Wayne County Hospital

“NURSING SERVICES CFR(s): A registered nurse or, where permitted by State law, a physician assistant, must supervise and evaluate the nursing care for each patient, including patients at a SNF level of care in a swing-bed CAH. This Standard is not met as evidenced by: 47335 Based on review of the Critical Access Hospital (CAH)’s policies and procedures, patient medical records, and interviews with staff, the CAH’s administrative staff failed to ensure hospital staff provided appropriate assessments of the patient’s care needs, health status, and response to interventions for 1 of 10 sampled patients (Patient #2). The cumulative effect of these failures and deficient practices increased the risk of Patient #2 (P2) not receiving effective or appropriate treatment to meet the care needs of the patient. Failure to provide appropriate nursing assessments for all patients could increase the risk of patients experiencing adverse health outcomes, including a deterioration in health and well-being. The CAH’s administrative staff identified an average daily inpatient census of 4 patients. Findings include: 1. Review of policy number 8179229, “Nursing Practice Standard for Routine Care, 514,” last revised 7/20, revealed in part: a. “All patients will be provided a basic level of care individualized to meet his/her personal needs based on the assessment done at the time of admission and changes with assessment during the patient’s hospital stay.” b. “Purpose: ...To assess the patient and plan for his/her care ...” c. “ ... The RN [Registered Nurse] will interview patient/responsible party/family member for a complete nursing history and complete a physical assessment of each patient ... This information will be documented in the patient’s medical record ...” d. “ ... The physical assessment will include ...: Baseline complete vital signs ... Complete system review. Complete skin assessment ... Mobility level, assistive devices, restrictions, and risk of falls ...” e. “ ...An entry will be made in the medical record. This entry will include ... Admit status and reason for admission, including diagnosis ..., and assessment findings ...” 2. Review of policy number 18355111, “Hourly Rounding - The 8 P’s of Purposeful Rounding,” last revised 2/23, revealed in part: a. “ ... During rounding, clinical staff will use the 8 P’s: ...Pain-evaluate the patient’s pain level ...” 3. Review of P2’s 2/21/26 medical record revealed the following: a. On 2/21/26 at 11:41 AM, P2 presented to the ED with complaints of back pain. Nursing staff documented the patient rated their pain as 0 out of 10 (with zero being no pain and ten being the worst possible pain). b. On 2/21/26 at 12:22 PM, Provider A evaluated P2. P2 complained of chronic lower back and hip pain with acute flares. Provider A ordered P2 intramuscular (IM) injections of two steroids and a pain medication. c. On 2/21/26 at 12:41 PM, Registered Nurse (RN) G administered two steroid IM injections. d. On 2/21/26 at 1:44 PM, RN G administered an IM injection of pain medication. e. On 2/21/26 at 3:04 PM, staff discharged P2 home. Nursing staff failed to complete follow-up pain assessments, per hospital policy, following the administration of IM injections of pain medication. Additionally, staff failed to perform a pain reassessment prior to the patient’s discharge. f. On 2/21/26 at 4:40 PM, Provider A documented a follow-up with P2. The patient reported the injections of pain medication helped “a little.” Provider A documented P2’s diagnosis as acute bilateral (both sides) hip pain, lumbar pain, and urinary tract infection (UTI). g. On 2/23/26 at 1:28 PM, Registered Nurse (RN) H documented contacting P2’s family member with an arrival time for surgery, and pre-operative (pre-op) teaching was reviewed. RN H noted P2’s presenting symptoms were flank pain. Hospital staff failed to document what surgery P2 was scheduled for or the reason for the surgery. Staff also failed to document anything regarding P2 being notified of having a kidney stone. h. On 2/24/26 at 12:07 PM, P2 arrived at the hospital for the scheduled surgery for a left kidney stone. i. On 2/24/26 at 12:17 PM, Surgery Director documented “surgery case canceled per anesthesia due to abnormal EKG.” j. On 2/24/26 at 1:59 PM, P2’s electrocardiogram (EKG) showed normal sinus rhythm (NSR). k. On 2/24/26 at 2:45 PM, P2 discharged home. Hospital staff failed to perform any assessments, including a pain assessment on P2. Hospital staff failed to provide any cares or treatment to P2. Hospital staff failed to document P2 had an intravenous (IV) catheter inserted for the scheduled surgery. Hospital staff failed to document that P2’s surgery was canceled due to P2 not having a CT that showed a kidney stone. 4. Review of a hospital incident report for P2 revealed: a. On 2/23/26, Provider C reviewed the referral form and the attached CT results for P2. Provider C called P2 and informed the patient they needed a procedure for a kidney stone. Hospital staff scheduled P2 for a procedure on 2/24/26 for a diagnosis of a kidney stone. b. On 2/24/26, P2 arrived at the hospital and began prep for surgery. The anesthesia provider arrived and provided a consultation for P2. Anesthesia reviewed P2’s history and ordered an EKG pre-op. During Anesthesia’s review of P2’s chart, it was discovered P2 did not have a recent CT in their medical record. Anesthesia questioned where and when P2 had the CT completed. Surgery staff reviewed the original referral form for P2 and discovered P2’s identification patient sticker was placed on the referral form with another patient’s CT results attached. Anesthesia reviewed P2’s EKG results and confirmed an abnormal EKG reading. Hospital staff notified Provider C, and Surgery Director and Anesthesia informed P2 and their family of the canceled procedure. 5. During an interview on 3/30/26 at 12:25 PM, Paramedic G recalled P2 came to the ED complaining of pain. Paramedic G reported administering IM medication to P2, and they performed a blood draw. Paramedic G acknowledged pain assessments should be completed after a patient receives pain medication and prior to discharge. Paramedic G reported they could not speak to why P2 did not have a pain assessment after receiving pain medication or prior to discharging from the ED. 6. During an interview on 3/30/26 at 11:45 AM, RN L recalled being assigned as P2’s nurse during the patient’s ED visit on 2/21/26. RN L reported P2 presented with complaints of back pain. RN L recalled administering medication ordered by the provider to P2, but could not recall whether it was pain medication. RN L reported they could not say why a pain assessment was not performed on P2 following the administration of pain medication or prior to P2’s discharge. RN L acknowledged P2 should have had a follow-up pain assessment completed. 7. During an interview on 3/31/26 at 1:00 PM, ED Director reported the hospital’s expectation was for nurses to complete a pain assessment after pain medications are administered, and prior to a patient’s discharge. ED Director acknowledged the ED staff failed to reassess P2’s pain after receiving pain medication and prior to discharge. 8. During an interview on 3/30/26 at 1:30 PM, RN H recalled contacting P2’s daughter by phone, and they scheduled P2 for surgery due to a kidney stone. RN H reported the provider wanted P2 scheduled for a laser lithotripsy (procedure to break up kidney stones) on 2/23/26, but the family was not able to bring P2 until 2/24/26. 9. During an interview on 3/30/26 at 1:00 PM, Anesthesia Provider D recalled P2 came for the scheduled surgery with their daughter. Anesthesia D reviewed with P2 and their daughter that P2 had a kidney stone, and both P2 and their daughter agreed. Anesthesia D reported after further review, Anesthesia and the surgery staff found P2 did not actually have a CT completed, and the referral form for the scheduled surgery had P2’s patient information present, but was attached to another patient’s CT results. Anesthesia D acknowledged P2’s surgery was canceled because P2 did not have a CT completed on 2/21/26 to support the diagnosis of a kidney stone. Anesthesia D reported obtaining an electrocardiogram (EKG) on P2 due to P2’s medical history, but explained P2’s surgery was not canceled due to an abnormal EKG. Anesthesia D reported P2’s EKG revealed NSR. Anesthesia D recalled starting an IV on P2, but did not recall if any other staff attempted to insert an IV prior to Anesthesia’s attempt. 10. During an interview on 3/31/26 at 10:00 AM, Surgery Director recalled P2. Surgery Director acknowledged P2’s surgery was canceled due to P2’s patient information being placed on a referral form with another patient’s CT results. Surgery Director acknowledged staff failed to document P2’s surgery being canceled due to the CT error, and P2 not having a CT to support a diagnosis of kidney stones. Surgery Director could not speak to whether P2 had a nursing assessment completed or an IV started and acknowledged the lack of staff documentation. 11. During an interview on 3/31/26 at 1:30 PM, Chief Nursing Officer (CNO) acknowledged P2’s EKG results were normal according to Anesthesia D. CNO acknowledged P2’s surgery was canceled because there was no CT or radiology imaging to support P2’s diagnosis of kidney stones. CNO also acknowledged nursing staff’s failures to complete any nursing assessments and/or documentation for P2 to support nursing staff’s assessment of P2’s care needs, health status, and/or response to interventions. 12. During an interview on 3/31/26 at 9:00 AM, Director of Quality/Process Excellence reported the hospital did not have a policy for patient pain assessment.”