Norton Clark Hospital

“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: 50584 Based on document review and interview nursing services failed to maintain documentation of pain rating prior to pain relief intervention and/or pain reevaluation within one hour after pain relief intervention was administered in 3 of 10 MRs (Medical Records) reviewed. (P1, P2, P10) 1.Facility policy titled Pain Management, Policy Number 4196.9, Last Review Date: 12/19/2025, under Policy: All clinical disciplines providing direct patient care are educated in the process for determining the patient’s subjective pain level using a pain scale, interventions to manage pain, barriers to reporting pain and use of analgesics. Important Clinical Information: 1. During the initial assessment by the registered nurse, the intensity of pain is rated and recorded using a scale as appropriate and patient goal is discussed and documented; subsequent ratings using the scale are recorded at reassessment. 5. Subsequent reassessment is conducted by all members of the clinical care team as appropriate. Following administration of a PRN analgesic, reassess the patient’s pain using the appropriate standard scale within 60 minutes to evaluate effectiveness. Documentation: Documentation by each discipline is entered into the patient medical record and includes, but is not limited to, an evaluation of pain level as reported by the patient, interventions and education provided. 1. Review of P1 MR indicated: a. On 6/24/26 P1 was admitted to F1 (acute care hospital) with diagnosis of Altered Mental Status and Pyelonephritis. b. On 6/25/26 at 2127 hours P1 received Morphine for pain. MR lacked documentation of pain scale rating at the time of administration and pain level reassessment within one hour of administration of intervention to assess effectiveness. c. On 6/26/26 at 2155 hours P1 received oxycodone for pain rating of 8 (severe pain). MR lacked documentation of pain level reassessment within one hour of administration of intervention to assess effectiveness. d. On 6/27/26 at 0259 hours P1 received oxycodone for pain rating of 8 (severe pain). MR lacked documentation of pain level reassessment within one hour of administration of intervention to assess effectiveness. h. On 6/27/26 at 2000 hours P1 received oxycodone for pain. MR lacked documentation of pain scale rating at the time of administration. j. On 6/30/26 P1 was discharged home in stable condition. 2. Review of P2 MR indicated: a. P2 was admitted to F1 on 6/23/26 with diagnosis of Pancreatitis. b. On 6/23/26 at 0043 hours P2 received Dilaudid for pain. MR lacked documentation of pain scale rating at the time of administration and pain level reassessment within one hour of administration of intervention to assess effectiveness. c. On 6/26/26 at 2357 hours P2 received Dilaudid for pain rating of 9 (severe pain). MR lacked documentation of pain level reassessment within one hour of administration of intervention to assess effectiveness. d. On 6/27/26 at 2357 hours P2 received Dilaudid for pain rating of 10 (severe pain). MR lacked documentation of pain level reassessment within one hour of administration of intervention to assess effectiveness. e. On 6/27/26 P2 was discharged home in stable condition. 3. Review of P10 MR indicated: a. P10 was admitted to F1 with diagnosis of Pneumonia. b. On 3/2/26 at 2046 hours P10 was given Dilaudid for pain. MR lacked documentation of pain scale rating at the time of administration and pain level reassessment within one hour of administration of intervention to assess effectiveness. c. On 3/3/26 at 0247 hours P10 was given Dilaudid for pain rating of 0 (no pain). MR lacked documentation of pain level reassessment within one hour of administration of intervention to assess effectiveness. d. On 3/3/26 at 0632 hours P10 was given Dilaudid for pain rating of 0 (no pain). MR lacked documentation of pain level reassessment within one hour of administration of intervention to assess effectiveness. e. On 3/3/26 P10 was discharged to a Skilled Nursing Facility with hospice in terminal condition. 4. In interview on 7/14/26 at 1030 hours with A7, he/she confirmed that a patient’s pain level should be reassessed within 60 minutes following administration of pain medication and that P1, P2, and P10’s MR lacked documentation of pain rating and/or pain reassessment within 60 minutes after pain intervention was given.”

“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: 50584 Based on document review and interview, nursing services failed to activate the bed alarm prior to a fall for 2 of 10 high fall risk patients MRs (Medical Records) reviewed (P4, P5). Findings include: 1. Facility policy titled Fall Risk Assessment and Prevention, Policy Number: 4172.8, Policy Approval Date: 6/18/2025, under Purpose: To reduce and prevent falls within the adult hospital setting. Under Policy: All patients presenting to the hospital will be screened for falls risk by a nurse upon admission. Patients will be rescreened once a shift, when there is a change in the patients’ status, following a fall. Interventions for Fall Prevention for all patients: Educate patient and family on falls prevention: (Use of call light for ambulation/toileting, call light within reach, bed in low position, provide non-skid socks, use of bed alarm etc.) If the score deems the patient at risk for falls (Moderate Fall Risk Score 6-13, High Fall Risk >13). If total score deems patient a High Risk Fall >13, place patient on bed alarm. 2. Review of P4 MR indicated P4 was a high-risk for falls with a score of 17. a. On 7/2/25 nurse note indicated P4 was observed laying on the floor in the bathroom by staff member, patient was assessed for injuries, pain, and stated “I lowered myself to the floor because I needed to use the bathroom and was unable to locate the call light”. P4 pulled him/herself along the floor until he/she was able to reach the toilet. P4’s vitals were assessed and he/she was assessed for injury. P4 stated I did not hurt myself, I did not fall”. b. Nursing flowsheets lacked documentation of bed alarm turned at the time of patient fall on 7/2/25 at 0315 hours. 3. Review of P5 MR indicated P5 was a high-risk for falls with a score of 14. a. On 8/21/25 at 0129 hours nurse notes indicated the sitter was standing near P5’s doorway stating P5 fell. N3 walked into P5’s room, P5 was laying on the floor by the trash can. b. MR lacked documentation the bed alarm was activated on 8/20/25 at 2020 hours and 2135 hours prior to P5’s fall on 8/21/25. 4. In interview on 9/16/25 at approximately 1330 hours with A4 (Nurse Manager), he/she confirmed patients P4 and P5 were a high risk for falls, and P4 and P5’s MRs lacked documentation of bed alarms activated per policy prior to the patients’ falls.”

“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: 49128 Based on document review and interview, nursing services failed to evaluate care for patients by not ensuring reassessments were completed per policy by a nurse on 4 of 10 medical records (MR) reviewed (Patient [P]4, P5, P6, and P10); failed to complete a Morse Fall Risk Assessment at the beginning of each shift on 1 of 10 MRs reviewed (P6); failed to assess vital signs per provider order on 2 of 10 MR reviewed (P1 and P5); failed to verify nasogastric (NG) tube placement and provide manual water flush every 4 hours with documentation for 1 of 10 MRs reviewed (P5); failed to follow the Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA-Ar) Protocol for 1 of 10 MR reviewed (P5). Findings include: 1. Facility policy titled, Patient Assessment and Reassessment for All Departments, PolicyStat ID: 13198797, last revised 7/2/23, indicated on page 2 of 18, under II. ASSESSMENT OF PHYSICAL, PSYCHOSOCIAL AND CULTURAL STATUS OF PATIENT, A. Medical Staff Assessment, Documentation: Physician orders, consults and progress notes serve as mechanisms for the medical staff to communicate the patient’s care, treatment needs and response to treatment, patient instructions, discharge plans and continued care requirements as appropriate. On page 15 of 18, under REASSESSMENT OF PATIENTS, 1. Med/Surgical, Oncology, Orthopedics, Pediatric, and OB/GYN Patient Care Units; All patients admitted to the Medical/Surgical, Pediatric, Oncology Orthopedics and/or OB/GYN patient care units will be reassessed every nursing shift by the RN/LPN. The RN Documents in the EMR the status of each patient with each tour of duty. RN will reassess and document in EMR any additional information based on patient Status/procedures. 2. Facility policy titled, Patient Fall Prevention and Post-Fall Management (Dr. Tumble), PolicyStat ID: 13315768, last revised 5/25/23, indicated on page 2 of 6, under IV. Fall Risk Assessment for Inpatients, Observation and Surgical patients: The Nurse will assess the patient using the Morse Fall Risk Assessment for their risk to fall: at the beginning of each shift. 3. Facility Policy titled, NG/OG/Dobhoff Tube Placement, PolicyStat ID: 12325432, last revised 1/19/23, indicated on page 2 of 3, under MAINTENANCE AND TUBE CARE: verify NG/OG/DHT tube placement every 4 hours and prior to each use. Observe visual characteristics of aspirate from tube. Check the marking on tube made at time of insertion. Manual flush with 30 cc’s of sterile water, unless contraindicated by physician. Under DOCUMENTATION: document placement verification and manual water flush every 4 hours by completing task list and documenting on flow sheet. Document any feeding, water flushes and medications that are given volumes on I&O flow sheet in EMR. 4. Facility Policy titled, Alcohol Withdrawal CIWA-Ar Protocol, PolicyStat ID: 12903386, last revised 1/10/20, indicated on page 1 of 4, under 1. Inclusion criteria; protocol requires a physician order; under 4. CIWA-Ar withdrawal assessment, initial; RN to calculate initial CIWA-Ar score and administer medication for a score > 10 per protocol. On page 2 of 4, under 6. CIWA-Ar withdrawal assessment, recurrent; 1. if initial score <10, re-assess the CIWA-Ar score every 12 hours, or sooner if symptoms arise; 2. If oral benzodiazepine is administered, reassess the CIWA-Ar score in 4 hours for a previous score of 10-15, or in 2 hours for a previous score of 16-20, or in 1 hour for a previous score of 21 or more; 3. If intravenous (IV) benzodiazepine is administered, reassess the CIWA-AR score in 2 hours for a previous score of 10-15, or in 1 hour for a previous score of 10-16, or in 15 minutes for a previous score of 21 or more; under 7. Monitoring: 1. Document the CIWA-Ar score with each dose of benzodiazepine and at least every 12 hours. 5. MR of P1 indicated the following: a. Facility admission 4/1/24 at approximately 10:20 pm through 4/5/24 at approximately 1:45 pm for Cholecystitis. b. MR Provider order indicated vital signs every 4 hours on admission. MR lacked discontinuation of vital signs order. MR lacked documented vital signs every 4 hours during facility stay, included but not limited to; 4/4/24 at 4:00 am, 4/4/24 at 12:00 pm, 4/5/24 at 12:00 am. 6. MR of P4 indicated the following: a. MR indicated facility admission 5/26/24 at approximately 6:34 pm through 5/31/24 at approximately 12:29 pm for Urinary Tract Infection. b. MR lacked head to toe shift assessment completed on 5/28/24 morning shift, and 5/30/24 morning shift. 7. MR of P5 indicated the following: a. Facility admission 6/13/24 at approximately 11:24 pm through 6/20/24 at approximately 2:14 pm for Cirrhosis with Alcoholism. b. MR lacked nurse head to toe assessment, including lower extremity edema, completed on 6/14/24 evening shift and 6/18/24 morning shift. c. MR Provider order indicated vital signs every 4 hours on admission. MR lacked discontinuation of vital sign order. MR lacked documented vital signs every 4 hours during hospital stay, included but not limited to; 6/14/24 at 12:00 pm; 6/15/24 at 12:00 am, 6/15/24 at 4:00 am, 6/15/24 at 12:00 pm, and 6/16/24 at 12:00 am. d. MR indicated a nasogastric (NG) tube was placed 6/17/24 at 12:24 pm, and discontinued 6/18/24 at 9:26 am. MR lacked documented every 4 hour NG tube placement verification and manual water flush from 6/17/24 at 12:24 pm to 6/18/24 at 9:26 am. e. MR lacked documented CIWA-Ar reassessments 2 hours after IV benzodiazepine administered, included, but not limited to: 6/15/24 at 10:15 am, 6/15/24 at 3:33 pm, and 6/16/24 at 6:23 pm. f. MR lacked documented CIWA-Ar reassessment 1 hour after IV benzodiazepine administered 6/16/24 at 11:47 pm. g. MR lacked documented CIWA-Ar reassessments 4 hours after oral benzodiazepine administered included but not limited to: 6/15/24 at 3:12 am, 6/18/14 at 1:50 am, 6/18/24 at 2:57 pm, and 6/19/24 at 2:36 pm. 8. MR of P6 indicated the following: a. Facility admission 7/5/24 at approximately 9:02 pm through current on day of survey 7/10/24 for Peripheral Artery Disease. b. MR lacked nurse head to toe assessment completed 7/6/24 morning shift. c. MR lacked Morse Fall Risk Assessment completed on 7/6/24 morning shift, and 7/9/24 morning shift. 9. MR of P10 indicated the following: a. Facility admission 7/6/24 at approximately 10:48 pm through current on day of survey 7/10/24 for Chronic Obstructive Pulmonary Disease. b. MR lacked nurse head to toe assessment completed on 7/7/24 evening shift. 10. In interview, on 7/10/24 at approximately 12:00 am, A6 (Medical Surgical Unit Manager [MSM]) verified the shift assessment in the Patient Assessment and Reassessment for All Departments was a head to toe assessment. Patients on the Medical Surgical Unit received a full head to toe assessment each shift. A6 verified the MR of P1, P2, P3, P4 and P5 were as reviewed. The vital signs were not assessed per provider order on P1 and P5. Shift assessments, including head to toe assessment, were not completed per policy on P4 and P5. NG tube placement verification and manual water flushes were not documented every 4 hours per policy on P5. 11. In interview, on 7/10/24 at approximately 1:45 pm, A2 (Quality Director) verified the medical records were as reviewed. Shift assessments, including head to toe assessments, were not completed per policy for P6 and P10. Morse Fall Risk Assessment was not documented every shift per policy for P6. In interview, on 7/24/24 at approximately 9:10 am, A2 (Quality Director) verified the medical record was as reviewed, the CIWA-Ar assessments were not always completed per policy.”

“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: 49128 Based on document review, observation, and interview nursing services failed to evaluate patient care by applying a known allergen to a patient during a procedure on 1 of 10 patient medical records (MR) reviewed (P2); and by not documenting all hourly rounding from 0700 hours to 2200 hours, and every 2 hours from 2200 hours to 0600 hours per policy on 7 of 10 patient’s MRs reviewed (P2, P5, P6, P7, P8, P9 and P10). Findings include: 1. Facility policy titled, Hourly Rounding, PolicyStat ID: 12250635, last revised 8/22/22, indicated nursing staff will perform formal hourly rounding for each patient from 0700-2200. From 2200-0600, nursing staff will round every 2 hours; Hourly Rounding: address the 4 P’s - Pain, Potty, Position, and Possessions; document rounding in the EMR or patient Rounding Log if on downtime. 2. P2 MR indiccated the following: a. Patient allergy listed as iodine. b. Straight catheterization (cath) completed and documented on 3/1/24 at 1421 hours by N3 (Emergency Room Technician [ERT]), and indicated an 8 french straight cath kit was used. c. MR lacked documentation of staff excluding iodine packet from cath procedure. d. MR lacked documentation of hourly rounding completed every hour from 0700 hours to 2200 hours and every 2 hours from 2200 hours to 0600 hours including but not limited to: 3/3/24 at 0300 hours through 3/3/24 at 0700 hours. 3. MR for P5 lacked documentation of hourly rounding completed every hour from 0700 hours to 2200 hours and every 2 hours from 2200 hours to 0600 hours including but not limited to: 1/25/24 at 1500 hours through 1/25/24 at 2000 hours. 4. MR for P6 lacked documentation of hourly rounding completed every hour from 0700 hours to 2200 hours and every 2 hours from 2200 hours to 0600 hours including but not limited to: 4/16/24 at 2100 hours through 4/17/24 at 0700 hours. 5. MR for P7 lacked documentation of hourly rounding completed every hour from 0700 hours to 2200 hours and every 2 hours from 2200 hours to 0600 hours including but not limited to: 4/16/24 at 2100 hours through 4/17/24 at 0700 hours. 6. MR for P8 lacked documentation of hourly rounding completed every hour from 0700 hours to 2200 hours and every 2 hours from 2200 hours to 0600 hours including but not limited to: 4/15/24 at 1000 hours through 4/15/24 at 2000 hours. 7. MR for P9 lacked documentation of hourly rounding completed every hour from 0700 hours to 2200 hours and every 2 hours from 2200 hours to 0600 hours including but not limited to: 4/16/24 at 1949 hours through 4/17/24 at 0700 hours. 8. MR for P10 lacked documentation of hourly rounding completed every hour from 0700 hours to 2200 hours and every 2 hours from 2200 hours to 0600 hours including but not limited to: 4/13/24 at 1900 hour through 4/13/24 at 2300 hours. 9. In interview, on 4/17/24 at approximately 1430 hours, A1 (Quality Director) and A6 (Manager Medical Surgical Unit) verified the MRs as detailed above. 4. On 4/17/24 at approximately 1438 hours, this writer observed the in/out cath kits in the emergency department. The 8 french in/out cath kit list iodine as a supply within the kit.”