Riverside Community Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure the patient’s right to receive care in a safe setting was provided when the patient was not securely placed on interventional radiology (a medical specialty which uses advanced imaging to guide tiny instruments through the body to diagnose and treat diseases) procedure table, for one of 19 sampled patients (Patient 3) (Refer to A-0144). The cumulative effects of these systemic failures resulted in Patient 3 falling from the IR procedure table and sustaining an intracranial hemorrhage (bleeding in the brain) and a laceration (a torn, ragged, or irregular wound) on the forehead.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48562 Based on interview and record review, the facility failed to ensure the patient’s right to receive care in a safe setting was provided when the patient was not securely placed on interventional radiology (a medical specialty which uses advanced imaging to guide tiny instruments through the body to diagnose and treat diseases) procedure table, for one of 19 sampled patients (Patient 3). This failure resulted in Patient 3 falling from the IR procedure table and sustaining an intracranial hemorrhage (bleeding in the brain) and a laceration (a torn, ragged, or irregular wound) on the forehead. Findings: On April 22, 2026, at 9:55 a.m., a review of Patient 3’s record was conducted with the Quality Coordinator (QC). A facility document titled, “ED (Emergency Department, unit which is open 24 hours a day and treats patients with severe or life-threatening conditions) Report,” dated February 20, 2026, at 11:53 p.m., was reviewed. The document indicated, “...Transfer from [name of Facility C] for LVO [large vessel occlusion, a blockage in one of the major blood vessels in the brain]...Last known well was 2/20 [February 20, 2026] 9:30 p.m. CT [computed tomography, a medical imaging which provides detailed, cross sectional images of the body] at [name of Facility C] showed the LVO...After CT, NIR [neurointerventional radiology, a branch of medicine which uses image-guided techniques to diagnose and treat blood vessel diseases of the brain, head, neck and spine] was paged to take patient [Patient 3] to OR [operating room]...” A facility document titled, “Nursing notes,” dated February 20, 2026, was reviewed. The document indicated, “...0009 [12:09 a.m.] patient [Patient 3] taken to IR...0012 [12:12 a.m.] in IR suite pending arrival of receiving team [IR team who will be caring for Patient 3]...” A facility document titled, “Critical Care H&P [History and Physical],” dated February 21, 2026, at 12:40 a.m., was reviewed. The document indicated, “...after he transferred to the procedure table and secured staff apparently heard a loud thud to only find him on the floor seizing...laceration sustained to his forehead...patient intubated (when a flexible tube is inserted into a patient’s windpipe to maintain an open airway, deliver oxygen, or facilitate breathing)...” An untitled facility document, dated February 21, 2026, was reviewed. The document indicated, “...Patient [Patient 3] on table [procedure table] 0041 [12:41 a.m.]...0053 [12:53 a.m.] patient fell from table having seizures [sudden and temporary change in the electrical and chemical activity in the brain which leads to a change in a person’s movement]...0100 [1 a.m.] Code [code blue, an emergency alert indicating a patient is experiencing a life-threatening, critical condition] team at bedside, patient intubated to protect airway, bleeding from forehead, taken to CT for brain and spine CT...” A facility document titled, “Operative Report,” dated February 21, 2026, was reviewed. The document indicated, “...Although brought to suite [IR suite] in timely manner, patient [Patient 3] had a seizure which caused him to fall from the table and strike his head, resulting in significant amount of bleeding. Sent to Xray [an imaging procedure] for a head CT which did not reveal an intracranial hem [hemorrhage, bleeding in the brain]...Brought back to IR for thrombectomy [a procedure performed to remove blood clots from blood vessels]. Following his seizure falling and head injury, patient was intubated and mechanically ventilated [a medical treatment using a machine to help a patient breathe when they are unable to on their own]...” An interview and record review were conducted on April 23, 2026, at 12:35 p.m., with the IR Registered Nurse (IR RN). The IR RN stated there are no straps, rails, nor safety belts used to secure Patient 3 while the patient was on the IR procedure table. The IR RN stated she usually sees facilities using a safety strap which secures the patients on the procedure table, but these are not used at this facility. The IR RN further stated the facility has no policy to secure a patient or for staff to stay with the patient while a patient is on the IR procedure table. An interview was conducted with the IR Tech (IRT), on April 23, 2026, at 12:57 p.m. The IRT stated there are no rails or straps used to secure patients on the IR procedure table. The IRT stated there are only L shaped arm boards which are slid under the mattress to support the patient’s arms while a patient is on the IR procedure table. The IRT stated his back was to Patient 3 when Patient 3 started to seize and fell from the IR procedure table. The IRT stated he heard a thud and found Patient 3 had fallen from the other side of the IR procedure table and was bleeding from his head. An interview was conducted on April 23, 2026, at 12:57 p.m., with the IR Supervisor (IRS). The IRS stated the facility does not have a policy for securing patients or for safety in the IR procedure room.”

“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: 42512 Based on interview and record review, the facility failed to ensure the facility’s policy and procedure (P&P) was implemented when a patient was not turned or repositioned every two hours, for one of 19 sampled patients (Patient 19). This failure could have contributed to the development of pressure injuries (area of damage to the skin and underlying tissues caused by prolonged pressure) to Patient 19’s coccyx and ankle. This failure had the potential to lead to prolonged hospital stay and the development of hospital-acquired infection for Patient 19. FINDINGS: According to an undated National Pressure Injury Advisory Panel (NPIAP) article, Stage 3 Pressure Injury is a full-thickness (extending from the skin to the fat below) skin loss, in which adipose (fat) is visible in the ulcer (wound) and granulation tissue (newly formed tissue which fills a wound during healing) and epibole (rolled wound edges) are often present. Slough (dead tissue which accumulates on a wound, potentially hindering healing and increasing infection risk) and/or eschar (dead tissue which forms dry, leathery layer over wound) may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity (fatty layer) can develop deep wounds. Undermining (tissue destruction which extends beneath the intact skin surrounding the wound creating hidden pockets which may hinder healing) and tunneling (formation of a narrow channel from the surface of a wound into deeper tissues, often complicating healing process) may occur. On April 27, 2026, at 2:25 p.m., a review of Patient 19’s record was conducted with the Performance Improvement (PI) and the Wound Care Nurse (WCN). A facility document titled, “In/Out/ER [Emergency Department, unit which provides immediate, unscheduled care for patients with serious illnesses or injuries] PATIENT ADMISSION RECORD,” dated December 24, 2025, was reviewed. The document indicated Patient 19 was admitted to the facility on December 24, 2025, at 11:54 p.m. A facility document titled, “History of Present Illness,” dated December 25, 2025, at 12:35 a.m., was reviewed and indicated, “...[Patient 19] transferred from outside hospital for neurosurgical [the branch of medicine dealing with the surgical treatment, diagnosis, and management of disorders affecting the brain, spinal cord, and spinal column] evaluation of severe spinal stenosis [a long-term, age-related condition characterized by the narrowing of the backbone]...” A facility document titled, “PATIENT ASSESSMENT,” dated December 25, 2025, at 2 a.m., was reviewed. The document indicated, “...SKIN RISK...Assess adult skin risk...yes...Sensory perception...no impairment...Moisture...Rarely moist...Out of bed activity...Bedfast [confined to bed]...In bed mobility...Slightly limited...Nutrition...Adequate...Friction and shear...No apparent problem...Pressure injury risk score [an assessment tool for risk of developing pressure injuries, with 13 to 14 meaning high risk, 15 to18 meaning mild risk]...18...Risk for pressure injury...Alert and oriented...Yes...Ambulation...non ambulatory...Skin alteration...BLANCHABLE [when the redness temporarily disappears when a reddened area of the skin is gently pressed then quickly returns to normal color when pressure is released] REDNESSS heels bilateral...BLANCHABLE REDNESS Posterior Coccyx [tailbone]...HEALING PRESSURE INJURY Lateral [away from the midline, on the side] Ankle left..” A facility document titled, “Wound/Ostomy [a surgical procedure that creates an opening in the body to divert bodily waste out of the body ] Service,” dated December 30, 2025, at 11:08 a.m., was reviewed. The document indicated, “...Reason for Consult...Lateral ankle pressure injury... Adult Risk Score=18...left medial malleolus [the bump on the inner side of the ankle] with scab vs. [versus] eschar. Small brown, rough textured raised area measuring approx.[approximately] 0.3 x [by] 0.7 cm [centimeter, a unit of measurement]...” A facility document titled, “Wound/Ostomy Service,” dated January 19, 2026, at 3:08 p.m., was reviewed. The document indicated, “...Reason for Consult...re-assessment of buttocks/coccyx...Adult Risk Score=18...coccyx [tailbone]/top of gluteal cleft [a vertical groove which separates the two buttocks] with combination of pressure injury- DTI [deep tissue injury, a pressure-related damage which affects the deeper layers of a muscle, fat, or sometimes bone]- which is evolving and partial thickness and full thickness open areas... Measuring approx. 5.5 [five and a half] x 4.5 [four and a half] x 0.2 cm...Edges our irregular, area is painful to palpation...Per [according to] patient [Patient 19] she has had a previous wound in the coccyx region which had resolved and closed prior to her admission here on 12/24/25 [December 24, 2025]... Right buttocks wounds which were seen on this patient’s right buttocks there are three partial thickness [damage to the epidermis and part of the dermis (parts of the skin), leaving deeper skin structures intact] open areas, circular in shape... Measuring less than 0.5 x 0.5 x 0.1 cm...” A facility document titled, “Wound/Ostomy Service,” dated January 28, 2026, at 2:53 p.m., was reviewed. The document indicated, “...Reason for Consult...coccyx/top of gluteal cleft now with Stage 3 pressure injury measuring approx. 3 [three] x 4 [four] x 1.2 cm, wound bed [the exposed tissue at the base of an open wound] with 60 % [percent] grey/brownish attached soft necrotic [dead tissues] tissue, 40 % pink/red. Edges flat and attached...Very sensitive when this area palpated [touched]...” A facility document titled, “Wound/Ostomy Service,” dated February 09, 2026, at 2:53 p.m., was reviewed. The document indicated, “...Reason for Consult...Multiple new/undocumented pressure injuries/skin tears/discoloration... Adult Risk Score=13...Unable to turn patient due to HD [hemodialysis,medical treatment that filters waste and excess fluids from the blood when the kidneys can no longer perform this function effectively] set up but was able to assess right chest and left foot wounds ...” A facility document titled, “Assessment Forms History,” dated December 25, 2025, through February 23, 2026, was reviewed. The document indicated Patient 19 was not turned or repositioned on the following dates and times, in accordance with the facility’s P&P: - From December 28, 2025, at 4 p.m., to December 28, 2025, at 8 p.m. (4 hours); - From December 30, 2025, at 2 p.m., to December 30, 2025, at 11 p.m. (9 hours); - From December 31, 2025, at 6 a.m., to December 31, 2025, at 4:56 p.m. (10 hours 56 minutes); - From January 2, 2026, at 12 p.m., to January 2, 2026, at 4 p.m. (4 hours); - From January 5, 2026, at 10:52 a.m., to January 5, 2026, at 8 p.m. (9 hours 8 minutes); - From January 5, 2026, at 8 p.m., to January 6, 2026, at 10:41 a.m. (14 hours 41 minutes); - From January 6, 2026, at 10:41 a.m., to January 6, 2026, at 8 p.m. (9 hours 19 minutes); - From January 6, 2026, at 8 p.m., to January 7, 2026, at 8 a.m. (12 hours); - From January 9, 2026, at 6 a.m., to January 9, 2026, at 8 p.m. (14 hours); - From January 10, 2026, at 4 a.m., to January 10, 2026, at 8 a.m. (4 hours); - From January 10, 2026, at 4 p.m., to January 10, 2026, at 8 p.m. (4 hours); - From January 14, 2026, at 6 a.m., to January 14, 2026, at 8:30 p.m. (14 hours 30 minutes); - From January 15, 2026, at 5:21 a.m., to January 15, 2026, at 10 a.m. (4 hours 39 minutes); - From January 15, 2026, at 8:45 p.m., to January 16, 2026, at 6:51 a.m. (10 hours 6 minutes); - From January 16, 2026, at 6:51 a.m., to January 16, 2026, at 8 p.m. (13 hours 9 minutes); - From January 17, 2026, at 4 p.m., to January 17, 2026, at 8 p.m. (4 hours); - From January 18, 2026, at 6 a.m., to January 18, 2026, at 11 a.m. (5 hours); - From January 18, 2026, at 11 a.m., to January 18, 2026, at 4:52 p.m. (5 hours 52 minutes); - From January 19, 2026, at 4 p.m., to January 19, 2026, at 8 p.m. (4 hours); - From January 21, 2026, at 3:58 p.m., to January 21, 2026, at 8 p.m. (4 hours); - From January 22, 2026, at 4 a.m., to January 22, 2026, at 8:25 a.m. (4 hours 25 minutes); - From January 22, 2026, at 2:03 p.m., to January 22, 2026, at 5:43 p.m. (3 hours 40 minutes); - From January 24, 2026, at 8 a.m., to January 24, 2026, at 7:50 p.m. (11 hours 50 minutes); - From January 25, 2026, at 12 p.m., to January 25, 2026, at 8 p.m. (8 hours); - From January 28, 2026, at 4 a.m., to January 28, 2026, at 8:11 a.m. (4 hours 11 minutes); - From January 29, 2026, at 1:03 a.m., to January 29, 2026, at 4:40 a.m. (3 hours 37 minutes); - From January 29, 2026, at 4:40 a.m., to January 29, 2026, at 8 a.m. (3 hours 20 minutes); - From January 29, 2026, at 1:21 p.m., to January 29, 2026, at 6:03 p.m. (4 hours 42 minutes); - From January 30, 3036, at 4 a.m., to January 30, 2026, at 8 a.m. (4 hours); - From January 30, 2026, at 4:16 p.m., to January 30, 2026, at 8:20 p.m. (4 hours 4 minutes); - From February 2, 2026, at 6 a.m., to February 2, 2026, at 10 a.m. (4 hours); - From February 3, 2026, at 4 a.m., to February 3, 2026, at 8 a.m. (4 hours); - From February 5, 2026, at 8 a.m., to February 5, 2026, at 12 p.m. (4 hours); - From February 5, 2026, at 12 p.m., to February 5, 2026, at 4 p.m. (4 hours); - From February 6, 2026, at 10 a.m., to February 6, 2026, at 2 p.m. (4 hours); - From February 6, 2026, at 4 p.m., to February 6, 2026, at 8 p.m. (4 hours); - From February 7, 2026, at 2 p.m., to February 7, 2026, at 8 p.m. (6 hours); - From February 12, 2026, at 12 p.m., to February 12, 2026, at 4 p.m. (4 hours); - From February 12, 2026, at 4 p.m., to February 12, 2026, at 8 p.m. (4 hours); - From February 14, 2026, at 12 p.m., to February 14, 2026, at 4 p.m. (4 hours); - From February 14, 2026, at 4 p.m., to February 14, 2026, at 10 p.m. (6 hours); - From February 16, 2026, at 6 a.m., to February 16, 2026, at 6 p.m. (12 hours); - From February 17, 2026, at 12 p.m., to February 17, 2026, at 4 p.m. (4 hours); and - From February 20, 2026, at 2 p.m., to February 20, 2026, at 8 p.m. (6 hours) There was no documented evidence the wounds to the coccyx/top of gluteal cleft of Patient 19 were assessed by the wound care team on or after January 28, 2026. There was no documented evidence Patient 19 was turned or repositioned every two hours in accordance with the facility’s P&P. During a concurrent interview conducted with the PI, the PI stated Patient 19 should have been turned or repositioned every two hours. The PI stated there were gaps in the turning or repositioning every two hours for Patient 19. On April 27, 2026, at 2:25 p.m., an interview was conducted with the WCN. The WCN stated when a wound care consult is ordered for a patient, the wound care team tries to see the patient within 48 hours. The WCN stated the patient’s nurse is responsible for repositioning a patient that cannot reposition themselves. A review of the facility P&P titled, “Pressure Injury Prevention,” dated July 23, 2025 was conducted. The policy indicated, “...Interventions and an individualized plan of care will be implemented and documented as appropriate...Preventative measures should be applied based on individualized risk factors...interventions may be considered, but not limited to...Mobility/Activity and Repositioning...promote early and frequent mobility...Provide/assist the patient with repositioning & [and] turning as needed...Friction and Shear...Reposition every 2 [two] hours...””

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 42512 Based on observation, interview, and record review, the facility failed to ensure a patient’s medications were locked and secured to prevent unauthorized access by the patient, staff, or visitors in the Medical Intensive Care Unit (MICU, a specialized unit which provides care to critically ill patients), for one of 19 sampled patients (Patient 18). This failure had the potential for unauthorized access to strong and addictive medications that may affect the safety of, cause overdosage (an excessive or deadly dose of a medication which overwhelms the body ’ s ability to manage it] of the medications, and a delay in Patient 18’s recovery. Findings: On April 20, 2026, at 3:23 p.m., a tour of the MICU was conducted with the Manager of MICU (MMICU). Upon entering Patient 18’s room, a clear box was observed enclosing two intravenous (IV, administered through a vein) medications. One of the medications was observed to be labeled “Propofol [a highly addictive and strong IV pain medication used to induce and maintain sedation (a state of calm, relaxation, or sleepiness induced by the use of medications) to patients receiving mechanical ventilation [life-support treatment using a machine to move breathable air into and out of the lungs when a person cannot breathe on their own] in the MICU with overdosing having a potential to cause death].” The other medication was observed to be labeled “Fentanyl [a pain medication used to help with sedation and carries a high risk for addiction with overdosing having a potential to cause death].” The medication box was observed to have a long piece of white adhesive strip holding the door of the box closed. The medication box was observed to have a keyhole and a metal mechanism used to lock the box. The metal mechanism on the medication box was observed to not be engaged and the medication box was observed to be open without using a key. The MMICU was observed to retrieve the key to the medication box from the Pyxis (an automated medication dispensing system used to securely store, manage, and dispense medications) and was observed to be able to lock the medication box in Patient 18’s room using the key. During a concurrent interview conducted with the MMICU, the MMICU stated propofol and fentanyl are controlled medications (medications which are strictly regulated by the government because of their high potential for abuse, addiction, and physical/mental dependence) and the box enclosing them was used to secure them. The MMICU stated tape should not be used to secure the medication box. The MMICU stated the medication box should have been locked to prevent access to the two medications by unauthorized persons. The MMICU stated he was unsure if the metal lock mechanism on the medication box was broken. The MMICU stated the key to the medication box is stored in the Pyxis. The MMICU stated the medication box was not broken, and should have been locked. On April 27, 2026, at 2 p.m., a review of Patient 18’s records was conducted with the Performance Improvement (PI). A facility document titled, “In/Out/ER PATIENT ADMISSION RECORD,” dated April 16, 2026, was reviewed. The document indicated Patient 18 was admitted to the facility on April 16, 2026, at 7:11 a.m. for hypoglycemia (low blood sugar, normal is 70 to 99 mg/dl [milligrams per deciliter, unit of measurement]) A review of a facility document titled, “History of Present Illness,” dated April 16, 2026, at 7:25 a.m., was conducted. The document indicated Patient 18 was admitted to the facility for altered mental status (a change in a person’s usual mental function), and blood sugar of 21. The document indicated Patient 18 has a past medical history of diabetes mellitus (a long term condition where the body cannot properly use its blood sugar leading to high or low blood sugar levels) and chronic kidney disease (a long term condition caused by damaged kidneys which lose their ability to filter waste from the body). A review of a facility document titled, “IV Medication,” dated April 18, 2026, at 7:42 a.m., was conducted. The document indicated, “...Volume...100 ml [milliliters, a unit of measurement] @ [at] TITRATE [to continuously measure and adjust the dose of the medication]...Directions...ASDIR [as directed]...Route...IV...Propofol...” A review of a facility document titled, “IV Medication,” dated April 22, 2026, at 12:51 p.m., was conducted. The document indicated, “...Start Date...April 22, 2026, 12:51 [12:51 p.m.]...Fentanyl Citrate...2 [two] ML...” A review of “DailyMed,” a nationally recognized drug reference, was conducted. The document indicated, “ ...PROPOFOL injection, emulsion...abuse of propofol for recreational and other improper purposes, which have resulted in fatalities and other injuries. Instances of self-administration of propofol injectable emulsion by heath care professionals have also been reported, which have resulted in fatalities...propofol injectable emulsion should be stored and managed to prevent the risk of diversion [illegal redirection of prescription drugs from their intended purpose to another person, or misuse], including restriction of access...to the clinical setting...” The document also indicated, “...FENTANYL CITRATE injection, solution ...Addiction, Abuse, and Misuse...Fentanyl...injection exposes patients and other users to the risk of opioid addiction, abuse and misuse, which can lead to overdose and death ...” A review of the facility’s policy and procedure titled, “Substance Use in the Workplace,” dated May 1, 2020, was conducted. The P&P indicated, “...To prohibit inappropriate drug...use...in the workplace...Safeguard Controlled Substances from unauthorized access...” A review of the facility’s P&P titled, “Medication Procurement Storage and Security,” dated September 2022, was conducted. The document indicated, “...MEDICATION SECURITY...All medications must be kept in a secure area, and locked when appropriate. A secure area means that medications are stored in a manner to prevent unmonitored access by unauthorized individuals...””

“The following reflects the findings of the California Department of Public Health, Life Safety Code Section, during a Complaint Validation Survey authorized by the Centers for Medicare and Medicaid Services Region IX to investigate the following intakes: CA00997248 and CA00997544. Inspection was limited to the authorized Conditions of Participation [42 Code of Federal Regulations 482.41(b) Life Safety Code] reviewed for the specific intakes and did not represent the findings of a full inspection of the facility. One Life Safety Code tag, K291, was written as a result of intakes CA00997248 and CA00997544. The average daily census was 24.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 43035 Based on document review and interview, the facility failed to maintain the battery powered emergency lighting. This was evidenced by a failure to complete corrections to a battery powered emergency lighting unit identified as failed during an annual testing. This affected one of six floors in C Tower at the Main Hospital and could result in inability and failure to evacuate in the event of an emergency. NFPA 101 - Life Safety Code, 2012 Edition 19.2.9 Emergency Lighting. 19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9. 7.9.3 Periodic Testing of Emergency Lighting Equipment. 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3. 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2)* The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 11/ 2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 7.9.3.1.2 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided. (2) Not less than once every 30 days, self-testing/self-diagnostic battery-operated emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine. (3) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall indicate failures by a status indicator. (4) A visual inspection shall be performed at intervals not exceeding 30 days. (5) Functional testing shall be conducted annually for a minimum of 11/ 2 hours. (6) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be fully operational for the duration of the 11/ 2-hour test. (7) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 7.9.3.1.3 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Computer-based, self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided. (2) Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine. (3) The emergency lighting equipment shall automatically perform annually a test for a minimum of 11/ 2 hours. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2) and (3). (5) The computer-based system shall be capable of providing a report of the history of tests and failures at all times. Findings: During document review and interview with the Director of Facility Management and Quality Vice President on 4/23/2026, the battery powered emergency lighting testing records were reviewed. At 10:11 a.m., the facility provided 90-minute annual testing documentation of the battery powered emergency lighting titled “Battery Powered Egress Lights” which indicated a failure of equipment number “CE-8.” The facility was unable to provide corrective documentation or an equivalent work order of the failed equipment. Upon interview, the Director of Facility Management and Quality Vice President confirmed the finding and stated that a proper work order was not submitted.”

“COMPLIANCE WITH LAWS CFR(s): 482.11(a) The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. This Standard is not met as evidenced by: 38479 Based on observation, interview, and record review, the facility failed to ensure the facility complied with state regulations when an approved program flex (a process where a hospital requests an exception from certain state licensing or regulatory requirements) was not obtained prior to the use of four isolation rooms (specialized hospital rooms designed to prevent the spread of infection) in the Post Anesthesia Care Unit (PACU, a unit where patients recover from anesthesia and surgery) (PACU Rooms 1, 2, 3, and 4) for the provision of dialysis (a medical treatment which removes waste products and excess fluid from the blood when the kidneys are not functioning) treatment. This failure resulted in the use of a facility space for which it was not licensed for. The use of the four isolation rooms resulted in the loss of private rooms which were intended to be used for patients with transmissible/infectious disease who require post anesthesia care which had the potential to compromise the care provided for these patients. Furthermore, the four rooms for dialysis was 20 percent over the five percent allowed space which can be used by the facility for whatever intent they need it for without an approved program flex waiver. Findings: On December 22, 2025, at 12:11 p.m., during a tour conducted in the PACU with the Associate Chief Nursing Officer (ACNO), Infection Control Director (ICD), and Surgical Services Director (SSD), an interview was conducted with the SSD. The SSD stated the PACU receives and care is provided for patients coming from the operating room (OR), Neuro IR (neurointerventional radiology, an invasive procedure using imaging procedures to treat blood vessel diseases in the brain, spine, head, and neck), and Cardiac Catheterization Laboratory (Cathlab, a department where invasive heart procedures using thin tubes [catheters] to diagnose and treat heart/blood vessel problems like blocked arteries [stents], leaky valves, and irregular heartbeats [ablations] without open-heart surgery, often guiding treatments with imaging like x-rays and potentially implanting devices like pacemakers are performed), who had surgery or procedures, and require post (after the administration of) anesthesia (administration of gases or the injection of drugs before surgical operations for pain management) care. The SSD stated PACU had 20 beds, four of which were intended as isolation rooms (PACU Rooms 1, 2, 3, and 4). On December 22, 2025, at 12:20 p.m., PACU Rooms 1, 2, 3, and 4, were visited and inspected with the SSD, the ACNO, and the ICD. Rooms 1 and 2 were observed to be vacant, while Rooms 3 and 4 was observed to have patients with ongoing dialysis procedures and Registered Nurse (RN) 4 was observed watching over the two patients. On December 23, 2025, at 2:23 p.m., a facility document, “APPROVAL OF PROGRAM FLEXIBILITY FOR FLEX-10363,” dated November 7, 2025, was reviewed with the Patient Safety Director (PSD). The document indicated, “...Your request for program flexibility of T22 DIV5 CH1 ART8-70805 is approved under the following conditions: 1. Hospital approved to offer inpatient adult hemodialysis for a maximum of six (6) patients...in the Dialysis Suite, OPSU 0226-21...” During a concurrent interview with the PSD, the PSD stated the document was an approved program flex for the use of the Dialysis Unit on the first floor of the facility. The PSD stated the facility did not have an approved program flex for the use of the PACU isolation room for dialysis procedures. The PSD stated they are using PACU Rooms 1, 2, 3, and 4, which are isolation rooms, for dialysis procedures on patients. On December 23, 2025, at 2:45 p.m., the PACU was visited with PSD. The PSD stated she was aware of the regulation that 5 (five) % (percent) of the beds in the PACU can be used for any purposes other than for which it was licensed when needed. On December 23, 2025, at 2:49 p.m., the Title 22 70805 and 70809(b) regulations were reviewed with the SSD. During a concurrent interview with the SSD in the presence of the PSD, the SSD stated, “I don’t know the exact allowable bed we can use for any purposes,” but four rooms (PACU Rooms 1, 2, 3, and 4) are being allocated for dialysis procedures and these rooms make up 20 percent of the 20 bed/bays in PACU. The SSD stated one bed was the only allowable bed the facility can use for dialysis or for any other purposes at the PAC without an approved program flex. According to California Code of Regulations (CCR), Title 22, Division 5, §70805, “...Spaces approved for specific uses at the time of licensure shall not be converted to other uses without the written approval of the Department [California Department of Public Health, a state agency]...” According to California Code of Regulations (CCR), Title 22, Division 5, §70809. Patient Accommodations. (b) “Five percent of a facility’s total licensed bed capacity may be used for classification other than that designated on the license. Upon application to the Director and a showing that seasonal fluctuations justify, the Director may grant the use of an additional five percent of the beds for other than the classified use...(c) Patients shall not be housed in areas which have not been approved...””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50454 Based on interview and record review, the facility failed to ensure safety measures were implemented, for one of 50 sampled patients (Patient 6), when amiodarone (a medication used to treat life-threatening heart rhythms) was not stocked in the emergency department (ED, a section within a hospital used for urgent needs and life-threatening conditions) crash cart (a mobile, wheeled cabinet in hospitals stocked with essential equipment, medications, and supplies needed for immediate response to life-threatening emergencies), during a code blue (a hospital alert for a critical, life-threatening emergency) which was initiated for Patient 6. This failure had the potential to result in a delay of emergency treatment and an increased risk of harm for Patient 6. Findings: On December 22, 2025, at 2:30 p.m., a review of Patient 6’s record was conducted with the Sepsis Coordinator (SC). A facility document titled, “EMERGENCY PROVIDER REPORT,” dated October 24, 2025, authored by the Resident (Res, a physician who has graduated from medical school but is undergoing supervised training in a specific medical specialty within a hospital or clinic to become fully qualified to practice independently) 3, was reviewed. The document indicated Patient 6 was admitted to the facility on October 24, 2025, and presented to the ED for abdominal (stomach area) pain, nausea, and vomiting for one day.The document indicated Patient 6 was given IV (intra venous, administered into a vein) fluids, Toradol (a medication used for management of moderate to severe acute pain), and Zofran (a medication used to prevent and treat nausea and vomiting). The document indicated about five minutes after receiving the medications, Patient 6 was found to be unresponsive with the cardiac monitor (a monitor which shows the recording of the patients heart rate and rhythm) showing her to be in ventricular tachycardia (V-Tach, a fast, abnormal heart rhythm where electrical signals cause the heart to pump too quickly, preventing enough blood from reaching the body, which can cause dizziness, chest pain, fainting, and even sudden cardiac arrest), and was found to have no pulse. The document indicated a code blue was initiated and cardiopulmonary resuscitation (CPR, an emergency life-saving procedure which is done when someone’s breathing or heartbeat has stopped) was started immediately. The document indicated, “...Code cart [crash cart] did not have amiodarone which caused a slight delay in administration, epinephrine [a widely used medication which is critical in managing various medical emergency conditions] was present [in the crash cart] and epinephrine was administered...” The document indicated Patient 6 was transferred to the high acuity (patients with a severe, complex, or unstable medical condition) area of the ED until she was admitted. A facility document titled, “Emergency Department Notes,” dated October 24, 2025, at 8:56 p.m., authored by the Registered Nurse (RN) 3, was reviewed. The document indicated, “...PT [Patient 6] BECAME UNRESPONSIVE, TENSING UP WITH SEIZURE LIKE ACTIVITY. PT TURNED FOR AIRWAY PROTECTION, IMMEDIATELY CONTACTED [name of Res 3]. PT SHOWING VTACH ON THE [cardiac] MONITOR, CODE BLUE CALLED AT 2057 [8:57 p.m.]...” A facility document titled, “CODE BLUE RECORD,” dated October 24, 2025, at 8:57 p.m., was reviewed. The document indicated, “...DATE: 10/24/25 [October 24, 2025]...TIME OF ARREST [when the heart suddenly stops beating] 2057...TYPE OF ARREST: Cardiac [relating to the heart]...UNCONSCIOUS [when a person can’t respond to people or their surroundings]:Yes...TIME: 2058 [8:58 p.m.]...EPINEPHRINE 1 [one] mg [milligram, unit of measurement]...CODE OUTCOME...TIME CODE STOPPED: 2100 [9 p.m.]...DISPOSITION FOLLOWING CODE: Critical Care [medical care for people who have life-threatening injuries and illnesses]...TEAM MEMBERS: [name of Res 3]...[name of RN 3]...” On December 23, 2025, at 12:40 p.m., an interview was conducted with the ED director (EDD). The EDD stated when there is not a shortage, it is the expectation that amiodarone should always be stocked in the crash carts. The EDD further stated, “We do not have a lot of code blues in ED 5 [POD-D, a low acuity portion of the ED in which patients are expected to go home, where Patient 6 was initially treated], so it is possible the crash cart was not restocked when the shortage ended.” On December 23, 2025, at 1:10 p.m., an interview was conducted with the Vice President of Quality (VPQ). The VPQ stated the amiodarone shortage started on April 30, 2025. The VPQ stated the amiodarone shortage lasted approximately four months and ended around August 2025 (two months before Patient 6 had a code blue when amiodarone was needed and was not available in the crash cart). On December 23, 2025, at 2:30 p.m., an interview was conducted with RN 3. RN 3 stated he was not aware of the amiodarone shortage. RN 3 stated during the code blue for Patient 6, Res 3 called out for the crash cart and announced there was no amiodarone in the crash cart once he (Res 3) opened the crash cart. RN 3 stated someone ran to the pyxis (an automated medication dispensing cabinet) to get amiodarone. RN 3 stated amiodarone should always be available in the crash cart. RN 3 stated the ED pharmacist was not present during the code blue initiated for Patient 6. RN 3 further stated the absence of amiodarone in the crash cart could have led to a delay in timely treatment for Patient 6. On December 23, 2025, at 2:54 p.m., an interview was conducted with PharmD 2. PharmD 2 stated the amiodarone shortage started in April 2025 and ended in August 2025. PharmD 2 stated after the shortage, as the crash carts were used, the facility’s Pharmacy Department would restock the carts with amiodarone. PharmD 2 stated there is no way to link (a relationship between two things or situations) the crash cart from October 24, 2025, during the code blue for Patient 6 to see if amiodarone was in the crash cart. PharmD 2 stated it is very likely there was no amiodarone in the ED five/POD-D crash carts. PharmD 2 further stated in the ED, a pharmacist should respond to all codes. On December 23, 2025, at 3:30 p.m., On December 23 2025, at 3:30 p.m., a facility document titled, “Amiodarone 150 mg/ 3 [three] ml [milliliter, unit of measurement] and Amiodarone 450 mg/9 [nine] ml,” dated April 30, 2025, authored by the Operations Manager of the Pharmacy department (the hospital’s central hub for managing all medications), was reviewed with PharmD 1. The document indicated, “...To: Medical Staff...Date: April 30, 2025...Situation/Background: There is a current shortage of IV Amiodarone...Recommendation...Pharmacist will reach out daily for transition unit the shortage situation is resolved...DURING CODE BLUE...Crash cart trays amiodarone shortage activated. Any trays being processed as of 4/30/25 [April 30, 2025] 2 p.m. will NOT have Amiodarone 150mg vials stocked...Department of Pharmacy...” During a concurrent interview conducted with PharmD 1, PharmD 1 stated the pharmacist did not restock each crash cart with amiodarone once the shortage was over since there are over 100 crash carts. PharmD 1 stated they restocked crash carts as they were used. PharmD 1 stated normally, we always keep amiodarone in crash carts as it is the expectation. PharmD 1 further stated if amiodarone is not available in a crash cart at the time of a code blue, it can “definitely” cause a delay in patient care. During a review of the facility’s policy and procedure (P&P) titled, “EMERGENCY CARTS CRASH CARTS,” dated April 30, 2025. The P&P indicated “...POLICY...Contents of crash carts, as determined by the above Committees, shall be maintained with the following controls...It shall be the responsibility of Department of Pharmacy services to...Implement such additions, deletion, or modifications by making changes on the CPR drug tray...PROCEDURE...Pharmacy shall be responsible for: Replacement of all required medication on the cart...ADULT CRASH CART DRUG TRAY CONTENTS...AMIODERONE 150MG/3ML...””

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 50433 Based on interview and record review, the facility failed to ensure a physician responds timely aut patient concerns a physician did not return a call after having been paged twice by the Registered Nurse (RN) about the concern of Patient 21’s elevated blood pressure (BP, normal blood pressure range is less than 120 systolic [SBP, top number of the BP reading which measures the pressure in the blood vessel when the heart beats and pushes blood out] and less than 80 diastolic [DBP, bottom number of the BP reading which measures the pressure in the blood vessels when the heart rests and refills with blood between beats]). This failure had the potential to delay patient care and treatment and could result in prolonged hospitalization for Patient 21. Findings: On December 22, 2025, at 2:07 p.m., a review of Patient 21’s chart was conducted with the Cardiovascular Quality Manger (CQM). A facility documented titled, “Hospitalist History & [and] Physical,” dated December 15, 2025, was reviewed. The document indicated Patient 21 was admitted to the facility on December 15, 2025, with a diagnosis of pleural effusion (a buildup of extra fluid in the thin space between the lungs and the chest wall). A facility flow sheet titled, “Blood pressure,” dated December 21, 2025, was reviewed. The document indicated Patient 21 had elevated BP readings of 185/91 on December 21, 2025, at 5:14 a.m., 184/90 at 5:30 a.m., and 164/74 at 7:30 a.m. A facility document titled, “Manage Refer Contact Notify,” dated December 21, 2025, at 5:30 a.m., was reviewed. The document indicated, “...Action: Paged (not notified)...Reason notified: Abnormal vital signs...Pt’s [Patient 21’s] SBP 179- [to] 190s, PRN [as needed] PO [by mouth] hydralazine [medication to lower blood pressure] given but ineffective...I need IV [intravenous, when a medication or fluid is administered directly into a vein] PRN orders for him...” A facility document titled, “Manage Refer Contact Notify,” dated December 21, 2025, at 5:53 a.m., was reviewed. The document indicated, “...Action: Paged (not notified)...Reason: Abnormal vital signs...Second page, pt’s [Patient 21’s] BP still 185/91...Need IV PRN orders...” On December 23, 2025, at 2:34 p.m., an interview was conducted with RN 2. RN 2 stated she had paged Patient 21’s physician twice for Patient 21’s elevated blood pressure on December 21, 2025, and the physician did not call her back. RN 2 stated a patient’s physician should be made aware if a patient’s systolic blood pressure is above 160. RN 2 stated physicians are expected to return a page within 30 minutes to one hour, however, physicians are often paged two or three times before they call back. On December 24, 2025, at 9:31 a.m., an interview was conducted with the Intermediate Care Nurse Manger (ICNM). The ICNM stated a patient’s physician should be notified for systolic blood pressure greater than 160. The ICNM stated physicians are expected to return a page within 30 minutes. A facility policy and procedure (P&P) titled, “Physician Notification Process,” dated February 2023, was reviewed. The P&P indicated, “...The attending physician...will be notified when medical orders are needed...The guidelines for physician response to pages or telephone calls are 30 minutes for a stat call and one hour for a routine call...” A facility document titled, “Medical Staff Rules & Regulations,” dated 2022, was reviewed. The document indicated, “...It is expected that the Medical Staff member will respond to calls from hospital personnel...””

“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: 47071 Based on observation, interview, and record review, the facility failed to ensure the facility’s policy and procedures (P&P) were implemented, for four of 50 sample patients (Patients 21, 24, 30, and 47), when: 1. For Patient 21, the Registered Nurse (RN) failed to escalate the concern about Patient 21’s elevated blood pressure (BP, normal is less than 120 systolic [SBP, top number of the BP reading which measures the pressure in the blood vessel when the heart beats and pushes blood out] and less than 80 diastolic [DBP, bottom number of the BP reading which measures the pressure in the blood vessels when the heart rests and refills with blood between beats]) when Patient 21’s physician did not return a call after having been paged by the RN twice; 2. For Patient 24, the nursing staff did not notify the physician of Patient 24’s elevated BP readings; 3. For Patient 30, the post fall debrief (a protocol following a fall identifying contributing factors to prevent future falls) was not completed and staff RNs were unaware of their responsibility to document the post fall debrief in the facility’s electronic medical record (EMR). In addition, Patient 30’s vital signs (clinical measurements, which include heart rate, temperature, respiratory rate, and BP, which indicate the state of a patient’s essential body functions) were not obtained during a blood transfusion (a medical procedure where donated blood is given directly into a patient’s blood stream) and an order placed by the physician was not completed in a timely manner; and 4. For Patient 47, the assessment of the plantar diabetic foot ulcer (poor control of blood sugar causing a serious open wound on the sole of the foot) was not performed once a shift and the dressing was not changed daily by nursing staff as ordered by the physician. These failures had the potential to compromise patient safety, delay treatment, increase the risk of infection, and may result in prolonged hospitalization for Patients 21, 24, 30, and 47. Findings: 1. On December 22, 2025, at 2:07 p.m., a review of Patient 21’s chart was conducted with the Cardiovascular Quality Manger (CQM). A facility documented titled, “Hospitalist History & [and] Physical (HHP),” dated December 15, 2025, was reviewed. The document indicated Patient 21 was admitted to the facility on December 15, 2025, with a diagnosis of pleural effusion (a buildup of extra fluid in the thin space between the lungs and the chest wall). A facility flow sheet titled, “Blood pressure,” dated December 21, 2025, was reviewed. The document indicated Patient 21 had an elevated BP readings of 185/91 on December 21, 2025, at 5:14 a.m., 184/90 at 5:30 a.m., and 164/74 at 7:30 a.m. A facility document titled, “Manage Refer Contact Notify,” dated December 21, 2025, at 5:30 a.m., was reviewed. The document indicated, “...Action: Paged (not notified}...Reason notified: Abnormal vital signs...Pt’s [Patient 21’s] SBP 179-190’s, PRN [as needed] PO [by mouth] hydralazine [medication to lower blood pressure] given but ineffective...I need IV [intravenous, when medication or fluid is given through a vein] PRN orders for him...” A facility document titled, “Manage Refer Contact Notify,” dated December 21, 2025, at 5:53 a.m., was reviewed. The document indicated, “...Action: Paged (not notified)...Reason: Abnormal vital signs...Second page, pt’s [Patient 21’s] BP still 185/91...Need IV PRN orders...” On December 23, 2025, at 2:34 p.m., an interview was conducted with RN 2. RN 2 stated she paged Patient 21’s physician twice for Patient 21’s elevated blood pressure on December 21. 2025, and the physician did not call back. RN 2 stated she did not utilize the chain of command to escalate the physician’s failure to call her back because Patient 21’s blood pressure was “trending down [decreased measurement over time].” RN 2 stated a patient’s physician should be made aware if a patient’s blood pressure is above 160 systolic. There was no documented evidence Patient 21’s blood pressure reading became lower prior to the end of RN 2’s shift (7 p.m. to 7 a.m. shift on December 23, 2025). There was no documented evidence RN 2 escalated the concern about Patient 21’s high BP using the chain of command, in accordance with the facility’s P&P. On December 23, 2025, at 9:24 p.m., an interview was conducted with RN 1. RN 1 stated if a patient’s SBP is in the upper 150’s to 160’s, she would call the physician if there were no PRN medications (as needed medications) ordered to be given to the patient. On December 24, 2025, at 9:31 a.m., an interview was conducted with the Intermediate Care Nurse Manger (ICNM). The ICNM stated a patient’s physician should be notified for SBP greater than 160. The ICNM stated the physicians are expected to return a page from the facility within 30 minutes of the page and if they don’t return the call a second page goes out to them. The ICNM stated, if the physician has still not called back, a third page can be sent out, if the patient is stable, and it will then be escalated. The facility P&P titled, “Chain of Command Delineation [clear instruction] for Medical Staff,” dated February 2025, was reviewed. The P&P indicated, “...When a patient’s condition requires urgent medical attention and the primary physician fails to respond within an appropriate time frame...staff should follow the chain of command process...until the matter is resolved...” 2. On December 23, 2025, at 9 a.m., a review of Patient 24’s record was conducted with the CQM. A facility document titled, “History and Physical,” dated December 18, 2025, was reviewed. The document indicated Patient 24 was admitted to the facility on December 18, 2025, for elective surgery (a planned, non-emergent procedure). A facility document titled, “Blood pressure,” dated December 20, 2025, was reviewed. The document indicated on December 20, 2025, Patient 24 had an elevated BP readings of 175/73 at 8:40 a.m., and 182/55 at 12:07 p.m. There was no documented evidence the physician was notified of Patient 24’s elevated BP readings on December 20, 2025, at 8:40 a.m. and at 12:07 p.m. On December 23, 2025, at 2:34 p.m., an interview was conducted with RN 2. RN 2 stated a patient’s physician should be made aware if a patient’s blood pressure is above 160 systolic. On December 23, 2025, at 9:24 p.m., an interview was conducted with RN 1. RN 1 stated if a patient’s SBP is in the upper 150’s to 160’s, she would call the physician if there were no PRN medications (as needed medications) ordered to be given to the patient. On December 24, 2025, at 9:31 a.m., an interview was conducted with the ICNM. The ICNM stated a patient’s physician should be notified for SBP greater than 160. The facility P&P titled, “Physician Notification Process,” dated February 2023, was reviewed. The P&P indicated, “...The attending physician...will be notified when medical orders are needed...Examples of circumstances to notify physician(s) include...Significant changes in vitals, such as...hypertension [high blood pressure]...” 3. On December 23, 2025, at 1 p.m., a review of Patient 30’s record was conducted with the CQM. A facility document titled, “GYN [gynecology, a branch of medicine specializing in female reproductive health] Admission H&P,” dated December 17, 2025, was reviewed. The document indicated Patient 30 was admitted to the facility on December 17, 2025, for a myomectomy (a surgical procedure to remove fibroids [non-cancerous growths] from the uterus [a pear shaped, hollow, muscular organ in the female pelvis where a baby develops during pregnancy]). a. A facility document titled, “Rapid Response/Code Record,” dated December 18, 2025, at 6:02 a.m., was reviewed. The document indicated, “...call for patient attempting to get OOB [out of bed] with RN to walk and fell...” There was no documented evidence a post fall debrief was conducted on Patient 30 after the patient fell on December 18, 2025. On December 23, 2025, at 2:34 p.m., an interview was conducted with RN 2. RN 2 stated she was not sure if the post fall debrief is documented on a patient’s chart. On December 23, 2025, at 9:24 p.m., an interview was conducted with RN 1. RN 1 stated she was not aware a post fall debrief should be documented in the patient’s chart. On December 24, 2025, at 9:31 a.m., an interview was conducted with the ICNM. The ICNM stated the RN assigned to a patient is responsible for completing a post fall debrief and there is a section in the facility’s electronic medical record system specific for documenting a post fall debrief. The facility P&P titled, “Patient Fall Prevention Policy,” dated July 2025, was reviewed. The P&P indicated, “...POST-FALL PROCESS...A fall debriefing...will occur on the same shift as the fall to gather all pertinent data...Reporting...For each patient fall, the nurse will document the following in the EHR [electronic hospital record]:...In the Post Fall Assessment intervention...Description of patient fall...Description of any injury to patient, or no injury...Contributing factors...” b. A facility document titled, “Laboratory Inquiry Report,” dated December 18, 2025, was reviewed. The document indicated Patient 30 had a blood transfusion on December 18, 2025, from 12:19 p.m. to 2:22 p.m. A facility document titled, “Blood pressure,” dated December 18, 2025, was reviewed. The document indicated Patient 30 had BP readings recorded on December 18, 2025, at 11:57 a.m. and at 2:22 p.m. There was no documented evidence vital signs were taken when the blood transfusion was being administered to Patient 30 on December 18. 2025, from 12:19 p.m. to 2:22 p.m. On December 23, 2025, at 2:34 p.m., an interview was conducted with RN 2. RN 2 stated, during a blood transfusion, vital signs are done before the transfusion begins, after the first 15 minutes of starting the blood transfusion, then hourly during blood transfusion, and at the end of the blood transfusion. RN 2 stated if vital signs are not assessed during a blood transfusion, a transfusion reaction (an adverse event when a person’s body reacts negatively to the donated blood) could be missed. On December 24, 2025, at 9:31 a.m., an interview was conducted with the ICNM. The ICNM stated vital signs during a blood transfusion are taken before the blood transfusion, at 15 minutes after the blood transfusion started, hourly during blood transfusion, and after the completion of the blood transfusion. The ICNM stated vital signs are taken during a blood transfusion so the transfusion can be stopped or the physician could be notified if a transfusion reaction occurs. The facility P&P titled, “Blood Administration,” dated September 25, 2024, was reviewed. The P&P indicated, “...Blood and/or components will be administered to patients in a safe manner...Monitoring Blood Administration...vital signs must be within 30 minutes of the start of the transfusion...Vital signs are to be repeated in 15 minutes...then every hour until transfusion is completed...” c. A facility document titled, “Order Record,” dated December 18, 2025, at 8:10 a.m. was reviewed. The document indicated, “...Vital Sings, Orthostatic [a procedure in which blood pressure and heart rate are obtained while the patient is lying down, sitting up, and standing up]...Frequency: x 1 [one] time...” A facility document titled, “Patient Care Notes,” dated December 19, 2025, at 4:01 a.m., was reviewed. The document indicated Patient 30’s orthostatic vital signs were taken on December 19, 2025, was 4:01 a.m. (20 hours after the physician placed the order). There was no documented evidence the physician order had been carried out prior to December 19, 2025, at 4:01 a.m. On December 23, 2025, at 2:34 p.m., an interview was conducted with RN 2. RN 2 stated orthostatic vital signs should be completed within 30 minutes of the physician placing the order. On December 24, 2025, at 9:31 a.m., an interview was conducted with the ICNM. The ICNM stated one time physician orders should be completed within 30 to 60 minutes of the order being placed. The ICNM stated completing the order 20 hours after it was placed would be a problem and should be escalated to management to find out why there was a delay and to review the window [of time] in which orders are expected to be completed with the assigned RN. An undated facility document titled, “Position Description,” was reviewed. The document indicated, “...RN STAFF...Performance Expectations...Interpret and carry out physician’s orders...” A facility P&P titled, “PHYSICIAN ORDERS Noting Physicians Orders,” dated April 23, 2025, was reviewed. The P&P indicated, “...The purpose of this policy is to ensure physician orders are...carried out efficiently, there by decreasing errors and improving patient care and safety...” 4. A review of Patient 47’s record was conducted on December 23, 2025, at 10:52 a.m., with the Patient Safety Coordinator Registered Nurse (PSCRN). A facility document titled, “History and Physical [H&P],” dated December 13, 2025, at 6:54 a.m., was reviewed. The H&P indicated Patient 47 was admitted for hypercapnic respiratory failure (a condition when the lungs cannot remove enough carbon dioxide [a type of gas essential for life]) due to obesity hypoventilation syndrome (a condition when excess weight leads to shallow breathing causing low oxygen and high carbon dioxide in the blood). A facility document titled, “WOUND CARE CONSULT,” dated December 13, 2025, at 9:23 p.m., was reviewed. The document indicated wound care consult was ordered by the physician for Patient 47 upon Ptint 47’s admission to the facility. A facility document titled, “WOUND CARE CONSULT/NOTES,” dated December 15, 2025, at 2:13 p.m., was reviewed. The document indicated, “...left foot plantar surface at first metatarsal [the bones of the big toe] diabetic ulcer [serious open wound] measures approx. [approximately]...2 [two] x [by] 2 x 0.2 centimeter [cm, unit of measurement], wound bed with moist pink/red non-granulating tissue [indicating poor healing] and yellow slough [dead tissue]. Scant [small] amount of serous drainage [thin watery, clear, yellow fluid from the wound]. Wound edge has dry callous [a thick layer of skin]...” A facility document titled, “Dressing/Wound Care,” dated December 15, 2025, at 2:15 p.m., was reviewed. The document indicated, “...Dressing Change/Wound Care...LEFT FOOT PLANTAR...Cleanse with...Wound Cleanser...Apply/Fill/Pack...Hydrogel [a moisture-rich, flexible wound covering] to wound bed...cover with...silicone foam [a highly absorbent dressing for wound drainage] border...Frequency...Daily/PRN [as needed]-Loose/Drainage...Comment...LEFT FOOT PLANTAR [bottom of the foot] DIABETIC ULCER...” There was no documented evidence Patient 47’s left foot plantar diabetic foot ulcer dressing was changed on December 15,16,17, 21, 22, 2025. There was no documented evidence Patient 47’s left foot plantar diabetic foot ulcer was assessed on December 17, 2025, at 8 a.m., December 21, 2025, at 8 a.m., and December 22, 2025, at 8 a.m. On December 23, 2025, at 1:40 p.m., an interview was conducted with the PSCRN. The PSCRN stated wound assessment should be completed every shift and the dressing for Patient 47’s wound was ordered to be changed daily and as needed. The PSCRN stated the nursing staff did not follow the physician’s order for the treatment of Patient 47’s wound. A facility P&P titled, “Skin Integrity Management,” dated October 2022, was reviewed. The P&P indicated, “...All patients will be assessed in regard to integumentary [skin] integrity...This will be documented...minimum once per shift...” An undated facility document titled, “Position Description,” was reviewed. The document indicated, “...RN STAFF...Performance Expectations...Interpret and carry out physician’s orders...” A facility P&P titled, “PHYSICIAN ORDERS Noting Physicians Orders,” dated April 23, 2025, was reviewed. The P&P indicated, “...The purpose of this policy is to ensure physician orders are...carried out efficiently, there by decreasing errors and improving patient care and safety...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 47071 Based on interview and record review, the facility failed to ensure compliance with the provisions in §CFR 489.24(d)(4-5), when the facility’s policies and procedures were not implemented, for one of 20 sample patients (Patient 2), when Patient 2 was triaged (the process of sorting patients in an emergency setting to determine the urgency of their medical needs) 28 minutes after arrival at the Emergency Department. This failure had the potential to result in a delay of care for Patient 2 and may cause harm to the patient.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 47071 Based on the interview and record review, the facility failed to ensure triage (the process of sorting patients in an emergency setting to determine the urgency of their medical needs) in the Emergency Department (ED) was completed timely in accordance with the facility’s policy and procedure (P&P), for one of the 20 sample patients (Patient 2), when Patient 2 was triaged 28 minutes after arrival at the ED. This failure had the potential to result in a delay of care for Patient 2 and may cause harm to the patient. Findings: On October 22, 2025, at 2:40 p.m., a concurrent interview and review of Patient 2’s record were conducted with the Patient Safety Coordinator (PSC). A facility document titled, “[Name of facility] Emergency Provider Report,” dated August 31, 2025, was reviewed. The document indicated Patient 2 was brought to the ED as a trauma tier 2 (two) alert (for patients with serious injuries or illness who might deteriorate or suffer long term medical problems if they do not receive treatment timely) after the patient had a partial crush injury (occurs when a body part is subjected to high force or pressure) on August 30, 2025, when a gate fell on Patient 2’s right side and a horse stood on the gate. On October 22, 2025, at 2:50 p.m., a facility document titled, “Emergency Patient Record,” dated October 21, 2025, was reviewed. The document indicated, “...Stated Complaint: Right Wrist Pain...Chief Complaint: Trauma...Priority: 2 [for patient with serious illness or injury]...Status Event History...8/30/25 [August 30, 2025] 2128 [9:28 p.m.]...2151 [9:51 p.m.] Room Placement...2156 [9:56] APOD [Ambulance Patient Offload Delay, the main area where patients are seen and treated faster related to the level of care needed]...Assessments...Rapid Initial Assessment...Date...8/30/2025 [August 30, 2025] 2156 [9:56 p.m.]...Rapid Initial Assessment...First Point of Contact: Yes...Arrived by: WI [walk in]...SUBJECTIVE ASSESSMENT...Patients description of reason for visit: TRAUMA ALERT CAUSED BY METAL GATE AND HORSE...Onset of Symptoms Date: 8/30/2025 [August 30, 2025]...” A review of an untitled and undated facility document was conducted. The document indicated, “...Arrival Date: 8/30/25...Arrival Time: 2128 [9:28 p.m.]...Triage Date: 8/30/25...Triage Time 2156 [9:56 p.m.]...Triage Level: 2 ...Placed in Bed Date 8/30/25...Placed in Bed Time: 2156 [28 minutes after Patient 2 arrived at the ED]...” There was no documented evidence Patient 2 was triaged upon the patient’s arrival in the ED. On October 23, 2025, at 11:30 a.m., an interview was conducted with the ED Manager (EDM). The EDM stated Patient 2 was not triaged upon arrival to the ED. The EDM stated Patient 2 arrived on August 20, 2025, at 9:28 p.m., and was not triaged until 9:56 p.m. on Augutst 20, 2025. The EDM stated the facility’s P&P to triage the patient upon arrival was not followed. A review of facility P&P titled, “Patient care in the Emergency Department: Triage, Medical Screening Exam [MSE, a process performed by qualified medical personnel at a hospital’s dedicated emergency department to determine if an individual has an emergency medical condition], and Patient Flow Until Discharge,” dated October 23, 2024, was conducted. The P&P indicated, “...Triage...Patients...presenting to the Emergency Department will be triaged by a Registered Nurse...To assess each patient upon arrival in the department to determine priority of care and intervention required...To recognize the patient who needs immediate intervention and to provide such in order to save life or limb...patients status will be evaluated and prioritized...””

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 50304 Based on interview and record review, the facility failed to ensure the facility’s bylaws and medical staff policies and procedures were implemented, for one of 23 sample patients (Patient 20), when : 1. Versed (a brand name of midazolam, a medication used to induce sleep) was administered by Physician (MD) 8, while Patient 20 was admitted in a Medical Surgical Unit (MedSurg, a unit which provides care for patients with medical conditions and those recovering from surgery] (Refer to A341); and 2. MD 8, who had not been granted clinical privileges (permissions granted to doctors to provide specific medical services within a particular healthcare facility) for moderate sedation (the use of medications to help a patient relax and/or reduce pain during medical procedures), administered Versed to Patient 20 (Refer to A341). The cumulative effects of these systemic failures resulted in Patient 20 experiencing respiratory distress and requiring transfer to the Intensive Care Unit (ICU, a unit for patients with serious illnesses who need close monitoring).”

“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: 34933 Based on interview and record review, the facility failed to ensure a safe discharge for three of 23 sample patients (Patients 14,16 and 21), when: 1. For Patient 14, the gastrostomy (a plastic tube inserted directly into the stomach for feeding) supplies and wound (a break in the skin) care supplies were not ordered for delivery before the patient was discharged from the facility, in accordance with the facility’s policy and procedure (P&P) (Refer to A0807); 2. For Patient 16, a patient with suicidal ideation, the patient eloped from the facility (Refer to A0807); and 3. For Patient 21, a conserved patient (when a court has appointed another individual [a conservator] to manage the affairs of an individual who was deemed incapable of doing so himself), the patient was discharged from the facility and left the facility by himself (Refer to A0807). The cumulative effects of these systemic failures resulted in Patients 14, 16, and 21 being discharged from the facility without adequate follow up completed and supplies arranged for use after discharge and placed Patients 14, 16, and 21 at risk for harm and injury.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 50304 Based on observations, interviews, and record reviews, the hospital failed to provide surgical services in a well-organized manner, in accordance with acceptable standards of practice and in a manner to prevent the risk of cross contamination, when: 1. Surgical instruments in peel packs (sterilization pouches used to maintain the sterility of instruments after they have been sterilized) were sterilized in the closed position (not unlatched) and two (2) peel packs with sterile surgical instruments contained brown staining on the inside and the outer package and seven (7) surgical instruments were sterilized in the closed position (Refer to A0951); 2. One low level sterilizer (a machine used to sterilize reusable surgical instruments) was not cleaned and maintained according to manufacture instructions (IFUs) (Refer to A0951); 3. One instrument washer (Washer 2- used to clean reusable surgical instruments) was not cleaned according to manufacture instructions (Refer to A0951); 4. Surgical brushes used to clean soiled surgical instruments were not cleaned between use and in accordance with the manufacturer’s instructions (Refer to A0951); 5. Ten (10) reusable surgical clamps (used for surgical procedures) were not cleaned and disinfected between patient use. In addition, one heart lung bypass machine (medical device that temporarily takes over the functions of the heart and lungs during certain surgical procedure), ready for patient use was not maintained according to manufacture instructions and contained red matter that was easily wiped off (Refer to A0951); 6. For one of 23 sample patients (Patient 22), a reamer (a surgical instrument used to enlarge or shape bone canals and cavities) which had a white substance on it was included in the back table [table where surgical instruments are placed] during surgery. In addition, the reamer was not verified as unsterile (has not been made completely clean or free from bacteria) before the start of the surgery (Refer to A0951); and 7. The mayo table [small movable table in the operating room] was positioned seven inches from the wall in Operating Room (OR) 2. The cumulative effects of these systemic failures had the potential to cause infection, disability (the condition of being unable to perform a task or function because of a physical or mental impairment), prolonged hospitalization, and possible death for patients who receive care and treatment form the facility.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50304 Based on interview and record review, the facility failed to ensure patient safety, for one of 23 sample patients (Patient 21), a conserved (when a court has appointed another individual [a conservator] to manage the affairs of an individual who was deemed incapable of doing so himself) patient, , when Patient 21 was discharged from the facility and left the facility by himself. This failure had the potential to cause harm or death to Patient 21.. Findings: On August 5, 2025, at 3:37 p.m., a review of Patient 21’s record was conducted with the Quality Data Abstractor (QDA). An undated and untitled facility document was reviewed. The document indicated Patient 21 was admitted to the facility on July 18, 2025, for fall. An untitled and undated facility document, authored by Physician (MD) 2, was reviewed. The document indicated, “...History of Present Illness...the patient...with past medical history of paranoid schizophrenia [a severe mental disorder with the patients believing others are trying to harm, control, or manipulate them]...is currently on conservatorship [the appointment by the court of a person to oversee the affairs of an individual who is unable to care for himself]...signed by: [Name of MD 2]...07/18/25 [July 18, 2025] at 1537 [3:57 p.m.]...” An untitled and undated facility document, authored by Registered Nurse (RN) 1, was reviewed. The document indicated, “...Assessment...Alert and oriented: No...Oriented to: Person...Time...hallucinations [experiencing something which is not present in reality]: Present/Exists...Auditory hearing voices or other sounds which is not present in reality]...PT STATES HE HEARS VOICES...” An untitled and undated facility document, authored by RN 2, was reviewed. The document indicated, “...Assessment...Jul 18, 25 [July 18, 2025] 20:00 [8 p.m.]...Alert and oriented: No...Oriented to: Person...Time...” An untitled and undated facility document was reviewed. The document indicated, “...Patient’s Order List...[Name of Patient 21]...Discharge order...07/19 [July 19, 2025] 0955 [9:55 a.m.]...Social Work [work carried out by trained professionals with the aim of helping people to improve their lives] Consult...07/19 [July 19, 2025] 1005 [10:05 a.m.]...Psych [psychiatry, a branch of medicine which is focused on the diagnosis, treatment, and prevention of mental disorders] consult...07/19 0953 [9:53 a.m.]...” An untitled and undated facility document, authored by MD 3, was reviewed. The document indicated, “...Consultation Note...[Patient 21] with past medical history of paranoid schizophrenia...Hallucinations: auditory...Judgment...poor...Signed by [Name of MD 3] ...07/19/25 [July 19, 2025] at 1112 [11:12 a.m.]...” An untitled and undated facility document, authored by the Social Worker (SW, a professional who helps improve people’s lives), was reviewed. The document indicated, “...SW SPOKE WITH BEDSIDE RN AND CONFIRMED CONVERSATION WAS HAD WITH PSYCHIATRIST AT [Name of Facility D]. BEDSIDE RN REPORTED THAT PT [Patient 21] WILL BE DC [discharged] BACK TO FACILITY [Facility D] AND TRANSPORTATION VIA [name of ride-share company] RIDE [a non-medical transportation service] WILL BE PROVIDED TO PT...HCM [Health Care Management, a department which focuses on the strategies for delivering and managing healthcare services] Discharge Planning [plan which prepares patients for leaving a healthcare facility] No HCM Planning data on file for this encounter...” An untitled and undated facility document, authored by RN 2, was reviewed. The document indicated, “...DISCHARGE INSTRUCTIONS...Jul 19, 25 [July 19, 2025]...13:12 [1:12 p.m.]...Patient (or Guardian) Signature...conserved...Date...7/19/25...Time...1415 [2:15 p.m.]...” There was no documented evidence case management [a process of coordinating and organizing the a patient’s needs during the patient’s discharge] or social worker discharge planning evaluation for Patient 21 was completed. On August 6, 2025, at 9:10 a.m., an interview was conducted with QDA. The QDA stated there was no documentation case management or social worker discharge planning evaluation was completed for Patient 21. On August 7, 2025, at 10:43 a.m., an interview was conducted with the SW. The SW stated she did not inform Patient 21’s conservator of Patient 21’s discharge because she did not know Patient 21was on a conserved patient. The SW stated she should have informed Patient 21’s conservator of Patient 21’s discharge from the facility. The SW stated Patient 21 should not have been discharged back to Facility D by himself. The SW stated conserved patients are deemed to not be able to make decisions for themselves. The SW stated it is unsafe for Patient 21 to be discharged on his own through a ride-share transportation. On August 7, 2025, at 11:31 a.m., an interview was conducted with RN 2. RN 2 stated he did not inform Patient 21’s conservator of Patient 21’s discharge. RN 2 stated he should have informed Patient 21’s conservator of Patient 21’s discharge. RN 2 stated he should not have discharged Patient 21on his own. RN 2 stated it was not safe for Patient 21 to be sent off on his own back to Facility D. A facility policy and procedure (P&P) titled, “CONSERVATORSHIP,” dated June 2019, was reviewed. The policy indicated, “...Patients may present to the hospital with a court appointed conservator to make decisions on their behalf...Hospital staff that identifies a patient as having a conservator will request a copy of the court order appointing the conservator and place it in the patient’s medical record...consents for patient medical care will be obtained based on the direction contained in the court orders...if there are questions about the role, scope, or authority of the conservator...social services may be contacted for assistance...” A facility P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES,” dated October 2024, was reviewed. The document indicated, “...[Name of Facility] respects the dignity and pride of each individual we serve. Every patient has the right to have his/her rights respected...to receive ethical, high-quality, safe and professional care without discrimination...” A facility P&P titled, “DISCHARGE PLANNING: ASSESSMENT, REFERRALS, TRANSFERS, PLACEMENTS, & TRANSPORTATION (Adult & Pediatric),” dated April 2025, was reviewed. The P&P indicated, “...Purpose: To establish a mechanism, for all patients, that encourages a smooth transition for all patients being discharged from the hospital...it is the responsibility of the hospital case manager [a professional who coordinates and oversees care for individuals with specific needs] to ensure needs...services are arranged, prior to discharge...””

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 50304 Based on interview and record review, the facility failed to ensure the facility’s bylaws and medical staff policies and procedures were implemented, for one of 23 sample patients (Patient 20), when : 1. Versed (a brand name of midazolam, a medication used to induce sleep) was administered by a Physician (MD) 8, while Patient 20 was admitted in a Medical Surgical Unit (MedSurg, a unit which provides care for patients with medical conditions and those recovering from surgery); and 2. Physician (MD) 8, a resident (physician in training) who had not been granted clinical privileges (permissions granted to physicians to provide specific medical services within a particular healthcare facility) for moderate sedation (the use of medications to help a patient relax and/or reduce pain during medical procedures) administered Versed to Patient 20. These failures resulted in Patient 20 experiencing respiratory distress and requiring transfer to the Intensive Care Unit (ICU, a unit for patients with serious illnesses who need close monitoring). Findings: On August 5, 2025, at 9:11 a.m., a review of Patient 20’s record was conducted with the Quality Data Abstractor (QDA). An undated and untitled facility document was reviewed. The document indicated Patient 20 was admitted to the facility on June 25, 2025, for abscess (a collection of pus, a yellow liquid produced in infected tissue) drainage (the process of removing the pus). An untitled and undated facility document was reviewed. The document indicated, “...History of Present Illness...with PMHx [Past Medical History] of HTN [hypertension, high blood pressure]...for eval [evaluation] of leftneck [sic] abscess...Physical exam...Neck: left neck swelling...with tenderness...Respiratory: aerating [breathing] well...alert, oriented x 3 [oriented to person, place, and time]...admit to med surg...Signed by [Name of MD 5...06/25/25 [June 25, 2025] at 0944 [9:44 a.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 20]...Jun 25, 2025 [June 25, 2025]...Order Details...transcervical [through the neck] drainage of neck abscess...[Name of MD 6]...” An untitled and undated facility document was reviewed. The document indicated, “...Vital Signs [temperature, blood pressure (normal is 120/80), pulse rate, respiration rate (normal is 12 to 20 per minute), and oxygen saturation (the measure of how much oxygen is carried in the blood)]...[Name of Patient 20]...Jun 26, 25 08:03 [8:03 a.m.]...temperature 37.4...pulse rate 73...blood pressure 147/74...bedside pulse oximetry [a non-invasive method for measuring the oxygen saturation] 96...” A facility document titled, “Admission/Shift Assessment,” dated June 25, 2025, was reviewed. The document indicated, “...Alert and oriented: Yes...RESPIRATORY...Respirations even and unlabored: Yes...BREATH SOUNDS...clear, equal and undiminished...Airway [the passage by which air reaches a person’s lung]: patent [not obstructed, allowing air to flow freely to the lungs] ...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 20]...Order History...Midazolam HCl [hydrochloride, a chemical]...Ordering Physician...[Name of MD 7]...1 mg [milligram, a unit of measurement]...IV [intravenous, administered through the vein]...Jun 26, 25 [June 26, 2025] 09:18 [9:18 a.m.]...Warning: respiratory depression [when breathing becomes abnormally slow and shallow] airway obstruction [occurs when something blocks the air from going into the lungs, making it difficult to breathe] ...” An untitled and undated facility document was reviewed. The document indicated, “...06/26/25 [June 26, 2025] 0951 [9:51 a.m.]...User: [Name of Registered Nurse (RN) 4]...Given: Yes...Midazolam HCL...medication given at bedside by [Name of MD 8] at this time...” An untitled and undated facility document was reviewed. The document indicated, “...Jun 26, 2025, 1547 [3:47 p.m.] by [Name of RN 5]... 0.5 MG OF VERSED WAS GIVEN BY MD...” A facility document titled, “Rapid Response Code [a hospital protocol which activates a special team to intervene when a patient’s condition begins to worsen],” dated June 27, 2025, was reviewed. The document indicated, “...RAPID RESPONSE CODE RECORD...Jun 27, 25 [June 27, 2025] 02:07 [2:07 a.m.] By: [Name of RN 6]...reason for call: Respiratory...rapid response team comments: CALL FOR STRIDOR [a high-pitched, noisy breathing caused by a blockage or narrowing of the throat]...RR [respiratory rate] 25. RACEMIC EPI [epinephrine, a medication used to temporarily relieve breathing problems] AND DECADRON [a medication which helps control inflammation] GIVEN. NO IMPROVEMENT IN STRIDOR...ENT [Eyes Nose Throat physician] notified...PT [Patient 20] UPGRADED TO ICU...” 1. On August 6, 2025, at 10:06 a.m., an interview was conducted with MD 8. MD 8 stated she administer Versed in the medsurg unit to Patient 20. MD 8 stated she did not know that she cannot administer Versed in the medsurg unit and if she had known, she would not have administered Versed. On August 7, 2025, at 10:26 a.m., an interview was conducted with the Medical Surgical Manager (MSM). The MSM stated Versed is not administered to patients on any medical surgical unit. A facility policy and procedure titled, “Intravenous Medication Administration Restrictions by Patient Care Area,” dated January 2025, was reviewed. The document indicated, “...Applies to: All licensed personnel: Nurses, Physicians...This policy indicates Intravenous Medication Administration Restrictions by Patient Care Area. Medications listed in this policy are approved for administration according to the chart..Medication...Approved for care area category = X...midazolam (Versed)...” The dcoument indicated X were placed under Adult ICU, Emergency Department (ED), Procedureal, Code Blue (a hospital code for a patient needing to be revived). The document indicated the boxes under Telemetry [unit where patients receive continuous remote electronic monitoring of their heart rates and rhythms] and General Nursing Floor [medsurg unit, the document indicated this was not filled out] were left blank (meaning midazolam was not approved to be administered in the telemetry and general nursing floor units. 2. An untitled and undated facility document was reviewed. The document indicated, “...the marked capabilities listed on this...spreadsheet should be granted to the corresponsing residents’ [sic] name...[Name of MD 8]...Sedation, Moderate...” The document indicated the box under Sedation, Moderate was not marked (MD 8 was not granted the capability to perform moderate sedation). There was no documented evidence MD 8 has been granted clinical privilege by the facility to administer moderate sedation. On August 6, 2025, at 10:06 a.m., an interview was conducted with MD 8. MD 8 stated she did know that she cannot administer Versed in the med surg unit. MD 8 stated if she had known, she would not have used Versed. MD 8 stated she did not have clinical privileges to administer moderate sedation. MD 8 stated she did not know that under the facility’s policy Versed is considered a moderate sedation medication. MD 8 stated she should not have performed moderate sedation on Patient 20. On August 7, 2025, at 1:42 p.m., an interview was conducted with the Director of Medical Staff (DMS). The DMS stated medical residents (physicians in a training program) must follow the Medical staff rules and regulations. The DMS stated it is important for physicians to practice within their clinical privileges to make sure they are practicing within their duties in the residency program (a program for the training of residents). A facility rules and regulations titled, “Medical Staff Rules and Regulations,” dated November 28, 2018, was reviewed. The document indicated, “...medical students will be subject to the bylaws rules and regulations of the [Name of Facility] medical staff...” A facility policy and procedure titled, “SEDATION ANALGESIA [lessening or absence of pain using medications],” dated June 2017, was reviewed. The policy indicated, “...to establish guidelines and procedures for administration of sedation/analgesia given by physicians who are not specialists in anesthesiology [the medical specialty focused on the administration of anesthesia (a medical procedure which blocks the sensation of pain]...Individuals administering sedation/ analgesia will have the appropriate credentials [documents or information which serve as evidence of a person’s qualifications] to manage the patient...physicians may request clinical privileges for moderate sedation/analgesia...Medications approved for administration by a clinically privileged physician or qualified RN include...Versed...” A facility rules and regulations titled, “AFFILIATED MEDICAL STUDENT and VISITING RESIDENT SUPERVISION,” dated July 2019, was reviewed. The document indicated, “...it is the policy and responsibility of [Name of Facility] to implement procedural requirements for medical student and visiting resident rotations which are consistent with its policies... applicable medical school regulations, policies, and processes, procedures and rules for Medical Education...Medical students and visiting residents must comply with the Medical Staff Bylaws and Rules, Regulations and Policies of [Name of Facility] where applicable...Ensure that all medical students are aware of [Name of Facility’s] policies, procedures, and the role of the medical students within the [Name of Facility] system...””

“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: 50122 Based on observation, interview, and record review, the facility failed to ensure the facility’s policy and procedure (P&P) regarding the discharge process was implemented, for one of 20 sample patients (Patient 1), when the discharge documents were not signed by the patient prior to the patient’s discharge. This failure had the potential for Patient 1 to not be informed of the discharge instructions, education, medications, and complications of a diagnosis after being discharged from the facility which could potentially cause harm to the patient. Findings: On August 4, 2025, at 10 a.m., an interview was conducted with Patient 1 in the Emergency Department (ED). Patient 1 stated he was being discharged home. Patient 1 stated he had not been given his discharge instructions yet and was waiting for them to be able to leave the facility. On August 5, 2025, at 9:15 a.m., a review of Patient 1’s record was conducted with the Risk Coordinator (RC). A facility document titled, “HPI [History of Present Illness]-General illness,” dated August 4, 2025, at 9:31 a.m., authored by Physician Assistant (PA) 1, was reviewed. The document indicated, “...[Patient 1] presenting for a refill of his [brand of medication] 100 mg [milligram, unit of measurement], which she [sic] takes for depression...Discharged to home...Yes...Time...1000 [10 a.m. ...Date...08/04/2025 [August 4, 2025]...” On August 5, 2025, at 9:20 a.m., a review of the facility document titled, “Patient Signature Page,” dated August 4, 2025, at 10:01 a.m., was conducted with the RC. The document did not indicate signature from Patient 1 was obtained. The document also did not indicate a date nor time of discharge. The document indicated, “...Please make sure you have read through this information before signing. I have read and understand the instructions given to me by my caregivers...” During a concurrent interview, the RC stated, “...there was no signature on the document and there should have been a signature from the patient...” On August 7, 2025, at 1:30 p.m., an interview was conducted with the Director of Patient Safety (DPS). The DPS stated if the patient is awake, alert, and oriented, the nurse should have had the patient sign the discharge instructions form...A review of the facility P&P titled, “PATIENT CARE IN THE EMERGENCY DEPARTMENT: Triage, Medical Screening Exam (MSE), and Patient Flow until Discharge,” revised October 23, 2024, was conducted. The P&P indicated “...All patients discharged from the Emergency Department will receive instructions for follow up care...” A review of the facility P&P titled, “Discharge Planning: Assessment, Referrals, Transfers, Placements & Transportation (Adult and Pediatric),” revised on May 28, 2025, was conducted. The P&P indicated, “...Discharge instructions...are to be given by the nursing staff to every patient discharged from the facility...Information on medications...treatments, follow up care, all follow up appointments, anticipated outcomes and potential complications related to the diagnosis should be included in the discharge instructions provided by the nurse discharging the patient...Discharge instructions will be communicated to the patient, by the nurse discharging the patient...to ensure an understanding of discharge care and follow up...””

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 34933 Based on interview and record review, the facility failed to ensure a safe discharge for two of 23 sample patients (Patient 14 and 16), when: 1. For Patient 14, the gastrostomy (a plastic tube inserted directly into the stomach for feeding) supplies and wound (a break in the skin) care supplies were not ordered for delivery before the patient was discharged from the facility, in accordance with the facility’s policy and procedure (P&P); 2. For Patient 16, a patient with suicidal ideation, the patient eloped from the facility; and 3. 3. For Patient 21, a conserved patient (when a court has appointed another individual [a conservator] to manage the affairs of an individual who was deemed incapable of doing so himself), the patient was discharged from the facility and left the facility by himself. These failures had the potential to cause a delay in treatment and/or harm to the patients. Findings: 1. On August 5, 2025, at 10:30 a.m., a review of Patient 14’s record and concurrent interview were conducted with the Patient Safety Coordinator (PSC). A review of the facility document titled, “History & Physical (H&P),” , was conducted. The document indicated Patient 14 was admitted to the facility on January 16, 2025, with diagnoses which included lethargy (lack of energy), tachycardia (fast heart rate above 100 beats per minute), chronic obstructive pulmonary disease (COPD, a lung disease which cause difficulty of breathing), coronary artery disease (CAD, a condition where the arteries that supply blood to the heart become narrowed or blocked), and dementia (a progressive state of decline in mental abilities). The H&P further indicated Patient 14 had a gastrostomy tube and a urostomy bag (special bags used to collect urine directly from the bladder) in place. A facility document, untitled dated January 17, 2025, at 12:30 p.m., was reviewed and indicated, “Skin alteration: none...” A facility document titled, “Service,” dated February 9, 2025, was reviewed. The document indicated, “Positioning Turn every 2 [two] hours...Comment: Specialty Bed Alternate...Reason for Nutrition Consult: Assess & Recomm [Recommend] Nutn [Nutrition] Plan Tube Feeding: Y [Yes] ...Dressing Change/Wound Care Body Part: Peri-Anal/Buttock. Cleanse with...bath wipe. Apply/Dill/Pack: Prct [protective] Barrier Crm [cream]/Oint [ointment]/ Wip [wipe].Frequency: Daily/PRN [as needed]-Loose/Drainage [flow of fluids]...” A facility document titled, “Service,” dated February 10, 2025, was reviewed. The document indicated, “...Case Management Dept [department] Consult. CM [Case Management] Services Requested: dischg [sic] Home Health Care Home Health Ordered: Y [yes] Home Health Nrsg [sic, nursing]/Thrpy [sic, therapy]: Skilled Nrsg [sic]/Thrpy [sic]: Medication Management Physical Therapy...” A facility document titled, “Wound Care Consults/Notes,” dated February 19, 2025, was reviewed. The document indicated, “...Assessment: 1) Right foot plantar [underside of the foot] surface fifth metatarsal [bones in the foot]-DTI [deep tissue injury, a type of pressure injury (injury due to a pressure on a body area) causing damage to underlying tissues, often with intact skin or blister on the surface] pressure injury measures approx [sic, approximately] 1.5 x 1 .5 cm [centimeters, unit of measurement] with blood filled blister. 2) Left foot plantar surface [sole] fifth metatarsal [fifth toe] - DTI pressure injury measures approx [sic]. 1.5 x1.5 cm with purple colored and non-blanchable [a skin discoloration that does not turn white when pressed] skin. 3) Left lateral [side of] ankle- DTI pressure injury measures approx. [sic] 1 x 1 cm with purple colored and non-blanchable skin. 4) Left great toe [big toe] and first metatarsal [second toe]- blanchable redness...” A facility document titled, “Service,” dated February 19, 2025, was reviewed. The document indicated, “...Heel Protectors. Dressing Change/Wound Care body Part: Left Lateral Ankle. Apply/Fill/Pack: Skin Protectant Wipe. Cover with: Silicone Adhering Foam. Frequency: Every Other Day and PRN...” A facility document titled, “Case Management Report,” dated February 24, 2025, was reviewed. The document indicated, “...service type: Home Health Agency...Referral status: booked...HCM [Hospital Case Management] Discharge Planning Evaluation...DME [durable medical equipment, medical devices and supplies] Hospital-specialty bed Feeding devices...” A facility document titled, “Case Management Report,” dated March 5, 2025, was reviewed. The document indicated,”...Pt [Patient 14] remains altered, not following commands but tracks on my [Case Manager (CM) 1] exam. 100% on 2 l [liters of oxygen, unit of measurement] pm [per minute] nc [nasal cannula, a medical device used to deliver oxygen to a patient through their nostrils], PEG [percutaneous endoscopic gastrostomy tube, a feeding tube inserted directly into the stomach] at 60/200 [milliliters, ml, unit of measurement]] q [every] 4 [four] hr [hour]...” A facility document titled, “Service,” dated March 15, 2025, was reviewed. The document indicated, “...Discharge Order with Parameter...Discharge Parameters: Home Health Arranged...Diet: Resume Home Diet/Feeds...” There was no documented evidence gastrostomy feeding and wound care supplies were arranged by the facility to be delivered to Patient 14’s home upon Patient 14’s discharge. On August 5, 2025, at 9:04 a.m., a review of Patient 14’s record and concurrent interview were conducted with the Director of Case Management (DCM). The DCM stated the facility has a policy which indicated the supplies are delivered to the patient’s home prior to the patient’s discharge. The DCM stated there was no documentation to show the orders for wound care nor for the gastrostomy feeding supplies were placed nor coordinated with the home health agency. On August 6, 2025, at 10:54 a.m., an interview was conducted with the Registered Nurse Manager (RNM). The RNM stated if there are no orders for feeding or wound supplies before a patient is discharged, the physician is notified and orders will be faxed to the home health agency. The RNM stated nursing can follow up with case management to find out when the supplies will be delivered to the patient’s home. The RNM further stated, “It is an expectation of the nurse to follow up on discharge orders.” A review of the facility’s P&P titled, “Discharge Planning: Assessment, Referrals, Transfers, Placements & Transportation (Adult and Pediatric),” dated May 28, 2025, was conducted. The P&P indicated, “...To establish a mechanism, for all inpatients, that encourages a smooth transition to all patients being discharged from the hospital. To identify at an early stage those patients who are likely to suffer adverse health consequences upon discharge, if adequate discharge planning is not provided...Due to the high potential for readmission, patients discharging home with a trach and/or peg: a. Will be provided with three days of trach and/or peg supplies by the nurse discharging the patient. b. Validation that DME required for the management of a trach and/or peg has been delivered to the home, will be completed by the Case Management department, prior to discharging the patient...” 2. On August 7, 2025, at 10 a.m., a review of Patient 16’s record and a concurrent interview were conducted with the Quality Coordinator (QC). A facility document titled, “Psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] Consultation Note,” dated July 29, 2025, authored by MD 1, was reviewed. The document indicated, “...[Patient 16] reports that she has attempted suicide every day this week without success...Patient meets the criteria for 5150 hold [an involuntary hold for up to 72 hours for individuals who are deemed a danger to themselves or others, or are unable to care for themselves] for suicide attempt and grave disability [inability to care for one’s basic needs like food, clothing, and shelter due to a mental health condition]...Calculated suicide risk level [a scale that categorizes suicide risk based on responses to questions about suicide ideation and behaviors, [name of facility] uses the Columbia-Suicide Severity Rating Scale [a suicide risk assessment tool: High risk...” A facility document titled, “History & Physical,” dated July 30, 2025, was reviewed. The document indicated, “...with past medical history of bipolar disorder [mood swings that range from the lows of depression to elevated periods of emotional highs] rapid cycling [a subtype of bipolar disorder characterized by four mood episodes (major depressive, manic, hypomanic, or mixed] within a 12-month period) currently depressive episode, suicide attempt, epilepsy seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]...” The document indicated Patient 16 was transferred to the nursing unit for management of alcohol withdrawal symptoms (the changes the body goes through when a person suddenly stops drinking after prolonged and heavy alcohol use) while awaiting transfer to the psychiatric facility. A review of the facility document titled, “List Patient Notes,” dated July 31, 2025, was reviewed. The document indicated, “...NN [nursing note] Pateint [sic, Patient 16] has been arranged to be transport to [name of Facility]. @ [at] 14.45 [2:45 p.m.] [Name of Transportation A] is here in front of the room with 2 [two] EMTs [emergency medical technician, individuals who provide pre-hospital emergency care]...[Patient 16] has mentioned that she has to get her belongings at the [name of a mall] parking lot. But [name of Transportation A] unable to drop her to pick up her stuffs [sic] before going to [name of Facility B]. [Patient 16] was standing about to sit on the gurney then she just ran to emergency door and elope [the act of leaving a facility unsupervised and without prior authorization]...” On August 6, 2025, at 10:54 a.m., an interview was conducted with the Registered Nurse Manager (RNM). The RNM stated she was in the room with Patient 16 and tried to prevent Patient from eloping. The RNM stated she tried to locate the patient later but was unable to find the patient. The RNM stated it is everyone’s responsibility to keep suicidal patients from eloping from the facility. A review of the facility policy and procedure titled, “Against Medical Advice AMA/Elopement Guidelines,” dated October 2024, was conducted. The policy indicated, “...[name of Facility] is dedicated to maintaining the safety of all patients that are within the hospital and all patients need to be accounted for at all times...AMA-Involuntary Elopement: Physician has begun treatment, is recommending treatment, or is recommending a particular patient disposition and the patient leaves but does not let anyone know and leaves from the treatment space. Patient may represent a danger to self or others...Exceptions...If the patient’s ability to make medical decisions is unclear, the attending physician or designee will provide direction or determine the need for a psychiatric evaluation...” 3. On August 5, 2025, at 3:37 p.m., a review of Patient 21’s record was conducted with the Quality Data Abstractor (QDA). An undated and untitled facility document was reviewed. The document indicated Patient 21 was admitted to the facility on July 18, 2025, for fall. An untitled and undated facility document, authored by Physician (MD) 2, was reviewed. The document indicated, “...History of Present Illness...the patient...with past medical history of paranoid schizophrenia [a severe mental disorder with the patients believing others are trying to harm, control, or manipulate them]...is currently on conservatorship [the appointment by the court of a person to oversee the affairs of an individual who is unable to care for himself]...signed by: [Name of MD 2]...07/18/25 [July 18, 2025] at 1537 [3:57 p.m.]...” An untitled and undated facility document, authored by Registered Nurse (RN) 1, was reviewed. The document indicated, “...Assessment...Alert and oriented: No ...Oriented to: Person...Time...hallucinations [experiencing something which is not present in reality]: Present/Exists...Auditory hearing voices or other sounds which is not present in reality]...PT STATES HE HEARS VOICES...” An untitled and undated facility document, authored by RN 2, was reviewed. The document indicated, “...Assessment ...Jul 18, 25 [July 18, 2025] 20:00 [8 p.m.]...Alert and oriented: No...Oriented to: Person...Time...” An untitled and undated facility document was reviewed. The document indicated, “...Patient’s Order List...[Name of Patient 21]...Discharge order...07/19 [July 19, 2025] 0955 [9:55 a.m.]...Social Work [work carried out by trained professionals with the aim of helping people to improve their lives] Consult...07/19 [July 19, 2025] 1005 [10:05 a.m.]...Psych [psychiatry, a branch of medicine which is focused on the diagnosis, treatment, and prevention of mental disorders] consult...07/19 0953 [9:53 a.m.]...” An untitled and undated facility document, authored by MD 3, was reviewed. The document indicated, “...Consultation Note...[Patient 21] with past medical history of paranoid schizophrenia...Hallucinations: auditory...Judgment...poor...Signed by [Name of MD 3]...07/19/25 [July 19, 2025] at 1112 [11:12 a.m.]...” An untitled and undated facility document, authored by the Social Worker (SW, a professional who helps improve people’s lives), was reviewed. The document indicated, “...SW SPOKE WITH BEDSIDE RN AND CONFIRMED CONVERSATION WAS HAD WITH PSYCHIATRIST AT [Name of Facility D]. BEDSIDE RN REPORTED THAT PT [Patient 21] WILL BE DC [discharged] BACK TO FACILITY [Facility D] AND TRANSPORTATION VIA [name of ride-share company] RIDE [a non-medical transportation service] WILL BE PROVIDED TO PT...HCM [Health Care Management, a department which focuses on the strategies for delivering and managing healthcare services] Discharge Planning [plan which prepares patients for leaving a healthcare facility] No HCM Planning data on file for this encounter...” An untitled and undated facility document, authored by RN 2, was reviewed. The document indicated, “...DISCHARGE INSTRUCTIONS...Jul 19, 25 [July 19, 2025]...13:12 [1:12 p.m.]...Patient (or Guardian) Signature...conserved...Date...7/19/25...Time...1415 [2:15 p.m.]...” There was no documented evidence case management [a process of coordinating and organizing the a patient’s needs during the patient’s discharge] or social worker discharge planning evaluation for Patient 21 was completed. On August 6, 2025, at 9:10 a.m., an interview was conducted with QDA. The QDA stated there was no documentation case management or social worker discharge planning evaluation was completed for Patient 21. On August 7, 2025, at 10:43 a.m., an interview was conducted with the SW. The SW stated she did not inform Patient 21’s conservator of Patient 21’s discharge because she did not know Patient 21was a conserved patient . The SW stated she should have informed Patient 21’s conservator of Patient 21’s discharge from the facility. The SW stated Patient 21 should not have been discharged back to Facility D by himself. The SW stated conserved patients are deemed to not be able to make decisions for themselves. The SW stated it is unsafe for Patient 21 to be discharged on his own through a ride-share transportation. On August 7, 2025, at 11:31 a.m., an interview was conducted with RN 2. RN 2 stated he did not inform Patient 21’s conservator of Patient 21’s discharge. RN 2 stated he should have informed Patient 21’s conservator of Patient 21’s discharge. RN 2 stated he should not have discharged Patient 21on his own. RN 2 stated it was not safe for Patient 21 to be sent off on his own back to Facility D. A facility policy and procedure (P&P) titled, “CONSERVATORSHIP,” dated June 2019, was reviewed. The policy indicated, “...Patients may present to the hospital with a court appointed conservator to make decisions on their behalf...Hospital staff that identifies a patient as having a conservator will request a copy of the court order appointing the conservator and place it in the patient’s medical record...consents for patient medical care will be obtained based on the direction contained in the court orders...if there are questions about the role, scope, or authority of the conservator...social services may be contacted for assistance...” A facility P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES,” dated October 2024, was reviewed. The document indicated, “...[Name of Facility] respects the dignity and pride of each individual we serve. Every patient has the right to have his/her rights respected...to receive ethical, high-quality, safe and professional care without discrimination...” A facility P&P titled, “DISCHARGE PLANNING: ASSESSMENT, REFERRALS, TRANSFERS, PLACEMENTS, & TRANSPORTATION (Adult & Pediatric),” dated April 2025, was reviewed. The P&P indicated, “...Purpose: To establish a mechanism, for all patients, that encourages a smooth transition for all patients being discharged from the hospital...it is the responsibility of the hospital case manager [a professional who coordinates and oversees care for individuals with specific needs] to ensure needs...services are arranged, prior to discharge...””

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 28020 Based on observations, interviews, and record reviews, the hospital failed to provide surgical services in a well-organized manner, in accordance with acceptable standards of practice and in a manner to prevent the risk of cross contamination, when: 1. Surgical instruments in peel packs (sterilization pouches used to maintain the sterility of instruments after they have been sterilized) were sterilized in the closed position (not unlatched) and two (2) peel packs with sterile surgical instruments contained brown staining on the inside and the outer package and seven (7) surgical instruments were sterilized in the closed position. 2. One low level sterilizer (a machine used to sterilize reusable surgical instruments) was not cleaned and maintained according to manufacture instructions (IFUs). 3. One instrument washer (Washer 2- used to clean reusable surgical instruments) was not cleaned according to manufacture instructions. 4. Surgical brushes used to clean soiled surgical instruments were not cleaned between use and in accordance with the manufacturer’s instructions. 5. Ten (10) reusable surgical clamps (used for surgical procedures) were not cleaned and disinfected between patient use. In addition, one heart lung bypass machine (medical device that temporarily takes over the functions of the heart and lungs during certain surgical procedure), ready for patient use was not maintained according to manufacture instructions and contained red matter that was easily wiped off; 6. For one of 23 sample patients (Patient 22), a reamer (a surgical instrument used to enlarge or shape bone canals and cavities) which had a white substance on it was included in the back table [a table where surgical instruments are placed] during surgery. In addition, the reamer was not verified as unsterile (has not been made completely clean or free from bacteria) before the start of the surgery; and 7. The mayo table [small movable table in the operating room] was positioned seven inches from the wall in Operating Room (OR) 2. These failures had the potential to cause infection, disability (the condition of being unable to perform a task or function because of a physical or mental impairment), prolonged hospitalization, and possible death for patients who receive care and treatment form the facility. Findings: 1. On 8/4/25 at 9:35 AM during an interview with the hospital Infection Control Director (ICD), she stated that the hospital followed Infection Control Standards from AAMI (Association for the Advancement of Medical Instrumentation - Infection Control National Standards which leads global collaboration in the development, management, and use of safe and effective health technology, among others). On 8/4/25 at 9:45 AM, during a tour of the hospital Sterile Processing Department (SPD) Prep and Pack area (an area where clean reusable surgical equipment is prepared for sterilization) an observation was made of peel packs which contained sterilized surgical instruments, the following concerns were identified: (a). 7 surgical instruments were sterilized in the closed position (not unlatched). (b). 2 peel packs with sterilized surgical instruments contained brown staining on the interior and exterior of the packages. During a concurrent interview with the Sterile Processing Manager (SPDM) who verified the findings and stated that they followed event related sterility (the concept that a sterile item remains sterile until an event compromises its packaging or exposes it to contamination, rather than having a predetermined expiration date) and the instruments would need to be reprocessed. In addition, SPDM stated that the clamps should have been reprocessed in the open/unlatched position. On 8/4/25 at 11:15 AM, a document provided by the Vice President of Quality (VPQ) was reviewed. The document titled, “Event Related Sterility - Shelf Life, effective 8/24/22” stipulated, “Sterilized items will be be outdated when the integrity of the package is compromised by becoming wet, damaged or soiled.” On 8/4/25 at 3 PM during a record review of “ANSI/AAMI ST79: 2017 Comprehensive guide to steam sterilization and sterility assurance in health care facilities” the National Standards the hospital followed, it stipulated: “8.2 Instruments ...IFU for placement should be followed, in addition to the following recommendations: b) Instruments should be positioned to allow the sterilant to come into contact with all surfaces. c) Lumened ports should be opened. d) Ratcheted instruments should be unlatched. Racks, pins, stringers, or other specifically designed devices can be used to hold the instruments in the unlatched position.” 2. On 8/4/25 at 11:05 AM during the tour of SPD Assembly area, an observation was made of the internal chamber of the V-Pro 60 Low Temperature Sterilizer. The chamber contained numerous stickers that were adhered throughout various areas of the chamber, and white and grey particles were found on the bottom of the internal area of the chamber. During a concurrent interview with the SPDM, who verified the findings and was asked to produce documented evidence to demonstrate the sterilizer was cleaned and maintained according to the manufacture. SPDM stated “we currently do not clean the equipment”, SPDM was asked to provide the sterilizer’s manufacture instructions for use. On 8/4/25 at 11:15 AM, a document provided by the ORD was reviewed of the manufacture instructions of the V-Pro 60 Low Temperature Sterilizer. The document provided detailed daily instructions on how the equipment should be cleaned from the inside chamber to the exterior of the machine. It included using a mild detergent solution such as Liqui-Jet 2 (which the hospital was unable to provide). The hospital was unable to provide documented evidence to demonstrate cleaning of the V-Pro 60 sterilizer was performed according to the manufacture instructions. 3. On 8/4/25 at 11:20 AM during the same tour of SPD Assembly Area, accompanied by the SPDM an observation was made of an instrument washer (Washer #2). The internal area of the washer contained loose black, brown and white particles. SPDM was asked to provide documented evidence to demonstrate the washer was cleaned and maintained according to the manufacture instructions. SPDM stated they did not currently perform routine cleaning of the washer. SPDM was asked to provide manufacture instructions for the washer. On 8/4/25 at 11:25 AM the Sterile Processing Department Supervisor (SPDS) provided the manufacture instructions of the washer. The instructions provided detailed instructions of how to perform “daily cleaning”, “weekly cleaning” and “routine cleaning” of the interior and exterior areas of the washer. The hospital was unable to provide documented evidence to demonstrate cleaning of the washer was performed according to the manufacture instructions. 4. On 8/4/25 at 1:40 PM during the tour of the hospital’s SPD decontamination room (a room where reusable surgical equipment is cleaned) a Surgical Technician (SPDT 2) was observed cleaning a surgical tray filled with multiple-soiled surgical instruments. SPDT 2 was observed using two different styles of cleaning brushes (toothbrush style and a long-wired brush). SPDT 2 was asked if she used the same brushes to clean other surgical instruments from various surgical cases and how she cleaned the brushes. SPDT 2 stated she used them to clean all instruments throughout the day and disposed of the brushes at the end of her shift day. SPDT 2 was asked if the brushes are ever cleaned and disinfected and SPDT 2 stated “no”. On 8/4/25 at 2:15 PM SPDS provided the manufacture instructions of the brushes that were used by SPDT 2 to clean soiled surgical instruments. The manufacture instructions stipulated, “Cleaning & Disinfecting: Clean after each use and disinfect between cases and/or daily, at a minimum...” 5. On 8/5/25 at 9:40 AM, during a tour of Operating Room 4 (OR4) an inspection of a Heart Lung Bypass Machine. The following concerns were identified: (a) 10 reusable surgical clamps were found hanging on the Heart Lung Machine. Five (5) clamps contained brown/red dried substance, and four (4) clamps contained dried white substance/staining. (b) An external tube connected to the Heart Lung Bypass Machine, was filled with cloudy fluid and the exterior of the machine contained dried red matter. During a concurrent interview with ORD who was present during the inspection of the Heart Lung Bypass Machine, stated that the red substance looked like blood, she did not know when the clamps were processed (cleaned and disinfected) and they have had conversations with the Perfusionists (PF- a specialized healthcare professional who operates the heart-lung machine during cardiac surgery and other procedures requiring cardiopulmonary support) about sending the clamps to SPD after each use. The ORD stated the PFs are the ones responsible for cleaning and maintaining the Heart Lung Bypass Machine. On 8/5/25 at 1 PM, a document (Policy and Procedure) provided by VPQ titled, “Cleaning Patient Equipment, effective 8/24/22 was reviewed. The policy stipulated, “ ...2. All reusable patient equipment originating from SPD, will be placed in the dirty utility room of that unit to be cleaned by SPD once use is discontinued ...” On 8/5/25 at 12:30 PM a document (the manufacture instructions of the Heart Lung Bypass Machine) was provided by VPQ. The document titled, “CardioQuip Operator/Service Manual; Publication Date: January 26, 2024” stipulated, “ ...Weekly Maintenance Procedure: The following weekly inspections shall be used to assess the condition of the tubing and water. 1. External Tubing Inspection: Visually inspect the device’s external tubing for cloudiness or discoloration. If the tubing does not appear to be clouded or discolored, return to use. ...” WARNING: If the tubing appears cloudy or discolored during the External tubing Inspection, immediately remove the device from service and contact CardioQuip Customer Service for details regarding servicing assistance.” On 8/5/25 at 2:25 PM an interview was conducted with a PF in OR4 adjacent to the Heart Lung Bypass Machine. PF stated he did not know when the machine was cleaned or who cleaned it however, all blood and debris should be wiped off the machine with the hospital disinfectant wipes. In addition, PF stated the 10 clamps should have been returned to SPD so they can be cleaned and disinfected, and the exterior tubing with the cloudy fluid should have been replaced. The hospital did not have documented evidence to demonstrate the machine was cleaned and maintained in accordance with the manufacture. 50304 6. On August 4, 2025, at 1:35 p.m., an interview was conducted with the SPD Supervisor (SPDS) at the Sterile Processing Department (SPD, a department responsible for cleaning, disinfecting [cleaning, especially with a chemical, in order to destroy bacteria.], and sterilizing [making something completely clean and free of all living microorganisms and viruses] devices and instruments) with concurrent interview were done with the SPDS. The SPDS stated they check for bioburden (the number and types of microorganisms [bacteria, fungi, viruses, etc.] present on a medical device or material before it undergoes sterilization [a process that eliminates all forms of microorganisms and their spores (a cell that certain fungi, plants, and bacteria produce)] on the assembly tables. On August 4, 2025, at 1:44 p.m., during an observation at the SPD conducted with the SPDS and the Infection Preventionist (IP), SPD Technician (SPDT, a healthcare worker who ensures all medical tools are safe and ready for use in patient care) 3 was observed inspecting instruments on an assembly table [a work surface used for the assembly of parts or components of surgical instruments] and entering the inspected instruments into the computer. SPDT 3 was observed not examining the drills under a magnifying glass. SPDT 3 was seen placing the pack of drills examined in a cart containing other packs to be sterilized. On August 4, 2025, at 1:46 p.m., an interview was conducted with SPDT 3. SPDT 3 stated he did not inspect the drills under a magnifying glass before sterilization. SPDT 3 stated he should have inspected the drills under a magnifying glass before sterilization. On August 4, 2025, at 2:03 p.m., an interview was conducted with the Infection Preventionist (IP). The IP stated it is important to clean and sterilize instruments to prevent infection. On August 6, 2025, at 9:20 a.m., a review of Patient 22’s record was conducted with the Quality Data Abstractor (QDA). An undated and untitled facility document was reviewed. The document indicated Patient 22 was admitted to the facility on February 12, 2025, for left hip osteonecrosis (a condition where bone tissue dies due to insufficient blood supply). An undated facility document titled, “Consent to Surgery or Special Procedure,” was reviewed. The document indicated, “...Your doctors have recommended the following operation or procedure: left total hip replacement...[Name of Doctor]...[Signature of Patient 22]...Date: 6-18-24 [June 18, 2024]...Time: 0621 [6:21 p.m.]...” An undated facility document titled, “Operative Report,” authored by Physician (MD) 1 was reviewed. The document indicated, “...PATIENT’S NAME: [Name of Patient 22]...Name of procedure performed: left total hip arthroplasty [a surgical procedure to replace some or all of the hip joint]...The size 8 [eight] reamer had a white substance on it according to the surgical tech and it was handed off the field and never inserted into the patient...” An undated and untitled facility document, authored by MD 1, was reviewed. The document indicated, “...during surgery...the surgical tech noted that a reamer had a white substance on it...handed it off the field before it went into the patient...After the procedure was over [Name of Operating Room Director (ORD)]...tell me the entire tray is considered contaminated...I will tell her [Patient 22] that because of potential of infection she will be treated with 2 [two] week course of antibiotic...” On August 6, 2025, at 11:17 a.m., an interview was conducted with MD 1. MD 1 stated during Patient 22’s surgery, the Certified Surgical Technologist (CST, a healthcare professional who assists surgeons and the surgical team in the operating room) removed a reamer with a white substance from the sterile field. MD 1 stated the CSTshould have checked if the instruments are clean/sterile before the surgery. MD 1 stated he was informed by the ORD that even though the reamer was not used on the patient, the back table was considered contaminated because the reamer was on the surgical table during Patient 22’s surgery. On August 6, 2025, at 2:21 p.m., an interview was conducted with the CST. The CST stated CSTs should visually inspect instruments for any bones or tissues while opening the trays before the start of the surgery. The CST stated there is a possibility of infection for the patient if unclean or unsterile equipment is used during the patient’s surgery. On August 6, 2025, at 3:51 p.m., an interview was conducted with ORD. ORD stated CSTs should check and verify the sterility of instruments before surgery. The facility policy and procedure titled, “Decontamination,” dated May 2019, was reviewed. The policy indicated, “...This policy provides guidance for decontamination of instruments, equipment, and medical devices to be used in the surgical environment. The expected outcome of primary importance to this policy is to prevent infection...Instruments will be processed according to manufactures [sic, manufacturer’s] guidelines to include the following: breakdown components to reach all surfaces, flushing lumens [injecting a water, into the internal channel (the lumen) of a tube or device] and ports [points of access or connections on medical devices]...” A document titled, “ANSI [American National Standards Institute, a nationally recognized standard of practice]/AAMI [Association for the Advancement of Medical Instrumentation, a nationally recognized standard of practice] ST 79 : 2017,” was reviewed. The document indicated, “...After completing the cleaning process, personnel should visually inspect each item carefully to detect any visible soil...Steam sterilization cannot be assured unless proper cleaning of the device and reduced bioburden and soil was achieved...cleaning encompasses the removal of organic residues [includes blood, tissues, bone fragments, secretions, and excretions [wastes like urine, feces, sweat, and other bodily fluids] and microorganisms from the patient ...Inspection using enhanced visualization tools such as lighted magnification...might identify residues not observable by the unaided eye...” An AST [Association of Surgical Technologists, a professional organization which represents and supports surgical technologists ] guideline titled, “Guidelines for Best Practices for Establishing the Sterile Field in the Operating Room,” dated November 4, 2019, was reviewed. The document indicated, “...the following Guidelines for Best Practices were researched and authored by the AST Education and Professional Standards Committee and are AST approved...prior to positioning an instrument set on the back table [table where surgical instruments are placed], the CST should confirm that [sic] are no foreign particles [FP], such as bone fragments, burned tissue or hair, within the instrument set. This includes inspection of bone cutting instruments in orthopedic sets to confirm there are no bone and or tissue fragments present. If FP is identified, the instrument set must be considered non sterile and passed off by the CST to the circulator...” 7. On August 6, 2025, at 1:35 p.m., an observation of OR 2 was conducted with the Director of Patient Safety (DPS) and the ORD. The mayo table [a type of medical equipment used in surgical and clinical settings to hold instruments and supplies close to the area where surgery is being performed] was observed to be close to the wall. The ORD measured the distance between the wall and the mayo table. The distance measured by the ORD between the mayo table and the wall was observed to be seven inches. On August 6, 2025, at 2:22 p.m., an interview was conducted with the CST. The CST stated, “It is too close,” when a photograph of OR 2 table set-up close to the OR wall was reviewed. The CST stated according to AORN, the mayo table should be 18 inches away from the wall. On August 6, 2025, at 2:22 p.m., an interview was conducted with the ORD. The ORD stated the expectation is to make sure the mayo is far from the OR wall when setting up the table. An AST guideline titled, “ Guidelines for Best Practices for Establishing the Sterile Field in the Operating Room,” dated November 4, 2019, was reviewed. The document indicated, “...the following Guidelines for Best Practices were researched and authored by the AST Education and Professional Standards Committee and are AST approved...Furniture that will eventually be sterilely draped including the back table, Mayo stand, and basin ring stand [a movable stand with a basin used to hold solutions or soiled surgical instruments] should be grouped and organized together...The furniture that will be set up and included in the sterile field should be positioned a minimum of 12 inches away from the wall and other non-sterile furniture and equipment...” An undated Association of periOperative Registered Nurses (AORN, a nationally recognized standard of practice) guideline titled, “AORN eGuidelines+ [plus] Guidelines for Perioperative Practice: Sterile Technique,” was reviewed. The guidelines indicated, “...Preparing a sterile field reduces the risk of microbial contamination [the presence of microorganisms where they are not normally found]and is a cornerstone of infection prevention...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 50122 Based on interview and record review, the facility failed to comply with provisions in 42CFR 489.20 and 489.24, when it failed to ensure a complete medical screening exam (MSE) was conducted on a suicidal patient in the emergency department (ED), for one patient (Patient 6). In addition, the facility failed to ensure Patient 6 was transferred appropriately. These failures caused Patient 6 to be discharged from the facility without a psychiatric consult and was transported by the facility by a ride-share transport (a non-medical transportation service) to an address which is not the direct address of Facility B (a psychiatric [relating to mental illness or its treatment] facility which provides 24- hour mental health services). This failure resulted in Patient 6 being transferred to Facility C (an emergency psychiatric facility) instead of Facility B which was the intended destination. This failure had a potential to delay the treatment for Patient 6 and may cause harm to the patient.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 50122 Based on interview and record review, the facility failed to ensure a complete medical screening exam (MSE) was conducted on a suicidal patient in the emergency department (ED), for one of 20 sample patients (Patient 6). This failure caused Patient 6 to be discharged from the facility without a psychiatric consult. This failure had a potential to delay the treatment for Patient 6 and may cause harm to the patient. Findings: On August 6, 2025, at 2:30 p.m., Patient 6’s record was reviewed with Risk Coordinator (RC). facility document titled, “Rapid Initial Assessment,” dated July 25, 2025, at 11:58 a.m., authored by Registered Nurse (RN) 1, was reviewed. The document indicated, “...PT [Patient 6] BIBA [brought in by ambulance] FOR SUICIDAL IDEATIONS [thoughts of death and committing suicide]. PT WAS RECENTLY RELEASED FROM JAIL, STATED TO STAFF HE WAS HAVING VISUAL HALLUCINATIONS [a sensory perception of something that isn’t actually there]. CURRENTLY PT STATES “I DON’T WANT TO BE ON THIS EARTH ANYMORE”. No active plan...HI [homicidal ideation, thoughts of harming others]...” The document indicated a “SUICIDE SCREENING [a systematic procedure which uses standardized instruments or protocols to identify individuals who may be at risk for suicide]” was completed by RN 3. The suicide screening indicated Patient 6’s suicide risk level using the Columbia Suicide Severity Rating Scale [C-SSRS, a tool used for assessing an individual’s risk of suicide] was high risk. On August 6, 2025, at 2:45 p.m., a facility document titled, “Emergency Provider Report,” dated July 25, 2025, at 12:08 a.m., authored by Physician (MD) 11, was reviewed with the Risk Coordinator (RC). The document indicated Patient 6 came into the ED with complaints of hallucinations and suicidal ideation (SI, suicidal ideation, thoughts of harming oneself). The document indicated Patient 6 was recently released from jail, homeless, had stated he heard auditory and visual hallucinations, and was having delusions that people were out to get him and he is scared for his life. The document indicated Patient 6 had a medical history of schizophrenia (a severe mental disorder which affects how a person thinks, feels, and behaves). the document indicated patient 6 had a past history of suicidal ideation and was placed on an involuntary legal hold (5150, a legal process where an individual is admitted to a mental health facility or receives supervised outpatient treatment against their will). The document indicated, “...no concern for SI [suicidal ideation, thoughts of harming self ], HI, command hallucinations [an auditory hallucination where a person hears voices instructing them to perform specific actions] at this time...Patient [Patient 6] is otherwise willing to present to a mental health CSU [crisis stabilization unit, a 24 hour urgent care for patients with psychiatric ([relating to mental illness or its treatment) needs] facility for further workup and treatment. I feel that this is appropriate as patient is a low risk...Overall risk level-suicide: no risk...” The document indicated, “...Discharged to Home...Yes...Time 0240 [2:40 a.m.]...Date...07/26/2025 [July 26, 2025]...” The document did not indicate a Suicide Detailed Risk Assessment (suicide DRA, a comprehensive evaluation process used by healthcare professionals to determine an individual’s likelihood of engaging in suicidal behavior) was conducted by MD 11. A facility document titled, “Disposition,” dated July 26, 2025, at 3:56 a.m., authored by RN 12, was reviewed with the RC. The document indicated, “...Patient left via ...public transportation...Destination details: PATIENT STATED THAT HE WOULD GO TO CUS [sic, CSU, Facility B]...” On August 7, 2025, at 7:45 a.m., an interview with RN 11 was conducted. RN 11 stated the patient (Patient 6) with high risk of suicidal ideations was endorsed to him by the nurse from the previous shift. RN 11 stated the ED physician did not ask him for explanation of the documented high risk of SI for the Patient 6 . On August 7, 2025, at 11:30 a.m., an interview was conducted with the Informatics Nurse (IN, a registered nurse who uses their clinical expertise and knowledge of information technology to improve patient care). The IN stated the suicide-DRA was not completed for Patient 6. The IN stated if the suicide-DRA was completed, it would have been included on the ED Note authored by the provider. The IN stated she did not see the S-DRA assessment on the ED Note for Patient 6. The IN stated, when the physician answers yes to a high risk C-SSRS, the electronic medical record provides instructions to the provider which would indicate, “ ...if the nursing calculated risk assessment shows pt [patient] at risk (low, moderate or high), the provider should then select Yes for the Pos [positive] Nur [nursing] Sui [suicide] Risk Screen [screening]...By doing so, 4 [four] additional queries will become required...” On August 7, 2025, at 1:30 p.m., an interview was conducted with MD 11. MD 11 stated he was not aware nursing made Patient 6 a high risk for suicide on the C-SSRS. MD 11 stated he was not aware a subsequent assessment titled, “Suicide - DRA,” was mandatory when the nurse deemed the patient a high risk on the C-SSRS in accordance with the facility’s the Suicide Prevention Plan policy. MD 11 stated if Patient 6 met the criteria for an involuntary hold, he would get Tele Psych (a contracted service who evaluates a patient with SI, HI, or gravely disabled [not able to care for oneself]) via video call for a legal hold involved to evaluate the patient for a legal hold. On August 7, 2025, at 2 p.m., an interview was conducted with the Director of Patient Safety (DPS). The DPS stated the subsequent assessment for the Suicide-DRA was not completed for Patient 6. The DPS stated the Suicide-DRA should have been completed by the physician once the registered nurse deems the patient a high risk for suicide. A review of the facility policy and procedure (P&P) titled, “Suicide Prevention Plan,” revised September 9, 2025, was conducted. The policy indicated, “...The C-SSRS [Columbia Suicide Severity Rating Scale] is the initial screening tool utilized by the nurse...Any patient with a positive, “at-risk” C-SSRS screening (i.e., low, moderate, or high risk) require a secondary level suicide DRA to identify activating events, protective factors, and contributing factors to risk of suicide. This should be completed by a licensed or credentialed physician/practitioner/Qualified Mental Health Practitioner...The Provider/Practitioner will use the information collected from the suicide DRA paired with clinical judgment to determine (estimate) the patient’s ORL [overall risk level]...””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 50122 Based on interview and record review, for one of sample 20 patients (Patient 6), the facility failed to ensure Patient 6, a suicidal patient, was transferred appropriately. This failure caused Patient 6 to be discharged from the facility without a psychiatric consult and was transported by the facility by a ride-share transport (a non-medical transportation service) to an address which is not the direct address of Facility B (a psychiatric [relating to mental illness or its treatment] facility which provides 24- hour mental health services). This failure resulted in Patient 6 being transferred to Facility C (an emergency psychiatric facility) instead of Facility B which was the intended destination. Findings: On August 6, 2025, at 2:30 p.m., Patient 6’s record was reviewed with Risk Coordinator (RC). facility document titled, “Rapid Initial Assessment,” dated July 25, 2025, at 11:58 a.m., authored by Registered Nurse (RN) 1, was reviewed. The document indicated, “...PT [Patient 6] BIBA [brought in by ambulance] FOR SUICIDAL IDEATIONS [thoughts of death and committing suicide]. PT WAS RECENTLY RELEASED FROM JAIL, STATED TO STAFF HE WAS HAVING VISUAL HALLUCINATIONS [a sensory perception of something that isn’t actually there]. CURRENTLY PT STATES “I DON’T WANT TO BE ON THIS EARTH ANYMORE”. No active plan...HI [homicidal ideation, thoughts of harming others]...” The document indicated a “SUICIDE SCREENING [a systematic procedure which uses standardized instruments or protocols to identify individuals who may be at risk for suicide]” was completed by RN 3. The suicide screening indicated Patient 6’s suicide risk level using the Columbia Suicide Severity Rating Scale [C-SSRS, a tool used for assessing an individual’s risk of suicide] was high risk. On August 6, 2025, at 2:45 p.m., a facility document titled, “Emergency Provider Report,” dated July 25, 2025, at 12:08 a.m., authored by Physician (MD) 11, was reviewed with the Risk Coordinator (RC). The document indicated Patient 6 came into the ED with complaints of hallucinations and suicidal ideation (SI, suicidal ideation, thoughts of harming oneself). The document indicated Patient 6 was recently released from jail, homeless, had stated he heard auditory and visual hallucinations, and was having delusions that people were out to get him and he is scared for his life. The document indicated Patient 6 had a medical history of schizophrenia (a severe mental disorder which affects how a person thinks, feels, and behaves). the document indicated patient 6 had a past history of suicidal ideation and was placed on an involuntary legal hold (5150, a legal process where an individual is admitted to a mental health facility or receives supervised outpatient treatment against their will). The document indicated, “...no concern for SI [suicidal ideation, thoughts of harming self ], HI, command hallucinations [an auditory hallucination where a person hears voices instructing them to perform specific actions] at this time...Patient [Patient 6] is otherwise willing to present to a mental health CSU [crisis stabilization unit, a 24 hour urgent care for patients with psychiatric ([relating to mental illness or its treatment) needs] facility for further workup and treatment. I feel that this is appropriate as patient is a low risk...Overall risk level-suicide: no risk...” The document indicated, “...Discharged to Home...Yes...Time 0240 [2:40 a.m.]...Date...07/26/2025 [July 26, 2025]...” The document did not indicate a Suicide Detailed Risk Assessment (suicide DRA, a comprehensive evaluation process used by healthcare professionals to determine an individual’s likelihood of engaging in suicidal behavior) was conducted by MD 11. A facility document titled, “Disposition,” dated July 26, 2025, at 3:56 a.m., authored by RN 12, was reviewed with the RC. The document indicated, “...Patient left via ...public transportation...Destination details: PATIENT STATED THAT HE WOULD GO TO CUS [sic, CSU, Facility B]...” A review of an undated facility document titled, “24/7 [24 hours seven days a week] MENTAL HEALTH URGENT CARE [CSU, Facility B],” was conducted with the RC and the Emergency room director (EDD). The document indicated the address of Facility B. During a concurrent interview, the EDD and the RC confirmed the address of Facilty B had a building number next to it. A facility document titled, “[name of ride-share company] concierge,” dated July 26, 2025, at 3:59 a.m., authored by RN 12, was reviewed with the RC and the EDD. The document indicated Patient 6 was given a ride from the facility to Facility B. The document did not include the building number for Facility B. During a concurrent interview, the EDD stated and confirmed there was no documentation of Facility B’s building number on the listed address. On August 7, 2025, at 8:30 a.m., an interview with RN 12 was conducted. RN 12 stated she arranged the ride-share transportation for Patient 6 upon the patient’s discharge. RN 12 stated she entered the address of Facility B as the destination address on the ride-share application on the facility’s computer. RN 12 stated the ride-share application did not give her the option of entering the building number as an additional location for Facility B. RN 12 stated she was not aware there were multiple buildings surrounding Facility B at the same address. RN 12 stated a report about Patient 6’s transfer was not given to Facility C because Patient 6 was discharged to Facility B. On August 7, 2025, at 1:30 p.m., an interview was conducted with Physician (MD) 11. MD 11 stated he was not aware Patient 6 was transported via a ride-share tranportation company to Facility B. MD 11 stated he was not aware Patient 6 ended up at another psychiatric facility (Facility C). On August 7, 2025, at 1:45 p.m., an interview was conducted with the Director of Patient Safety DPS. The DPS stated the discharge nurse should have made sure the correct address was given to ride-share transportation company when arranging transportation for Patient 6 from the facility to Facility B. A review of the facility policy and procedure titled, “Discharge Transportation Services Program,” dated February 1, 2025, was conducted. The policy indicated, “...If the Discharged Patient is transported by ride share company Transport Vendor...a Transport Coordinator shall contact the ride share company and request the transportation...The Transport Coordinator shall include the...address to which the patient is to be transported (patient’s residence or Alternate location) in the transport request...””

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure the facility’s policy and procedure was implemented, for one of 34 patients reviewed (Patient 13), when Patient 13 was discharged home from intermediate care (a department designed for patients recovering from critical medical conditions] and not downgraded to the telemetry (a unit where patients are continuously monitored for heart rhythm) for monitoring after the completion of the intravenous heparin (a medication used to help prevent blood clots from forming) drip (continuous administration of the prescribed dose of heparin) ordered for pulmonary embolism (a blood clot in the lung) and deep vein thrombosis (a blood clot in the vein) (Refer to A-0347). The cumulative effects of this systemic failure could have contributed to the deterioration of Patient 13’s medical condition which led to cardiac arrest (when the heart stops beating) and re-admission to the facility.”

“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: 44871 Based on interview and record review, the facility failed to ensure transfer to another facility for higher level of care was conducted timely, for one of 34 sample patients (Patient 11), before the patient decompensated (to lose the ability to maintain a stable state) and was not stable to be transferred (Refer to A 0813) The cumulative effects of this systemic failure could have contributed to the deterioration of Patient 11’s medical condition and had the potential to cause delays in the provision of patient care and impact the health and treatment of the patient.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure the facility’s heparin (a medication used to help prevent blood clots from forming) policy and procedure (P&P) was implemented, for three of 34 sample patients (Patient 13, 25, and 33), when the PTT (partial thromboplastin time, a laboratory test which measures how long it takes for the blood to clot) was not drawn timely. These failures had the potential to delay patient care and treatment. Findings: 1. On June 11, 2025, at 9:20 a.m., a review of Patient 13’s record was conducted with Quality Coordinator (QC) 3. A facility document titled, “EMERGENCY PROVIDER REPORT,” was reviewed and indicated Patient 13 arrived by ambulance to the Emergency Department on May 3, 2025, at 6:39 a.m., for shortness of breath (SOB). A facility document titled, “Emergency Provider Report,” dated May 3, 2025, at 8:29 p.m., was reviewed. The document indicated, “...Patient [Patient 13]...medical history of hypertension [high blood pressure]...presents with 1 [one] week of intermittent [on and off] shortness of breath with associated chest pain starting today [May 3, 2025] at 5:00 p.m. [5 p.m.]...reports that chest pain onset was sudden and has not relented...worsened chest pain with inspiration...She is on 3 [three] L [liters, unit of measurement] nasal cannula [a plastic tube which delivers oxygen through the nostril], and is on room air [RA, with no supplemental oxygen] at baseline...Cardiovascular: Tachycardic [a medical condition where patient has a fast heart rate of over 100 beats per minute]...Satting [oxygen saturation, measurement of how much oxygen is in blood stream, normal is 95-100 %] > 93% on RA...CT angio [computed tomography angiography, an imaging technique that uses X-rays and computer processing to create detailed images of blood vessels] of the chest showed large burden bilateral main pulmonary emboli [blockage of the arteries in a lung]... Given patient’s large pulmonary emboli...was started on heparin drip [a continuous infusion through a vein at a prescribed dose]...Disposition: Admit...” A facility document titled, “Critical Care H&P,” dated May 4, 2025, at 3:58 a.m., was reviewed. The document indicated, “...sudden SOB and CP [chest pain] day of admission...bilateral PE [pulmonary embolism, condition where the artery in the lung is blocked]...initial HR [heart rate, normal is 60-100 beats per minutes] 120...dyspnea [difficulty breathing] noted primarily with exertion [the physical effort during activity] and relieved with rest...on the day of admission, dyspnea would not resolve and there was also associated chest pain... bilateral pulmonary embolism...Anticoagulation [process of preventing blood clots] would be reasonable...” An undated facility document titled, “EMERGENCY PATIENT RECORD,” was reviewed. The document indicated, “...IV [intravenous, administered through a vein] Drip [continuous administration of a prescribed dose of a medication] Status...Date 05/04/25 [May 24, 2025] Time 0037 [12:37 a.m.]...Heparin...25000 UNITS/250 ML (unit per milliliter, unit of measurement) IV Drip 1 new dosage: 1600...IV drip 1 titrate [continuously measure and adjust the balance of a medication] parameters: Labs [laboratory]...IV drip 1 parameter value: 70-95 [seconds, normal prothrombin time (PTT), amount of time for the blood to clot]...IV drip 1 actual parameter value 26...” A facility document titled, “Staff Lab Draws,” dated June 3, 2025, at 7:27 p.m., to June 6, 2025, at 7:06 a.m., was reviewed. The document indicated the following lab tests for PTT drawn by laboratory technicians: - On June 3, 2025, at 9:17 p.m., initial PTT lab draw; - On June 3, 2025, at 12:37 a.m., heparin medication started; - On June 4, 2025, at 6:44 a.m., six (6) hours and 16 minutes from the initiation of heparin drip; - On June 4, 2025, at 12:52 p.m., 6 hours and eight (8) minutes after the last PTT draw; - On June 4, 2025, at 7:50 p.m., 6 hours and 58 minutes after the last PTT draw; - On June 5, 2025, at 1:47 a.m., five hours and 57 minutes after the last PTT draw ; - On June 5, 2025, at 9:11 a.m., seven hours and 24 minutes after the last PTT draw; - On June 5, 2025, at 3:56 p.m., 6 hours and 44 minutes after the last PTT draw; - On June 6, 2025, at 12:17 a.m., 8 hours and 21 minutes after the last PTT draw; and - On June 6, 2025, at 7:06 a.m., 6 hours and 49 minutes after the last PTT draw. The document indicated PTT was drawn later than every six hours while Patient 13 was on a heparin drip. During the record review, there was no documented evidence PTT was drawn every six hours for Patient 13, in accordance with the facility’s heparin P&P. During a concurrent interview with the QC, on June 11, 2025, at 9:20 a.m., QC 3 stated Patient 13’s initial PTT level was at 26 seconds. QC 3 stated registered nurses should follow the facility’s heparin P&P which indicated patients on a heparin drip must have labs drawn every six hours to check for PTT until they meet the therapeutic range (laboratory result value which indicates the normal range for PTT) of 70-95 seconds. On June 11, 2025, at 4:49 p.m., an interview was conducted with the Laboratory Director (LD). The LD stated the heparin drip P&P indicated PTT should be drawn on time every 6 hours or less. b. A review of Patient 25’ s record was conducted on June 11, 2025, at 2:41 p.m., with QC 3. A facility document titled, “History and Physical- Adult,” dated June 6, 2025, was reviewed. The document indicated Patient 25 was admitted to the facility for atrial fibrillation (a fib) with rapid ventricular response (a heart rhythm disorder where the heart’s upper chambers beat irregularly and rapidly, and the lower chambers also beat too fast). A facility document titled, “PHA [pharmacy] ORDER,” dated June 9, 2025, was reviewed. The document indicated, “Heparin [a blood thinner medication] Pharmacy to dose...dose: 1 each ...Route: IV...Instructions and Comments...Patient currently on Heparin ACS [acute coronary syndrome, a heart condition]/MI [myocardial infarction, heart attack]/AFIB treatment...” A facility document titled, “Medication Data,” dated June 6, 2025, indicated, “...PTT q [every] 6 h [hour] after previous PTT or rate change...” An undated facility document titled, “Medication Administration,” was reviewed. The document indicated, “...Heparin 25000 units/0.45% NS [normal saline, a sterile solution of salt and water] 250 ml [milliliter, unit of measurement]...Date June 9, 2025...10:32 [a.m.]...” A facility document titled, “Coagulation Data,” dated from June 8, 2025, through June 11, 2025, indicated the following PTT lab draws completed on Patient 25: - On June 9, 2025, at 7:56 a.m., before heparin drip was started; - On June 9, 2025, at 10:32 a.m., start of heparin drip; - On June 9, 2025, at 1:55 p.m., PTT draw was cancelled; - On June 9, 2025, at 5:30 p.m., seven [7] hours and 58 minutes from initiation of heparin drip; - On June 9, 2025, at 7:55 p.m., PTT draw was cancelled; - On June 10, 2025, at 12:42 a.m., 7 hours and 12 minutes from the last PTT draw; - On June 10, 2025, at 1:55 a.m., PTT was drawn; - On June 10, 2025, at 7:55 a.m., PTT draw was canceled; - On June 10, 2025, at 8:53 a.m., 6 hours and 68 minutes from the last PTT draw; - On June 10, 2025, at 1:55 p.m. PTT draw was cancelled; - On June 10, 2025, at 5:43 p.m., eight [8] hours and 50 minutes from the last PTT draw; - On June 10, 2025, at 7:55 p.m., PTT draw was cancelled; and - On June 11, 2025, at 4:02 a.m., 10 hours and 19 minutes from last PTT draw. During a concurrent interview on June 11, 2025, at 2:41 p.m., QC 3 stated the date and the time on the document titled, “Medication Administration,” meant when the heparin was started for Patient 25. A concurrent interview and review of Patient 25’s record were conducted on June 16, 2025, at 3 p.m., with the LD. A facility document titled, “Coagulation Data,” for Patient 25, was reviewed. The LD stated the lab draws were conducted by the laboratory technician and PTT were not drawn every 6 hours per the facility’s heparin protocol. c. A review of Patient 33’ s record was conducted on June 11, 2025, at 4:15 p.m., with QC 3. A facility document titled, “History and Physical- Adult,” dated June 7, 2025, was reviewed. The document indicated Patient 33 was admitted to the facility for non-ST elevation myocardial infarction (a type of heart attack where the blockage of a coronary artery reduces blood flow to the heart muscles). A facility document titled, “PHA ORDER,” dated, June 7, 2025, indicated, “...Heparin Sodium...5,000 units/ml...Dose: 4,000 units...IV...stat [immediately]...instruction and comments...max [maximum] dose is 4,000 units...” A facility document titled, “Medication Data,” dated June 7, 2025, indicated, “...PTT q 6 h after previous PTT or rate change...” An undated facility document titled, “Medication Administration,” was reviewed. The document indicated, “...Heparin Sodium 5000 units/ml...Date June 7, 2025...14:23 [2.23 p.m.]...” A facility document titled, “Coagulation Data,” dated from June 7, 2025, through June 11, 2025, indicated the following PTT lab draws completed on Patient 33: - On June 7, 2025, at 12:25 p.m., initial PTT draw prior to infusion of the heparin medication; - On June 7, 2025, at 2:42 p.m., start of the heparin drip; - On June 7, 2025, at 10:13 p.m., 7 hours and 29 minutes from the initiation of the heparin drip; - On June 9, 2025, at 5:54 p.m., 7 hours and 41 minutes from the last PTT draw; - On June 10, 2025, at 2:19 a.m. 7 hours and 35 minutes from last PTT draw; - On June 10, 2025, at 9:30 p.m., 7 hours and 11 minutes from the last PTT drawn; and - On June 11, 2025, at 5:06 a.m., 7 hours and 36 minutes from last PTT draw. During a concurrent interview, QC 3 stated the date and the time on the document titled, “Medication Administration,” meant when heparin administration was started on Patient 33. A concurrent interview and record review were conducted on June 11, 2025, at 4:49 p.m. with the Laboratory Director (LD). Patient 33’s facility documents titled, “Medication Data,” and “Coagulation Data,” were reviewed. The LD stated, “The heparin drip protocol indicated that laboratory technicians are responsible for drawing the PTT every 6 hours.” The LD also stated, “Labs [PTT] should be drawn on time so every 6 hours or less.” A concurrent interview and review of Patient 33’s record were conducted on June 16, 2025, at 3 p.m., with the LD. A facility document titled, “Coagulation Data,” for Patient 33, was reviewed. The LD stated the lab draws were conducted by the laboratory technician and PTT were not drawn every 6 hours in accordance with the facility’s heparin protocol. A review of the facility’s P&P titled, “Heparin - Treatment Guidelines,” dated February 2023, was conducted. The document indicated, “...to provide standards for the prescribing, preparation/dispensing, administration and monitoring of treatment indications with...heparin...Standard Protocol (PTT Goal 70-95 seconds)...Treatment of deep vein thrombosis (clot in a deep vein) or pulmonary embolism...PTT q 6 h (every six hours) after previous PTT or rate change...Adjust dosage to keep PTT between 70-95 seconds...””

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure the facility’s policy and procedure was implemented, for one of 34 patients reviewed (Patient 13), when Patient 13 was discharged to home from the intermediate care (IMC, a unit designed for patients recovering from critical medical conditions) and not downgraded to telemetry (a unit where patients’ heart rate and rhythm are continuously monitored remotely) for monitoring after completion of the intravenous heparin (a medication used to help prevent blood clots from forming) drip [continuous administration of the prescribed dose of heparin] ordered for pulmonary embolism (a blood clot in the lung) and deep vein thrombosis (a blood clot in the vein). These failures could have contributed to Patient 13 collapsing and going into cardiac arrest [when the heart stops beating] in the parking lot after being discharged and leaving the facility and requiring cardiopulmonary resuscitation (CPR, a lifesaving procedure performed when the heart stops beating) and readmission to the hospital. Findings: On June 11, 2025, at 9:20 a.m., a concurrent interview and review of Patient 13’s record were conducted with Quality Coordinator (QC) 3. A facility document titled, “EMERGENCY PROVIDER REPORT,” was reviewed and indicated Patient 13 arrived by ambulance to the Emergency Department (ED) on May 3, 2025, at 6:39 a.m., for shortness of breath (SOB). A facility document titled, “Emergency Provider Report,” dated May 3, 2025, at 8:29 p.m., was reviewed. The document indicated, “...Patient [Patient 13]...medical history of hypertension [high blood pressure]...presents with 1 [one] week of intermittent [on and off] shortness of breath with associated chest pain starting today [May 3, 2025] at 5:00 p.m. [5 p.m.]...reports that chest pain onset was sudden and has not relented...worsened chest pain with inspiration...She is on 3 [three] L [liters, unit of measurement] nasal cannula [a plastic tube which delivers oxygen through the nostril], and is on room air [RA, with no supplemental oxygen] at baseline...Cardiovascular: Tachycardic [a medical condition where patient has a fast heart rate of over 100 beats per minute]...Satting [oxygen saturation, measurement of how much oxygen is in blood stream, normal is 95-100 %] > 93% on RA...CT angio [CTA, computed tomography angiography, an imaging technique that uses X-rays and computer processing to create detailed images of blood vessels] of the chest showed large burden bilateral main pulmonary emboli [blockage of the arteries in a lung]... Given patient’s large pulmonary emboli...was started on heparin drip [a continuous infusion through a vein at a prescribed dose]...Disposition: Admit...” A facility document titled, “Critical Care H&P,” dated May 4, 2025, at 3:58 a.m., was reviewed. The document indicated, “...sudden SOB and CP [chest pain] day of admission...bilateral PE [pulmonary embolism, condition where the artery in the lung is blocked]...initial HR [heart rate, normal is 60-100 beats per minutes] 120...dyspnea [difficulty breathing] noted primarily with exertion [the physical effort during activity] and relieved with rest...on the day of admission, dyspnea would not resolve and there was also associated chest pain... bilateral pulmonary embolism...Anticoagulation [process of preventing blood clots] would be reasonable...” A facility document titled, “Critical Care Progress Note,” dated May 4, 2025, at 7:15 a.m., was reviewed. The document indicated, “...ED work up significant for CTA chest demonstrating...PE in distal [further away] main pulmonary arteries...ICU [intensive care unit, a unit for patients with serious illness or life-threatening conditions needing close observation] team consulted for evaluation and management...Patient [Patient 13] was started on heparin and admitted to ICU...Patient evaluated in ED...satting well on 5L [five liters oxygen] NC...continues to report left sided chest pain and dyspnea...reports getting short of breath with exertion. Heparin drip running...Diagnosis, Assessment & Plan...Submassive bilateral pulmonary embolism...intermediate risk...Dispo [disposition] Stable for downgrade to IMC [intermediate care, a unit for patients who require more monitoring than general units but do not need intensive care unit]...” A facility document titled, “Discharge Report,” dated May 4, 2025, was reviewed. The document indicated, “...Procedure Name...INTENSIVIST [physician who specializes in the care and treatment of patient in intensive care] CONSULT...Reason for Consult...ADMIT...Time Frame for Consult...Emergent/STAT [immediately]...Procedure Name...ADMIT STATUS ORDER...INITIAL...Date...05/04/2025 [May 4, 2025]..Time...0330 [3:30 a.m.]...Patient Status...Admit to Inpatient...Medical Reason...PE...Procedure Name...ADMISSION LEVEL OF CARE...Intensive Care...Procedure Name...TRANSFER IN-HOUSE ORDER...Date...05/04/2025...Time...0754 [7:54 a.m.]...Level of Care...Intermediate Care [IMC]...Procedure Name...INTERNAL MEDICINE CONSULT...Date 05/04/2025...Reason for Consult...ICU downgrade...Procedure Name...Unconditional Discharge Order...Date 05/06/2025 [May 6, 2025]...Time...0834 [8:34 a.m.]...Discharge to...Home/Self Care...Attending Physician...[name of Physician 4]...” A facility document titled, “Adult General Consultation,” dated May 5, 2025, at 6:35 a.m., was reviewed. The document indicated, “...Large...pulmonary emboli...Occlusive [block] thrombus [blood clot] of the left distal...femoral [relating to thigh], left popliteal [back if knee], left peroneal [outer part of leg], and left small saphenous veins [vein that sends blood from leg to the heart]...” A facility document titled, “MEDICATION DISCHARGE SUMMARY,” dated May 6, 2025, was reviewed. The document indicated, “...Eliquis (APIXABAN) [a blood thinner] 5mg [milligram, unit of measurement]...10 mg PO [by mouth] twice daily...Total Doses...14 (1 of 14 given)...nursing acknowledged order...at 9:24 [a.m.] gave...10 mg...” A facility document titled, “CLINICAL DOCUMENTATION RECORD,” dated May 6, 2025, indicated, “...Activity Date...05/06/25 [May 6, 2025]...Time...1033 [10:33 a.m.] IV drip...discontinue time...1033 [10:33 a.m.]...” A facility document titled, “EMERGENCY PATIENT RECORD,” dated May 6, 2025, was reviewed. The document indicated, “...DEPARTURE INFORMATION...Departure Date/Time: 05/06/25 [May 6, 2025]...1048 [10:48 a.m.]...” A facility document titled, “Discharge Summary,” dated May 6, 2025, was reviewed. The document indicated, “...patient was admitted for SOB; found to have... main pulmonary emboli on CTA chest and DVT [deep vein thrombosis, blood clot in a vein] on left leg on venous doppler u/s [ultrasound, an imaging procedure used to assess circulation in large veins]; the patient was initially admitted to the ICU...Internal medicine was consulted since pt [patient] was transferred out of ICU...patient remained in the ED duiring [sic, during] her hospitalization; patient reported to be unresponsive when she got into her car and code blue [an emergency code experiencing life threatening emergency such as a cardiac arrest] was called...pt was intubated [insertion of a flexible tube into the airway to assist in breathing] and re-admitted to the ICU...” A facility document titled, “Emergency Provider Report,” dated May 6, 2025, at 12:50 p.m., was reviewed. The document indicated, “...Patient...with past medical history of hypertension...and recent diagnosis of bilateral submassive PE’s on 05/04/2025 [May 4, 2025], started on Eliquis and discharged from the hospital today presenting to the emergency department in cardiac arrest. Patient was reportedly in the parking lot and had a witnessed PEA [pulseless electrical activity, having no pulse] arrest. Patient was resuscitated [revived]...Patient received TNK [Tenecteplase, a medication that dissolves blood clots] at approximately 11:51 a.m...ROSC [return of spontaneous circulation, when the heart starts beating again] was achieved after about 20 minutes...Patient was emergently intubated..Labs [laboratory] reviewed and notable for...WBC [white blood cells, a component of blood, normal is 4-11] 25.4...repeat CT pending...lactate [a substance produced in the body when oxygen levels are low, normal is less than 2] 9...CT pulmonary [lung] angio [CTA] revealed bilateral [involving both sides]...pulmonary emboli within the main pulmonary artery/pulmonary trunk...concerning for...hemorrhage [bleeding]/pulmonary contusions [bruising] and or pneumonitis [inflammation of lung]...patient presents in cardiac arrest with recent diagnosis and admission for large burden pulmonary embolism. TKN was given, ROSC achieved after approximately 20-25 minutes. Repeat CT scan of her chest will be obtained...” A facility document titled, “Hospitalist Progress Note,” dated May 10, 2025, at 10:19 a.m., was reviewed. The document indicated, “...6/3 [June 3, 2025]: Patient seen thism orning [sic, this morning] and she was able to open her eyes spontaneously but isn’t tracking [when the eyes follow a moving object] or no improvement of her mentation [mental activity]...Spoke extensively regarding patient’s condition...continue long term facility. CM [case management] for ltach [long term acute care hospital] given patient still requiring monitoring for edema and respiratory status. Patient to be given one dose of versed [a medication to relax] to help with patient’s locked jaw cuasing [sic-causing] trauma to her tongue...6/4 [June 4, 2025] patient seen thism orning [sic-this morning] with no change in mentation...6/5 [June 5, 2025] patient seen this monring [sic-morning] without any change in mentation...Family refusing ltach...Patient not cleared for subacute [a unit providing less intensive care and monitoring than an ICU but more specialized than a typical skilled nursing care] at this time...6/7 [June 7, 2025] Patient seen this morning with no change...6/8 [June 8, 2025] Patient seen this morning and in similar state...WBC still elevateda [sic, elevated] at 21. ID [infectious disease physician] consulted and patient positive for legionella [bacteria that affects the lungs, brain, and intestines]. Hemoglobin [component of red blood cells which carry oxygen to the body parts] dropped...one unit of prbcs [packed red blood cells, a type of blood used for transfusion] ordered...6/9 [June 9, 2025] Patient seen this morning and no change in mentation...6/10 [June 10, 2025] Trach [tracheostomy, a procedure when a tube is surgically placed into windpipe] on vent [ventilator, a machine which assists in breathing]...Tolerating tube feeds [administration of feeding through a plastic tube] via PEG [percutaneous endoscopic gastrostomy, a tube passed through patient’s abdominal wall into stomach used for feeding]...Plan...discussion with family members today for LTAC [ltach] versus hospice [a specialized care for patients with terminal illnesses]...Diagnosis, Assessment & Plan...respiratory failure requiring intubation mechanical ventilation status post [after] trach and PEG...Anoxic [absence of oxygen supply] brain injury...Status post...cardiac arrest...Multiple DVTs in bilateral lower extremities...Pulmonary embolism...MRI [magnetic resonance imaging, an imaging procedure] showed diffuse anoxic brain injury...EEG [a test which measures electrical activity in the brain] showed anoxic myoclonic status [condition that occurs after a period of oxygen deprivation characterized by involuntary movements]...” During review of Patient 13’s record, there was no documented evidence Patient 13 was downgraded to telemetry level of care for further monitoring after the heparin drip was discontinued and Eliquis was started. On June 16, 2025, at 1:26 p.m., an interview was conducted with the Regulatory Director (RD). The RD stated, according to Physician 4’s attorney, Physician 4 would no longer be coming at 2 p.m. today for an interview. On June 16, 2025, at 2:36 p.m., an interview was conducted with Physician 2. Physician 2 stated, when a patient comes into the facility with a suspected pulmonary embolism, the emergency department would conduct a CTA to check for the PE. Physician 2 stated when a patient is transitioned from heparin to Eliquis, the patient is checked for hemodynamic [blood flow] stability to make sure risk for bleeding is not present. Physician 2 stated a patient is usually monitored for 24-48 hours after a heparin drip is discontinued to ensure the patient is tolerating an oral anticoagulant. If the patient was on IMC level of care, it would have been expected to have the patient downgraded to telemetry level of care for monitoring prior to considering discharge. A review of the facility’s policy and procedure (P&P) titled, “Admissions, Transfers, and Discharge of Stepdown Patients,” dated November 30, 2023, was conducted. The document indicated, “...Intensivist Service...shall have the overall supervision, management, and triage of the patients...includes full authority to admit, transfer, and discharge to and from the stepdown unit based on clinical appropriateness and in communication with the attending physician as indicated...Patients will only be admitted to stepdown from ICU...Patients who are admitted from ED...will be re-evaluated by the attending physician...Discharge Criteria for patients from Stepdown shall include...When a patient’s...status has stabilized and the need for frequent monitoring is no longer necessary and the patient can be cared for on a general unit...” A review of the facility’s P&P titled, “ADMISSION DISCHARGE CRITERIA MEDICAL SURGICAL UNITS,” dated June 26, 2024, was conducted. The document indicated, “...guidelines to assist in determining appropriateness for patient admissions/discharges to the General Medical/surgical units...common candidates for admission include: DVT...Dyspnea...Units are staffed and designed for the acutely ill patient, not the critical ill... Discharge criteria...Stable body systems...Systems controlled or controllable outside of inpatient setting...” A review of the facility’s P&P titled, “PLAN FOR THE PROVISION OF PATIENT CARE - SCOPE OF SERVICE,” dated April 2024 was conducted. The document indicated, “...To define, develop, implement and evaluate an overall hospital plan for patient care...Based on interdisciplinary collaborative efforts...Nursing services, clinical, and non-clinical staffs...Goal is to coordinate care in a manner that is conducive to optimal patient outcomes, quality, and safety...The medical executive committee (MEC) is responsible for the oversight of care provided by medical staff...IMC...Provide step down level of critical nursing care including but not limited to continuous cardiac monitoring, high level pharmacological therapy...Care that is delivered to patients whose needs fall along the less acute end of the critical care continuum with medical cardiac and respiratory diagnosis...IMC patients are moderately stable with less complexity, requiring moderate resources and require intermittent nursing vigilance and requiring increased intensity of care...Titratable non-vasoactive drugs...Telemetry...nursing care is provided to patients requiring cardiac monitoring...respiratory therapy...designated unit for cardiac patients not requiring ICU or step down level of care...” A review of the facility document titled, “BYLAWS GOVERNING,” dated July 25, 2018, were conducted. The document indicated, “...The board shall, in the exercise of its discretion and to the extent consistent with law...delegate to the Medical Staff the overall responsibility for the quality of the professional services provided by individuals with clinical privileges...Each member of the Medical Staff shall have appropriate authority and responsibility for the diagnosis and treatment of his/her patients...””

“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: 44871 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for one of 34 sample patients (Patient 12), when wound photos were not taken for a dog bite. This failure had the potential to place Patient 12 at risk for delayed treatment and harm. Findings: On June 16, 2025, at 9:46 a.m., a review of Patient 12’s record was conducted with the Director of Patient Safety (DPS). A facility titled, “EMERGENCY PROVIDER REPORT,” dated May 2, 2025, at 3:44 p.m., was reviewed. The document indicated, “...Procedures...Laceration management # [number] 1 [one]...Location of Wound...left lower extremity...Wound Length (cm) [centimeter, a unit of measurement]: 8 [eight]...Laceration management # 2 [two]...Location of Wound...left thigh...Wound Length (cm) 4 [four]...” A facility document titled, “History and Physical,” dated May 4, 2025, at 8:51 a.m., was reviewed and indicated Patient 12 was admitted to the facility on May 3, 2025, for a dog bite to the left lower extremity (leg). An untitled facility document was reviewed. The document indicated three photos of Patient 12’s left lower extremity were taken on May 5, 2025, at 4:35 p.m. During review of Patient 12’s record, there was no documented evidence photos were taken on the following dates: - On May 2, 2025, in the Emergency Department when the wounds were discovered on assessment; and - On May 4, 2025, through May 9, 2025, for the weekly photograph and a photograph at discharge. On May 16, 2025, at 10:48 a.m., a concurrent interview and review of Patient 12’s record were conducted with the DPS. The DPS stated photos of Patient 12’s wounds should have been taken within four hours of admission, when the wound was first identified, once a week, and at discharge. The DPS stated the facility’s policy was not followed. The facility policy and procedure (P&P) titled, “Skin Integrity Management,” dated September 2022, was reviewed. The P&P indicated, “...Photographs of all wounds requiring treatment will be taken...On admission within the first 4 hours...When there is a change in the skin condition (debridement [a medical procedure involving the removal of dead tissue], surgery, or dehiscence [a partial or total separation of previously approximated wound edges, due to a failure of proper wound healing])...Weekly thereafter...Prior to discharge...””

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 44871 Based on interview and record review, the facility failed to ensure the transfer to another facility for higher level of care (HLOC) was conducted timely, for one of 34 sample patients (Patient 11), before the patient decompensated (to lose the ability to maintain a stable state) and was not stable to be transferred. This failure could have contributed to the deterioration of Patient 11’s medical condition and had the potential to cause delays in the provision of patient care and impact the health and treatment of the patient. Findings: On June 12, 2025, at 8:57 a.m., a review of Patient 11’s record was conducted with the Director of Patient Safety (DPS). A facility document titled, “History and Physical,” dated May 27, 2025, at 8:13 a.m., was reviewed and indicated Patient 11 was admitted to the facility on May 26, 2025, for cholelithiasis (gall stones, a hardened deposit within the fluid in the gallbladder) and cirrhosis (a disorder with liver damage). A facility document titled, “General Surgery Consultation,” dated May 27, 2025, at 1:01 p.m., was reviewed. The document indicated, “...liver cirrhosis 2/2 [secondary to] celiac disease [autoimmune disorder which damages the small intestines]...MELD [Model for End stage Liver Disease, a numerical scale used to assess the severity of long-term liver disease and predicts the likelihood of death within three months for patients awaiting liver transplant, with a range of six to 40, with higher scores indicating more severe disease and a greater need for transplantation] 21...Plan...Recommend GI [gastrointestinal, pertaining to the stomach and intestines] consult...rec [recommend] EUS [endoscopic ultrasound, a procedure that combines using a flexible tube to look into the esophagus and stomach and ultrasound to help diagnoses and stage disease] + [plus] ERCP [endoscopic retrograde cholangiopancreatography, a procedure to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas] needs transfer...” A facility document titled, “GE [Gastroenterologist, a physician who specializes in the treatment and diagnoses of gastrointestinal disorders] Consultation Note,” dated May 27, 2025, at 3:31 p.m., was reviewed. The document indicated, “...skin...jaundice [yellowish skin due to the accumulation of bilirubin (a yellow pigment which results from the normal breakdown of red blood cells, normal levels for adults are between 0.2 and 1.3 milligram per milliliter, a unit of measurement)]...Plan ...Recommend transfer for HLOC with EUS...ERCP...” a. A facility document titled, “Order History Data,” dated May 28, 2025, at 11:56 a.m., was reviewed. The document indicated, “...Transfer for ERCP...” A facility document titled, “GE Consultation Note,” dated June 3, 2025, at 7:03 p.m., was reviewed. The document indicated, “...GI was reconsulted given persistent elevated bilirubin bilirubin at 8.4...AST [aspartate aminotransferase, an enzyme found in the liver, normal AST range is between 8 to 33 U/L (units per liter, unit of measurements)] slowly rising to 172...Discussed with patient upper endoscopy with possible ultrasound and or ERCP to evaluate the etiology [cause] of her ongoing elevated bilirubin...Plan for EGD [esophagogastroduodenoscopy, a procedure to diagnose and treat the esophagus, stomach and the first part of the intestines using a camera to view them] with EUS and possible ERCP tomorrow 6/4 [June 4, 2025]...” A facility document titled, “Case Management Report,” dated May 29, 2025, through June 4, 2025, was reviewed. The document indicated, “...May 29, 2025, at 3:29 p.m ...HLOC TRANSFER INTAKE FORM AND PACKET FAXED TO [Name of corporate transfer center (NOCTC, office which coordinate transfers of patients to another facility)]. REQUESTED TC [transfer center] RN [Registered Nurse] TO REACH OUT TO [Name of HLOC Facilities (HLOC 1, HLOC 2, HLOC 3, and HLOC 4)]...May 30, 2025, at 4:08 p.m...[Name of HLOC 1] PENDING FINANCIAL CLEARANCE...SBAR [situation, background, assessment, and recommendations] EMAILED...FROM [Name of HLOC 1] TO BE SIGNED...May 31, 2025, at 10:18 a.m...spoke with [Name of HLOC 1] todday [sic, today] and no plan for transfer this weekend. States they will reassess on Monday for schedule availability...June 1, 2025, at 5:29 p.m...pending a bed at [Name of HLOC 1] today. [Name of HLOC 1] will have a bed tomorrow...June 2, 2025, 11:32 a.m ...Pending transfer update...with transfer center...June 2, 2025, 3:52 p.m...Still no update...CM [case manager] sent another message...requesting an update...June 3, 2025, at 2:07 p.m...CM called the transfer center to f/u [follow up] on bed at HLOC 1...patient is pending a bed at [Name of HLOC 1], no bed at this time...June 4, 2025, at 11:34 a.m...pt [Patient 11] is scheduled to have EGD with Ultrasound at [Name of the facility] today. During review of Patient 11’s record, there was no documented evidence the process of transferring Patient 11 was started on May 28, 2025, when the transfer order was written by the physician. During review of Patient 11’s record, there was no documented evidence the facility followed up with the transfer center for an available bed after the information was sent to NOCTC on May 29, 2025. During review of Patient 11’s record, there was no documented evidence the facility followed up with HLOC 2, HLOC 3, and HLOC 4, on May 30, 2025, May 31, 2025, June 1, 2025, June 2, 2025, June 3, 2025, and June 4, 2025, regarding transferring Patient 11 to any of these facilities. b. A facility document titled, “Gastroenterology Progress Notes,” dated June 5, 2025, at 5:55 p.m., was reviewed. The document indicated, “...GI was reconsulted given persistently elevated bilirubin...Decompensated [deteriorating] cirrhosis - worsening...MELD 3.0 = [Equals] 34 on 6/5/2025 [June 5, 2025]...HOLD diuretics given worsening renal function...AKI [acute kidney injury, sudden decrease in kidney function]...Patient with worsening renal [kidney] function sCR [serum creatinine, a blood test which measures the amount of creatinine, a waste product, normal range from 0.7 to 1.1 mg/dl for women] up to 1.940 concerning for developing hepatorenal syndrome [a life threatening complication of advanced liver failure]...Liver transplant evaluation...Given worsening MELD 34 and that patient has no prior alcohol use and has excellent family support, we recommend urgent transfer for HLOC for liver transplant...” A facility document titled, “Gastroenterology Progress Note,” dated June 6, 2025, at 8:23 a.m., was reviewed. The document indicated, “...Reports decreased urine output ...Worsening renal function. sCR elevated now to 2.370. Patient states she has not voided. Spoke with Attending [Name of Transplant Hepatologist, a physician specializing in the diagnosis and treatment of liver diseases and in performing liver transplant] this morning at [Name of HLOC 5] who will accepts [sic, accept] patient. Spoke with Primary Team regarding request for transfer for HLOC for liver transplant eval [evaluation]...Abdomen...ascites [fluid in the abdominal cavity], distended, tenderness...Skin...jaundice [yellow discoloration of the skin due to increased bilirubin]...Decompensated cirrhosis - worsening...MELD 3.0 = 34...urgent transfer for HLOC for liver transplant evaluation...” A facility document titled, “Order History Data,” dated June 6, 2025, at 5:10 p.m., was reviewed. The document indicated, “...Transfer for HLOC liver transplant [Name of HLOC 5]...” A facility document titled, “Gastroenterology Progress Note,” dated June 7, 2025, at 2:21 p.m., was reviewed. The document indicated, “...Patient is still pending transfer for higher level of care for transplant evaluation...MELD 3.0 = 37...urgent transfer for HLOC for liver transplant evaluation...” A facility document titled, “Gastroenterology Progress Note,” dated June 8, 2025, at 2:03 p.m., was reviewed. The document indicated, “...Patient still pending transfer ...Abdomen...ascites, distended, tenderness...Skin jaundice...Decompensated cirrhosis [complicated by] jaundice, ascites...urgent transfer for HLOC for liver transplant evaluation...” A facility document titled, “Gastroenterology Progress Note,” dated June 9, 2025, at 6:54 p.m., was reviewed. The document indicated, “...Reports worsening dyspnea [shortness of breath] and lower extremity [legs and feet] edema [swelling]...Decompensated cirrhosis...Given worsening MELD 37...recommend urgent transfer for HLOC for liver transplant evaluation...” A facility document titled, “Gastroenterology Progress Note,” dated June 10, 2025, at 6:46 p.m., was reviewed. The document indicated, “...Clinically worsened today. Worsening hypoxemia [low level of oxygen in the blood] on mask rebreather [a type of device used to deliver higher concentrations of oxygen]. Chest x ray [an imaging procedure] shows significant bilateral pulmonary edema [a condition when fluids accumulate in the lungs]...Still waiting for bed at [Name of HLOC 5]...Given worsening clinical status, recommend evaluation if patient is a liver transplant candidate at other transplant centers [Names of HLOC 4 and HLOC 6], etc [and others] while we wait bed at [Name of HLOC 5]...” A facility document titled, “Post Intubation Note,” dated June 11, 2025, at 9:42 a.m., was reviewed. The document indicated, “...Indications: respiratory failure [condition with inefficient breathing]...ET [endotracheal tube, a flexible plastic tube inserted into the windpipe to maintain airway used to assist in breathing]...Mechanical ventilation [use of a machine to support breathing] initiated: Yes...” A facility document titled, “Gastroenterology Progress Note,” dated June 11, 2025, 6:43 p.m., was reviewed. The document indicated, “...intubated [insertion of an ET tube] this morning. Patient’s overall status is critical...MELD 3.0 = 41...” A facility document titled, “Case Management Report,” dated June 6, 2025, through June 11, 2025, was reviewed. The document indicated, “...Medicine Team MD [medical doctor] request CM to follow up with HLOC transfer...June 6, 2025, at 7:44 p.m...CM called transfer center. Accepted to [Name of HLOC 5]...[Name of patient’s insurance company] to request auth [authorization], unable to reach anyone who can assist at that number...member services [phone number of insurance company] also just a recording at this time. CM will continue to follow...June 7, 2025, at 4:02 p.m...pending transfer auth, updated patient...June 8, 2025, at 2:29 p.m... [Name of insurance company] is closed today, [Name of HLOC 5] accepted the patient awaiting auth, CM will continue to follow...4:09 p.m...multiple escalations for auth acquisition, called multiple numbers for [Name of patient’s insurance company], CM can’t get any auth since [Name of patient’s insurance company] is closed M-F [Monday through Friday] 6 am -6 pm [6 a.m. to 6 p.m.]...June 9, 2025, at 11:43 a.m...patient’s accepted by [Name of HLOC 5]...HLOC will reach out when they have a bed...4:22 p.m...Pending a bed at [Name of HLOC 5]...[Name of HLOC 5] will put her on the bed list...June 10, 2025, at 4:56 p.m...Updated clinical and orders faxed to [Name of HLOC 5] transfer center to reflect ICU [Intensive Care Unit, unit for critically ill patients] services with continuous BIPAP [bilevel positive airway pressure, a device that assists with breathing]...June 10, 2025, 7:17 p.m...pt upgraded to IMC [Intermediate Care, unit for patients needing closer monitoring but less than critical care] today...Rapid [rapid response, a specialized group of healthcare professionals who are trained to quickly assess and intervene when a patient’s condition deteriorates] called, pt needs BIPAP, respiratory failure with AKI...Updated family, still pending a bed at [Name of HLOC 5]. CM received multiple calls from family, family addressed they’re frustrated because patient deteriorated while waiting for a bed at [Name of HLOC 5]...Family requested CM to reach out to additional facilities who is capable to manage patient’s condition while waiting for a bed at [Name of HLOC 5]. Informed TC [transfer center] RN to follow up with [Names of HLOC 4 and HLOC 1]...June 11, 2025, at 9:49 a.m...patient is pending bed at [Name of HLOC 5]...patient transfer from ICU and now patient is intubated...June 11, 2025, at 11:26 a.m...Spoke with GI Fellow regarding transfer...is [sic] we can able to expand more referrals...” During review of Patient 11’s record, there was no documented evidence the facility attempted to expand their search for other HLOC facilities to transfer Patient 11 to until June 10, 2025. During review of Patient 11’s record, there was no documented evidence follow up with HLOC 1 and HLOC 4 to facilitate Patient 11’s transfer were conducted on June 10, 2025, and June 11, 2025. On June 12, 2025, at 11:03 a.m., an interview and review of Patient 11’s record were conducted with the DPS. The DPS stated, “We do not have a policy that speaks to inpatient transfers.” On June 12, 2025, at 2:35 p.m., an interview and review of Patient 11’s record were conducted with Physician 2. Physician 2 stated the expectation to transfer Patient 11 out would have been an urgent transfer because the patient’s MELD score was going up. Physician 2 stated Patient 11 clinically didn’t appear too bad, but “her numbers were indicating otherwise.” Physician 2 stated if there was no bed, the expectation would be for case management to reach out to her or the GI team to notify them there was no bed available to transfer Patient 11 to another facility and get further input. Physician 2 stated, “I don’t recall case management reaching out to have that conversation.” On June 12, 2025, at 2:42 p.m., an interview and review of Patient 11’s record were conducted with Physician 1. Physician 1 stated an order for transfer of Patient 11 to another facility for higher level of care was initially written because the physician who is the advanced endoscopist (Physician 3) was not on call until the first week of June (2025) and was not available. Physician 1 stated Patient 11 was seen on May 26, 2025, and transfer was recommended for higher level of care because the physician on call did not have proctoring (to watch someone do something before they can do it on their own) and did not have a fluoroscopy (imaging that uses X-rays to obtain real time images of the interior of an object) license at the time. She further stated there was a request for Patient 11 to be transferred for higher level to get those procedures but then on June 4, 2025, the patient was able to get the endoscopy because Physician 3 was back. Physician 1 stated there was a separate request to transfer Patient 11 out as the patient began to get worse, that was for a liver transplant evaluation. Physician 1 stated, after the endoscopy, Patient 11 was not doing well, with worsening kidney function, unable to make urine, becoming short of breath, and the patient’s MELD score kept rising. Physician 1 stated the order should have happened earlier for transfer for EUS/EGD/ERCP because they saw Patient 11 on May 26, 2025. Physician 1 stated, when the order was written for transfer for liver transplant evaluation, the order was open for other facilities and not just for (Name of HLOC 5). Physician 1 stated Physician 3 knew (Name of accepting physician at HLOC 5) who is a liver transplant specialist and this would have expedited the acceptance, but that didn’t mean to only coordinate Patient 11’s transfer to (name of HLOC 5). She further stated what should have happened was that the search for a facility with HLOC for Patient 11 should have still continued to ensure Patient 11 is transferred. Physician 1 stated, “If this patient dies, it is because she didn’t get the transplant in time.” Physician 1 further stated, “If there was no bed, why wouldn’t you search for another bed at a different facility?” Physician 1 stated she spoke with [Name of GI Fellow, a physician in training to specialize in gastroenterology], who covered the weekend and asked case management about the transfer, and he was told the weekend case manager stated the insurance was closed. Physician 1 stated, as physicians, “We know there is an emergency line they can get through on.” Physician 1 stated, “Maybe they need to learn that they need to reach out to multiple hospitals.” Physician 1 stated there was a window when Patient 11 could have gone for a liver transplant, but the patient needs dialysis now and is decompensating. Physician 1 stated the physicians never said to transfer Patient 11 only to [Name of HLOC 5]. On June 12, 2025, at 3:22 p.m., an interview and review of Patient 11’s record were conducted with the ICU Case Manager (CM). The CM stated the facility has no policy on how often they should call transfer centers back for updates. The CM stated, if another case manager comes in, they are expected to pick up the case and call the transfer center. The CM stated expectation is to reach out a few times a day to see if the transfer centers did get an accepting hospital and bed. The CM stated, on May 29, 2025, referrals were sent out to (Names of HLOC 1, HLOC 2, HLOC 3, and HLOC 4). The CM stated the expectation on the weekend is that the case managers will document if the insurance is closed, but the patient should still be sent out even if the insurance is closed. The CM stated there was no documentation the case managers followed up with (Names of HLOC 2, HLOC 3, and HLOC 4) on May 30, 2025, May 31, 2025, June 1, 2025, June 2, 2025, June 3, 2025, and June 4, 2025. She further stated ultimately it is the responsibility of the case manager to document what hospital was not available or had beds and to document that other facilities were contacted. The CM stated there was no documentation the case mangers attempted to expand their HLOC search until June 10, 2025. The CM stated there was no follow up documentation for (Names of HLOC 1 and HLOC 4) on June 10, 2025, and June 11, 2025. She stated case management staff should have been more aggressive with (Name of patient’s insurance company) and maybe they should have spoken to the physician about expanding outside of (Name of HLOC 5) and look for other facilities. The facility policy and procedure (P&P) titled, “California EMTALA - Transfer Policy,” dated December 5, 2024, was reviewed. The P&P indicated, “...The transferring hospital must call the receiving hospital or the PLC [Patient Logistic Center, transfer center] if the facility is part of a PLC network to verify the receiving hospital has available space and qualified personnel for the treatment of the individual. The receiving hospital must agree to accept the transfer and provide appropriate treatment...” The facility P&P titled, “Discharge Planning: Assessment, Referrals, Transfers, Placements and Transportation (Adult and Pediatric),” dated April 22, 2020, was reviewed. The P&P indicated, “...To establish a mechanism, for all inpatients, that encourages a smooth transition for all patients being discharged from the hospital. To identify at an early stage those patients who are likely to suffer adverse health consequences upon discharge...To aid in the appropriate transfer of relevant clinical information to the patient/family or accepting facility/service at the time of discharge...” The facility P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES,” dated October 2022, was reviewed. The P&P indicated, “...To receive ethical, high quality, safe and professional care without discrimination...To expect emergency procedures to be carried out without unnecessary delay...the patient may be transferred to another facility only with a full explanation of the reason for transfer, provision for continuing care and acceptance by the receiving institution...””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48562 Based on interview, and record review, the facility failed to ensure the patients’ right to receive care in a safe setting was provided, for three of 30 sample patients (Patients 18, 20, and 21), when: 1. For Patients 18, and 21, who were a high fall risk, appropriate high fall risk interventions (steps taken to reduce the likelihood of falls by addressing various risk factors and implementing preventive measures) were not implemented according to facility policy; This failure resulted in Patient 18 falling and had the potential to place 18 at risk for harm and injury. This failure also resulted in Patient 21 falling and sustaining severe injury requiring surgery. In addition, these failures may lead to other patients falling which may cause harm, injury, or death to the patients. 2. For Patient 20, who was a high fall risk, the facility did not notify the patient’s family after a fall according to facility policy. This failure had the potential to delay patient care and may lead to harm or injury. Findings: 1a. On May 6, 2025, at 10:20 a.m., a review of Patient 18’s medical record was conducted with Quality Coordinator (QC) 1. A facility document titled, “Trauma - History & Physical,” was reviewed. The document indicated, “...[Name of Patient 18] presents as a trauma code s/p [status post] MVC [motor vehicle crash]...Due to [Patient 18’s] altered mental status [change in consciousness that occurs when illnesses, disorders and injuries affect brain function] and likely unable to protect his airway so the decision was made to intubate [medical procedure where a flexible tube is inserted into the windpipe to maintain or establish an open airway] the patient ...assessment indicated multiple spinal fractures...acute subdural hemorrhage [a collection of blood between the inner layer of the skull and the surface of the brain] as well as few scattered SAH [Subarachnoid hemorrhage; medical emergency caused by bleeding into the space between the brain and the membranes surrounding it] overlying the L [left] parietal lobe [located near the back and top of the head]...” An untitled facility document, dated March 24, 2025, at 10 a.m., was reviewed. The document indicated, “...Morse Fall Scale score, and risk level [a tool used to assess a patient’s risk of falling. The total score can range from 0 to 125, with higher scores indicating a higher risk of falling]: 50 - High Risk...active fall prevention interventions: Bed/chair alarm...low bed...nonskid socks...” An untitled facility document, dated March 24, 2025, at 8 p.m., was reviewed. The document indicated, “...Morse Fall Scale score, and risk level: 50 - High Risk...active fall prevention interventions: Bed/chair alarm...low bed...nonskid socks...Ambulation: Non ambulatory...” An untitled facility document, dated March 25, 2025, at 12:40 a.m., was reviewed. The document indicated, “...Multidisciplinary Notes...Last rounded on patient at 0040 [12:20 a.m.] to provide care to other patient. At 0048 [12:48 a.m.] monitor tech [name of monitor tech 1] called upon entering the room noted patient was on the floor lying on his side. Noted the patient [Patient 18] was not breathing and did not have a pulse...patient was taken for stat CT [A CT (computed tomography) scan is an imaging test that helps healthcare providers detect diseases and injuries]. Upon return a full assessment was completed...no new injuries were present...” A concurrent interview was conducted with QC1. QC1 stated it was documented on March 24, 2025, at 8 p.m. that a bed alarm was in use for Patient 18. QC1 further stated, there is no documentation that the alarm was going off prior to the fall. On May 7, 2025, at 1:24 p.m., an interview was conducted with Monitor Tech 1. Monitor Tech 1 stated he had come back from assisting a patient to CT and when he saw Patient 18 wasn’t showing on the monitor, Monitor Tech 1 went into the room and found Patient 18 on the ground face down. Monitor tech 1 stated he called for the nurse who was bathing a patient in a nearby room. Monitor Tech 1 stated Patient 18 had has previous moments of anxiety and restlessness and was altered due to a brain injury. Monitor Tech 1 further stated there was no bed alarm going off when he entered Patient 18’s room. Monitor Tech 1 stated there was no bed alarm going off at the nurse’s station prior to entering Patient 18’s room. On May 7, 2025, at 1:28 p.m., an interview was conducted with Unit Manager 1. Unit Manager 1 stated he was not on call at the time of the incident, but he is aware of what was discussed during the post fall debriefing. Unit Manager 1 stated it was determined that the bed alarm was not on at the time of the fall. Unit Manager 1 stated staff never heard a bed alarm going off, but he is unable to answer why the alarm was not on. Unit Manager 1 further stated, the policy for high fall risk patients like Patient 18, would be to have the bed alarm on. Unit Manager 1 stated Patient 18’s bed alarm should have been on to help prevent falls. 1b. On May 7, 2025, at 9:36 a.m., a review of Patient 21’s medical record was conducted with Patient Safety Coordinator (PSC) 1. A facility document titled, “Trauma - History & Physical,” dated April 30, 2025, at 5:26 p.m., was reviewed. The document indicated, “...[Name of Patient 21]...activated as a trauma tier 1 [refers to the highest level of trauma care, typically for patients with the most severe and life-threatening injuries] after a fall in the ED [Emergency Department]. Patient was seen again for recurrent opioid overdose and was given Narcan [a medication that can reverse an opioid overdose] again...[Patient 21] fell backward striking his head to the floor...immediately placed in the trauma bay, was given 4mg [unit of measurement] of Narcan and was intubated for airway protection...attestations: Patient initially seen in the ED for opioid overdose...eloped from the ED and per reports, had an unwitnessed fall in a church...reported to have a witnessed fall with head strike in the ED...CT immediately obtained and showed a moderate size subdural hemorrhage and midline shift...planning to emergently take patient [21] to the operating room for decompressive craniectomy [a surgical procedure where a large portion of the skull is removed to relieve pressure within the skull, particularly in cases of severe swelling or bleeding in the brain]...” An untitled facility document, dated April 30, 2025, at 3:16 p.m., was reviewed. The document indicated, “...Fall Risk Assessment ...history of falling: yes...Morse Fall Scale score and risk level: 70- High Risk...Active fall prevention interventions: low bed...supervised/assisted amb [ambulation; walking]...” A facility document titled, “Patient Notes,” was reviewed. The document indicated, “...4/30/25 1530 [March 30, 2025, at 3:30 p.m.] PT [Patient 21] combative with staff, refusing treatment, placed in line of sight of staff...” A facility document titled, “Patient Notes,” was reviewed. The document indicated, “...4/30/25 1645 [March 30, 2025, at 4:45 p.m.]... fall unwitnessed by this RN...multiple staff reported pt stood up at foot of gurney and saw pt fall back immediately...RN/MD at pt side immediately. This RN arrived at pt bedside, trauma code called immediately...see Trauma flowsheet for workup...” An untitled facility document, dated April 30, 2025, at 3:46 p.m., was reviewed. The document indicated, “...Post Fall Assessment ...type of fall: witnessed...level of injury: Major...Deteriorating condition requiring transfer to higher level of care: yes...” On May 7, 2025, at 11:15 a.m., an interview was conducted with the Director of the Emergency Department (DED). The DED stated Patient 21 came in by ambulance after he was found on the grass at the church. The DED stated the patient was given Narcan and woke up more stable and then went to sleep and was resting on a gurney in the hallway near a tech and across from the nurse’s station. The DED stated the patient was sleeping in one moment, then woke up, stood up quickly and went down before anyone could reach him. The DED stated the patient was sent to trauma immediately and then had to be sent to surgery and the ICU [intensive care unit]. The DED further stated if a patient is identified as a high fall risk, they should be placed on all the interventions according to policy. The DED stated Patient 21 was refusing treatment at the time of the fall assessment and staff were not able to implement all interventions. On May 7, 2025, at 1 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated Patient 21 came in by ambulance for an overdose. RN 1 stated the patient was given Narcan and placed in a bed next to the nurse’s station to keep eyes on him. RN 1 stated when he came into the ED, he told us to leave him alone and did not want us near him. RN 1 stated the patient would have been a moderate to high fall risk but remembers patient refusing fall interventions. RN 1 stated the patient should have had intervention in place including yellow gown and socks, fall risk bracelet, and the bed alarm for gurneys, but they were not in place because the patient refused. A review of the facility policy and procedure (P&P) titled, “Fall Prevention Plan,” dated April 2022, was conducted. The P&P indicated, “...All patients will be evaluated for fall potential through completion of the appropriate falls risk assessment. This will occur during the initial admission assessment process and daily nursing assessment; at minimum once per shift...based on the level of fall risk, nursing interventions will be initiated and captured on the patient’s plan of care...Adult fall prevention interventions to be implemented...Moderate/high fall risk (Morse score 25-69)...bed/chair alarm activated...Very high fall risk (Morse score 70+) ...Moderate/high risk precautions...yellow gown...following to be considered...sitter at bedside...following the calculation of a fall sore and risk level, the nurse will document all active, applicable interventions...” 2. On May 6, 2025, at 10:20 a.m., a review of Patient 20’s medical record was conducted with Quality Coordinator (QC) 1. An untitled facility document, dated February 6, 2025, at 9:30 a.m., was reviewed. The document indicated, “...Fall risk...Morse fall scale score and risk level: 75- High Risk...active fall prevention interventions...bed/chair alarm...low bed...nonskid socks...” An untitled facility document, dated February 6, 2025, at 9:39 a.m., was reviewed. The document indicated, “...was notified by nurse colleague that the patient [Patient 20] has fallen on the floor while he was attempting to get up out of the chair. Patient was assisted back to bed...full assessment completed. Patient states no pain or headache at this time...no deficit was found...doctors were notified...” A concurrent interview was conducted with QC 1 during the record review. The QC 1 stated there is no documentation that Patient 20’s family was notified of the patient’s fall according to policy. A review of the facility policy and procedure (P&P) titled, “Fall Prevention Plan,” dated April 2022, was conducted. The P&P indicated, “...Post Fall Process...Notifications of the fall...at a minimum, the attending physician, nursing leader, and patient’s legal representative will be notified as soon as possible...all notifications with date and time of fall will be documented in the HER [electronic health 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: 48562 Based on interview, and record review, the facility failed to implement their policy and procedures for three of 30 sample patients (Patients 18, 20, and 21), when: 1. For Patients 18, and 21, who were a high fall risk, appropriate high fall risk interventions (steps taken to reduce the likelihood of falls by addressing various risk factors and implementing preventive measures) were not implemented according to facility policy; This failure resulted in Patient 18 falling and had the potential to place 18 at risk for harm and injury. This failure also resulted in Patient 21 falling and sustaining severe injury requiring surgery. In addition, these failures may lead to other patients falling which may cause harm, injury, or death to the patients. 2. For Patient 20, who was a high fall risk, the facility did not notify the patient’s family after a fall according to facility policy. This failure had the potential to delay patient care and may lead to harm or injury. Findings: 1a. On May 6, 2025, at 10:20 a.m., a review of Patient 18’s medical record was conducted with Quality Coordinator (QC) 1. A facility document titled, “Trauma - History & Physical,” was reviewed. The document indicated, “...[Name of Patient 18] presents as a trauma code s/p [status post] MVC [motor vehicle crash]...Due to [Patient 18’s] altered mental status [change in consciousness that occurs when illnesses, disorders and injuries affect brain function] and likely unable to protect his airway so the decision was made to intubate [medical procedure where a flexible tube is inserted into the windpipe to maintain or establish an open airway] the patient ...assessment indicated multiple spinal fractures...acute subdural hemorrhage [a collection of blood between the inner layer of the skull and the surface of the brain] as well as few scattered SAH [Subarachnoid hemorrhage; medical emergency caused by bleeding into the space between the brain and the membranes surrounding it] overlying the L [left] parietal lobe [located near the back and top of the head]...” An untitled facility document, dated March 24, 2025, at 10 a.m., was reviewed. The document indicated, “...Morse Fall Scale score, and risk level [a tool used to assess a patient’s risk of falling. The total score can range from 0 to 125, with higher scores indicating a higher risk of falling]: 50 - High Risk...active fall prevention interventions: Bed/chair alarm...low bed...nonskid socks...” An untitled facility document, dated March 24, 2025, at 8 p.m., was reviewed. The document indicated, “...Morse Fall Scale score, and risk level: 50 - High Risk...active fall prevention interventions: Bed/chair alarm...low bed...nonskid socks...Ambulation: Non ambulatory...” An untitled facility document, dated March 25, 2025, at 12:40 a.m., was reviewed. The document indicated, “...Multidisciplinary Notes...Last rounded on patient at 0040 [12:20 a.m.] to provide care to other patient. At 0048 [12:48 a.m.] monitor tech [name of monitor tech 1] called upon entering the room noted patient was on the floor lying on his side. Noted the patient [Patient 18] was not breathing and did not have a pulse...patient was taken for stat CT [A CT (computed tomography) scan is an imaging test that helps healthcare providers detect diseases and injuries]. Upon return a full assessment was completed...no new injuries were present...” A concurrent interview was conducted with QC1. QC1 stated it was documented on March 24, 2025, at 8 p.m. that a bed alarm was in use for Patient 18. QC1 further stated, there is no documentation that the alarm was going off prior to the fall. On May 7, 2025, at 1:24 p.m., an interview was conducted with Monitor Tech 1. Monitor Tech 1 stated he had come back from assisting a patient to CT and when he saw Patient 18 wasn’t showing on the monitor, Monitor Tech 1 went into the room and found Patient 18 on the ground face down. Monitor tech 1 stated he called for the nurse who was bathing a patient in a nearby room. Monitor Tech 1 stated Patient 18 had has previous moments of anxiety and restlessness and was altered due to a brain injury. Monitor Tech 1 further stated there was no bed alarm going off when he entered Patient 18’s room. Monitor Tech 1 stated there was no bed alarm going off at the nurse’s station prior to entering Patient 18’s room. On May 7, 2025, at 1:28 p.m., an interview was conducted with Unit Manager 1. Unit Manager 1 stated he was not on call at the time of the incident, but he is aware of what was discussed during the post fall debriefing. Unit Manager 1 stated it was determined that the bed alarm was not on at the time of the fall. Unit Manager 1 stated staff never heard a bed alarm going off, but he is unable to answer why the alarm was not on. Unit Manager 1 further stated, the policy for high fall risk patients like Patient 18, would be to have the bed alarm on. Unit Manager 1 stated Patient 18’s bed alarm should have been on to help prevent falls. 1b. On May 7, 2025, at 9:36 a.m., a review of Patient 21’s medical record was conducted with Patient Safety Coordinator (PSC) 1. A facility document titled, “Trauma - History & Physical,” dated April 30, 2025, at 5:26 p.m., was reviewed. The document indicated, “...[Name of Patient 21]...activated as a trauma tier 1 [refers to the highest level of trauma care, typically for patients with the most severe and life-threatening injuries] after a fall in the ED [Emergency Department]. Patient was seen again for recurrent opioid overdose and was given Narcan [a medication that can reverse an opioid overdose] again...[Patient 21] fell backward striking his head to the floor...immediately placed in the trauma bay, was given 4mg [unit of measurement] of Narcan and was intubated for airway protection...attestations: Patient initially seen in the ED for opioid overdose...eloped from the ED and per reports, had an unwitnessed fall in a church...reported to have a witnessed fall with head strike in the ED...CT immediately obtained and showed a moderate size subdural hemorrhage and midline shift...planning to emergently take patient [21] to the operating room for decompressive craniectomy [a surgical procedure where a large portion of the skull is removed to relieve pressure within the skull, particularly in cases of severe swelling or bleeding in the brain]...” An untitled facility document, dated April 30, 2025, at 3:16 p.m., was reviewed. The document indicated, “...Fall Risk Assessment ...history of falling: yes...Morse Fall Scale score and risk level: 70- High Risk...Active fall prevention interventions: low bed...supervised/assisted amb [ambulation; walking]...” A facility document titled, “Patient Notes,” was reviewed. The document indicated, “...4/30/25 1530 [March 30, 2025, at 3:30 p.m.] PT [Patient 21] combative with staff, refusing treatment, placed in line of sight of staff...” A facility document titled, “Patient Notes,” was reviewed. The document indicated, “...4/30/25 1645 [March 30, 2025, at 4:45 p.m.]... fall unwitnessed by this RN...multiple staff reported pt stood up at foot of gurney and saw pt fall back immediately...RN/MD at pt side immediately. This RN arrived at pt bedside, trauma code called immediately...see Trauma flowsheet for workup...” An untitled facility document, dated April 30, 2025, at 3:46 p.m., was reviewed. The document indicated, “...Post Fall Assessment ...type of fall: witnessed...level of injury: Major...Deteriorating condition requiring transfer to higher level of care: yes...” On May 7, 2025, at 11:15 a.m., an interview was conducted with the Director of the Emergency Department (DED). The DED stated Patient 21 came in by ambulance after he was found on the grass at the church. The DED stated the patient was given Narcan and woke up more stable and then went to sleep and was resting on a gurney in the hallway near a tech and across from the nurse’s station. The DED stated the patient was sleeping in one moment, then woke up, stood up quickly and went down before anyone could reach him. The DED stated the patient was sent to trauma immediately and then had to be sent to surgery and the ICU [intensive care unit]. The DED further stated if a patient is identified as a high fall risk, they should be placed on all the interventions according to policy. The DED stated Patient 21 was refusing treatment at the time of the fall assessment and staff were not able to implement all interventions. On May 7, 2025, at 1 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated Patient 21 came in by ambulance for an overdose. RN 1 stated the patient was given Narcan and placed in a bed next to the nurse’s station to keep eyes on him. RN 1 stated when he came into the ED, he told us to leave him alone and did not want us near him. RN 1 stated the patient would have been a moderate to high fall risk but remembers patient refusing fall interventions. RN 1 stated the patient should have had intervention in place including yellow gown and socks, fall risk bracelet, and the bed alarm for gurneys, but they were not in place because the patient refused. A review of the facility policy and procedure (P&P) titled, “Fall Prevention Plan,” dated April 2022, was conducted. The P&P indicated, “...All patients will be evaluated for fall potential through completion of the appropriate falls risk assessment. This will occur during the initial admission assessment process and daily nursing assessment; at minimum once per shift...based on the level of fall risk, nursing interventions will be initiated and captured on the patient’s plan of care...Adult fall prevention interventions to be implemented...Moderate/high fall risk (Morse score 25-69)...bed/chair alarm activated...Very high fall risk (Morse score 70+) ...Moderate/high risk precautions...yellow gown...following to be considered...sitter at bedside...following the calculation of a fall sore and risk level, the nurse will document all active, applicable interventions...” 2. On May 6, 2025, at 10:20 a.m., a review of Patient 20’s medical record was conducted with Quality Coordinator (QC) 1. An untitled facility document, dated February 6, 2025, at 9:30 a.m., was reviewed. The document indicated, “...Fall risk...Morse fall scale score and risk level: 75- High Risk...active fall prevention interventions...bed/chair alarm...low bed...nonskid socks...” An untitled facility document, dated February 6, 2025, at 9:39 a.m., was reviewed. The document indicated, “...was notified by nurse colleague that the patient [Patient 20] has fallen on the floor while he was attempting to get up out of the chair. Patient was assisted back to bed...full assessment completed. Patient states no pain or headache at this time...no deficit was found...doctors were notified...” A concurrent interview was conducted with QC 1 during the record review. The QC 1 stated there is no documentation that Patient 20’s family was notified of the patient’s fall according to policy. A review of the facility policy and procedure (P&P) titled, “Fall Prevention Plan,” dated April 2022, was conducted. The P&P indicated, “...Post Fall Process...Notifications of the fall...at a minimum, the attending physician, nursing leader, and patient’s legal representative will be notified as soon as possible...all notifications with date and time of fall will be documented in the HER [electronic health record]...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48562 Based on observation, interview, and record review, the facility failed to ensure the patients’ right to receive care in a safe setting was provided, for seven patients of 30 sample patients (Patients 1, 2, 4, 5, 6, 16, and 28), when: 1. Patient Care Technician (PCT) 1, who was assigned as the 3:1 sitter (a hospital patient care arrangement where one patient sitter/staff is assigned to observe and support three patients at the same time) to observe and monitor three patients behavioral health patients on a 5150 (a section of the Welfare and Institutions Code that allows for the involuntary psychiatric evaluation and temporary detention of individuals deemed a danger to themselves, others, or are gravely disabled due to a mental health disorder) hold, was observed to be turned away from the patients, resulting in the potential for three behavioral health patients who are deemed to be suicidal, to elope (an unauthorized departure of a patient from a hospital) from the Emergency Department (ED) (Refer to A0144); 2. For Patients 1 and 5, who were on a 5150 hold, the patients were able to elope from the Emergency Department (ED) (Refer to A0144); 3. For Patient 2, who was on a 5150 hold, the patient was not placed under constant observation in accordance with the facility’s policy (Refer to A0144); 4. For Patient 4, the facility staff allowed a visitor to provide the patient with shoes and clothing and walked the patient out of the ED (Refer to A0144); 5. For Patient 6, staff did not change a patient into a green gown and failed to conduct a search of the patient and patient belongings in accordance with the facility’s policy. This failure resulted in Patient 6 having a knife on him and stabbing the furniture and had the potential to place the patient and other patients in the ED at risk of harm (Refer to A0144); 6. For Patient 28, the patient’s family member inserted an intravenous (IV, through a vein) catheter (used to deliver fluids, medications, blood products, or nutrition) on the patient’s left hand. This failure resulted in the patient acquiring left hand bruising and had the potential to cause vein inflammation, infection or death (Refer to A0144); and 7. For Patient 16, the facility failed to ensure a hot pack was applied safely. This failure resulted in Patient 16 developing skin burns to the abdomen after a hot pack was applied the patient’s abdominal skin for one to two hours (Refer to A0145). The cumulative effects of these systemic failures resulted in Patients 1, 2, 4, 5 eloping from the ED and had the potential to place Patients 1, 2, 4, 5, 6, 16, and 28 at risk for harm and injury. In addition, these failures may lead to other patient elopement which may cause harm, injury, or death to the patients.”

“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: 48562 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for 10 patients of 30 sample patients (Patients 1, 2, 4, 5, 6, 16, 21, 22, 26, and 28), when: 1. Patient Care Technician (PCT) 1 was observed to have his back turned from the three behavioral health patients on a 5150 hold (a section of the Welfare and Institutions Code that allows for the involuntary psychiatric evaluation and temporary detention of individuals deemed a danger to themselves, others, or are gravely disabled due to a mental health disorder) he was observing and monitoring at the same time as a 3:1 sitter (a hospital patient care arrangement where one patient sitter/staff is assigned to observe and support three patients at the same time). This failure had the potential for three behavioral health patients who are deemed to be suicidal to elope (an unauthorized departure of a patient from a hospital) from the Emergency Department (ED) (Refer to A0398); 2. For Patients 1 and 5, who were on a 5150 hold, the patients were able to elope from the ED. This failure resulted in Patients 1 and 5 eloping from the ED (Refer to A0398); 3. For Patient 2, who was on a 5150 hold, the patient was not placed under constant observation in accordance with the facility’s policy. This failure resulted in Patient 2 eloping from the ED (Refer to A0398); 4. For Patient 4, the facility staff allowed a visitor to provide Patient 4 with shoes and clothing and to walk Patient 4 out of the ED. This failure resulted in Patient 4 eloping from the ED (Refer to A0398); 5. For Patient 6, staff did not change a patient into a green gown and search the patient and patient belongings in accordance with the facility’s policy. This failure resulted in Patient 6 having a knife on him and stabbing the furniture and had the potential to place the patient and other patients in the ED at risk of harm (Refer to A0398); 6. For Patient 28, a family member (FM) was allowed to insert an intravenous (IV, into a vein) catheter (used to deliver fluids, medications, blood products, or nutrition) on Patient 28’s left hand (Refer to A0398); 7. For Patient 21, the patient’s blood pressure (BP, normal for adults is 120/80) was not reassessed after labetalol (medication to lower the BP) was administered (Refer to A0398); 8. For Patient 22, the patient’s BP was not assessed every 15 minutes during the first hour of magnesium sulfate (MGSO4, medicine to prevent seizure in pregnant women) infusion. In addition, Patient 22’s deep tendon reflexes (a muscle contraction that occurs when a tendon is tapped) was not assessed every hour during intrapartum (from the onset of labor through delivery of the placenta [organ that forms in the womb during pregnancy)] (Refer to A0398); 9. For Patient 26, the patients’ lung sounds (breath sounds a doctor or nurse can hear using a stethoscope) were not assessed before and after dialysis (a treatment that removes waste and extra fluid from the blood when the kidneys are no longer functioning properly) (Refer to A0398); 10. For Patient 22, the patient’s pain was not addressed (Refer to A0398); and 11. For Patient 16, the facility failed to ensure a hot pack was applied safely (Refer to A0398). The cumulative effects of these systemic failures had the potential to place the patients at risk for delayed treatment and harm.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 50304 Based on observations, interviews, and record reviews, the facility failed to ensure surgical services were maintained according to standards of practice, for one of 30 sample patients, when an unsterilized (not made free of bacteria and viruses) scope (an instrument with light and camera used for visualization inside the body) was used during Patient 27’s surgery and the operating room technician did not verify the scope was sterilized before being used during the surgery (Refer to A0951). The cumulative effect of these failures resulted in a prolonged hospital stay for Patient 27 and placed Patient 27 at risk for infection and blood borne diseases (diseases caused by bacteria or virus in the blood transmitted through contact with infected blood or body fluids).”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 48562 Based on observation, interview, and record review, the facility failed to ensure the patients’ right to receive care in a safe setting was provided, for five patients of 30 sample patients (Patients 1, 2, 4, 5, and 6), when: 1. Patient Care Technician (PCT) 1 was observed to have his back turned from the three behavioral health patients on a 5150 hold (a section of the Welfare and Institutions Code that allows for the involuntary psychiatric evaluation and temporary detention of individuals deemed a danger to themselves, others, or are gravely disabled due to a mental health disorder) he was observing and monitoring at the same time as a 3:1 sitter (a hospital patient care arrangement where one patient sitter/staff is assigned to observe and support three patients at the same time). This failure had the potential for three behavioral health patients who are deemed to be suicidal to elope (an unauthorized departure of a patient from a hospital) from the Emergency Department (ED) (Refer to A1104); 2. For Patients 1 and 5, who were on a 5150 hold, the patients were able to elope from the Emergency Department (ED) (Refer to A1104); 3. For Patient 2, who was on a 5150 hold, the patient was not placed under constant observation in accordance with the facility’s policy (Refer to A1104); 4. For Patient 4, the facility staff allowed a visitor to provide the patient with shoes and clothing and walk the patient out of the ED (Refer to A1104); and 5. For Patient 6, staff did not change a patient into a green gown and search the patient and patient belongings in accordance with the facility’s policy. This failure resulted in Patient 6 having a knife on him and stabbing the furniture and had the potential to place the patient and other patients in the ED at risk of harm (Refer to A1104). The cumulative effects of these systemic failures resulted in Patients 1, 2, 4, 5 eloping from the ED and had the potential to place Patients 1, 2, 4, 5, and 6 at risk for harm and injury. In addition, these failures may lead to other patient elopement which may cause harm, injury, or death to the patients.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48562 Based on observation, interview, and record review, the facility failed to ensure the right for behavioral health patients and patients at risk for suicide or self-harm patients to receive care in a safe setting was provided, for five patients of 30 sample patients (Patients 1, 2, 4, 5, and 6), when: 1. Patient Care Technician (PCT) 1, who was assigned as the 3:1 sitter (a hospital patient care arrangement where one patient sitter/staff is assigned to observe and support three patients at the same time) to observe and monitor three patients behavioral health patients on a 5150 (a section of the Welfare and Institutions Code that allows for the involuntary psychiatric evaluation and temporary detention of individuals deemed a danger to themselves, others, or are gravely disabled due to a mental health disorder) hold, was observed to be turned away from the patients, resulting in the potential for three behavioral health patients who are deemed to be suicidal, to elope (an unauthorized departure of a patient from a hospital) from the Emergency Department (ED); 2. For Patients 1 and 5, who were on a 5150 hold, the patients were able to elope from the ED. This failure had the potential to place Patients 1 and 5at risk of harming themselves or others, and had the potential to cause a delay in the patients’ treatment; 3. For Patient 2, who was on a 5150 hold, the patient was not placed under constant observation in accordance with the facility’s policy. This failure resulted in Patient 2 eloping from the ED and had the potential to place Patient 2 at risk of harming herself or others; 4. For Patient 4, the facility staff allowed a visitor to provide Patient 4 with shoes and clothing and to walk Patient 4 out of the ED. This failure resulted in Patient 4 eloping from the ED and had the potential to place Patient 4 at risk of harming herslef or others; and 5. For Patient 6, staff did not change a patient into a green gown and search the patient and patient belongings in accordance with the facility’s policy. This failure resulted in Patient 6 having a knife on him and stabbing the furniture and had the potential to place the patient and other patients in the ED at risk of harm. These failures resulted in Patients 1, 2, 4, 5 eloping from the ED and had the potential to place the patients at risk for harm and injury. Findings: 1. On March 17, 2025, at 9:30 a.m., a tour of the ED was conducted with the assistant Chief Nursing Officer (ACNO) and the Director of the ED (DED). While touring, the ED hallways were observed to be high traffic areas with many staff, patients, and visitors walking and gurneys being pushed through them. Hallway 1 is observed located adjacent to the nurse’s station and near the ambulance bay (the space where the ambulance parks to bring patients inside the ED) and the trauma (designated area within an emergency department specifically equipped and staffed to provide immediate, life-saving care for patients with serious injuries from accidents) rooms of the ED. Hallway 1 was observed with four hallway beds. During a concurrent interview, the DED stated Hallway 1 is typically used for psychiatric (relating to mental illness or its treatment) patients and patients on a 5150. The DED stated Rooms A and B are the two common rooms used for psychiatric patients. The DED stated a 5150-patient may be placed in any bed in the ED depending on patient’s need. During the continued tour, an observation was made of the patients and sitters in Hallway 1. On March 17, 2025, at 9:40 a.m., Patient Care Technician (PCT) 1 was observed standing at the doorway of Room B and was observed talking to another facility staff. PCT 1’s back was observed to be turned away from her assigned patients in Hallway 1. PCT 1 was observed to not maintain direct sight of the patients assigned to her. On March 17, 2025, at 9:45 a.m., an interview was conducted with PCT 1. PCT 1 stated he was assigned to three 5150 patients. PCT 1 stated the patients in Hallway 1 were on a 5150 hold for being a danger to themselves. PCT 1 stated the sitter should keep eyes on the patients on 5150 hold at all times to ensure the patients’ safety. On March 20, 2025, at 12 p.m., an interview was conducted with the DED. The DED stated PCT 1 was observed talking to another sitter across the hallway and was not appropriately monitoring her patients. The DED stated PCT 1 should have had all three patients assigned to her within her eyesight at all times, and should not be talking to another staff while monitoring the patients. The DED further stated the hallway used for the 5150 patients is in a high traffic area close to an exit door and may be contributing to the patient’s ability to elope from the ED. 2a. On March 18, 2025, at 9:20 a.m., a review of Patient 1’s record was conducted with Quality Coordinator (QC) 1. A facility document titled, “Application for assessment, evaluation, and crisis intervention of placement for evaluation and treatment,” was reviewed. The document indicated, “...[name of Patient 1] was in the middle of the street...was banging his head against the windows inside my patrol car...possibly took 4 [four] Xanax [a medication used to treat anxiety] pills...Based upon the above information, there is probable cause to believe that said person is, as a result of mental health disorder [sic]: A danger to self...date: 01/28/25 [January 28, 2025] time: 1840 [6:40 p.m.]...” A facility document titled, “Emergency Provider Report,” dated January 28, 2025, at 7:10 p.m., was reviewed. The document indicated, “...Chief Complaint: Violent Behavior and intoxication... past medical history of anxiety and depression...presents to the ED with police for violent behavior and intoxication...patient already on 5150 hold...per 5150 documentation patient was physical in his mothers [sic] car while she was driving and then jumped out of the vehicle...found in the middle of the street...noted to be banging his head against the windows inside the police care...hold [5150 hold] was placed for patient being a danger to himself...” An undated facility document titled, “Medication discharge summary,” was reviewed. The document indicated Patient 1 received intramuscular (IM, injection that goes into muscle) medication on January 28, 2025, at 9:41 and 9:42 p.m. The document indicated Patient 1 was not administered any other medications prior to elopement. A facility document titled, “Telehealth Psychiatric Consult,” dated January 29, 2025, at 12:26 p.m., was reviewed. The document indicated, “...Reason for consult: SI [suicidal ideations, having thoughts of killing oneself]...Overall risk level-suicide: high risk...per the mother...while in the car, hitting head, jumped out of car and found in the middle of the road. Banging head in cop car. His hands are bruised due to punching self...terrible tempter at home...making suicidal statements...recommendations: The patient does meet criteria for in-patient psychiatric admission due to self-harm attempts, violence, and drug use...continue mental health hold [5150]...” A facility document titled, “Patient Observation Form,” dated January 29, 2025, was reviewed. The document indicated, “...Indication for observation: SI-Minor ...Suicidal ideation, self-injury, assaultive/aggression. Time: 1630 [4:30 p.m.] LC [location] Bed, AC [attribute codes] Restless/agitated...INT [intervention] Redirection...Time: 1645 [4:45 p.m.] Ran out...” A facility document titled, “Emergency provider report,” dated January 29, 2025, at 5:55 p.m., was reviewed. The document indicated, “...Patient jumped up and ran out of emergency department before he was able to be detained. Law enforcement was notified and located patient at his home and will undergo decision making with mother regarding where they will take him...” A facility document titled, “Emergency Notes,” dated January 29, 2025, at 4:35 p.m., was reviewed. The document indicated, “...Was notified by sitter staff at this time patient got up to use restroom and left running down the hall to front of the hospital property, [name of local police department] called and report for 5150 elopement description given to PD...” 2b. On March 18, 2025, at 11 a.m., a review of Patient 5’s record was conducted with QC 1. A facility document titled, “Emergency Provider Report,” dated March 2, 2025, at 11:53 p.m., was reviewed. The document indicated, “...[name of Patient 5]...Presents stating he is suicidal...Tired of living...and wants to kill himself because of the continuous pain. The patient [Patient 5] has a plan to overdose on medications...has access to guns...is having thoughts of harming others when they upset him...currently homeless...off medication...Suicide risk level: [No result]...Overall risk level: Low Risk...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Suicide Assessment ED: Occurred 3/03/25 [March 3, 2025] 0040 [12:40 a.m.]... Suicide assessment...risk level: High Risk...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Violence/aggression screening: Occurred 3/03/25 0800 [8 a.m.]...risk type: High...” A facility document titled, “Emergency Provider Report,” dated March 3, 2025, at 11:17 a.m., was reviewed and indicated, “...Note...Suicide Risk Level: High Risk ...Overall Risk level-suicide: Moderate risk...” A facility document titled, “Emergency Notes,” dated March 3, 2025, at 7:30 p.m., was reviewed. The document indicated, “...PT [Patient 5] resting in Hall [hallway] 3 gurney, safety precautions in place. Sitter present...patient endorses +SI +HI [homicidal ideation, having thoughts of harming others]...not specific to plan...” A facility document titled, “Emergency Notes,” dated March 4, 2025, at 7:51 a.m., was reviewed and indicated, “...patient placed on 5150 hold...endorses suicidal ideations...sitter at bedside...” A facility document titled, “Emergency Provider Report,” dated March 4, 2025, at 9 a.m., was reviewed and indicated, “...Note...Still endorsing suicidal ideations...Overall Risk level-suicide: Moderate risk...” A facility document titled, “Medication discharge summary,” was reviewed and indicated Patient 5 was given Xanax 0.5mg (milligram, unit of measurement) oral (by mouth) and Zyprexa (medication to treat mental disorder) 10 mg injection on March 4, 2025, at 2:40 p.m. The document indicated no other medications were given or offered prior to the patient eloping. A facility document titled, “Emergency Provider Report,” dated March 5, 2025, at 10:42 a.m., was reviewed. The document indicated, “...Note...Chart reviewed...patient had been sleeping this morning, suddenly woke up and ran out of the emergency department before security could stop him or me having [sic] a chance to talk with him...law enforcement notified by staff...” A facility document titled, “Emergency Notes,” dated March 5, 2025, at 10:40 a.m., was reviewed. The document indicated, “...Patient [Patient 5] eloped...asked if hold was up and was told no. Pt [Patient 5] became immediately agitated and stated, “Then I’m leaving.” Staff tried to stand in front of patient and educate him that PD [police department] would be called if he leave but he walked through staff and into the ambulance bay. Pt did not take his belongings and was wearing a green gown...” On March 19, 2025, at 1:45 p.m., an interview was conducted with the ED Medical Doctor (EDMD). The EDMD stated a patient is placed with a sitter based on their overall risk level (ORL). The EDMD stated a patient’s ORL is determined based on the patient’s suicide, violence, and elopement risks as well as support factors [skills, strengths, or resources that help people deal more effectively with stressful events]. The EDMD stated ORL may differ between providers. The EDMD stated, if a patient is on a hold waiting for either treatment or transfer and becomes restless, agitated, and wants to leave, staff would start with verbal de-escalation [techniques used to help calm down a patient who may be angry or upset], offer medications including oral meds, and if the behavior escalates to risk the patient’s safety or safety of others, the physician could administer injectable sedatives. The EDMD stated the decision to restrain a patient eloping would depend on the patient’s behavior, such as if the patient has current thoughts to harm self and others and other factors. 3. On March 18, 2025, and 9:40 a.m., a review of Patient 2’s record and concurrent interview were conducted with QC 1. A facility document titled, “Emergency Department Physician/Triage Form,” dated February 20, 2025, at 11:13 a.m., was reviewed and indicated, “...5150 for DTS [danger to self]...” An untitled facility document was reviewed. The document indicated, “...Emergency Department Notes Entered: February 20, 2025, 1305 [1:05 p.m.]...PT [Patient 2] transported to ED for medical reasons from [Name of Facility B] with sitter [from Facility B]. Pt and sitter placed Infront [sic] of nurse’s station in [Hallway bed C]...Sitter from [Name of Facility B] came up to nurses’ desk and informed staff that pt had...walked past her out the ED entrance. Sitter [from Facility B] stated she called out for security, but no one was there...” A facility document titled, “Emergency Provider Report,” dated February 20, 2025, at 2:22 p.m., was reviewed. The document indicated, “...Patient comes into the ER complaining of abdominal pain...came to ER by ambulance from a psychiatric facility...on a 5150 hold and comes with a sitter from the facility...patient had already had a medical screening exam [a comprehensive evaluation of a patient’s health status to identify potential medical conditions or risks] and labs [laboratory tests] and imaging were ordered...before I was able to see and examine the patient [Patient 2] [sic] had eloped from the department. Nursing staff is aware and has contacted the police...” Patient 2’s record was reviewed and did not include documented evidence a suicide screening was completed for and a sitter from the facility was assigned to the patient for monitoring. QC 1 stated the record did not indicate Patient 2 had a suicide screening completed for her and did not have a facility sitter assigned to the patient. QC 1 stated Patient 2 should have been assigned a sitter from the facility. On March 18, 2025, at 12 p.m., an interview was conducted with the DED. The DED stated if patients come from another facility with a sitter, staff should still assign a facility’s sitter to the patient. The DED stated another facility’s sitter cannot be the assigned to a patient who is in the facility. 4. On March 18, 2025, and 10:38 a.m., a review of Patient 4’s record was conducted with QC 1. A facility document titled, “Emergency Provider Report,” dated March 3, 2025, at 9:55 p.m., was reviewed. The document indicated, “...[name of Patient 4]...Presents to the ED with suicidal ideation which has been on and off for the past 6 [six] months. Patient reports multiple attempts in the past, most recent being end of October...Telehealth psych [virtual psychiatrist] was consulted and recommended 5150 hold along with inpatient psychiatry admission. 5150 forms were completed, and patient is now pending placement...calculated suicide risk level: Moderate Risk...Overall risk level-suicide: Low risk...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Emergency Notes...03/03/25 [March 3, 2025] 2335 [11:35 p.m.]... PT [Patient 4] placed in RM [room number of Room D]. C/C [chief complaint] suicidal ideation. PT is a minor and [FM, family member] is at bedside. Sitter at bedside. Per report, PT was banging head on side rails upon arrival...crying uncontrollably with [FM] at bedside...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Safe Environment...Occurred 03/04/25 [March 4, 2025] 0000 [12 a.m.]...Suicide safe environment...belongings removed/secure, contraband clothing check...safety attendant-physical, use gown withs naps [snap] only...” A facility document titled, “Psychiatric Consultation Note,” dated March 4, 2025, at 3:17 a.m., was reviewed. The document indicated, “...Patient [Patient 4] endorses suicidal ideation...reports multiple suicide attempts in the past, most recent being end of October...patient is not able to contract for safety outside the hospital...meets the criteria for 5150 hold...inpatient psych hospitalization...Overall level suicide risk: Moderate Risk...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Emergency Notes...03/04/25 [March 4, 2025] 0736 [7:37 a.m.]...[FM] at bedside. PT in green hospital attire room is safety ready at this time...Safety measures remain in place. Sitter at door...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Emergency Notes...03/04/25 [March 4, 2025] 1405 [2:05 p.m.]...Pt was sitting on edge of bed fully dressed. Per Pt’s [FM] she is going to take the patient...[FM] reinstructed that patient was on hold and she could not leave. [FM] told I was going to get the MD...[FM] stated that she would leave. MD to be notified that the PT wants to leave...PT was seen walking with [FM] to exit the ED...[FM] and patient were told they cannot go per DR [doctor]...told that police would be called if she left with minor child...” On March 18, 2025, at 12 p.m., an interview was conducted with the DED. The DED stated minor patients would be placed on a 1:1 sitter and placed into a room for safety. The DED stated that for Patient 4, the patient’s FM brought in clothes for the patient to change into. The DED stated the 1:1 sitter should not have allowed the patient to change into the clothing. The DED stated all belongings should be searched and removed from the room for safety according to policy, and FM should not have been allowed to bring the patient clothing. On March 18, 2025, at 2:10 p.m., an interview was conducted with the VPQ. The VPQ stated all patients on a 5150 hold should be placed into a green gown. The VPQ stated a gap was identified in the case of Patient 4, with family bringing belongings in. The VPQ stated Patient 4’s [FM] brought the patient clothes and had Patient 4 get dressed so they could leave. The VPQ stated the patient should not have been given the clothing and allowed to change. The VPQ stated nothing should go into the rooms with patients, visitors, and family without safety search and approval. 5. On March 18, 2025, and 11:25 a.m., a review of Patient 6’s record and concurrent interview were conducted with QC 1. A facility document titled, “Emergency Department Trauma Flowsheet,” dated March 5, 2025, at 9:10 p.m., was reviewed. The document indicated, “...Narrative nursing notes...2235 [11:35 p.m.] psych hold written for gravely disabled secondary to mental illness...admit to: Other: 5150...” A facility document titled, “Emergency provider report,” dated March 5, 2025, at 9:17 p.m., was reviewed. The document indicated, “...presents to the ED after MVA [motor vehicle accident]...he was going at an unknown speed, hit the front tire on a curb...Patient was given Geodon [medication used to treat mental disorders] due to acute agitation. Due to patient’s psych [psychiatric] history, history provided by [FM 2] who brought him in, inability to respond to questions appropriately and inability to care for himself, patient was placed on 5150 hold...patient is awaiting telehealth psychiatrist and eventually inpatient placement...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Detailed assessment...03/06/25 [March 6, 2025 0000...Suicide screening: yes...Detailed assessment comments: 5150...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Emergency Notes...03/06/25 0000...PT [Patient 6] transferred from trauma charting...PT is alert and oriented x2 [two, knows person and place]. Aggressive. Having pressured speech [rapid, loud, nonstop pattern of speech]...” A facility document titled, “Emergency Patient Record,” dated March 6, 2025, was reviewed. The document indicated, “...Emergency Notes...03/06/25 0600 [6 a.m.] ...Security called...pt is not redirectable. Security, along with multiple staff members assisted patient back to bed...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Emergency Notes...03/06/25 0915 [9:15 a.m.]...Sitter saw knife in PT’s hand and called code Grey [a hospital code called for a violent patient]. Security Bedside...” A facility document titled, “Emergency provider report,” dated March 6, 2025, at 5:41 a.m., was reviewed. The document indicated, “...awaiting placement at an inpatient psychiatric receiving facility...Overall risk level- suicide: Moderate risk...Addendum: update: Patient became aggressive again, he came threatening and armed himself with a knife. He was barricaded in his room with security standing by. 911 [an emergency call number] was activated and police responded...they will be taking custody of him at this point and transporting to an appropriate psychiatric destination...03/06/25 at 1000 [10 a.m.]...” A review of Patient 6’s record did not indicate documented evidence a safety check (a check of the patient’s belongings for contrabands and for anything the patient could use to harm himself or others) was conducted on Patient 6 in accordance with the facility’s policy and procedure. QC 1 stated Patient 6’s record does not indicate he was searched or placed into a green gown. On March 18, 2025, at 12 p.m., an interview was conducted with the DED. The DED stated if a patient comes in on a 5150 for medical or is a trauma patient placed on a 5150, staff should still follow 5150 policies which include the environmental safety checks, sitter, and a safety check of patient and belongings. The DED stated this should be done for every 5150 patient. The DED further stated Patient 6 came in and was evaluated as trauma patient initially. The DED stated Patient 6 came in with a shirt, shorts, and jacket only and went through metal detector before going to trauma. The DED stated Patient 6 was “a big, kind of scary person” and was not cooperating with the search. The DED stated the patient was not searched and changed into a green gown according to facility policy. On March 18, 2025, at 2:10 p.m., an interview was conducted with the VPQ. The VPQ stated all 5150 patients in the ED should have a safety check and be changed into a green gown according to policy. The VPQ stated Patient 6 came in as a trauma patient and the 5150 was determined after initial intake. The VPQ stated the weapons detector and belongings process should have been done but there was fallout. The VPQ stated the process of assessing and processing the patient’s belongings was not done. The VPQ stated when patient’s do come through the weapons detector in the main entrance, the machine does not have an audible alarm, so if security is not present, or is distracted, it may be missed. The VPQ further stated the facility’s current policies and processes for 5150 patients are not working to prevent elopements from the ED. A review of the facility policy and procedure (P&P) titled, “Suicide Prevention Plan,” dated September 2023, was conducted. The P&P indicated, “...Patients reporting suicidal thoughts, recent suicide attempt, and/or self-harm behaviors require intensive support, close observation, and frequent reassessment for their emotional and physical well-being at all times...all patients 12 years and older should be screened using the C-SSRS [Columbia Suicide Severity Rating Scale, or C-SSRS, a suicidal ideation and behavior rating scale]...The at-risk patient’s (low, moderate, or high) environment will be made safe by implementing the checklist and observation precautions...Virtual PSA[camera or video sitter]/line of sight (Q15 [every 15 minutes]) is required if the patient is screened moderate suicide risk on the C-SSRS or ORL [Overall Risk Level]...Staff member may monitor more than 1 [one] patient at the same time and must have direct view of each patient at all times...visitors, including parents/guardians of minor patients, are monitored for safety and are not allowed to have personal property in patient rooms...safety interventions are implemented for ALL patients on suicide precautions...interventions include: Perform a thorough search of the patients clothing, personal articles, room and belongings...patient will remove all street clothing and wear psychiatric safe clothing that is without strings or ties...shoes will be without laces or strings...Emergency Detention: California (5150): if a patient is determined to be low, moderate, or high risk for suicide and refuses to remain in the hospital for a psychiatric evaluation, an emergency detention may be requested and executed if applicable...” A review of the facility P&P titled, “Involuntary Hold: Lanterman Petris Short Act 5150 Placement,” dated August 2024, was conducted. The P&P indicated, “...Patients that are being held on a 5150 hold or for whom an assessment is pending should be monitored by nursing staff for increasing agitation or risk of elopement. If indicated, medications shall be requested from the physician to minimize patient risk to self or others while awaiting evaluation or placement...” 50304 6. On March 19, 2025, a review of Patient 28’s record was conducted with the Patient Safety Coordinator (PSC) 2. A facility document titled, “Hospitalist History and Physical,” dated February 1, 2025, was reviewed. The document indicated Patient 28 was admitted to the facility on February 1, 2025, for coronary artery disease (a condition where the arteries supplying blood to the heart become narrowed or blocked). An untitled and undated facility document was reviewed. The document indicated, “...Multidisciplinary Team Notes Occurred Feb 7, 2025 [February 7, 2025] 1632 [4:32 p.m.] By: [Name of RN 4]...@ 1545 [at 3:45 p.m.], patient’s [FM] came up to me at the nurses station and stated that she put an IV in [Patient 28’s] left hand. I reported the incident to the team lead and manager. I assessed patient after manager spoke with patient’s [FM], the IV was removed prior to the assessment. IV site has no signs of redness, no bleeding, dry and intact. Will continue to monitor for the next twelve hours ...” An untitled and undated facility document was reviewed. The document indicated, “...Multidisciplinary Team Notes Occurred Feb 7, 2025 1836 [6:36 p.m.] By: [Name of RN 4]...bruising to left hand, color is dark in color with surround area green and yellow...” An untitled and undated facility document was reviewed. The document indicated, “...Multidisciplinary Team Notes Occurred Feb 7, 2025 1852 [6:52 p.m.] By: [Name of RN 4] ...patients provider, [Name of MD 4], was notified of patients left hand bruising right...” On March 19, 2025, at 2:25 p.m., an interview was conducted with PSC 2. PSC 2 stated Patient 28’s FM should not have placed an IV on Patient 28. PSC 2 stated it was a patient safety concern. PSC 2 stated, “We need to make sure the quality care is being provided by licensed staff and the patients don’t have a bad outcome.” A facility policy and procedure titled, “Patients Rights and Responsibilities,” dated October 28, 2020 was reviewed. The document indicated, “...every patient has the right to have his/her rights respected without regard to age, gender, disability...to receive ethical ( pertaining to right and wrong in conduct), high quality, safe and professional care without discrimination (nfair treatment of someone based on their belonging to a particular group such as race, age, gender, religion, or disability)...” A facility policy and procedure titled, “Patient Safety Plan,” dated June 26, 2024, was reviewed. The document indicated, “...the goal of the Patient Safety Plan is to reduce medical errors (incorrect) and hazardous (dangerous) conditions by utilizing a systematic, coordinated and continuous approach to the improvement of patient safety...””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 34933 Based on interview and record review, the facility failed to ensure a hot pack was applied safely, for one of 30 sampled patients (Patient 16). This failure resulted in Patient 16 developing skin burns to the abdomen after a hot pack was applied the patient’s abdominal skin for one to two hours. Findings: On March 20, 2025, at 2:13 p.m., a review of Patient 16’s record and a concurrent interview were conducted with the Patient Safety Coordinator (PSC). A facility document titled, “History & Physical,” dated January 20, 2025 at 12:44 p.m., was reviewed. The document indicated Patient 16 was admitted to the facility on January 20, 2025, with diagnoses which included pneumonia (an infection in the lungs), intellectual disability, and schizophrenia (a mental illness that is characterized by disturbances in thought). The document indicated, “...Skin: dry, intact...” A facility document titled, “Admission/Shift Assessment,” dated January 20, 2025, at 8 p.m., was reviewed and indicated the section on the document labeled, “skin alteration” was not completed. A facility document titled, “Admission/Shift Assessment,” dated January 24, 2025, at 8 a.m., was reviewed. The document indicated, “...skin alteration: Present /Exists Skin alteration: Blister Anterior Abdomen...skin alteration details: Blisters. Wound surrounding tissue appearance: Pink. Wound surrounding tissue temperature: Warm. Dressing status: Open to air. Wound/skin alteration comments: burns...” A facility document titled, “Wound Specialist Notes,” dated January 30, 2025, at 2:11 p.m., was reviewed. The document indicated, “ ...Wound/Ostomy Service Reason for Consult: burn to abdomen...Per consult reason there are burns on abdomen. Unclear as to how these occurred. There are full [a wound that extends beyond the skin’s surface and potentially reaching deeper structures like muscle or bone] and partial thickness [a wound that extends into the first two layers of skin but does not penetrate deeper layers] open areas on abdomen. Abdomen ...inferior [below] and left of the umbilicus there is full thickness open area measuring 2.6 x 1.7 x 0.2 cm [centimeters, unit of measurement]...Abdomen ...left side with a clear fluid filled bullae [blister], measuring 1 [one] x 4 [four] cm...Abdomen ...right side with clear fluid filled bullae, measuring 1.5 x 1.4 cm... Updated [name of MD 5] of wound assessment and orders received...” A facility document titled, “Dressing- Dressing Change/Wound Care Order Details,” dated January 30, 2025, was reviewed. The document indicated, “ ...Body Part: abdomen-several areas...Cleanse with: Wound Cleanser Apply/Fill/Pack: Silver contact layer (Urgotul-AG+) [non-adhesive wound dressing containing silver sulfate designed to promote healing] Cover with: Silicone Adhering Foam ...” Patient 16’s record was reviewed and there was no documented evidence Patient 16 had burns on admission, how the burn/blisters occurred, that the physician was notified of the burns and if treatment were ordered or photos were obtained. On March 20, 2025, at 3:49 p.m., an interview was conducted with Registered Nurse (RN) 5. RN 5 stated RN 8 had reported to her during the shift change on January 24, 2025, that RN 8 used the hot pack on Patient 16 and burned the patient. RN 5 stated she did not document what RN had told her and RN 8 also did not document that she placed a hot pack on Patient 16 and the patient was burned. RN 5 stated RN 8 did not call the physician. I informed the resident physician but did not document this. RN 5 stated she did not get orders for the treatment of the burn on Patient 16’s abdomen and just left it open to air. RN 5 stated the facility’s policy for a patient with a burn or wound is to notify the MD, report incident to the charge nurse, take photos, and document. On March 21, 2025, at 11:20 a.m., an interview was conducted with the Patient Safety Director Risk Management (PSDRM). The PSDRM stated Patient 16’s burn was not reported to CDPH (Department of Public Health, a state agency) because it was a blister at the time it was investigated and was not established until later that it was a burn. The PSDRM stated investigation was dropped after seeing the one blister. The PSDRM stated she was not aware of the other blisters at the time. On March 21, 2025, at 11:50 a.m., an interview was conducted with the Director of Medical Intensive Care (DMICU). The DMICU stated RN 8 left a hot pack on Patient 16’s abdomen for one to two hours while she taking care of another patient. The DMICU stated RN 8 also used heating blankets in addition to the hot packs to warm Patient 16. The DMICU stated there was no documentation the physician was notified. The DMICU stated the events surrounding patient 16’s burn on the abdomen was not documented on the medical record. The DMICU further indicated the wound care nurse was not consulted until January 30, 2025, when Patient 16 was transferred out of Unit B. A review of the hot pack manufacturer’s instructions titled, “Medline Instant Hot Pack,” was conducted. The document indicated, “...For use whenever instant, safe, hot therapy is required...Do not use the hot therapy for more than 20 minutes...Warnings...avoid excessive heat ...Monitor the skin to avoid injuries ...” A facility policy titled, “Serious Patient Adverse Events,” dated March 2022, was reviewed. The policy indicated,” ...this Policy is intended to define the strategy for management of all Serious Patient Adverse Events (SPAEs) across all Company affiliated facilities... All company affiliated facilities will: Provide immediate care and support to the patient, Patient’s Representative/Family...any impacted staff in response to a SPAE; notify the administrator on call and the attending physician. The Patient Focus First Response Team will be activated to investigate and report events as outlined...and in alignment with all federal/state and/or accreditation agency requirements. This process will be triggered in a timely manner even when a cause for the event is not yet known...””

“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: 48562 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for 10 patients of 30 sample patients (Patients 1, 2, 4, 5, 6, 16, 21, 22, 26, and 28), when: 1. Patient Care Technician (PCT) 1 was observed to have his back turned from the three behavioral health patients on a 5150 hold (a section of the Welfare and Institutions Code that allows for the involuntary psychiatric evaluation and temporary detention of individuals deemed a danger to themselves, others, or are gravely disabled due to a mental health disorder) he was observing and monitoring at the same time as a 3:1 sitter (a hospital patient care arrangement where one patient sitter/staff is assigned to observe and support three patients at the same time). This failure had the potential for three behavioral health patients who are deemed to be suicidal to elope (an unauthorized departure of a patient from a hospital) from the Emergency Department (ED); 2. For Patients 1 and 5, who were on a 5150 hold, the patients were able to elope from the ED. This failure resulted in Patients 1 and 5 eloping from the ED; 3. For Patient 2, who was on a 5150 hold, the patient was not placed under constant observation in accordance with the facility’s policy. This failure resulted in Patient 2 eloping from the ED; 4. For Patient 4, the facility staff allowed a visitor to provide Patient 4 with shoes and clothing and to walk Patient 4 out of the ED. This failure resulted in Patient 4 eloping from the ED; 5. For Patient 6, staff did not change a patient into a green gown and search the patient and patient belongings in accordance with the facility’s policy. This failure resulted in Patient 6 having a knife on him and stabbing the furniture and had the potential to place the patient and other patients in the ED at risk of harm. 6. For Patient 28, a family member (FM) was allowed to insert an intravenous (IV, into a vein) catheter (used to deliver fluids, medications, blood products, or nutrition) on Patient 28’s left hand; 7. For Patient 21, the patient’s blood pressure (BP, normal for adults is 120/80) was not reassessed after labetalol (medication to lower the BP) was administered; 8. For Patient 22, the patient’s BP was not assessed every 15 minutes during the first hour of magnesium sulfate (MGSO4, medicine to prevent seizure in pregnant women) infusion. In addition, Patient 22’s deep tendon reflexes (a muscle contraction that occurs when a tendon is tapped) was not assessed every hour during intrapartum (from the onset of labor through delivery of the placenta [organ that forms in the womb during pregnancy)]; 9. For Patient 26, the patients’ lung sounds (breath sounds a doctor or nurse can hear using a stethoscope) were not assessed before and after dialysis (a treatment that removes waste and extra fluid from the blood when the kidneys are no longer functioning properly); 10. For Patient 22, the patient’s pain was not addressed; and 11. For Patient 16, the facility failed to ensure a hot pack was applied safely. These failures had the potential to place the patients at risk for delayed treatment and harm. Findings: 1. On March 17, 2025, at 9:30 a.m., a tour of the ED was conducted with the assistant Chief Nursing Officer (ACNO) and the Director of the ED (DED). While touring, the ED hallways were observed to be high traffic areas with many staff, patients, and visitors walking and gurneys being pushed through them. Hallway 1 is observed located adjacent to the nurse’s station and near the ambulance bay (the space where the ambulance parks to bring patients inside the ED) and the trauma (designated area within an emergency department specifically equipped and staffed to provide immediate, life-saving care for patients with serious injuries from accidents) rooms of the ED. Hallway 1 was observed with four hallway beds. During a concurrent interview, the DED stated Hallway 1 is typically used for psychiatric (relating to mental illness or its treatment) patients and patients on a 5150. The DED stated Rooms A and B are the two common rooms used for psychiatric patients. The DED stated a 5150-patient may be placed in any bed in the ED depending on patient’s need. During the continued tour, an observation was made of the patients and sitters in Hallway 1. On March 17, 2025, at 9:40 a.m., Patient Care Technician (PCT) 1 was observed standing at the doorway of Room B and was observed talking to another facility staff. PCT 1’s back was observed to be turned away from her assigned patients in Hallway 1. PCT 1 was observed to not maintain direct sight of the patients assigned to her. On March 17, 2025, at 9:45 a.m., an interview was conducted with PCT 1. PCT 1 stated he was assigned to three 5150 patients. PCT 1 stated the patients in Hallway 1 were on a 5150 hold for being a danger to themselves. PCT 1 stated the sitter should keep eyes on the patients on 5150 hold at all times to ensure the patients’ safety. On March 20, 2025, at 12 p.m., an interview was conducted with the DED. The DED stated PCT 1 was observed talking to another sitter across the hallway and was not appropriately monitoring her patients. The DED stated PCT 1 should have had all three patients assigned to her within her eyesight at all times, and should not be talking to another staff while monitoring the patients. The DED further stated the hallway used for the 5150 patients is in a high traffic area close to an exit door and may be contributing to the patient’s ability to elope from the ED. 2a. On March 18, 2025, at 9:20 a.m., a review of Patient 1’s record was conducted with Quality Coordinator (QC) 1. A facility document titled, “Application for assessment, evaluation, and crisis intervention of placement for evaluation and treatment,” was reviewed. The document indicated, “...[name of Patient 1] was in the middle of the street...was banging his head against the windows inside my patrol car...possibly took 4 [four] Xanax [a medication used to treat anxiety] pills...Based upon the above information, there is probable cause to believe that said person is, as a result of mental health disorder [sic]: A danger to self...date: 01/28/25 [January 28, 2025] time: 1840 [6:40 p.m.]...” A facility document titled, “Emergency Provider Report,” dated January 28, 2025, at 7:10 p.m., was reviewed. The document indicated, “...Chief Complaint: Violent Behavior and intoxication... past medical history of anxiety and depression...presents to the ED with police for violent behavior and intoxication...patient already on 5150 hold...per 5150 documentation patient was physical in his mothers [sic] car while she was driving and then jumped out of the vehicle...found in the middle of the street...noted to be banging his head against the windows inside the police care...hold [5150 hold] was placed for patient being a danger to himself...” An undated facility document titled, “Medication discharge summary,” was reviewed. The document indicated Patient 1 received intramuscular (IM, injection that goes into muscle) medication on January 28, 2025, at 9:41 and 9:42 p.m. The document indicated Patient 1 was not administered any other medications prior to elopement. A facility document titled, “Telehealth Psychiatric Consult,” dated January 29, 2025, at 12:26 p.m., was reviewed. The document indicated, “...Reason for consult: SI [suicidal ideations, having thoughts of killing oneself]...Overall risk level-suicide: high risk...per the mother...while in the car, hitting head, jumped out of car and found in the middle of the road. Banging head in cop car. His hands are bruised due to punching self...terrible tempter at home...making suicidal statements...recommendations: The patient does meet criteria for in-patient psychiatric admission due to self-harm attempts, violence, and drug use...continue mental health hold [5150]...” A facility document titled, “Patient Observation Form,” dated January 29, 2025, was reviewed. The document indicated, “...Indication for observation: SI-Minor ...Suicidal ideation, self-injury, assaultive/aggression. Time: 1630 [4:30 p.m.] LC [location] Bed, AC [attribute codes] Restless/agitated...INT [intervention] Redirection...Time: 1645 [4:45 p.m.] Ran out...” A facility document titled, “Emergency provider report,” dated January 29, 2025, at 5:55 p.m., was reviewed. The document indicated, “...Patient jumped up and ran out of emergency department before he was able to be detained. Law enforcement was notified and located patient at his home and will undergo decision making with mother regarding where they will take him...” A facility document titled, “Emergency Notes,” dated January 29, 2025, at 4:35 p.m., was reviewed. The document indicated, “...Was notified by sitter staff at this time patient got up to use restroom and left running down the hall to front of the hospital property, [name of local police department] called and report for 5150 elopement description given to PD...” 2b. On March 18, 2025, at 11 a.m., a review of Patient 5’s record was conducted with QC 1. A facility document titled, “Emergency Provider Report,” dated March 2, 2025, at 11:53 p.m., was reviewed. The document indicated, “...[name of Patient 5]...Presents stating he is suicidal...Tired of living...and wants to kill himself because of the continuous pain. The patient [Patient 5] has a plan to overdose on medications...has access to guns...is having thoughts of harming others when they upset him...currently homeless...off medication...Suicide risk level: [No result]...Overall risk level: Low Risk...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Suicide Assessment ED: Occurred 3/03/25 [March 3, 2025] 0040 [12:40 a.m.]... Suicide assessment...risk level: High Risk...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Violence/aggression screening: Occurred 3/03/25 0800 [8 a.m.]...risk type: High...” A facility document titled, “Emergency Provider Report,” dated March 3, 2025, at 11:17 a.m., was reviewed and indicated, “...Note...Suicide Risk Level: High Risk ...Overall Risk level-suicide: Moderate risk...” A facility document titled, “Emergency Notes,” dated March 3, 2025, at 7:30 p.m., was reviewed. The document indicated, “...PT [Patient 5] resting in Hall [hallway] 3 gurney, safety precautions in place. Sitter present...patient endorses +SI +HI [homicidal ideation, having thoughts of harming others]...not specific to plan...” A facility document titled, “Emergency Notes,” dated March 4, 2025, at 7:51 a.m., was reviewed and indicated, “...patient placed on 5150 hold...endorses suicidal ideations...sitter at bedside...” A facility document titled, “Emergency Provider Report,” dated March 4, 2025, at 9 a.m., was reviewed and indicated, “...Note...Still endorsing suicidal ideations...Overall Risk level-suicide: Moderate risk...” A facility document titled, “Medication discharge summary,” was reviewed and indicated Patient 5 was given Xanax 0.5mg (milligram, unit of measurement) oral (by mouth) and Zyprexa (medication to treat mental disorder) 10 mg injection on March 4, 2025, at 2:40 p.m. The document indicated no other medications were given or offered prior to the patient eloping. A facility document titled, “Emergency Provider Report,” dated March 5, 2025, at 10:42 a.m., was reviewed. The document indicated, “...Note...Chart reviewed...patient had been sleeping this morning, suddenly woke up and ran out of the emergency department before security could stop him or me having [sic] a chance to talk with him...law enforcement notified by staff...” A facility document titled, “Emergency Notes,” dated March 5, 2025, at 10:40 a.m., was reviewed. The document indicated, “...Patient [Patient 5] eloped...asked if hold was up and was told no. Pt [Patient 5] became immediately agitated and stated, “Then I’m leaving.” Staff tried to stand in front of patient and educate him that PD [police department] would be called if he leave but he walked through staff and into the ambulance bay. Pt did not take his belongings and was wearing a green gown...” On March 19, 2025, at 1:45 p.m., an interview was conducted with the ED Medical Doctor (EDMD). The EDMD stated a patient is placed on a sitter based on their overall risk level (ORL). The EDMD stated a patient’s ORL is determined based on the patient’s suicide, violence, and elopement risks as well as support factors [skills, strengths, or resources that help people deal more effectively with stressful events]. The EDMD stated ORL may differ between providers. The EDMD stated, if a patient is on a hold waiting for either treatment or transfer and becomes restless, agitated, and wants to leave, staff would start with verbal de-escalation [techniques used to help calm down a patient who may be angry or upset], offer medications including oral meds, and if the behavior escalates to risk the patient’s safety or safety of others, the physician could administer injectable sedatives. The EDMD stated the decision to restrain a patient eloping would depend on the patient’s behavior, such as if the patient has current thoughts to harm self and others and other factors. 3. On March 18, 2025, and 9:40 a.m., a review of Patient 2’s record and concurrent interview were conducted with QC 1. A facility document titled, “Emergency Department Physician/Triage Form,” dated February 20, 2025, at 11:13 a.m., was reviewed and indicated, “...5150 for DTS [danger to self]...” An untitled facility document was reviewed. The document indicated, “...Emergency Department Notes Entered: February 20, 2025, 1305 [1:05 p.m.]...PT [Patient 2] transported to ED for medical reasons from [Name of Facility B] with sitter [from Facility B]. Pt and sitter placed Infront [sic] of nurse’s station in [Hallway bed C]...Sitter from [Name of Facility B] came up to nurses’ desk and informed staff that pt had...walked past her out the ED entrance. Sitter [from Facility B] stated she called out for security, but no one was there...” A facility document titled, “Emergency Provider Report,” dated February 20, 2025, at 2:22 p.m., was reviewed. The document indicated, “...Patient comes into the ER complaining of abdominal pain...came to ER by ambulance from a psychiatric facility...on a 5150 hold and comes with a sitter from the facility...patient had already had a medical screening exam [a comprehensive evaluation of a patient’s health status to identify potential medical conditions or risks] and labs [laboratory tests] and imaging were ordered...before I was able to see and examine the patient [Patient 2] [sic] had eloped from the department. Nursing staff is aware and has contacted the police...” Patient 2’s record was reviewed and did not include documented evidence a suicide screening was completed for and a sitter from the facility was assigned to the patient. QC 1 stated the record did not indicate Patient 2 had a suicide screening completed for her and did not have a facility sitter assigned to the patient. QC 1 stated Patient 2 should have been assigned a sitter from the facility. On March 18, 2025, at 12 p.m., an interview was conducted with the DED. The DED stated if patients come from another facility with a sitter, staff should still assign a facility’s sitter to the patient. The DED stated another facility’s sitter cannot be the assigned to a patient who is in the facility. 4. On March 18, 2025, and 10:38 a.m., a review of Patient 4’s record was conducted with QC 1. A facility document titled, “Emergency Provider Report,” dated March 3, 2025, at 9:55 p.m., was reviewed. The document indicated, “...[name of Patient 4]...Presents to the ED with suicidal ideation which has been on and off for the past 6 [six] months. Patient reports multiple attempts in the past, most recent being end of October...Telehealth psych [virtual psychiatrist] was consulted and recommended 5150 hold along with inpatient psychiatry admission. 5150 forms were completed, and patient is now pending placement...calculated suicide risk level: Moderate Risk...Overall risk level-suicide: Low risk...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Emergency Notes...03/03/25 [March 3, 2025] 2335 [11:35 p.m.]... PT [Patient 4] placed in RM [room number of Room D]. C/C [chief complaint] suicidal ideation. PT is a minor and [FM, family member] is at bedside. Sitter at bedside. Per report, PT was banging head on side rails upon arrival...crying uncontrollably with [FM] at bedside...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Safe Environment...Occurred 03/04/25 [March 4, 2025] 0000 [12 a.m.]...Suicide safe environment...belongings removed/secure, contraband clothing check...safety attendant-physical, use gown withs naps [snap] only...” A facility document titled, “Psychiatric Consultation Note,” dated March 4, 2025, at 3:17 a.m., was reviewed. The document indicated, “...Patient [Patient 4] endorses suicidal ideation...reports multiple suicide attempts in the past, most recent being end of October...patient is not able to contract for safety outside the hospital...meets the criteria for 5150 hold...inpatient psych hospitalization...Overall level suicide risk: Moderate Risk...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Emergency Notes...03/04/25 [March 4, 2025] 0736 [7:37 a.m.]...[FM] at bedside. PT in green hospital attire room is safety ready at this time...Safety measures remain in place. Sitter at door...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Emergency Notes...03/04/25 [March 4, 2025] 1405 [2:05 p.m.]...Pt was sitting on edge of bed fully dressed. Per Pt’s [FM] she is going to take the patient...[FM] reinstructed that patient was on hold and she could not leave. [FM] told I was going to get the MD...[FM] stated that she would leave. MD to be notified that the PT wants to leave...PT was seen walking with [FM] to exit the ED...[FM] and patient were told they can not go per DR [doctor]...told that police would be called if she left with minor child...” On March 18, 2025, at 12 p.m., an interview was conducted with the DED. The DED stated minor patients would be placed on a 1:1 sitter and placed into a room for safety. The DED stated that for Patient 4, the patient’s FM brought in clothes for the patient to change into. The DED stated the 1:1 sitter should not have allowed the patient to change into the clothing. The DED stated all belongings should be searched and removed from the room for safety according to policy, and FM should not have been allowed to bring the patient clothing. On March 18, 2025, at 2:10 p.m., an interview was conducted with the VPQ. The VPQ stated all patients on a 5150 hold should be placed into a green gown. The VPQ stated a gap was identified in the case of Patient 4, with family bringing belongings in. The VPQ stated Patient 4’s [FM] brought the patient clothes and had Patient 4 get dressed so they could leave. The VPQ stated the patient should not have been given the clothing and allowed to change. The VPQ stated nothing should go into the rooms with patients, visitors, and family without safety search and approval. 5. On March 18, 2025, and 11:25 a.m., a review of Patient 6’s record and concurrent interview were conducted with QC 1. A facility document titled, “Emergency Department Trauma Flowsheet,” dated March 5, 2025, at 9:10 p.m., was reviewed. The document indicated, “...Narrative nursing notes...2235 [11:35 p.m.] psych hold written for gravely disabled secondary to mental illness...admit to: Other: 5150...” A facility document titled, “Emergency provider report,” dated March 5, 2025, at 9:17 p.m., was reviewed. The document indicated, “...presents to the ED after MVA [motor vehicle accident]...he was going at an unknown speed, hit the front tire on a curb...Patient was given Geodon [medication used to treat mental disorders] due to acute agitation. Due to patient’s psych [psychiatric] history, history provided by [FM 2] who brought him in, inability to respond to questions appropriately and inability to care for himself, patient was placed on 5150 hold...patient is awaiting telehealth psychiatrist and eventually inpatient placement...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Detailed assessment...03/06/25 [March 6, 2025] 0000...Suicide screening: yes...Detailed assessment comments: 5150...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Emergency Notes...03/06/25 0000...PT [Patient 6] transferred from trauma charting...PT is alert and oriented x2 [two, knows person and place]. Aggressive. Having pressured speech [rapid, loud, nonstop pattern of speech]...” A facility document titled, “Emergency Patient Record,” dated March 6, 2025, was reviewed. The document indicated, “...Emergency Notes...03/06/25 0600 [6 a.m.] ...Security called...pt is not redirectable. Security, along with multiple staff members assisted patient back to bed...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Emergency Notes...03/06/25 0915 [9:15 a.m.]...Sitter saw knife in PT’s hand and called code Grey [a hospital code called for a violent patient]. Security Bedside...” A facility document titled, “Emergency provider report,” dated March 6, 2025, at 5:41 a.m., was reviewed. The document indicated, “...awaiting placement at an inpatient psychiatric receiving facility...Overall risk level- suicide: Moderate risk...Addendum: update: Patient became aggressive again, he came threatening and armed himself with a knife. He was barricaded in his room with security standing by. 911 [an emergency call number] was activated and police responded...they will be taking custody of him at this point and transporting to an appropriate psychiatric destination...03/06/25 at 1000 [10 a.m.]...” A review of Patient 6’s record did not indicate documented evidence a safety check (a check of the patient’s belongings for contrabands and for anything the patient could use to harm himself or others) was conducted on Patient 6 in accordance with the facility’s policy and procedure. QC 1 stated Patient 6’s record does not indicate he was searched or placed into a green gown. On March 18, 2025, at 12 p.m., an interview was conducted with the DED. The DED stated if a patient comes in on a 5150 for medical or is a trauma patient placed on a 5150, staff should still follow 5150 policies which include the environmental safety checks, sitter, and a safety check of patient and belongings. The DED stated this should be done for every 5150 patient. The DED further stated Patient 6 came in and was evaluated as trauma patient initially. The DED stated Patient 6 came in with a shirt, shorts, and jacket only and went through metal detector before going to trauma. The DED stated Patient 6 was “a big, kind of scary person” and was not cooperating with the search. The DED stated the patient was not searched and changed into a green gown according to facility policy. On March 18, 2025, at 2:10 p.m., an interview was conducted with the VPQ. The VPQ stated all 5150 patients in the ED should have a safety check and be changed into a green gown according to policy. The VPQ stated Patient 6 came in as a trauma patient and the 5150 was determined after initial intake. The VPQ stated the weapons detector and belongings process should have been done but there was fallout. The VPQ stated the process of assessing and processing the patient’s belongings was not done. The VPQ stated when patient’s do come through the weapons detector in the main entrance, the machine does not have an audible alarm, so if security is not present, or is distracted, it may be missed. The VPQ further stated the facility’s current policies and processes for 5150 patients are not working to prevent elopements from the ED. A review of the facility policy and procedure (P&P) titled, “Suicide Prevention Plan,” dated September 2023, was conducted. The P&P indicated, “...Patients reporting suicidal thoughts, recent suicide attempt, and/or self-harm behaviors require intensive support, close observation, and frequent reassessment for their emotional and physical well-being at all times...all patients 12 years and older should be screened using the C-SSRS [Columbia Suicide Severity Rating Scale, or C-SSRS, a suicidal ideation and behavior rating scale]...The at-risk patient’s (low, moderate, or high) environment will be made safe by implementing the checklist and observation precautions...Virtual PSA[camera or video sitter]/line of sight (Q15 [every 15 minutes]) is required if the patient is screened moderate suicide risk on the C-SSRS or ORL [Overall Risk Level]...Staff member may monitor more than 1 [one] patient at the same time and must have direct view of each patient at all times...visitors, including parents/guardians of minor patients, are monitored for safety and are not allowed to have personal property in patient rooms...safety interventions are implemented for ALL patients on suicide precautions...interventions include: Perform a thorough search of the patients clothing, personal articles, room and belongings...patient will remove all street clothing and wear psychiatric safe clothing that is without strings or ties...shoes will be without laces or strings...Emergency Detention: California (5150): if a patient is determined to be low, moderate, or high risk for suicide and refuses to remain in the hospital for a psychiatric evaluation, an emergency detention may be requested and executed if applicable...” A review of the facility P&P titled, “Involuntary Hold: Lanterman Petris Short Act 5150 Placement,” dated August 2024, was conducted. The P&P indicated, “...Patients that are being held on a 5150 hold or for whom an assessment is pending should be monitored by nursing staff for increasing agitation or risk of elopement. If indicated, medications shall be requested from the physician to minimize patient risk to self or others while awaiting evaluation or placement...” 50304 6. On March 19, 2025, a review of Patient 28’s record was conducted with the Patient Safety Coordinator (PSC) 2. A facility document titled, “Hospitalist History and Physical,” dated February 1, 2025, was reviewed. The document indicated Patient 28 was admitted to the facility on February 1, 2025, for coronary artery disease (a condition where the arteries supplying blood to the heart become narrowed or blocked). An untitled and undated facility document was reviewed. The document indicated, “...Multidisciplinary Team Notes Occurred Feb 7, 2025 [February 7, 2025] 1632 [4:32 p.m.] By: [Name of RN 4]...@ 1545 [at 3:45 p.m.], patient’s [FM] came up to me at the nurses station and stated that she put an IV in [Patient 28’s] left hand. I reported the incident to the team lead and manager. I assessed patient after manager spoke with patient’s [FM], the IV was removed prior to the assessment. IV site has no signs of redness, no bleeding, dry and intact. Will continue to monitor for the next twelve hours...” An untitled and undated facility document was reviewed. The document indicated, “...Multidisciplinary Team Notes Occurred Feb 7, 2025 1836 [6:36 p.m.] By: [Name of RN 4]...bruising to left hand, color is dark in color with surround area green and yellow...” An untitled and undated facility document was reviewed. The document indicated, “...Multidisciplinary Team Notes Occurred Feb 7, 2025 1852 [6:52 p.m.] By: [Name of RN 4] ...patients provider, [Name of MD 4], was notified of patients left hand bruising right...” There was no documented evidence of a doctor’s order for the left-hand bruising. On March 19, 2025, at 2:25 p.m., an interview was conducted with PSC 2. PSC 2 stated Patient 28’s FM should not have placed an IV on Patient 28. PSC 2 stated it was a patient safety concern. PSC 2 stated, “We need to make sure the quality care is being provided by licensed staff and the patients don’t have a bad outcome.” A facility policy and procedure titled, “Patients Rights and Responsibilities,” dated October 28, 2020 was reviewed. The document indicated, “...every patient has the right to have his/her rights respected without regard to age, gender, disability...to receive ethical ( pertaining to right and wrong in conduct), high quality, safe and professional care without discrimination (nfair treatment of someone based on their belonging to a particular group such as race, age, gender, religion, or disability)...” A facility policy and procedure titled, “Patient Safety Plan,” dated June 26, 2024, was reviewed. The document indicated, “...the goal of the Patient Safety Plan is to reduce medical errors (incorrect) and hazardous (dangerous) conditions by utilizing a systematic, coordinated and continuous approach to the improvement of patient safety...” 7. On March 18, 2025, at 9:27 a.m., a review of Patient 21’s record was conducted with the Patient Safety Director Risk Management (PSDRM). An untitled and undated facility document was reviewed. The document indicated Patient 21 was admitted to the facility on March 13, 2025, for gestational diabetes mellitus (a condition with high blood sugar during pregnancy) and preeclampsia (persistent high blood pressure that develops during pregnancy or after the infant is delivered). An untitled facility document was reviewed. The document indicated, “...Patient: [Name of Patient 21] ...traniv520-labetalol hcl (trandate) [ a blood pressure medicine]100 mg [milligrams, unit of measurement]/20 ml [milliliters, a unit of measurement]...dose: 20 mg (4ml per dose) route: IV...total doses: 1...PRN [as needed] reason : SBP [Systolic blood pressure,-top number in blood pressure reading] ...>/= [greater or equal to] 160 or DBP [diastolic blood pressure, lower number in blood pressure reading]...start: 03/12/2025 [March 12, 2025] -1706 [5:06 p.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 21]...[Name of RN]...Traniv520- Trandate...Administered 03/12 [March 12, 2025] 1724 [5:24 p.m.]...” There was no documented evidence Patient 21’s BP was taken ten minutes after labetalol was administered on March 12, 2025, at 5:24 p.m. On March 18, 2025, at 9:27 a.m., an interview was conducted with the PSDRM. The PSDRM stated the nurse did not take Patient 21’s BP ten minutes after labetalol was administered on March 12, 2025, at 5:24 p.m. The PSDRM stated the nurse should have taken Patient 21’s BP ten minutes after labetalol was administered “to monitor the effectiveness of the medication.” A review of facility policy and procedure titled, “Maternal Severe Hypertension and Preeclampsia,” dated November 27, 2024, was conducted. The policy indicated, “...to outline clinical management of pregnant and postpartum [after delivery] patients who experience maternal severe hypertension/preeclampsia...Preeclampsia with Severe Features-two severe BP values (SBP greater than or equal to 160 or DBP greater than or equal to 110)...Labetalol Severe Hypertension Protocol...Step 1...administer labetalol 20 mg IV push over 2 minutes. Repeat BP 10 minutes after the dose...All documentation will be in the patient’s electronic medical record...” 8. On March 18, 2025, at 10:52 a.m., a review of Patient 22’s record was conducted with the Labor and Delivery Manager (LDM). An untitled and undated facility document was reviewed. The document indicated Patient 22 was admitted to the facility on March 13, 2025, for preeclampsia with severe features. An untitled facility document was reviewed. The document indicated, “...Patient: [Name of Patient 22]...MagniPB - Magnesium Sulfate...20 gm [gram, unit of measurement]/500 ml bag-100 ml...total volume 100 mls Rate: 200 mls/hr [hour] Duration 30 min [minutes]...start : 10/20/2024 [October 20, 2024] - 0535 [5:35 a.m.]...Administered 10/20/2024-0548 [5:48 a.m.] Given: Yes...user : [Name of RN 2]...” An untitled facility document was reviewed. The document indicated, “...Patient: [Name of Patient 22]...MagniPB - Magnesium Sulfate...20 gm/500 ml bag-500 ml...total volume 500 mls Rate : 25 mls/hr Duration 20 HR...start : 10/20/2024 - 0630 [6:30 a.m.]...Ord Dr: [Name of MD 2]...Administered 10/20 [October 20, 2024] 0548 [5:48 a.m.] Given: Yes...admin user: [Name of RN 2]...” Based on review of Patient 22’s record, there was no documented evidence Patient 22’s BP and respiratory rate (RR) was assessed from 6:16 a.m. to 6:57 a.m. on October 20, 2024, after MgSO4 was administered at 5:48 a.m. There was no documented evidence the deep tendon reflexes (DTRs) were assessed on October 20, 2024, from 9:28 a.m. to 10:57 a.m. after MgSO4 was administered on October 20, 2024, at 5:48 a.m. On March 18, 2025, at 10:52 a.m., an interview was conducted with the LDM. The LDM stated the nurse did not document vital signs (VS, reflect essential body functions, including heart rate, respiratory rate, temperature and BP) every 15 minutes on October 20, 2024, after MgSO4 was administered at 5:48 a.m. The LDM stated the nurse should have documented Patient 22’s VS every 15 minutes while MgSO4 was being administered to see if interventions or additional blood pressure medications were needed. On March 19, 2025, at 9:23 a.m., an interview was conducted with the LDM. The LDM stated there was no documentation Patient 22’s DTRs were assessed on October 20, 2024, from 9:01 a.m. to 10:59 a.m., after MgSO4 was administered at 5:48 a.m. The LDM stated the nurse should have assessed Patient 22’s DTRs to know if interventions for magnesium toxicity [symptoms which develop when too much magnesium is administered] are needed. A review of facility policy and procedure titled, “Magnesium Sulfate Use in Perinatal Patients,” dated September 25, 2024, was conducted. The policy indicated, “...the use of magnesium sulfate for the treatment of perinatal conditions include the treatment of preeclampsia...Loading those assessment...during the first hour of infusion, the BP, respiratory rate, DTR’s and I&O [intake and output- measurement of the fluids that enter the body and the fluids that leave] will be assessed and documented every 15 minutes...Antepartum or intrapartum maintenance dose assessment...BP, respiratory rate, DTRs, and I&O will be assessed and documented every one hour (or more frequently as per the patient’s condition or the provider’s order)...all documentation will be in the patients electronic medical record...” 9. On March 19, 2025, at 11:05 a.m., a review of Patient 26’s record was conducted with the Patient Safety Coordinator (PSC). An untitled and undated facility document was reviewed. The document indicated Patient 26 was admitted to the facility on February 22, 2025, for altered mental status (a change in a person’s level of consciousness or awareness) and end stage renal disease (the final stage of kidney failure) on dialysis (hemodialysis, procedure to remove waste products and excess fluid from the body when the kidney’s stop working properly using a machine). An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 26]...Hemodialysis Treatment Entered: Feb 23, 25 [February 23, 2025] 10:05 [10:05 a.m.] By: [Name of RN 3]...Hemodialysis phase: Pre-treatment...Dialysis medication orders reviewed, verified and implemented as ordered: Dialysis machine orders reviewed, verified and implemented as ordered...Left upper lobe [a major section of a lung]: [blank]...Left lower lobe: [blank]...right upper lobe: [blank]...right middle lobe: [blank]...right lower lobe: [blank]...” An undated facility document titled, “Patient Assessment,” was reviewed. The document indicated, “...Patient: [Name of Patient 26]...Hemodialysis phase: Post-treatment Entered: Feb 23, 25 [February 23, 2025] 10:05 [10:05 a.m.] By: [Name of RN 3]...Left upper lobe: [blank]...Left lower lobe: [blank]...right upper lobe: [blank]...right middle lobe: [blank]...right lower lobe: [blank]...” Based on review of patient 26’s record, there was no documented evidence Patient 26’s lung sounds were assessed before and after Patient 26’s hemodialysis on February 23, 2025. On March 19, 2025, at 11:05 a.m., an interview was conducted with the PSC. The PSC stated there was no documentation the patient’s lung sounds were assessed before and after Patient 26’s dialysis on February 23, 2025. On March 19, 2025, at 11:48 a.m., an interview was conducted with the Dialysis RN Charge Nurse (DRNC). The DRNC stated the nurse should have assessed Patient 26’s lung sounds before and after Patient 26’s dialysis on February 23, 2025. The DRNC stated it is important to assess lung sounds before and after dialysis, “to check if there’s fluid overload [a condition where there is an excessive amount of fluid in the body].” A review of the facilities policy and procedure titled, “Assessment and Documentation for Patients undergoing Hemo-dialysis..,” dated December 16, 2020, was conducted. The policy and procedure indicated, “...to establish general guidelines for assessment and documentation of care of the patient undergoing hemodialysis...The dialysis nursing assessment by a dialysis nurse on all patients prior to (before) and post (after) each hemodialysis treatment...lung sounds...Evaluation...An assessment of...lung sounds...is repeated at end of treatment and documented on the Hemodialysis Record...” 10. On March 18, 2025, at 10:52 a.m., a review of Patient 22’s record was conducted with the Labor and Delivery Manager (LDM). An untitled and undated facility document was reviewed. The document indicated Patient 22 was admitted to the facility on March 13, 2025, for preeclampsia with severe features. An undated facility document titled, “Maternal Vitals,” was reviewed. The document indicated, “...10/20/2024 [October 20, 2020]...pain...1930 [7:30 p.m.]...3-mild pain...[Name of RN 7]...” There was no documented evidence that pain was addressed in Patient 22’s medical record. On March 18, 2025, at 10:52 a.m., an interview was conducted with the LDM. The LDM stated Patient 22’s pain was not addressed. The LDM stated the nurse should have addressed Patient 22’s pain to keep the patient out of pain. A facility policy and procedure titled, “Pain assessment and Reassessment,” dated October 28, 2020, was reviewed. The policy and procedure indicated, “...team recognizes that pain can be a part of the patient experience. Unrelieved pain has adverse physical and psychological effects...obligation to manage pain and relieve the patient’s suffering is at the core of our professional commitment. As a result we,-plan, support, and coordinate activities and resources to assure the pain of all patients are addressed...” 11. On March 20, 2025, at 2:13 p.m., a review of Patient 16’s record and a concurrent interview were conducted with the Patient Safety Coordinator (PSC). A facility document titled, “History & Physical,” dated January 20, 2025 at 12:44 p.m., was reviewed. The document indicated Patient 16 was admitted to the facility on January 20, 2025, with diagnoses which included pneumonia (an infection in the lungs), intellectual disability, and schizophrenia Schizophrenia (a mental illness that is characterized by disturbances in thought). The document indicated, “...Skin: dry, intact...” A facility document titled, “Admission/Shift Assessment,” dated January 20, 2025, at 8 p.m., was reviewed and indicated the section on the document labeled, “skin alteration” was not completed. A facility document titled, “Admission/Shift Assessment,” dated January 24, 2025, at 8 a.m., was reviewed. The document indicated, “...skin alteration: Present /Exists Skin alteration: Blister Anterior Abdomen...skin alteration details: Blisters. Wound surrounding tissue appearance: Pink. Wound surrounding tissue temperature: Warm. Dressing status: Open to air. Wound/skin alteration comments: burns...” A facility document titled, “Wound Specialist Notes,” dated January 30, 2025, at 2:11 p.m., was reviewed. The document indicated, “ ...Wound/Ostomy Service Reason for Consult: burn to abdomen...Per consult reason there are burns on abdomen. Unclear as to how these occurred. There are full [a wound that extends beyond the skin’s surface and potentially reaching deeper structures like muscle or bone] and partial thickness [a wound that extends into the first two layers of skin but does not penetrate deeper layers] open areas on abdomen. Abdomen ...inferior [below] and left of the umbilicus there is full thickness open area measuring 2.6 x 1.7 x 0.2 cm [centimeters, unit of measurement]...Abdomen ...left side with a clear fluid filled bullae [blister], measuring 1 [one] x 4 [four] cm...Abdomen ...right side with clear fluid filled bullae, measuring 1.5 x 1.4 cm... Updated [name of MD 5] of wound assessment and orders received...” A facility document titled, “Dressing- Dressing Change/Wound Care Order Details,” dated January 30, 2025, was reviewed. The document indicated, “ ...Body Part: abdomen-several areas...Cleanse with: Wound Cleanser Apply/Fill/Pack: Silver contact layer (Urgotul-AG+) [non-adhesive wound dressing containing silver sulfate designed to promote healing] Cover with: Silicone Adhering Foam ...” Patient 16’s record was reviewed and there was no documented evidence Patient 16 had burns on admission, how the burn/blisters occurred, that the physician was notified of the burns and if treatment were ordered or photos were obtained. On March 20, 2025, at 3:49 p.m., an interview was conducted with Registered Nurse (RN) 5. RN 5 stated RN 8 had reported to her during the shift change on January 24, 2025, that RN 8 used the hot pack on Patient 16 and burned the patient. RN 5 stated she did not document what RN had told her and RN 8 also did not document that she placed a hot pack on Patient 16 and the patient was burned. RN 5 stated RN 8 did not call the physician. I informed the resident physician but did not document this. RN 5 stated she did not get orders for the treatment of the burn on Patient 16’s abdomen and just left it open to air. RN 5 stated the facility’s policy for a patient with a burn or wound is to notify the MD, report incident to the charge nurse, take photos, and document. On March 21, 2025, at 11:20 a.m., an interview was conducted with the Patient Safety Director Risk Management (PSDRM). The PSDRM stated Patient 16’s burn was not reported to CDPH (Department of Public Health, a state agency) because it was a blister at the time it was investigated and was not established until later that it was a burn. The PSDRM stated investigation was dropped after seeing the one blister. The PSDRM stated she was not aware of the other blisters at the time. On March 21, 2025, at 11:50 a.m., an interview was conducted with the Director of Medical Intensive Care (DMICU). The DMICU stated RN 8 left a hot pack on Patient 16’s abdomen for one to two hours while she taking care of another patient. The DMICU stated RN 8 also used heating blankets in addition to the hot packs to warm Patient 16. The DMICU stated there was no documentation the physician was notified. The DMICU stated the events surrounding patient 16’s burn on the abdomen was not documented on the medical record. The DMICU further indicated the wound care nurse was not consulted until January 30, 2025, when Patient 16 was transferred out of Unit B. A review of the hot pack manufacturer’s instructions titled, “Medline Instant Hot Pack,” was conducted. The document indicated, “...For use whenever instant, safe, hot therapy is required...Do not use the hot therapy for more than 20 minutes...Warnings...avoid excessive heat ...Monitor the skin to avoid injuries ...” A facility policy titled, “Serious Patient Adverse Events,” dated March 2022, was reviewed. The policy indicated,” ...this Policy is intended to define the strategy for management of all Serious Patient Adverse Events (SPAEs) across all Company affiliated facilities... All company affiliated facilities will: Provide immediate care and support to the patient, Patient’s Representative/Family...any impacted staff in response to a SPAE; notify the administrator on call and the attending physician. The Patient Focus First Response Team will be activated to investigate and report events as outlined...and in alignment with all federal/state and/or accreditation agency requirements. This process will be triggered in a timely manner even when a cause for the event is not yet known...””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 50304 Based on observation, interview, and record review, the facility failed to ensure standard infection control procedures were maintained when: 1. For Patient 27, an unsterilized (when bacteria or viruses are not eliminated from a surgical instrument) scope was used on the patient during surgery; and 2. An opened sterile mucus trap (container used to collect thick sticky body fluid) was observed on top of an infant warmer in Room AA. These failures have the potential to transmit infectious bacteria and viruses to the patients and place the patients at risk for infection. Findings: 1. On March 19, 2025, at 1:15 p.m., a review of Patient 27’s record was conducted with the PSC 2. An undated facility document titled, “History and Physical,” was reviewed. The document indicated Patient 27 was admitted to the facility on February 12, 2025, for abdominal pain, nausea, and suspicion of choledocholithiasis (presence of stones in the tube-like structure that carries bile). An undated facility document titled, “Consent to Surgery or Special Procedure,” was reviewed. The document indicated, “...your doctors have recommended the following operation or procedure: robotic [assisted by a robot], possible laparoscopic [inserting a thin tube with camera through a small cut in the skin], possible open cholecystectomy [a surgical procedure to remove the gallbladder]...Name of the practitioner who is performing the procedure or administering the medical treatment: [Name of Doctor of Medicine (MD) 3]...Signature: [Signature of Patient 22]...Date: 02-14-25 [February 14, 2025] Time: 6:56 p.m....” A facility document titled, “Critical Care Event Note,” dated February 15, 2025, authored by MD 3, was reviewed. The document indicated, “...I was notified shortly after completion of the operative case, which was performed without complication and after the patient had already been transported out and monitored out of the Operating Room (OR) under standard post anesthesia protocol, that the robotic camera (scope) used for the entirety of the case was not fully sterilized under standard process. Essentially, the entire case was performed with a cleaned and washed, but unsterilized camera...I was made aware of the breach in sterile protocol [set of rules for disinfection] after the case due to the staff conducting their standard cleanup and they identified a sterility marker [marker to ensure the object is free from bacteria and virus] not properly indicating a sterilization had taken place was applied to an instrument, namely the robotic camera...” An untitled facility document, dated February 16, 2025, authored by MD 3 was reviewed. The document indicated, “...I had an extended conversation with the patient [Patient 27] as well as 2 [two] [Patient 27’s family members] and nursing at bedside. Patient states she has met with [Name of Operating Room Director, ORD], Director of Surgery as well as [Name of Patient Safety Director from Risk Management PSDRM]...Patient states the event of the suspected and sterilized instrument was disclosed to her today and understands the event that has taken place...” An untitled and undated facility document was reviewed. The document indicated, “...Per unit MDR [multidisciplinary rounds] s/p [status post, after surgery] cholecystectomy. Risk management [a process that involves analyzing risks that can affect a facility] is following due to situation with procedure equipment. Monitoring serology labs [laboratory tests that focus on the study of the clear fluid in blood and other bodily fluids, primarily to identify and measure the presence and levels of antibodies]...” On March 17, 2025, at 2:40 p.m., an observation of the Sterile Processing Department (SPD, department responsible for cleaning, disinfecting, and sterilizing devices and instruments) with concurrent interview were done with the SPD Supervisor (SPDS). An SPD staff was observed sorting surgical instrument packs. Black stripes were observed on the tape which were observed on the packs. The SPDS stated it is the responsibility of the SPD Technician (SPD tech, staff assigned to perform decontamination, preparation, and disinfection of surgical instruments) to properly sterilize surgical instruments for operating room (OR) use. The SPDS stated the SPDT also verifies the surgical instrument packs were properly sterilized before sending them to the operating room. On March 20, 2025, at 9:57 a.m., an interview was conducted with the SPD Technician (SPDT). The SPDT stated “dirty “instruments are washed, assembled, sterilized, and sent back to the OR. The SPDT further stated it is important that instruments are sterilized, “for patient safety to avoid infection and death.” On March 20, 2025, at 10:21 a.m., an interview was conducted with the Operating Room Director (ORD). The ORD stated the SPD tech placed the scope used in Patient 27’s surgery in the instrument tray for OR use without proper sterilization. The ORD stated the SPD tech did not sterilize the scope used in Patient 27’s surgery after washing it. On March 21, 2025, at 9:28 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated it is important to make sure instruments are sterile. The IP stated, “It is about patient safety and prevention of infection and blood borne infection.” On March 21, 2025, at 10:47 a.m., an interview was conducted with the Vice President of Quality (VPQ). The VPQ stated the facility did not have a pre-sterilization policy for SPD. The facility’s policies and procedures were reviewed. The facility did not have a policy and procedure on pre-sterilization for SPD. 2. On March 17, 2024, at 10;09 a.m., a tour of Labor and Delivery and Maternal and Child Units was done with the PSDRM and the Labor and Delivery Manager (LDM). A mucus trap (container used to collect thick sticky body fluid) which is not in a sealed container was observed on top of the infant warmer in Room AA. On March 17, 2024, at 10:09 a.m., an interview was conducted with the LDM. The LDM stated there shouldn’t be an opened mucus trap on top of the infant warmer. The LDM stated it is an infection risk to the patient. On March 21, 2025, at 9:28 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated it is important to maintain the sterility (the state of being free from all bacteria an dviruses) of instruments. The IP stated, “It is about patient safety and prevention of infection and blood borne infection (infection caused by bacteria or virus in the blood and transmitted through contact with infected blood or body fluids).” A facility policy and procedure titled, “Sterile Technique,” dated August 24, 2022, was reviewed. The policy indicated, “...sterile technique involves the use of specific actions and activities to prevent contamination and maintain sterility of identified areas during operative and other invasive [involves cutting or puncturing the skin] procedures. All individuals who are involved in operative or other invasive procedures have a responsibility to provide a safe environment for patients. Preparing a sterile field for patients undergoing surgical or other invasive procedures reduces the risk of microbial contamination and is a cornerstone of infection prevention. Failure to adhere to aseptic [free from contamination] practices during invasive procedures has been associated with surgical site and procedural related infections...to ensure that only sterile items are present to the sterile field [an area from microorganism], all items will be inspected immediately before presentation to the field for proper packaging, processing, seal, package container integrity, expiration date if applicable and inclusion of a sterilization indicator [a device used to tell if object is sterile]...” A facility policy and procedure titled, “Infection Control Plan,” dated June 26, 2024, was reviewed. The document indicated, “...the infection prevention (IP) program utilizes a multidisciplinary, systematic approach to quality patient care that emphasizes disease transmission risk reduction in the health care environment by use (sic) sound epidemiological [relating to the control of disease] principles and evidence -based practices [practices supported by strong, reliable research]. Effectiveness is achieved by integrating principles of infection prevention with each department’s standards. Program objectives...To prevent/minimize disease transmission within the facility...To analyze practices that may have the potential to cause health care associated infections...To recommend practices oriented towards preventing healthcare associated infections...””

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 34933 Based on interview and record review, the facility failed to ensure a safe discharge, for two of 30 sampled patients (Patient 12 and Patient 16), when: 1.Patient 12 was discharged home without the appropriate medications, supplies, and Durable Medical Equipment (DME, medical equipment used for a patient’s long-term use). In addition, Patient 12 was not provided with education on how to manage the wound vac machine. This failure had the potential to cause harm to Patient 12; and 2. For Patient 14, the facility failed to coordinate the discharge with the shelter prior to discharge. Patient 14 was denied access to the shelter upon arrival and then transferred to a crisis stabilization (CSU, a facility that provides short term, intensive care for individuals experiencing a mental health crisis) for further assessment and care. This failure resulted in Patient 14’s visit to the Emergency Department for follow up care and transfer to a CSU within 24 hours of discharge. Findings: 1. On March 18, 2025, at 9:22 a.m., a review of Patient 12’s record and concurrent interview were conducted with the Patient Safety Coordinator (PSC) 2. A review of the facility document titled, “History & Physical,” was conducted. The document indicated Patient 12 was admitted to the facility on June 14, 2024, with diagnoses which included disseminated coccidio (a fungal infection that spreads from the lungs through the blood), hydrocephalus (excessive accumulation of cerebrospinal fluid (CSF) in the brain’s ventricles) s/p (status post, after) ventriculopleural shunt (a surgical procedure that diverts excess CSF from the ventricles into the space between the lung and chest wall), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and end stage renal disease (ESRD, irreversible kidney failure). A facility document titled, “List Patient Notes,” dated January 14, 2025, at 3:24 p.m., was reviewed. The document indicated, “...Wound/Ostomy Care RN (Registered Nurse) note: consult received to evaluate pressure injury...Patient is trached and vented [refers to a medical situation where a person has a tracheostomy (a surgical opening in the windpipe)] and is also receiving mechanical ventilation [breathing support from a machine], does not follow commands...Coccyx [tailbone]-stage 4 pressure injury [full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone] s/p debridement [surgical procedure to remove non-viable tissue] on 12/15 [December 15]...Currently on wound vac [treatment that uses a vacuum to promote wound healing]...” A facility document titled, “Discharge Order with Parameter,” dated January 16, 2025, at 3:54 p.m., was reviewed. The document indicated,”...Discharge Parameters: pending wound vac authorization...Discharge to: Home/Self Care. Diet: Tube Feeding [a medical procedure that provides nutrition and fluids through a tube inserted into the digestive system]...” A facility document titled, “Discharge Order with Parameter,” dated January 31, 2025, at 4:25 p.m., was reviewed. The document indicated, “...Discharge Parameters: Home Health DME...Discharge to: Home Health with Plan of Care...” A facility document titled, “Hospitalist Discharge Summary,” dated February 1, 2025, at 9:15 a.m., was reviewed. The document indicated, “...Patient is stable to discharge to home, DME order signed, home health service has been approved, pending HD [hemodialysis, the removal of toxins from the blood using a machine] center to approval and home care training before patient can be discharged home...” A facility document titled, “Multidisciplinary Ream Notes,” dated February 1, 2025, at 10:34 a.m., was reviewed. The document indicated,”...NN [Nurse Note]: Patient transported with [Name of Facility] RN [registered nurse]. Left message for [family member, FM] informing him that Patient discharged...” A facility document titled, “Case Management Report,” dated February 1, 2025, at 2:17 p.m., was reviewed. The document indicated, “...[FM] was upset stating that medications were not sent, the pharmacy stating that no medications were on file...Call placed to the Director of Unit A to inform of the medication not being sent, per Director of [Unit A] [FM] spoke with the [name of Provider 1], and [name of Provider 1] sent the new medications that [name of Patient 12] was on and not the “home meds” that Patient 12 was previously on. Per [name of provider 1]...he sent all the home medications to pharmacy 45 mins [sic] ago...call placed to Provider 1 who informed...majority of medications did not go through...” A facility document titled, “Multidisciplinary Team Notes,” dated February 1, 2025, at 5:04 p.m., was reviewed. The document indicated, “...NN: [name of RN 1] spoke with [FM]...[FM] informed [name of RN 1] that Novalog [a medication to treat diabetes] was not covered under [name of Insurance 2]. Call was then placed to [name of Provider 1] regarding insulin issue. [FM] called again and stated Humalog [a medication to treat diabetes] is also not covered and [FM] also stated he did not have a feeding pump or tubing...” A facility document titled, “Case Management Report,” dated February 2, 2025, at 2:41 p.m., was reviewed. The document indicated, “...call finally went through to [name of Facility A], [Facility A] just received the medications list and just now received the medications. Per [Facility A] there were no prescriptions received at all, currently there ar[sic] 17 prescriptions that were finally received. Verified medications: Metoprolol [medication for high blood pressure] 100 mg [milligrams, unit of measure] Lisinopril [medication for high blood pressure] 20 mg Polythelyin Glycol powder [medication for constipation] Albuterol [medication used for shortness of breath or wheezing] 5mg/ml [milliliter, unit of measure] nebulizer solution Keppra liquid [medication for seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness)] 30 ml...norvasc [medication for high blood pressure] 10 mg Pulmicort [medication to decrease nasal and sinus inflammation] nebulizer solution Santyl ointment [medication for bedsores] Compazine [medicine for nausea] 10 mg Zofran [medicine for nausea] liquid 4 mg Lantus [medication for DM] 100 u [units, unit of measurement] per ml Sensipar [medication for high calcium levels] per [Facililty 1] this is not authorized per [Insurance 1] and the [FM] would need to pay a copay Juven powder [nutrition powder for healing of bedsores] per [Facility 1] is not authorized per [Insurance 1] and [FM] would need to pay a copay and will attempt to contact [Insurance 2] for prior auth [authorization] on Monday Benadryl Liquid [medication for allergy or sleep] Novolog [medication for DM] 70/30 mix [mixture of intermediate acting and rapid acting insulin] Lactulose [medication for constipation] Renavit [a nutrition supplement] per [Facility 1] this is not authorized per Insurance 1 and would need to be changed to another formulary for coverage...” A facility document titled, “Case Management Report,” dated February 2, 2025, at 8:49 a.m., late entry for February 1, 2025, at 5:48 p.m., was reviewed. The document indicated, “...Received and escalated message from [Provider 1] stating that patients insulin was not covered and the [FM] was upset...Notified [Facility B] for assistance with medication coverage, per [Facility B] will be able to assist with the 30 day supply for the medications that are not covered...1848 [6:48 p.m.] received a late call back from [Facility B] stating medications have been covered with a ETA [estimated time of arrival] of 5 [five] hours from time of notification...” Based on review of Patient 12’ s record, there was no documented evidence [FM] was taught how to manage the wound vac machine prior to Patient 12’s discharge. On March 18, 2025, at 1:44 p.m., an interview was conducted with RN 2. RN 2 indicated the providers complete the medication reconciliation forms in the computer for discharge including cancelling or adding prescriptions. RN 2 stated the RN will confirm with the pharmacy and print the packet. RN 2 stated any medication the patient is currently on will automatically continue as a home medication. RN 2 stated the FM was told all the medications were faxed to the pharmacy and the pharmacy will text when medications are ready. The FM called two hours later and stated he did not have the regular medications, so I took a picture of the medication list and called Provider 1 to order the remaining medications. We do not call the pharmacy to verify if the medications are ready or if they are covered prior to discharge. RN 2 indicated the wound vac was changed to the company wound vac the morning of discharge and there was no teaching done on wound vac care with the FM over the phone. On March 19, 2025, at10:37 a.m., a concurrent review of Patient 12’s record and interview were conducted with the Director of Case Management (DCM). The DCM stated it is very important that supplies arrive to the patient’s home before discharge. The DCM stated she called the pharmacy and verifed Patient 12’s the medications were not sent over. On March 20, 2025, at 10:33 a.m., an interview was conducted with Provider 1. Provider 1 stated he found out the pharmacy did not have the medications ordered for Patient 12. The facility policy and procedure (P&P) titled, “Discharge Planning: Assessment, Referrals, Transfers, Placements & Transportation (Adult and Pediatric),” dated April 22, 2020, was reviewed. The P&P indicated, “...The goal is to prepare the patient/patient’s support system or decision maker(s) for a safe transition from hospital care to the targeted environment. Steps should be taken to implement the established discharge plan...Medication Reconciliation with clear indication of changes from the patient’s preadmission medications...Providing supplies such as materials for changing dressings on wounds, when needed immediately post-discharge by the nurse discharging the patient...Arrangements for durable medial equipment, necessary to facilitate a safe discharge, will be completed by the case manager, social worker, or hospital designee...” 2. On March 19, 2025, at 3 p.m., a review of Patient 14’s record and a concurrent interview were conducted with the Patient Safety Coordinator (PSC). A facility document titled, “History & Physical,” dated January 25, 2025, was reviewed. The document indicated Patient 14 was admitted to the facility on January 25, 2025, for left sided chest pain. The document indicated, “...Diagnosis, Assessment & Plan...Possible homelessness Patient avoids questions about his housing situation but he states he is always “out”...Social work [SW] consult for homelessness...” A facility document titled, “Internal Medicine Progress Note,” dated January 26, 2025, at 6:59 a.m., was reviewed. The document indicated, “...Head/Eyes: Tardive dyskinesia [uncontrollable body movements often caused by long term use of psychiatric drugs] with smacking of lips and tongue noted...Psychiatric disorder, unknown med [medication] rec [reconcitaltion, a review of medications the patient is on] showed risperidone [medication for schizophrenia [a mental illness that is characterized by disturbances in thought], bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs], and irritability caused by autism [a condition that affects how people socialize and behave] as home med...” A facility document titled, “Case Management Report,” dated January 27, 2025, at 11:57 a.m., was reviewed. The document indicated, “...SW received a financial/ social assist order; Homeless. SW met with pt [Patient 14] at bedside. Pt was A/O x 3 [alert/orientated to person, place, and time] at time of assessment. Pt reported to be homeless for a few years...Pt had no nok [no known] contact to provide...Pt reported having no income...Pt reported going to churches and food banks for food...SW provided pt with community resource packet and DPSS [Department of Social Services, a state agency] office locations...” A facility document titled, “Discharge Order with Parameters,” dated January 27, 2025, at 4:32 p.m., was reviewed. The document indicated, “...Discharge Parameters: medications delivered bedside and shelter arrangement...” A facility document titled, “Case Management Report,” dated January 28, 2025, at 1:40 p.m., was reviewed. The document indicated, “...SW Note: SW met with pt [Patient 14] at bedside to follow up on his DCP [discharge plan]...SW provided Pt with homeless resources in [name of County A] and informed him how to utilize emergency shelters...SW met with PT at bedside and provided him with homeless resources in the city of [name of city]. SW also provided pt with the guide to homelessness in [name of County B] which consist of a list of homeless shelters...was provided to CNC [Clinical Nurse Coordinator] for when pt is ready to dc...” A facility document titled, “Discharge Summary,” dated January 27, 2025 at 4:33 p.m., was reviewed. The document indicated, “...Discharge Instructions PCP: No primary or family physician Discharge to: Shelter...” A facility document titled, “Multidisciplinary Team Notes,” dated January 29, 2025, at 11:22 a.m., was reviewed. The document indicated, “Pt discharged to shelter via lyft. All belongings and discharge paperwork and medication given. Pt verbalized understanding...” On March 19, 2025, at 3:56 p.m., an interview was conducted with the Registered Nurse Case Manager (RNCM). The RNCM stated a discharge assessment is completed first on the patient, then the patient’s medical needs are evaluated. Patient 14 reported he was homeless so we call for a SW consult in case patient is interested in Shelters. The RNCM stated Patient 14 was assessed clinically if DME or medications were needed and the discharge to the shelter was done by the SW. On March 20, 2025, at 11:17 a.m., an interview was conducted with SW 1. SW 1 stated, “We usually provide the patients with resources and its up to the patient to call and make the arrangement for the shelter.” SW 1 stated she did not call the shelter and she did not arrange for Patient 14 to stay at the shelter. SW 1 stated, “I am not sure what the policy says.” On March 20, 2025, at 11:30 a.m., an interview was conducted with the Social Services Supervisor (SSS). The SSS stated, “The goal is to work collaboratively for the discharge but we did not call the shelter and coordinate the stay.” A facility P&P titled, “Discharge Planning: Assessment, Referrals, Transfers, Placements & Transportation (Adult and Pediatric),” dated April 22, 2020, was reviewed. The P&P indicated, “...A post discharge destination will be identified for each patient which may be...A social services agency, nonprofit social services provider, or governmental services provider that has agreed to accept the patient. The hospital staff...will document the name of the person at the receiving agency or shelter who agreed to accept the patient. The designated hospital employee will send the receiving entity written or electronic information about the patient’s post-discharge health and behavioral health needs the homeless patient’s “residence,” which is defined as “the location identified to the hospital by the patient as his or her principal dwelling place”...An alternative destination, as indicated by the homeless patient. The hospital will not “cause the transfer” of a homeless patient to another county for the purpose of receiving supportive services from a social services agency, health care service provider of nonprofit social services provider in the other county unless the hospital has received prior authorization from the receiving entity to accept the specific patient...””

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 50304 Based on observations, interviews, and record reviews, the facility failed to ensure surgical services were maintained according to standards of practice, for one of 30 sample patients, when an unsterilized (not made free of bacteria and viruses) scope (an instrument with light and camera used for visualization inside the body) was used during Patient 27’s surgery and the operating room technician did not verify the scope was sterilized before being used during the surgery. These failures resulted in a prolonged hospital stay for Patient 27 and placed Patient 27 at risk for infection and blood borne diseases (diseases caused by bacteria or virus in the blood transmitted through contact with infected blood or body fluids). Findings: On March 19, 2025, at 1:15 p.m., a review of Patient 27’s record was conducted with the Patient Safety Coordinator (PSC) 2. An undated facility document titled, “History and Physical,” was reviewed. The document indicated Patient 27 was admitted to the facility on February 12, 2025, for abdominal pain, nausea, and suspicion of choledocholithiasis (presence of stones in the tube like structure that carries bile). An undated facility document titled, “Consent to Surgery or Special Procedure,” was reviewed. The document indicated, “...your doctors have recommended the following operation or procedure: robotic [assisted by a robot], possible laparoscopic [inserting a thin tube with camera through a small cut in the skin], possible open cholecystectomy [a surgical procedure to remove the gallbladder]...Name of the practitioner who is performing the procedure or administering the medical treatment: [Name of Doctor of Medicine (MD) 3]...Signature: [Signature of Patient 27]...Date: 02 14 25 [February 14, 2025] Time: 6:56 p.m....” A facility document titled, “Critical Care Event Note,” dated February 15, 2025, authored by MD 3, was reviewed. The document indicated, “...I was notified shortly after completion of the operative case, which was performed without complication and after the patient had already been transported out and monitored out of the Operating Room (OR) under standard post anesthesia protocol, that the robotic camera (scope)used for the entirety of the case was not fully sterilized under standard process. Essentially, the entire case was performed with a cleaned and washed, but unsterilized camera...I was made aware of the breach in sterile protocol [set of rules for disinfection] after the case due to the staff conducting their standard cleanup and they identified a sterility marker [marker to ensure the object is free from bacteria and virus] not properly indicating a sterilization had taken place was applied to an instrument, namely the robotic camera...” An untitled facility document, dated February 16, 2025, authored by MD 3 was reviewed. The document indicated, “...I had an extended conversation with the patient [Patient 27] as well as 2 [two] [Patient 27’s family members] and nursing at bedside. Patient states she has met with [Name of Operating Room Director, ORD], Director of Surgery as well as [Name of Patient Safety Director from Risk Management PSDRM]...Patient states the event of the suspected and unsterilized instrument was disclosed to her today and understands the event that has taken place...” An untitled and undated facility document was reviewed. The document indicated, “...Per unit MDR [multidisciplinary rounds] s/p [status post, after surgery] cholecystectomy. Risk management [a process that involves analyzing risks that can affect a facility] is following due to situation with procedure equipment. Monitoring serology labs [laboratory tests that focus on the study of the clear fluid in blood and other bodily fluids, primarily to identify and measure the presence and levels of antibodies]...” On March 17, 2025, at 2:40 p.m., an observation of the Sterile Processing Department (SPD, department responsible for cleaning, disinfecting, and sterilizing devices and instruments) with concurrent interview were done with the SPD Supervisor (SPDS). An SPD staff was observed sorting surgical instrument packs. Black stripes were observed on the tape which were observed on the packs. The SPDS stated it is the responsibility of the SPD Technician (SPD tech, staff assigned to perform decontamination, preparation, and disinfection of surgical instruments) to properly sterilize surgical instruments for operating room (OR) use. The SPDS stated the SPDT also verifies the surgical instrument packs were properly sterilized before sending them to the operating room. On March 20, 2025, at 9:57 a.m., an interview was conducted with the SPD Technician (SPDT). The SPDT stated “dirty “instruments are washed, assembled, sterilized, and sent back to the OR. The SPDT further stated it is important that instruments are sterilized, “for patient safety to avoid infection and death.” On March 20, 2025, at 10:21 a.m., an interview was conducted with the Operating Room Director (ORD). The ORD stated the SPD tech placed the scope used in Patient 27’s surgery in the instrument tray for OR use without proper sterilization. The ORD stated the Operating Room technician that prepared the instruments for the surgery did not verify if the scope was properly sterilized. The ORD stated another OR tech found out after surgery that the scope was not properly sterilized. The ORD stated the SPD tech did not sterilize the scope used in Patient 27’s surgery after washing it. On March 21, 2025, at 9:28 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated it is important to make sure instruments are sterile. The IP stated, “It is about patient safety and prevention of infection and blood borne infection.” On March 21, 2025, at 10:47 a.m., an interview was conducted with the Vice President of Quality (VPQ). The VPQ stated the facility did not have a pre sterilization policy for SPD. A facility policy and procedure titled, “Sterile Technique,” dated August 24, 2022, was reviewed. The policy indicated, “...sterile technique involves the use of specific actions and activities to prevent contamination and maintain sterility of identified areas during operative and other invasive [involves cutting or puncturing the skin] procedures. All individuals who are involved in operative or other invasive procedures have a responsibility to provide a safe environment for patients. Preparing a sterile field for patients undergoing surgical or other invasive procedures reduce the risk of microbial [bacterial and viral] contamination and is a cornerstone of infection prevention. Failure to adhere to aseptic [to render free from bacterial and viral contamination] practices during invasive procedures have been associated with surgical site and procedural related infections...to ensure that only sterile items are present to the sterile field [an area which is free of bacteria and viruses], all items will be inspected immediately before presentation to the field for proper packaging, processing, seal, package container integrity, expiration date if applicable and inclusion of a sterilization indicator [a device used to tell if object is sterile]...” A facility policy and procedure titled, “Infection Control Plan,” dated June 26, 2024, was reviewed. The document indicated, “...the infection prevention (IP) program utilizes a multidisciplinary, systematic approach to quality patient care that emphasizes disease transmission risk reduction in the health care environment by use (sic) sound epidemiological [relating to the control of disease] principles and evidence based practices [practices supported by strong, reliable research]. Effectiveness is achieved by integrating principles of infection prevention with each department’s standards. Program objectives...To prevent/minimize disease transmission within the facility...To analyze practices that may have the potential to cause health care associated infections...To recommend practices oriented towards preventing healthcare associated infections...” The facility’s policies and procedures were reviewed. The facility did not have a policy and procedure on pre sterilization for SPD.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 48562 Based on observation, interview, and record review, the facility failed to ensure the patients’ right to receive care in a safe setting was provided, for five patients of 30 sample patients (Patients 1, 2, 4, 5, and 6), when: 1. Patient Care Technician (PCT) 1 was observed to have his back turned from the three behavioral health patients on a 5150 hold (a section of the Welfare and Institutions Code that allows for the involuntary psychiatric evaluation and temporary detention of individuals deemed a danger to themselves, others, or are gravely disabled due to a mental health disorder) he was observing and monitoring at the same time as a 3:1 sitter (a hospital patient care arrangement where one patient sitter/staff is assigned to observe and support three patients at the same time). This failure had the potential for three behavioral health patients who are deemed to be suicidal to elope (an unauthorized departure of a patient from a hospital) from the Emergency Department (ED); 2. For Patients 1 and 5, who were on a 5150 hold, the patients were able to elope from the Emergency Department (ED); 3. For Patient 2, who was on a 5150 hold, the patient was not placed under constant observation in accordance with the facility’s policy; 4. For Patient 4, the facility staff allowed a visitor to provide the patient with shoes and clothing and walk the patient out of the ED; and 5. For Patient 6, staff did not change a patient into a green gown and search the patient and patient belongings in accordance with the facility’s policy. This failure resulted in Patient 6 having a knife on him and stabbing the furniture and had the potential to place the patient and other patients in the ED at risk of harm. These failures resulted in Patients 1, 2, 4, 5 eloping from the ED and had the potential to place Patients 1, 2, 4, 5, and 6 at risk for harm and injury. In addition, these failures may lead to other patient elopement which may cause harm, injury, or death to the patients. Findings: 1. On March 17, 2025, at 9:30 a.m., a tour of the ED was conducted with the assistant Chief Nursing Officer (ACNO) and the Director of the ED (DED). While touring, the ED hallways were observed to be high traffic areas with many staff, patients, and visitors walking and gurneys being pushed through them. Hallway 1 is observed located adjacent to the nurse’s station and near the ambulance bay (the space where the ambulance parks to bring patients inside the ED) and the trauma (designated area within an emergency department specifically equipped and staffed to provide immediate, life-saving care for patients with serious injuries from accidents) rooms of the ED. Hallway 1 was observed with four hallway beds. During a concurrent interview, the DED stated Hallway 1 is typically used for psychiatric (relating to mental illness or its treatment) patients and patients on a 5150. The DED stated Rooms A and B are the two common rooms used for psychiatric patients. The DED stated a 5150-patient may be placed in any bed in the ED depending on patient’s need. During the continued tour, an observation was made of the patients and sitters in Hallway 1. On March 17, 2025, at 9:40 a.m., Patient Care Technician (PCT) 1 was observed standing at the doorway of Room B and was observed talking to another facility staff. PCT 1’s back was observed to be turned away from her assigned patients in Hallway 1. PCT 1 was observed to not maintain direct sight of the patients assigned to her. On March 17, 2025, at 9:45 a.m., an interview was conducted with PCT 1. PCT 1 stated he was assigned to three 5150 patients. PCT 1 stated the patients in Hallway 1 were on a 5150 hold for being a danger to themselves. PCT 1 stated the sitter should keep eyes on the patients on 5150 hold at all times to ensure the patients’ safety. On March 20, 2025, at 12 p.m., an interview was conducted with the DED. The DED stated PCT 1 was observed talking to another sitter across the hallway and was not appropriately monitoring her patients. The DED stated PCT 1 should have had all three patients assigned to her within her eyesight at all times, and should not be talking to another staff while monitoring the patients. The DED further stated the hallway used for the 5150 patients is in a high traffic area close to an exit door and may be contributing to the patient’s ability to elope from the ED. 2a. On March 18, 2025, at 9:20 a.m., a review of Patient 1’s record was conducted with Quality Coordinator (QC) 1. A facility document titled, “Application for assessment, evaluation, and crisis intervention of placement for evaluation and treatment,” was reviewed. The document indicated, “...[name of Patient 1] was in the middle of the street...was banging his head against the windows inside my patrol car...possibly took 4 [four] Xanax [a medication used to treat anxiety] pills...Based upon the above information, there is probable cause to believe that said person is, as a result of mental health disorder [sic]: A danger to self...date: 01/28/25 [January 28, 2025] time: 1840 [6:40 p.m.]...” A facility document titled, “Emergency Provider Report,” dated January 28, 2025, at 7:10 p.m., was reviewed. The document indicated, “...Chief Complaint: Violent Behavior and intoxication... past medical history of anxiety and depression...presents to the ED with police for violent behavior and intoxication...patient already on 5150 hold...per 5150 documentation patient was physical in his mothers [sic] car while she was driving and then jumped out of the vehicle...found in the middle of the street...noted to be banging his head against the windows inside the police care...hold [5150 hold] was placed for patient being a danger to himself...” An undated facility document titled, “Medication discharge summary,” was reviewed. The document indicated Patient 1 received intramuscular (IM, injection that goes into muscle) medication on January 28, 2025, at 9:41 and 9:42 p.m. The document indicated Patient 1 was not administered any other medications prior to elopement. A facility document titled, “Telehealth Psychiatric Consult,” dated January 29, 2025, at 12:26 p.m., was reviewed. The document indicated, “...Reason for consult: SI [suicidal ideations, having thoughts of killing oneself]...Overall risk level-suicide: high risk...per the mother...while in the car, hitting head, jumped out of car and found in the middle of the road. Banging head in cop car. His hands are bruised due to punching self...terrible tempter at home...making suicidal statements...recommendations: The patient does meet criteria for in-patient psychiatric admission due to self-harm attempts, violence, and drug use...continue mental health hold [5150]...” A facility document titled, “Patient Observation Form,” dated January 29, 2025, was reviewed. The document indicated, “...Indication for observation: SI-Minor ...Suicidal ideation, self-injury, assaultive/aggression. Time: 1630 [4:30 p.m.] LC [location] Bed, AC [attribute codes] Restless/agitated...INT [intervention] Redirection...Time: 1645 [4:45 p.m.] Ran out...” A facility document titled, “Emergency provider report,” dated January 29, 2025, at 5:55 p.m., was reviewed. The document indicated, “...Patient jumped up and ran out of emergency department before he was able to be detained. Law enforcement was notified and located patient at his home and will undergo decision making with mother regarding where they will take him...” A facility document titled, “Emergency Notes,” dated January 29, 2025, at 4:35 p.m., was reviewed. The document indicated, “...Was notified by sitter staff at this time patient got up to use restroom and left running down the hall to front of the hospital property, [name of local police department] called and report for 5150 elopement description given to PD...” 2b. On March 18, 2025, at 11 a.m., a review of Patient 5’s record was conducted with QC 1. A facility document titled, “Emergency Provider Report,” dated March 2, 2025, at 11:53 p.m., was reviewed. The document indicated, “...[name of Patient 5]...Presents stating he is suicidal...Tired of living...and wants to kill himself because of the continuous pain. The patient [Patient 5] has a plan to overdose on medications...has access to guns...is having thoughts of harming others when they upset him...currently homeless...off medication...Suicide risk level: [No result]...Overall risk level: Low Risk...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Suicide Assessment ED: Occurred 3/03/25 [March 3, 2025] 0040 [12:40 a.m.]... Suicide assessment...risk level: High Risk...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Violence/aggression screening: Occurred 3/03/25 0800 [8 a.m.]...risk type: High...” A facility document titled, “Emergency Provider Report,” dated March 3, 2025, at 11:17 a.m., was reviewed and indicated, “...Note...Suicide Risk Level: High Risk ...Overall Risk level-suicide: Moderate risk...” A facility document titled, “Emergency Notes,” dated March 3, 2025, at 7:30 p.m., was reviewed. The document indicated, “...PT [Patient 5] resting in Hall [hallway] 3 gurney, safety precautions in place. Sitter present...patient endorses +SI +HI [homicidal ideation, having thoughts of harming others]...not specific to plan...” A facility document titled, “Emergency Notes,” dated March 4, 2025, at 7:51 a.m., was reviewed and indicated, “...patient placed on 5150 hold...endorses suicidal ideations...sitter at bedside...” A facility document titled, “Emergency Provider Report,” dated March 4, 2025, at 9 a.m., was reviewed and indicated, “...Note...Still endorsing suicidal ideations...Overall Risk level-suicide: Moderate risk...” A facility document titled, “Medication discharge summary,” was reviewed and indicated Patient 5 was given Xanax 0.5mg (milligram, unit of measurement) oral (by mouth) and Zyprexa (medication to treat mental disorder) 10 mg injection on March 4, 2025, at 2:40 p.m. The document indicated no other medications were given or offered prior to the patient eloping. A facility document titled, “Emergency Provider Report,” dated March 5, 2025, at 10:42 a.m., was reviewed. The document indicated, “...Note...Chart reviewed...patient had been sleeping this morning, suddenly woke up and ran out of the emergency department before security could stop him or me having [sic] a chance to talk with him...law enforcement notified by staff...” A facility document titled, “Emergency Notes,” dated March 5, 2025, at 10:40 a.m., was reviewed. The document indicated, “...Patient [Patient 5] eloped...asked if hold was up and was told no. Pt [Patient 5] became immediately agitated and stated, “Then I’m leaving.” Staff tried to stand in front of patient and educate him that PD [police department] would be called if he leave but he walked through staff and into the ambulance bay. Pt did not take his belongings and was wearing a green gown...” On March 19, 2025, at 1:45 p.m., an interview was conducted with the ED Medical Doctor (EDMD). The EDMD stated a patient is placed on a sitter based on their overall risk level (ORL). The EDMD stated a patient’s ORL is determined based on the patient’s suicide, violence, and elopement risks as well as support factors [skills, strengths, or resources that help people deal more effectively with stressful events]. The EDMD stated ORL may differ between providers. The EDMD stated, if a patient is on a hold waiting for either treatment or transfer and becomes restless, agitated, and wants to leave, staff would start with verbal de-escalation [techniques used to help calm down a patient who may be angry or upset], offer medications including oral meds, and if the behavior escalates to risk the patient’s safety or safety of others, the physician could administer injectable sedatives. The EDMD stated the decision to restrain a patient eloping would depend on the patient’s behavior, such as if the patient has current thoughts to harm self and others and other factors. 3. On March 18, 2025, and 9:40 a.m., a review of Patient 2’s record and concurrent interview were conducted with QC 1. A facility document titled, “Emergency Department Physician/Triage Form,” dated February 20, 2025, at 11:13 a.m., was reviewed and indicated, “...5150 for DTS [danger to self]...” An untitled facility document was reviewed. The document indicated, “...Emergency Department Notes Entered: February 20, 2025, 1305 [1:05 p.m.]...PT [Patient 2] transported to ED for medical reasons from [Name of Facility B] with sitter [from Facility B]. Pt and sitter placed Infront [sic] of nurse’s station in [Hallway bed C]...Sitter from [Name of Facility B] came up to nurses’ desk and informed staff that pt had...walked past her out the ED entrance. Sitter [from Facility B] stated she called out for security, but no one was there...” A facility document titled, “Emergency Provider Report,” dated February 20, 2025, at 2:22 p.m., was reviewed. The document indicated, “...Patient comes into the ER complaining of abdominal pain...came to ER by ambulance from a psychiatric facility...on a 5150 hold and comes with a sitter from the facility...patient had already had a medical screening exam [a comprehensive evaluation of a patient’s health status to identify potential medical conditions or risks] and labs [laboratory tests] and imaging were ordered...before I was able to see and examine the patient [Patient 2] [sic] had eloped from the department. Nursing staff is aware and has contacted the police...” Patient 2’s record was reviewed and did not include documented evidence a suicide screening was completed for and a sitter from the facility was assigned to the patient. QC 1 stated the record did not indicate Patient 2 had a suicide screening completed for her and did not have a facility sitter assigned to the patient. QC 1 stated Patient 2 should have been assigned a sitter from the facility. On March 18, 2025, at 12 p.m., an interview was conducted with the DED. The DED stated if patients come from another facility with a sitter, staff should still assign a facility’s sitter to the patient. The DED stated another facility’s sitter cannot be the assigned to a patient who is in the facility. 4. On March 18, 2025, and 10:38 a.m., a review of Patient 4’s record was conducted with QC 1. A facility document titled, “Emergency Provider Report,” dated March 3, 2025, at 9:55 p.m., was reviewed. The document indicated, “...[name of Patient 4]...Presents to the ED with suicidal ideation which has been on and off for the past 6 [six] months. Patient reports multiple attempts in the past, most recent being end of October...Telehealth psych [virtual psychiatrist] was consulted and recommended 5150 hold along with inpatient psychiatry admission. 5150 forms were completed, and patient is now pending placement...calculated suicide risk level: Moderate Risk...Overall risk level-suicide: Low risk...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Emergency Notes...03/03/25 [March 3, 2025] 2335 [11:35 p.m.]... PT [Patient 4] placed in RM [room number of Room D]. C/C [chief complaint] suicidal ideation. PT is a minor and [FM, family member] is at bedside. Sitter at bedside. Per report, PT was banging head on side rails upon arrival...crying uncontrollably with [FM] at bedside...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Safe Environment...Occurred 03/04/25 [March 4, 2025] 0000 [12 a.m.]...Suicide safe environment...belongings removed/secure, contraband clothing check...safety attendant-physical, use gown withs naps [snap] only...” A facility document titled, “Psychiatric Consultation Note,” dated March 4, 2025, at 3:17 a.m., was reviewed. The document indicated, “...Patient [Patient 4] endorses suicidal ideation...reports multiple suicide attempts in the past, most recent being end of October...patient is not able to contract for safety outside the hospital...meets the criteria for 5150 hold...inpatient psych hospitalization...Overall level suicide risk: Moderate Risk...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Emergency Notes...03/04/25 [March 4, 2025] 0736 [7:37 a.m.]...[FM] at bedside. PT in green hospital attire room is safety ready at this time...Safety measures remain in place. Sitter at door...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Emergency Notes...03/04/25 [March 4, 2025] 1405 [2:05 p.m.]...Pt was sitting on edge of bed fully dressed. Per Pt’s [FM] she is going to take the patient...[FM] reinstructed that patient was on hold and she could not leave. [FM] told I was going to get the MD...[FM] stated that she would leave. MD to be notified that the PT wants to leave...PT was seen walking with [FM] to exit the ED...[FM] and patient were told they can not go per DR [doctor]...told that police would be called if she left with minor child...” On March 18, 2025, at 12 p.m., an interview was conducted with the DED. The DED stated minor patients would be placed on a 1:1 sitter and placed into a room for safety. The DED stated that for Patient 4, the patient’s FM brought in clothes for the patient to change into. The DED stated the 1:1 sitter should not have allowed the patient to change into the clothing. The DED stated all belongings should be searched and removed from the room for safety according to policy, and FM should not have been allowed to bring the patient clothing. On March 18, 2025, at 2:10 p.m., an interview was conducted with the VPQ. The VPQ stated all patients on a 5150 hold should be placed into a green gown. The VPQ stated a gap was identified in the case of Patient 4, with family bringing belongings in. The VPQ stated Patient 4’s [FM] brought the patient clothes and had Patient 4 get dressed so they could leave. The VPQ stated the patient should not have been given the clothing and allowed to change. The VPQ stated nothing should go into the rooms with patients, visitors, and family without safety search and approval. 5. On March 18, 2025, and 11:25 a.m., a review of Patient 6’s record and concurrent interview were conducted with QC 1. A facility document titled, “Emergency Department Trauma Flowsheet,” dated March 5, 2025, at 9:10 p.m., was reviewed. The document indicated, “...Narrative nursing notes...2235 [11:35 p.m.] psych hold written for gravely disabled secondary to mental illness...admit to: Other: 5150...” A facility document titled, “Emergency provider report,” dated March 5, 2025, at 9:17 p.m., was reviewed. The document indicated, “...presents to the ED after MVA [motor vehicle accident]...he was going at an unknown speed, hit the front tire on a curb...Patient was given Geodon [medication used to treat mental disorders] due to acute agitation. Due to patient’s psych [psychiatric] history, history provided by [FM 2] who brought him in, inability to respond to questions appropriately and inability to care for himself, patient was placed on 5150 hold...patient is awaiting telehealth psychiatrist and eventually inpatient placement...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Detailed assessment...03/06/25 [March 6, 2025 0000...Suicide screening: yes...Detailed assessment comments: 5150...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Emergency Notes...03/06/25 0000...PT [Patient 6] transferred from trauma charting...PT is alert and oriented x2 [two, knows person and place]. Aggressive. Having pressured speech [rapid, loud, nonstop pattern of speech]...” A facility document titled, “Emergency Patient Record,” dated March 6, 2025, was reviewed. The document indicated, “...Emergency Notes...03/06/25 0600 [6 a.m.] ...Security called...pt is not redirectable. Security, along with multiple staff members assisted patient back to bed...” A facility document titled, “Emergency Patient Record,” was reviewed. The document indicated, “...Emergency Notes...03/06/25 0915 [9:15 a.m.]...Sitter saw knife in PT’s hand and called code Grey [a hospital code called for a violent patient]. Security Bedside...” A facility document titled, “Emergency provider report,” dated March 6, 2025, at 5:41 a.m., was reviewed. The document indicated, “...awaiting placement at an inpatient psychiatric receiving facility...Overall risk level- suicide: Moderate risk...Addendum: update: Patient became aggressive again, he came threatening and armed himself with a knife. He was barricaded in his room with security standing by. 911 [an emergency call number] was activated and police responded...they will be taking custody of him at this point and transporting to an appropriate psychiatric destination...03/06/25 at 1000 [10 a.m.]...” A review of Patient 6’s record did not indicate documented evidence a safety check (a check of the patient’s belongings for contrabands and for anything the patient could use to harm himself or others) was conducted on Patient 6 in accordance with the facility’s policy and procedure. QC 1 stated Patient 6’s record does not indicate he was searched or placed into a green gown. On March 18, 2025, at 12 p.m., an interview was conducted with the DED. The DED stated if a patient comes in on a 5150 for medical or is a trauma patient placed on a 5150, staff should still follow 5150 policies which include the environmental safety checks, sitter, and a safety check of patient and belongings. The DED stated this should be done for every 5150 patient. The DED further stated Patient 6 came in and was evaluated as trauma patient initially. The DED stated Patient 6 came in with a shirt, shorts, and jacket only and went through metal detector before going to trauma. The DED stated Patient 6 was “a big, kind of scary person” and was not cooperating with the search. The DED stated the patient was not searched and changed into a green gown according to facility policy. On March 18, 2025, at 2:10 p.m., an interview was conducted with the VPQ. The VPQ stated all 5150 patients in the ED should have a safety check and be changed into a green gown according to policy. The VPQ stated Patient 6 came in as a trauma patient and the 5150 was determined after initial intake. The VPQ stated the weapons detector and belongings process should have been done but there was fallout. The VPQ stated the process of assessing and processing the patient’s belongings was not done. The VPQ stated when patient’s do come through the weapons detector in the main entrance, the machine does not have an audible alarm, so if security is not present, or is distracted, it may be missed. The VPQ further stated the facility’s current policies and processes for 5150 patients are not working to prevent elopements from the ED. A review of the facility policy and procedure (P&P) titled, “Suicide Prevention Plan,” dated September 2023, was conducted. The P&P indicated, “...Patients reporting suicidal thoughts, recent suicide attempt, and/or self-harm behaviors require intensive support, close observation, and frequent reassessment for their emotional and physical well-being at all times...all patients 12 years and older should be screened using the C-SSRS [Columbia Suicide Severity Rating Scale, or C-SSRS, a suicidal ideation and behavior rating scale]...The at-risk patient’s (low, moderate, or high) environment will be made safe by implementing the checklist and observation precautions...Virtual PSA[camera or video sitter]/line of sight (Q15 [every 15 minutes]) is required if the patient is screened moderate suicide risk on the C-SSRS or ORL [Overall Risk Level]...Staff member may monitor more than 1 [one] patient at the same time and must have direct view of each patient at all times...visitors, including parents/guardians of minor patients, are monitored for safety and are not allowed to have personal property in patient rooms...safety interventions are implemented for ALL patients on suicide precautions...interventions include: Perform a thorough search of the patients clothing, personal articles, room and belongings...patient will remove all street clothing and wear psychiatric safe clothing that is without strings or ties...shoes will be without laces or strings...Emergency Detention: California (5150): if a patient is determined to be low, moderate, or high risk for suicide and refuses to remain in the hospital for a psychiatric evaluation, an emergency detention may be requested and executed if applicable...” A review of the facility P&P titled, “Involuntary Hold: Lanterman Petris Short Act 5150 Placement,” dated August 2024, was conducted. The P&P indicated, “...Patients that are being held on a 5150 hold or for whom an assessment is pending should be monitored by nursing staff for increasing agitation or risk of elopement. If indicated, medications shall be requested from the physician to minimize patient risk to self or others while awaiting evaluation or placement...””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47071 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for six of 46 sample patients (Patients 11, 18, 20, 27, 29 and 43), when the consent to surgery or special procedures were not completed by the physician/s. These failures had the potential to cause a delay in Patients 11, 18, 20, 27, 29 and 43’s surgical procedures, and may cause harm for the patients. Findings: 1. On December 3, 2024, at 8:30 a.m., a review of Patient 11’s record was conducted with Quality Coordinator (QC ) 1. A facility document titled, “History and Physical,” dated September 20, 2024, indicated Patient 11 was admitted to the facility on September 20, 2024, for Sepsis (life-threatening medical emergency, bodies overreacts to an infection). A facility document titled, “Consent to Surgery or Special Procedure” dated October 31, 2024, was reviewed and indicated, “...your doctors have recommended the following operation or procedure: Exploratory laparotomy [a surgical incision (cut) into the abdominal cavity] possible bowel resection possible ostomy...Physician Certification...I, the undersigned physician, hereby certify that I have discussed the procedure described in this consent form with this patient...including...the risks and benefits of the procedure...any adverse reactions...any alternative methods...The potential problems...any research...Physician signature...date...time...” A facility document titled, “Clinical Note” dated October 31, 2024, was reviewed and indicated, “...plan for emergent exploratory laparotomy possible bowel resection possible ostomy...risks, benefits and alternatives discussed...all questions answered and informed consent was obtained...” On December 3, 2024, at 8:45 a.m., an interview was conducted with QC 1. The QC 1 stated if the physician does not sign the consent form, they need to include the risks and benefits of the procedure, any adverse reactions, any alternative methods, any potential problems, and any research. The QC 1 stated the documentation in the doctor’s note was not completed with all the requirements and the informed consent was incomplete. 2. On December 2, 2024, at 11:06 a.m., a concurrent record review and interview for Patient 18 were conducted with the Critical Care Manager (CCM). A facility document titled, “Consent to Surgery or Special Procedure” dated December 1, 2024, was reviewed and indicated, “...your doctors have recommended the following operation or procedure: Percutaneous tracheostomy [a surgical procedure that creates an opening in the neck for breathing]...Physician Certification...I, the undersigned physician, hereby certify that I have discussed the procedure described in this consent form with this patient...including...the risks and benefits of the procedure...any adverse reactions...any alternative methods...The potential problems...any research...Physician signature...date...time...” The CCM stated the consent should have been signed by the surgeon before the procedure. On December 3, 2024, at 2:15 p.m., a review of patient 18’s record was conducted with QC 1. A facility document titled, “History and Physical,” dated November 20, 2024, indicated Patient 18 was admitted to the facility on November 20, 2024, for Nontraumatic subarachnoid hemorrhage (brain bleed that occurs without head trauma). A facility document titled, “General Surgery Progress Note” dated December 1, 2024, was reviewed and indicated, “...Plan for percutaneous trach today 12/1 [December 1, 2024]...risks, benefits and alternatives discussed...all questions answered...informed consent obtained...” On December 3, 2024, at 2:15 p.m., an interview was conducted with QC 1. The QC 1 stated if the physician does not sign the consent form, they need to include the risks and benefits of the procedure, any adverse reactions, any alternative methods, any potential problems, any research. The QC 1 stated the documentation in the doctor’s note was not completed with all the requirements and the informed consent was incomplete. 3. On December 4, 2024, at 9:23 a.m., a review of patient 20’s record was conducted with Quality Coordinator (QC ) 2. A facility document titled, “History and Physical,” dated November 25, 2024, indicated Patient 20 was admitted to the facility on November 25, 2024, for cough and confusion. A facility document titled, “Consent to Surgery or Special Procedure” dated November 26, 2024, was reviewed and indicated, “...your doctors have recommended the following operation or procedure: Lumbar puncture [a medical procedure that involves inserting a needle into the spine]...Physician Certification...I, the undersigned physician, hereby certify that I have discussed the procedure described in this consent form with this patient...including...the risks and benefits of the procedure...any adverse reactions...any alternative methods...The potential problems...any research...Physician signature...date...time...” A facility document titled, “Bedside Procedure Note” dated November 26, 2024, was reviewed and indicated, “...start date...11/26/24 [November 26, 2024]...after obtaining informed consent...” On December 4, 2024, at 9:29 a.m., an interview was conducted with Patient Safety Director (PSD). The PSD stated the bed side procedure note does not have the required information for the informed consent. The PSD further stated the informed consent is incomplete. 4. On December 3, 2024, at 10:19 a.m., a review of Patient 27’s record was conducted with PSD. A facility document titled, “Progress Note,” dated November 12, 2024, indicated, “...[Patient 27]...with right sacroiliac joint [the connection between the spine and the pelvis] instability...discussed treatment with a right sacroiliac joint instrumented stabilization and fusion...” A facility document titled, “Consent to Surgery or Special Procedure” dated December 2, 2024, was reviewed and indicated, “...your doctors have recommended the following operation or procedure: Right Sacroiliac Joint Instrumented stabilization and fusion...Physician Certification...I, the undersigned physician, hereby certify that I have discussed the procedure described in this consent form with this patient...including...the risks and benefits of the procedure...any adverse reactions...any alternative methods...The potential problems...any research...Physician signature...date...time...” There was no documented evidence the consent was signed by the physician performing the procedure. 5. On December 3, 2024, at 10:28 a.m., a review of Patient 29’s record was conducted with PSD. A facility document titled, “History of Present Illness”, dated December 2, 2024, indicated, Patient 29 was admitted on December 2,2024 for acute onset right lower quadrant abdominal pain. A facility document titled, “Consent to Surgery or Special Procedure” dated December 2, 2024, was reviewed and indicated, “...your doctors have recommended the following operation or procedure: Diagnostic Laparoscopy [a surgical procedure used to examine the organs in the belly (abdomen)], possible bowel resection, possible exploratory laparotomy...Physician Certification...I, the undersigned physician, hereby certify that I have discussed the procedure described in this consent form with this patient...including...the risks and benefits of the procedure...any adverse reactions...any alternative methods...The potential problems...any research...Physician signature...date...time...” There was no documented evidence the consent was signed by the physician performing the procedure. An interview was conducted on December 3, 2024, at 2:56 p.m., with the PSD. The PSD stated there was no documented evidence informed consent was obtained by the physician performing the procedure for Patient’s 27, and 29 prior to the procedurs. 6. On December 3, 2024, at 12:59 p.m., Patient 43’s record was reviewed with the Quality Manager (QM). The facility document titled, “History and Physical” dated November 6, 2024, was reviewed, and indicated Patient 43 was admitted to the facility for Atrial fibrillation with rapid ventricular response (a type of irregular heart rhythm) on November 6, 2024. A facility document titled, “Pulmonary Critical Care Note,” dated November 7, 2024, authored by MD 1, was reviewed with the QM. The document indicated, Patient 43 would need an IVC (inferior vena cava-A large vein that empties into the heart) filter (a small metal device that prevents blood clots from traveling from the legs to the lungs or heart) placement. A facility document titled, “Cardiology Progress Note,” dated November 10, 2024, authored by MD 3, was reviewed with the QM. The document indicated, IVC filter pending with no documentation showing discussion of risks and benefits, alternative treatments, or nature of the procedure/operation, or treatment for the pending procedure. A facility document titled, “Consent to Surgery or Special Procedure” dated November 10, 2024, at 5:43 p.m., was reviewed. The document indicated a signature by Patient 43, and a witness signature. No signature of physician certification was documented indicating, “...risks and benefits of the procedure...adverse reactions that may reasonably be expected to occur ...alternative efficacious [effective] methods of treatment...potential problems that may occur...” were discussed with Patient 43. A facility document titled, “Cardiac Cath Report”, dated November 12, 2024, authored by MD 3, indicated, “...Successful IVC filter placement...” On December 3, 2024, at 2:15 p.m., a concurrent interview and record review with the QM was conducted. The QM stated, “consent should have been obtained by the physician prior to the procedure...It should have been done and documented...” A facility P&P titled, “Consent for Procedures,” dated October 2022, was reviewed. The document indicated, “A valid consent will be completed prior to any complex procedure or surgery...The informed consent process is the responsibility of the individual performing the procedure...the licensed independent practitioner is responsible for providing the patient ...with the information that is necessary to allow an “informed decision” to be made. The topics that must be addressed, at a minimum are...The nature of the operation or procedure, including other care, treatment or medications ...Potential benefits, risks or side effects of the operation or procedure, including potential problems that might occur...Reasonable alternatives and the relevant risks, benefits, and side effects related to such alternatives...””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48562 Based on interview and record review, the facility failed to provide care in a safe environment, for one (Patient 1) of 46 sampled patients, when the Patient Safety Attendant (PSA) left Patient 1 unsupervised while Patient 1 was on a one to one (1:1) sitter. This failure led to Patient 1 getting out of restraints and pulling out their IV (Intravenous, with in the vein), and had the potential to lead to Patient 1 harming himself or others. Findings: On December 2, 2024, an unannounced complaint validation survey was conducted at the facility. On December 3, 2024, at 8:35 a.m., a review of Patient 1’s record was conducted with Quality Coordinator (QC) 2. The facility document titled, “Psychiatric Consultation Note” dated October 26, 2024, at 11:40 a.m., indicated, “Reason for consult: Concern for altered mental status/catatonia [a disorder that disrupts a person’s awareness of the world around them. People with this condition sometimes react very little or not at all to their surroundings, or might behave in ways that are unusual, unexpected or unsafe to themselves or others.]...On evaluation, the patient was resting in bed with his eyes open; however, he was staring ahead with a blank expression on his face and was nonverbal and unable to be engaged...the patient’s mother was present at his bedside and volunteered information...Assessment and Plan...Diagnosis: Altered mental status, likely secondary to catatonia; and/or delirium [a mental state of confusion and disorientation that can develop suddenly over hours or days]...Please note that a 1:1 sitter, group sitter, or virtual sitter may remain indicated in the setting of concern for altered mental status...at this time, there is inadequate evidence to substantiate that the patient meets the criteria for a 5150 involuntary psychiatric hold...” The facility document titled, “Hospitalist History & [and] Physical” dated October 26, 2024, at 4:13 p.m., indicated, “...presents to ED [Emergency Department] for behavioral crisis episode...On evaluation, pt [patient] had flat affect while mom and grandma in the room...Once family left, patient able to answer questions...admitted he ate some mushrooms for the first time and symptoms began since then...appears catatonic...psych consulted, recs [recommendations] 1:1 [one to one] sitter or virtual sitter may remain indicated in setting of concern for AMS [altered mental status]...” The facility document titled, “Order History Data” dated October 28, 2024, indicated, “...Order...Sitter...Sitter-Suicidal...Order Date Time...October 28, 2024, 10:04 [a.m.]...” An untitled facility document dated October 28, 2024, at 1:33 p.m., indicated, “...Multidisciplinary Team Notes...NN [nurses note]...Patient became erratic and combative. Began screaming, jumped out of bed, pulled out IV. Came outside of the room in hall. Patient body slammed his fiancé. Patient screaming and hit staff members. Code grey [a hospital announcement for a violent patient] called...4-point restraints [straps used to limit a patient’s movement] applied on patient...MD [Medical Doctor] informed. Management came to bedside. Received orders for patient to transfer to ICU [Intensive Care Unit]...” An untitled facility document dated October 28, 2024, at 11 p.m., indicated, “...Multidisciplinary Team Notes...NN [nurses note]...@ [at] 2235 [10:35 p.m.] during MD rounds, pt mother called notified RN [Registered Nurse] and MD regarding patient breaking BUE [bilateral upper extremity] wrist restraints. RN, multiple staff, and MD enter the room to find patient breaking out of restraints...standing on top of hospital bed. Code grey activated. Pt then aggressively demands staff to go to one side of room. MD attempted to deescalate [calm a situation] situation with patient...patient then jumps out of bed. Pt runs towards window and hits shoulder on window. Staff wraps patient to deescalate. Pt then brought to bed and restrained. New IV started per MD at bedside...Pt family at bedside and updated by MD. Pt in hospital bed...sitter at bedside...” The facility document titled, “Pulmonary Critical Care Note” dated October 29, 2024, at 2:08 a.m., indicated, “...During the evening rounds, I was called by nursing staff and the patient’s mother calling for help, given that [patient], was standing on the bed, ripping off his IV lines and yelling at the nursing staff. As we tried to get some how closer to him to calm him down, he kept screaming “back away” in a threatening way. As we were backing off from the bed where he was standing on, he jumped from the bed and went to the back of the room where the windows are. During this time security was called...In 2 [two] attempts he struck the windows without breaking them, when the patient’s mother and nursing staff rushed towards him and finally, he was subdued by force. He was taken to the bed and had to be restrained...during all this process, the mother was extremely upset complaining that we did not do anything to help him and that we had allowed him to jump to the window (which did not happen). I attempted to explain to her, that [patient] was very violent and dangerous and “tackle him” could come with dangerous consequences...while trying to explain this, she kept hyperventilating [heavy rapid breathing] and kept speaking with her family over the phone leaving me several times without finishing...she continued to state that her son was “possessed” by some sort of devil-evil spirit and was not himself...” The facility document titled, “Camera observer- Patient Activity Log- Safety” dated October 28, 2024, indicated, Patient 1 was under camera observation from 11 a.m. until 3 p.m on October 28, 2024. The facility document titled, “Patient Sitter Observation Form” dated October 28, 2024, did not indicate observations were documented from 3 p.m. to 7 p.m. The document indicated PSA 1 was sitting with the patient from 7 p.m. October 28, 2024, until 6:45 a.m. on October 29, 2024. On December 3, 2024, at 3 p.m., an interview and review of sitter observation forms was conducted with the PSD. The PSD stated facility orders for a 1:1 sitter show in the computer as “sitter- suicidal” and would follow the suicide prevention plan policy. The PSD stated there should have been sitter documentation between 3 p.m. and 7 p.m. on October 28, 2024. The PSD further stated the sitter should stay with the patient at all times. The PSD stated when the sitter needs to leave the room at any time, they need to call the nurse so the nurse can get someone to sit with the patient until they return. The PSD stated they recall this patient because there was an investigation done. The PSD stated they recall that there was a gap where the sitter stepped out of the room prior to the incident. The PSD stated the patient was able to get out of restraints and pull out his lines after the sitter left the room. On December 3, 2024, at 3:30 p.m., a concurrent interview and review of facility incident reports was conducted with the PSD. An incident report dated October 28, 2024, at 9: 45 p.m. indicated, “...Sitter left patient alone. Patient broke out of restraints and attempted to jump through window...Sitter left to the bathroom while patient was resting. Mother was in the room and yelled for help...Patient broke out of restraints and was pulling on lines...jumped on the bed...code grey was called...mom was upset the patient was left alone...had a discussion with the sitter [PSA 1] about responsibilities...” The PSD stated it was reported to them that the sitter left the room to use the restroom and did not notify the nurse or get coverage. The PSD stated the sitter should have stayed with the patient and gotten someone to cover for them while they went to the restroom...” On December 4, 2024, at 10:05 a.m., a telephone interview was conducted with the Patient Safety Attendant (PSA) 1. The PSA 1 stated, at 10:30 p.m. on October 28, 2024, they left to use the restroom. The PSA 1 stated the nurse was with the physician so they told [Patient 1’s] mom they needed to go and asked mom if it was ok if she watched him while they went to the restroom. The PSA 1 stated the patient’s mom said she would watch him. The PSA 1 stated they were not gone for more than five minutes but when they came back to the room, the patient was on top of the bed and staff was in the room. The PSA 1 stated the patient had ripped out his IV line. The PSA 1 stated staff got Patient 1 back into bed and checked the restraints. The PSA 1 stated staff were not notified by the mom until after the patient was out of restraints and was on the bed. The PSA 1 further stated it is standard practice to utilize the family to cover and watch the patient if needed. The PSA 1 stated they did not attempt to notify any staff prior to leaving the patient alone with family. The PSA 1 stated she should have stayed with the patient and notified the RN. On December 4, 2024, at 10:15 a.m., a concurrent interview was conducted with the PSD. The PSD stated it is not a standard practice to use family to cover a sitter. On December 4, 2024, at 11:05 a.m., an interview was conducted with PSA 2. The PSA 2 stated they have been a sitter at [name of facility] for eight years. The PSA 2 stated when a sitter needs to leave a patient room for any reason, the process is to call the nurse, CNA (certified nurses assistant), or another PSA to have them cover the patient. The PSA 2 stated when assigned as a sitter, the expectation is to stay with the patient at all times, even if family is present in the room. The PSA 2 further stated it is never acceptable, and is not a standard, to leave a patient and have family cover for the sitter. The facility Policy and Procedure titled, “Suicide Prevention Plan”, revised September 2023, was reviewed. The policy indicated “...Suicide risk levels and Observations...Continuous observation (1:1)...at no time is the patient out of visual contact of a staff member...one on one (1:1) observation is constant and uninterrupted...staff is able to immediately intervene should the patient attempt self-harm and/or unsafe behavior is observed...””

“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: 47071 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures were implemented, for nine of 46 sample patients (Patients 1, 11, 13, 14, 18, 21, 35, 37, and 46), when: 1. For Patient 11, the lactic acid (test used to indicate a serious life-threatening condition) 5.0 mmol/L (millimoles per liter, unit of measurement) (normal 0.4 mmol/L to 2.0 mmol/L) critical lab was not reported to the physician. 2. For Patients 13 and 21, the patients were not provided oral care every shift as required. 3. For Patients 13 and 14, the patients were not turned every two hours as required. 4. For Patient 18, daily weights were not obtained as required. 5. For Patient 18, trach care was not provided every 4 hours as required. 6. For Patient 35, 37, and 46, when the patient’s pain level was not reassessed after medication administration. 7. For Patient 1, the Patient Safety Attendant (sitter) left the patient unsupervised. These failures had the potential to impact the health, safety, and delay treatment of the patients. Findings: 1. On December 3, 2024, at 8:30 a.m., a review of Patient 11’s record was conducted with Quality Coordinator (QC) 1. A facility document titled, “History and Physical (H&P),” dated November 27, 2024, indicated Patient 11 was admitted for Sepsis (life-threatening medical emergency, body’s overreacts to an infection). A facility document titled, “Lactic Acid Level,” was reviewed and indicated, “...Nov. 5, 24 [November 5, 2024] 13:38 [1:38 p.m.]...5.0 P...mmol/L...” On December 3, 2024, at 8:54 a.m., an interview was conducted with QC 1. The QC 1 stated she was unable to find documentation the physician was notified of the critical lab for lactic acid of 5.0. A facility document titled, “Critical Value Reporting,” dated September 25, 2024, was reviewed and indicated, “...Immediate notification of test results that suggest an urgent or life-threatening condition...to the appropriate health care professional. Delays in reporting...may adversely affect the quality of patient care...Results...Critical lab results...Lactate/lactic acid level...greater than 3.0 mmol/L...” 2 a. On December 3, 2024, at 11:07 a.m., a review of Patient 13’s record was conducted with Quality Coordinator (QC) 1. A facility document titled, “H&P,” dated September 20, 2024, indicated Patient 13 was admitted for altered mental status. There was no documented evidence Patient 13 was provided oral care once a shift on the following dates: November 28, 29, and December 1, 2024, am shift (7 a.m. to 7 p.m.) and November 30, 2024, p.m. shift (7 p.m. to 7 a.m.). On December 3, 2024, at 11:22 a.m., an interview was conducted with QC 1. The QC 1 stated there was no documented evidence oral care was performed on Patient 13 on the ablove listed dates and times. The QC1 stated the nurses did not perform the oral care every shift per the policy. 2 b. On December 4, 2024, at 9:54 a.m., a review of patient 21’s record was conducted with Quality Coordinator (QC) 2. A facility document titled, “History and Physical,” dated November 30, 2024, was reviewed. The document indicated Patient 21 was admitted to the facility for confusion, agitation, and disorientation (state of mental confusion). There was no documented evidence Patient 21 was provided oral care once a shift on the following dates: December 1, 2, and 3, 2024, am shift (7 a.m. to 7 p.m.). On December 4, 2024, at 10:08 a.m., an interview was conducted with QC 2. The QC 2 stated there is no documentation of the oral care being completed. The QC2 stated oral care should be completed once per shift. The QC 2 further stated the nurses did not perform the oral care every shift per the policy. Review of facility policy and procedure, “[Name of facility] Standards of Care, Practice Guidelines and Assessment of the Adult Patient (Excluding Maternal/child),” dated September 12, 2024, was conducted. The document indicated, “...assist with/offer oral hygiene q [every] shift and PRN [as needed]...” 3 a. On December 3, 2024, at 11:07 a.m., a review of Patient 13’s record was conducted with Quality Coordinator (QC) 1. A facility document titled, “History and Physical [H&P],” dated September 20, 2024, indicated Patient 13 was admitted for altered mental status. There was no documented evidence Patient 13 was turned every two hours on the following dates and times: November 29, 2024, at 4 a.m. and 6 a.m.; and November 30, 2024, at 12 a.m., 2 a.m., 4 a.m., and 6 a.m. On December 3, 2024, at 11:20 a.m., an interview was conducted with QC 1. The QC 1 stated there is no documentation that Patient 13 was turned consistently every two hours. The QC1 stated there is no documentation indicating why Patient 13 was not turned. 3 b. On December 3, 2024, at 1 p.m., a review of Patient 14’s record was conducted with QC 1. A facility document titled, “H&P,” dated November 26, 2024, was reviewed. The document indicated Patient 14 was admitted to the facility for Chronic (longer than 6 months) kidney disease and elevated (greater than 100) heart rate. There was no documented evidence Patient 14 was turned every two hours on the following dates and times: November 27, 2024, at 6 a.m.; and November 29, 2024, at 2 a.m., 4 a.m. and 6 a.m. On December 2, 2024, at 1:12 p.m., an interview was conducted with the QC 1. The QC 1 stated there is no documentation that patient 14 was turned consistently every two hours. The QC 1 stated there is no documentation indicating why Patient 14 was not turned. Review of facility policy and procedure, “[Name of facility] Standards of Care, practice Guidelines and Assessment of the Adult Patient (Excluding Maternal/child),” dated September 12, 2024. The document indicated, “...if patient unable to repositioned...patient turning needs will be individualized. Patient must be turned at least every 2 hours as condition allows, maintaining proper body alignment...” 4. On December 3, 2024, at 2:15 p.m., a review of Patient 18’s record was conducted with QC 1. A facility document titled, “H&P,” dated November 20, 2024, indicated Patient 18 was admitted to the facility on November 20, 2024, for Nontraumatic subarachnoid hemorrhage (brain bleed that occurs without head trauma). A facility document titled, “daily weights,” dated October 21, 2024, was reviewed and indicated, “...Weight, Obtain...Frequency: Daily...” There was no documented evidence Patient 18’s daily weight was taken on the following dates: November 22, 2024, through November 25, 2024, and November 30, 2024, through December 2, 2024. A facility document titled, “Physician Orders,” dated, November 22, 2024, was reviewed and indicated, “...NUR.PHY...Tube feeding...Adult...routine...11/22/24 [December 22, 2024.]...pivot 1.5 cal. liter [unit of measurement]...NPO [nothing by mouth]...55 ML/HR [milliliter/hour, unit of measurement] (1320 ml)...free water...300...Q4H [every 4 hours]...” On December 3, 2024, at 2:35 p.m., an interview was conducted with QC 1. The QC 1 stated she was unable to find weights taken for Patient 18 on the dates above. The QC 1 stated according to the policy and procedure for patients with continuous tube feeding the weight should be taken daily. The QC 1 further stated, there should be daily weights taken for Patient 18. The QC 1 further stated the RNs (Registered Nurse) did not follow the facility’s policy for the dates. A review of facility P&P titled, “[Name of Facility] Standards of Care, Practice Guidelines and Assessment for the Adult Patient (Excluding Maternal/Child)”, dated September 12, 2024, was conducted. The P&P indicated, “...Nutrition...if on enteral nutrition (tube feeding)...weight Daily...” 5. On December 3, 2024, at 2:15 p.m., a review of Patient 18’s record was conducted with QC 1. A facility document titled, “History and Physical,” dated November 20, 2024, indicated Patient 18 was admitted to the facility on November 20, 2024, for Nontraumatic subarachnoid hemorrhage. A facility document titled, “Bedside procedure Note,” dated December 1, 2024, was reviewed and indicated, “...Start date...12/1/2024 [December 1, 2024.]...Bedside Procedure Note...Procedure performed...Percutaneous tracheostomy [a surgical opening in the neck to allow breathing]...Successful placement of 8 cuffed...tracheostomy...” There was no documented evidence Patient 18’s post operative trach care was completed every 4 hours on the following dates: December 1, 2024, 10:50 p.m. to December 2, 2024, 2:50 p.m. On December 3, 2024, at 2:40 p.m., an interview was conducted with QC 1. The QC 1 stated the trach care for Patient 18 was not completed every four (4) hours for the first 24 hours per policy. The QC 1 stated the staff did not follow the policy for trach care. A review of facility P&P titled, “[Name of Facility] Tracheostomy Care,” dated February 23, 2022, was conducted. The P&P indicated, “...Meticulous cleaning and maintenance of this airway must be individualized...and be performed minimally every twelve hours by nursing...Patients with less than twenty-four hours post-op [post operative] tracheostomy will receive trach care every four hours by nursing...” 6 a. On December 3, 2024, at 8:38 a.m., a review of Patient 35’s record with the Quality Manager (QM) was conducted. A review of the facility document titled, “History and Physical”, dated October 14, 2024, at 9:41 a.m., indicated Patient 35 was admitted to the facility on October 13, 2024, at 12:51 p.m. for cellulitis (a bacterial infection of the skin and subcutaneous tissue) of the right lower extremity (leg). The document further indicated Patient 35 had a medical history of Hypertension (high blood pressure) and diabetes (a chronic disease that occurs when the body can’t produce or use insulin properly, resulting in high levels of blood sugar). A review of an untitled facility document, dated October 13, 2024, at 10:54 p.m., indicated a medication order for “ ...Hydromorphone HCL [Dilaudid] ...1 milligram [mg- unit of measurement] ...intravenous [IV - in the vein] now ...”, was placed by MD 1. A review of an untitled facility document, dated October 13, 2024, at 11:05 p.m., indicated, “...1 mg Dilaudid was administered to Patient 35 for pain level of 10 out of 10 using a numeric rating scale [NRS; from 0 to 10, where 0 means no pain and 10 means the worst possible pain].” The document further indicated pain reassessment should be completed within 30 minutes. The document did not indicate reassessment after administration. On December 3, 2024, at 8:38 a.m. a concurrent interview and record review with the QM was conducted. The QM stated, “ ...pain reassessment should have been done, according to P&P, within 60 minutes after administration...” 6 b. On December 3, 2024, a review of Patient 37’s record with the QM was conducted. A review of the facility document titled, “History and Physical”, dated October 14, 2024, at 7:04 p.m. indicated, Patient 37 was admitted to the facility on October 13, 2024, at 5:27 p.m. for headache, dizziness (a common health problem that can feel like a range of sensations such as feeling weak), and elevated blood glucose levels. The document further indicated Patient 37 had a medical history of diabetes. A review of the facility document titled, “Medications Data”, dated October 13, 2024, at 7:31 p.m. indicated an order was placed by MD 2. Document indicated an order for, “ ...Ketorolac Tromethamine (Toradol) ...15 mg ...IV ...” A review of an untitled facility document, dated October 13, 2024, at 8:36 p.m., indicated, medication was administered to Patient 37 for pain of 4 out of 10. The document further indicated pain reassessment should be completed within 30 minutes. The document did not indicate reassessment after administration. On December 3, 2024, at 9:15 a.m. a concurrent interview and record review with the QM was conducted. The QM stated, “ ...pain reassessment should have been done, according to P&P, within 60 minutes after pain medication administration...” 6 c. On December 3, 2024, a review of Patient 46’s record with the QM was conducted. A review of the facility document titled, “History & Physical”, dated December 2, 2024, at 9:52 a.m., indicated, Patient 46 was admitted to the facility on December 2, 2024, at 3:05 a.m., for flank pain (pain in one side of the body between the upper abdomen and the back). The document further indicated Patient 46 had a medical history of nephrolithiasis (kidney stones). A review of the facility document titled, “Order History Data”, dated December 2, 2024, at 3:07 a.m., indicated an order placed by MD 3 for “ ...Hydrocodone Bitart/Acetaminophen (medication used for pain) ...1 tablet ...q4h (every four hours) PRN (as needed) ...po (by mouth) ...PRN reason ...Pain scale 7-10 ...” The document further indicated medication was administered on December 2, 2024, at 3:28 a.m. for pain scale of 9 out of 10. The document further indicated pain reassessment should be completed within 30 minutes. There was no documented evidence Patient 46’s pain was reassessed after administration. On December 3, 2024, at 2 p.m. a concurrent interview and record review with the QM was conducted. The QM stated, “ ...pain reassessment should have been done, according to P&P, within 60 minutes after administration...” A review of the facility P&P document titled, “Pain Assessment and Reassessment”, dated October 28, 2020, indicated, “ ...Reassessments will be done after any intervention/reassessment within 60 minutes after IV/IM (intramuscular), PO, or Non-pharmalogical intervention ...pain ...reassessment should be documented on the Pain Assessment and Reassessment Screens in Meditech ...” 7. On December 3, 2024, at 8:35 a.m., a review of Patient 1’s record was conducted with Quality Coordinator (QC) 2. The facility document titled, “Psychiatric Consultation Note” dated October 26, 2024, at 11:40 a.m. indicated, “Reason for consult: Concern for altered mental status/catatonia [a disorder that disrupts a person’s awareness of the world around them. People with this condition sometimes react very little or not at all to their surroundings, or might behave in ways that are unusual, unexpected or unsafe to themselves or others.]...On evaluation, the patient was resting in bed with his eyes open; however, he was staring ahead with a blank expression on his face and was nonverbal and unable to be engaged...the patient’s mother was present at his bedside and volunteered information...Assessment and Plan...Diagnosis: Altered mental status, likely secondary to catatonia; and/or delirium [a mental state of confusion and disorientation that can develop suddenly over hours or days]...Please note that a 1:1 sitter, group sitter, or virtual sitter may remain indicated in the setting of concern for altered mental status...at this time, there is inadequate evidence to substantiate that the patient meets the criteria for a 5150 involuntary psychiatric hold...” The facility document titled, “Hospitalist History & [and] Physical” dated October 26, 2024, at 4:13 p.m. indicated, “...presents to ED [Emergency Department] for behavioral crisis episode...On evaluation, pt [patient] had flat affect while mom and grandma in the room...Once family left, patient able to answer questions...admitted he ate some mushrooms for the first time and symptoms began since then...appears catatonic...psych consulted, recs [recommendations] 1:1 [one to one] sitter or virtual sitter may remain indicated in setting of concern for AMS [altered mental status]...pt does not meet criteria for 5150 involuntary psych hold at this time...” The facility document titled, “Order History Data” dated October 28, 2024, indicated, “...Order...Sitter...Sitter-Suicidal...Order Date Time...October 28, 2024, 10:04 [a.m.]...” An untitled facility document dated October 28, 2024, at 1:33 p.m. indicated, “...Multidisciplinary Team Notes...NN [nurses note]...Patient became erratic and combative. Began screaming, jumped out of bed, pulled out IV. Came outside of the room in hall. Patient body slammed his fiancé. Patient screaming and hit staff members. Code grey [a hospital announcement for a violent patient] called...4-point restraints [straps used to limit a patient’s movement] applied on patient...MD [Medical Doctor] informed. Management came to bedside. Received orders for patient to transfer to ICU [Intensive Care Unit]...” An untitled facility document dated October 28, 2024, at 11 p.m. indicated, “...Multidisciplinary Team Notes...NN [nurses note]...@ [at] 2235 [10:35 p.m.] during MD rounds, pt mother called notified RN [Registered Nurse] and MD regarding patient breaking BUE [bilateral upper extremity] wrist restraints. RN, multiple staff, and MD enter the room to find patient breaking out of restraints...standing on top of hospital bed. Code grey activated. Pt then aggressively demands staff to go to one side of room. MD attempted to deescalate [calm a situation] situation with patient...patient then jumps out of bed. Pt runs towards window and hits shoulder on window. Staff wraps patient to deescalate. Pt then brought to bed and restrained. New IV started per MD at bedside...Pt family at bedside and updated by MD. Pt in hospital bed...sitter at bedside...” The facility document titled, “Pulmonary Critical Care Note” dated October 29, 2024, at 2:08 a.m. indicated, “...During the evening rounds, I was called by nursing staff and the patient’s mother calling for help, given that [patient], was standing on the bed, ripping off his IV lines and yelling at the nursing staff. As we tried to get some how closer to him to calm him down, he kept screaming “back away” in a threatening way. As we were backing off from the bed where he was standing on, he jumped from the bed and went to the back of the room where the windows are. During this time security was called...In 2 [two] attempts he struck the windows without breaking them, when the patient’s mother and nursing staff rushed towards him and finally, he was subdued by force. He was taken to the bed and had to be restrained...during all this process, the mother was extremely upset complaining that we did not do anything to help him and that we had allowed him to jump to the window (which did not happened). I attempted to explain to her, that [patient] was very violent and dangerous and “tackle him” could come with dangerous consequences...while trying to explain this, she kept hyperventilating [heavy rapid breathing] and kept speaking with her family over the phone leaving me several times without finishing...she continued to state that her son was “possessed” by some sort of devil-evil spirit and was not himself...” The facility document titled, “Camera observer- Patient Activity Log- Safety” dated October 28, 2024, indicated, Patient 1 was under camera observation from 11 a.m. until 3 p.m on October 28, 2024. The facility document titled, “Patient Sitter Observation Form” dated October 28, 2024, did not indicate observation was documented from 3 p.m. to 7 p.m. The document indicated PSA 1 was sitting with the patient from 7 p.m. October 28, 2024, until 6:45 a.m. on October 29, 2024. On December 3, 2024, at 3 p.m., an interview and review of sitter observation forms was conducted with the PSD. The PSD stated facility orders for a 1:1 sitter show in the computer as “sitter- suicidal” and would follow the suicide prevention plan policy. The PSD stated there should have been sitter documentation between 3 p.m. and 7 p.m. on October 28, 2024. The PSD further stated the sitter should stay with the patient at all times. The PSD stated when the sitter needs to leave the room at any time, they need to call the nurse so the nurse can get someone to sit with the patient until they return. The PSD stated they recall this patient because there was an investigation done. The PSD stated they recall that there was a gap where the sitter stepped out of the room prior to the incident. The PSD stated the patient was able to get out of restraints and pull out his lines after the sitter left the room. On December 3, 2024, at 3:30 p.m., a concurrent interview and review of facility incident reports was conducted with the PSD. An incident report dated October 28, 2024, at 9: 45 p.m. indicated, “...Sitter left patient alone. Patient broke out of restraints and attempted to jump through window...Sitter left to the bathroom while patient was resting. Mother was in the room and yelled for help...Patient broke out of restraints and was pulling on lines...jumped on the bed...code grey was called...mom was upset the patient was left alone...had a discussion with the sitter [PSA 1] about responsibilities...” The PSD stated it was reported to them that the sitter left the room to use the restroom and did not notify the nurse or get coverage. The PSD stated the sitter should have stayed with the patient and gotten someone to cover for them while they went to the restroom. On December 4, 2024, at 10:05 a.m., a telephone interview was conducted with the Patient Safety Attendant (PSA) 1. The PSA 1 stated, at 10:30 p.m. on October 28, 2024, they left to use the restroom. The PSA 1 stated the nurse was with the physician so they told [Patient 1’s] mom they needed to go and asked mom if it was ok if she watched him while they went to the restroom. The PSA 1 stated the patient’s mom said she would watch him. The PSA 1 stated they were not gone for more than five minutes but when they came back to the room, the patient was on top of the bed and staff was in the room. The PSA 1 stated the patient had ripped out his IV line. The PSA 1 stated staff got Patient 1 back into bed and checked the restraints. The PSA 1 stated staff were not notified by the mom until after the patient was out of restraints and was on the bed. The PSA 1 further stated it is standard practice to utilize the family to cover and watch the patient if needed. The PSA 1 stated they did not attempt to notify any staff prior to leaving the patient alone with family. The PSA 1 stated she should have stayed with the patient and notified the RN. On December 4, 2024, at 10:15 a.m., a concurrent interview was conducted with the PSD. The PSD stated it is not a standard practice to use family to cover a sitter. On December 4, 2024, at 11:05 a.m., an interview was conducted with PSA 2. The PSA 2 stated they have been a sitter at [name of facility] for eight years. The PSA 2 stated when a sitter needs to leave a patient room for any reason, the process is to call the nurse, CNA (certified nurses assistant), or another PSA to have them cover the patient. The PSA 2 stated when assigned as a sitter, the expectation is to stay with the patient at all times, even if family is present in the room. The PSA 2 further stated it is never acceptable, and is not a standard, to leave a patient and have family cover for the sitter. The facility Policy and Procedure titled, “Suicide Prevention Plan”, revised September 2023, was reviewed. The policy indicated “...Suicide risk levels and Observations...Continuous observation (1:1)...at no time is the patient out of visual contact of a staff member...one on one (1:1) observation is constant and uninterrupted...staff is able to immediately intervene should the patient attempt self-harm and/or unsafe behavior is observed...””

“DELIVERY OF SERVICES CFR(s): 482.56(b)(2) The provision of care and the personnel qualifications must be in accordance with national acceptable standards of practice and must also meet the requirements of §409.17 of this chapter. This Standard is not met as evidenced by: 47071 Based on interview and record review, the facility failed to ensure a physical therapy order was followed for one of 46 patients (Patient 12). These failures had the potential to cause a delay in patients 12’s care and physical rehabilitation. Findings: On December 3, 2024, at 10:08 a.m., a review of Patient 12’s record was conducted with Quality Coordinator (QC) 1. A facility document titled, “History and Physical,” dated November 28, 2024, indicated Patient 12 was admitted for syncopal episode (brief loss of consciousness) versus a stroke (blood is blocked to part of the brain). A facility document titled, “Medical Doctor [MD] Order,” dated November 25, 2024, was reviewed. The document indicated, “...PTEVAL- PT [Physical Therapy] Evaluation & [and]Therapy...order...routine...11/25/24 [November 25, 2024]...reason for visit...stroke...” A facility document titled, “PT [Physical Therapy] Evaluation,” dated November 26, 2024, was reviewed. The document indicated, “...PT therapy indicated...Y [yes]...frequency...7x/wk [seven times a week]...duration...2 [two]...Problems/Impressions...patient presents w/ [with] decreased strength, balance...” There was no documented evidence Patient 12 was provided Physical Therapy on November 27, 2024. On December 3, 2024, at 10:29 a.m, an interview with QC 1 was conducted. The QC 1 stated that based on the PT evaluation and treatment plan the patient was not seen on November 27, 2024. The QC 1 stated there was no documentation of any treatment on that date. The QC 1 further stated the patient should have had PT one time each day. A review of the facility Policy and Procedure, titled, “[facility name] Physical Therapy standards of practice,” dated September 22, 2021 was conducted. The document indicated, “...the therapist shall implement the physical therapy program according to the treatment plan...””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48776 Based on observation, interview, and record review, the facility failed to ensure education and personal protective equipment (PPE, personal protective equipment, used to prevent or minimize exposure to hazards and can include gloves and gowns) were provided to the family member (FM 1) of one of 46 sample patients (Patient 17), who was on contact plus isolation (a set of infection prevention measures which may be put in place when a patient is being treated for an infection and would include wearing a gown and gloves), and FM 1 was observed in Patient 17’s room not wearing a gown and gloves, in accordance with the facility’s policy and procedure (P&P). This failure had the potential to spread infection to other patients. Findings: On October 14, 2024, at 11:30 a.m., an observation was made on the telemetry unit (Tele, unit where patients’ heart rates and rhythms are continuously monitored remotely). A sign which indicated, “Contact Plus,” was observed posted outside of Patient 17’s door. FM 1 was observed sitting on a chair inside Patient 17’s room and was not wearing a gown nor gloves. A concurrent interview was conducted with FM 1. FM 1 stated she was not told by the facility regarding what type of isolation Patient 17 was on or what PPE was necessary to be worn in the patient’s room when visiting Patient 17. On October 16, 2024, at 9 a.m., a concurrent interview and review of Patient 17’s record were conducted with Quality Coordinator (QC) 2. A facility document titled, “History and Physical,” dated September 26, 2024, was reviewed and indicated Patient 17 was admitted to the facility with bilateral (both) feet osteomyelitis (bone infection) and non-ST-elevation myocardial infarction (NSTEMI, a type of heart attack that occurs when one of the coronary arteries is partially blocked thus reducing the blood flow to the heart). On October 16, 2024, at 9:45 a.m., a concurrent interview and review of Patient 17’s record were conducted with Infection Preventionist (IP) 1. An untitled facility document, dated September 26, 2024, was reviewed and indicated Patient 17 had, “...History...C. Auris [Candida auris, a type of yeast infection that is difficult to treat and can cause serious infections in humans]...” A facility document titled, “Infectious Dis. [Disease] Progress Note,” dated October 9, 2024, was reviewed and indicated, “...Diagnosis, Assessment & [and] Plan...history of...Candida auris...” IP 1 stated all staff members and family members must wear appropriate PPE which included gloves and gown when inside Patient 17’s room and the family member should have been educated. IP 1 stated the P&P for isolation precautions was not followed. During a review of the facility’s P&P titled, “Guidelines for the Management of Patients Known or Suspected to be Infected with Candida Auris,” dated June 20, 2024, the P&P indicated, “...C. auris...is a fungus that can cause illness in patinets with many medical problems...can be difficult to treat...Strict adherence to...Contact-Plus Precautions are important aspects in preventing and controlling the spread of C. auris...Use appropriate personal protective equipment (PPE), gloves and gowns, upon entry to room or patient area...””

“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: 47071 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for 10 of 46 sample patients (Patients 2, 8, 11, 24, 27, 34, 37, 38, 40, and 41), when: 1. For Patient 24, the wound dressing completed before the patient was admitted to the facility and which the patient came in with on admission to the facility was not removed nor changed, and the wound was not assessed; 2. For Patient 27, the supplies to be used in bladder irrigation (a procedure that flushes the bladder with sterile liquid) procedure, which should be done using aseptic (a set of practices which prevent the spread of microorganisms and protect patients and healthcare workers from infection) techniques, were placed on the floor of the patient’s room; 3. For Patients 8, 37, 38, and 40, the patients were not turned nor repositioned, in accordance with the facility’s P&P; 4. For Patients 37, 38, 40, and 41, skin assessment was not completed in accordance with the facility’s P&P; 5. For Patient 11, the physician was not notified of abnormal heart rate, blood pressure, and oxygen saturation (amount of oxygen in the blood). In addition, for Patient 37, the blood sugar checks were not performed, in accordance with the physician’s orders; 6. For Patient 11, the physician was not notified of the blood sugar results in accordance with the facility’s P&P; and 7. For Patients 2 and 34, the patients’ wounds were not treated in accordance with the facility’s P&P. These failures had the potential to cause a delay in patient care and harm for the patients. Findings: 1. On October 14, 2024, at 10 a.m. a concurrent observation and interview were conducted with Infection Preventionist (IP) 1. On October 14, 2024, at 11:15 a.m., an observation of Patient 24’s dressing on the right foot was conducted with IP 1 and the Registered Nurse Telemetry (unit where patients’ heart rates and rhythms are continuously monitored remotely) Manager (RNTM). The dressing was observed to be loose and falling off Patient 24’s right foot and had dried yellowish color and a handwriten label which indicated, “October 8, 2024.” The exposed portion of Patient 24’s right foot was observed to be swollen, reddish, with dry skin, and had a blister that is fluid filled. The RNTM stated the nurse assigned to the patient is responsible for assessing and dressing the patient’s wound. The RNTM stated the nurse should have removed the dressing on Patient 24’s right foot and should have assessed the wound. On October 14, 2024, at 11:15 a.m., an observation and interview were conducted with RN 1. RN 1 stated daily wound care for Patient 24 should have been completed. RN 1 stated the dressing on Patient 24’s foot is dated October 8, 2024, and it should have been changed. On October 15, 2024, at 10:05 a.m., Patients 24’s record was reviewed with Quality Coordinator (QC) 1. A facility document titled, “History and Physical,” dated October 13, 2024, was reviewed and indicated Patient 24 was admitted to the facility on October 13, 2024, for possible osteomyelitis (inflammation in the bone) with MSSA (methicillin-susceptible staphylococcus aureus, a type of bacteria) bacteremia (bacteria in the blood). On October 15, 2024, at 10:10 a.m., an interview was conducted with IP 1. IP 1stated Patient 24 was admitted to the facility on October 13, 2024. IP 1 further stated, based on the review of the picture taken of Patient 24’s wound and the date on the dressing, wound care has not been performed on Patient 24’s wound. A review of the P&P titled, “[Name of Facility] Skin Integrity Management,” dated October 2022, was conducted. The P&P indicated, “...All inpatients will be assessed in regard to integumentary [skin] integrity...All pre-hospital dressings are to be removed on admission for assessment...” 2. On October 14, 2024, at 9:30 a.m., a concurrent observation and interview were conducted with IP 1 in Patient 27’s room. A blue chucks pad (a thin absorbent pad) was observed under Patient 27’s urine bag. The blue chucks pad was observed to be folded in half and had a 100 milliliter (ml, unit of measurement) container of sterile Normal Saline fluid (a type of fluid), a triangular graduated container (tall narrow container with volume scale used for measuring liquids), a catheter irrigation container (a plastic container containing materials used to flush the bladder with sterile liquid to remove debris, mucus, and blood clots), and a 60 ml piston syringe on it. IP 1 stated the supplies and the blue chucks should not have been left on the floor as it was an infection control risk. IP 1 further stated the nurse should have disposed of the supplies properly. On October 15, 2024, at 2 p.m., Patients 27’s record was reviewed. A facility document titled, “History and Physical,” dated October 10, 2024, indicated Patient 27 was admitted for ST elevation (an irregular electrical conduction in the heart) consistent with a ST- segment elevation myocardial infarction (heart attack), urinary retention (when one cannot empty one’s bladder), and blood in his urine. A review of an untitled facility document indicated, “...10/14/24 [October 14, 2024] 0945 [9:45 a.m.]...Urinary catheter [when urinary catheters are inserted into the bladder to allow urine to drain] type...temporary/indwelling...Insertion/applied date...10/10/24 [October 10, 2024]...Indication for urinary catheter...Gross hematuria [blood in urine]/irrigate (to flush the bladder with sterile liquid to remove debris, mucus, and blood clots..” An untitled facility document indicated, “...Bladder irrigation...routine...10/10/24...frequency...PRN [as needed]...irrigation fluid: Normal Saline...” A review of the P&P titled, “[Name of Facility] Standardized Procedure Urinary Catheter and Blader Management Protocol,” dated June 2024, was conducted. The P&P indicated, “...Catheter tubing junction should be disinfected before disconnection...A large-volume sterile syringe and sterile irrigation solution should be used and then discarded. The person performing irrigation should use aseptic technique...” 3a. On October 15, 2024, at 1:05 p.m., a review of Patient 8’s record was conducted with Scribe 1. An untitled facility document, dated September 28, 2024, at 12 a.m., was reviewed and indicated, “ ...Skin Alteration...Stage 2 [injury due to pressure on a body area with open wound or blister; tail bone] coccyx [tailbone]...present upon admission...stage 3 [sic, injury due to pressure on a body area extending through skin into deeper tissue] right heel present upon admission...” An untitled facility document, dated September 28, 2024, at 11:24 p.m., was reviewed and indicated, “ ...Multidisciplinary notes...SII [Stage 2] to coccyx and stage III [Stage 3] to R [right] heel; Pictures taken, Patient aware and updated on POC [plan of care], both present upon admission; MD [medical doctor] aware...Q2H [every two hours] turns...” An untitled facility document, dated September 30, 2024, at 11:43 a.m., was reviewed and indicated, “ ...Wound/Ostomy [a surgically created opening in the abdominal wall that allows waste to exit the body] Care RN [registered nurse] note: Consult received to evaluate Stage 2 coccyx & stage 3 R Heel...Assessment ...coccyx...Right heel - stage 3...Recommendation: Continue pressure injury prevention bundle with turning every two hours...” An untitled facility document, dated October 10, 2024, at 12:33 p.m., was reviewed and indicated, “ ...Wound/Ostomy Care RN note: Consult received to evaluate “L buttock and R heel unstageable...Assessment...Left buttock - stage 3 pressure injury (previous DTI [a deep tissue injury, a purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear])...Right heel - unstageable pressure injury [a full thickness injury due to pressure on a body area] (previous stage 3)...Recommendation: Continue pressure injury prevention with turning every 2 hours...” A facility document titled, “Plan of Care,” indicated, “Skin integrity alteration...comment: Q2 turns...” A facility document titled, “Routine Daily Care,” from September 28, 2024, through October 15, 2024, was reviewed. There was no documented evidence Patient 8 was turned or repositioned on the following dates and times: - From September 29, 2024, 4 p.m., to 9 p.m. (5 hours); - From October 3, 2024, 6 a.m., to 8 p.m. (14 hours); - From October 7, 2024, 6 a.m., to 12:30 p.m. (6.5 hours); - From October 11, 2024, 8 a.m., to 8 p.m. (12 hours); - From October 12, 2024, 8 a.m., to 8 p.m. (12 hours); - From October 13, 2024, 8 a.m., to 10 p.m. (14 hours); and - From October 14, 2024, 10 p.m., to October 15, 2024, at 2 a.m. (4 hours) Scribe 1 stated turning for Patient 8 was not documented every two hours in the medical record. 3b. A review of Patient 37’s record was conducted on October 15, 2024, at 9:31 a.m., with the Patient Safety Director and Risk Management (PSDRM). A facility document titled, “History and Physical,” dated January 27, 2024, was reviewed and indicated Patient 37 was admitted to the facility on January 27, 2024, with a diagnoses which included pleural effusion (fluid buildup in the lungs), sepsis (a life threatening condition), and pressure injury Stage 4 (a full-thickness tissue loss which exposes bone, muscle, tendon, ligament, cartilage, or the tissue surrounding these). A facility document titled, “Orders,” dated January 28, 2024, indicated, “...Activity: Bedrest/Turn Q 2hours...” A facility document titled, “Admission/Shift Assessment - Skin Alteration,” dated January 28, 2024, was reviewed and indicated, “...SKIN ALTERATION...Pressure Injury SacrumSacrum [area of the triangular bone at the base of the spine]...Pressure Injury Staging: 4...” The facility document titled, “ROUTINE DAILY CARE,” from February 4, 2024, through February 7, 2024, were reviewed and indicated there was no documented evidence Patient 37 was turned on the following dates and times: - On February 13, 2024, from 4 p.m., to 10 p.m. (6 hours); - On February 14, 2024, from 10 p.m., to 6 a.m. (8 hours); and - On February 15, 2024, from 2 p.m., to 6 p.m. (4 hours). An interview was conducted on October 15, 2024, at 1:57 p.m., with the PSDRM. The PSDRM stated the expectation is for staff to turn the patient every two hours and document the reason for not turning. The PSDRM stated these were not done. 3c. A review of Patient 38’s record was conducted on October 15, 2024, at 3:15 p.m., with Scribe 1. A facility document titled,”History and Physical,” dated August 9, 2024, was reviewed and indicated Patient 38 was admitted to the facility with a diagnoses which include Duchenne muscular dystrophy (DMD, a genetic disorder characterized by progressive muscle degeneration and weakness) and chronic hypoxic respiratory failure (inefficient breathing which lead to too little oxygen in the blood). An untitled facility document, dated August 11, 2024, was reviewed and indicated, “...WOUND CARE CONSULTS /NOTES...Assessment...Left hip- stage 2 pressure injury...left buttock - DTI pressure injury...Right Buttock - DTI pressure injury...Continue pressure injury prevention measures with turning every 2 hours...” A concurrent interview and review of Patient 38’s record was conducted on October 16, 2024, at 9:33 a.m., with Scribe 1. A facility document titled, “ROUTINE DAILY CARE - Activity: Turn,” from August 10, 2024, through August 17, 2024, was reviewed.There was no documented evidence Patient 38 was turned on the following dates and times: - On August 11, 2024, from 2 a.m., to 6 a.m. (4 hours); and - On August 13, 2024, from 2 a.m., to 6 a.m. (4 hours). Scribe 1 stated facility’s policy was not followed when Patient 38 was not turned every two hours. 3d. A tour of the Intermediate Care Unit (a hospital unit that provides care for patients who are too sick for a general ward but not sick enough for intensive care) was conducted on October 14, 2024, at 1:13 p.m., with the Assistant Chief Nurse Officer (ACNO) and Quality Coordinator (QC) 2. A concurrent observation and interview were conducted on October 14, 2024, at 1:45 p.m., in Patient 40’s room with Intermediate Care Registered Nurse (IMCRN) 2. Patient 40 was observed to have a tracheostomy (a surgically created opening in the neck to provide an airway and remove secretions from the lung) connected to a ventilator (a breathing machine). Patient 40 was also observed to have a wound on the coccyx area. IMCRN2 stated Patient 40 is totally dependent with turning. A review of Patient 40’s medical record was conducted on October 16, 2024, at 10:18 a.m., with Scribe 1. A facility document titled, “History and Physical,” dated September 26, 2024, indicated Patient 40 was admitted to the facility on September 26, 2024, with a diagnoses which included subacute bacterial endocarditis (an inflammation of the heart’s inner lining and valve) and sepsis. A facility document titled, “Nurse’s Notes,” dated September 26, 2024, indicated, “...WOUND CARE CONSULTS /NOTES...Assessment...Coccyx Stage 3...right buttock - pressure injury stage 3...left buttock - pressure injury stage 3...Continue pressure injury prevention measures with turning every 2 hours...” A facility document titled, “ROUTINE DAILY CARE - Activity: Turn,” from September 27, 2024, through October 4, 2024, were reviewed. There was no documented evidence Patient 40 was turned on the following shifts: - On September 27, 2024, from 8 p.m., to 10 p.m. (4 hours); - On September 28, 2024, from 6 p.m., to 10 p.m. (4 hours); - On September 29, 2024, from 12 a.m., to 6 a.m. (6 hours); - On September 30, 2024, from 12 a.m., to 6 a.m. (6 hours); - On October 3, 2024, from 8 p.m., to 10 p.m. (4 hours); and - On October 4, 2024, from 12 a.m., to 6 a.m. (6 hours). Scribe 1 stated the facility’s policy was not followed when Patient 40 was not turned every two hours. A review of the facility’s P & P titled, “Standards of Care, Practice Guidelines and Assessment for the Adult Patient (Excluding Maternal/Child),” dated September 2024, was conducted. The P & P indicated, “...The following routine care/practice guidelines are provided to the adult patient...If patient unable to reposition self...Patient turning needs will be individualized. Patient must be turned at least every 2 hours...” 4a. A review of Patient 37’s record was conducted on October 15, 2024, at 9:31 a.m. with the PSDRM. A facility document titled, “History and Physical,” dated January 27, 2024, indicated Patient 37 was admitted on January 27, 2024, with diagnoses which included pleural effusion (fluid in the lungs), sepsis, and pressure injury Stage 4. A facility document titled, “Nurse’s Notes,” dated January 29, 2024, indicated, “...WOUND CARE CONSULTS /NOTES...Assessment...Coccyx/ bilateral buttock - unstageable pressure ulcer [the base of the wound is covered by a layer of dead tissue and the stage of the pressure injury is unclear]...Continue pressure injury prevention measures with turning every 2 hours...” A concurrent interview and review of Patient 37’s record were conducted on October 15, 2024, at 2:10 p.m., with the PSDRM. A facility document titled, “Admission/Shift Assessment - Skin Alteration,” dated January 28, 2024, through February 2, 2024, was reviewed. There was no documented evidence the skin assessment on Patient 37 was completed on February 28 and 29, 2024, during the night shift (7 p.m. to 7 a.m.). The PSDRM stated the expectation is for the skin assessment to be completed and documented once a shift and these were not done. 4b. A review of Patient 38’s record was conducted on October 15, 2024, at 3:15 p.m., with Scribe 1. A facility document titled, “History and Physical,” dated August 9, 2024, indicated Patient 38 was admitted to the facility o August 9, 2024, with diagnoses which included DMD and chronic hypoxic respiratory failure. A facility document titled, “Nurse’s Notes,” dated August 11, 2024, indicated, “...WOUND CARE CONSULTS /NOTES...Assessment...Left hip- stage 2 pressure injury...left buttock - DTI pressure injury...Right Buttock - DTI pressure injury...Continue pressure injury prevention measures with turning every 2 hours...” A concurrent interview and review of Patient 38’s record was conducted on October 16, 2024, at 9:33 a.m., with Scribe 1. A facility document titled, “Admission/Shift Assessment - Skin Alteration,” dated August 10, 2024, through August 17, 2024, was reviewed. There was no documented evidence Patient 38’s skin assessments were done from September 13 to 17, 2024, day shift (7 a.m. to 7 p.m.). Scribe 1 stated the facility’s policy was not followed when Patient 38’s skin assessment was not completed every shift. 4c. A review of Patient 40’s record was conducted on October 16, 2024, at 10:18 a.m., with Scribe 1. A facility document titled, “History and Physical,” dated September 26, 2024, was reviewed and indicated Patient 40 was admitted to the facility on September 24, 2024, with diagnoses which included subacute bacterial endocarditis and sepsis. A facility document titled, “Nurse’s Notes,” dated September 26, 2024, indicated, “...WOUND CARE CONSULTS /NOTES...Assessment...Coccyx Stage 3...right buttock - pressure injury stage 3...left buttock - pressure injury stage 3...Continue pressure injury prevention measures with turning every 2 hours...” A concurrent interview and review of Patient 40’s record was conducted on October 16, 2024, at 11:08 a.m., with Scribe 1. A facility document titled, “Admission/Shift Assessment - Skin Alteration,” dated September 27, 2024, through October 4, 2024, was reviewed. There was no documented evidence Patient 40’s skin assessment was completed on September 27, 2024, day shift (7 a.m. to 7 p.m.) and night shift (7 p.m. to 7 a.m.). Scribe 1 stated the nurses did not follow the facility’s policy when Patient 40’s skin assessment was not completed every shift. 4d. A tour of the Medical Intensive Care Unit (MICU, a unit for critically ill patients) was conducted on October 14, 2024, at 11:05 a.m., with the ACNO and Scribe 1. An observation was conducted on October 14, 2024, at 11:15 a.m., at Patient 41’s room. Patient 41 was observed lying in bed with eyes closed, was not moving, and had a tracheostomy on his neck connected to a ventilator. A review of Patient 41’s record was conducted on October 15, 2024, at 3:15 p.m., with Scribe 1. A facility document titled, “History and Physical,” dated August 25, 2024, indicated Patient 41 was admitted to the facility on August 25, 2024, with diagnoses which included shock secondary to pericarditis (a swelling and irritation of the thin saclike membrane surrounding the heart), uremia (a condition involving abnormally high levels of waste products in the blood), and possible sepsis. A facility document titled, “Nurse’s Notes,” dated August 26, 2024, indicated,”...WOUND CARE CONSULTS /NOTES...Assessment...Coccyx with scattered partial thickness open areas...does not appear to be pressure injuries, they appear to have been caused by moisture... left heel unstageable pressure injury...” A facility document titled, “Admission/Shift Assessment - Skin Alteration,” dated October 4, 2024, through October 12, 2024, was reveiwed. There was no documented evidence skin assessment was done on Patient 41 on the following dates and shifts: - On October 7, 2024, night shift (7 p.m. to 7 a.m.); - On October 8, 2024, night shift; - On October 9, 2024, night shift; and - On October 11, 2024, day shift (7 a.m. to 7 p.m.). Scribe 1 stated the facility’s policy was not followed when Patient 41’s skin assessment was not completed every shift. An interview was conducted on October 17, 2024, at 10:01 a.m., with ACNO 2. ACNO 2 stated her expectation is for nurses to perform a skin assessment once a shift. A review of the facility’s P&P titled, “Skin Integrity Management,” dated October 2022, was conducted. The P&P indicated, “...Policy...All inpatients will be assessed in regard to integumentary integrity...This will be documented on admission, minimum once per shift...” 5a. A concurrent interview and review of Patient 37’s record were conducted on October 17, 2024, at 9:35 a.m., with the Chief Nursing Officer (CNO) and the Intermediate Care Unit Manager (IMCUM). A facility document titled, “Discharge Report,” dated January 27, 2024, was reviewed and indicated, “...Order Date: January 27, 2024 ...NUR [Nurse] PHYS [Physician] Notify ...Order Details...O2 [Oxygen], Sat [saturation, level of oxygen in the blood] under (%) [percent] 92 [normal is between 95% and 100%] ...HR [heart rate, normal is 60 to 100] over (beats/min [minute]): 110 ...HR under: 60 ...Syst [Systolic] BP [blood pressure, normal is 120] over (mm/Hg) [millimeter mercury, unit of measurement]: 170 ...Sys BP under (mm/Hg): 90 ...Diastolic BP over (mm/Hg, normal is 60 to 90): 100...” A facility document titled, “Clinical Monitor Interface,” dated January 28, 2024, through February 25, 2024, was reviewed.There was no documented evidence the physician was notified of the following values on the following dates, in accordance with the physician’s order: - On January 28, 2024, at 1:15 a.m., when Patient 37’s blood pressure was 86/56; - On January 28, 2024, at 1:46 a.m., when Patient 37’s pulse rate (same as the heart rate) was 127 and the SPO2% (O2 saturation) was 91; - On January 28, 2024, at 2 a.m., when Patient 37’s pulse rate was 127; - On January 28, 2024, at 2:30 a.m., when Patient 37’s pulse rate was 132; - On January 28, 2024, at 3 a.m., when Patient 37’s pulse rate was 132; - On January 28, 2024, at 3:31 a.m., when Patient 37’s pulse rate was 132; - On January 28, 2024, at 4 a.m., when Patient 37’s pulse rate was 131; - On January 28, 2024, at 5:30 a.m., when Patient 37’s pulse rate was 133; - On January 28, 2024, at 6 a.m., when Patient 37’s pulse rate was 132; - On January 28, 2024, at 8 a.m., when Patient 37’s pulse rate was 136 and SPO2 %: was 90; - On February 2, 2024, at 6:22 p.m., when Patient 37’s blood pressure was 89/57; - On February 3, 2024, at 5:01 p.m., when Patient 37’s SPO2 %: was 91; - On February 3, 2024, at 6 p.m., Patient 37’s pulse rate was 124, respiratory rate was 33, and SPO2% was 88; - On February 3, 2024, at 8:37 p.m., when Patient 37’s pulse rate was 134; - On February 4, 2024, at 7 a.m., when Patient 37’s pulse rate was 132; - On February 4, 2024, at 8 a.m., when Patient 37’s pulse rate was 134; - On February 4, 2024, at 9 a.m., when Patient 37’s pulse rate was 131; - On February 4, 2024, at 10 a.m., when Patient 37’s pulse rate was 120; - On February 6, 2024, at 9:08 a.m., when Patient 37’s SPO2% was 91; - On February 6, 2024, at 11 p.m., when Patient 37’s blood pressure was 78/51; - On February 8, 2024, at 7 p.m., when Patient 37’s pulse rate was 136; - On February 9, 2024, at 12 a.m., when Patient 37’s blood pressure was78/51; - On February 9, 2024, at 5 a.m., when Patient 37’s pulse rate was 121; - On February 10, 2024, at 3 a.m., when Patient 37’s pulse rate was 116 and SPO2 % was 88; - On February 11, 2024, at 10 a.m., when Patient 37’s SPO2% was 91; - On February 11, 2024, at 12 p.m., when Patient 37’s blood pressure was 74/54; - On February 13, 2024, at 11 p.m., when Patient 37’s blood pressure was 76/50; - On February 24, 2024, at 10 p.m., when Patient 37’s pulse rate was 130 and SPO2% was 91; and - On February 25, 2024, at 2:42 a.m., when Patient 37’s pulse rate was 160. The IMCUM stated on the majority of patient values she was unable to determine if nurses notified the physician as ordered. On October 17, 2024, at 9:35 a.m., the CNO was interviewed. The CNO stated after reviewing the record, he is unable to determine if the nurses followed the physician’s order or policy. The facility’s P&P titled, “Physician Notification Process,” dated February 2023, was reviewed and indicated, “...Applies to ...All staff and physicians...Policy Statement...Examples of circumstances to notify physician(s) include but are not limited to...Per physician instructions or preset parameters...” 5b. On October 14, 2024, at 2:15 p.m., a concurrent interview and review of Patient 11’s record was conducted with IP 1. A facility document titled, “History and Physical,” dated June 14, 2024, was reviewed and indicated Patient 11 was admitted to the facility on June 14, 2024, with diagnoses which included sepsis, pyelonephritis (infection causing inflammation of the kidneys), peripheral artery disease (condition in which narrowed blood vessels reduce blood flow to limbs), and hypertension (high blood pressure). The document indicated Patient 11 had a history of diabetes mellitus (condition with abnormal blood sugar level). On October 15, 2024, at 1:05 p.m., a review of Patient 11’s record was conducted with Quality Coordinator (QC) 2. An untitled facility document dated September 7, 2024, at 6:11 a.m., was reviewed and indicated, “...ACCUCHECK-BLOOD GLUCOSE (point of care testing for blood sugar) MONITORING...Frequency: Every hour...” An untitled facility document dated, October 6, 2024, at 1:48 p.m., was reviewed and indicated, “...Blood Glucose Monitoring...Frequency: Every 2 hours...” On October 16, 2024, at 10:40 a.m., a concurrent interview and review of Patient 11’s record were conducted with the IMCUM. There is no documented evidence accucheck was performed on Patient 11 every hour on September 7, 2024, through October 6, 2024, as ordered by the physician. The IMCUM stated the order for blood glucose monitoring was not completed as ordered from September 7, 2024, to October 6, 2024. The IMCUM stated the order should have been changed from hourly blood sugar monitoring to every two hours but this was not done. 6. On October 15, 2024, at 10:50 a.m., a concurrent interview and review of Patient 11’s record were conducted with the IMCUM. A facility document titled, “Laboratory Test History,” indicated the physician was not notified when Patient 11’s blood sugar (BS) level was less than 50 milligram/deciliter (mg/dl, unit of measurement, normal is between 80 to 130 mg/dL) or more than 450 mg/dl, in accordance with the facility’s P&P on the following dates and times: - On September 14, 2024, at 6:46 a.m., when Patient 11’s BS was 521; - On September 17, 2024, at 12:47 a.m., when Patient 11’s BS was 46; - On September 18, 2024, at 7:27 a.m., when Patient 11’s BS was 452; - On September 18, 2024, at 8:19 a.m., when Patient 11’s BS was 460; - On September 18, 2024, at 10:19 a.m., when Patient 11’s BS was 533; - On October 4, 2024 at, 11:58 a.m., when Patient 11’s BS was 525; - On October 6, 2024 at, 11:43 a.m., when Patient 11’s BS was greater than 600; - On October 6, 2024 at, 12:24 p.m., when Patient 11’s BS was greater than 600 and the laboratory draw BS= 849; - On October 6, 2024 at, 2:18 p.m., when Patient 11’s BS was 499; - On October 7, 2024 at, 12:16 p.m., when Patient 11’s BS was 596; and - On October 9, 2024 at, 2:03 p.m., when Patient 11’s BS was 474. The IMCUM stated the facility’s P&P for critical results was not followed and the physician should have been notified for BS of less than 50 or greater than 450 mg/dl for Patient 11. During a review of the facility’s P&P titled, “Critical Results Management,” dated February, 2023, the P&P indicated, “...For inpatient critical results...Licensed caregiver will attempt to notify ordering/covering Provider within 15 minutes of receiving critical result per unit standard...Notification of critical test must be documented in the Medical Record...APPENDIX B CRITICAL LAB RESULTS...Glucose, Adult...Less Than 50 mg/dL...Greater Than 450 mg/dL...” 7a. On October 14, 2024, at 9:35 a.m., an interview was conducted with the ED (Emergency Department) Director (EDD). The EDD stated if a patient comes into the ED after a motor vehicle accident (MVA) the process is to follow ABCs (Airway, Breathing, Circulation) or whatever needs to be stabilized and treated first. The EDD stated it also depends on what problem the patient presents to the ED with. The EDD stated if the patient’s airway is stabilized, tests and scans are done, and when the patient is stable, the ED staff would move on to the patients’ wounds. The EDD further stated patients would not be discharged with wounds that were not cleaned. On October 14, 2024, at 2:40 p.m., a review of Patient 2’s record was conducted with the CV Quality Manager (CVQM). A facility document titled, “Emergency Provider Report,” dated August 22, 2024, at 11:23 p.m.. indicated Patient 2 came to the ED on August 22, 2024, as a trauma patient after a motorcycle accident. The document indicated Patient 2 had a three by four centimeters (a unit of measurement) gaping laceration to the right lower abdomen near the hip and multiple abrasions to the legs and right flank. The document further indicated, “ ...(Patient 2) complaining of right calf pain with large abrasion to the calf. Trauma team involved in his care...ordered an Xray [an imaging procedure] of [Patient 2’s] right lower leg...prophylactic [administered to prevent infection] antibiotics...tetanus vaccine...Patient found to have a right 7th [seventh] rib fracture [a break in the bone] and a very small pneumothorax [occurs when air leaks into the space between the lung and the chest wall)...patient admitted by the trauma team...” A facility document titled, “Emergency Department Trauma Flowsheet,” dated August 22, 2024, was reviewed and indicated Patient 2 had abrasions to left and right lower legs and the right hand. The document indicated, on August 22, 2024, at 11:45 p.m., “ ...patient [Patient 2] complained of right hip, right thumb, right calf, and generalized chest wall pain at this time...” The document did not indicate Patient 2’s abrasions were cleaned. A facility document titled, “Discharge Summary,” dated August 23, 2024, indicated, “ ...patient to follow up with his PCP [primary care physician] in 5-7 [five to seven] days.” The document did not indicate instructions on how to clean the patient’s wounds after the patient is discharged. On October 15, 2024, at 1:05 p.m., a concurrent interview and review of Patient 2’s record was conducted with Scribe 1. Scribe 1 stated staff should clean and dress any wounds prior to discharge. Scribe 1 stated they could not find any documentation Patient 2’s wounds were cleaned prior to discharge. On October 15, 2024, at 1:45 p.m., an interview was conducted with the EDD. The EDD stated wound cleaning should be documented in the nursing notes or trauma charting notes, or the MD may document it in their notes if the MD cleaned the wound. The EDD stated the patient’s wounds should be cleaned prior to the patient being discharged from the facility. The EDD stated there is no documentation indicating Patient 2’s wounds were cleaned prior to Patient 2’s discharge. The EDD further stated deeper wounds usually get washed out, but more superficial wounds may not always be cleaned out prior to discharge. The EDD stated patients would be instructed to shower and clean wounds after discharge. 7b. On October 16, 2024, at 9 a.m., a review of Patient 34’s record was conducted with the PSDRM. A facility document titled, “Emergency Provider Report,” dated October 10, 2024, was reviewed and indicated Patient 34 came to the ED on October 10, 2024, as a trauma patient after a MVA. A facility document titled, “Trauma - History & Physical,” dated October 10, 2024, was reviewed and indicated, “...Skin: dry, superficial abrasions to right medial knee and right hand...” A facility document titled, “[Name of Facility] Coding Summary,” was reviewed and indicated, “ ...Adm [Admit] Date: 10/10/24 [October 10, 20204] ...Diagnoses...Abrasion, right knee...abrasion of right hand...” A facility document titled, “Emergency Department Trauma Flowsheet,” dated October 10, 2024, indicated Patient 34 had abrasions to the right knee and right hand. During a concurrent interview, the PSDRM stated the trauma charting indicates Patient 34 had abrasions to the right hand and right knee. The PSDRM stated there is no documentation the patient’s hand or knee were cleaned prior to discharge. A review of the facility P&P titled, “[Name of Facility] Skin Integrity Management,” dated October 2022, was conducted. The P&P indicated, “...Scope: All nursing staff at [Name of facility]...Purpose: to provide a standard for assessment, documentation, prevention and treatment of skin integrity...The nurse should notify the practitioner of any new or existing wound and obtain appropriate treatment orders...the nurse will initiate treatment for all wounds...” A review of the facility P&P titled, “[Name of Facility] Standards of Care, Practice Guidelines and Assessment for the Adult Patient (Excluding Maternal/Child),” dated September 2024, was conducted and indicated, “...Skin Integrity ...Evaluate skin condition with each assessment and PRN...Monitor skin integrity...Keep skin clean and dry...””

“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: 47071 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures were implemented, for six of 48 sample patients (Patients 7, 9, 17, 34, 18, and 27), when: 1. For Patient 17, six units of insulin (medication to treat abnormal blood sugar) was administered instead of 10 units as ordered by the physician. In addition, the facility failed to notify the physician of the change in the administered dose (Refer to A0398); 2. For Patient 34, metoprolol (medication used to treat high blood pressure, BP, normal adult BP is 120/80) was administered to Patient 34 who had a BP of 76/42 (Refer to A0398); 3. For Patient 18, the patient was not turned regularly and developed a pressure injury (a wound due to pressure on a body area) on the coccyx (tailbone) (Refer to A0398); 4. For Patient 27, daily weights were not obtained as ordered by the physician (Refer to A0398); 5. For Patient 7, the appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards and prevent the spread of germs) was not used by a staff while in the room of a patient in contact isolation (where a set of precautions are used to prevent the spread of germs from a patient to others through direct or indirect contact) (Refer to A0398); and 6. For Patient 9, the intravenous (IV, administered through a vein) medication meropenem (an antibiotic) was not administered as ordered by the physician (Refer to A0405). The cumulative effects of these systemic failures had the potential to impact the health, safety, and treatment of the patients, and may have contributed to Patient 34’s death.”

“LICENSURE OF HOSPITAL CFR(s): 482.11(b) The hospital must be - o Licensed; or o Approved as meeting standards for licensing established by the agency of the State or locality responsible for licensing hospitals. This Standard is not met as evidenced by: 42512 Based on observation, interview, and record review, the facility failed to ensure patient rooms were used in accordance to what they were licensed for, when 16 patient rooms (Rooms A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P), which were licensed as single occupancy rooms in Unit 1, were being used as double occupancy rooms. This failure had the potential to cause harm and delay of care to patients in the facility. Findings: On September 4, 2024, at 10 a.m., a tour of the facility was conducted with the Assistant Chief Nursing Officer (ACNO) and the Quality Coordinator (QC). On September 4, 2024, at 10:23 a.m., an observation of Unit 1 was conducted with the ACNO and the QC. Rooms A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P were observed to have two beds each occupied by patients. The facility document titled, “Approval of Program Flexibility,” was reviewed. The document indicated, “...approved to use the following beds twenty-five (25) additional beds for adult acute care (medical, surgical, telemetry) patients on [Unit 1]...approval shall remain in effect from July 26, 2023, until May 1, 2024...” The facility document titled, “Vice President of Quality Hospital 1,” was reviewed. The document indicated, “...Flex...has been in revision status since 02.01.24 [February 1, 2024]...which means the application was sent back to your facility for more information...” The facility was not able to provide documented evidence an application was submitted to the Centralized Application Branch (CAB, a branch of the state agency which processes and approves applications for any changes in a facility’s license) for the approved license of the additional beds in Rooms A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P. The facility was not able to provide documented evidence a program flex to convert the single occupancy Rooms A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P to double occupancy roms was approved. On September 5, 2024, at 2:20 p.m., an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated the facility’s plan is to not place patients in the second beds in the rooms on Unit 1 once the current patients are discharged from the hospital.”

“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: 47071 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures were implemented, for five of 48 sample patients (Patients 7, 17, 34, 18, and 27), when: 1. For Patient 17, six units of insulin (medication to treat abnormal blood sugar) was administered instead of 10 units as ordered by the physician. In addition, the facility failed to notify the physician of the change in the administered dose; 2. For Patient 34, metoprolol (medication used to treat high blood pressure, BP, normal adult BP is 120/80) was administered to Patient 34 who had a BP of 76/42; 3. For Patient 18, the patient was not turned regularly and developed a pressure injury (a wound due to pressure on a body area) on the coccyx (tailbone); 4. For Patient 27, daily weights were not obtained as ordered by the physician; and 5. For Patient 7, the appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards and prevent the spread of germs) was not used by a staff while in the room of a patient in contact isolation (where a set of precautions are used to prevent the spread of germs from a patient to others through direct or indirect contact). These failures had the potential to impact the health, safety, and treatment of the patients, and may have contributed to Patient 34’s death. Findings: 1. On September 5, 2024, at 1:22 p.m., a review of Patient 17’s record was conducted with the Quality Data Abstractor (QDA). A facility document titled, “History & [and] Physical,” dated August 12, 2024, at 4:21 p.m., indicated Patient 17 was admitted to the facility on August 12, 2024, for melena (black stools), dizziness and dyspnea (difficulty breathing). The document indicated Patient 17 had a history of end-stage renal disease (permanent condition in which the kidneys could no longer filter waste from blood) on hemodialysis (HD, procedure to remove the fluids and waste from the blood using a machine). The document also indicated Patient 17’s home medications included, “...Insulin Lispro (medication to control high blood sugar) 100 Units/1 [one] ML [milliliter, unit of measurement] Vial 4-8 [four to eight] Units SubQ [subcutaneous, under the skin] BID [two times a day]...” An untitled facility document, dated September 2, 2024, at 7:48 p.m., was reviewed and indicated, “...Glucose [blood sugar]...372...Reference [normal value]...60-130 mg [milligrams, unit of measurement]/dl [deciliter, unit of measurement]...” An untitled facility document was reviewed and indicated, “...Given Dose...09/02 [September 2, 2024] 2027 [8:27 p.m.]...6 [six] unit...Humalog [type of insulin medication to control blood sugar] Site: Right Upper Arm...Admin [administration] Comment: pt [Patient 17] request [sic] 6 instead of 10 units...Instructions And Comments...Supplemental Insulin...For blood sugar...351-400 = 10 units... “ There was no documented evidence the physician was notified six units of insulin instead of the ordered dose of 10 units were administered to Patient 17 on September 2, 2024. There was no documented evidence the physician changed the medication order for insulin for Patient 17. There was no documented evidence the physician was notified of the change in the dosage of the administered insulin to Patient 17 on September 2, 2024. On September 5, 2024, at 2 p.m., an interview was conducted with the QDA. He stated, when the nurse does not follow the physician’s instructions or if the patient refuses a medication, the nurse needs to notify the physician about patient’s refusal or the change in medication. 2. On September 5, 2024, at 2:05 p.m., a review of Patient 34’s record was conducted with Quality Coordinator (QC) 1. A facility document titled, “History and Physical,” dated June 3, 2024, indicated Patient 34 was admitted to the facility on June 3, 2024, for bilateral pleural effusion (fluids in both lungs). The document indicated Patient 34 had a history of chronic kidney disease (a long term kidney disease), diabetes (abnormal blood sugar), and high blood pressure. An untitled facility document was reviewed and indicated, “...View Medication Order...Metoprolol Tartrate [medication to treat high blood pressure] Tab [tablet] PO [by mouth] 50 mg BID 09 [9:00 a.m.], 21 [9:00 p.m.]...Start 06/03 [June 3, 2024] 2100...Stop 08/02 [August 2, 2024]...” A facility document titled, “Progress Note,” authored by Physician 1, dated July 23, 2024, at 12:43 p.m., was reviewed and indicated, “...Patient looks poorly today...discussed case with family. Patient is now a DNR [do not resuscitate, a physician’s order instructing the healthcare provider to not do chest compressions in the event the patient stops breathing or the patient’s heart stops beating] at this time...Frail, debilitated [weakened] patient, lying in bed, confused, disorientated, not eating or drinking...Try to send the patient to outpatient dialysis and comfort measures to be continued...” An untitled facility document, dated July 23, 2024, at 7:05 p.m., was reviewed and indicated, “...BP 76/42 and Pulse [number of times the heart beats per minute] rate 54...” An untitled facility document, dated July 23, 2024, at 9 p.m., was reviewed and indicated the registered nurse (RN) administered metoprolol 50 mg to Patient 34. A facility document titled, “Multidisciplinary Notes,” dated July 23, 2024, at 11:34 p.m., was reviewed and indicated, “...At 23:30 [11:30 p.m.], Patient [Patient 34] found to be unresponsive and expired...” There was no documented evidence Patient 34’s BP was taken prior to the administration of metoprolol on July 23, 2024, at 9 p.m. There was no documented evidence the physician was notified of Patient 34’s previous low BP on July 23, 2024, at 7:05 p.m., before the metoprolol was administered on July 23, 2024, at 9 p.m. On September 6, 2024, at 1:20 p.m., an interview was conducted with the Registered Nurse Manager (RNM) and the Vice President of Quality (VPQ). The RNM stated the standard of practice of the nurses is to take the patient’s BP prior to the administration of any BP medication and then call the physician if they have a concern about the BP reading. The RNM stated not all patients have blood pressure parameters, so it is important to call the physician for orders. The VPQ stated there is nothing in the hospital policy that speaks to BP parameters or what the nurse would need to do if there are no parameters for a medication. The VPQ stated, “It is up to the nurse to use her critical thinking skills and nursing judgement in these cases.” On September 10, 2024, at 4:10 p.m., an interview was conducted with the Vice President of Quality (VPQ). The VPQ stated, “Yes, I think RNs must assess.” The VPQ stated, “Questioning a physician order would be expected.” The VPQ further stated, “I am certified in patient safety so I believe in it for all patients.” A review of the policy and procedure (P&P) titled, “Medication Administration,” dated September 27, 2023, was conducted. The P&P indicated, “...All medications must be ordered by a physician...Medications should only be administered when the licensed healthcare provider giving the medication knows the following...why the patient is receiving medication...what effects to expect...what adverse effects may be expected...Medications shall be administered exactly as ordered by the physician. Dosages or routes of administration shall not be altered without the written order of the physician...” A review of facility P&P titled, “Standards of Nursing Care and Practice,” dated April 2023, was conducted. The policy indicated, “...”Standards of Practice” describe a competent level of nursing care as demonstrated by the nursing process, involving assessment, diagnosis, outcome identification, planning, implementation, and evaluation...(such as providing culturally and ethically relevant care, maintaining a safe environment, educating clients about their illness, treatment, health promotion or self-care activities, and planning for continuity of care)...Assessment: RNs must be able to effectively collect data and patient information that is relative to their condition or situation...Outcomes Identification...RNs should be able to effectively predict outcomes for the patient...Advocacy...Nurses must demonstrate advocacy and support the needs of their patients...” 3. On September 6, 2024, at 9:05 a.m., a review of Patient 18’s record was conducted with the QDA. A facility document titled, “History and Physical,” dated August 18, 2023, at 11:19 p.m., indicated Patient 18 was admitted to the facility on August 18, 2023, for shortness of breath. The document indicated Patient 18 had a past medical history of congestive heart failure (a serious condition that occurs when the heart can’t pump enough blood to meet the body’s needs), coronary artery disease (a condition that occurs when the heart’s blood supply is reduced or blocked), diabetes mellitus (abnormal blood sugar), hypertension (high blood pressure), and kidney disease. An untitled facility document, dated October 5, 2023, was reviewed and indicated, “...Skin alteration...None...” An untitled facility document, dated October 5, 2023, was reviewed and indicated, “...Ambulation [walking]: 2 [two] person assist...” An untitled facility document, dated October 17, 2023, was reviewed and indicated, “...Skin alteration...Present/Exists...Posterior Coccyx...Pressure injury present on admission: No...Pressure injury staging: Stage 3 [wound extending through the skin into the deeper tissue and fat ]...” An untitled facility document, dated October 18, 2023, through November 2, 2023, was reviewed. The document indicated Patient 18 was not turned nor repositioned on the following dates and times: -From October 19, 2023, at 2 p.m., to 8 p.m. (six hours); -From October 21, 2023, at 2 a.m., to 8 a.m. (six hours); and -From November 1, 2023, at 8 a.m., to 8 p.m. (12 hours). During a concurrent interview, the QDA stated the patient was not able to turn himself and should have been turned frequently by the registered nurse. The QDAr further stated a skin break down could occur if a patient is not turned frequently. A review of the P&P titled, “Skin Integrity Management,” dated October 2022, indicated, was conducted. The P&P indicated, “...All inpatients will be assessed in regard to integumentary [skin] integrity including admission from the Emergency Department...Pressure injuries identified more than 24 hours after admission are considered hospital acquired...Interventions...Promote early & [and] frequent mobility...Provide/assist the patient with repositioning & turning as needed to offload pressure on dependent areas...For prone [lying face down] patient positioning, assess bony prominences [areas of the body where bones are close to the skin’s surface and have limited cushioning] and utilize small shifts to offload pressure...” 4. On September 10, 2024, at 10:45 a.m., a review of Patient 27’s record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, “History and Physical,” dated August 19, 2023, at 3:16 p.m., indicated Patient 27 was admitted to the facility on August 20, 2023, for diagnoses which included renal failure (kidneys are not functioning) and end stage renal disease (a permanent condition in which the kidneys could no longer filter waste from blood). A facility document titled, “Order History Data,” dated August 21, 2024, at 2:01 p.m., was reviewed and indicated, “...Weight, Obtain...Frequency: Daily...” A facility document titled, “Query Responses by Group...Height Weight Group,” dated July 11, 2024, through September 10, 2024, ws reviewed and indicated, “...HTWT [height/weight] 09/03/2024 [September 3, 2024]...144.900 kg...08/19/2024 [August 19, 2024]...145.455 kg [kilograms, unit of measurement]...” There was no documented evidence Patient 27’s daily weight was taken other than on August 19, 2023, and September 3, 2023. On September 10, 2024, at 11 a.m., an interview was conducted with the PSC. The PSC stated there were only two weights taken for Patient 27 during the patient’s admission on August 20, 2023. The PSC stated the patient should be weighed daily by the RN if the physician placed that order. She stated all nurses should follow the physician’s orders per the policy. A review of the P&P titled, “Standards of Care, Practice Guidelines and Assessment for the Adult Patient (Excluding Maternal/Child),” dated December 2019, was conducted. The P&P indicated, “...The following routine care/practice guidelines are provided to the adult patient. Documentation in the patient’s Display Board Queries screen of Computerized documentation system by the licensed nurse confirms that these standards of care/practice guidelines have been met unless otherwise documented in the patient care record...These general standards of care apply to all areas of adult patient care...Routine Monitoring...Height and weight on admission per policy, wight daily if...renal (pertaining to one with kidney conditions)...or as ordered...” 5. On September 4, 2024, at 10 a.m., a tour of the facility was conducted with the Assistant Chief Nursing Officer (ACNO) and the Quality Coordinator (QC). On September 4, 2024, at 10:23 a.m., an observation of Unit 1 was conducted with the ACNO and the QC. A sign was observed on Patient 7’s door indicating contact isolation (when a set of precautions are used to prevent the spread of germs from a patient to others through direct or indirect contact). Registered Nurse (RN) 1 was observed inside Patient 7’s room and was observed to be not wearing a gown nor gloves. During a concurrent interview, the ACNO stated RN 1 should have been wearing a gown and gloves while in the patient’s room. She stated the patient is on contact isolation based on the sign at the patient’s door. On September 4, 2024, at 3:21 p.m., an interview was conducted with RN 1. RN 1 stated he had PPE but took it off while still in the room next to the patient near the patient’s bathroom and not by the patient’s room’s door. He stated there was a trash can near the door and he should have taken the gown and gloves off by that trash can. A review of Patient 7’s record was conducted with the RNM on September 6, 2024, at 10:03 a.m. The facility document titled, “History and Physical,” dated July 26, 2024, indicated Patient 7 was admitted to the facility for acute hypoxemic respiratory failure (low oxygen level in the blood due to inefficient breathing) on July 26, 2024. An untitled facility document was reviewed and indicated, “...Isolation Precautions...Start 07/27 [July 27, 2024]...Isolation...Contact...Comment...ESBL [Extended-spectrum beta-lactamases, a type of bacteria] E. coli [Escherichia coli, a type of bacteria]...” A review of the P&P titled, “Isolation & [and] Standard Precautions,” dated June 2023, was conducted. The P&P indicated, “...Contact precautions...Personal Protective Equipment...wear a gown every time you enter the patient’s room...””

“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: 47071 Based on interview and record review, the facility failed to ensure an intravenous (IV, administered through a vein) medication was administered in accordance with the physician’s order and the facility’s policy and procedure, for one of 48 sampled patients (Patient 9). This failure had the potential to cause harm and increased risk for infection. Findings: A review of Patient 9’s record was conducted with the Quality Coordinator (QC) 1 on September 6, 2024, at 11:39 a.m. A facility document titled, “History and Physical,” dated August 22, 2024, indicated Patient 9 was admitted to the facility on August 22, 2024, with diagnoses which included leg wound. The document indicated Patient 9 had a medical history of paraplegia (paralysis of lower body and legs) and end stage renal disease (a kidney disease that occurs when the kidneys can no longer function properly) on hemodialysis (machine that filters waste from the body). A facility document titled, “Medication Data,” was reviewed and indicated, “...IV Medication...Volume...100 ml [milliliter, unit of measurement]...Q [every] 24 hr. [hours]...IV...Start date...Aug. 24, 24 [August 24, 2024]...Stop date...Aug. 31, 24 [August 31, 2024]...500 MG [milligram, unit of measurement] Meropenem [an antibiotic]...” A facility document titled, “Medications Data,” was reviewed and indicated, “...Meropenem...Aug. 27, 24 [August 27, 2024] 07:30 [7:30 a.m.]...Not Given IV...” A facility document titled, “Medications Data,” was reviewed and indicated, “...Meropenem...Aug. 27, 24 07:30...Administration comments...Not Given Prior to Shift Change...” A facility document titled, “Medications Data,” was reviewed and indicated, “...Meropenem...Administration queries for Aug. 27, 24, 07:30...Reason...Not Given...” An interview was conducted with QC 1 on September 6, 2024, at 2:06 p.m. QC 1 stated the meropenem should have been given as ordered by the physician. She stated there was no documentation indicating a reason why the medication was not given. A review of the facility policy and procedure (P&P) titled, “Medication Administration,” dated September 27, 2023, was conducted. The P&P indicated, “...Medications shall be administered exactly as ordered by the physician...If a dose is omitted, the nurse will “Full Document” in eMAR [electronic Medication Administration Record] the appropriated time slot, the reason the patient did not receive the medication with a comment and also notify the physician...””

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 45431 Based on interview and record review the facility failed to ensure a complete and accurate Emergency Department (ED) central log was maintained when four of 20 sample patients (Patient 3, 5, 12, and 19) were incorrectly entered in the central log. This failure had the potential to cause a delay in treatment and/or deterioration of patients’ medical conditions. Findings: On August 14, 2024, an unannounced visit was conducted at the facility for an Emergency Medical Treatment And Labor Act (EMTALA, a federal regulation that prevents hospitals from denying or limiting treatment to patients based on their insurance or ability to pay) survey. A review of a facility document titled, “Central Log,” dated July 2024, through August 14, 2024, was conducted. The Central log indicated a disposition status of “AMA” (Against Medical Advice), for Patient’s 3, 5,12, and 19. 1. A review of Patient 3’s medical record was conducted on August 14, 2024, at 11 a.m., with the Emergency Department Director (EDD). The facility document titled, “Emergency Provider Report,” dated, July 7, 2024, indicated, “Chief Complaint...presents to the emergency room needing medical clearance for incarceration...Stated Complaint: ok to book...Disposition Decision: patient eloped...” 2. A review of Patient 5’s medical record was conducted on August 14, 2024, at 1 p.m., with Scribe 1. The facility document titled, “Emergency Provider Report,” dated July 31, 2024, indicated, “History of Present Illness...Patient was apparently endorsing suicidal ideation. She presents with 5150 (involuntary detainment for patients who are a danger to self, others, or gravely disabled) hold written by [local police department]...” The facility’s document titled, “Emergency Provider Report,” dated, August 1, 2024, indicated, “...patient managed to get out of restraints and eloped from the ED...” The facility’s document titled, “Emergency Patient Record,” dated August 8, 2024, indicated, “Disposition: Patient Disposition: AMA...comments: patient eloped after getting out of restraints and walked out the department...” A concurrent interview was conducted on August 14, 2024, at 3 p.m., with the EDD. EDD stated nurses use the AMA option on the Central Log Form and then create a note that states the patient eloped. 3. A review of Patient 12’s medical record was conducted on August 14, 2024, at 1:30 p.m., with Scribe 2. The facility’s untitled document indicated, “...Reason For Visit/Chief Complaint: Medication Refill...Discharge Date: July 28, 2024...Time: 9:30 p.m....Dispo [Disposition]: AMA...” A facility document titled, “EMERGENCY PATIENT RECORD,” dated July 28, 2024, indicated “RN [WAS] TOLD PT [Patient 12] WAS LEAVING, WITNESSED PT LEAVE... Patient disposition: AMA...Disposition Category: Refused Treatment...Chief Complaint: Behavioral Health Related...Disposition comments: PT [patient] ELOPED AS PSYCH AMA PD [Police Department] CALLED CODE GREY [a code for combative person] CALLED...” On August 14, 2024, at 1:30 p.m., a concurrent interview was conducted with Scribe 2. Scribe 2 stated Patient 12 eloped on July 28, 2024, while on a psychiatric hold. 4. A review of Patient 19’s medical record was conducted on August 14, 2024, at 1:10 p.m., with Scribe 3. The untitled facility document indicated “Reason For Visit/Chief Complaint: Ok To Book...Discharge Date: July 20, 2024,...Time: 8:10 p.m...Dispo: AMA...” A review of facility document titled, “Emergency Provider Report,” dated July 20, 2024, was conducted. The document indicated “...Chief Complaint...Bilateral Eyelid Swelling...brought in by [Local Police Department] for evaluation...[Local Police Department] at the bedside...shortly after [Local Police Department] left the patient, and prior to completion of ED workup, the patient eloped and ambulated out of the emergency room...” A review of a facility document titled, “Disposition,” dated July 20, 2024, indicated, “...Disposition : AMA...disposition category: Refused Treatment...disposition comments: No contact with patient. Charting D/C [discharge] only...” On August 14, 2024, at 1:10 p.m., a concurrent interview was conducted with Scribe 3. Scribe 3 stated, “Ok To Book” means the patient is in police custody. Scribe 3 stated there was no nursing documentation that the patient [Patient 19] eloped or that attempts to find the patient were made. A review of the facility’s policy and procedure (P&P) titled, “Against Medical Advice- AMA/ Elopement Guidelines”, dated January 2023, indicated, “...Definitions...Involuntary Detainment Elopement applies when a patient under some form of custody...Police, 5150/1799/medical hold, CPS (Child Protective Services)...that leaves the hospital without staff knowledge...C. Elopement of Confused Patients and Involuntary Detainment Elopements...f. Public Safety:...8. Public Safety will detain any patients on hold at the direction of staff...” A review of the facility’s P&P titled, “EMTALA - CENTRAL LOG POLICY,” dated April 27, 2023, was conducted. The P&P indicated, “...The Central Log, including all additional logs incorporated into the Central Log by reference, shall be maintained in the same manner and with the same central core of information. The logs must contain at a minimum, the name of the individual, the date, time and means of the individual’s arrival, the individual’s age, the individual’s sex, the individual’s record number, the nature of the individual’s complaint, the individual’s disposition, the individual’s time of departure, and whether the individual: refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged, or expired...””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 45431 Based on observation, interview, and record review, the facility failed to ensure stabilizing treatment and the maintenance of safety and security relevant to the psychiatric emergency medical condition (EMC), was provided for three of 20 sampled patients (Patient 5,12 and 20), who were admitted on a psychiatric hold (5150 - when a person is deemed a danger to self, others, or gravely disabled, could be involuntary detained for 72 hours) was allowed to walk out of the facility’s Emergency Department (ED). This failure resulted in Patients 5, 12, and 20 to elope (patient leaving the hospital before discharged) from the ED, and had the potential to harm themselves and/or others. Findings: On August 15, 2024, an unannounced visit was conducted at the facility for an Emergency Medical Treatment And Active Labor Act (EMTALA, known as the federal Act that prevents hospitals from deny or limiting treatment to patients based on their insurance or ability to pay) survey. 1. A review of Patient 5’s medical record was conducted with Scribe 1 on August 14, 2024, at 1 p.m. A document titled, “Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment” dated July 31, 2024, at 12:28 a.m., indicated Patient 5 was placed on a 5150 hold by the local police department, for a danger to self after stating she wanted to kill herself, effective July 31, 2024, at 12:28 a.m. The facility document titled, “Emergency Provider Report,” dated July 31, 2024, at 1:59 a.m., indicated, “...History of present illness...history of seizure [a sudden, uncontrolled burst of electrical activity in the brain] disorder...patient was apparently endorsing suicidal ideation [SI, danger to self]. She presents with a 5150-hold written by [Local Police Department]. Per 5150 report, patient stated she wanted to kill herself by strangling herself with a jacket. Still endorses SI here...” The facility document titled, “Emergency Provider Report,” dated July 31, 2024, at 12:44 p.m., indicated, “...waiting placement at 5150 receiving facility.” A concurrent interview and record review was conducted with Scribe 1 on August 14, 2024, at 1:10 p.m. There was no documented evidence an accepting psychiatric facility was obtained. Scribe 1 stated there was no Social Worker assigned in the ED at night. The facility document titled, “Restraint Documentation ED,” dated July 31, 2024, at 8:25 p.m., indicated, “Restraint status: start. Clinical Justification: Attempt self-harm, combative, destructive, physical aggression, violent...Level of restraint: Violent/Self- destructive. Violent restraint device: quick release synthetic BUE [bilateral upper extremities], Quick release synthetic BLE [bilateral lower extremities]...” The facility document titled, “Behavioral Health Related,” dated July 31, 2024, at 9:21 p.m., indicated, “Ongoing signs/symptoms: Agitated, Auditory hallucinations, suicidal ideation, violent behaviors...Behavior health related reassessment complications comment: patient intermittently screaming when attempting to replace restraints...pt [patient] endorsing auditory hallucinations [hearing voices or sounds that aren’t there] and SI w/ [with] a plan and endorses wanting to strangle self...” The facility document titled, “Suicide Reassessment,” dated July 31, 2024, at 9:30 p.m., indicated, “Calculated Risk Level: High Risk.” The facility document titled, “Restraint Documentation ED,” dated August 1, 2024, at 3:51 a.m., indicated, “Restraint status: start. Clinical Justification: Attempt self-harm, combative, physical aggression, violent...Level of restraint: Violent/Self- destructive. Violent restraint device: quick release synthetic BUE, soft BLE...Time restraints initiated: 2 a.m...” The facility document titled, “Suicide Reassessment,” dated August 1, 2024, at 3:58 a.m., indicated, “Calculated Risk Level: High Risk.” The facility’s document titled, “Suicide Reassessment,” dated August 1, 2024, at 4:03 a.m., indicated, “Calculated Risk Level: High Risk.” The facility document titled, “Behavioral Health Related,” dated August 1, 2024, at 4:07 a.m., indicated, “Ongoing signs/symptoms: Agitated, Suicidal ideation’s, violent behavior...Behavior health related reassessment complications comment: Pt [patient] continuous to become intermittently loud and aggressive, often yelling at staff and frequently getting out of restraints and thrashing around in bed.” The facility document titled, “Restraint Documentation ED,” dated August 1, 2024, at 5:07 a.m., indicated, “Restraint status: start. Clinical Justification: Attempt self-harm, combative, physical aggression, violent...Level of restraint: Violent/Self-destructive. Violent restraint device: quick release synthetic BUE, soft BLE...” The facility’s document titled, “Disposition,” dated August 1, 2024, at 6:43 a.m., indicated, “Comments: Pt [patient] eloped after getting out of restraints and walked out of the department. Per security, pt [patient] walked into an unknown white vehicle.” An interview was conducted on August 14, 2024, at 1:15 p.m., with Scribe 1. Scribe 1 stated, “The facility has a “No Touch” policy, meaning staff cannot touch patients if they walk out of the facility, and we can’t restraint or medicate her to make her stay even on a 5150 hold.” An interview was conducted on August 14, 2024, at 2 p.m., with the Patient Safety Director (PSD). PSD stated, “We are not a psych [psychiatric] facility so we can’t hold the patient.” A review of facility document titled, “[Name of Security Agency],” dated August 1, 2024, indicated, “Information...Start time of incident: 4:45 a.m...End time of incident: 5 a.m...Narrative: “I was dispatched to call for a patient assistant to room in the ER when I arrived on seeing the patient...grabbed nurse...I was able to get the patient off the nurse and staff was able to place her in restraints. [Physician1] then instructed us not to stop the patient if she gets loose from the restraints and left. Patient...then broke out of the restraint about 30 to 45 minutes later...[Name of officer], [Patient Safety Observer (PSO3)], and I escorted the patient [Patient 5] off the property until she was off property. The patient then ran across Magnolia Avenue and flagged down a white scion. The patient entered the white vehicle and drove off with them...” A review of the facility document titled, “[Name of Facility]...Coding Summary,” dated August 4, 2024, indicated, “Admit date: July 31, 2024 at 1:17 a.m...Disposition: Psychiatric Elopement...Reason for Visit DX [diagnosis]...Autistic disorder...suicidal ideation’s...altered mental status...” An interview was conducted on August 14, 2024, at 5:20 p.m., with the Vice President of Quality (VPQ). VPQ stated she does not agree that elopements of patients with a psychiatric EMC on a 5150 is an EMTALA violation. VPQ stated [Name of Facility] is not a psych facility and does not do seclusion or chemical restraints. VPQ further stated [Name of Facility] staff do not hold patients if they attempt to leave, even if they are on a 5150 hold for danger to themselves or others. An interview was conducted on August 15, 2024, at 7:46 a.m., with the Chief Medical Officer (CMO). CMO stated, in the case of EMTALA, being mentally stable is separate from being medically stable. CMO stated patients are seen in the ED and are medically cleared. CMO stated from a mental health perspective the patient on a 5150 would not be stable, but [Name of Facility] is not a mental health facility. CMO stated [Name of Facility] sees a lot of psychiatric patients in the ED. CMO further stated the ED cannot hold the patient in their ED until they get treatment. CMO stated “if a patient is medically stable it is not an EMTALA concern, and the patient can leave at any time. From a mental health perspective if the patient doesn’t like their treatment plan, they can leave at any time.” CMO further stated “a 5150 is an involuntary hold but if the patient is medically clear it is not EMTALA, and they can leave the hospital even if they are on a 5150 for danger to self or others. A patient with an acute mental health condition, on a 5150 is not covered under EMTALA.” A review of the facility’s video footage was conducted on August 15, 2024, at 3:15 p.m., with the PSD. The video footage dated August 1, 2024 indicated, a) Video 1 - At 4:57 a.m., observed PCO3 standing in the doorway of ED 2, room 1. Security is observed approaching the room and standing outside, across from room 2. During a concurrent interview, the PSD stated at this time Patient 5 was inside room 1, removing herself from restraints. b) Video 2 - At 4:57:50 a.m., observed PCO3 leaving the room, approaches and speaks with security near room 2. c) Video 3 - At 4:58 a.m., observed PCO3 going back into the doorway of room 1. d) Video 4 - At 4:58 a.m., observed PCO3 walking into the room, however, was not visible on camera while inside the room. e) Video 5 - At 4:58:17 a.m., observed PCO3 at the doorway of room 1 again. f) Video 6 - At 4:58:29 a.m., observed PCO3 walking out of room 1 and walks across the hall to push a button mounted on the wall. ED exit doors open. Observed PCO3 standing with arms crossed near the button and across the hall from room 1. Security approached. g) Video 7 - At 4:58:38 a.m., observed PCO3 and security standing across the hall from room 1. h) Video 8 - At 4:58:40 a.m., observed Patient 5 slowly walking out of the room in a green gown, with open back. Patient 5 pauses and then walks slowly out of the open exit doors while PCO3 and security watched. The nurse, CNC (Clinical Nurse Coordinator), nor other staff were seen on the video. i) Video 9 - At 4:58:45 a.m., observed PCO3 following Patient 5 out of the exit doors while security follows a few feet behind them. PCO3 and security do not attempt to stop the patient from leaving the exit doors. j) Video 10 - 4:58:52 a.m., observed Patient 5 standing in a hallway holding her wrist, before walking down another hallway to the right towards the external exit doors. k) Video 11 - At 4:59 a.m., observed Patient 5 and PCO3 begin to leave the view of the camera moving towards the exit. Observed security following behind Patient 5 and PCO3. l) Video 12- At 4:59:14 a.m., observed another security staff exiting the ED. m) Video 13 - At 4:59:18 a.m., Patient 5 is observed outside of the hospital, heading towards hospital’s main lobby entrance. Patient observed to be walking slowly. n) Video 14 - At 4:59:41 a.m., observed Patient 5 outside the building, walking towards the hospital’s main entrance. o) Video 15 - At 5:00 a.m., observed Security and PCO3 walking out the main lobby entrance. PCO3 and security standing outside the main entrance. Patient 5 visible walking into the parking lot alone. p) Video 16 - At 5:01:27 a.m., observed PCO3 and security staff walking down the sidewalk to the left of the lobby entrance, perpendicular to where Patient 5 walked. Patient 5 is no longer visible in the cameras. An interview was conducted on August 15, 2024, at 8:20 a.m., with the CNC. The CNC stated Patient 5 was admitted in the ED for pseudo seizures (episode that mimics seizures) and behavioral issues. The CNC stated around shift change there was a need for restraints as Patient 5 was attempting to choke herself. The CNC stated Patient 5 was placed in 4-point, hard restraints, and had a sitter. The CNC stated Patient 5 was able to get out of restraints multiple times. The CNC further stated patients on a 5150 hold for psychiatric conditions need to be medically cleared and that Patient 5 was medically cleared prior to eloping. The CNC stated medical conditions and psychiatric conditions are different. The CNC stated a patient on a 5150 cannot leave against medical advice (AMA); this was considered elopement and police department (PD) were notified. An interview was conducted on August 15, 2024, at 1:55 p.m., with Security 1. Security 1 stated if a patient is on a 5150 hold and is attempting to elope, security can detain the patient as long as they don’t do anything that could harm the patient. Security 1 further stated if the patient is aggressive, they do not touch the patient and allow PD to deal with them. On August 15, 2024, at 3:55 p.m., a concurrent interview and review of facility policy titled “Against Medical Advice- AMA/Elopement Guidelines,” was conducted with the CMO. The CMO stated his interpretation of EMTALA is “Psychiatric patients, even those on an involuntary hold for danger to self or others are allowed to leave the hospital if they want to.” The CMO further stated, his interpretation of hospital policy for AMA/Elopement section #8 which states that security may detain a patient on a 5150 hold is “Detaining the patient is upon discretion of the MD and staff. In case of potential physical injury to staff security may intervene but they do not stop psychiatric patients from leaving the hospital.” An interview with PSO3 was conducted on August 16, 2024, at 7:40 a.m. PSO3 stated, the ED staff was familiar with Patient 5 because of her frequent visits to the ED. PSO3 stated the ED staff was also familiar of Patient 5’s combative behavior and was considered a “flight risk.” PSO3 further stated Patient 5 was in restraints, on both her upper and lower extremities, but still managed to get out of them. PSO3 stated she did not attempt to stop Patient 5 because she was informed by the ED charge nurse, supervisor, and the assigned nurse to let the patient leave because the 5150 was not written by their facility. PSO3 further stated, she opened the door for Patient 5 when she was leaving per the instruction of security. 2. A review of Patient 12’s medical record was conducted on August 14, 2024, at 1:30 p.m., with Scribe 2. The facility document titled, “Emergency Provider Report,” dated July 28, 2024, indicated Patient 12 presented to the ED after reporting homicidal ideation (thought pattern characterized by the desire to kill another person) earlier in the day and then eloped from the ED prior to being seen by the physician. Patient 12 was brought back to the facility by the police after punching a window with his hand. A document titled, “Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment” dated July 28, 2024, at 8:30 a.m., indicated Patient 12 was placed on a 5150 hold by a Medical Social Worker, for a danger to self after stating he was hearing voices telling him to kill himself, effective July 28, 2024, at 8:30 a.m. A review of the facility document titled, “Emergency Provider Report,” dated July 28, 2024, indicated “...given the evidence of homicidal ideation 5150 hold placed, patient to be held in our ER until able to transfer...” A concurrent interview and record review was conducted on August 14, 2024, at 1:40 p.m., with Scribe 2. Scribe 2 stated, Patient 12 was allowed to elope from the ED on July 28, 2024, at 1:47 p.m. Scribe 2 stated Patient 12 was always with a safety attendant with direct line of sight and every 15-minute checks. A review of the facility document titled, “EMERGENCY PATIENT RECORD,” dated July 28, 2024, indicated “RN [WAS] TOLD PT [patient] WAS LEAVING, WITNESSED PT LEAVE TOWARDS AMBULANCE BAY...PT CONTINUED TO BECOME MORE AGGRESSIVE AND BEGAN WALKING DOWN RAMP OFF TO CURB 911 CALLED... Patient disposition: AMA...Disposition Category: Refused Treatment...Chief Complaint: Behavioral Health Related...Disposition comments: PT [patient] ELOPED AS PSYCH AMA PD [Police Department] CALLED CODE GREY (a code for combative person) CALLED...” A concurrent interview and record review was conducted on August 15, 2024, at 9:10 a.m., with RN 4. RN 4 stated Patient 12 was agitated and wanted to leave the hospital on June 28, 2024. RN 4 stated the social worker was working on psychiatric facility placement for Patient 12 but the patient eloped prior to transfer. 3. A review of Patient 20’s medical record was conducted on August 14, 2024, at 1:40 p.m., with Scribe 3. The facility document titled “APPLICATION FOR ASSESSMENT, EVALUATION AND CRISIS INTERVENTION OR PLACEMENT FOR EVALUATION AND TREATMENT,” written by [Name of Facility] resident on July 12, 2024, at 11:25 a.m. indicated Patient 20 was “found by police running around naked, yelling, unable to describe mental health history.” Document indicated the patient met criteria for 5150 as a danger to self and gravely disabled adult. The facility document titled “Emergency Provider Report” dated July 12, 2024, indicated, “chief complaint of Altered mental status. Document indicated EMS [Emergency Medical Staff] reports the patient was found running around naked and yelling. Patient was placed on a 5150 hold at 11:25 a.m., for grave disability [legal term that refers to a person’s inability to meet their basic needs due to a mental health condition] and danger to self. Denies SI [suicidal ideation’s or HI [hallucinations ideation’s]. The document further indicated that while in the emergency room, the patient was agitated requiring chemical restraint [medical procedure that uses drugs to restrict a patient’s movement or freedom, or to sedate them]. Patient signed out to fellow resident pending tele psych evaluation [practice of providing psychological services using telecommunications]”. The facility document titled “Emergency Provider Report” dated July 12, 2024, indicated, “...patient was given multiple rounds of antipsychotic medications [a class of drugs that treat symptoms of psychosis] and was unable to participate so we reached out to the tele psych doctor again. Patient still pending formal evaluation.” The facility document titled “Case Management Report” dated July 12, 2024, indicated, “SW [Social Worker] attempted to meet with patient to complete a Psychosocial Assessment (PSA). Patient unable to participate due to erratic behavior, appears to be responding to internal stimuli [changes, experiences, or feelings that occur within a person].” Review of a document titled “Case Management Report” dated July 13, 2024, for Patient 20, indicated, “ SW is covering ER, observed that patient is discharged and reviewed ER RN notes. Per ER patient left AMA [Against Medical Advice] today and [Local Police Department] was contacted by ER.” Review of Patient 20’s “Emergency Notes” dated July 12, 2024, through July 13, 2024, indicated Patient 20 had a safety sitter at the bedside. Review of Patient 20’s record “Emergency Notes” dated July 13, 2024, indicated “Pt [patient] left witnessed by staff to be in regular clothes, scrub pants and grey top, stating “mission inn”. Report made with [local police department] for 5150 not yet rescinded, pending SW [social worker] consult.” An interview was conducted on August 14, 2024, at 1:10 p.m., with Scribe 3. Scribe 3 stated sitter documentation should be scanned and entered into the patient’s medical record. Scribe 3 stated there was no documented evidence a sitter was with Patient 20 in the ED. Scribe 3 further stated the record indicated Patient 20 eloped before she was seen by the SW and before the 5150 hold was rescinded. An interview was conducted on August 15, 2024, at 8:50 a.m., with RN 4. RN 4 stated tele psych gives recommendations, but the recommendation is not a formal order. RN 4 stated if tele psych recommends rescinding a hold, the social worker (SW) would come in and see the patient and then rescind the hold if they don’t meet criteria. RN 4 stated psych patients are kept in green gowns and given their clothes and valuables back on discharge. RN 4 stated she is not sure why Patient 20 was in regular clothes and not a patient gown at the time she eloped. RN 4 stated she or another staff must have given her the clothes. RN 4 stated Patient 20 did not have a discharge order and eloped. RN 4 stated they do not force the patient to stay and can’t hold them down to make them stay. A review of the facility’s policy and procedure (P & P) titled, “Against Medical Advice- AMA/ Elopement Guidelines”, dated January 2023, was conducted. The policy indicated, “Definitions...Involuntary Detainment Elopement applies when a patient under some form of custody, i.e., Police, 5150/1799/medical hold, CPS (Child Protective Services)...that leaves the hospital without staff knowledge...Elopement of Confused Patients and Involuntary Detainment Elopements...Public Safety...Public Safety will detain any patients on hold at the direction of staff.” On August 14, 2024 at 5:20 p.m., the survey team identified significant concerns in the hospital’s Emergency Department (ED). Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation with the potential to cause harm to the health and safety of the patients) was called in the presence of the facility’s Chief Nursing Officer (CNO), Chief Operating Officer (COO), Assistant Chief Nursing Officer (ACNO), Vice President for Business Development (VPBD), Vice President for Quality (VPQ) and Patient Safety Director (PSD). The facility’s Administrators were verbally notified regarding the concerns of the hospital’s failure to ensure an active system was in place to prevent 5150 patients from leaving the hospital before stabilization had been completed. On August 15, 2024, at 8:15 am, the facility provided a Corrective Action Plan (CAP). On August 15, 2024, at 1:08 p.m., the CAP for the immediate jeopardy at the ED was reviewed and accepted. On August 15, 2024, at 5:07 p.m., the immediate jeopardy at the ED was removed in the presence of the PSD, after the CAP implementation was verified through observation, interviews, and record reviews. The CAP included the following components: 1. On August 14, 2024, the leadership team met and reviewed and amended the facility’s RI.119 policy. 2. The Director of Security and the Emergency Department were updated on the policy changes. 3. All Emergency Department and Security staff were educated on the updated policy during shift change huddles and prior to assuming a patient assignment.”

“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: 42512 Based on interview and record review, the facility failed to ensure interventions were implemented, for one patient (Patient 20), when Patient 20 had multiple episodes of decreased oxygen saturation (SPO2, level of oxygen in the blood) and decreased heart rate, which were not addressed timely, in accordance with the facility’s policies and procedures (Refer to A 0398). The cumulative effects of this systemic failure resulted in a delay of treatment for Patient 20 and could have contributed to Patient 20’s death.”

“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: 42512 Based on interview and record review, the facility failed to ensure interventions were implemented, for one patient (Patient 20), when Patient 20 had multiple episodes of decreased oxygen saturation (SPO2, level of oxygen in the blood) and decreased heart rate (HR), which were not addressed timely, in accordance with the facility’s policies and procedures. This failure resulted in a delay of treatment for Patient 20 and could have contributed to Patient 20’s death. Findings: On February 26, 2023, an unannounced visit was conducted at the facility for a complaint validation survey. During a record review conducted with the Patient Safety Director (PSD) on February 28, 2024, at 1:15 p.m., the facility document titled, “History & (and) Physical,” dated November 19, 2022, indicated, “...male with past medical history...for new onset of paraplegia (paralysis of the lower half of the body and legs) and possible quadriplegia (paralysis of arms and legs)...complaining of upper bilateral extremity (both arms) pain and forehead pain...states he cannot feel below his nipple line and cannot move his lower extremities...” A review of the facility document titled, “Clinical Documentation Record,” dated December 30, 2022, at 5 p.m., indicated, “...Pulse 79 [normal range in adults is 60 to100 beats per minute]...Respiratory rate: 24 [normal range in adults is 12 to 18 breaths per minute]...Blood Pressure 108/57 [normal is 90/60 to 120/80 in adults]...SPO2 % [percent]: 97...Oxygen delivery devices: Ventilator [machine connected to the patient tube to assist in breathing through a breathing tube]...” A review of the facility document titled, “Code Blue [a hospital code for a patient needing resuscitation] Record,” dated December 30, 2022, at 5:58 p.m., indicated, “...1759 (5:59 p.m.)...pulse...no...Rhythm...paced...PEA [Pulseless Electrical Activity, a condition where your heart stops because the electrical activity in your heart is too weak to make your heart beat]...” A review of the facility document titled, “Code Blue Note,” dated December 30, 2023, at 6:50 p.m., indicated, “...Code Blue called overhead for PEA arrest [when the heart stopped beating]. RN [registered nurse] had seen patient [Patient 20] 1 [one] hour prior...transferred to MICU [Medical Intensive Care Unit, unit for critically ill patients] where he would arrest again...” A review of the facility document titled, “Dischage Summary,” dated January 4, 2023, at 5:06 p.m., indicated, “...Discharge diagnosis: Hypoxemic [low level of oxygen] brain injury due to multiple cardiac [pertaining to the heart] arrests...Code Blue called again for PEA arrest on 12/30 [December 30, 2023]...Pt. [Patient 20] condition on discharge: expired...” A review of the email sent by RN 2 to the Director of Intermediate Care (Director 1) and other staff was conducted with the PSD. The email indicated, “...Subject: CODE BLUE/TELEMONITORING,” dated December 30, 2022 at 7:40 p.m., indicated, “...JUST WANTED TO FORWARD...THE VIGILANZ [SIC] MADE AND ADD MORE DETAILS REGARDING THE CODE BLUE IN [Patient 20’s room number]...AT [sic] 12/30/22 [December 30, 2022 1758 [5:58 p.m.]...1715 [5:15 p.m.]: HR 82, SPO2 91%, RR [respiratory rate, normal is 12 to 18 breaths per minute in adults] 68. NO CALL [from the tele room, room where the patient’s heart rate and rhythms were remotely monitored]...1740 [5:40 p.m.]: HR 60, SPO2 47%, RR 0. NOCALL OR CRITICAL ALARM...1755 [5:55 p.m.]: HR 23, NO SPO2, RR 0. NO CALL OR CRITICAL ALARM...1758 [5:58 p.m.]: HR0 [sic], NO SPO2, RR 0. CRITICAL ALARM ASYSTOLE, BUT STILL NO CALL FROM TELE ROOM...PT FOUND UNRESPONSIVE AND DISCONNECTED FROM VENT...CODE BLUE WAS CALLED...” During a concurrent interview and record review conducted with the Patient Safety Director (PSD), the PSD stated there was no documented evidence Patient 20 was seen by staff between 5 p.m. to 5:58 p.m. on December 30, 2022. The PSD stated Registered Nurse (RN) 1 was assigned to Patient 20 and was in another patient’s room during this time and did not hear Patient 20’s alarm sounding. The PSD stated RN 2 was on modified duty and was assigned to the nurse’s station desk. She further stated RN 2 sent out an email to Unit Director and Unit Manager after the code blue called for Patient 20. The PSD stated during this time the facility had several fire alarms going on at 5:07 p.m. and at 5:32 p.m. which triggered the unit fire doors and two patient doors to automatically close. She further stated the door to Patient 20’s room was a door which automatically closes during a fire alarm. The PSD stated these events made it difficult for staff to hear any patient alarms on the unit. The PSD stated during this time the facility did not have a designated telemetry monitor technician (tele tech) assigned to this unit. She stated the RNs were responsible for monitoring their own patients. She stated the tele techs did have access to patient monitors for this unit but only called the registered nurse for red codes (when the vital signs are outside of the set perimeters). The PSD stated the facility is unable to locate the tele tech log for December 30, 2022. During an interview on February 28, 2024, at 2:40 p.m., conducted with RN 3, RN 3 stated the unit did not have an assigned tele tech to watch the monitors for their patients. RN 3 stated the telemetry [remote monitoring of patient’s heart rates and rhythms] alarms usually go off for SPO2 below 88, but on this day, the fire alarms were going off and were very loud making it hard to hear any other alarms. RN 3 stated they heard an alarm for low oxygen at the nurse’s station monitors and RN 4 went to Patient 20’s room to investigate after she was notified by RN 2 of the heart rhythm change RN 2 saw on the tele monitor. RN 3 stated RN 4 noticed Patient 20’s trachea tubing was detached from the ventilator and then called a Code Blue. During a concurrent interview and record review on February 29, 2024, at 9:30 a.m., conducted with Manager 1, Manager 1 stated the tele techs do not print any rhythm strips or change of oxygen. She further stated the RN would be responsible for interpreting and printing their own patients’ telemetry strips (recording of the heart rate and rhythm on a special type of paper). Manager 1 stated during this time there was no organized way for tele techs to document these events or who they contacted for telemetry alarms and no tele logs have been located for December 30, 2022. During a concurrent interview and record review on February 29, 2024, at 9:40 a.m., conducted with Manager 2, Manager 2 stated the expectation is for the unit RNs to print the tele strips for their patients every four hours and when there is a rhythm change, then the RN is to notify the physician. She stated the RN is expected to contact the physician if there is a prolonged or sustained oxygen event. Manager 2 stated there was no documentation Patient 20’s sustained oxygen event was addressed nor was it reported to the physician. During a concurrent interview and record review on February 29, 2024, at 10 a.m., conducted with Tele Tech 1, Tele Tech 1 stated, during this event the tele techs were not responsible for this unit and the tele techs were only there as “second eyes” and would contact the RN if there was a red alarm. Tele Tech 1 stated, if the patient’s oxygen went below the parameters, they would have seen a red alarm and called the RN. She stated she was not sure about this event without looking at the log. During a concurrent interview and record review on February 29, 2024, at 10:16 a.m., conducted with Director 1, Director 1 stated there were multiple fire alarms going on December 30, 2023, and the unit did not receive any calls from a tele tech for the change in Patient 20’s status. Director 1 stated the RN assigned to the patient should print an event change, then communicate the change to the physician. During an interview and record review on February 29, 2024, at 11:01 a.m., conducted with RN 4, RN 4 stated she came to the nurse’s station to chart and heard an alarm at the monitor located in the nurse’s station. RN 4 stated the alarm was for oxygen saturation drop. She stated she went into Patient 20’s room and noticed his ventilator tubing was disconnected. RN 4 stated Patient 20’s monitor indicated a rhythm change to asystole (condition where the heart stopped beating) she then started cardiopulmonary resuscitation (chest compressions) and called a Code Blue. During a concurrent interview and record review on February 29, 2024, at 11:15 a.m., conducted with the Respiratory Technician Manager (RT Manager), the RT Manager stated the ventilator alarm settings are always set to the highest volume possible. The RT Manager stated the ventilator would have started to alarm when Patient 20’s ventilator tubing became disconnected. The RT Manager further stated the RN should have been able to hear the alarm through a closed door but it may have been difficult with a closed door and fire alarms going off. During an interview on February 29, 2024, at 1:30 p.m., conducted with the Assistant Chief Nursing Officer (ACNO), the ACNO stated, on December 30, 2022, during a fire alarm, nursing staff should have walked around the unit to check on the patients to ensure their safety. The ACNO stated the patient monitor settings are set to alarm when the patient’s oxygen level falls below 90%. She further nursing staff should have responded to this alarm timely. A review of the undated facility document titled, “Telemetry Safety Bundle: Practice Standards & [and] Communication,” was conducted. The document indicated, “...Staff Roles and Responsibilities...Registered Nurses...Ensure patient is appropriately monitored at all times...Telemetry Technicians...Notify Primary RN promptly of rhythm changes and/or alarms requiring ventilation. Document method of notification and time of alarm resolution...Record alarm notification in a facility-specific Telemetry Notification Log...” A review of the facility’s policy and procedure titled, “Clinical Alarm System Efficacy for Patient Care,” dated July 22, 2020, was conducted. The policy indicated, “...All clinical staff and contract employees assigned to clinical areas...Alarms on clinical monitoring and interventions systems will be maintained in the “on” position and will be sufficiently audible to staff...Alarm volumes will be set at a level so that staff can hear them. If there is competing noise in the area, or the patient is housed at some distance from the staff, then the volume of the alarms will be high enough or augmented in a manner that allows staff to hear them above the competing noise...Clinical staff will provide the following assessment...Under reasonable and predictable extremes of environmental conditions the alarm can be heard (including ambient noise levels)...” A review of the facility policy and procedure titled, “Far West Division Cardiac Telemetry Monitoring,” dated June 23, 2021, was conducted. The policy indicated, “...Patients being monitored on continuous telemetry will be observed by a Telemetry Technician or Nurse who is competent in cardiac rhythm interpretation & arrhythmia detection. Rhythm changes, life-threatening arrhythmias, and/or loss of signal will be responded to in an immediate manner...Patients requiring telemetry will have their cardiac rhythm continuously monitored and documented each shift and PRN with cardiac rhythm changes...The Telemetry Technician should immediately notify the RN of changes in patient’s rhythm...Monitor strips will be run to capture changes in rate or rhythm...The RN is responsible to notify the Provider of changes in patient’s cardiac rhythm/condition...If no resolution from a nurse within 2 minutes from time of initial notification, the monitor tech should call the unit’s charge nurse and enter the notification time on the log...If no response within 5 minutes from time of initial notification, the monitor tech should initiate a “Telemetry Alert” broadcast to the unit staff which will automatically notify the Charge Nurse and House Supervisor by sending a broadcast through immobile...””