El Centro Regional Medical Center

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 45063 Based on interview and record review the facility failed to ensure a patient’s (Patient 1) Peripheral Intravenous (PIV- placement of a small flexible plastic tube into a surface vein to deliver fluids, medications, or blood products) access was consistently assessed. This failure had the potential for Patient 1 to experience PIV related complications. Findings: Patient 1 was admitted to the hospital on 7/3/26 with diagnoses which included degenerative disk disease (a condition that describes natural breakdown and wear of the soft cushioning discs between spine’s bones over time) and non-displaced fracture of T12 (a stable crack in the twelfth thoracic vertebra where the bone remains properly aligned). Patient 1 had a history of falling from a ladder at home two (2) weeks prior, per the History and Physical (H&P). A concurrent interview and record review was conducted with the Clinical Nurse Specialist (CNS) on 8/4/26 at 2:21 P.M. Patient 1’s Intravenous Lines & Tubings (IVLT) flowsheet, dated 7/3/26 was reviewed. The IVLT flowsheet indicated, that on 7/3/26 at 8 A.M., a PIV, gauge 20 catheter, was placed on Patient 1’s left forearm. The IVLT flowsheet indicated that the PIV was assessed on: 7/5/26 at 8 P.M. and 7/6/26 at 8 P.M. There was no documented assessment of the PIV on 7/4/26 and 7/7/26. Per Patient 1’s Code Blue (life threatening crisis), note dated 7/8/26, Patient 1’s PIV was not patent (open, clear, unobstructed) and not functional on 7/8/26 at 2 A.M. The CNS stated that Patient 1’s PIV should have been assessed and documented every shift to prevent adverse outcomes like infection, deep vein thrombosis (DVT- medical condition where a blood clot forms in a deep vein in the body), and ensure patency (the state of being open, clear, or free from any obstruction). On 8/5/26 at 8:05 A.M., an interview with the Registered Nurse (RN) was conducted. The RN acknowledged that there was no PIV assessment and documentation on 7/7/26. The RN stated that Patient 1’s PIV should have been assessed and documented for patency, redness, and/or infiltration, once per shift. The RN stated if it was not documented, it was not done. The RN stated it was important to assess Patient 1’s PIV to ensure patency and prevent infection. On 8/5/26 at 8:45 A.M., an interview with the Director of Adult In-Patient Services (Dir- APS) was conducted. The Dir-APS acknowledged that there was no consistent assessment and documentation of Patient 1’s PIV. The Dir-APS stated the expectation was for all Registered Nurses to assess and document PIV assessment every shift, but this was not done. The Dir-APS stated it was important to assess and document PIV assessment to monitor for possible signs of infection and to ensure that Patient 1’s PIV was patent and functional. A review of the facility’s policy and procedure (P&P) titled, “Preventing IV Therapy Complications” - Dynamic Health undated, the P& P indicated, ...Procedure ...5. Assess IV site ...6. Assess patency and proper functioning of IV catheter ...Post procedure ..1. “Assess IV site regularly and before each infusion for signs of infiltration or other abnormalities.””

“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: 45909 Based on interview and record review, the facility failed to follow its policy and procedure related to pain assessment, for one out of 15 sampled patients (Patient 16). As a result, Patient 16’s pain was not reassessed (to look at again; reevaluate), which had the potential to ineffectively control Patient 16’s pain level (pain measurement using a scale; 0 - no pain, 1-3 mild pain, 4-6 moderate pain and 7-10 severe pain) and affect her well-being. Findings: Patient 16 was admitted to the facility on 7/29/26 with diagnoses of Parkinson’s disease (progressive nervous system disorder that affects movement), per the history and physical. A concurrent interview and record review was conducted with the clinical educator (CE) on 8/5/26 at 11:01 A.M. Patient 16’s pain assessment flowsheet indicated that on 8/4/26 at 2:37 P.M., Patient 16 complained of a neck pain level of 6. The CE stated that per Patient 16’s medication administration record (MAR) dated 8/4/26 at 2:37 P.M., Patient 16 received one tablet of Percocet (pain medication) 325 milligrams (mg- unit of measurement). The CE stated that the licensed nurse (LN) did not reassess Patient 16’s pain level. The CE further stated that licensed nurses (LN) should have reassessed Patient 16’s pain level after an hour (one hour) of pain medication administration to address if further pain management should have been implemented. An interview was conducted with the chief nursing officer (CNO) on 8/6/26 at 1:14 P.M. The CNO stated that licensed nurses should reassess every patient’s level of comfort after administering pain medication. The CNO stated that the LN who administered the pain medication should have reassessed Patient 16’s level of comfort to identify/assess if the medication was effective. The facility’s policy titled Pain Assessment and Management dated 4/12/2024 indicated, “ ...32. Pain level should be assessed before the intervention and within one hour after the intervention, in order to assess the patient’s response.””

“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: 45909 Based on interview and record review, the facility failed to ensure medication was administered as ordered by the physician for one out of 15 sampled patients (Patient 17) when an incorrect dose of insulin (medication that lowers blood sugar level) was administered to Patient 17. This failure had the potential to lower Patient 17’s blood sugar level and affect her well-being. Findings: Patient 17 was admitted to the facility on 8/4/26 with medical diagnosis of diabetes mellitus (elevated blood sugar) per the history and physical. A review of Patient 17’s physician order dated 8/4/26 indicated, “Give insulin lispro (IL; brand name of insulin) - inject subcutaneous (under the skin) at HS (bedtime) sliding scale: ...” Finger stick blood glucose (FSBG) Less than 151 - 0 units 151 -200 - 0 units 201 -250 - 2 units 251 - 300 - 4 units 301- 350 - 6 units 351 - 400 - 8 units A concurrent interview and record review was conducted with the clinical educator (CE) on 8/5/26 at 2:34 P.M. The CE stated that on 8/4/26 at 10:36 P.M., Patient 17’s FSBG was 204. The CE stated that per Patient 17’s medication administration record (MAR), Patient 17 received 3 units of IL in her left arm. The CE stated that Patient 17 should have received 2 units of IL per the physician order. The CE further stated that the licensed nurses (LN) should have verified that Patient 17 should have received the right dose to prevent low blood sugar. An interview was conducted with the chief nursing officer (CNO) on 8/6/26 at 1:40 P.M. The CNO stated that the LNs should have verified the right dose of the IL administered to Patient 17, to prevent low blood sugar complications. The facility’s policy titled Medication Administration Guidelines dated 7/28/24 indicated, “ ...31. The licensed nurse administers the right medication to the right patient, in the right dose, via the right route at the right time ....””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 28183 Based on interview and record review, the hospital failed to ensure a Medicare Outpatient Observation Notice (MOON) (a document that informs patients that they are outpatients and not inpatients, which can impact their costs) was provided to one sampled patient (Patient 9), per hospital policy. Findings: The clinical record was reviewed on 9/18/24 and 9/19/24. Patient 9 was admitted to the hospital as Outpatient/Observation status on 9/16/24, per the patient information form. In the Electronic Health Record (EHR), was a scanned copy of the patient’s Medicare Outpatient Observation Notice. On the last page, there was no signature, however the words “patient unable to sign due to being in recovery” were written on the signature line and was dated 9/16/24 at 1:22 P.M. Per a physician’s progress note, dated 9/17/24, the patient had surgery 9/16/24 and was discharged from the hospital on 9/17/24. On 9/19/24 at 10:10 A.M., the Patient Access Director stated during an interview, that when a patient is unable to sign, “If we have the ability to send someone every day, we will. It’s staffing dependent.” The Patient Access Director further stated, “I did go into the system for this patient. There were no documented attempts. We’re trying to enforce that for staff to go in manually to add those notes into system.” The Patient Access Director acknowledged that the form was scanned into the EHR but there were no notes about further attempts during the patient’s stay. According to the hospital’s policy, Notice of Outpatient/Inpatient Status, dated 7/9/19, “When the decision is made to place a patient in Observation Status, the registration personnel will notify the patient of their outpatient status and provide them with a copy of the Notice of Outpatient/Inpatient Status...The registration clerk will have the patient, or the beneficiary acting on behalf of the patient, sign and date the form, then witness the document. The original document will be placed in the medical record, and a copy (pink copy) provided to the patient.” According to the hospital’s policy, Admission for Services, last reviewed 8/17/22, “When the patient is comatose or otherwise unable to participate in required signing of forms or admission process, Admitting will admit/register the patient with whatever information is available, then follow up on a daily basis to obtain correct information, completion of required forms, signatures, etc.””

“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: 38542 Based on interview and record review, the facility failed to ensure the staff obtained signatures for the Conditions of Admissions in a timely manner for four out of 30 sampled patients (1, 4, 7 and 8). As a result, there was a potential treatments were performed without consents. Findings: Patient 1 was admitted to the facility on 9/13/24 with diagnoses which included acute kidney injury per the facility’s facesheet. A review of records was conducted. The document titled Conditions of Admissions (COA) indicated Patient 1 was unable to sign on 9/13/24 due to “medical condition.” Patient 4 was admitted to the facility on 9/12/24 with diagnoses per the facility’s facesheet. A review of records was conducted. The document titled COA indicated Patient 4 was “unable to sign” on 9/12/24. Patient 7 was admitted to the facility on 8/6/24 per the facility’s facesheet. A review of records was conducted. The document titled COA indicated Patient 7 was unable to sign on 8/6/24. Patient 8 was admitted to the facility on 9/11/24 per the facility’s facesheet. A review of records was conducted. The document titled COA indicated Patient 8 was unable to sign on 9/11/24 due to patient is “altered per nurse.” On 9/17/24 at 3:45 P.M., an interview with the Patient Access Director (PAD) was conducted. The PAD stated the staff should document attempts to obtain the patient’s or the patient representatives’ signatures on the COA. On 9/19/24 at 10:10 A.M., an interview with the PAD was conducted. The PAD stated when a patient was unable to sign, “If we have the ability to send someone everyday [to obtain the signatures], we will. It’s staffing dependent.” Per the facility’s policy and procedure titled, Admission for Services last reviewed 8/17/22, “Patient is unable to communicate/No family members present When the patient is comatose or otherwise unable to participate in required signing of forms or admission process, Admitting will admit/register the patient with whatever information is available, then follow-up on a daily basis to obtain correct information, completion of required forms, signatures,etc.””