University of Kansas Health System Olathe Hospital

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 51768 Based on policy review, record review, and interview the hospital failed to ensure registered nurses (RNs) supervised and evaluated appropriate care for 1 (Patient 1) of 3 sampled patients in accordance with accepted standards of practice. This deficient practice places any patient receiving care at this hospital at risk for serious injury or harm. Findings Include: 1. The hospital failed to ensure nursing staff effectively assessed and evaluated patient care per facility policy and procedure. (Refer to tag A-0395) 2. The hospital failed to ensure RNs are adhering to hospital policy and procedure regarding medication reconciliation, assessment and reassessment. (Refer to tag A-0398)”

“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: 51768 Based on policy review, record review, and interview the hospital failed to ensure registered nurses (RNs) effectively assessed and evaluated patient care per facility policy and procedure for 1 (Patient 1) of 3 sampled patients. This deficient practice places any patient receiving services at this hospital at risk for serious injury or harm. Findings Include: Review of a hospital policy titled, “Required Nursing Assessments and Documentation: Emergency Departmentt [sic] (ED)-UKHS,” last reviewed on 04/30/25, showed that emergency nurses must document a neurological assessment with each baseline physical assessment, every change in the patient’s primary care nurse, and with any change in patient condition. This assessment includes documenting signs and symptoms of stroke, TIA (transient ischemic attack), or seizures, completing a Glasgow coma score, observing patient level of consciousness, patient cognition, assessing speech and hearing, performing pupil checks and assessing four extremities for sensation, function and strength. Review of a hospital policy titled, “Medication Reconciliation,” approved 09/2022, showed that a medication history must be performed and electronically documented upon admission to inpatient areas and emergency care centers. Review of a national medical research agency’s document titled “Nursing Admission Assessment and Examination,” last updated 08/28/23, showed that an appropriate nursing admission assessment should include the following patient information: name, medical record number, age, date, time, probable medical diagnosis, chief complaint, source of information, past medical history, pain, allergies, medication list, valuables, rights, level of activity, fall assessment, psychosocial status, nutritional intake and vital signs. Upon admission and change of patient’s condition, a physical examination should be conducted and documented. A physical assessment includes the review of cardiovascular, respiratory, gastrointestinal, genitourinary, neuromuscular and integumentary systems. Patient 1 Review of Patient 1’s discharged medical record showed a 42-year-old admitted to the emergency department (ED) on 05/21/25 at 8:10 PM with a diagnosis of altered mental status. Patient 1 would later be admitted to the hospital on 05/26/25 with a diagnosis of bilateral lower edema (water retention, causing swelling in both legs) and deep vein thrombosis (a blood clot that blocks the flow of blood, with the potential to cause further cardiovascular complications.) Patient 1 had a past medical history of pervasive developmental disorder (associated with decreased mental capacity and cognition), behavioral issues, bipolar, (swings in mood, causing sadness and hyperactivity) hemiparesis, (decreased muscle movement) hypertension (chronic increased blood pressure) chronic heart failure and previous deep vein thrombosis. Review of patient 1’s medical record showed that multiple staff RNs (Staff K, P, Q, R, and S) did not document a full assessment on Patient 1. The assessments failed to show an appropriate neurological, cardiac and integumentary systems assessment. Review of a hospital document titled, “Inpatient Clinical Nutrition,” dated 05/26/25 at 9:54 AM, showed that Patient 1 had right lower extremity (RLE) edema, pitting 2+ (slight pitting) and left lower extremity (LLE) edema, pitting +3 (deep pitting). Review of a hospital document titled, “ED Notes by Staff T, RN,” dated 05/26/25 at 2:00 PM, showed that Patient 1 had bilateral lower extremity swelling and a cough. During an interview on 09/16/02 at 5:00 PM, Staff N, Director of Clinical Practice, stated that the expectation is that each patient receives an assessment of their airway, breathing, circulatory and neurological systems, along with a focused assessment that is related to their chief complaint. During an interview on 09/16/02 at 5:00 PM, Staff N, Director of Clinical Practice, reviewed Patient 1’s medical record and confirmed that multiple nursing staff did not perform an appropriate assessment on the following dates: On 05/22/25 Staff P, RN, did not complete an assessment On 05/23/25 Staff K, RN, did not complete an assessment On 05/24/25 Staff Q, RN, did not complete an assessment On 05/24/25 Staff R, RN, did not complete an assessment On 05/25/25 Staff K, RN, did not complete an assessment On 05/25/25 Staff S, RN, did not complete an assessment During an interview on 09/16/25 at 2:08 PM, Staff H, Medical Doctor, stated that Patient 1’s deteriorating condition was a “miss” for the entire emergency department and that the patient needed to be admitted inpatient, based on the severity of their physical condition. The expectation is that nursing assesses the patient on a “regular basis”. Nursing should be preforming duties that would enable them to notice edema, such as offering a shower, checking the patient’s pulses when in restraints, or laying eyes on the patient. The boarding situation for psychiatric patients is “not good.” During an interview on 09/17/25 at 10:36 PM, Staff M, Director of Nursing, stated that the expectation for assessment and reassessment is that a nurse preforms an exam of a patient’s airway, breathing, cardiovascular and neurological systems along with a focused assessment every shift and on patient admission. However, it can be hard to get those assessments every time on psychiatric patients. Review of Patient 1’s medical record showed that upon admission, Patient 1 did not have an up-to-date medical history and medication reconciliation completed. Review of a hospital document titled, “ED Notes,” by Staff T, RN, showed that Staff T contacted Patient 1’s guardian on 05/26/25 at 4:45 PM. Guardian voiced concerns that patient had not been receiving home medications. Staff T reached out to Patient 1’s group home who provided an updated medical record and current medication list. Review of Patient 1’s record failed to show documented evidence that patient 1 was provided with his/her home cardiovascular and psychiatric medications from time of admission on 05/21/25 to 05/26/25 During an interview on 09/17/25 at 8:30 AM, Staff J, Registered Nurse (RN), stated that during triage, Patient 1 arrived with no information. A group home staff member provided a brief indication that the patient was experiencing altered mental status, but did not provide information on patient’s condition, current medications, or medical history. Staff J did not reach out to the guardian or group home for further medical history or medication reconciliation. During an interview on 09/16/25 at 2:08 PM, Staff H, Medical Doctor, stated that medication history and reconciliation does not happen how it should in the emergency department. It is a frequent occurrence that nursing or pharmacy will reach out to providers when home medications were missed or if new medication information is provided by a facility or caregiver that needs added to a patient’s medication administration record, but the reason is unclear as to why this did not occur sooner with Patient 1. During an interview on 09/16/02 at 5:00 PM, Staff N, Director of Clinical Practice, stated that medication reconciliation can be completed by an appropriate team member, such as a pharmacy tech. However, the “safety net” is the primary nurse and it is ultimately the responsibility of the nurse to make sure this task is completed. During an interview on 09/17/25 at 10:36 PM, Staff M, Director of Nursing, stated that when a patient is unable to provide information, such as a medication list or medical history, nursing should give a “good faith effort” and try to contact a patient’s guardian, next of kin or home for that information.”

“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: 45841 Based on interview, record review, and facility policy review, the facility failed to ensure nursing staff developed a nursing care plan that reflected the patient’s goals and the nursing care to be provided to meet the patient’s needs for 1 (Patient #3) of 3 sampled patients reviewed for care plans. The failure resulted in the patient’s glucose not being monitored or managed. Findings include: A facility policy titled, “Plan of Care,” dated 08/2019, showed, “Procedure: I. The plan of care will be initiated within 12 hours of admission ...” A “History and Physical Report[s],” dated 12/14/23, showed Patient #3 was admitted on 12/13/23 for further workup and treatment after going to the emergency room for abnormal laboratory tests and an inflamed small bowel. An “Arrival on Unit” record, dated 12/14/23 at 12:20 AM, showed Patient #3 arrived to the 2 South unit on 12/14/23 at 12:03 AM. An “IPOC [Interdisciplinary Plan of Care]” flowsheet for Patient #3 showed the IPOC for “Unstable Glucose” was initiated on 12/14/23 at 5:23 PM. During an interview on 12/04/24 at 9:47 AM, Senior Director of Nursing (SDON) #1 stated that the “Unstable Glucose” care plan for Patient #3 was initiated on 12/14/23 at 5:23 PM. SDON #1 stated there was no other documentation by the nurse about glucose monitoring or diabetes management for the patient.”

“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: 45841 Based on interview, record review, and facility policy review, the facility failed to ensure licensed staff adhered to the policies and procedures of the hospital for 1 (Patient #1) of 3 sampled patients reviewed for insulin administration. The failure resulted in a medication administration discrepancy. Findings include: A facility policy titled, “Guidelines for Nursing Practice,” dated 08/2023, showed, “ ...F. All insulin dosages are verified by a second nurse. This verification should include checking the MAR [medication administration record] with the insulin vial(s) and actual dosage drawn up...” A “History and Physical Report[s],” dated 10/16/24, showed Patient #1 was admitted on 10/16/24, for new onset type two diabetes mellitus and hyperglycemia. Patient #1’s “Orders” flowsheet showed an order dated 10/18/24, for insulin lispro 12 units with meals. A “Medication Administration Record” flowsheet showed Patient #1 received eight units of insulin lispro on 10/18/24 at 5:20 PM, and no dual verification was documented. During an interview on 12/03/24 at 10:41 AM, Senior Director of Nursing (SDON) #1 stated that eight units of insulin was administered to Patient #1 on 10/18/24 at 5:20 PM. SDON #1 stated that she did not see a note as to why the nurse gave eight units instead of 12 unit. SDON #1 stated that a dual sign off was not required for insulin , and the documentation should have flagged the incorrect dose. During an interview on 12/03/24 at 1:30 PM, Registered Nurse (RN) #9 stated that she did not recall the incident when Patient #1 received eight units of insulin lispro. During an interview on 12/03/24 at 2:27 PM, RN #9 acknowledged there was not a second nurse that verified the dosage of insulin administered to Patient #1. RN #9 stated that short-acting insulin was drawn up by the nurses independently, and the long-acting insulin was drawn up and sent by the pharmacy. During an interview on 12/03/24 at 3:46 PM, SDON #1 stated that the facility policy did not require the documentation of dual verification for insulin, that there was a spot that allowed for it in the record, but it was not required. SDON #1 stated that documentation of dual verification would not be seen in Patient #1’s record or any other insulin administration because it was not required by the policy.”