Clifton Springs Hospital and Clinic

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 22484 Based on policy review, document review, and interview, the hospital failed to identify issues through quality assurance data collection related to the lack of medical record documentation compliance and multiple adverse performance events that involved Staff (G), Travel Registered Nurse. Reference: §482.21(b)(2)(ii), (c)(1), (c)(3): Quality Improvement Activities. §482.21(c)(2): Patient Safety.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 22484 Based on policy review, document review, and interview, it was determined the hospital failed to use data collected to identify opportunities for improvement and implement changes that will lead to improvement related to the lack of medical record documentation compliance for the Intensive Care Unit (ICU) and the medical surgical units on 1200 and 1400. No evidence was provided to indicate the data was brought to the Quality Assurance Performance Improvement (QAPI) department for review, analysis, and the implementation of corrective actions to improve staff compliance and prevent adverse patient events. Findings include: Review on 11/15/24 of the “2024 Rochester Regional Health: Quality Assurance, Patient Safety, & Performance Improvement Plan,” indicated the analysis of the collected data is used to determine levels of performance and variation in processes and outcomes. When opportunities for improvement are identified, the decision to act is based on prioritization processes that acre commensurate with the referenced guided principles. The program accomplishes these activities through the following (but not limited to) internal audits performed with department staff and viewed as an opportunity to educate department staff on requirements and standards. Following completion of the audit, the level of conformance is determined by the lead auditor and audit team. An executive summary of findings and results is shared with the identified process owners. Nonconformance requires correction and/or corrective action plans; the process owner is responsible to ensure corrections and corrective actions are planned and implemented without delay. Top management is accountable to ensure corrective action plans are implemented and the issues resolved; Documented information shall be retained to ensure internal audits are completed, and the internal audit process is effective and maintained according to standards. Performance improvement information is shared at various meetings including departmental staff meetings, leadership meetings, committee meetings, and employee meetings. Review on 11/15/24 of the “2024 Chart Review,” audit from January to October 2024 revealed some audit dates are blank due to not having a patient sample and/or not conducting the audit. - The Intensive Care Unit (ICU): Two medical record audits were conducted each month (total of 20 audits). A sample of the audits includes the following: compliance with tele/cardiac monitor rhythm strip analysis/interpretation with signature is completed every shift was 50% or less for 8 of 10 audits. 5 of the audits were 0%; compliance with documenting pain reassessment 60 minutes after as needed medication was given was 66.7% or less for 11 of 16 audits; compliance for wound care documentation matching the wound care is 50% or less for 5 of 9 audits; compliance with fall risk interventions documented with daily care and care plan updated was less than 60% for 15 of 20 audits; compliance with bowel movement assessment is 60% of less for 17 of 20 audits; compliance with documenting strict intake and output every shift or as appropriate was 25% or less for 20 of 20 audits; and compliance with completing vital signs per order was 60% or less for 19 of 20 audits. - The 1200 Medical Surgical Floor: Two medical record audits were conducted each month except for October (total of 19 audits). A sample of the audits includes the following: compliance with documenting strict intake and output every shift or as appropriate was 40% or less for 19 of 19 audits; compliance with documenting pain assessments every four hours or per provider order was 60 % or less in 18 of 19 audits (one audit had no data); compliance with fall risk interventions documented with daily care and care plan updated was less than 60% for 12 of 19 audits; compliance with completing vital signs per order was 60% or less for 14 of 19 audits; and compliance for wound care documentation matching the wound care order is “0”, there were no patient’s with wound care. - The 1400 Medical Surgical Floor: Two medical record audits were conducted each month except in May and October (total of 18 audits). A sample of the audits includes the following: compliance with tele/cardiac monitor rhythm strip analysis/interpretation with signature is completed every shift was 0% for 1 of 1 audits of two patients; compliance with fall risk interventions documented with daily care and care plan updated was less than 40% for 17 of 18 audits; compliance with documenting pain reassessment 60 minutes after as needed medication was given was 50 % of less for 13 of 18 audits; compliance for wound care documentation matching the wound care order is less than 50 % for 3 of 6 audits; compliance with bowel movement assessment is 60% of less for 13 of 18 audits; compliance with documenting strict intake and output every shift or as appropriate was 20% or less for 18 of 18 audits; and compliance with completing vital signs per order was 60% or less for 14 of 18 audits (the 2nd August audit lists 400%). Review on 11/15/24 of the confidential Nursing Services Quality Assurance Meeting minutes “Eastern Region Nurse Leadership,” meeting” minutes from January to October 2024, “Eastern Region Quality Oversight Committee,” meeting minutes from January to September 2024, and the “Acute Care Front Line CUSP (front-line staff meetings),” meeting minutes from March to September 2024 revealed no evidence that the 2024 “Chart Review” audit data was reviewed and analyzed. No corrective actions were implemented to improve staff documentation compliance in the ICU and the 1200 & 1400 Medical Surgical Units. Interview on 11/13/24 at 02:35 PM with Staff (A), Clinical Regulatory Compliance Supervisor, revealed information for chart audits is gathered, reviewed, and given back to the units. The audits were not discussed in any quality assurance meetings. There is no documentation of data analysis and no action plans have been implemented for the chart audit results.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 22484 Based on policy review, document review, and interview, it was determined the hospital failed to review, track, and analyze “Safe Connect, “adverse patient event reports to identify issues and implement prevention actions. Specifically, from March to November 2024 there were six “Safe Connect” event reports filed that involved Staff (G), Travel Registered Nurse. Quality Assurance failed to identify performance issue trends related to Staff (G). There is no hospital mechanism for the performance review of travel nurse agency staff. Findings include: Review of the “2024 Rochester Regional Health: Quality Assurance, Patient Safety, & Performance Improvement Plan,” indicated Quality Assurance reviews an incident, case/clinical situation for compliance with the standard of care, current standards, guidelines, and best practices; Significant Event Review Committee reviews significant events and near misses to determine reportability, prioritization, risk mitigation, disclosure, and situational awareness; Patient Safety Program includes safety event reporting and event management; Event Reporting System and Event Management allows for tracking and trending of events to identify areas that need improvement projects or interventions. A process for reviewing all events that is facilitated by the local quality teams in collaboration with service line leadership to ensure that events are responded to in a timely manner. The system incorporates compliments, complaints, employee events, patient events, and visitor events; The Internal Audit Program should be performed with department staff and viewed as an opportunity to education department staff on requirements and standards. The level of conformance is determined by the lead auditor and audit team. An executive summary of findings and results is shared with process owners. Nonconformance requires correction and/or corrective action plans. If correction action is required, the process owner is responsible to ensure corrections and corrective actions are planned and implemented without delay. Top management is accountable to ensure corrective action plans are implemented and the issues resolved; Documented information shall be retained to provide objective evidence that the internal audit program has been established, internal audits are completed, and that the internal audit process is effective and maintained according to standards; Performance improvement information is shared at various meetings including departmental staff meetings, leadership meetings, committee meetings, and employee meetings. Review of the agency contract “Healthcare Workforce Logistics (HWL): Managed Services Agreement,” dated 04/26/23 and the “HWL Addendum A-1: Terms and Conditions- Nursing, Rehab, and Allied (exhibit C),”indicated all agency staff members will be evaluated by the hospital charge nurse or unit supervisor periodically through the Vendor Management System (VMS-healthcare staffing software that provides a platform for managing the staffing process including on-boarding and performance tracking). The hospital agrees to notify HWL and the Agency’s Risk Management Department in writing within 30 days of any incident arising out of or relating to services provided by an agency staff member, any threatened or pending litigation or claims, and any patient care or safety concern. The hospital staff will directly supervise all agency staff. The hospital accepts full responsibility for patient care while using the agency staff. Review of the hospital confidential quality assurance “Safe Connect,” event reports revealed from March to November 2024, there were six documented events pertaining to Staff (G), Travel Registered Nurse. -On 3/22/24: Staff (G) delayed the transfer of patients out of the ICU resulting in the delay of care for two other patients that needed ICU level care. Staff (W), Clinical Nurse Leader documented “no harm to patients, will discuss the event with the ICU nurse and monitor for further events. -On 03/23/24: A patient was agitated, not redirectable, and harming self throughout the shift. Staff (G) contacted the provider about the patient’s behavior and medication not working. Later in the shift, the patient was intubated (tube inserted to maintain airway) due to hypoxia (insufficient oxygen) and unresponsiveness. At 06:00 PM, the patient was started on a 1.0 mg/hr. Versed (medication used to treat anxiety) drip. At 06:15 PM, the patient received a Versed bolus (onetime dose), however a Richmond Agitation-Sedation Scale (RASS- a medical scale used to measure the agitation or sedation level of a person) score was not documented to support the bolus and the Versed drip was not increased to 2.0 mg hr. as ordered. At 07:15 PM, the Versed drip was increased to 7 mg/hr. without a provider order and there was no RASS score documented. Staff (LL), Associate Director for Quality, was aware of the event. The Risk Management Department was added to this event , no reviews were included. Staff (E), Chief Nursing Officer and Staff (W), Clinical Nurse Leader both reviewed the event and spoke with Staff (G). Education was completed with Staff (G) about the importance of following orders and the need to contract the provider if they feel a patient needs a higher dose. Staff (G) stated he understood, would make sure they followed orders, and complete their documentation. -On 03/24/24: three separate reports were filed for the same event: A patient had STAT (immediate) basic metabolic panel (BMP- a blood test that measures eight substances in your blood to provide information about your metabolism, fluid balance, and kidney function.) blood work ordered to be drawn every four hours with instructions to call hospitalist with results. Staff (G) did not draw the ordered chemistry laboratory studies due at 07:00 AM, 11:00 AM, and at 05:00 PM. Only one BMP was drawn during the 12-hour shift. On 03/27/24, Staff (W), Clinical Nurse Leader, spoke with Staff (G), about following orders and reaching out if an order is unable to be fulfilled. Staff (G) stated he understands who his resources are if he is unable to draw a lab. -On 05/24/24: Staff (G) was belligerent and unprofessional with a provider. Staff (X), Medical Director, reviewed the event and recommended that the nursing manager speak with Staff (G) about the interaction. Staff (F), Nurse Manager reviewed the event and had a discussion with the team member. -On 08/19/24: Staff (G) turned away the transport staff for a scheduled radiology examination for a patient. A new time was scheduled but the patient did not arrive in radiology. Staff (G) was contacted and indicated the patient was too difficult to move for the examination and they had not coordinated with the respiratory department. Care has been unnecessarily delayed. The nurse manager reviewed the event indicating it was the nursing supervisor, not Staff (G), who “made the suggestion given the patient’s condition.” Staff (Z), Director of Diagnostic Imaging, reviewed the case and disagreed with the nurse manager. - On 09/30/24: Staff (G) did not complete the required documentation throughout their shift. There was no head-to-toe assessment documented, no intake & output (I&O) were completed, and a laboratory study (blood work) ordered to be drawn at 04:00 PM was not completed. On 10/4/24, Staff (F), Nurse Manager documented “this is a good nurse who missed a critical piece of documentation and lab draw. The patient did subsequently expire, however, in review and discussion with doctors, this did not lead to the demise of the patient. The team member is being performance managed regarding the failure to meet expectations around documentation and care. Review on 11/15/24 of the confidential Nursing Services Quality Assurance Meeting minutes “Eastern Region Nurse Leadership,” meeting” minutes from January to October 2024, and “Eastern Region Quality Oversight Committee,” meeting minutes from January to September 2024 revealed no evidence various performance non-compliance events were identified for Staff (G). Review on 11/13/24 of the personnel file for Staff (G), Travel Registered Nurse, revealed no performance reviews, verbal/written counseling, education remediation plans, and/or disciplinary actions in the file. There was no indication that Human Resources and/or the staffing agency were notified of any performance issues. Interview on 11/13/24 at 10:50 AM, with Staff (Y), Employee Relations Partner, revealed that their department has received no notice of staff coaching, counseling, disciplinary actions, and/or re-education regarding Staff (G), Travel Registered Nurse. Interview at 11:10 AM, with Staff (Z), Human Resources Associate, revealed agency nursing contracts and performance evaluations are not handled by the human resources department.”

“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: 48506 Based on medical record review, policy review, document review, and interview in two of three medical records reviewed, it was determined on 09/30/24 from 07:00 AM to 07:00 PM, Staff (G) failed to document intake and outputs (Patients #1 and #12.) Additionally, Staff (G) failed to obtain a blood test ordered by the physician and did not document a head-to-toe assessment for Patient #1. Findings: Review on 11/14/24 of policy “Rochester Regional Health Nursing Documentation Guidelines Policy” last approved 08/09/23 revealed in the critical care/stepdown unit a head-to-toe nursing assessments will occur minimally, every twelve-hour shift (two times in a 24-hour period) and with every change in nurse caring for the patient for greater than four hours. Intake and Output and medication administration will occur based on provider order. Review on 11/13/24 of “Safe Connect Event Report” dated 10/01/24 at 04:31 AM revealed an error was reported on 09/30/24 at 08:00 AM that Staff (G), Travel Registered Nurse did not complete required documentation throughout the shift on Patient #1. No head-to-toe assessment was documented, no intake and output were completed. Patient #1 was on enteral feeds being titrated to the prescribed goal. A laboratory specimen was ordered to be drawn at 04:00 PM and was not completed. Review on 11/14/24 of the medical record for Patient #1 revealed on 09/27/24 at 02:17 AM, Patient #1 arrived to the emergency department for hypoxia (low oxygen levels) and shortness of breath from the nursing home. At 04:57 AM, Staff (DD), Physician Assistant placed an order for hourly intake and output documentation. On 09/29/24 at 07:58 AM, Staff (M), Physician placed an order to resume trickle feeds. Begin tube feeding via enteral pump at 10 milliliters per hour and to advance by 10 milliliters per hour every eight hours to a goal rate of 55 milliliters per hour. On 09/30/24 at 07:28 AM, Staff (M), Physician placed an order to flush Patient #1’s feeding tube with 150 milliliters of sterile water every four hours starting on 09/30/24 at 08:00 AM. On 09/30/24 at 08:00 AM, 12:00 PM, and 04:00 PM, Staff (G), Travel Registered Nurse documented a late entry head-to-toe assessment on 10/01/24 at 09:03 AM. From 09/30/24 at 07:00 AM until 07:00 PM, the only feeding tube documentation found was at 08:00 AM where Staff (G), Travel Registered Nurse documented Glucerna 1.5 full strength continuous tube feeds infusing at 30 milliliters per hour. Feeding tube residual was checked and there were no residuals. (There was no tube feeding or flushes infusion volume documented.) On 09/30/24 at 03:44 PM, Staff (M), Physician placed an order for a basic metabolic panel blood draw to be drawn at 06:00 PM. The laboratory draw was collected on 09/30/24 at 11:26 PM. Review on 11/14/24 of the medical record for Patient #12 revealed on 09/20/24 at 11:14 PM, Patient #12 presented to the emergency department from the nursing home with shortness of breath and hypoxia (low oxygen levels.) On 09/21/24 at 01:18 AM, Staff (DD), Physician Assistant placed an order for strict intake and output with a frequency of every shift. At 01:24 AM, Staff (DD) placed an order for tube feeds Glucerna 1.5 at 79 milliliters per hour for 16 hours with free water flushes of 40 milliliters per hour for 16 hours, to be given daily from the hours of 06:00 PM and stop at 10:00 AM, or until a total volume of 1,260 milliliters is infused. On 09/30/24 at 08:00 AM, Staff (G), Travel Registered Nurse documented continuous tube feeding of Glucerna 1.5 with an infusion rate of 30 and no tube feeding residuals. (The ordered infusion rate was 79 milliliters per hour from the hours of 06:00 PM until 10:00 AM.) At 04:00 PM, Staff (G), Travel Registered Nurse documented a tube feeding infusion rate of 40 and no tube feeding residual. (The ordered infusion rate was 79 milliliters per hour from the hours of 06:00 PM until 10:00 AM.) On 09/30/24 from 07:00 AM until 07:00 PM, there was no documented intake volume of feeding tube feeds, free water flushes or output from urine or stool. Interview on 11/13/24 at 11:05 AM with Staff (F), Nurse Manager, revealed Patient #1’s chart was reviewed, and it was noted that there was missing documentation and a laboratory draw. Feedback and counseling was provided to Staff (G), Travel Registered Nurse regarding the lack of documentation and care. It was requested that if Staff (G) did complete an assessment of Patient #1, that they should completed their late entry documentation. Interview on 11/13/24 at 03:45 PM with Staff (W), Clinical Nurse Leader verified on 09/30/24, Staff (G), Travel Registered Nurse did not document intake and output per policy in Patient #12’s medical record.”

“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: 22484 Based on policy review, document review, and interview, it was determined in one of seven personnel files reviewed, the nursing supervisor failed to identify performance issues and implement prevention actions related to four of six “Safe Connect” event reports. Findings include: Review of the “2024 Rochester Regional Health: Quality Assurance, Patient Safety, & Performance Improvement Plan,” indicated the Event Reporting System and Event Management allows for tracking and trending of events to identify areas that need improvement projects or interventions. A process for reviewing all events that is facilitated by the local quality teams in collaboration with service line leadership to ensure that events are responded to in a timely manner. The system incorporates compliments, complaints, employee events, patient events, and visitor events; The Internal Audit Program should be performed with department staff and viewed as an opportunity to education department staff on requirements and standards. The level of conformance is determined by the lead auditor and audit team. An executive summary of findings and results is shared with process owners. Nonconformance requires correction and/or corrective action plans. If correction action is required, the process owner is responsible to ensure corrections and corrective actions are planned and implemented without delay. Top management is accountable to ensure corrective action plans are implemented and the issues resolved; Documented information shall be retained to provide objective evidence that the internal audit program has been established, internal audits are completed, and that the internal audit process is effective and maintained according to standards; Performance improvement information is shared at various meetings including departmental staff meetings, leadership meetings, committee meetings, and employee meetings. Review of the agency contract “Healthcare Workforce Logistics (HWL): Managed Services Agreement,” dated 04/26/23 and the “HWL Addendum A-1: Terms and Conditions- Nursing, Rehab, and Allied (exhibit C),”indicated all agency staff members will be evaluated by the hospital charge nurse or unit supervisor periodically through the Vendor Management System (VMS-healthcare staffing software that provides a platform for managing the staffing process including on-boarding and performance tracking). The hospital agrees to notify HWL and the Agency’s Risk Management Department in writing within 30 days of any incident arising out of or relating to services provided by an agency staff member, any threatened or pending litigation or claims, and any patient care or safety concern. The hospital staff will directly supervise all agency staff. The hospital accepts full responsibility for patient care while using the agency staff. Review of the hospital confidential quality assurance “Safe Connect,” event reports revealed from March to November 2024, there were six documented events pertaining to Staff (G), Travel Registered Nurse. -On 3/22/24: Staff (G) delayed the transfer of patients out of the ICU resulting in the delay of care for two other patients that needed ICU level care. Staff (W), Clinical Nurse Leader documented “no harm to patients, will discuss the event with the ICU nurse and monitor for further events. -On 03/23/24: A patient was agitated, not redirectable, and harming self throughout the shift. Staff (G) contacted the provider about the patient’s behavior and medication not working. Later in the shift, the patient was intubated (tube inserted to maintain airway) due to hypoxia (insufficient oxygen) and unresponsiveness. At 06:00 PM, the patient was started on a 1.0 mg/hr. Versed (medication used to treat anxiety) drip. At 06:15 PM, the patient received a Versed bolus (onetime dose), however a Richmond Agitation-Sedation Scale (RASS- a medical scale used to measure the agitation or sedation level of a person) score was not documented to support the bolus and the Versed drip was not increased to 2.0 mg hr. as ordered. At 07:15 PM, the Versed drip was increased to 7 mg/hr. without a provider order and there was no RASS score documented. Staff (LL), Associate Director for Quality, was aware of the event. The Risk Management Department was added to this event, no reviews were included. Staff (E), Chief Nursing Officer and Staff (W), Clinical Nurse Leader both reviewed the event and spoke with Staff (G). Education was completed with Staff (G) about the importance of following orders and the need to contract the provider if they feel a patient needs a higher dose. Staff (G) stated he understood, would make sure they followed orders, and complete their documentation. -On 03/24/24: three separate reports were filed for the same event: A patient had STAT (immediate) basic metabolic panel (BMP- a blood test that measures eight substances in your blood to provide information about your metabolism, fluid balance, and kidney function.) blood work ordered to be drawn every four hours with instructions to call hospitalist with results. Staff (G) did not draw the ordered chemistry laboratory studies due at 07:00 AM, 11:00 AM, and at 05:00 PM. Only one BMP was drawn during the 12-hour shift. On 03/27/24, Staff (W), Clinical Nurse Leader, spoke with Staff (G), about following orders and reaching out if an order is unable to be fulfilled. Staff (G) stated he understands who his resources are if he is unable to draw a lab. -On 05/24/24: Staff (G) was belligerent and unprofessional with a provider. Staff (X), Medical Director, reviewed the event and recommended that the nursing manager speak with Staff (G) about the interaction. Staff (F), Nurse Manager reviewed the event and had a discussion with the team member. -On 08/19/24: Staff (G) turned away the transport staff for a scheduled radiology examination for a patient. A new time was scheduled but the patient did not arrive in radiology. Staff (G) was contacted and indicated the patient was too difficult to move for the examination and they had not coordinated with the respiratory department. Care has been unnecessarily delayed. The nurse manager reviewed the event indicating it was the nursing supervisor, not Staff (G), who “made the suggestion given the patient’s condition.” Staff (Z), Director of Diagnostic Imaging, reviewed the case and disagreed with the nurse manager. Review on 11/13/24 of the personnel file for Staff (G), Travel Registered Nurse, revealed a date of hire on 09/26/22 to 07/30/24 as a travel nurse completing mandatory training and education that includes medication administration, nursing documentation, and laboratory blood draws on 12/23/22, 04/04/23, and 07/31/24. Staff (G) signed a new travel nurse agency contract in August and was currently working at the hospital at the time of the survey. There were not performance reviews, verbal/written counseling, education remediation plans, and/or disciplinary actions in the file. There was no indication that Human Resources and/or the staffing agency were notified of any performance issues. Interview on 11/13/24 at 10:50 AM, with Staff (Y), Employee Relations Partner, revealed that their department has received no notice of staff coaching, counseling, disciplinary actions, and/or re-education regarding Staff (G), Travel Registered Nurse. Interview at 11:10 AM, with Staff (Z), Human Resources Associate, revealed agency nursing contracts and performance evaluations are not handled by the human resources department. Interview on 11/13/24 at 09:15 AM with Staff (N), 07:00 PM to 07:00 AM Registered Nurse, revealed they received a verbal report from Staff (G), Travel Registered Nurse that did not include any outstanding tasks to be completed. In Patient #1’s room, the kangaroo pump (medical device that provides programmed amounts of feeds and flushes through a feeding tube) contained tube feeds that were being administered at an incorrect rate and there was a full water flush bag which was unusual because of the ordered water flushes. Staff (N) reviewed Patient #1’s orders and programmed the kangaroo pump to reflect the rate per order. There was no charting of intakes for the last shift and was unable to tell if water flushes were given to Patient #1. Staff (U), Nursing Supervisor, and Staff (V), Physician Assistant, were notified of the lack of documentation. Staff (V) alerted me that laboratory work that was not drawn as ordered. At approximately 04:30 AM, Patient #1 had a change in cardiac rhythm to ventricular tachycardia (rapid abnormal heart rhythm causing the heart to beat ineffectively) and torsades de pointes (a rare, life-threatening heart rhythm disturbance). Patient #1 had a do not resuscitate order (a legal document that instructs medical professionals not to perform cardiopulmonary resuscitation (chest compressions to restart the heart) if a patient’s heart or breathing stops.) and was pronounced deceased. A Safe Connect event report was documented by the nursing supervisor. Many staff have brought up concerns about Staff (G). Similar instances of the lack of complete charting, not drawing labs, not carrying out orders, medications passes skipped, and antibiotics given late have occurred. Interview on 11/13/24 at 11:05 AM with Staff (F), Nurse Manager, revealed on 10/01/24, they were notified of Patient #1’s death by staff and a Safe Connect event report. The chart was reviewed, and there was missing documentation and a laboratory draw. Feedback and counseling was provided to Staff (G), Travel Registered Nurse regarding the lack of documentation and care. It was requested that if Staff (G) did complete an assessment of Patient #1, they should completed their late entry documentation. Staff (Y) was tasked with auditing Staff (G)’s charting and to provide feedback. The first week of audits revealed an improvement in documentation, but education to Staff (G) was required. On weeks two and three, documentation was complete, and no education to Staff (G) was required. On 11/12/24, additional education was provided to Staff (G) on documentation. The information was shared amongst the nurse manager, clinical nurse leaders, and clinical resource nurse. There have been no other complaints from patients or staff regarding Staff (G). The travel agency was not involved. Interview on 11/13/24 at 12:05 PM with Staff (U), Nursing Supervisor, revealed Staff (N), Registered Nurse informed them of physician orders were not followed and the head-to-toe assessment on 09/30/24 were not documented by Staff (G), Travel Registered Nurse for Patient #1. At the end of my shift, Staff (F), Nurse Manager was notified of the events that had occurred. Bedside nursing staff have vocalized frustrations with Staff (G) regarding lack of documentation and care issues with medication administration and not obtaining laboratory samples. Staff (U) provided direction to the bedside care staff to continue to vocalize their concerns to Staff (F), Nurse Manger, to Staff (Y), Clinical Nurse Leader, and to follow up with Safe Connect event reports. Interview on 11/13/24 at 04:00 PM with Staff (Y), Clinical Nurse Leader, revealed care complaints were brought to their attention regarding missing documentation for Patient #1 on 09/30/24. Upon record review, it was noted that head-to-toe assessment and intake and output documentation was not completed. A Safe Connect event report was filed for the lack of documentation and not following physician orders. After Patient #1 expired, follow up was also done in person with Staff (F), Nurse Manager. Staff (Y) did not discuss this event with Staff (G), Travel Registered Nurse, but has had conversations with them in the past. The highest level of notification of issues was with Staff (F), Nurse Manager who provided the direction to monitor patient care documentation for Staff (G) and to provide feedback for improvement in charting compliance.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48506 Based on medical record review, policy review, and interview in two of two medical records reviewed, Staff (G), Travel Registered Nurse, failed to administer medications utilizing the five rights of medication administration. Specifically, utilizing the right time (the appropriate time to ensure adherence to the prescribed frequency and time of administration.) (Patients #1 and #12) Findings: Review on 11/13/24 of policy “Medication Administration” last approved 09/06/24, revealed medications scheduled once daily should be administered up to two hours before scheduled administration time or may be administered up to two hours after scheduled administration time. The staff administering the medication must document the reason a medication is administered early or late or has been omitted. Review on 11/14/24 of the medical record for Patient #1 dated 09/27/24 to 10/01/24 revealed from 09/27/24 to 10/01/24 the following medications were administered late by Staff (G), Travel Registered Nurse without a documented reason: -Amlodipine (medication to treat high blood pressure) 10 milligrams to be given via feeding tube daily at 09:00 AM and administered at 11:31 AM. -Ascorbic Acid (a water-soluble vitamin - vitamin C) 500 milligrams to be given via feeding tube daily at 09:00 AM and administered at 11:31 AM. -Aspirin (medication that reduces pain, fever, inflammation, and blood clotting) 81 milligrams to be given via feeding tube daily at 09:00 AM for blood clot prevention and was administered at 11:31 AM. -Chlorhexidine (an antiseptic compound that kills bacteria and prevents bacteria growth) 15 milliliter solution to be given two times daily at 09:00 AM and 09:00 PM via mouth/throat with directions to swish around in mouth for 30 seconds then expectorate for mouth infection prevention. The 09:00 AM dose was administered at 11:33 AM. -Enoxaparin syringe (medication used for prevention and treatment of blood clots) 30 milligrams to be given subcutaneous daily at 09:00 AM for anticoagulation and was administered at 11:32 AM. -Pantoprazole (medication that reduces the amount of acid the stomach makes) 40 milligrams to be given intravenous daily at 09:00 AM and was administered at 11:32 AM. -Piperacillin-tazobactam (antibiotic) 3.375 grams to be given intravenous every eight hours (at 01:30 AM, 09:30 AM, and 05:30 PM) over 240 minutes. The 09:30 AM dose was administered at 11:32 AM. -Potassium chloride (treatment of low potassium in the blood) 40 milliequivalents to be given via feeding tube once on 09/30/24 at 08:00 AM for low potassium level and was administered at 11:31 AM. -Potassium chloride 40 milliequivalents to be given via feeding tube once on 09/30/24 at 01:00 PM and was administered at 04:14 PM. -Potassium chloride 10 milliequivalents to be given intravenous one time on 09/27/24 at 08:30 AM and was administered at 03:20 PM. -Terazosin (medication to treat the symptoms of benign prostate hypertrophy and lowers blood pressure by relaxing the blood vessels) one milligram to be given via feeding tube two times daily at 09:00 AM and 09:00 PM for high blood pressure. The 09:00 AM dose was administered at 11:32 AM. -Venlafaxine (medication to treat anxiety, depression, and panic attacks) 18.75 milligrams to be given via feeding tube daily after lunch at 01:00 PM for anxiety and was administered at 04:14 PM. -Venlafaxine 37.5 milligrams to be given via feeding tube daily every twelve hours (09:00 AM and 09:00 PM) for anxiety. The 09:00 AM dose was administered at 11:32 AM. -Zinc Sulfate (medication to treat zinc deficiency) 220 milligrams to be given daily with breakfast at 08:00 AM via feeding tube and was administered on at 11:32 AM. Review on 11/14/24 of the medical record for Patient #12 dated 09/20/24 to 10/15/24 revealed on 09/30/24 the following medications were administered late by Staff (G), Travel Registered Nurse without a documented reason: -Diclofenac Sodium (medication used to treat the symptoms of rheumatoid arthritis) 1% gel one gram to be given topical to the lower back four times per day. On 09/30/24, the 01:00 PM scheduled dose was administered at 03:54 PM. -Insulin regular (medication for the treatment of elevated blood sugars) to be given every six hours subcutaneously (injection under the skin) based on a blood sugar scale give one unit of insulin for every 25 milligrams per deciliter blood sugar was above the target. On 09/30/24, the 12:00 PM scheduled dose was administered at 03:54 PM. -Lansoprazole (medication that reduces the amount of acid made in the stomach) 30 milligrams to be given daily before breakfast via feeding tube. On 09/30/24, the scheduled 07:30 AM dose was administered at 10:53 AM. -Oxycodone (pain medication) to be given every six hours via feeding tube. On 09/30/24, the scheduled 01:00 PM dose was administered at 03:54 PM. Interview on 11/13/24 at 10:20 AM with Staff (G), Travel Registered Nurse, revealed they cared for Patient #1 on 09/30/24 from 07:00 AM until 07:00 PM and a few of Patient #1’s medications were administered late. Interview on 11/13/24 at 03:45 PM with Staff (W), Clinical Nurse Leader verified on 09/30/24, Staff (G), Travel Registered Nurse did not administer Patient #12’s medications timely per policy.”