Lac/Olive View-UCLA Medical Center

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 45560 Based on interview and record review, the hospital failed to ensure the nursing staff followed the provider’s orders and the hospital’s P&P for the administration of blood and blood products for one of 15 sampled patients (Patient 15) as evidenced by: 1. The nursing staff did not follow the provider’s order to transfuse one unit of packed red blood cells as ordered. 2. The nursing staff did not assess and document a complete vital sign within 15 minutes after initiating the blood transfusion and at the completion of the blood transfusion. 3. The nursing staff did not document the transfusion end time or the total amount of blood infused. 4. The nursing staff did not document patient education regarding the blood transfusion These failures posed a risk to overall patient safety. Findings: Medical record review for Patient 15 was initiated and showed the patient was admitted to the hospital on 6/22/26. 1. During a review of the hospital’s P&P titled Blood - Blood Component Transfusion -Adult dated 2/12/25, the P&P showed the Registered Nurse will verify the physician’s transfusion order in the EHR and the patients informed consent, including rate of infusion or flow rate if specified. During a review of Patient 15’ physician order dated 6/30/26 at 0631 hours, it showed to transfuse one unit of red blood cells over 1 hour, stat. During a review of Patient 15’s Blood Product Transfusion flowsheet dated 6/30/26, it showed the transfusion of one unit of packed red blood cells began at 1010 hours. During a review of Patient 15’s Crossmatch Transfusion Record dated 6/30/26, it showed the transfusion of packed red blood cells that was initiated at 1010 hours and was completed at 1320 hours (3 hours and 10 minutes after initiation). On a concurrent interview and record review on 7/14/26 at 1520 hours with the Telemetry Manager, Patient 15’s blood transfusion order dated 6/30/26 was reviewed. The Telemetry Nurse Manager acknowledged Patient 15’s blood transfusion was not transfused at the rate ordered by the physician. During an interview on 7/14/26 at 1530 hours. with the Telemetry Manager and Associate Risk Manager, they were notified and acknowledged the above findings. 2. During a review of the hospital’s P&P titled Blood - Blood Component Transfusion -Adult dated 2/12/25, the P&P showed under content/steps, vital signs should be taken at a minimum: - Within 30 minutes prior to initiating transfusion. - 15 minutes after starting transfusion or after 50 ml transfused, whichever comes first. - Hourly during transfusion and at completion. - Vital signs should be taken with any signs/symptoms of adverse reaction. a. During a review of Patient 15’s blood product transfusion flowsheet dated 6/30/26, it showed the transfusion of one unit of packed red blood cells began at 1010 hours. No documented vital signs were found 15 minutes after transfusion was initiated. During concurrent interview and record review on 7/14/26 at 1520 hours, with the Telemetry Manager, Patient 15’s Blood Product Transfusion and Vital Signs flowsheet dated 6/30/26 was reviewed. The Telemetry Manager was unable to locate documentation showing Patient 15 vital signs were rechecked 15 minutes after transfusion initiation as per their P&P. On 7/14/26 at 1530 hours, the Telemetry Manager and Associate Risk Manager were notified and acknowledged the above findings. b. During a review of Patient 15’s Blood Product Transfusion flowsheet flowsheet dated 6/30/26, it showed the transfusion of one unit of packed red blood cells began at 1010 hours. During review of Patient 15’s Crossmatch Transfusion Record dated 6/30/26, it showed the transfusion of packed red blood cells that was initiated at 1010 was completed at 1320 hours. Review of Patient 15’s Vital Signs flowsheet dated 6/30/26, showed no documented vital signs at 1320 hours, when the blood transfusion was completed. During concurrent interview and record review on 7/14/26 at 1520 hours with the Telemetry Manager, Patient 15’s Blood Product Transfusion and Vital Signs flowsheet dated 6/30/26 was reviewed. The Telemetry Manager was unable to locate documentation showing Patient 15’s vital signs were checked at the completion of the blood transfusion as per the hospital’s P&P. On 7/14/26 at 1530 hours, the Telemetry Manager and Associate Risk Manager were notified and acknowledged the above findings. 3. During a review of the hospital’s P&P titled Blood - Blood Component Transfusion -Adult dated 2/12/25, the P&P showed under content/steps, if no reaction noted, complete required information on Transfusion Record, including stop time, amount transfused, etc. During a review of Patient 15’s Blood Product Transfusion flowsheet dated 6/30/26, it showed the transfusion of one unit of packed red blood cells began at 1010 hours. During a review of Patient 15’s Crossmatch Transfusion Record dated 6/30/26, it showed the transfusion of packed red blood cells that was initiated at 1010 hours and was completed at 1320 hours. During a concurrent interview and record review on 7/14/26 at 1520 hours, with the Telemetry Manager, Patient 15’s Blood Product Transfusion flowsheet dated 6/30/26 was reviewed. The Telemetry Manager was unable to locate documentation showing the end time of the transfusion or the total amount infused as per the hospital’s P&P. On 7/14/26 at 1530 hour, the Telemetry Manager and Associate Risk Manager were notified and acknowledged the above findings. 4. During a review of the hospital’s P&P titled Blood - Blood Component Transfusion -Adult dated 2/12/25, the P&P showed under content/steps, the Registered Nurse will document in the EHR instruction and education provided to patient/family including: -Understanding of procedure. -Previous transfusion history and reactions. -Description of the procedure, component, length of transfusion and expected outcome to patient. -Patient/family to report any unusual symptoms immediately. During a review of Patient 15’s Blood Product Transfusion flowsheet dated 6/30/26, it showed Patient 15 was transfused one unit of packed red blood cells. During a concurrent interview and record review on 7/14/26 at 1520 hours, with the Telemetry Manager, Patient 15’s EHR was reviewed. The Telemetry Manager was unable to locate documentation showing education was provided to Patient 15 or their family regarding the blood transfusion that was completed on 6/30/26. On 7/14/26 at 1530 hours, the Telemetry Manager and Associate Risk Manager were notified and acknowledged the above findings.”

“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: 35310 Based on interview and record review, the hospital failed to ensure the temperature in SPD was monitored when temperatures were out of range in SPD as required by the hospital’s P&P. This failure had the potential to contribute to the spread of infections and negatively impact patients’ health conditions. Findings: Review of the hospital’s P&P titled Room Temperature, Humidity and Airflow dated 6/25/26, showed the approved values for temperature is between 68 to 73 degrees F. in general work areas in SPD. The P&P also showed the following: * Notify facilities management when the temperature and/or humidity are out of range and document accordingly. * Record follow-up temperatures and/or humidity. On 7/13/26 at 1005 hours, during the tour of the SPD with the Central Service Supervisor in the presence of the OR Manger and Health Facilities Consultant, the temperature of the assembly room was 76.1 degrees F. Review of the Sterile Processing -Temperature and Humidity Log for Assembly Area showed the following: * On 6/25/26 at 0700 hours, the temperature was 75.9 degrees F. * On 6/26/26 at 0700 hours, the temperature was 77.9 degrees F. * On 6/28/26 at 0700 hours, the temperature was 80.1 degrees F. * On 6/29/26 at 0700 hours, the temperature was 80.2 degrees F. * On 6/30/26 at 0700 hours, the temperature was 78.8 degrees F. * On 7/1/26 at 0700 hours, the temperature was 78.0 degrees F. * On 7/2/26 at 0700 hours, the temperature was 78.4 degrees F. * On 7/3/26 at 0700 hours, the temperature was 74.7 degrees F. * On 7/5/26 at 0700 hours, the temperature was 73.8 degrees F. * On 7/7/26 at 0700 hours, the temperature was 73.8 degrees F. * On 7/8/26 at 0700 hours, the temperature was 74.7 degrees F. * On 7/9/26 at 0700 hours, the temperature was 75.8 degrees F. * On 7/10/26 at 0700 hours, the temperature was 74.4 degrees F. * On 7/11/26 at 0700 hours, the temperature was 75.0 degrees F. * On 7/12/26 at 0700 hours, the temperature was 73.2 degrees F. * On 7/13/26 at 0700 hours, the temperature was 74.9 degrees F. * On 7/14/26 at 0700 hours, the temperature was 74.2 degrees F. * On 7/15/26 at 0700 hours, the temperature was 75.0 degrees F. Further review of the Sterile Processing -Temperature and Humidity Log showed the work orders were placed when temperatures were out of range. However, there was no follow-up temperatures were taken or documented after the work orders were placed. During an interview on 7/15/26 at 1300 hours, with the Health Facilities Consultant, the Health Facility Consultant verified the above findings.”

“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: 35310 Based on observation, interview, and record review, the hospital failed to ensure the decontamination process was followed according to the manufacturer’s IFU and professional standards. This failure had the potential to cause the spread of infections and negatively impact patients’ health conditions. Findings: During an interview on 1/14/26 at 0948 hours with the OR Nurse Manager, in the presence of the Associate Risk Manager, Infection Control Prevention and Control Director, the OR Nurse Manager stated the hospital followed the AORN Guidelines for perioperative services, including OR and SPD. During a review of the AORN’s Guidelines for Perioperative Practice: Instrument Cleaning (2026 edition) showed under 9, Manual Cleaning item 9.4: “Prepare a compatible fresh cleaning solution in a clean sink in accordance with the detergent manufacturer’s IFU for temperature, concentration, and water quality.” 1. Review of the manufacturer’s IFU for Prolystica enzymatic presoak and cleaner showed the instructions to add 1/2 oz of concentrate per one gallon of water for manual cleaning. On 1/13/25 at 1050 hours, during a tour of the decontamination area with the OR Nurse Manager and RN 2. Four stainless steel containers with clear solution were observed on the sink counter. During an interview with the SPD Tech on 1/13/25 at 1050 hours, the SPD Tech stated the four containers were one with enzymatic solution, one with surgistain, and two with water. The SPD Tech stated for the enzymatic solution, he added two oz of the concentrate for four gallons of water, and for the surgistain, he added 16 oz per one gallon of hot water. The measurement cup or the measurement line in the container was not observed. The SPD Tech stated he eyeballed the measurement. 2. Review of the manufacturer’s IFU for STORZ Karl Storz under 8.2.5. Manual Cleaning, showed to prepare neutral pH enzymatic solution in a container larger enough to fully submerge the camera head. Dilute the solution to proper concentration per manufacturer’s instructions. On 1/13/26 at 1043 hours, the SPD was toured with the OR Nurse Manager and RN 2. During an interview with the CST at that time, the CST stated they cleaned the camera head in water with a sponge. The CST stated the sponge already included the enzymatic product, so enzymatic solution was not added to the water when cleaning the camera head. On 1/14/26 at 1145 hours, the Associate Risk Manager and RN 2 acknowledged the above findings.”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the extended resolution letter for a grievance was written in the same language in which the grievance was filed for one of three sampled patients (Patient 1). This failure had the potential to result in a violation of the patient’s rights by limiting their ability to understand the status of their grievance. creating a risk of violating patients’ rights. Findings: During a review of the hospital’s P&P titled Complaint and Grievance Management dated 2/28/25, the P&P showed the following: * Grievances: Most grievances can be resolved within seven days. Grievances requiring extensive investigation may need additional time. * Extended Resolution: If a grievance cannot be resolved, or if the investigation is not completed within seven days, the Patient Advocacy Office will notify the patient or the patient’s authorized representative in writing. During a review of the grievance form for Patient 1 on 11/24/25, the grievance form showed it was written in English on 10/31/25. During a review of the final resolution letter on 11/24/25, the letter showed it was dated 11/12/25. During a review of the extended resolution letter on 11/25/25, the letter showed it was dated 10/31/25. However, the letter was written in different language than the original grievance. During a concurrent interview and record review with the Associate Risk Manager on 11/25/25 at 1210 hours, the Associate Risk Manager stated the extended resolution letter should not have been written in different language.”

“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: 35310 Based on interview and record review, the hospital failed to ensure the patients received care in a safe environment for one of three sampled patients (Patient 1) as evidenced by: 1. The nursing staff failed to document consistently the effectiveness of intervention and behaviors trends for hypersexuality for Patient 1 as required by the hospital’s P&P. 2. The nursing staff failed to measure Patient 1’s VS as required by the hospital’s P&P. These failures created the risk of substandard healthcare outcomes to the patients in the hospital. Findings: During a review of medical record for Patient 1 starting on 11/24/25, Patient 1’s medical record showed Patient 1 was admitted to the hospital on 10/15/25. 1. During a review of the hospital’s P&P titled Sexually Inappropriate Behavior/Hypersexuality-Precaution Guidelines dated 8/2/24, the P&P showed the following: I. Assessment and Interventions C. For Sexually Inappropriate Behavior, the following interventions shall be implemented: E. If hypersexual behavior is present, in addition to Sexually Inappropriate Behavior (SIB) interventions, the RN will implement the following Risk Reduction Interventions, the RN will implement the following Risk Reduction Interventions: 1. 1:1 constant nursing observation 2. Seclusion or restraints per MD order, if necessary II. Communication B. The RN will evaluate the effectiveness of interventions each shift and any increase or decrease in sexually inappropriate behavior and or hypersexual behavior and communicate these with the MD, nursing staff, and other care team members by way of daily shift reports, during multidisciplinary team meetings and documentation in the EHR. During a review of the Psych ED Consultation dated 10/16/25 at 2005 hours, the Psych ED Consultation showed Patient 1 was documented as sexually inappropriate to staff and other patients. During a concurrent interview and record review with Nurse Manager 1 on 11/25/25 at 1037 hours, the Hypersexual Risk Factor documentation for Patient 1 from 10/15/25 to 10/19/25 included: - Hypersexual Risk Factor Present - Exposing self/public sexual gestures - Trying to coerce other into sex activity - Inappropriate touching of others - Making unwanted sexual advances During an interview on 11/25/25 at 1037 hours, with Nurse Manager 1, Nurse Manager 1 stated the interventions for hypersexual behaviors included medications and redirecting Patient 1 to another room. Further review of Patient 1’s medical record failed to show the effectiveness of the interventions and trends of the sexually inappropriate behavior. Nurse Manager 1 verified the above findings. 2. During a review of the hospital’s P&P titled Patient Care Documentation Guidelines (Inpatient) dated 2/8/24, the P&P showed to measure vital signs every eight hour minimum as ordered by MD or more frequently if clinically indicated for behavioral health area. Review of the Vital Signs showed the following: * On 10/15/25 at 1506 hours, Patient 1’s VS were measured. * On 10/15/25 at 2045 hours, Patient 1’s VS were measured. * On 10/16/25 at 0830 hours, Patient 1’s VS were measured. * On 10/16/25 at 1541 hours, Patient 1’s VS were measured. * On 10/19/25 at 0759 hours, Patient 1’s VS were measured. There were no documented vital signs for 10/17 or 10/18/25. During a concurrent interview and record review with Nurse Manager 1 on 11/25/25 at 1037 hours, Nurse Manager 1 stated the unit protocol was once daily, nurses typically measured vital signs once per shift. Nurse Manager 1 verified the VS in behavioral health unit was not measured every eight hours as per the hospital’s P&P requirement.”

“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: 37663 Based on interview and record review, the hospital failed to ensure one of three sampled patients (Patient 1) received care in a safe setting as evidenced by: 1. Patient 1’s pain was not managed as per the hospital’s P&P as evidenced by: a. The ED RN failed to provide intervention for Patient 1’s pain level of 5 out of 10. b. The nursing staff failed to assess and reassess Patient 1’s pain level before and after the administration of pain medications. c. The nursing staff failed to ensure Patient 1’s pain was managed to maintain Patient 1’s goal pain level. 2. The physician failed to complete a medication reconciliation upon admission for Patient 1 as per the hospital’s P&P. 3. A STAT brain MRI ordered by the physician for Patient 1, was not performed as per the hospital’s P&P. These failures posed an increased risk of substandard health outcomes for the patient by not addressing the patient care needs timely. Findings: Review of Patient 1’s closed medical record was conducted on 7/16/25. 1. Review of the hospital’s P&P titled Pain Assessment and Management Policy reviewed date 2/13/25, showed in part: * Policy: Patients indicating pain upon screening shall be assessed further for pain. Patients shall be treated for pain and other related symptoms if they report pain interfering with function anytime during their hospital stay or visit. Patients responses to pain intervention shall be evaluated and documented in a timely manner. * Definitions: - Pain: defined as unpleasant sensory and emotional experience associated with actual or potential tissue damage or describing in terms of such damage. - Numerical Rating Scale (NRS): Rates pain from 0, meaning no pain to 10, meaning the worst possible pain. 0: no pain, 1-3: mild pain, 4-6: moderate pain, 7-10: severe pain. * Assessment and Reassessment: - All patients will be assessed for the presence or absence of pain upon admission, point of entry to the Department of Emergency Medicine (triage) or Behavioral Health area, and clinic visit. This assessment will be documented in Electronic Health Record (EHR). - Pain assessment and reassessment will continue while pain is being treated and with any new patient complaint of pain. This includes the evaluation of patient’s satisfaction with pain management. - The health care professional will assess the patient’s pain utilizing the appropriate pain assessment tool, for example, patient’s self-report (0-10 or faces) or the assessment tool for non-verbal patients. - The initial patient assessment will be comprehensive based on the patient’s self-reported pain score. Factors can include but are not limited to the following parameters: location, laterality, quality, pattern. - The patient’s acceptable level of pain will be documented in the medical record (if applicable). - Pain assessment or reassessment shall be done as indicated by persistence of pain, initiation of potentially pain procedures, change in medical status, and/or after pharmacological intervention. The following will be reported immediately to the provider: uncontrollable pain, pain intervention that do not achieve patient’s pain goal in a time frame appropriate to the intervention, new or worsening pain, and adverse effects of pain medication. - Timing of pain reassessment, after intervention, will be appropriate for the modality or medication and route of admission. IV or IM medication shall be reassessed within 30 minutes post administration. Other medications (including but not limited to, by PO, SQ etc.) shall be assessed for no more than two hours post administration. - In the Department of Emergency Medicine (DEM), pain will be assessed or reassessed as follows: at triage or initial nursing assessment if patient does not go through triage, reassessed minimum every eight hours from the original pain assessment or as needed if there is a change in patient condition. * Interventions: Pain management will include any of the following: - Pharmacologic: non-opioid - there is not a minimum or maximum number of medications which can be prescribed to the patient under the law. - Non- pharmacologic pain management and/or CAM may be considered which included physical interventions, acupuncture, or cognitive behavior strategies. - The provider should tailor pharmacological therapy to the individual medical needs of each patient. Multiple treatment modalities and rehabilitation programs may be necessary if the pain is complex or is associated with physical and psychological impairment. * Documentation: All pain complaints, assessments, interventions, reassessments, plan of care, patient or family education, medication administration, and provider notification will be documented in EHR. a. Review of Patient 1’s medical record was conducted with the Nurse Educator on 7/16/25 at 1345 hours. Patient 1’s medical record showed the patient was admitted to the hospital’s ED on 2/28/25 at 1600 hours, brought in by ambulance and complaining of generalized weakness after a fall sustained 5 days ago. Review of the ED triage documentation showed on 2/28/25 at 1630 hours, Patient 1 complained of pain with the pain level of 5 out of 10 (or moderate pain) on the right shoulder. The Nurse Educator was asked for the intervention provided to the patient for the pain level of 5 out of 10 on the right shoulder. The Nurse Educator stated there was no documentation of the intervention the ED RN provided to the patient to alleviate the right shoulder pain with the pain level of 5 out of 10. Review of the ED RN’s pain assessment for Patient 1’s right shoulder on 2/28/25 showed the following: - At 1820 hours, lidocaine topical (a medication used to prevent pain by blocking the signals at the nerve endings in the skin) and Tylenol (analgesic, a pain medication) 650 mg given orally. However, there was no documented evidence of assessment of the pain level. - At 1830, 1853, and 1933 hours, the patient’s pain level was 5 out of 10. - At 2142 hours, the patient’s pain level was 4 out of 10. - At 2355 hours, the patient’s pain level was 5 out of 10. The Nurse Educator stated there was no documented evidence the RN provided non-pharmacological or pharmacological intervention for the patient’s moderate pain of the right shoulder. b. Review of the hospital’s P&P titled Inpatient Care Documentation Guidelines review date 2/8/24, showed the policy guidelines was to provide a general overview of the minimum documentation requirements for the various adult inpatient areas. Dependent on patient condition and situation, documentation may be modified based upon response to interventions and/or physician’s order. - Patient assessment and monitoring requirement for Medical Surgical unit: minimum of four hours. Vital signs every four hours or as ordered by the physician. Pain assessment upon admission, onset or patient complaints of pain, before, during and after each procedure as indicated. Review of Patient 1’s medical record was conducted with the Nurse Educator. Patient 1’s medical record showed the patient was admitted to the Medical Surgical unit on 3/1/25 at 0512 hours. The pain assessment at 0518 hours showed the patient’s pain level was 0 out of 10 and the patient’s acceptable pain level was 2 out of 10. Review of Patient 1’s pain assessment, reassessment and intervention showed the following: - On 3/1/25 at 0800 hours, Patient 1’s pain level was 0 out of 10. At 1200 hours, there was no documentation the patient’s pain was assessed. At 1600 hours, the patient complained of back pain with the pain level at 10 out of 10; the patient was given Tylenol 650 mg for pain. The pain was reassessed at 1700 hours and the patient’s pain level was 3 out of 10; there was no documented intervention provided to the patient. - On 3/2/25 at 0805 hours, Patient 1 complained of generalized pain with the pain level of 6 out of 10; there was no documentation to show pharmacologic /non-pharmacologic intervention was provided to the patient. At 0940 hours, the patient complained of generalized pain with the pain level of 7 out of 10 and the patient was medicated with ketorolac (a nonsteroidal anti-inflamatory drug that used for pain relief) 15 mg IVP; however, there was no documentation of reassessment of the patient’s pain. At 1227 hours, the patient was given oxycodone (an opioid pain medication) 2.5 mg PO; however, there was no level of pain assessment documented and reassessment of pain after the medication intervention was provided to the patient. In addition, the assessment of pain was blank four hours after. At 2056 hours, the patient reported pain level of 10 out of 10 on the right shoulder and was medicated with Tylenol 650 mg PO. At 0022 hours (after 3 hours and 26 minutes), The pain was reassessed, and the patient’s pain level was 0 out of 10. - On 3/3/25 at 0142 hours, Patient 1 was given oxycodone 2.5 mg PO without documentation of pain level assessment. There was no documented assessment of pain from 0210 hours to 0904 hours (or approximately 7 hours). There was no documented pain assessment from 0944 hours to 1556 hours (6 hours and 12 minutes). - On 3/4/25, there was no documented pain assessment from 1704 hours to 2340 hours (6 hours and 36 minutes). - On 3/6/25, there was no documented pain assessment from 1823 hours to 0020 hours (5 hours and 57 minutes). - On 3/8/25 at 0018 hours and 0607 hours, the patient was given oxycodone 2.5 mg PO; however, there was no pain level assessment for the indication of pain medication and reassessment after the pain medication was given. The Nurse Educator stated she believed pain assessment was performed when every vital sign was taken. The Nurse Educator stated the NAs took the vital signs and asked the patient for the presence of pain, then the NAs informed the RN of the patient’s presence of pain; the RN would assess the patient’s pain. The Nurse Educator verified the above findings. c. Review of the hospital’s P&P titled Patient Rights and Responsibilities review date 2/13/25, showed the hospital observes and respects the rights of patients and staff at all times and provides patients and visitors with information as to their rights and responsibilities. Patients have the right to considerate and respectful care. Patients have the right to pain management. Review of Patient 1’s medical record was conducted with the Nurse Educator. Review of the orders for Patient 1’s pain medications showed the following: - On 3/1/25 at 1521 hours, the order showed to give Tylenol 650 mg PO every six hours PRN for pain. The order did not show the indication for specific level of pain. - On 3/1/25 1605 hours, the order showed to give oxycodone 2.5 mg PO every eight hours PRN for pain not relieved by non-opioid medications. - On 3/3/25 at 0803 hours, the order showed to give Dilaudid (an opioid pain medication) 0.2 mg IV every six hours PRN for pain (5-10), for breakthrough pain. The order was discontinued on 3/10/25. - On 3/1/25 at 1607 hours, the order showed to give diclofenac (a nonsteroidal anti-inflammatory drugs used to treat pain) 1% topical gel, topical application QID PRN for pain. - On 3/4/25 at 1400 hours, the order showed to give lidocaine 5% topical cream, 1 application TID. Random review of Patient 1’s MAR, showed Tylenol 650 mg po was given on the following: - On 3/4/25 at 0842, 1547, and 2353 hours. - On 3/5/25 at 2356 hours. - On 3/6/25 at 0522 and 1153 hours. - On 3/7/25 at 0020, 0613, and 2119 hours. - On 3/8/25 at 1035 and 1908 hours. - On 3/9/25 at 1633 hours. Review of Patient 1’s pain assessment, administration of oxycodone 2.5 mg PO, and reassessment after intervention showed the following: - On 3/3/25 at 0142 hours, the patient was given oxycodone 2.5 mg; however, there was no pain level assessment documented. At 0215 hours, the patient’s pain level was reassessed, and the patient’s pain level was 0 out of 10. At 1556 hours, oxycodone was given for pain level of 10 out of 10 and the patient was reassessed at 1718 hours, with the pain level of 0 out of 10. - On 3/4/25 at 0055 hours, oxycodone was given for pain level of 10 out of 10. The patient was reassessed at 0155 hours, with the pain level of 2 out of 10. At 0531 hours, oxycodone was given for 10 out of 10 one-time dose. The patient was reassessed at 0631 hours with the pain level 0 out of 10. Oxycodone was given to the patient at 1358 hours, for the pain level of 10 out of 10 pain level and the patient was reassessed at 1458 hours with the pain level of 0 out of 10. Oxycodone was given at 2340 hours for pain level of 10 out of 10. - On 3/5/25 at 0040 hours, the reassessed pain level was at 2 out of 10. Oxycodone was given at 0814 hours for the pain level of 10 out of 10 and the patient’s pain level was reassessed at 0902 hours and was 0 out of 10. Oxycodone was given at 1637 hours for pain level of 10 out of 10 and the patient’s pain level was reassessed at 1713 hours and was 0 out of 10. - On 3/6/25 at 0139 hours, oxycodone was given to the patient for the pain level of 9 out of 10 and the patient’s pain level was reassessed at 0225 hours and was 0 out of 10. Oxycodone was given at 1522 hours, for pain level of 8 out of 10 and the patient’s pain level was reassessed at 1622 hours and was 2 out of 10. - On 3/7/25 at 0127 hours, oxycodone was given to the patient for the pain level of 5 out of 10 and the patient’s pain level was reassessed at 0227 hours and was 0 out of 10. Oxycodone was given at 1024 hours, for the pain level of 7 out of 10 and the patient’s pain level was reassessed at 1124 hours and was 2 out of 10. Oxycodone was given at 1826 hour for the pain level of 8 out of 10; there was no pain reassessment after the medication was given. - On 3/8/25 at 0018 hours, oxycodone was given without pain level assessment and reassessment documented. At 0607 hours, oxycodone was given without documented pain level assessment and reassessment. At 1258 hours, oxycodone was given for the pain level 10 out of 10 and the patient’s pain level was reassessed at 1358 hours and was 0 out of 10. At 1950 hours, oxycodone was given for the pain level 7 out of 10; there was no reassessment of pain level. Review of Patient 2’s pain assessment, administration of Dilaudid 0.2 mg IV PRN for breakthrough pain, and reassessment after the medication showed the following: - On 3/3/25 at 0904 hours, Dilaudid 0.2 mg IV was given for the pain level 10 out of 10 and the patient’s pain level was reassessed at 0944 hours and was 0 out of 10. Dilaudid was given for pain at 2117 hours, for the pain level of 10 out of 10 and the patient’s pain level was reassessed at 2132 hours and was 2 out of 10. - On 3/4/25 at 0327 hours, Dilaudid 0.2 mg IV was given for the pain level of 10 out of 10 and the patient’s pain level was reassessed at 0342 hours and was pain level 2 out of 10. Dilaudid was given at 1005 hours for the pain level of 10 out of 10 and the patient’s pain level was reassessed at 1020 hours and was 2 out of 10. Dilaudid was given at 1649 hours for the pain level of 10 out of 10 and the patient’s pain level was reassessed at 1704 hours and was 0 out of 10. - On 3/5/25 at 0320 hours, Dilaudid 0.2 mg IV was given for the pain level of 10 out of 10 and the patient’s pain level was reassessed at 0335 hours and was 2 out of 10. Dilaudid was given at 1135 hours for the pain level of 10 out of 10 and the patient’s pain level was reassessed at 1232 hours and was 0 out of 10. Dilaudid was given at 2112 hours for the pain level of 10 out of 10 and the patient’s pain level was reassessed at 2155 hours and was 2 out of 10. - On 3/6/25 at 0827 hours, Dilaudid 0.2 mg IV was given for the pain level of 7 out of 10. At 0842 hours, the patient’s pain level was reassessed and was 2 out of 10. Dilaudid was given at 1808 hours for the pain level of 7 out of 10 and the patient’s pain level was reassessed at 1823 hours and was 2 out of 10. - On 3/7/25 at 1442 hours, Dilaudid 0.2 mg IV was given for the pain level of 10 out of 10 and the patient’s pain level was reassessed at 1457 hours and was 0 out of 10. Patient 1’s pain level assessment from 3/1/25 to 3/8/25 showed the patient’s pain assessment levels were generally 10 out of 10 (severe) before the PRN pain medications were administered. The patient’s trend of pain level did not show the pain level of 2 out of 10 was maintained despite Patient 1 receiving the PRN pain medications. On 7/17/25 at 1510 hours, the Nurse Educator was asked what the expectation from the RNs was when the patient’s desired pain goal level of 2 out of 10 was not maintained and prevent the pain level from escalating at 10 out of 10. The Nurse Educator stated the RN should call the physician to obtain an order for pain medication to be administered on a scheduled regular basis not as a PRN to maintain the desired patient’s goal level of pain 2 out of 10 and prevent the pain level increasing up to 10. The Nurse Educator verified the findings. 2. Review of the hospital’s P&P tilted Medication Reconciliation reviewed date 8/8/22, showed: * Policy: Providers (physicians and NPs) shall adhere to medication reconciliation procedures to maximize safe medication practices at points of care and care transitions. Clinicians shall make a good faith effort to obtain accurate medication information from the patient and or other sources and accurate medication information from the patient and/or other sources and document this information in a useful way to those who manage medications. * Procedure: Inpatient: Admission: Responsible healthcare providers will record the current list of medications the patient is taking on admission. The list contains name, dose, frequency, and route, whenever possible based on the information available. The primary means for obtaining the list is the patient/parent/caregiver interview, the Electronic Medical Record (EMR), and any other outside records. The medication list will be reviewed and compared to admission orders written for duplications, omissions, and interactions. Review of Patient 1’s H&P examination dated 3/1/25 at 0248 hours, showed Patient 1’s family accompanied the patient at the bedside. The patient reported having a mechanical fall about five days ago, tripping over her feet and was unable to get up. Per family, only known medical history of breast cancer; otherwise, unclear past medical history or medications. The patient reportedly saw several doctors closer to the patient’s home (a different city) unknown where. The patient lived by themselves at home, was independent with all ADLs. The sections of Ongoing and Historical Problem List/Past Medical history showed no qualifying data. The section of Medications showed no active home medications. The Emergency contact list was Family Member 1. Review of Patient 1’s H&P examination dated 3/1/25 at 1842 hours, showed an addendum update showing Family Member 2 was at bedside, collateral obtained... Corroborates story told to us by the patient fell, was able to crawl to phone after some time and text Family Member 3 to call 911, and Family Member 3 called the patient’s neighbor to check on the patient. Review of the Internal Medicine Progress Note dated 3/10/25, showed the Assessment and Plan section showing Patient 1 had back pain, shoulder pain, history of RA, discovered later in the hospital stay that the patient had history of RA, on methotrexate (anti-inflammatory and immunosuppressant), Plaquenil (anti rheumatic medication - reduced pain, swelling, and stiffness in joints. lessen inflammation) with folate supplementation at home. There was no documented evidence that Patient 1 received home medication for RA. The Nurse Educator stated she could not find the medication reconciliation for Patient 1 upon admission to the hospital. 37548 3. Review of the hospital’s P&P titled MRI Hours of Operation and Off-Hours MRIS dated 9/21/24, showed “Policy: MRI Scope of Service and Workflow for Emergent MRI...The routine MRI daily hours of operations are Mon-Fri 7:00 am to 12:00 am (midnight) for inpatients...and outpatients...After hours, the referring physician will place the order for the MRI and contact either the radiologist on duty in the hospital or the neuroradiologist on call. If approved, the radiologist or their representative will contact the MRI technologist on call...” Review of the Emergency Documentation dated 2/28/25 at 1813 hours, showed Patient 1 was brought to the ED by ambulance for a fall and generalized weakness on 2/28/25. Review of the MRI order dated 3/1/25, showed a STAT MRI of the brain with and without contrast was electronically ordered and signed on 3/1/25 at 0122 hours (After hours). The relevant history documented was “dysarthria 2 days ago.” The MRI order showed RN 2 reviewed the order at 0129 hours on 3/1/25. On 7/17/25 at 1343 hours, an interview and concurrent review of Exhibit B Attachment A-6 TAT Expectation for radiology was conducted with the Risk Management. The Risk Management stated Exhibit B Attachment A-6 TAT Expectation for radiology showed the TAT for a STAT MRI order was one hour. Review of the medical record did not show documentation that explained why the MRI was not performed STAT, as ordered. Review of Patient 1’s medical record did not show that the MRI Scope of Service and Workflow for Emergency MRI was implemented as per the hospital’s P&P for Patient 1’s STAT MRI order, that was placed after hours. On 7/17/25 at 1602 hours, the Risk Management confirmed the findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 37663 Based on observation, interview, and record review, the hospital failed to ensure the hospital’s P&P for Restraints was implemented for one of three sampled patients (Patient 2). This failure posed an increased risk for the violation of patient’s rights. Findings: Review of the hospital’s P&P titled Restraints and or Seclusion reviewed on 3/4/25 showed under the section for Definitions: Restraints: Any manual method or physical or mechanical device, material, or equipment, that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Types of Physical Restraints: ...Four side rails. The section for Ordering Restraints or Seclusion: A LIP must order the restraints and or seclusion. Within one hour after the initiation of restraints and or seclusion for violent behavior management. Orders for restraints of patient with non-violent behavior management needs are limited to one calendar day.... In an emergency. A RN may initiate use of restraints and or seclusion before an order is obtained from an LIP. The LIP responsible for the care of the patient must be consulted as soon as possible within one hour of restraints or seclusion. On 7/16/25 at 1055 hours, an observation of Patient 2 was conducted on the Medical/Surgical Floor 4 D, accompanied by the Nurse Manager. Patient 2 was observed lying in bed asleep, with the four side rails up. NA 1 was observed sitting outside Patient 2’s room door. NA 1 stated she was the sitter for Patient 2. NA 1 stated Patient 2 tried to pull his catheter, get out of bed, exhibited aggressive behavior and attempted to hit the staff. NA 1 stated the four siderails were up to prevent falls. NA 1 stated Patient 2 was on isolation precautions for VRE and CRP, and she would need to put on the isolation PPE before entering Patient 2’s room, which would delay from stopping Patient 2 from pulling his catheter and from falling out of bed. On 7/17/25 at 1440 hours, review of Patient 2’s medical record was conducted with the Nursing Educator. The Nurse Educator stated there was no physician’s order for Patient 2’s four siderails to be up. The Nursing Educator stated when the four siderails were up, it was considered as restraints, and there was no P&P for the use four side rails up to prevent falls. The above finding was shared with the Nurse Educator.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure the nursing staff developed an individualized nursing care plan to address the care needs of the patient with pain and pleural effusion for one of five sampled patients (Patient 4). This failure posed the risk of patient care and treatment were not appropriately provided to the patient. Findings: Review of the hospital’s P&P titled Interdisciplinary Plan Of Care (IPOC) dated 11/16/22, showed the following: * Policy: The hospital plans the patient’s care, treatment, and services based on the needs identified by the patient’s initial assessment, reassessment, and result of diagnostic testing. The Plan of Care is based on the patient’s goal and the time frames, settings, and services required to meet those goals. Based on the goals established in the patient’s plan of care, staff evaluate the patient’s progress towards goals. The hospital revises plans and goals for care, treatment, and services based on the patient’s needs. * Procedure: Initiating a Plan of Care: - Completion of the Nursing Assessment will trigger a suggested IPOC displayed on the order section of the patient’s EMR. - The nurse collaborates with the Interdisciplinary Care Team. A member of the care team may also identify, search, and select an appropriate IPOC. - The Nurse/Interdisciplinary Care Team reviews goals and interventions and initiates the IPOC. - The Plan of Care is individualized by for each patient based on medical diagnosis and actual or potential problems identified in the initial assessment and reassessment during hospitalization. Patient specific goals and/or patient specific interventions should be used to individualize the IPOC. - The Nurse or Interdisciplinary Care Team updates outcomes and interventions. On 11/18/24 at 1534 hours, an interview and concurrent review of Patient 4’s medical record was conducted with RN 5, Nurse Manager 3, and Director 2. Patient 4’s medical record showed Patient 4 was admitted to the hospital on 11/14/24. Review of Patient 4’s H&P examination dated 11/14/24 at 0032 hours, showed Patient 4 had progressively worsening intermittent coughing spells over the past several weeks. The Assessment/Plan section showed the patient was found to have progressively enlarged right pleural effusion on the chest X-ray. The patient was potentially to have thoracentesis. Review of the Procedure Note Required Details dated 11/14/24 at 1130 hours, showed a chest tube insertion was performed for the patient. Review of RN’s pain assessment for Patient 4 showed on 11/14/24 at 1612 hours, Patient 4’s pain level was six (on a pain scale from zero to 10, zero means no pain and 10 means the worst possible pain); the pain location was the right abdomen; and Patient 4’s acceptable pain level was zero. Patient 4’s medical record showed Patient 4 was given oxycodone (a pain medication) 5 mg PO as needed for pain. Patient 4’s pain level was reassessed on 11/14/24 at 1652 hours and the patient’s pain level was zero. Review of Patient 4’s medical record failed to show documented evidence the nursing staff developed the plan of care related to pain, and the patient’s large pleural effusion. RN 5 confirmed there was no care plan developed for pain and for the patient’s problem of pleural effusion.”

“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: 37663 Based on interview and record review, the hospital failed to ensure the nursing staff implemented the hospital’s P&P related to recording the chest tube output for one of five sampled patients (Patient 4). This failure posed the risk of patient care and treatment were not provided appropriately for the patient. Findings: Review of the hospital’s P&P titled Patient Care Documentation Guidelines (Inpatient) dated 2/8/24, showed in part: * Policy: The hospital nursing staff will adhere to specified patient care documentation guidelines in the Inpatient Units, including assessment, reassessment, and documentation. * Purpose: To outline patient care expectations and documentation requirements in the Inpatient Units. * For the Telemetry Unit, the documentation of the intake and output is every 8 hours. On 11/18/24 at 1534 hours, an interview and concurrent review of Patient 4’s medical record was conducted with RN 5, Nurse Manager 3, and Director 2. Patient 4’s medical record showed Patient 4 was admitted to the hospital on 11/14/24. Review of the Procedure Note Required Details dated 11/14/24 at 1130 hours, showed a chest tube insertion was performed for the patient. Review of Patient 4’s flowsheet for the chest tube outputs showed the following: - On 11/15/25 from 0700 to 1859 hours (day shift), the chest tube output section was left blank. - On 11/15/24 from 1900 to 0659 hours (night shift), the chest tube output was 280 ml, recorded on 11/16/24 at 0720 hours. - On 11/16/24 for the day shift, the chest tube output was 480 ml; and for the night shift, the chest tube output was 760 ml. - On 11/17/24 for day shift, the chest tube output was 100 ml; and for night shift, the chest tube section was left blank. On 11/18/24 at 1557 hours, an interview and record review was conducted with RN 6. RN 6 stated he took care of the patient on 11/17/24 day shift. RN 6 was asked about the Patient 4’s chest tube output on 11/17/24 night shift. RN 6 stated Patient 4’s chest tube did not have output on the night shift of 11/17/24. However, there was no documented evidence on 11/17/24 night shift the RN documented that there was no chest tube output. The chest tube output was left blank. RN 5 and Nurse Manager 3 stated the nursing staff should document the chest tube output. The findings were shared with RN 5 and Nurse Manager 3.”