NW Indiana-Amg Specialty Hospital

“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: 14445 Based on document review and interview, nursing services failed to document medication administration in one instance (Patient # 4). Findings include: 1. Review of hospital policy titled: K.11.31 Administration of Medication, Policy Stat ID 17926994, indicated under Procedure, on page 3, C. The Pharmacist will check all new medication orders; D. The healthcare professional administering the medication will review the medical record and verify that there are no contraindications for administering the medication; F. The healthcare professional administering the medication will document medication administered on the MAR (Medication administration record). Last reviewed 4/2025. 2. Review of Patient # 4’s MR (Medical Record), reflected the following: (a). Patient # 4, a 66 year old, admitted to ALTH # 40 (Long Term Acute Care Hospital) on 6/25/2025 from AH # 60 (Acute Care Hospital); with diagnosis(es) of, but not limited to: S.O.B. (Shortness of breath) & respiratory failure. Patient coded on 6/26/2025 at 11:25 am, and expired on 6/26/2025 at 11:56 am. (b). Order on 6/26/2025 at 10:30 am, by MD # 31 (Doctor of Medicine-MD/Pulmonary) indicated Morphine 2 mg (milligram) IV (Intravenous) Q (every) 4 hrs (hours) as needed. (c). MAR dated 6/26/2025 lacked documentation entry by N # 20 (RN {Registered Nurse}- Staff Nurse - Agency Nurse) for Morphine administration for am/day shift (7:00 am - 6:59 pm). 3. Review of Pharmacy document (medLogic) for Med-dispense, on 6/26/2025; for pull of Morphine, for patient # 4, indicated - Quantity 1; Morphine Injectable - 2 mg; User: N # 20, Witness: A # 1 (Chief Clinical Officer); for patient # 4; date/time: 6/26/2025 at 10:06 am. 4. In interview on 8/19/2025 at approximately 2:20 pm (via phone) with A # 1, confirmed the following: (a). Verified Morphine 2 mg IV was given to patient # 4, after pull from the Med-dispense at 10:06 am, and was noted as a new order - on 6/26/2025. (b). N # 20 did not note entry - initial on MAR for Morphine 2 mg IV given at 10:06 am.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 48704 Based on document review and interview, facility failed to provide documentation of results of a patient’s grievance in 1 of 1 grievances reviewed. Findings include: 1. Facility policy titled, A.1.02 Patient - Family Grievances, PolicyStat ID 16073807, last revised 07/2024, indicated under POLICY: Complaint/Grievance Process Guidelines, B. Grievance, 5. Once the Committee in the Corporate Quality/Risk Management Representative make a final decision a written response will be provided to the complainant within 5 working days. The written response will include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigative process, as appropriate, and the date of the completion. The response will not exceed 30 days from the original receipt of the grievance. 2. Review of grievance dated 10/23/2024, indicated patient 4 was not admitted with any wounds and after this current hospitalization, has wounds; report indicated A3 (Director of Quality) met with family and began an investigation. Grievance indicated a turning schedule every 2 hours was implemented and would be monitored to confirm compliance; report indicated compliance was met and grievance was closed on 11/12/2024. 3. Interview with A3 (Director of Quality) on 11/21/2024 at approximately 3:30 p.m. confirmed there was no documentation of an audit for compliance with every 2 hour turns for the grievance related to patient 4 dated 10/23/2024.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to follow the staffing policy for 2 of 28 shifts reviewed. Findings Include: 1. Facility policy titled, D.4.01 Staffing Plan, PolicyStat ID 12509543, last reviewed 10/2022, indicated under PROCEDURE: 8. Work Schedule: D. The appropriate number of qualified staff should be on duty at all times according to staffing guidelines based on census and acuity. 2. Review of Facility document titled, Moderate AMG Acuity Staffing Grid CMI (1.3-1.8) indicated that for census of 22 patients, the facility would be staffed with 3 Registered Nurses, 2 Licensed Practical Nurses, and 3 Certified Nursing Assistants. 3. Review of the Staffing Pattern Worksheet completed by the facility, indicated the facility was not staffed per staffing guidelines on the following dates between 10/06/2024 through 11/16/2024: a. 10/17/2024: census of 22, which required 3 Registered Nurses, 2 Licensed Practical Nurses, and 3 certified nursing assistance, short 1 certified nursing assistant from 6:00 a.m. to 6:00 p.m. b. 11/16/2024: census of 22, which required 3 Registered Nurses, 2 Licensed Practical Nurses, and 3 certified nursing assistance, short 1 certified nursing assistant from 6:00 a.m. to 6:00 p.m.”

“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: 48704 Based on document review and interview, nursing services failed to document Braden Scale assessments in 10 of 10 patient (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) medical records reviewed; failed to document wound skin assessment, failed to document daily bath, failed to document patient turns every two hours, and failed to document wound care on the Treatment Administration Record in 1 of 10 patient (Patient 4) medical records reviewed. Findings include: 1. Facility policy titled, L.12.07 Skin Care Protocol, PolicyStat ID 11075060, last reviewed 01/2022, indicated under PROCEDURE: 1. Braden Scale is completed at time of admission and daily.; 4. Low Risk (?16), A. Skin Hygiene and Inspection, i. Bathe daily with mild soap, rinse, and dry thoroughly; At Risk (<16), A. Skin Hygiene and Inspection, ii. Bathe daily with mild soap, rinse, and dry thoroughly. 2. Facility policy titled, L. 12.06 Pressure Injury Prevention, PolicyStat ID 15781619, last revised 05/2024, indicated under PROCEDURE: 2. A general skin assessment will be performed by the RN or LPN/LVN on every shift; and under PROCEDURE: 12. If bed bound, reposition every two hours; if chair bound, reposition a minimum of every hour or more frequently if necessary. 4. Review of Patient 1’s medical record lacked documentation of the patient’s Braden Scale upon admission and on 10/04/2024. 5. Review of Patient 2’s medical record lacked documentation of the patient’s Braden Scale upon admission and on 10/04/2024. 6. Review of Patient 3’s medical record lacked documentation of the patient’s Braden Scale upon admission and on 10/04/2024. 7. Review of Patient 4’s medical record indicated the following: a. Medical record lacked documentation of the Braden Scale assessment on 10/04/2024, 11/06/2024, 11/10/2024, and 11/13/2024. b. Medical record lacked documentation of the wound/skin assessment on the following dates: 10/03/2024 day shift, 10/04/2024 day and night shift, 10/05/2024 day and night shift, 10/06/2024 day and night shift, 10/08/2024 night shift, 10/09/2024 night shift, 10/10/2024 night shift, 10/11/2024 night shift, 10/12/2024 night shift, 10/13/2024 day and night shift, 10/14/2024 day and night shift, 10/15/2024 day and night shift, 10/16/2024 day and night shift, 10/17/2024 day and night shift, 10/18/2024 night shift, 10/19/2024 day shift, 10/21/2024 day and night shift, 10/22/2024 night shift, 10/23/2024 day and night shift, 10/27/2024 night shift, 10/28/2024 day and night shift, 10/29/2024 evening shift, 10/30/2024 day shift, 10/31/2024 day and night shift, 11/02/2024 day shift, 11/07/2024 day shift, 11/08/2024 day and night shift, 11/09/2024 day and night shift, 11/10/2024 day and night shift, 11/11/2024 day and night shift, 11/12/2024 day and night shift,11/14/2024 night shift, 11/15/2024 night shift, 11/18/2024 day and night shift, 11/19/2024 day and night shift, and 11/20/2024 day and night shift. c. Medical record lacked documentation of the patient’s daily bath on 10/02/2024, 10/03/2024, 10/10/2024, 10/11/2024, 10/12/2024, 10/15/2024, 10/18/2024, 10/23/2024, 10/25/2024, 10/26/2024, 10/28/2024, 10/29/2024, 10/31/2024, 11/04/2024, and 11/09/2024. d. Medical record lacked documentation of patient turns every two hours: on 10/21/2024, patient was turned at 1 p.m. and lacked documentation at 3 p.m., 5 p.m., and 7 p.m.; on 10/26/2024, patient was turned at 5 p.m. and lacked documentation at 7 p.m., 9 p.m., 11 p.m. and on 10/27/2024 at 1 a.m., 3 a.m., 5 a.m. e. Medical record indicated on 10/22/2024 at 3:23 p.m. the provider ordered to cleanse the left and right ischial wounds, apply Therahoney cover with foam dressing on Mondays, Wednesdays, and Fridays, and prn; cleanse sacrum wound, apply Therahoney cover with foam dressing on Monday Wednesdays, and Fridays, and prn. The Treatment Administration Record lacked documentation of wound dressing changes and care on 10/23/2024, 10/25/2024, 10/28/2024, and 10/30/2024. 8. Review of Patient 5’s medical record lacked documentation of the patient’s Braden Scale upon admission, on 11/06/2024, and on 11/13/2024. 9. Review of Patient 6’s medical record lacked documentation of the patient’s Braden Scale upon admission. 10. Review of Patient 7’s medical record lacked documentation of the patient’s Braden Scale on 10/15/2024. 11. Review of Patient 8’s medical record lacked documentation of the patient’s Braden Scale upon admission, on 11/06/2024, and on 11/13/2024. 12. Review of Patient 9’s medical record lacked documentation of the patient’s Braden Scale upon admission, on 10/30/2024, on 11/06/2024, and on 11/13/2024. 13. Review of Patient 10’s medical record lacked documentation of the patient’s Braden Scale upon admission, on 11/16/2024, on 11/17/2024, and on 11/18/2024. 14. Interview with S1 (Wound Care Nurse) on 11/21/2024 at approximately 3:00 p.m. confirmed patient 4’s Treatment Administration Record lacked documentation of wound care as mentioned above. 15. Interview with A1 (Chief Clinical Officer) and A3 (Director of Quality) on 11/21/2024 at approximately 4:35 p.m. confirmed the following: a. Patients 1, 2, 3, 5, 6, 7, 8, 9, and 10’s medical record lacked documentation of the Braden Scales as mentioned above. b. Patient 4’s medical record lacked documentation of the Braden Scale assessment, lacked nursing documentation of the wound care/nursing dressing change assessment, lacked documentation of every 2 hour turns, and lacked documentation of the patient’s daily bath as mentioned above.”