 1033 [10:33 a.m. an hour and a half later] morphine 4 mg/ml injection 4 mg Given ... 10:39 a.m. ... Pain Score: 7 ... 1058 [10:58 a.m.] ... to department [transferred to in patient admission unit] ...” The DED again stated her expectation was that LNs reassess pain, as previously stated and per policy and as ordered. B. During a review of Pt 24’s “History & Physical (H&P)”, dated 3/13/25, the “H&P” indicated, Pt 24 was admitted to an acute care unit for a right renal (kidney) mass and two pulmonary (lung) nodules (small firm lumps of knots). During a review of Pt 24’s “Progress Note (PN)”, dated 3/19/25, the “PN” indicated, Pt 24 had a port placement (surgically implanted device under the skin to provide long-term access to a large vein for treatments and blood draws) and tumor biopsy (a procedure where a small sample of tissue or cells is removed from the body for examination under a microscope) on 3/17/25. The “PN” indicated, Pt 24’s post (after) surgery pain was to be managed by morphine (a narcotic for pain) PRN (as needed). During an interview on 3/19/25 at 3:00 p.m. with Registered Nurse (RN) 8, RN 8 stated pain is assessed at least every four hours on the acute care units. During a concurrent interview and record review on 3/20/25 at 10:10 a.m. with RN 8, Pt 24’s “Pain Flowsheet (PF)”, dated 3/19/25, was reviewed. The “PF” indicated, Pt 24’s pain was assessed at 8:00 a.m. and not again until 8:30 p.m. RN 8 stated she could not see any pain assessment for Pt 24’s between 8:00 a.m. and 8:30 p.m. on 3/19/25. The “PF” indicated, Pt 24 had vital signs (heart rate, respiratory rate, and blood pressure) taken between 8:00 a.m. and 8:30 p.m. on 3/19/25. During an interview on 3/21/25 at 11:07 a.m. with the Chief Nursing Officer (CNO), the CNO stated, nurses were expected to follow hospital P&Ps. The CNO stated the potential risk to the patient for not reassessing pain is being over medicated (too much medication that can lead to harmful effects) or under medicated (not enough medication to treat and illness). The CNO stated the goal is to keep the patient comfortable. The CNO stated [this issue] has come up as an opportunity before, will need to implement measures to ensure staff follow policy. During a review of the hospital P&P “Pain Management,” the P&P indicated, “ ... [Hospital name] is committed to making pain assessment a priority ... pain intensity and pain relief will be assessed and reassessed at regular intervals and will contribute to the choice of appropriate therapeutic intervention ... Patient assessments, reassessments, interventions, and responses to interventions will be documented ... Process ... Key Points ... Vital signs should not be used alone to assess pain ... Pain Reassessment ... Reassessment of pain shall occur at the following points ... With routine vital signs per department standards, regardless of pai intensity level ... Patients who are sleeping do not need to be awakened for a pain rating. However, their pain should be reassessed upon awakening ... At a suitable interval after each pharmacologic or non-pharmacologic intervention ... Within 30 minutes after parenteral [administered elsewhere than by mouth or anal] drug therapy, and within one hour after oral or rectal medication has been given ...”. 2. During a concurrent observation and interview on 3/18/25 at 2:15 p.m. with Director Pediatric Intensive Care Unit (DPICU) (PICU- a specialized hospital unit designed to provide advanced care for critically ill or injured children, offering comprehensive monitoring and treatment for serious medical conditions), a cart was observed to be unattended, unlocked and in the hallway near the unit exit doors. DPICU observed the cart did not have a locking mechanism. DPICU stated the cart should be locked and in a secure location where staff can monitor and prevent unauthorized access to the supplies stocked in the line cart. DPICU stated there are central line kits [that contain needles/sharps] stocked in the line cart and should be locked. DPICU stated the potential risk of unauthorized access to sharps is harm or injury to staff, patients and visitors. During an interview on 3/21/25 at 11:07 a.m. with the CNO, the CNO stated, nurses were expected to follow hospital P&Ps to ensure staff, patient and visitor safety while in the hospital. According to the National Library of Medicine, retrieved electronically on 3/26/25, from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8216297/ Woo K, Rigberg D, Lawrence PF. Safe Central Venous Access in an Overburdened Health System. JAMA. 2021 Jan 19;325(3):299-300. doi: 10.1001/jama.2020.20361. PMID: 33464338; PMCID: PMC8216297. “...an adequately stocked line cart increases the efficiency of line placements. This cart should have all the supplies and personal protective equipment (PPE) necessary to safely perform the procedure(s). An appropriately stocked cart minimizes potential clinician exposure to infectious agents and allows for a more streamlined performance. Further increases in the efficiency of clinician utilization can be realized by limiting the number of clinicians in the room performing the procedure to 2, with a runner outside the room to retrieve additional supplies as needed. This likewise can preserve PPE and minimize personnel exposed to infectious agents ...” According to The Joint Commission (TJC-a US-based, independent, not-for-profit organization that accredits and certifies healthcare organizations and programs, focusing on improving patient safety and quality of care through standards and evaluations) electronically retrieved on 3/26/25 from: https://www.jointcommission.org/standards/standard-faqs/ambulatory/environment-of-care-ec/000001214/, TJC ...”defines “secure” as locked in containers, in a locked room, or under constant surveillance. Furthermore, in many cases, monitoring remotely via camera is not adequate in meeting constant surveillance if there is an opportunity for something to occur without the means to immediately react to minimize the risk ...” TJC indicated organizations are to conduct a risk assessment regarding unique security issues in accordance with standard EC.02.01.01. A course of action should be established that is both defensible and rational. The organization is expected to implement the course of action, then analyze if the desired effect was achieved. Reference EC.02.01.01 ...””

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 45929 Based on observation, interview, and record review, the hospital failed to ensure unusable drugs were not available for patient use when an IV (intravenous, in the vein) solution bag subjected to conditions inconsistent with the manufacturer’s approved labeling was in stock and available for patient use and the hospital’s policy & procedure (P&P) did not consider the IV manufacturer’s instructions for use. These failures had the potential for patients to receive altered, ineffective, and contaminated medications. Findings: During a concurrent observation and interview on 3/18/25 at 1:20 p.m. with the Director of Acute Care (DAC) in an Apollo Acute Care Medication Room (room used for the storage and preparation of patient’s medications) a 1000 ml (milliliters, a unit of measure) IV solution bag of 5% dextrose (sugar water) and 0.9% Sodium chloride (salt water) was found with its protective (moisture barrier) overwrap removed. The IV bag was labeled with a sticker indicating, “ ... open 3/17/25 1700 [5:00 pm.] Exp [expires] 4/17/25 1700 ...”. The manufacturer instructions printed on the bag indicated, “ ... [Storage] Store in overwrap ...” The DAC stated staff are to date a bag with the time of opening and date expiration for 30 days later if not used once out of overwrap per the hospital policy. During a review of the hospital’s P&P titled, “Medication Stability (MS)”, dated 1/2025, the “MS” indicated, “ ... Purpose Statement ... Provides guidelines for the appropriate use of single-and multi-use medication containers [containers use one dose only and multiple doses] on patient care units to ensure they are used in a manner that assures sterility and stability of their contents ... Definitions ... BUD (Beyond use date) ... The date, or date and time, after which administration of a drug shall not begin, the preparation shall not be stored ... Process ... Nursing Unit Multiple Use Medication Container Beyond Use Dating BUD shall be assigned as follows ... Injectables ... IV fluid bags removed from the overwrap packaging must be labeled with a revised expiration date as follows ... > 100 mL [milliliters] bags 30 days after opening ...” During a review of the IV solution’ Manufacturer’s “Prescribing Information Dextrose and Sodium Chloride Injection (PIDS)”, date 12/14/18, The “PIDS” indicated, “ ... Directions for use ... Do not remove unit from overwrap until ready to use ...” During a review of a professional reference titled, “Working up a sweat (WUS)”, dated 10/2002, the “WUS” indicated, “ ... The purpose of the overwrap [for IV bags] is to improve shelf life and to stabilize the drug concentration. What happens then if a bag is removed from its overwrap and remains unused for days or weeks? Over time, the fluid volume inside the bag decreases and the drug concentration per milliliter [ml, a unit of measure] increases ... Don’t remove the overwrap from any I.V. bag stored in your unit until you’re ready to use the solution ...” During a review of a professional reference titled, “Expiration dates and removal of i.v. bag overwrap (EDR)”, dated 9/1/95, the “EDR” indicated, “ ... The overwrap protects against evaporation of the solution, desiccation [removal of moisture] of the container, drug oxidation [common way of degrading a drug], and photochemical [with light] inactivation of the drug. Without a barrier, substantial moisture loss may occur, increasing the drug concentration ... Manufacturers of these products recommend ... removing the overwrap just before the drug or solution is administered ...””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 47205 Based on observations, interviews and record review, the hospital failed to maintain a clean and sanitary environment in accordance with hospital policy and procedures, Centers for Disease Control (CDC- a U.S. federal government agency whose mission is to protect public health by preventing and controlling disease, injury, and disability) and clinical standards of practice for infection control when: 1. Patient freezers, refrigerators, and ice and water machines on multiple units in the hospital were visibly soiled with debris, spill and splatter marks, and/or textured stains. Freezers on several units in the hospital had excessive ice buildup. 2. Medication, clean and dirty utility rooms (rooms designated to prepare and/or store clean supplies/medications and waste products separately) on several units in the hospital had used patient equipment collected into buckets which were stored directly on the floor, clean supplies found on the floor, and/or trash and soiled linen bag(s) overflowing and spilling onto the floor. A new unused spill kit (a collection of equipment and materials used to clean up and dispose of spills) was found in a dirty utility room in the Neonatal Intensive Care Unit (NICU), inconsistent with other areas of the hospital. 3. Two (2) members of the PICU Interdisciplinary Rounds (IDRs- a structured approach where healthcare professionals from various disciplines (like physicians, nurses, therapists, and social workers that gather to discuss and coordinate patient care, often at the patient’s bedside) were observed to be drinking from cups while actively participating in patient rounds in the hallway just outside of patient room doors. These failures resulted in the potential risk of cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) to patients, visitors, and staff which can lead to infection and diseases. Findings: 1. During a concurrent observation and interview on 3/18/25 at 10:33 a.m. during a tour of the Emergency Department (ED) with the Director of the Emergency Département (DED), in ED Zone 0, the freezer had built up ice. DED stated staff are expected to submit a work order to have Plant Engineering perform defrosting service as needed. In the ED nutrition areas, two (2) ice and water dispensing machines on the unit were visibly soiled, with splatter marks and white-colored/textured residue noted to the exterior, chutes, catch trays and racks of the machine. DED stated Plant Engineering performs preventive maintenance (PM) on the ice machines. DED stated she had to defer to them [Plant Engineering] on when the ice machines were last serviced or cleaned because she was not sure who cleaned them. During a concurrent observation and interview on 3/18/25 at 1:17 p.m. during a tour of the Pediatric ICU (PICU- a specialized hospital unit designed to provide advanced care for critically ill or injured children, offering comprehensive monitoring and treatment for serious medical conditions), with Director of the PICU (DPICU), in the nutrition room, the refrigerator, freezer ice and water dispensing machine were visibly soiled with red colored spots, splatter marks and white colored, textured residue noted to the exterior, chutes, catch tray (was missing) and racks of the machine; freezers had built up and melting ice chunks and frozen popsicles in original boxes, opened and dated. DPICU stated although not clearly defined, unit practice is to date when the box is opened. The PICU patient personal food items refrigerator was visibly soiled with white and cream-colored spills where prepared formula and a patient cake were stored. DPICU stated it was his expectation that staff maintain and/or submit a report (computer or telephone call) to Environmental Services (EVS-housekeeping) or Plant Engineering, for them to respond and service. During a concurrent observation and interview on 3/18/25 at 1:17 p.m. during a tour of the Operating Room (OR), Cath Lab (a specialized hospital room or area equipped with advanced imaging (x-ray) technology where doctors perform minimally invasive procedures to diagnose and treat heart and blood vessel conditions), Pre-op (a designated area in a hospital or surgical center where patients are prepared for surgery) and Post Anesthesia Care Unit (PACU- a critical care unit and specialty that focuses on patient recovery after surgery) departments with Peri-Op Leader/Liaison (POL) and Charge Nurse (CN) 1, CN 1 stated the nutrition room was shared by patients and staff. The ice and water dispensing machine in the nutrition room was visibly soiled, with splatter marks and white-colored/textured residue noted to the exterior, chutes, catch trays and racks of the machine. The tissue test (method used to determine is debris is present on a surface) performed on the water dispensing chute resulted in a small circular black plastic piece coming away from the water chute. The tissue test performed on the ice dispensing chute resulted in pink-colored stains on the tissue. CN 1 stated that was not expected [tissue test results] and a work order would be submitted for service by the Plant Engineering department. CN 1 and POL stated Environmental Services (EVS) clean the outside of the machine and Plant Engineering was responsible for cleaning the ice and water dispensing machines. POL stated expectation was that machines are cleaned regularly with staff alerting EVS or Plant Engineering as needed if there is a concern. During a concurrent observation and interview on 3/18/25 at 2:07 p.m. with RN 4 in acute care oncology (where patients with cancer are treated) unit’s patient nutrition room (where food for patients is stored) #1, the refrigerator was noted to have a large puddle of clear liquid on the bottom shelf. A label on the bottom shelf of the refrigerator indicated, “ ... BOTTOM SHELF Breastmilk Storage Only ...” RN 4 stated the liquid could be condensation but should not be there as the bottom shelf was where breastmilk was stored. During a concurrent observation and interview on 3/18/25 at 2:13 p.m. with RN 4 in acute care oncology unit’s patient nutrition room #2, the refrigerator was noted to have a large puddle of clear liquid on the bottom shelf. The refrigerator also had six small white frozen pieces, and one large white frozen chunk of a substance stuck to the bottom shelf. RN 4 stated the substance could be from food defrosting or something leaking from upper shelves. RN 4 stated this could be an infection issue. 2. During a concurrent observation and interview on 3/18/25 at 10:33 a.m. during a tour of the Emergency Department (ED) with the Director of the ED (DED), in a Medication Room, 3 white buckets containing used patient equipment were stored, for recycling, directly on the floor. The DED stated was not aware that buckets should not be stored on the floor. In the ED clean supply and equipment room, trash was observed to be overflowing and spilling over onto the floor. DED stated trash should not be overflowing and spilling onto the floor. DED stated her expectation was staff monitor and report to EVS to prevent trash from overflowing. During a concurrent observation and interview on 3/18/25 at 10:40 a.m. with the Director of Neonatal Intensive Care Unit (DNI) and Registered Nurse (RN) 9 in the NICU soiled utility room (a designated area for temporary storage and handling of soiled materials and equipment before they are cleaned, processed or disposed of) a new unused spill kit was found. RN 9 stated everything in the soiled utility is considered dirty. During an observation on 3/18/25 at 11:00 a.m. in the acute care medical unit’s clean utility room (a designated area where clean supplies are stored), a spill kit was stored. During a concurrent observation and interview on 3/18/25 at 1:17 p.m. during a tour of the Pediatric ICU with DPICU in the medication room, an unused/plastic wrapped syringe was found on the floor. DPICU stated, the syringe should not be on the floor and should not be used on patients after being on the floor due to risk for cross contamination. In the soiled utility room, a blue plastic bag was observed on the floor. DPICU stated the bag must have “fallen out” of the soiled linen container. DPICU stated trash and soiled linen bags should be contained in designated container and not be overflowing and falling onto the floor. During an observation on 3/18/25 at 1:20 p.m. in the acute care respiratory unit ‘s clean utility room, a spill kit was stored. During an observation on 3/18/25 at 1:40 p.m. in the acute care surgical unit’s clean utility room, a spill kit was stored. 3. During a concurrent observation and interview on 3/18/25 at 1:17 p.m. during a tour of the Pediatric ICU with DPICU two (2) members of the PICU IDRs were observed to be drinking from cups while actively participating in patient rounds in the hallway just outside of patient room doors. DPICU stated staff are to keep drinks in designated areas on the unit away from patient care equipment and supplies. DPICU stated drinking outside of these designated areas poses a risk of cross-contamination and illness to patients, visitors, and staff. During an interview on 3/20/25 at 9:38 a.m. with the Manager, Plant Engineering (MPE), MPE stated once monthly maintenance of ice machines: copy of work form provided. MPE stated these work orders are generated monthly and assigned for work to be done. MPE stated techs are assigned by Zones and the tech remains as primary contact for these zones for consistency and rapport with leaders and staff. Semi-annual take down full inspection and cleaning of all surfaces, inspection and replacements as indicated and replace filters (sediment and charcoal), per hospital policy. Will be replacing the uncleanable stained w/textured staining and have nearly completed cleaning of hospital ice machines. Refrigerators: Mechanical and condensers are maintained by Eng. During an interview on 3/20/25 at 1:36 p.m. with the Director of EVS (DEVS), DEVS stated refrigerators require use of food safe chemicals, nutrition [services] does these. Human milk is cleaned by nutrition or unit staff. Staff are expected to disinfect, allowing for dwell time (s the amount of time a disinfectant must remain visibly wet on a surface to effectively kill a specific pathogen) then come back to polish off the film and polish off smudges and fingerprints. DEVS stated the expectation was for it to be done twice per day on the morning and evening shifts. DEVS stated on the PACU department, EVS staff are expected to clean in evening- not during day due to cleaning focused on the flow of room turnover (cleaning and sanitizing between patients), but at night [shift] a full clean was expected. DEVS stated EVS staff are expected to clean outside of the refrigerators and ice machines. DEVS stated he will have to speak with staff and follow up with them to ensure they are meeting expectation. DEVS stated from viewing pictures, it did not look like it was happening as expected. DEVS stated he participates in regularly scheduled Environment of Care (EOC) rounds which occur with unit leadership, Quality Assurance, Plant Engineering and EVS to identify deficiencies and have unit leadership correct and will recommend adding these observations to track and monitor compliance with expectations. During an interview on 3/20/25 at 3:11 p.m. with the Director of Culinary Services (DCS) photos of refrigerators and freezers were shared with DCS. DCS stated her understanding was the unit aides were responsible for maintaining the cleanliness of the inside of the fridge, EVS wipes down the outside. DCS stated nutrition staff (reporting to DCS) are responsible for monitoring when centralized temperature monitoring is not active. DCS stated staff stocks food in the fridge, rotating stock and looking for any expired items and rotate out the formulas. DCS stated EVS doesn’t look in the refrigerators/freezers. DCS stated unit aides maintain cleanliness of nourishment rooms. DCS reacted to the photos shown by stating there was “obvious formula spill” in the refrigerator in the PICU. DCS stated her staff does not clean the bins in refrigerator used to separate patient items. DCS stated keeping the refrigerators clean prevents risk of cross contamination; spores (a cell that certain fungi , plants (moss, ferns), and bacteria produce) could be growing, if something is left open in the fridge. DCS stated her team doesn’t clean [the refrigerators or freezers]. DCS stated there is an opportunity to begin accountability rounds for her team, along with Environment Of Care rounding to include the cleanliness of the nutrition rooms including refrigerators, freezers on their rounds. DCS stated “we don’t defrost freezers because they have to be turned off leaving the unit without a refrigerator.” DCS stated if she has this issue [ice buildup] on her unit, they put in a work order [to Plant Engineering]. During an interview on 3/21/25 at 10:39 a.m. with the Manager of Infection Prevention (MIP), and the Vice President (VP) of Quality Assurance (QA), photos of the observations were shared with MIP. MIP stated, anything on the floor needed to be thrown away. VPQA stated the risk of unidentified liquid and built-up ice in refrigerators, could indicate temperature dysregulation and identifying the source is important to prevent infection. VPQA stated there was concern for possible contamination and spoilage [of food items]. VPQA stated staff should help by cleaning up spills and contacting EVS. VPQA stated [for refrigerators and freezers] EVS is responsible to clean outside, inside cleaned by unit aides. VPQA reviewed photos, and stated the photo indicated that those items should not be as found . VPQA and MIP stated they were not aware the “Who Cleans What [Appendix table]” did not indicate what department cleans the refrigerators. During an interview on 3/21/25 at 10:41 a.m. with the Manager of Infection Prevention (MIP), the MIP stated an unused spill kit is a clean item and item in a soiled utility room are considered dirty. During an interview on 3/21/25 at 10:44 a.m. with the MIP, the MIP stated the frozen and liquid substances in the patient nutrition refrigerators could be condensation of defrosting food and could be a potential for cross-contamination of patient food. During an interview on 3/21/25 at 11:07 a.m. with the Chief Nursing Officer (CNO), the CNO stated, supplies for patients should not be on the floor in the clean supply room. The CNO stated when supplies were found on the floor they should not be used on patients and should go back to the central supply department, or in the trash. The CNO stated it was her expectation that if an infection control concern is observed, the staff was expected to make good decisions and escalate the concern to have EVS clean/sanitize as needed. During a review of the hospital’s policy and procedure (P&P) titled, “Infection Prevention Program” dated 2/25, the P&P indicated, “... Policy ... 2. Organizational Oversight...F. Observe procedures for decontaminating equipment and environmental surfaces ... K. ... 3. A clean and sanitary environment for patients, personnel and visitors will be maintained. All cleaning, disinfection, sterilization and decontamination procedures, agents, equipment and schedules shall be defined in writing and approved by the Infection Prevention & Control Subcommittee ... L. 3. Department managers shall enforce infection prevention and control policies and ensure that all personnel in their department are competent to participate in infection prevention and control activities ...” During a review of the hospital’s P&P titled, “Disinfection of Patient Care Equipment and Devices” dated 2/23, the P&P indicated, “ ... Purpose Statement Reusable ... The purpose of this procedure is to prevent healthcare associated infections that are associated with contaminated patient care equipment and devices... Definitions...Cleaning The removal of visible soil ... from objects and surfaces ... Appendix A: Who Cleans What ... ITEMS: Ice Machine STANDARD: Scheduled METHOD: Per policy GROUP: Facilities/Engineering cleans inside of machine EVS cleans outside ... ITEMS: Refrigerators, nutrition rooms STANDARD: When visibly soiled or dusty METHOD: Hospital-approved disinfectant GROUP: EVS ...” During a review of the hospital’s P&P titled, “Refrigerator Policy” dated 4/22, the P&P indicated, “ ... Purpose Statement To ensure that medications and patient food are stored at the appropriate temperatures to ensure medication integrity and patient safety ...” During a review of the hospital’s procedure titled, “Nutrition Room Cleaning Procedure” (undated), the procedure indicated, “ ... Step 3 - Disinfection damp wipe of surfaces: The Tech will use a microfiber towels saturated in disinfectant solution or premixed disinfection wipe for cleaning of surfaces in the room. The saturated microfiber towels are to be gently wringed out to retained dampness for dwell time of the chemical. Start the disinfection wipe of items/fixtures from the doorway of the room and work in a clockwise direction through the room. The disinfection wipe will include all horizontal surfaces and spot wipe of vertical high touch surfaces. It is important to keep used dirty wipes from touching clean wipes. After carefully wiping down all the required surfaces and the dwell has been reached, the Tech should go over surfaces with a dry wipe to remove chemical residue ...” During a review of the hospital’s procedure titled, “Soiled Utility Room Procedure” undated, the procedure indicated, “ ... It is the practice of the EVS department to ensure that the Soiled Utility room is cleaned thoroughly once per day and policed continuously ...” During a review of the document provided by the hospital titled, “Environment of Care (EOC) Manager Rounds” dated 3/12/25, the EOC Tracer indicated, “... Location ... Discovery... Observe/Check/Verify ... X...16. Storage - 6” (6 inches) off the floor and 18” (18 inches) from ceiling ... Finding #0232 Storage on the floor ... resolved ... 20. All supplies/products have current dates; no expired supplies/products. 21. Patient food stored, labeled, dated and/or discarded per policy. 22. Refrigerators that store patient food are clean ...” During a review of the document provided by the hospital titled, “Environment of Care (EOC) Tracer” dated 1/14/25, the EOC Tracer indicated, “... Location ... ED ... N/A...16. Storage - 6” (6 inches) off the floor and 18” (18 inches) from ceiling ...” According to the “Brand Name Ice Machine and Dispensers” Cleaning and Sanitizing Instruction for Use (IFU) provided by the hospital, the IFU indicated “... Periodic cleaning of “brand name” ice and water dispenser and ice machine system is required to ensure peak performance and delivery of clean, sanitary ice. The recommended cleaning procedures that follow should be performed at least as frequently as recommended and more often if environmental conditions dictate ...” During the review of a professional reference titled, “Managing Condensation in Medical-Grade Refrigerators (MC)”, dated 2019, the “MC” indicated, “ ... Why condensation removal is important ... The management of condensation inside a refrigerator is important for several reasons. First, molds and other biofilms can grow in wet environments. Small microscopic water droplets forming on the walls of shelving inside a refrigerator can be an ideal site for the growth of molds, yeasts and bacteria that are in the ambient air. The drier the environment, the less likely this is to occur ... In addition, packaging inside the units can be moist and soggy if the condensation is not adequately removed from the storage cabinet ...” During a review of a professional reference from the Agency for Healthcare Research and Quality (AHRQ) titled, “Infection Prevention (IP)” (undated), “IP” indicated, “ ... Providing a sanitary environment ... There is a clear separation of clean and dirty work areas. Clean areas are used for storage and preparation of medications and unused supplies; dirty areas are used for contaminated equipment ...” During a review of the professional reference titled, “The role of the surface environment in healthcare-associated infections”, dated August 2013, the professional reference indicated, “ ... Hospital surfaces are frequently contaminated with important healthcare-associated pathogens (bacteria). Contact with the contaminated environment by healthcare personnel is equally as likely as direct contact with a patient to lead to contamination of the healthcare provider’s hands or gloves that may result in patient-to-patient transmission of nosocomial (originating from the hospital) pathogens ...” During a review of the professional reference titled, “Good Storage and Distribution Practices for Medical Products”, (retrieved from https://www.who.int/publications/m/item/trs-1025-annex-7) dated 6/17/20, the professional reference indicated, “ ... Storage and distribution are important activities in the supply chain management of medical products ... Storage areas should be of sufficient capacity to allow orderly storage of the various categories of medical products ... Storage areas should be appropriately designed, constructed, maintained or adapted. They should be kept clean and there should be sufficient space and lighting ... Materials and medical products should be stored off the floor, away from walls and ceilings, protected from direct sunlight and suitably spaced, to permit ventilation, cleaning and inspection ... Materials and medical products should be handled and stored in such a manner as to prevent contamination, mix-ups and cross-contamination...””

“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: 45580 Based on observation, interview, and record review, the hospital failed to ensure licensed nurses adhered to the hospital’s policies and procedures when: 1. Three of 30 sampled patients (Pt 2, Pt 4, and Pt 5) did not have their pain reassessed after the administration of pain medications in accordance with the hospitals policy and procedure (P&P) titled “Pain Management”. These failures had the potential to result in Pt 2, Pt 4 and Pt 5 to have inadequate pain management and could negatively affect the physical, emotional, and psychosocial well-being of the patients. 2. One of two sampled patients (Pt 5) had a fever of 101.1 (degrees Fahrenheit-[F-a scale for measuring temperature; normal: 97-99 F, fever: greater than or equal to 100.4 F]), 15 minutes after the completion of a blood transfusion and was not reported to the physician and no interventions were implemented. This failure resulted in Pt 5’s fever after the blood transfusion to not be reported to the physician and no interventions were implemented and had the potential to develop into an adverse reaction i which could be minimal to life threatening. 3. Licensed Nurse (LNs) did not document Pt 2’s heels were elevated off the bed on 11/5/24, 11/6/24, 11/7/24 and 11/8/24 to prevent a pressure injury (damage to skin and underlying tissue caused by prolonged pressure) for one of 30 sampled patients (Pt 2) in accordance with the hospitals P&P titled “Pressure Injury Risk Assessment and Prevention”. This failure resulted in Pt 2 developing a stage 2 pressure injury (partial thickness loss of skin, appearing as a shallow open sore or blister, where the skin has broken open, exposing the dermis layer, usually representing as a red or pink wound bed without any deeper tissue damage like muscle or bone exposure) to the right heel on 11/7/24. Findings: 1.During a review of Pt 2’s “History & Physical (H&P)”, dated 11/17/24, the H&P indicated, Pt 2 was admitted from 11/4/24 to 11/15/24 for post-surgical care after right hip surgery. During a concurrent interview and record review on 11/22/24 at 10:55 a.m. with the Clinical Coordinator (CC) and Nurse Manager (NM) 3, Pt 2’s “Pain Screening/Assessment Scale Flowsheet (PSASF)”, dated 11/4/24 to 11/21/24 was reviewed. The PSASF indicated, Pt 2 was assessed for pain using the Face, Legs, Activity, Cry and Consolability (FLACC scale- a behavioral pain assessment scale used to evaluate pain severity in children who are unable to communicate pain, 0 no pain, 1-3 mild pain, 4-6 moderate pain, 7-9 severe pain, 10 worst pain) scale. The PSAF indicated, on 11/9/24 at 5:32 a.m., Pt 2 was assessed for pain, had a FLACC score of 3 on a 0-10-point scale, no pain interventions were done and there was no reassessment of pain. On 11/9/24 at 8 a.m., Pt 2 was assessed for pain, had a FLACC score of 2, on a 0-10-point scale, no pain interventions were done and there was no reassessment of pain. On 11/9/24 at 11:41 a.m., Pt 2 was assessed for pain, had a FLACC score of 4, on a 0-10-point scale, and was administered ibuprofen (an anti-inflammatory drug used to relieve pain, fever, and inflammation) and there was no reassessment of pain. On 11/9/24 at 4:06 p.m., Pt 2 was assessed for pain, had FLACC score of 5, on a 0-10-point scale, no pain interventions were done and there was no reassessment of pain. On 11/13/24 at 2:30 p.m., Pt 2 was assessed for pain, had FLACC score of 6, on a 0-10-point scale was administered ibuprofen and was reassessed for pain One hour and 45 minutes later at 4:15 p.m. The CC validated there was no documentation of non-pharmacological interventions done, pain medications were not administered, and pain was not reassessed. The CC stated pain medications should have been administered. The CC stated the LNs could have implemented interventions such as, repositioning, distraction, or should have notified the physician promptly. The CC stated the expectation for the LN’s were to reassess pain an hour after pain medication was administered and it was not done. The CC stated Pt 2’s pain was not controlled. The CC stated it was important to keep the patient at a comfortable pain level since the patient could not communicate. NM 3 stated the LN’s did not provide relief for Pt 2’s pain. During a concurrent interview and record review on 11/25/24 at 10:30 a.m. with Registered Nurse (RN) 5, Pt 2’s “Pain assessment Flowsheet (PAF)” dated 11/9/24 and “Daily Cares / Safety Flowsheet (DSF)”, dated 11/9/24 were reviewed. RN 5 stated she was the nurse assigned to Pt 2 on 11/9/24 from 7 a.m. to 7:30 p.m. RN 5 stated on 11/9/24 at 8 a.m. Pt 2 had a pain level of 2 on the FLACC scale. RN 5 stated no intervention were done because she was busy and should have reassessed Pt 2’s pain and documented the pain assessment. RN 5 stated on 11/9/24 at 11:41 a.m. Pt 2 had a pain score of 4 on the FLACC scale, and Pt 2 was administered ibuprofen 350 milligrams (mg-unit of measurement) at 11:41 a.m. RN 5 stated she did not reassess Pt 2’s pain. RN 5 stated the policy was to reassess pain within an hour after interventions and she should have reassessed and documented pain assessments after the intervention. RN 5 stated Pt 2’s vital signs (VS-measurements of the body’s basic function, such as breathing, heart rate (HR), respiration rate (RR) and temperature) on 11/9/24 at 4:06 p.m. were HR of 101 (normal heart rate 60-100), RR of 17 (normal respiratory rate 12-18) and pain score of 5 on the FLACC scale. RN 5 stated Pt 2 was repositioned, the DSF did not indicate Pt 2 was repositioned and she did not document the pain intervention. RN 5 stated she did not follow the facility’s policy to document the interventions that were done. RN 5 stated Pt 2’s VS on 11/9/24 at 5 p.m. were a HR of 116, RR of 34, RN 5 stated she believed the changes in VS from 4:06 p.m. to 5 p.m. had to do with the pain experienced by Pt 2 and the failure to provide intervention. RN 5 stated she tried to reach the provider twice and received a pain medication order on 11/9/24 at 5:38 p.m. for Hydrocodone-acetaminophen (potent drug for moderate-to-severe pain control in patients) Hydrocodone-acetaminophen was administered at 5:55 p.m. RN 5 stated interventions were not provided promptly enough. RN 5 stated, “ ...I should have called whoever is over the hospitalist, or the on-call doctor ...”. RN 5 stated there was no documentation of reassessment of pain after administering the medication at 5:55 p.m. RN 5 stated the importance of reassessing the patients’ pain was to see if the intervention worked and Pt 2’s pain could have increased. RN 5 stated, “ ...Our goal as nurses is to treat the patient and help with their pain ...”. During a concurrent interview and record review on 11/25/24 at 11:23 a.m. with RN 4, Pt 2’s PAF dated 11/13/24 was reviewed. RN 4 stated she was assigned to Pt 2 on 11/13/24 from 7 a.m. to 7:30 p.m. RN 4 stated on 11/13/24 at 2:30 p.m. Pt 2’s FLACC score was 6 and Pt 2 was administered ibuprofen 350 mg at 2:30 p.m. and reassessment of pain was completed at 4:15 p.m. RN 4 stated reassessment should have been done within an hour but was not done according to her documentation. RN 4 stated the importance of reassessing the patient’s pain was to determine if Pt 2’s pain was managed by the intervention and to know if it was successful or not. RN 4 stated Pt 2 could have unmanageable pain due to reassessing the patient’s pain late. During a concurrent interview and record review on 11/25/24 at 10:48 a.m. with RN 8, Pt 5’s “History and Physical (H&P-a doctor’s initial assessment of a patient by asking about their medical history and physically examining them),” dated 11/14/24 was reviewed. RN 8 stated the H&P indicated, “Chief Complaint: Acute anemia [a rapid decrease in red blood cells], suspected hemolytic uremic syndrome [a serious disease that affects the kidneys and blood clotting system] ...vomiting and diarrhea for four days ...Patient was admitted to acute care floor. Morning labs were drawn and showed significant drop in hemoglobin [a protein in red blood cells that carries oxygen from the lungs to the body’s tissues and organs-normal levels:10-15.5] from 11 to 5 ...” During a concurrent interview and record review on 11/25/24 at 10:48 a.m. with RN 8, Pt 5’s “Physician Orders (PO),” Pt 5’s “Medication Administration Record (MAR-all medications administered to a patient),” and Pt 5’s “Pain Screening/Assessment Scale (PS),” dated 11/14/24 were reviewed. RN 8 stated the PO indicated, acetaminophen (a pain reliever and fever reducer medication) 160 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount)/5 milliliter (mL-unit of measure) suspension (liquid) 368mg, ordered dose: 15mg/kilogram (kg-a unit of measurement for weight) x 24 kg oral every four hours as needed for mild pain and temperature greater than 100.4 F with a start date of 11/13/24 and end date of 11/26/24. RN 8 stated the MAR indicated acetaminophen was administered on 11/14/24 at 3:51 p.m. RN 8 stated the PS indicated at 3:53 p.m., Pt 5’s pain was 8/10 and Pt 5’s pain was not reassessed until 8:21 p.m., a time lapse of four hours and 28 minutes. During a concurrent interview and record review on 11/25/24 at 3:02 p.m. with RN 8, Pt 4’s “H&P,” dated 11/14/24 was reviewed. RN 8 stated the H&P indicated Pt 4’s chief complaint (primary symptom or concern) was pain and fever. During a concurrent interview and record review on 11/25/24 at 3:30 p.m. with RN 8, Pt 4’s “PO,” Pt 4’s “MAR,” and Pt 4’s “PS,” dated 11/14/24 were reviewed. RN 8 stated the PO indicated, morphine (a strong pain reliever medication) 4 mg intravenous (IV-given directly into the blood stream) once was ordered at 10:15 a.m. RN 8 stated the MAR indicated, at 10:31 a.m. Pt 4 was administered morphine. RN 8 stated the PS indicated Pt 4’s pain was 10/10 (1-least pain and 10-worst possible pain). RN 8 stated a patient’s pain should be assessed within an hour of pain medication administration. RN 8 stated Pt 4’s pain was not reassessed until 12:45 p.m., which was two hours and 14 minutes after the pain medication was administered. During an interview on 11/26/24 at 1:40 p.m. with the Director of Acute Care (DAC), the DAC stated her expectations of nurses was to follow the physician’s orders. The DAC stated nurses should assess their patient’s pain and reassessment of their patient’s pain depending on the route the medication was given. The DAC stated when a patient was administered IV pain mediation their pain should be reassessed within 15 minutes and by mouth medications should be assessed within 30 minutes. The DAC stated the importance of assessing and reassessing pain was to determine if the patient’s pain was under control. The DAC stated pain control was an important part of healing. The DAC stated she expected nurses to always follow hospital P&P. The DAC stated the importance of nurses following hospital P&P was to ensure evidence-based practices were implemented. During a review of the hospital’s policy and procedure (P&P) titled, “Pain, Management,” dated November 2023, the P&P indicated, “Outlines assessment and treatment of pain ...committed to making pain assessment a priority and to developing a pain management plan in collaboration with the patient/family that balances pain relief, safety, side effects ...1. The physician, nurse, and other healthcare professionals ...are educated about pain treatment and collaborate to manage pain in the child ...Proper treatment of a patient’s pain will include a careful diagnosis of the etiology of pain, selection of appropriate and cost-effective treatments, and ongoing evaluation of the results of treatment. 3. Pain intensity and pain relief will be assessed and reassessed at regular intervals and will contribute to the choice of appropriate therapeutic intervention. 4. Patients are assessed for pain using developmentally appropriate, reliable methods. 5. Patient assessments, reassessments, interventions, and responses to interventions will be documented ...The [registered nurse (RN)] is accountable to initiate and ensure completion of the teaching plan. An interdisciplinary approach is to be utilized in completion of the plan with input and actual teaching as appropriate from other healthcare team members ...Pain ...An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage ...Expected Outcome(s) ...Appropriate screening and assessment of pain, provision of safe and effective treatment of pain for all patients, and participation of the patient and family in the pain management plan to the greatest extent possible ...Pain Screening and Assessment ...Initial screening and assessment for pain will occur as follows ...Inpatients ...All inpatients will be screened for pain during the initial assessment process ...Pain assessment shall be performed for all patients who screen positive for having pain. This assessment will include the following ...Intensity of pain, reported using the appropriate pain intensity rating scale ...Location(s) of pain for verbal patients, as age-appropriate ...The patient’s self-report shall be the primary source of pain assessment information ...Reassessment of pain may include location(s), intensity and effectiveness of pharmacological or nonpharmacological interventions ...Reassessment of pain shall occur at the following points ...With routine vital signs per department standards, regardless of pain intensity level ...Patients who are sleeping do not need to be awakened for a pain rating ...pain should be reassessed upon awakening ...At a suitable interval after each pharmacological or nonpharmacological intervention ...Within 30 minutes after parenteral drug therapy, and within one hour after an oral or rectal medication has been given ...Reassessment after opioid administration should include a pain assessment and assessment for the presence or absence of side effects-including, but not limited respiratory depression ...” 2. During a concurrent interview and record review on 11/25/24 at 10:30 a.m. with RN 8, Pt 5’s “PO” and Pt 5’s “Blood Transfusion Record (BTR),” dated 11/14/24 were reviewed. RN 8 stated the PO indicated; Pt 5 had an order to transfuse (to transfer into a blood vessel of a person) packed red blood cells (PRBC-a type of blood replacement product used for blood transfusions) on 11/14/24. RN 8 stated the BTR indicated, at 7:45 a.m. the blood transfusion started and Pt 5’s temperature was 99 F. RN 8 stated the BTR indicated, at 11 a.m. the blood transfusion stopped and at 11:15 a.m. Pt 5 had a temperature of 101.1 F. RN 8 stated the BTR indicated, the next temperature was assessed at 4:40 p.m., which was a time lapse of five hours and 25 minutes. RN 8 stated Pt 5’s temperature should have been rechecked within an hour of the fever, whether a fever reducing medication was administered or not to ensure the fever went down. During a concurrent interview and record review on 11/25/24 at 10:35 a.m. with RN 8, Pt 5’s “Provider Notification (PN),” dated 11/14/24 was reviewed. RN 8 stated the PN indicated, there was no documentation a physician was notified about Pt 5’s fever at the end of the blood transfusion. RN 8 stated if her patient had a fever at the end of a blood transfusion, she should have paged or notified the physician about the fever. RN 8 stated the importance of notifying the physician when a patient had a fever after a blood transfusion was to ensure the physician had knowledge about the patient’s change in condition and the physician could decide what to do. During an interview on 11/26/24 at 1:50 p.m. with the DAC, the DAC stated her expectations of nurses when their patient had a fever at the end of a blood transfusion was the fever should have been reported as a potential reaction to the blood. The DAC stated the nurse should have reported to the blood bank and the physician. The DAC stated the importance of reporting a potential reaction was, the reaction could have caused anaphylaxis (a severe life-threatening allergic reaction that could affect the entire body) or the patient could have an infection and in an immunocompromised patient, the patient should of had blood cultures and antibiotics started by contacting the physician. During a review of the hospital’s P&P titled, “Blood Product Management,” dated November 2024, the P&P indicated, “Outlines the management of patients receiving selected blood products such as packed red blood cells (PRBC) ...Beginning the Transfusion and Monitoring the Patient ...Obtain and record a full set of baseline vital signs (must be taken within previous 1 hour of initiation of the administration of blood products) then at 15 minutes after the beginning of the transfusion, again at 1 hour, upon completion of the transfusion, and again at approximately 1 hour after the end of the transfusion ...Begin infusion ...over the first 15 minutes, and then advance to the ordered rate after the 15 minute vitals if no adverse reactions are seen ...Closely monitor the patient for the first 15 minutes of the transfusion ...Remain at the bedside for the first 5 minutes of the transfusion ...For the next 10 minutes, continue to watch the patient closely and do not leave the patient unobserved for more than 2-3 minutes ...Intervene immediately should the patient display signs of a severe ...reaction and follow instructions in “Suspected Transfusion Reaction” ...Assess for adverse reactions throughout the transfusion and for an appropriate time thereafter for ...Fever-temperature increase [greater than or equal to] 1 [degree Celsius (C-a scale for measuring temperature, in which water freezes at 0 degrees and boils at 100 degrees)] above baseline vitals ...Itching ...Chills ...Rash ...Respiratory distress ...Explain possible adverse reaction to patient/family, and whom to notify if these are noted ...Instruct the patient/family to report any irritation of the IV site or suspected delayed transfusion reaction ...” During a review of the hospital’s P&P titled, “Transfusion Reactions,” dated November 2024, the P&P indicated, “Purpose Statement ...To assist medical and nursing staff in recognizing and managing transfusion reactions and to minimize serious complications that may occur during or after a transfusion ...Transfusing staff shall follow this procedure for the recognition of and response to immediate transfusion reactions and for recording of relevant information in the patient’s medical record ...Fever ...An increase of [greater than or equal to] 1 [C] in temperature over the pre-transfusion temperature during or within 4 hours of the completion of the transfusion ...If there are symptoms or findings suggestive of a transfusion reaction, an investigation must be undertaken. Based on the findings of the testing, each complication will be categorized by the pathologist reviewing the case ...Any significant change in a patient’s vital signs or status during and up to 6 hours following a transfusion should include an acute transfusion reaction in the differential diagnosis. Early recognition is the key to minimizing serious complications. Signs and symptoms of a transfusion reaction include: Hives, rash, itching ...Warmth at infusion site ...fever ...Headache ...Transfusion Reaction Workup ...For any acute reaction other than mild allergic (rash, hives, itching), or it an investigation is requested by the physician (or pathologist reviewing the case), the transfusing nurse or medical staff should select “Transfusion Reaction-Workup” ...For any acute reaction other than mild allergic (hives, rash, itching), the transfusing nurse or medical staff should take the following action: 1. STOP the transfusion immediately and disconnect the entire transfusion set from the needle or catheter. 2. Keep the IV line open with a slow drip of normal saline, using a new transfusion set. 3. Check the blood bag label and tag against the patient’s ID band to confirm that the patient received the correct unit. 4. Notify the attending physician so that treatment, if necessary, can begin immediately. 5. Take vital signs every 15 minutes (including [oxygen] saturation) until the patient is stable. 6. Notify the Blood Bank ([extension] 36066) and describe the signs and symptoms of the reaction. 7. Order a “Transfusion Reaction Workup” in Epic and fill out the information. 8. Send the following items to the Blood Bank [immediately (STAT)]: a. Blood component bag with attached transfusion set and IV fluids. b. Post-transfusion EDTA blood sample: labeled for blood bank. Minimum: 2.0 mL c. Post-transfusion urine specimen if hemolytic reaction is suspected. Minimum: 5.0 mL ...” 3. During a review of Pt 2’s “H&P”, dated 11/17/24, the H&P indicated, a 17-year-old male was admitted to the hospital from 11/4/24 to 11/15/24 for post-surgical care after right hip surgery. During a concurrent interview and record review on 11/22/24 at 9:39 a. m. with the Clinical Coordinator (CC) and Nurse Manager (NM) 3, Pt 2’s “Wound Care Nurse Note (WCNN)” dated 11/5/2024, 11/8/2024, “Daily Care Flowsheet History (DCFH) dated 11/4/2024 to 11/9/2024” and the facility’s P&P titled, “Pressure Injury Risk Assessment and Prevention” were reviewed. The WCNN dated 11/5/24 indicated, “ ... Reason for Consult: [Pt 2] is being seen today for a consultative service at the request of [Medical Director (MD)] ... regarding pressure injury prevention ... Assessment ... [Pt 2] is high risk for pressure injury development due to immobility, inactivity and limited response to discomfort ... Plan ...This patient is at risk for pressure injury development to areas ... under all medical devices, and heels ... Recommendations ... Patient Repositioning: Turn [every two hours]. .... Elevate heels off bed ...”. The WCNN dated 11/8/24 indicated, “ ... Reason for Consult: Pt 2 is being seen at the request of the [Doctor of Osteopathic Medicine (DO)] ... regarding pressure injury treatment, hospital acquired stage 2 pressure injury to right heel; medical device related, abductor pillow and future pressure injury prevention ... [Pt 2] has developed a stage 2 pressure injury to his medial heel... right leg with brace on and is slightly externally rotated [limb away from the body’s center]. Both legs in an abductor pillow [soft, firm foam pillow that is used to keep patients’ legs aligned and prevent hip movement after surgery]. Right heel is resting on abductor pillow with [dressing] over wound. There is an annular area of non-blanching erythema (skin condition where the redness does not fade when pressed), [2.5 centimeters (cm-unit of measurement by] 3 cm, with a serous filled bulla [fluid filled blister] at center, to the right medial heel .... Initially noted last night, MD was notified, and attempts were made to offload heel as much as possible ... he had/has an abductor pillow in place which as some point his heel rested on, applying unintended pressure to the area ...”. The DCFH indicated on 11/5/24 from 7:31 a.m. to 6:23 p.m., on 11/6/24 from 6 a.m. to 6:11 p.m., on 11/7/24 from 8 a.m. to 7:10 p.m., and on 11/8/24 from 8:17 a.m. to 5:30 p.m. there was no documentation to indicate Pt 2’s heels had been elevated off the bed. The CC validated Pt 2 did not have a pressure injury when he was admitted on 11/4/24. The CC validated a recommendation was given on 11/5/24 to float Pt 2’s heels off the bed and it was not done on 11/5/24, 11/6/24, 11/7/24 and 11/8/24. NM 3 stated Pt 2’s heels should have been elevated and not rested on the pillow. NM 3 stated the licensed nurses did not follow the policy and a stage 2 pressure injury developed. NM 3 stated the pressure injury could have been preventable with better attention to the heels. NM 3 stated Pt 2’s repositioning should have been more often than the 2 hours. During an interview on 11/25/24 at 2:25 p. m. with the Wound and Ostomy Specialist (WOS), the Wound and Ostomy Intern (WOI) and the Director Specialty Nursing (DSN). The WOS stated when a patient had a pressure injury a standardized procure (SP) was to be followed which entailed a pressure injury bundle of a physician’s orders and a signature is not required, and the SP is covered under the P&P Appendix C “pressure ulcer prevention”. The WOS stated nurses were aware of this procedure. The WOS stated the nurses were not following the process, and the nurses should have been offloading the heels and documenting. The WOS stated the importance of offloading the heels were to prevent injury. The WOS stated a pressure injury developed because the process was not followed and was preventable. During a concurrent interview and record review on 11/26/24 at 11:30 a. m. with Registered Nurse (RN) 6 and NM 5, Pt 5’s DCFH dated 11/7/2024 was reviewed. RN 6 stated she was assigned to Pt 2 on 11/7/24 from 7 a.m. to 7:30 p.m. RN 6 stated Pt 2’s “ ...heels were off the bed ... and his feet were elevated the entire shift ...I forgot to document the heels were elevated off the bed ...”. RN 6 stated the importance of elevating heels were to ensure the patient did not get a pressure injury. NM 5 stated the policy was not followed. During a review of the facility’s policy and procedure (P&P) titled, “ Pressure Injury Risk Assessment and Prevention “, Policy/Procedure Number PC-4150, dated effective 8/2022, the P&P indicated, “PURPOSE: Guides skin assessment, wound assessment, standardizes pressure injury staging and outlines treatment practices for the care of patients who are experiencing a break in skin integrity. POLICY: All inpatients will be assessed by the registered nurse for risk of skin breakdown, as clinically indicated, at minimum every 12 hours patients who are either partially or completely immobile, neurologically impaired, critically, ... Are at risk for pressure injury development. Effective implementation of pressure injury prevention guidelines requires early identification of heart- risk patients based on risk assessment score and clinical evaluation. QUALIFIED/ APPLICABLE PERSONNEL: RNs are responsible for all aspects of this policy.... PROCEDURE 1. Risk Assessment: A. All patients over 3 weeks old and less than 18 years old shall have a risk assessment evaluation for pressure injury development by a registered nurse upon admission using Braden Q assessment scale (see appendix A) .... D. Reassessment of risk, using Braden Q scale or the Braden scale shall be done every shift or whenever the patient’s condition changes or deteriorates. E. All patients shall have a systemic head to toe skin inspection on admission and at least every 12 hours, paying particular attention to Bony prominences and under medical devices. 1. Rotate (as applicable) or release pressure under medical devices including... Heel and elbow protectors... every 4 hours or more often unless physician orders otherwise .... 2. Inspect visible skin surrounding non removable medical devices such as ECLS cannulas, central line cannulas, intravenous lines..., nasal cannula tubing secured with tape/ target them etc., ...a. If redness or skin breakdown is found, the device should be padded, securement readjusted or replaced with a better fitting device as ordered. Attending provider must be notified. b. Leave dressings in place unless removal or dressing changes are ordered. F. Common sites for pressure injury formation includes: ...3. Adolescents and adults hold on sacrum, heel, elbow, ... Under medical devices.2. Prevention ...B. ...3. Bed- bound patients: a. Turn at least every two hours with frequent repositioning, unless specifically contraindicated by physician orders .... d. Suspend or float heels by placing pillow or other positioning device on the patient’s calves with knees slightly bent. “do not turn” instructions should require a provider order and be reevaluated every 24 hours .... 5. Medical devices: ...b. Cushion and protect the skin under medical devices with dressing such as foam dressing, and silicone dressing, transparent film, sheets hydrogel etc. c. Ensure patient is not lying on top of any medical device .... e. Rotate or release/ reapply medical devices every four hours unless contraindicated. f. Assess skin in contact with medical device every four hours unless contraindicated. Key points: medical devices known to cause pressure injuries include respiratory devices (masks, cannulas, ETTs, securement devices), immobilizers, orthotics, nasal and enteral feeding tubes, and peripheral and central venous access devices and related securement devices...C. Positioning devices 1. Use heel and elbow protectors, multiple pillows or other padding devices as indicated, to prevent direct contact between Bony prominences (i.e. knees, ankles), and relieve pressure on heels by use of pillows or other positioning devices under the calves to suspend heels off the underlying surface. Assess any sign of foot drop. ...EDUCATION: instruct patient/ family in risk factors, nutrition, skin care and positioning procedures. DOCUMENTATION: Document the following in the medical record: 1. Skin assessment, including baseline score using the Braden Q scale for assessing the risk of pressure injury development. 2. Condition of patient skin, use of special equipment, interventions, and the patient’s response. 3.patient/ family teaching. During the review of a professional reference titled, “Quick Safety 25: Preventing pressure injuries”, Updated March 2022 from https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-25-preventing-pressure-injuries/preventing-pressure-injuries/. The reference stated, ...Pressure injury prevention and treatment requires multi-disciplinary collaborations, good organizational culture and operational practices that promote safety. Per the International Guideline, risk assessment is a central component of clinical practice and a necessary first step aimed at identifying individuals who are susceptible to pressure injuries. Other interventions that influence an individual’s healing process may include identifying nutritional needs, repositioning and early mobilization, skin care, use of support surfaces, cleansing and debridement, pain assessment and management, psychological and spiritual support, and family support .... Positioning and Mobilization: Immobility can be a big factor in causing pressure injuries. Immobility can be due to several factors, such as age, general poor health condition, sedation, paralysis, and coma. Turn and reposition at-risk patients, if not contraindicated. Plan a scheduled frequency of turning and repositioning the patient .... Monitor the prevalence and incidence of pressure injuries. Educate and train all members of the interdisciplinary team. Make sure they are aware of the plan of care and that all care is documented in the patient’s record ....””