Deaconess Hospital Inc.

“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 document patient refusal of a medication on the MAR (Medication Administration Record), failed to follow physician’s order for medication administration, failed to document a change in patient’s condition and notification of the physician in 1 of 10 MRs (Medical Records) reviewed. (P1) Findings include: 1. Facility policy titled Medication Administration, Policy & Procedure No. 40-31S, Last Review Date: 4/1/2025, page 1, under II. Purpose: This document defines and establishes the policies and the procedures to be followed regarding medication administration to ensure the right patient will receive the right medication for the right reason in the right dose by the right route at the right time to ensure the right response and the medication administration will be documented. Page 8, under E. Administration/Monitoring, 8. Administration Process: b. Check patient’s chart and Medication Administration Record for: m. Always remember and follow the “6 Rights” 1) Right dose 2) Right drug 3) Right route 4) Right time 5) Right patient 6) Right documentation. p. Scan each medication barcode, including home medications prior to administration and removal from packaging to assure medication to be administered is consistent with prescriber order. r. If medication is not given, document reason on the MAR (i.e. patient refused, criteria not met, etc.) Omitted documentation should be entered as soon as possible. 2. Facility policy titled Patient Assessment/Reassessment Plan, Policy and Procedure No. 40-29 S, last Review Date: 01/14/2026, page 1, under II. Purpose: The assessment process will be a continuous, collaborative, effort with all of the health care members functioning as a team. Patient assessment is an interdisciplinary function. The importance of input by various members of the health care team is valued and supported by the organization. Effective communication among all members of the health care team will be ensured and the patient will be provided with the best plan and treatment possible. Page 2, under VI. Procedure: V. Responsibility: It is the responsibility of all department managers and directors of the below departments to ensure that all their staff are compliant with all aspects of this policy. It is the responsibility of staff members of all departments listed below to comply with all aspects of this policy. Page 6, 3. Assessment/Reassessment Processes, a. A Patient Assessment is completed for all admitted in-house patients and to record patient assessment, evaluate patient progress, and document the individualized patient plan of care. i. Reassessments will be completed whenever there is a significant change in the patient’s status or condition. ii. Documentation of reassessments completed after the initial assessment include findings that have changed and a statement that assessment is unchanged except where noted. iv. By the end of the shift, all assessments pertinent to the individual patient will be documented. 3. Review of P1 MR indicated: a. On 4/30/26 at 1237 hours MiraLAX 238 grams was marked given on the MAR (Medication Administration Record). Administration Instructions indicated to mix one half of 238-gram dose with 32 ounces of electrolyte beverage. Administer over 1 to 2 hours. If this does not generate any bowel movement, repeat with the second half of the medication and another 32 ounces of electrolyte beverage. MR lacked documentation that half of the 238 grams of MiraLAX was mixed as ordered. MR lacked documentation P1 refused MiraLAX. b. P1 MR lacked documentation in the nursing flowsheets of P1’s complaint of numbness and tingling prior to the Rapid Response on 4/30/26 and lacked documentation in the nursing flowsheets of N1 (LPN [Licensed Practical Nurse]) notifying the physician of the numbness and tingling. 4. In interview on 6/9/26 at 1200 hours with N4 (Nursing Manager), he/she confirmed N1 did mix the entire bottle of MiraLAX with water and stirred it with a gloved hand using a short spoon, the MiraLAX was then scanned and charted it was given prior to the medication being administered. P1 refused to take the medication and N4 confirmed that N1 did not document P1’s refusal of the medication on the MAR. N4 also confirmed that N1 did not read the instructions on mixing the MiraLAX and was supposed to only mix half of the medication and if no results the other half of the MiraLAX was to be administered to P1. N4 also indicated that there is a section on the nursing flowsheets to document contact with the physician and confirmed that there was not documentation of P1’s complaint of numbness and tingling or that the physician was notified of P1’s change in condition prior to the rapid response. 5. In interview on 6/9/26 at 1215 hours with N2 (Registered Nurse), he/she confirmed that he/she was the charge nurse on 4/30/26, P1’s family member came out into the hall and reported P1 was not feeling right with complaints of numbness and tingling. N1 then contacted the physician and was told to just monitor P1. N2 indicated 10 minutes later P1 became less responsive and a rapid response was called. 6. In phone interview on 6/9/26 at 1810 hours with N1 (LPN [Licensed Practical Nurse]), he/she confirmed he/she mixed the entire bottle of MiraLAX with a spoon wearing gloves and handed the mix to P1. N1 confirmed P1 was complaining of numbness and tingling on his/her right side. N1 confirmed he/she contacted the physician regarding P1’s symptoms prior to the rapid response via secure chat in the EMR. N1 also confirmed he/she did not document on the MAR that P1 did not take the MiraLAX, did not document P1’s complaint of numbness and tingling or that he/she contacted the physician in the nursing flowsheets.”

“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 place orders for wound care, review plan of care, notify physician of wound care recommendations to obtain orders, reassess wound and perform wound care three times daily and as needed and document nutritional supplement intake for 1 of 10 MRs (Medical Records) reviewed (P5); failed to document oral intake and nutritional supplement intake for 1 of 10 MRs reviewed (P7). Findings include: 1. Facility policy titled Medication Administration, Policy & Procedure No. 40-31, Last Review Date: 4/1/2025, Page 3, C. Ordering: 1. A legible order written by a provider with prescriptive authority is required for the administration of any medication. 2. Facility policy titled Patient Assessment/Reassessment Plan, Policy and Procedure No. 40-29S, Last Review Date: 1/14/2026, Page 1, II. Purpose: To ensure that all patients are appropriately assessed (including initial screening and reassessment) by qualified individuals within the organizational setting. Page 2. VI. Procedure: A. Assessment Framework: The assessment framework will be structured around two components: initial screening and assessment/reassessment of all patients as appropriate to the clinical discipline and the individual patient condition. The assessment/reassessment process is a continuous one, evolving with the patient’s changing condition and response to care. VI. Procedure: B: 1. All departments will assume the responsibility to review those aspects of the patient’s medical record that directly relate to each department’s scope of care and clinical involvement with the patient. 2. Information generated via a patient’s assessment will be integrated with other disciplines to identify and prioritize the patient’s needs for care and treatment. a. The various disciplines will share and provide information about their portion of the patient assessment relevant to their scope of care. 3. Review of Mosby’s Nursing Standard of Care under Activity and Daily Care, 6. Intake and Output will be monitored and recorded a minimum of every 8 hours or prn unless otherwise ordered. 4. Review of Nutritional Supplements Epic Flowsheet Row indicated under Nutrition: Documentation requirement for Nutritional Supplement name and % intake of Supplements. 5. Review of P5 MR indicated: a. On 10/3/25 at 2051 hours P5 arrived at F1 (acute care hospital) and was admitted with diagnosis of SMA (Superior mesenteric artery) stenosis, abdominal pain. b. On 10/9/25 at 1115 hours Wound Ostomy Eval and Treat Note indicated Bilateral buttocks: area of red slow to blanch discoloration and small shear/areas of peeling epithelium. Recommendations: Bilateral buttocks: 1. Cleanse area with soap and water. Use remedy cleanser in green and white bottle. Pat dry.2. Apply Flanders Cream tid (three times daily) and PRN (as needed) with any episodes of incontinence/cleansing. Indicated orders were placed. Discussed plan of care with primary RN (Registered Nurse). MR lacked documentation of wound care orders placed, wound assessment, documentation of wound care and application of Flanders Cream completed per recommendations from 10/9/25 through 10/14/25. c. On 10/10/25 at 1054 hours Clinical Dietitian note indicated Recommendations: Novasource Renal bid (two times daily), help with meals and cues, needed assistance ordering meals. d. MR lacked documentation of Novasource supplement intake percentage/milliliters drank two times daily from 10/10/25 through 10/14/25 with exception on 10/11/25 at 1419 hours Boost intake 50% and on 10/12/25 at 1434 hours Boost intake 0%. 6. Review of P7 MR indicated: a. P7 was admitted to F1 on 2/26/26 with diagnosis of wound dehiscence, status post repair of ruptured AAA (Abdominal Aortic Aneurysm) with retroperitoneal hematoma, and abdominal pain. b. On 3/3/25 at 1243 hours Clinical Dietician Note indicated P7 weight was currently down 40 pounds from his/her admission in January (16% body weight) which was significant. Few PO (oral) intakes documented since admission. P5 was at a high nutrition risk. Boost VHC (very high calorie) supplements ordered tid (three times daily). c. On 3/5/25 Clinical Dietician Note indicated P7 was on a General Diet order for Boost VHC (vanilla) with all meals. There were no PO intakes recorded since 3/3/25. d. MR lacked documentation in nursing flowsheets of Boost VHC supplement intake percentage or milliliters three times daily from 3/3/26 through 3/5/26 at time of discharge. e. MR lacked documentation of P7 oral intake on 2/27/26, 3/1/26, 3/2/26, 3/4/26 and 3/5/26. 7. In interview on 4/27/26 at 1100 hours with A1 (Regulatory and Accreditation Officer), he/she confirmed the facility follows Mosby’s Nursing Standard of Care and Nutrition Assessment/Feeding assist. 8. In interview on 4/27/26 at 1130 hours with A3 (Clinical Informatics Specialist), A3 confirmed he/she trains the PCTs and documentation of nutritional supplements is included in the orientation training. A3 confirmed P5 MR lacked documentation he/she received the nutritional supplement Novasource two times daily on the nursing flowsheet under nutrition from 10/10/25 through 10/14/25 with exception on 10/11/25 at 1419 hours and 10/12/25 at 1434 hours. A3 confirmed P7 was ordered Boost VHC three times daily and MR lacked documentation P7 received Boost VHC three times daily from 3/3/26 through 3/5/26. A3 also confirmed MR lacked documentation of P7 oral intake on 2/27/26, 3/1/26, 3/2/26, 3/4/26, and 3/5/26. 9. In interview on 4/27/26 at 1300 hours with A5 (WOCN, Wound, Ostomy, and Continence Nurse), he/she confirmed the wound care evaluation completed on 10/9/26 for P5 indicated recommendations to cleanse the wound to bilateral buttocks with soap and water, remedy cleanser in green and white bottle, pat dry and apply Flanders Cream tid and prn. A5 also confirmed orders were not placed, wound was not assessed after evaluation, and wound care was not completed from 10/9/26 through 10/14/26 on P5. A5 confirmed Flanders cream comes from the pharmacy and an order has to be placed. 10. In interview on 4/27/26 at 1410 hours with A8 (RN Charge Nurse), he/she indicated when a referral is made for wound care, the WOCN evaluates the patient, makes recommendations for wound care, the primary nurse then reads the evaluation note, if orders are not placed by WOCN, he/she reaches out to the physician to obtain orders. If the medication prescribed comes from the pharmacy it will appear on the MAR, the medication will be marked on the MAR each time it is applied, and the wound care documented in the nursing flowsheets. A8 also indicated if a nutritional supplement is ordered, the amount the patient drank and the name of the supplement would be recorded in the nursing flowsheets under nutrition in the EMR (Electronic Medical Record).”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 50584 Based on document review and interview, nursing services failed to activate the bed alarm for high fall risk patients resulting in patients falls for 3 of 10 MRs (Medical Records) reviewed. (P3, P8, P10) The cumulative effect of this systemic problem resulted in the hospitals inability to promote Nursing Services in a safe setting.”

“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 for high fall risk patients prior to the patient falls in 3 of 10 MRs (Medical Records) reviewed. (P3, P8, P10) Findings include: 1. Facility policy titled Fall Prevention And Management, Policy and Procedure No. 40-58, Last Review Date: 01/20/2026, under II. Purpose: To provide fall prevention guidelines for F1 (acute care hospital) with the aim of promoting a safe environment, thereby reducing the potential for injuries to patients, visitors and staff. IV. Policy: This policy was developed to identify and communicate which patients are at a risk for fall, identify interventions for patients based on fall risk score and individual needs, promote consistent and clear documentation and enhance desirable outcomes. E. All employees responsibilities: 1. Implement fall risk interventions identified by the patient’s individual plan of care. VI. Procedure: 3. High Fall Risk Interventions: Additional interventions for high fall risk patients. a. Yellow fall risk armband. b. Yellow, nonskid footwear with ambulation and transfers. c. Falls-risk sign set outside room. d. Gait belt with any ambulation or transfer. e. Stay within arm’s reach and attentive during toileting. 4. Risk Factor-Based Interventions. f. Alarms for patients who may forget or choose not to call out for assistance. i. Bed alarm set to Zone 2 while patient in bed and plugged into call system. 2. Review of P3 MR indicated: a. On 2/19/26 P3 was admitted to F1 (Acute care hospital) with complaints of altered mental status. Fall risk score upon admission was 75, indicating P3 was a high fall risk. b. On 2/22/26 at 2006 hours P3 had a fall risk score of 55, indicating P3 was a high risk for falls requiring the bed alarm to be activated. c. On 2/23/26 at 0057 hours nurse note indicated N5 (PCT [Patient Care Technician]) stated that he/she hit the bed alarm button to activate alarm, but the bed alarm apparently did not turn on prior to leaving P3 room. P3 yelled out for help, N5 went to the room, and found P3 near the door on his/her left side. P3 stated that he/she hurt his/her left hip. d. Focus Entry note indicated P3 was a high risk for falls, policy and procedure was not followed, bed alarm was off at the time of the patients fall, and fall resulted in a major injury (left femur fracture) to P3. 3. Review of P8 MR indicated: a. On 2/20/26 P8 was admitted to F1 with complaints of generalized weakness and history of Parkinson’s Disease. b. Fall risk score upon admission was 100, indicating P8 was a high risk for falls requiring the bed alarm to be activated. c. On 2/23/26 at 1700 hours P8 had a fall risk score of 100 indicating P8 was a high risk for falls requiring the bed alarm to be activated. d. On 2/23/26 at 1825 hours Nurse’s note indicated N7 (RN [Registered Nurse]) walked into P8’s room and found him/her sitting on the floor in front of the bed. P8 was assisted back to bed and stated he/she hit his/her head. A small abrasion with erythema was noted to the back of P8’s head. e. Focus Entry note indicated P8 was a high risk for falls, policy and procedure was not followed, bed alarm was off at the time of the patients fall due to N6 (RN) turning off alarm and not resetting alarm prior to exiting P8’s room. The fall resulted in minor injury of redness, bruising and abrasion to P8. 4. Review of P10 MR indicated: a. On 2/1/26 P10 was admitted to F1 with complaint of agitation and known dementia. b. Fall risk score upon admission was 95 indicating P10 was a high risk for falls requiring the bed alarm to be activated. c. On 2/10/26 at 1359 hours P10 had a fall risk score of 85 indicating P10 was a high risk for falls requiring the bed alarm to be activated. d. On 2/10/26 at 1538 hours P10 had an unwitnessed fall from bed. N1 (RN) found P10 crouching on the floor in his/her room on the opposite side of the bed of the fall mat. e. Focus Entry note indicated P10 was a high risk for falls, policy and procedures were not followed, bed alarm was off at the time of the patient’s fall and P10 did not receive an injury from the fall. 5. In interview on 3/16/26 at 1100 hours with A2 (Accreditation and Regulatory Officer), he/she confirmed P3, P8 and P10 were all high risk for fall patients and the bed alarms were not activated per policy prior to their falls.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 50584 Based on document review and interview the facility failed to make arrangements to discharge patient to appropriate facility to meet patient needs in 1 of 10 MRs (Medical Records) reviewed. (P3) The cumulative effect of this deficient practice prevented the facility from providing a safe discharge.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 50584 Based on document review and interview, the facility failed to make arrangements to discharge patient to appropriate facility to meet patient needs in 1 of 10 MRs (Medical Records) reviewed. (P3) Findings include: 1. Facility policy titled Patient Discharge Planning and Discharge Procedure, Policy and Procedure No. 40-02 S, under II. Purpose: To identify a coordinated discharge planning process. To identify the appropriate discharge destination that meets the needs of the patient. To provide a smooth and safe transition from the hospital to the discharge destination. 2. Review of P3 MR indicated: a. Patient admitted to the facility on 3/3/25 at 0830 hours with diagnosis of Nausea and Vomiting, Diarrhea and Debility. Patient was wheelchair bound. b. On 3/3/25 at 1432 hours Case Management Note indicated RD1 (Homeless Shelter Regional Director) from F1 (Homeless Shelter) phoned Case Management and stated P3 is not able to return to F1 due to his/her inability to perform ADLs (Activities of Daily Living) on his/her own and requested P3 get some kind of higher level of care/rehabilitation. c. On 3/4/25 at 0910 hours Occupational Therapy Assessment Note indicated P3 reported he/she does not feel strong enough to be able to perform all of his/her ADLs independently at this time and does not have anyone to help him/her. Assessment: decreased ADL status, decreased UE (upper extremity)strength, decreased activity tolerance, decreased self-care transfer, decreased high-level ADLs, decreased fine motor control. Recommendations: Patient would benefit from continued therapy at facility level. d. On 3/14/25 at 1542 hours Provider Progress Note indicated P3 remained deconditioned/debilitated and working toward rehabilitation. Discharge delayed by difficulties securing placement for skilled care. e. On 3/17/25 at 1149 hours Occupational Therapy Treatment Note indicated under Recommendations: Patient would benefit from continued therapy at a facility level, does not have assist needed for safe mobility/transfer and unable to complete basic hygiene. f. On 3/18/25 at 1054 hours Provider Progress Note indicated P3 remains deconditioned and debilitated. Insurance requested peer to peer, provider called and left a message with no return call. g. On 3/19/25 at 0848 hours Case Management Note indicated P3 aware he/she would be discharged back to the shelter. At 1020 hours N4 spoke with an employee at F1 and questioned if wheelchair was at F1 and if they would have it ready for P3. At 1042 hours F2 van to transport P3 at 1545 hours to F1. h. On 3/19/25 at 1127 hours Discharge Summary indicated P3 was medically stable and would be discharged back to the community. Neurological examination indicated Diffusely weak lower extremities worse than upper. 3. In phone interview on 4/1/25 at approximately 1314 hours with RD1 (Homeless Shelter Regional Director), he/she indicated on 3/3/25 he/she called F2 and spoke with Case Management and told them P3 would not be able to return to F1 due to his/her inability to perform his/her ADLs (Activities of Daily Living) on his/her own. RD1 requested P3 be discharged to a higher level of care or rehabilitation facility. RD1 indicated F1 had P3’s wheelchair and belongings and would keep them until P3 was discharged. RD1 also indicated F2 called F1 on 3/19/25 and spoke to an employee at the front desk asking if P3’s wheelchair was ready, and employee told F2 it was. RD1 was under the impression F2 was just coming to pick up P3’s wheelchair and belongings since he/she had called F1 upon admission indicating F1 could not take P3 back. N2 from F2 showed up later in the afternoon with P3, requested P3’s wheelchair and dropped P3 off at F1. RD1 told N4 that he/she could not leave P3 at F1 due to the fact they were not equipped to care for P3, N4 would not answer any questions and left P3 at F1. RD1 then called transportation for P3 and sent him to F3 (Acute Care Hospital). RD1 indicated since that time F3 came to pick up P3’s belongings and is unsure where P3 was discharged to. 4. In interview on 4/1/25 at approximately 1500 hours with A8 (RN Manager of Case Management), he/she confirmed when P3 came to the ER (Emergency Room) RD1 phoned Case Management at F2 and informed them P3 was not able to return to F1 due to his/her inability to perform ADLs on his own and requested that P3 get a higher level of care. 5. In interview on 4/1/25 at approximately 1330 hours with N2, he/she indicated P3 was alert and oriented and in a wheelchair. N2 arrived at F1, wheeled P3 in, and requested P3’s wheelchair. Facility told N2 they could not take P3. Facility tried to ask N2 a lot of questions and he/she responded with I don’t know. Facility found P3’s wheelchair, N2 phoned F2’s dispatch center and told them F1 could not take P3, Case Management was then paged and N2 was told to leave P3 at F1.”

“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 perform vital signs per policy for 5 of 10 medical records reviewed. (P#3, P#5, P#6, P#7, and P#10). Findings include: 1. Facility policy titled, Assessment and Documentation Of The Emergency Room Patient, policy number ED8, last revised 02/06/2023, indicated ESI ( Emergency Severity Index) Level 2: vital signs will be documented upon admission then every 1 hour thereafter if stable. A full set of vital signs will be documented if a change in condition is noted. 2. Medical record (MR) review completed on 05/20/2024 indicated the following: a. P3 MR indicated ESI level 2, record lacked documentation of vital signs completed every 1 hour per policy from 2053 hours on 04/15/2024 through 0013 hours on 04/16/2024. b. P5 MR indicated ESI level 2, record lacked documentation of vital signs completed every 1 hour per policy from 0053 hours on 4/18/24 through 0354 hours on 4/18/2024. c. P6 MR indicated ESI level 2, record lacked documentation of vital signs completed every 1 hour per policy from 1838 hours on 04/18/2024 through 0051 on 04/19/2023. d. P7 MR indicated ESI level 2, record lacked documentation of vital signs completed every 1 hour per policy from 1225 hours on 4/19/2024 through 1916 hours on 04/19/2023. e. P10 MR indicated ESI level 2, record lacked documentation of vital signs completed every 1 hour per policy from 2058 hours on 04/20/2024 through 0359 hours on 04/21/2024. 3. In interview on 05/20/2024 at approximately 1420 hours, A4 (Manager of of Risk Management and Privacy), confirmed medical records lacked documentation of vital signs every 1 hour per policy for ESI level 2 patients in the Emergency Room.”

“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 document in the medical record (MR) the discontinuation of intravenous (IV) access on 3 of 10 patient medical records reviewed (P2, P4, and P5). Findings include: 1. Facility procedure titled, Skills: Intravenous Therapy: Discontinuation-CE/NCPD, published April 2023, indicated on page 2, 26. Document the procedure in the patient’s record. 2. Review of P2’s MR indicated IV placed on 2/4/24 at 1:32 am to the right forearm. P2 DC’d (discharged) from facility on 2/8/24. MR lacked documentation of IV site discontinuation. 3. Review of P4’s MR indicated IV placed on 3/3/24 at 2:33 pm to the right brachial. P4 DC’d from facility on 3/7/24. MR lacked documentation of IV site discontinuation. 4. Review of P5’s MR indicated port a cath to right chest accessed on 2/25/24 at 7:00 am and de-accessed by P5 on 2/29/25 at 1:00 am. MR indicated port a cath re-accessed on 2/29/24 at 2:00 am. P5 DC’d from facility on 3/2/24. MR lacked documentation of port a cath de-access. 5. In interview, on 4/3/24 at approximately 3:00 pm, A5 (Clinical Informatics) verified P2, P4, and P5 did not have discontinuation of IV access documented prior to DC (discharge) from facility. A5 verified P2, P4, and P5 did not require IV access for arranged medical care after discharge from facility. 6. In interview, on 4/3/24 at approximately 6:10 pm, A1 (Accreditation and Regulatory Office) verified the document provided, titled Skills: Intravenous Therapy: Discontinuation-CE/NCPD, was a facility policy.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 47685 Based on document review and interview, nursing services failed to address alternative route needed for prescribed patient medication administration, failed to administer prescribed medication for 6 (six) consecutive days and failed to supervise the care being provided to patient in restraints, for 1 of 10 patients (P #1); and failed to implement and complete training/education for nursing as identified from facility documentation. See Tag A0395 The cumulative effect of this deficient practice prevented the facility from providing a safe environment by the nursing staff.”

“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: 47685 Based on document review and interview, nursing services failed to address alternative route needed for prescribed patient medication administration, failed to administer prescribed medication for 6 (six) consecutive days and failed to supervise the care being provided to patient in restraints for 1 of 10 patient medical records reviewed (P #1); and failed to implement and complete training/education for nursing as identified from facility documentation. Findings include: 1. Facility policy titled “Medication Administration”, Policy & Procedure No. 40-31 S, last reviewed 9/12/2023, indicated 8. Administration Process: d. 6) Factors modifying medication - e.g. ability to be crushed, split, release mechanism. Consult pharmacist or physician if medications to be crushed or switched to liquid form. 2. Facility policy titled “Restraints Medical Surgical and Behavioral/Violent”, policy and procedure No. 40-19, last reviewed 11/7/2023 indicated on page 4, B. Registered Nurses: Responsible for initial application and removal of restraints, assessment, monitoring and documentation related to patients in restraints. The nurse is also required to attend annual education as outlined in this policy. 3. Facility documentation indicated one report titled: Medication- submitted on 10/2/2023, indicated Patient #1 was on valproic acid for seizures. Patient lost enteral access on 9/24/2023 and medication was held from 9/25/2023 until 10/01/2023. No documentation of anyone reaching out for alternative route since patient did not have enteral access. Action Plan approval on 11/15/2023 indicated: Processes - Action Item: 1. Creating a pharmacy protocol to change determined medication from PO to IV and obtained appropriate approval. a. Educate pharmacy staff of new protocol. b. Educate nursing staff through NERP (facility monthly education for nurses online system) - Anticipated completion date: 1/31/2024. Education/Training - Action Item: 2. Education of Central Line dislodging actions to all clinical staff. a. NERP- Nursing education - Anticipated Completion Date 1/1/2024. Standardized provider training to include: medication reviews, set up reports, education on views and reports to all current providers - anticipated completion date: 11/17/2023. 4. RCA (Root Cause Analysis) report indicated patient #1 on valproic acid for seizures, lost enteral access on 9/24/2023 and medication was held from 9/25/2023 until 10/1/2023. No documentation of anyone reaching out for alternative route. Patient was found unresponsive in room on 10/1/2023 that required code blue for emergency intubation. MRI (Magnetic Resonance Imaging) of brain showed multiple acute infarcts. There is concern for seizure activity. Patient did not receive prescribed valproic acid from 9/25/2023 through 10/1/2023. Report indicated error reached patient #1 and required a higher level of care and possible prolonged hospitalization. 5. Enrollments and Completions for Nursing education on Pharmacy: Oral PO to IV Protocol, assigned on 12/8/2023, with an anticipated completion date of 1/31/2024, indicated unit D400 (NeuroSurgical Unit) had a compliance of 79% (percent) as of 3/22/2024 of staff completion. Facility wide compliance as of 3/22/2024, had a completion status of 72%. 6. Facility Skills Education: Medication Administration, indicated if the patient’s ability to swallow is in question, the medication should be held temporarily, and the practitioner should be asked to change the medication order to an alternative route (e.g., IV or enteral). 7. Patient #1 MR (Medical Record) indicated Valproic acid acid 1250 mg (milligram) oral every 12 (twelve) hours was ordered by MD (Medical Doctor) on 9/5/2023 at 0924 hours for seizure diagnosis. Medication Administration Record (MAR) indicated nursing staff did not administer medication from 9/25/2023 through 10/1/2023. 8. MR lacked documentation of Nursing personnel notifying providers of patient not being administered seizure medication for 6 (six) consecutive days due to ordered route not functioning. 9. MR lacked documentation of nursing staff contacting pharmacy or MD to have medication switched to an available route. 10. Nursing note dated 10/01/2023 at 0134 hours indicated patient was being assisted to restroom by sitter. Patient reached up and pulled PICC (Peripherally Inserted Central Catheter) line out of his/her neck. No bleeding at the site. MD was paged at 0134 hours. At 0142 hours, rapid response called. Patient became unresponsive on toilet. 11. MR lacked documentation that an RN removed patient #1 wrist restraints per policy. 12. In interview on 3/22/2024 at approximately 1740 hours with A6 (pharmacy), he she indicated new pharmacy protocol had a start date of March 2024 for auditing and findings. A6 also indicated action plan items were not completed by the dates anticipated and the action plan was not updated. 13. In interview on 3/22/2024 at approximately 1815 hours with N2, Registered Nurse, he/she indicated on 9/30/2023 received report from outgoing nurse that NG (nasogastric) tube was not functioning and medications were being held. 14. In interview on 3/22/2024 at approximately 1920 hours with N3, Registered Nurse, he/she indicated patient was assigned to their care multiple times, patient was not receiving valproic acid for seizure medication due to lack of enteral access in the week prior to patient going unresponsive. N3 indicated he/she did not alert MD due to receiving in nurse to nurse report that medication was being held. 15. In interview on 3/25/2024 at approximately 1950 hours with N1 (Patient Care Assistant, PCA), he/she indicated early morning of 10/1/2023, P#1 was in restraints in bed. He/she had requested to get up and use restroom. PCA undid restraints and assisted patient to the restroom. Patient had an IJ in place. Once patient was sat on toilet, PCA indicated he/she turned his/her head to grab toilet paper and reach for a washcloth, P#1 grabbed IJ and pulled the IJ out. PCA called nurse for assistance. 16. In interview of 3/26/2024 at approximately 1600 hours with MD1 (Doctor of Osteopathy), he/she indicated was not made aware of patient not receiving prescribed seizure medications or that nursing services consulted to have medications changed to an available route. MD1 also indicated when paged about P#1 incident in the restroom, he/she was concerned that the patient was out of bed with only a sitter and not in restraints as ordered. MD1 indicated P#1 had behavioral outbursts and according to past medical history had pulled out PEG tube numerous times.”