Antelope Valley 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: 46238 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient Rights was met, as evidenced by: 1. The facility failed to ensure its nursing staff and radiology department staff coordinated and communicated effectively to ensure a STAT (a medical abbreviation for immediately or without delay) computerized tomography angiography (CTA, a medical imaging technique to create detailed images of the inside of the body using iodine-based contrast dye to detect clots, blockages or plaque in the brain, lungs, heart and kidneys) chest scan was done as soon as possible per physician order, for one for 34 sampled patients (Patient 16), in accordance with the facility’s policy regarding provision of care. Patient 16’s CTA chest scan was completed 4.5 hours later on 7/28/2025. This deficient practice had potential to cause delay in diagnosing Patient 16’s elevated heart rate and treatment for Patient 16, which may lead to patient harm and/or death. (Refer to A-0129) 2. The facility failed to ensure one of 34 sampled patients (Patient 17), received appropriate pain management when Patient 17 was discharged from emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) on 10/8/2025, despite reporting severe pain, nine (9) out of ten (10) pain, on the numeric pain scale (0-10, a pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain). This deficient practice had the potential to result in Patient 17 continuing to suffer from pain and discomfort after being discharged. (Refer to A-0129) 3. The facility failed to ensure one of 34 sampled patients (Patient 17) received an accurate diagnosis, when the radiologist (MD 18) failed to identify a T2 (part of thoracic spine) fracture (broken bone) on a computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) image. MD 18 did not identify and report a T2 fracture on the original CT cervical spine report on 10/8/2025. As a result, Patient 17 was discharged from the facility’s ED (Emergency Department) without knowing about the T2 fracture. This deficient practice led to a delay in treating Patient 17’s T2 fracture and increased the risk of fracture worsening. (Refer to A-0129) 4. The facility failed to ensure one of 34 sampled patients (Patient 17) was provided with accurate information regarding a missed T2 fracture after submitting a grievance (formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care that requires investigation) to the facility. This deficient practice violated Patient 17’s right to receive correct information and had the potential to lead diminished trust in the healthcare system, psychological distress, and continued dissatisfaction with the facility’s services. (Refer to A-0129) 5. The facility failed to ensure one of 34 sampled patient’s (Patient 20) nursing care plan (a structured, written document that outlines a personalized, holistic approach to a patient’s care; It acts as a roadmap for nurses to identify patient needs, establish measurable goals, and coordinate care among the healthcare team) for restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), was developed and maintained, in accordance with the facility’s policy regarding restraints care plan. This deficient practice had the potential for Patient 20’s care needs and risks to not be communicated among the healthcare team, which could affect Patient 20’s treatment plan and overall care outcome. (Refer to A-0166) 6. The facility failed to ensure that nursing staff assessed one of 34 sampled patients (Patient 20), every two hours, while on bilateral (left and right) soft wrist restraints (mechanical device that reduces the ability of a patient to move or access any part of their body), in accordance with the facility’s policy and procedure titled, “Restraint and Seclusion (involves isolating a patient in a locked room to prevent immediate harm to a patient or others) Guidelines.” This deficient practice had the potential to result in impaired circulation (blood flow), skin breakdown (the damage to skin integrity, ranging from redness to open wounds, caused by prolonged pressure, friction, shear, or moisture), or emotional distress, by not assessing Patient 20’s restraints use. (Refer to A-0175) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“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: 46238 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Medical Staff was met, as evidenced by: 1. The facility failed to ensure its medical staff coordinated and provided quality care, for one of 34 sampled patients (Patient 16), in accordance with the facility’s medical staff bylaws, when physicians (MD 3 and MD 6) failed to review and follow up diagnostic tests ordered, communicate and act upon on the abnormal findings identified from the chest X ray (an imaging procedure to create detailed image of the body’s internal structure such as bones, tissues and organs) and the computerized tomography angiography (CTA, a medical imaging technique to create detailed images of the inside of the body using iodine-based contrast dye to detect clots, blockages or plaque in the brain, lungs, heart and kidneys) chest scan, completed on 7/28/2025 until the next day (7/29/2025), to address Patient 16’s elevated heart rate. This deficient practice resulted in delayed diagnosis, intervention and treatment to manage Patient 16’s anastomotic leak (a post-surgery complication occurs when a surgical anastomosis [a surgical procedure connecting two tubular structures in the body such as blood vessels or loops of intestine] fails and contents of a reconnected body channel leak from the surgical connection), which led to Patient 16 requiring an emergency surgery for exploratory laparotomy (an open surgery requiring large incision in the abdomen to directly view and examine the organs) with small bowel resection (a surgery to remove a damaged or diseased section of the small intestine [bowel]) and colectomy (surgical removal of part or all of the colon), and mesenteric angiography (special procedure to visualize the blood vessels supplying the small and large intestines to locate bleeding or ischemia [reduced blood flow to the organ and tissues]) on 7/29/2025. (Refer to A-0353) 2. The facility failed to ensure its medical staff conducted a peer review (a mandatory, systematic evaluation of a physician’s clinical performance, conduct, or medical outcomes conducted by professional peers to ensure patient safety and quality care) for one of 34 sampled patients (Patient 16), after Patient 16 experienced a surgical complication requiring a second surgery to repair an anastomosis leak (a post-surgery complication occurs when a surgical anastomosis [a surgical procedure connecting two tubular structures in the body such as blood vessels or loops of intestine] fails and contents of a reconnected body channel leak from the surgical connection) during the hospitalization on 7/29/2025, in accordance with the facility’s Medical Staff Bylaws (are the official, legally binding rules that govern the self-governance, credentialing, and professional conduct of physicians and other clinicians within a healthcare organization. Approved by the hospital’s board, they outline responsibilities for quality care, due process, and peer review, acting as a contract between clinicians and the organization) and Peer review protocol. Patient 16 died on 7/30/2025 at 4:38 a.m. as a coroner’s case (a death investigation initiated when a person dies under unexpected, suspicious, violent, or unattended circumstances). No peer review has occurred since the case was referred to the department of surgery on 7/31/2025. This deficient practice had the potential to result in medical staff not identifying the root cause of the incident, to provide intervention or education to the providers in order to prevent similar cases from recurrence. (Refer to A-0347) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“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: 46238 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by: 1. The facility failed to ensure that registered nurses supervised and evaluated the nursing care for four (4) of 34 sampled patients (Patient 2, Patient 5, Patient 15, and Patient 27) who were experiencing uncontrolled pain (defined as pain that remains above the patient’s acceptable level, persists despite reported assessments, or is not addressed with timely interventions or reassessments), in accordance with the facility’s policy regarding pain assessment and management, when: 1.a. The RN assessed Patient 2’s pain repeatedly as 10/10 (indicates severe pain on a numeric scale; 0-no pain, 1 to 3-mild pain, 4 to 6-moderate pain, 7 to 10-severe pain), but did not provide timely interventions, did not reassess pain within 30 minutes after medication administration, and did not notify the provider of persistent severe pain. This deficient practice resulted in unrelieved pain for Patient 2 and the potential for prolonged discomfort and psychological distress. In addition, this deficient practice violated Patient 2’s right (the patient’s entitlement to safe, timely, and appropriate care) to receive timely and appropriate care. (Refer to A-0395) 1.b. Nursing staff failed to assess Patient 5’s pain level hourly per physician’s order, reassess pain level post (after) medication administration, or escalate care to a provider, even though Patient 5 experienced persistent severe pain rated 8-10/10 on a numeric scale (indicating severe to the worst possible pain on the standard 0-10 pain scale), despite receiving analgesics (medications used to relieve pain), throughout Patient 5’s ED (Emergency Department, a hospital department that provides urgent and unscheduled medical care) stay. This deficient practice resulted in unrelieved pain for Patient 5 and placed Patient 5 at risk for delayed recognition of changes in their condition, prolonged severe discomfort, and potential deterioration of clinical status. (Refer to A-0395) 1.c. Nursing staff failed to evaluate/assess Patient 15’s pain level, every 2 hours, during vital signs check to determine the need for appropriate pain management. This deficient practice had the potential to result in unrelieved pain for Patient 15 and had the potential to place Patient 15 at risk of delayed recognition of changes in Patient 15’s condition. In addition, this deficient practice violated Patient 15’s right (the patient’s entitlement to safe, timely, and appropriate care) to receive timely and appropriate management of pain. (Refer to A-0395) 1.d. Nursing staff assessed/evaluated Patient 27’s pain level but did not provide interventions to relieve pain prior to Patient 27’s discharge from the emergency department (ED, a hospital department that provides urgent and unscheduled medical care). This deficient practice had the potential to result in unrelieved pain for Patient 27 and violated Patient 27’s right to receive timely pain management. (Refer to A-0395) 2. The facility failed to ensure adequate monitoring and safe nursing care for four of 34 sampled patients (Patient 4, Patient 5, Patient 6, and Patient 15) in the Red Zone (APOT area, meaning Ambulance Patient Offload Time area where EMS, Emergency Medical Services, transfers patients to the hospital when no ED beds are available) area of the facility’s Emergency Department (ED). Patients in the red zone area experienced missed vital signs (VS, meaning measurements such as heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation) checks, missed pain assessments, lack of patient monitoring, lack of pain management, and one patient (Patient 6) was found unresponsive (unconscious, meaning they do not react to voice, touch, or pain, and cannot be woken up. It indicates a medical emergency where the person is completely still and unresponsive to stimulation) without nursing oversight or monitoring. This deficient practice resulted in the risk of serious harm or death for Patient 4, Patient 5, Patient 6, and Patient 15, as well as all facility patients requiring urgent and emergent care who continued to be offloaded by ambulance into the Red Zone areas in the facility. (Refer to A-0395) 3. The facility failed to ensure one (1) of 34 sampled patients (Patient 7), who was admitted to the facility with stroke symptoms (sudden weakness, trouble speaking, vision problems, dizziness, or severe headache), received an initial NIHSS (National Institutes of Health Stroke Scale, a standardized tool used to measure stroke severity) or a completed neurological examination (a medical assessment of the nervous system), in accordance with the facility’s “Stroke” policy and procedures. This deficient practice had the potential to delay the recognition of a change in condition for Patient 7 and for patients who presented to the facility’s Emergency Department (ED, area in the hospital where people go when they need immediate medical care for sudden or serious health problems) with stroke symptoms. (Refer to A-0395) 4. The facility failed to ensure nursing staff adhered to the facility’s policies and procedures when: 4.a. One of 34 sampled patients (Patient 20), was placed on bilateral (left and right) soft wrist restraints (mechanical device that reduces the ability of a patient to move or access any part of their body) and was not assessed at an interval of every two (2) hours, in accordance with the facility’s policy and procedure titled, “Restraint and Seclusion (involves isolating a patient in a locked room to prevent immediate harm to a patient or others) Guidelines.” This deficient practice had the potential for Patient 20 to suffer from complications of not having his (Patient 20) care needs assessed, while on restraints, which includes impaired skin circulation (blood flow), skin breakdown (damage to the skin), and emotional distress. (Refer to A-0398) 4.b. One of 34 sampled patients (Patient 20) was not repositioned every two hours, in accordance with the facility’s policy and procedure titled, “Skin Care Assessment and Treatment.” Patient 20 had a Braden Scale (tool used to evaluate a person’s risk of developing a pressure injury [localized damage to the skin and/or underlying tissue usually over a bony prominence]) score of less than 18, which indicated that Patient 20 was at risk of a skin breakdown (damage to the skin) if not repositioned in a timely manner. This deficient practice had the potential for Patient 20 to develop a pressure injury (localized damage to the skin and underlying soft tissue, usually occurring over bony prominences, caused by prolonged pressure, friction, or shear), which could have caused discomfort, infection and pain. (Refer to A-0398) 5. The facility failed to ensure one of 34 sampled patient’s (Patient 2) medication reconciliation (the process of creating the most accurate list of all medications a patient is taking and comparing it to provider orders to ensure that medications are not omitted, duplicated, or contraindicated) form, was completed, in accordance with the facility’s policy regarding medication reconciliation, during Patient 2’s Emergency Department (a hospital department that provides urgent and unscheduled medical care) visit on 8/12/2025. This deficient practice resulted in Patient 2 being placed at risk for medication errors, including the risk of omitted, duplicated, or contraindicated medications, and potential delays in receiving safe, accurate and appropriate treatment. (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“ANESTHESIA SERVICES CFR(s): 482.52 If the hospital furnishes anesthesia services, they must be provided in a well-organized manner under the direction of a qualified doctor of medicine or osteopathy. The service is responsible for all anesthesia administered in the hospital. This Condition is not met as evidenced by: 46333 Based on Observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Anesthesia Services was met, as evidenced by: 1. The facility failed to ensure anesthesia services identified and corrected an unsafe draping process that created a tent (a pocket of trapped air under the drapes) that allowed oxygen (a gas that supports combustion) to accumulate beneath the surgical drapes during a procedure for one (1) of 34 sampled patients (Patient 8), in which supplemental oxygen and electrocautery (a heat?producing surgical device used to cut tissue or stop bleeding), were used, in accordance with the facility’s policy regarding anesthesia safety requirements. This deficient practice likely contributed to a surgical fire that occurred during the procedure for Patient 8 and placed current and future surgical patients at risk for fire-related harm. (Refer to A-1002) 2. The facility failed to ensure its anesthesiologist (medical doctor specializing in perioperative care, and administering sedation [administering drugs to produce a state of calm or sleep] to patients before, during and after surgery, [MD7]) completed a pre-anesthesia (before sedation) evaluation for one of 34 sampled patients (Patient 16) prior to surgery on 7/29/2025, in accordance with the facility’s policy regarding anesthesia (a controlled, temporary medical state induced by drugs [anesthetics] to prevent pain, discomfort, and memory of medical procedures ) safety requirements. This deficient practice had the potential to result in Patient 16 experiencing potential anesthesia problems and complications. (Refer to A-1003) 3. The facility failed to ensure its anesthesiologist (medical doctor specializing in perioperative care, and administering sedation [administering drugs to produce a state of calm or sleep] to patients before, during and after surgery, [MD7]) completed a post-anesthesia (after sedation) evaluation for one of 34 sampled patients (Patient 16) after surgery performed on 7/29/2025, in accordance with the facility’s policy regarding anesthesia safety requirements. This deficient practice had the potential to result in Patient 16’s anesthesia complications not being evaluated and identified. (Refer to A-1005) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to: 1. Ensure its nursing staff and radiology department staff coordinated and communicated effectively to ensure a STAT (a medical abbreviation for immediately or without delay) computerized tomography angiography (CTA, a medical imaging technique to create detailed images of the inside of the body using iodine-based contrast dye to detect clots, blockages or plaque in the brain, lungs, heart and kidneys) chest scan was done as soon as possible per physician order, for one for 34 sampled patients (Patient 16), in accordance with the facility’s policy regarding provision of care. Patient 16’s CTA chest scan was completed 4.5 hours later on 7/28/2025. This deficient practice had potential to cause delay in diagnosing Patient 16’s elevated heart rate and treatment for Patient 16, which may lead to patient harm and/or death. 2. Ensure one of 34 sampled patients (Patient 17), received appropriate pain management when Patient 17 was discharged from emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) on 10/8/2025, despite reporting severe pain, nine (9) out of ten (10) pain, on the numeric pain scale (0-10, a pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain). This deficient practice had the potential to result in Patient 17 continuing to suffer from pain and discomfort after being discharged. 3. Ensure one of 34 sampled patients (Patient 17) received an accurate diagnosis, when the radiologist (MD 18) failed to identify a T2 (part of thoracic spine) fracture (broken bone) on a computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) image. MD 18 did not identify and report a T2 fracture on the original CT cervical spine report on 10/8/2025. As a result, Patient 17 was discharged from the facility’s ED (Emergency Department) without knowing about the T2 fracture. This deficient practice led to a delay in treating Patient 17’s T2 fracture and increased the risk of fracture worsening. 4. Ensure one of 34 sampled patients (Patient 17), was provided with accurate information regarding a missed T2 fracture after submitting a grievance (formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care that requires investigation) to the facility. This deficient practice violated Patient 17’s right to receive correct information and had the potential to lead to diminished trust in the healthcare system, psychological distress, and continued dissatisfaction with the facility’s services. Findings: 1. During a review of Patient 16’s “Operative Report (surgery report),” dated 7/24/2025, the “Operative Report” indicated, Patient 16 had partially obstructing hepatic flexure (the sharp bend between the ascending and transverse colon at the right upper quadrant near the liver) colon cancer mass. The “Operative Report” also indicated, Patient 16 had robotic (robotic surgery, robot-assisted surgery) converted to open extended right hemicolectomy (a surgery removing the right side of the colon) and partial omentectomy (surgical removal of a fatty layer of tissue in the abdomen) on 7/24/2025. During a review of Patient 16’s vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) record, dated 7/28/2025, the vital signs record indicated, on 7/28/2025, Patient 16’s heart rate (normal heart rate between 60 and 100 beats per minute) was 127 beats per minute (bpm) at 8:36 a.m. and 122 bpm at 11:48 a.m. During a review of Patient 16’s “MD communication (documentation of communication between nurses and physicians),” dated 7/28/2025, the “MD communication” indicated, on 7/28/2025 at 4:37 p.m., Registered Nurse (RN 18) contacted physician (MD 3) for Patient 16’s elevated D-Dimer (a blood test to detect blood clot in the body) result. The “MD communication” also indicated, MD 3 responded on 7/28/2025 at 5:14 p.m. and ordered to do computerized tomography angiography (CTA, a medical imaging technique to create detailed images of the inside of the body using iodine-based contrast dye to detect clots, blockages or plaque in the brain, lungs, heart and kidneys) chest scan. During a concurrent interview and record review on 3/4/2026 at 3:44 p.m. with the Sepsis (a body’s overwhelming and life-threatening response to infection) Coordinator (SC 2), Patient 16’s physician orders (orders written by physicians to direct care and treatment), dated 7/28/2025, were reviewed. The physician order indicated, on 7/28/2025 at 5:12 p.m., MD 3 ordered to perform CTA chest scan with intravenous (IV, medical method for delivering fluids, medications, nutrition, or blood directly into patient’s bloodstream via a vein) contrast (dye) STAT (a medical abbreviation for immediately or without delay), citing tachycardia (high heart rate) as the indicated reason. The physician order also indicated two (2) comment notes: “at 5:36 p.m. - labs (blood test result) good. 20 G (gauge, size of an intravenous catheter [IV, a thin, flexible, hollow tube inserted into a vein to deliver fluids and medications directly into the bloodstream]) in AC (antecubital, the shallow depression located in front of the elbow) or FA (forearm) pending by radiology technologist (RAD 1); and at 8:51 p.m. - pending 20 G (IV) in AC for CTA by radiology technologist (RAD 2).” SC 2 stated the two comments indicated the radiology department staff (RAD 1 and RAD 2) was waiting for a nurse to insert a 20 G IV for Patient 16 in order to complete the CTA chest scan. During an interview on 3/4/2026 at 4:09 p.m. with RN 18, RN 18 stated RN 18 did not recall if radiology department had spoken to RN 18 requesting a 20 G IV. RN 18 stated it did not take long to insert an IV. RN 18 further stated STAT CT scan should be completed within an hour. RN 18 further stated the purpose of the CTA chest was to evaluate any type of bleeding, blockage, or clots so the team could provide intervention in a timely manner. During a concurrent interview and record review on 3/6/2026 at 11:51 a.m. with the Manager (MR 5) of Radiology Department, Patient 16’s physician orders, dated 7/28/2025, were reviewed. The physician order indicated, on 7/28/2025 at 5:12 p.m., MD 3 gave an order to perform CTA chest scan with IV contrast STAT with indicated reason for tachycardia. The physician order also indicated two (2) comment notes: “at 5:36 p.m. - labs good. 20 G (IV) in AC or FA pending by radiology technologist (RAD 1); and at 8:51 p.m. - pending 20 G (IV) in AC for CTA by radiology technologist (RAD 2). MR 5 stated it was the radiology department’s practice to inform the patient’s nurse regarding any reason for not being able to take the patient to CT scan. MR 5 stated the radiology department staff were required to document whom the radiology staff spoke with. MR 5 stated RAD 1 and RAD 2 did not comment on who they (RAD 1 and RAD 2) spoke with to follow up on inserting IV for Patient 16. MR 5 stated it was unknown which nurse was contacted to be responsible for putting in the IV for Patient 16. MR 5 stated the communication was incomplete. During a concurrent interview and record review on 3/6/2026 at 12:01 p.m. with MR 5, Patient 16’s “CTA chest scan report (CT scan report),” dated 7/28/2025, was reviewed. The “CT scan report” indicated the exam date and time was on 7/28/2025 at 10:59 p.m. and signed off by radiologist (MD 20) on 7/29/2025 at 1:45 a.m. MR 5 stated the goal for STAT CT scan completion was one hour. MR 5 stated Patient 16’s CTA chest scan was completed almost six (6) hours from the original order time (CTA chest scan was ordered on 7/28/2025 at 5:12 p.m.) and it took another two (2) hours and forty-five (45) minutes to be read by radiologist (MD 20). MR 5 stated the CT scan was performed and interpreted late. (CTA chest ordered on 7/28/2025 at 5:12 p.m.). During an interview on 3/6/2026 at 12:08 p.m. with radiologist technologist (RAD 3), RAD 3 stated radiologist technologists (RADs) should communicate with nurses when the CT scan required an IV and follow up again in fifteen to twenty minutes. RAD 3 further stated it was important to communicate and follow up to ensure the STAT scan was done as soon as possible. During a review of Patient 16’s “CTA chest scan report (CT scan report),” dated 7/28/2025, the “CT scan report” indicated, “Impression: 1. No pulmonary embolism (blood clot in lungs) ... 3. Large amount of intraperitoneal free air and portal venous gas (gas trapped in the blood vessels that carries blood from the intestines to the liver), which may be secondary to recent surgery as was discussed in the prior chest X ray report on 7/28/2025. However, a perforated viscus (a medical emergency where a hole or tear develops in the stomach or intestines) and ischemic bowel (a serious condition where blood flow to the intestines is reduced or blocked causing tissue death) can not entirely be excluded in the appropriate clinical setting.” During an interview on 3/5/2026 at 3:05 p.m. with physician (MD 3), MD 3 stated he (MD 3) would consider the CTA chest scan result, which was completed on 7/28/2025 and indicating large amount of free air, an urgent finding, and it should have been escalated to physician’s attention. MD 3 also stated he (MD 3) was not aware of the CTA chest scan because the result was released after 7 p.m. on 7/28/2025. During an interview on 3/6/2026 at 12:16 p.m. with surgeon (MD 6), MD 6 stated he (MD 6) was part of the surgery team who cared for Patient 16. MD 6 stated that on 7/28/2025, he (MD 6) requested MD 3 to evaluate Patient 16’s elevated heart rate and to rule out pulmonary embolism. MD 6 stated that Patient 16’s CTA chest scan report, completed on 7/28/2025, was concerning. During a review of Patient 16’s “Progress Notes (physician note),” dated 7/29/2025 at 1:17 p.m., authored by surgeon (MD 7), the “Progress Notes” indicated, “Patient (Patient 16) now in ICU (Intensive Care Unit, specialist hospital wards that provide treatment and monitoring for people who are very ill) status, PEA arrest (Pulseless Electrical Activity- a form of cardiac [heart] arrest where the heart shows organized electrical activity on monitor but not producing a pulse or effective blood flow) and intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) ... Assessment/Plan ... CT with a lot of free air. Will discuss with [MD 7’s] partner regarding takeback to OR (Operating Room) for question of leak.” During an interview on 3/6/2026 at 12:32 p.m. with MD 6, MD 6 stated that treatment for anastomotic leak (occurs when a surgical anastomosis [a surgical connection between two tubular structures, such as blood vessels] fails and contents of a reconnected body channel leak from the surgical connection) would be taking the patient back to the operation room (OR) to repair the leak surgically. MD 6 further stated if the surgery team was notified sooner, Patient 16 could be in the OR sooner. During a review of Patient 16’s “Operative Report (surgery report),” dated 7/29/2025, the “Operative Report” indicated, Patient 16 had exploratory laparotomy (an open surgery requiring large incision in the abdomen to directly view and examine the organs) with small bowel resection and colectomy (surgical removal of part or all of the colon), and mesenteric angiography (special procedure to visualize the blood vessels supplying the small and large intestines to locate bleeding or ischemia [reduced blood flow to the organ and tissues]) on 7/29/2025. The “Operative Report” also indicated, “findings: purulence (the state of containing, discharging or forming pus indicating infection, severe inflammation or a wound that is not healing properly) throughout the abdomen. Small anastomotic leak at the ileocolic (region where the small intestine joins the large intestine) anastomosis ... An ABThera (Advance Open Abdomen Dressing, negative pressure wound therapy system designed to treat open abdominal wound) was placed. The patient (Patient 16) was transferred back to the ICU (Intensive Care Unit).” During a review of Patient 16’s “Discharge Summary,” dated 11/4/2025, the “Discharge Summary” indicated, “on 7/29 (7/29/2025): Patient (Patient 16) expressed that he (Patient 16) was not feeling well in the morning, CT chest showed free air but not PE (pulmonary embolism). Patient (Patient 16) underwent cardiac arrest (sudden, fatal electrical malfunction causing heart to stop beating) headed PEA arrest ... surgery will be consulted ... Family discussed the case with surgery ... and they decided to change the code status (level of medical interventions a person wishes to have started if their heart or breathing stops) to DNR/DNI (do not resuscitate/do not intubate, a medical order written by a doctor to instruct health care providers not to do cardiopulmonary resuscitation [CPR, an emergency lifesaving procedure performed when the heart stops beating] if a patient’s breathing or heart stops) Full Medical Treatment ... 7/30 (7/30/2025): the patient (Patient 16) expired (died) on 7/30/2025 at 4:38 a.m.” During a review of the facility’s policy and procedure (P&P) titled, “Patients’ Rights and Responsibilities,” dated 9/2025, the P&P indicated, “To help improve patient outcomes by respecting each patient’s rights; to promote the consideration of patient values and preferences; to inform patient their responsibilities in the care process ... The patient has the right to ... A. Considerate and respectful care ...” During a review of the facility’s policy and procedure (P&P) titled, “Radiology Department Provision of Care, Service and Treatment,” dated 9/2025, the P&P indicated, “Scope of Service ... the department is committed to service and demonstrates clinical excellence through interdisciplinary performance improvement, teamwork, and education. It is a coordinated and collaborative effort stressing open and effective communication.” During a review of the facility’s radiology department huddle topic titled, “CT Huddle 11-25,” dated 11/2025, the “CT Huddle 11-25” indicated, “updating patient notes consistently ... all notes need to include: date and time, person you spoke to, what was discussed, your initials ...” 2. During a review of Patient 17’s face sheet (face sheet, document provides patient’s demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance), undated, the face sheet indicated, Patient 17 had an emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) visit on 10/8/2025 at 6:50 a.m. and was discharged from the ED on 10/8/2025 at 11:16 a.m. During a review of Patient 17’s “Emergency Documentation (ED physician note),” dated 10/8/2025, the “ED physician note” indicated, Patient 17 suffered chest wall and head injury after Patient 17 slipped on the stairs and rolled down. The ED physician note indicated Patient 16 was discharged home on 10/8/2025 with diagnoses of cervical strain (common neck injury where the neck is turned or twisted), concussion (a mild traumatic brain injury caused by a bump, blow or jolt to head or body causing the brain to remove rapidly within the skull), scalp hematoma (“goose egg”), and tibial (the bone in the lower leg) fracture (broken bone). During a review of Patient 17’s “Medication Administration Record (MAR, record of medications given to patients),” dated 10/8/2025, the MAR indicated Patient 17 received Morphine (medication to treat severe pain) four (4) milligrams (mg, unit of measure) on 10/8/2025 at 10:17 a.m. with a pain level of nine (9/10). During a concurrent interview and record review on 3/5/2026 at 2:48 p.m. with the Director (DIR 1) of Emergency Department, Patient 17’s pain assessment, dated 10/8/2025, was reviewed. The “pain assessment” indicated, (on 10/8/2025) Patient 17 had generalized pain with pain level at ten (10) out of 10 on a numeric pain scale (0-10, a pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain) at 10:13 a.m., nine (9) out of 10 at 11:12 a.m. and 9 out of 10 at 11:14 a.m. The “pain assessment” also indicated, Patient 17’s acceptable pain intensity was zero (0) out of 10. DIR 1 stated Patient 17’s pain remained at 9. DIR 1 stated Patient 17’s pain was not managed upon discharge. DIR 1 stated nurse should have advocated for Patient 17 and communicated with the physician if the pain medication did not relieve Patient 17’s pain so that the ED physician could evaluate the need for further pain medication or pain prescription. During a concurrent interview and record review on 3/5/2026 at 2:55 p.m. with DIR 1, Patient 17’s “Discharge Instructions (Patient),” dated 10/8/2025, was reviewed. The “Discharge Instructions (Patient)” indicated, “New medications and Prescriptions ... ondansetron 1 tablet oral every six (6) hours as needed for nausea (an urge to vomit) for four (4) days.” DIR 1 stated there was no pain prescription written for Patient 17. During a review of the facility’s policy and procedure (P&P) titled, “Patients’ Rights and Responsibilities,” dated 9/2025, the P&P indicated, “To help improve patient outcomes by respecting each patient’s rights; to promote the consideration of patient values and preferences; to inform patient their responsibilities in the care process ... The patient has the right to ... K. Appropriate assessment and management of the patient’s pain, information about pain, pain relief measures and to participate in pain management decisions.” During a review of the facility’s policy and procedure (P&P) titled, “Pain Assessment & Management,” dated 9/2025, the P&P indicated, “Healthcare providers at [the facility] shall: A. screen patients for pain when visiting the emergency room (same as ED), upon admission, and alongside routine vital signs based on unit protocols. B. Accept and respect patients’ self-report of pain using a verbal self-report pain scale which defines pain levels under the following guidelines: 1. 0 defines a patient who is free of pain; 2. 1 - 3 = mild pain; 3. 4 - 6 = moderate pain; 4. 7 - 10 = severe pain ... Reassessment after interventions ... A reassessment must reoccur no later than two (2) hours after the administration of pain medication. The registered nurse (RN) shall communicate with the physician to coordinate an alternative treatment plan when pain is above the identified comfort goal.” 3. During a review of Patient 17’s face sheet, undated, the face sheet indicated Patient 17 had an emergency department (ED) visit on 10/8/2025 at 6:50 a.m. and was discharged from the ED on 10/8/2025 at 11:16 a.m. During a review of Patient 17’s “Emergency Documentation (ED physician note),” dated 10/8/2025, the “ED physician note” indicated, Patient 17 suffered chest wall and head injury after Patient 17 slipped on the stairs and rolled down. The ED physician note also indicated Patient 17 was discharged home on 10/8/2025 with diagnoses of cervical strain, concussion, scalp hematoma, and tibial fracture. During a concurrent interview and record review on 3/6/2026 at 11:09 a.m. with the Chair (MD 9) of Radiology, Patient 17’s “Computerized Tomography (CT, a medical imaging technique to create detailed images of the inside of the body) Spine Cervical (neck bones supporting the head and allow neck motion) without Contrast (dye) Report (CT report),” dated 10/8/2025, was reviewed. The “CT report” indicated, “date finalized: 10/8/2025 at 9:16 a.m. ... impression: 1. No acute (new onset) fracture (broken done) or subluxation (partial joint dislocation).” The “CT report” also indicated, “Addendum created on 11/5/2025 at 2:16 a.m. ... addendum: acute fracture involving T2 spinous process (a long, slender bony projection on the second thoracic vertebra that points downward, often overlapping the T3 vertebra) which is possibly extending into the posterior (back side) aspect of T2 vertebral body on the left, limited visualization due to osteopenia (reduced bone mineral density). Acute fracture involving the spinous process of T3 which is extending beyond the field of view. Recommend further evaluation with thoracic spine CT or MRI (magnetic resonance imaging, a radiation-free diagnostic procedure using a powerful magnet and radio-wave to create high-quality image of organs and soft tissues).” The “CT report” indicated both original and addendum entries were made by radiologist (MD 18). MD 9 stated the addendum was added on 11/5/2025 almost a month after the original read (10/8/2025). MD 9 said MD 18 re-read the CT imagine and identified the T2 fracture. During a concurrent observation and interview on 3/6/2026 at 11:09 a.m. with MD 9, Patient 17’s CT image of cervical spine, was viewed, MD 9 pointed the T2 fracture located at the bottom edge of the CT image. MD 9 stated the fracture was captured at the bottom edge of the image. MD 9 stated in an ideal world, the radiologist (MD 18) should have caught the fracture and reported it. MD 9 stated it was a missed diagnosis, but it was understandable. During a review of the facility’s policy and procedure (P&P) titled, “Patients’ Rights and Responsibilities,” dated 9/2025, the P&P indicated, “To help improve patient outcomes by respecting each patient’s rights; to promote the consideration of patient values and preferences; to inform patient their responsibilities in the care process ... The patient has the right to ... A. Considerate and respectful care ... D. Received information about the patient’s health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms the patient can understand.” 4. During a review of Patient 17’s face sheet, undated, the face sheet indicated Patient 17 had an emergency department (ED) visit on 10/8/2025 at 6:50 a.m. and was discharged from the ED on 10/8/2025 at 11:16 a.m. During a review of Patient 17’s “Emergency Documentation (ED physician note),” dated 10/8/2025, the “ED physician note” indicated, Patient 17 suffered chest wall and head injury after Patient 17 slipped on the stairs and rolled down. The ED physician note also indicated Patient 17 was discharged home on 10/8/2025 with diagnoses of cervical strain, concussion, scalp hematoma, and tibial fracture. During a concurrent interview and record review on 3/6/2026 at 11:09 a.m. with the Chair (MD 9) of Radiology, Patient 17’s “Computerized Tomography (CT) Spine Cervical without Contrast Report (CT report),” dated 10/8/2025, was reviewed. The “CT report” indicated, “date finalized: 10/8/2025 at 9:16 a.m. ... impression: 1. No acute fracture or subluxation.” The “CT report” also indicated, “Addendum created on 11/5/2025 at 2:16 a.m. ... addendum: acute fracture involving T2 spinous process which is possibly extending into the posterior aspect of T2 vertebral body on the left, limited visualization due to osteopenia. Acute fracture involving the spinous process of T3 which is extending beyond the field of view. Recommend further evaluation with thoracic spine CT or MRI.” The “CT report” indicated both original and addendum entries were made by radiologist (MD 18). MD 9 stated the addendum was added on 11/5/2025 almost a month after the original read (10/8/2025). MD 9 said MD 18 re-read the CT imaging and identified the T2 fracture. During an interview on 3/6/2026 at 1:40 p.m. with the Director of Quality (DQ), DQ stated the facility received a written grievance (formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care that requires investigation) from Patient 17’s insurance on 11/4/2025 on behalf of Patient 17, who had multiple concerns including but not limited to missed spinal fractures findings, improper pain management and care coordination. During a concurrent interview and record review on 3/6/2026 at 1:42 p.m. with DQ, Patient 17’s “Computerized Tomography (CT) Spine Cervical without Contrast Report (CT report),” dated 11/5/2025 and the facility’s resolution letter (a formal, written response sent to a patient [or their representative] after an investigation into a grievance-a formal complaint regarding care, safety, or rights-has been completed) issued to Patient 17’s insurance, dated 11/7/2025, were reviewed. The “CT report” indicated, “Addendum created on 11/5/2025 at 2:16 a.m. ... addendum: acute fracture involving T2 spinous process which is possibly extending into the posterior aspect of T2 vertebral body on the left, limited visualization due to osteopenia. Acute fracture involving the spinous process of T3 which is extending beyond the field of view. Recommend further evaluation with thoracic spine CT or MRI.” The resolution letter indicated, “a different radiologist re-read the exam’s and the results were the same, no fractures were identified.” DQ stated that the CT report addendum indicated Patient 17 had T2 fracture, but the resolution letter indicated no fracture. DQ stated the information on the resolution letter did not match with the addendum on CT report. During a review of the facility’s policy and procedure (P&P) titled, “Patients’ Rights and Responsibilities,” dated 9/2025, the P&P indicated, “To help improve patient outcomes by respecting each patient’s rights; to promote the consideration of patient values and preferences; to inform patient their responsibilities in the care process ... The patient has the right to ... A. Considerate and respectful care ... D. Received information about the patient’s health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms the patient can understand ... J. Reasonable responses to any reasonable requests made for service.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 50516 Based on interview and record review, the facility failed to ensure one of 34 sampled patient’s (Patient 20) nursing care plan (a structured, written document that outlines a personalized, holistic approach to a patient’s care; It acts as a roadmap for nurses to identify patient needs, establish measurable goals, and coordinate care among the healthcare team) for restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), was developed and maintained, in accordance with the facility’s policy regarding restraints care plan. This deficient practice had the potential for Patient 20’s care needs and risks to not be communicated among the healthcare team, which could affect Patient 20’s treatment plan and overall care outcome. Findings: During a record review of Patient 20’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/5/2026, the H&P indicated Patient 20 was admitted to the facility for generalized weakness, fatigue (tired) and difficulty walking. The H&P further indicated that Patient 20’s medical history included deep vein thrombosis (blood clot in the vein), anemia (low amount of blood cells to carry oxygen throughout the body) and skin cancer. During an interview on 3/4/2026 at 3:58 p.m. with Registered Nurse (RN) 6, RN 6 stated that patient-specific care plans (a structured, written document that outlines a personalized, holistic approach to a patient’s care; It acts as a roadmap for nurses to identify patient needs, establish measurable goals, and coordinate care among the healthcare team) served as reassessment reminders, were updated every shift, and could be modified as needed. During a concurrent interview and record review on 3/6/2026 at 10:39 a.m. with the Director of Medical-Surgical and Telemetry (DIR 3), DIR 3 verified that Patient 20 did not have a care plan for restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and stated that there should be a care plan. DIR 3 stated that a care plan ensured that there was a set protocol for Patient 20’s care throughout the hospital stay. During a review of the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion Guidelines,” dated 5/28/2025, the P&P indicated, “The use of restraints will be reflected in the plan of care.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 50516 Based on interview and record review, the facility failed to ensure that nursing staff assessed one of 34 sampled patients (Patient 20), every two hours, while on bilateral (left and right) soft wrist restraints (mechanical device that reduces the ability of a patient to move or access any part of their body), in accordance with the facility’s policy and procedure titled, “Restraint and Seclusion (involves isolating a patient in a locked room to prevent immediate harm to a patient or others) Guidelines.” This deficient practice had the potential to result in impaired circulation (blood flow), skin breakdown (the damage to skin integrity, ranging from redness to open wounds, caused by prolonged pressure, friction, shear, or moisture), or emotional distress, by not assessing Patient 20’s restraints use. Findings: During a record review of Patient 20’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/5/2026, the record indicated Patient 20 was admitted to the facility for generalized weakness, fatigue (tired) and difficulty walking. The record further indicated Patient 20’s medical history included deep vein thrombosis (blood clot in the vein), anemia (low amount of blood cells to carry oxygen throughout the body) and skin cancer. During a record review on 3/4/2026 at 11:12 a.m. with the Data Specialist and Administrative Assistant (DS), Patient 20’s “Order Sheet,” dated 1/6/2026, was reviewed. The Order Sheet indicated that Patient 20 had an order for soft left and right wrist restraints (mechanical device that reduces the ability of a patient to move or access any part of their body) due to patient 20 pulling at tubes and lines. During an interview on 3/4/2026 at 3:58 p.m. with Registered Nurse (RN) 6, RN 6 stated there should be an assessment every two hours to release the restraints, check the skin and range of motion (movement), capillary refill (test to see how fast blood flows by pinching the fingernail), and offer hydration and restroom for Patient 20. RN 6 further stated that the assessment sequence must not exceed two hours. During a concurrent interview and record review on 3/6/2026 at 9:50 a.m. with RN 8, Patient 20’s “Restraint View,” dated 1/6/2026 to 1/7/2026, was reviewed. The record indicated on 1/6/2026 at 8:00 a.m., Patient 20 was on restraints. Patient 20 was next assessed at 12:00 p.m. (four hours later). RN 8 acknowledged that the 10:00 a.m. documentation of restraint assessment was missing. RN 8 stated that restraint documentation must be done every two hours, and the nursing staff should check the patient’s skin and circulation (blood flow), patient activity and if the patient’s behavior improved, necessitating restraints discontinuation. RN 8 stated that documentation served as a legal record and also outlined a patient safety plan. During a review of the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion Guidelines,” dated 5/28/2025, the P&P indicated, “Care of the patient, including needs for hygiene, toileting, Skin and Circulation Assessment comfort, repositioning, and all other medical needs should continue during the restraint period at intervals not to exceed 2 hours.””

“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: 48212 Based on interview and record review, the facility failed to ensure its medical staff conducted a peer review (a mandatory, systematic evaluation of a physician’s clinical performance, conduct, or medical outcomes conducted by professional peers to ensure patient safety and quality care) for one of 34 sampled patients (Patient 16), after Patient 16 experienced a surgical complication requiring a second surgery to repair an anastomosis leak (a post-surgery complication occurs when a surgical anastomosis [a surgical procedure connecting two tubular structures in the body such as blood vessels or loops of intestine] fails and contents of a reconnected body channel leak from the surgical connection) during the hospitalization on 7/29/2025, in accordance with the facility’s Medical Staff Bylaws (are the official, legally binding rules that govern the self-governance, credentialing, and professional conduct of physicians and other clinicians within a healthcare organization. Approved by the hospital’s board, they outline responsibilities for quality care, due process, and peer review, acting as a contract between clinicians and the organization) and Peer review protocol. Patient 16 died on 7/30/2025 at 4:38 a.m. as a coroner’s case (a death investigation initiated when a person dies under unexpected, suspicious, violent, or unattended circumstances). No peer review has occurred since the case was referred to the department of surgery on 7/31/2025. The deficient practice had the potential to result in medical staff not identifying the root cause of the incident, to provide intervention or education to the providers in order to prevent similar cases from recurrence. Findings: During a review of Patient 16’s “Operative Report (surgery report),” dated 7/24/2025, the “Operative Report” indicated, Patient 16 had partially obstructing hepatic flexure (the sharp bend between the ascending and transverse colon at the right upper quadrant near the liver) colon cancer mass. The “Operative Report” also indicated, Patient 16 had robotic (robotic surgery, robot-assisted surgery) converted to open extended right hemicolectomy (a surgery removing the right side of the colon) and partial omentectomy (surgical removal of a fatty layer of tissue in the abdomen) on 7/24/2025. During a review of Patient 16’s vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) record, dated 7/28/2025, the vital signs record indicated, on 7/28/2025, Patient 16’s heart rate (normal heart rate between 60 and 100 beats per minute) was 127 beats per minute (bpm) at 8:36 a.m. and 122 bpm at 11:48 a.m. During a review of Patient 16’s “Chest x ray (an imaging procedure to create detailed image of the body’s internal structure such as bones, tissues and organs, [CXR]) report,” dated 7/28/2025, the “CXR report” indicated, “large intraperitoneal (inside abdominal cavity) free air (presence of gas within the abdominal cavity, could be an indication of perforated hollow viscus [a hole developed in the stomach or intestines], may presence post-operative status). Correlate for acute (on onset) abdomen or recent abdominal surgery. If indicated, computerized tomography (CT, a medical imaging technique to create detailed images of the inside of the body) abdomen pelvis may be performed.” During a review of Patient 16’s “CTA chest scan report (CT scan report),” dated 7/28/2025, the “CT scan report” indicated, “Impression: 1. No pulmonary embolism (blood clot in lungs) ... 3. Large amount of intraperitoneal free air and portal venous gas (gas trapped in the blood vessels that carries blood from the intestines to the liver), which may be secondary to recent surgery as was discussed in the prior chest X ray report on 7/28/2025. However, a perforated viscus (a medical emergency where a hole or tear develops in the stomach or intestines) and ischemic bowel (a serious condition where blood flow to the intestines is reduced or blocked causing tissue death) can not entirely be excluded in the appropriate clinical setting.” During a concurrent interview and record review on 3/4/2026 at 3:44 p.m. with the Sepsis (a body’s overwhelming and life-threatening response to infection) Coordinator (SC 2), Patient 16’s physician orders, dated 7/28/2025, were reviewed. The physician orders indicated there was no order for CT abdomen and pelvis. SC 2 confirmed there was no order for CT abdomen pelvis and Patient 16 did not get a CT abdomen and pelvis scan. During a review of Patient 16’s “Code Blue (hospital emergency code use to summon help when a patient is in need of resuscitation) Team (code blue record),” dated 7/29/2025, the “Code Blue Team” indicated, Patient 16’s code blue was called on 7/29/2025 at 11:47 a.m. due to respiratory arrest (a medical emergency where breathing stops or becomes ineffective). During a review of Patient 16’s “Progress Notes (physician note),” dated 7/29/2025 at 1:17 p.m., authored by surgeon (MD 7), the “Progress Notes” indicated, “Patient (Patient 16) now in ICU (Intensive Care Unit, specialist hospital wards that provide treatment and monitoring for people who are very ill) status, PEA arrest (a form of cardiac [heart] arrest where the heart shows organized electrical activity on monitor but not producing a pulse or effective blood flow) and intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) ... Assessment/Plan ... CT with a lot of free air. Will discuss with [MD 7’s] partner regarding takeback to OR for question of leak.” During an interview on 3/6/2026 at 12:59 p.m. with the physician (MD 2) Chair of Surgery, MD 2 stated Patient 16 had elevated heart rate. MD 2 stated both the CXR and the CTA chest scan indicated there was free air. MD 2 stated there should be CT abdomen pelvis scan with contrast done and prepared Patient 16 for surgery for possible anastomotic leak. During a concurrent interview and record review on 3/6/2026 at 1:05 p.m. with MD 2, Patient 16’s “Operative Report,” dated 7/29/2025, was reviewed. The “Operative Report” indicated, Patient 16 had exploratory laparotomy (an open surgery requiring large incision in the abdomen to directly view and examine the organs) with small bowel resection (a surgery to remove a damaged or diseased section of the small intestine [bowel]) and colectomy (surgical removal of part or all of the colon), and mesenteric angiography (special procedure to visualize the blood vessels supplying the small and large intestines to locate bleeding or ischemia [reduced blood flow to the organ and tissues]) on 7/29/2025. The “Operative Report” also indicated, “findings: purulence (the state of containing, discharging or forming pus indicating infection, severe inflammation or a wound that is not healing properly) throughout the abdomen. Small anastomotic leak at the ileocolic (region where the small intestine joins the large intestine) anastomosis ... An ABThera (Advance Open Abdomen Dressing, negative pressure wound therapy system designed to treat open abdominal wound) was placed. The patient (Patient 16) was transferred back to the ICU ... This case was done in a truly emergent manner with the patient (Patient 16) being unstable prior to the operation having coded (code blue) earlier in the day.” MD 2 stated it seemed that Patient 16 had anastomotic leak and became septic and then arrested. MD 2 stated there was concern about a significant deviation (depart from) from care practice and should have been sent (the case involving patient 16) for peer review (a mandatory, systematic evaluation of a physician’s clinical performance, conduct, or medical outcomes conducted by professional peers to ensure patient safety and quality care). During an interview on 3/6/2026 at 1:09 p.m. with MD 2, MD 2 stated the peer review process would start within the department first. MD 2 stated he (MD 2) would first review the case and give a score, then it would be discussed in the department of surgery meeting then moved forward to Practitioner Peer Review Committee (PPRC) for review, then would go to Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital) for final discussion. MD 2 stated the purpose of peer view was not punitive (to punish). MD 2 stated the peer review was educational, helping physicians avoid repeating mistakes and protecting patients. During an interview on 3/6/2026 at 1:12 p.m. with the Director (DIR 7) of Medical Staff Services and MD 2. DIR 7 stated Patient 16’s case was referred to the department of surgery for review on 7/31/2025. DIR 7 stated there was a department of surgery meeting on 8/5/2025 and Patient 16’s case was not scored or recommended for PPRC review. During the same interview with MD 2, MD 2 stated, “it (Patient 16’s case) escaped from review.” During an interview on 3/6/2026 at 9:46 a.m. with the Chair (MD 8) of Practitioner Peer Review Committee (PPRC), MD 8 stated the PPRC consisted of eight (8) physicians with different medical backgrounds to perform the case review after receiving the referral from medical departments. MD 8 stated the PPRC would score the case again to ensure the initial score from the department was fair. MD 8 stated PPRC would then send the review results to MEC for final approval and recommendation. MD 8 stated the peer review could take three to four months to complete. MD 8 also stated the PPRC did not receive referral to perform peer review for Patient 16’s case. During a review of Patient 16’s “Discharge Summary,” dated 11/4/2025, the “Discharge Summary” indicated, “on 7/29 (7/29/2025): Patient (Patient 16) expressed that he (Patient 16) was not feeling well in the morning, CT chest showed free air but not PE (pulmonary embolism). Patient (Patient 16) underwent cardiac arrest (sudden, fatal electrical malfunction causing heart to stop beating) headed PEA arrest ... surgery will be consulted ... Family discussed the case with surgery ... and they decided to change the code status (level of medical interventions a person wishes to have started if their heart or breathing stops) to DNR/DNI (do not resuscitate/ do not intubate, a medical order written by a doctor to instruct health care providers not to do cardiopulmonary resuscitation [CPR, an emergency lifesaving procedure performed when the heart stops beating] if a patient’s breathing or heart stops) Full Medical Treatment ... 7/30 (7/30/2025): the patient (Patient 16) expired (died) on 7/30/2025 at 4:38 a.m.” The “Discharge Summary” also indicated, Patient 16 was a coroner’s case (a death investigation initiated when a person dies under unexpected, suspicious, violent, or unattended circumstances). During a review of the facility’s “Medical Staff Bylaws,” dated 2/2020, the “Medical Staff Bylaws” indicated, “the purposes of the Medical Staff are: 2.1-2 to provide a structure through these Bylaws, Rules and Regulations, and related manuals which defines the responsibility, authority, and accountability of each organizational component and individual appointee of the Medical Staff ... 2.1-3 to provide a mechanism for appropriate delineation of clinical privileges and a means for the ongoing evaluation of performance of all practitioners authorized to practice in the Hospital ... 2.1-5 to assure that all patients admitted or treated in any of the hospital’s facilities receive care at a level of quality and efficiency consistent with generally standards attainable within the hospital’s means and circumstances ... 2.1-8 to provide for accountability of the Medical Staff to the Governing Body ... to accomplish the above purposes, it is the obligation and responsibility of the Medical Staff: 2.2-1 to participate in organized review activities by: a. evaluating practitioner and institutional performance through sound measurement systems; b. monitoring patient care practices and enforcement of Medical Staff and Hospital policies ...” During a review of the facility’s medical staff “Practitioner Peer Review Committee Charter (PPRC charter),” dated 2024, the “PPRC charter” indicated, “The Practitioner Peer Review Committee (PPRC) is established by the Medical Staff organization to provide oversight of the overall Medical Staff Peer Review process ... the goal of all peer review is education and remediation with the anticipated outcome of improved patient care and enhanced patient safety. The PPRC shall be a multidisciplinary committee responsible for overseeing the peer review and consistent case rating assignments of the medical staff clinical departments .... All individual cases must be reviewed and finalized within three (3) months of when they are first presented to the PPRC for review and no longer than four (4) months after the incident ... Department chair, vice-chairs, or their designees are responsible for conducting the initial review of cases ... all cases will be scored using the rating system recommended by the PPRC and approved by the MEC ... Any cases scored 3 - 4, marginal or significant deviation, or undecided will be submitted to the PPRC for final evaluation and scoring ... the PPRC will use the following rating system for all cases ... 1 - standard of care met: predictable occurrence. 2 - standard of care met: unpredictable occurrence. 3 - occurrence related to marginal deviation from standard of care. 4 - occurrence related to significant deviation from standard of care.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its medical staff coordinated and provided quality care, for one of 34 sampled patients (Patient 16), in accordance with the facility’s medical staff bylaws, when physicians (MD 3 and MD 6) failed to review and follow up diagnostic tests ordered, communicate and act upon on the abnormal findings identified from the chest X ray (an imaging procedure to create detailed image of the body’s internal structure such as bones, tissues and organs) and the computerized tomography angiography (CTA, a medical imaging technique to create detailed images of the inside of the body using iodine-based contrast dye to detect clots, blockages or plaque in the brain, lungs, heart and kidneys) chest scan, completed on 7/28/2025 until the next day (7/29/2025) to address, Patient 16’s elevated heart rate. This deficient practice resulted in delayed diagnosis, intervention and treatment to manage Patient 16’s anastomotic leak (a post-surgery complication occurs when a surgical anastomosis [a surgical procedure connecting two tubular structures in the body such as blood vessels or loops of intestine] fails and contents of a reconnected body channel leak from the surgical connection), which led to Patient 16 requiring an emergency surgery for exploratory laparotomy (an open surgery requiring large incision in the abdomen to directly view and examine the organs) with small bowel resection (a surgery to remove a damaged or diseased section of the small intestine [bowel]) and colectomy (surgical removal of part or all of the colon), and mesenteric angiography (special procedure to visualize the blood vessels supplying the small and large intestines to locate bleeding or ischemia [reduced blood flow to the organ and tissues]) on 7/29/2025. Findings: During a review of Patient 16’s “Operative Report (surgery report),” dated 7/24/2025, the “Operative Report” indicated, Patient 16 had partially obstructing hepatic flexure (the sharp bend between the ascending and transverse colon at the right upper quadrant near the liver) colon cancer mass. The “Operative Report” also indicated, Patient 16 had robotic (robotic surgery, robot-assisted surgery) converted to open extended right hemicolectomy (a surgery removing the right side of the colon) and partial omentectomy (surgical removal of a fatty layer of tissue in the abdomen) on 7/24/2025. During a review of Patient 16’s vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) record, dated 7/28/2025, the vital signs record indicated, on 7/28/2025, Patient 16’s heart rate (normal heart rate between 60 and 100 beats per minute) was 127 beats per minute (bpm) at 8:36 a.m. and 122 bpm at 11:48 a.m. During a review of Patient 16’s “MD communication (documentation of communication between nurses and physicians),” dated 7/28/2025, the “MD communication” indicated, on 7/28/2025 at 2:24 p.m., Registered Nurse (RN 18) contacted physician (MD 3) for Patient 16’s high heart rate. The “MD communication” also indicated, MD 3 responded on 7/28/2025 at 2:26 p.m. and ordered to do Chest X Ray (an imaging procedure to create detailed image of the body’s internal structure such as bones, tissues and organs, [CXR]), Ultrasound (non-invasive imaging test using high-frequency sound waves to visualize organs, tissues, and blood flow) of bilateral (both) lower extremities (legs), D-dimer (a blood test to detect blood clot in the body) and intravenous (IV, medical method for delivering fluids, medications, nutrition, or blood directly into patient’s bloodstream via a vein) fluid. During a review of Patient 16’s physician order (orders written by physicians to direct care and treatment), dated 7/28/2025, the physician order indicated that on 7/28/2025 at 2:30 p.m., physician (MD 3) ordered for a Chest X Ray (CXR) STAT (a medical abbreviation for immediately or without delay) for Patient 16, with indicated reason for elevated (high) heart rate during ambulation (walking). During a review of Patient 16’s “CXR report,” dated 7/28/2025, the “CXR report” indicated, “large intraperitoneal (inside abdominal cavity) free air (presence of gas within the abdominal cavity, could be an indication of perforated hollow viscus [a hole developed in the stomach or intestines] ... post-operative status). Correlate for acute (on onset) abdomen or recent abdominal surgery. If indicated, computerized tomography (CT, a medical imaging technique to create detailed images of the inside of the body) abdomen pelvis may be performed.” The CXR report indicated the report was signed off on 7/28/2025 at 4:56 p.m. During a concurrent interview and record review on 3/4/2026 at 3:44 p.m. with the Sepsis (a body’s overwhelming and life-threatening response to infection) Coordinator (SC 2), Patient 16’s physician orders, dated 7/28/2025, were reviewed. The physician orders indicated there was no order for CT abdomen and pelvis. SC 2 confirmed there was no order for CT abdomen pelvis and Patient 16 did not get a CT abdomen and pelvis scan. During an interview on 3/5/2026 at 3:02 p.m. with physician (MD 3), MD 3 stated the following: MD 3 was Patient 16’s consultant to manage Patient 16’s chronic medical condition. MD 3 would review any test result that came back before 7 p.m. (before end of working shift). He (MD 3) was aware of the chest X ray (CXR) result on 7/28/2025. MD 3 recommended CT abdomen pelvis scan. MD 3 did not recall discussing the CXR result with surgeon (MD 6) that day (7/28/2025). During a review of Patient 16’s “MD communication,” dated 7/28/2025, the “MD communication” indicated, on 7/28/2025 at 4:37 p.m., Registered Nurse (RN 18) contacted physician (MD 3) regarding Patient 16’s elevated D-Dimer result. The “MD communication” also indicated, MD 3 responded on 7/28/2025 at 5:14 p.m. and ordered to do computerized tomography angiography (CTA, a medical imaging technique to create detailed images of the inside of the body using iodine-based contrast dye to detect clots, blockages or plaque in the brain, lungs, heart and kidneys) chest scan. During a review of Patient 16’s physician order, dated 7/28/2026, the physician order indicated that on 7/28/2025 at 5:12 p.m., MD 3 ordered to perform CTA chest scan with intravenous (IV, medical method for delivering fluids, medications, nutrition, or blood directly into patient’s bloodstream via a vein) contrast (dye) STAT with indicated reason for tachycardia (high heart rate). During a review of Patient 16’s “CTA chest scan report (CT scan report),” dated 7/28/2025, the “CT scan report” indicated, “Impression: 1. No pulmonary embolism (blood clot in lungs) ... 3. Large amount of intraperitoneal free air and portal venous gas (gas trapped in the blood vessels that carries blood from the intestines to the liver), which may be secondary to recent surgery as was discussed in the prior chest X ray report on 7/28/2025. However, a perforated viscus (a medical emergency where a hole or tear develops in the stomach or intestines) and ischemic bowel (a serious condition where blood flow to the intestines is reduced or blocked causing tissue death) can not entirely be excluded in the appropriate clinical setting.” During an interview on 3/5/2026 at 3:05 p.m. with MD 3, MD 3 stated he (MD 3) would consider the CTA chest scan result, which was completed on 7/28/2025, indicating a large amount of free air, to be an urgent finding and it should have been escalated to the physician’s attention. MD 3 also stated he (MD 3) was not aware of the CTA chest scan because the result came out after 7 p.m. on 7/28/2025. During a concurrent interview and record review on 3/5/2026 at 3:08 p.m. with MD 3, Patient 16’s “progress notes (physician note),” dated 7/29/2025 at 10:47 a.m., was reviewed. The “progress notes” indicated, “assessment/plan: 1. mass of colon ... status post right hemicolectomy ... recommend evaluation for anastomotic leak (a post-surgery complication occurs when a surgical anastomosis [a surgical procedure connecting two tubular structures in the body such as blood vessels or loops of intestine] fails and contents of a reconnected body channel leak from the surgical connection) vs (versus) abscess (collection of pus, dead tissue, and germs), given patient had intraperitoneal free air, up-trending CRP (C-reactive protein, a blood test used to detect systemic inflammation caused by infections, injuries or chronic diseases) and tachycardia, may consider contrast enhanced CT of abdomen and pelvis ... recommend initiation (to start) of antibiotics (medications to treat infection) empirically.” MD 3 stated he (MD 3) saw Patient 16 on 7/29/2025 in the morning and reviewed both CXR and CTA chest results. MD 3 stated he (MD 3) suspected a possible anastomotic leak because of Patient 16’s persistent elevated heart rate, rising inflammation marker and presence of free air in the diagnostic test. MD 3 stated there was also possible infection. During the same concurrent interview and record review on 3/5/2026 at 3:08 p.m. with MD 3, MD 3 further stated that given his (MD 3) own clinical assessment, MD 3 made a recommendation in his (MD 3) progress notes which included performing a CT abdomen and pelvis and giving antibiotics to Patient 16. MD 3 confirmed he (MD 3) did not enter orders for CT abdomen and pelvis and antibiotics for Patient 16. MD 3 further stated he (MD 3) believed that he (MD 3) reached out to the surgery team but did not document any discussion with the surgery team in his (MD 3’s) own progress notes. MD 3 further stated that the surgery team had access to Patient 16’s medical record and he (MD 3) stated that he (MD 3) “assumed the surgery team would review the test results during their round in the morning.” During an interview on 3/6/2026 at 12:16 p.m. with surgeon (MD 6), MD 6 stated he (MD 6) was part of the surgery team who provided care for Patient 16. MD 6 stated that on 7/28/2025, MD 6 requested MD 3 to evaluate Patient 16’s elevated heart rate and to rule out pulmonary embolism. MD 6 stated that Patient 16’s CTA chest report result, which was completed on 7/28/2025, was concerning. MD 6 stated he (MD 6) was unaware there were CXR and CTA chest scan ordered for Patient 16. MD 6 further stated he (MD 6) did not receive any call regarding the results of CXR and CTA chest. MD 6 further stated he (MD 6) signed out Patient 16 to a colleague surgeon (MD 7) in the morning of 7/29/2025 without knowing the test results (CXR and CTA chest scan completed on 7/28/2025). MD 6 further stated that the surgery team received a call that Patient 16 coded (life-threatening medical emergency) on 7/29/2025 and was then made aware of the CXR and CTA chest results afterwards during rounds. During an interview on 3/6/2026 at 12:22 p.m. with MD 6, MD 6 stated the presence of free air in the CXR, which was completed on 7/28/2025, would raise suspicions of possible anastomotic leak and alert the surgery team to order CT abdomen and pelvis with contrast for further evaluation. MD 6 stated normally the radiologist would call him (MD 6), but he (MD 6) did not receive any call. MD 6 further stated he (MD 6) did not receive any call from MD 3 regarding the CXR result (from 7/28/2025). During an interview on 3/6/2026 at 12:27 p.m. with MD 6, MD 6 stated the surgery team was unaware of MD 3’s recommendation of ordering CT abdomen and pelvis and antibiotics treatment for Patient 16. MD 6 stated the consultant had freedom to enter physician orders without the surgery team’s permission but would expect the consultant to let MD 6 know after. During an interview on 3/6/2026 at 12:32 p.m. with MD 6, MD 6 stated treatment for anastomotic leak would be taking the patient back to the operation room (OR) to repair the leak surgically. MD 6 further stated if the surgery team was notified sooner, Patient 16 could be in OR sooner. During an interview on 3/6/2026 at 1:13 p.m. with the physician (MD 2) Chair of Surgery Department, MD 2 stated tachycardia could be the first sign of anastomotic leak. During a review of Patient 16’s “Code Blue (hospital emergency code use to summon help when a patient is in need of resuscitation) Team (code blue record),” dated 7/29/2025, the “Code Blue Team” indicated, Patient 16’s code blue was called on 7/29/2025 at 11:47 a.m. with respiratory arrest (a medical emergency where breathing stops or becomes ineffective). During a review of Patient 16’s “Progress Notes (physician note),” dated 7/29/2025 at 1:17 p.m., authored by surgeon (MD 7), the “Progress Notes” indicated, “Patient (Patient 16) now in ICU (Intensive Care Unit, specialist hospital wards that provide treatment and monitoring for people who are very ill) status, PEA arrest (Pulseless Electrical Activity- a form of cardiac [heart] arrest where the heart shows organized electrical activity on monitor but not producing a pulse or effective blood flow) and intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) ... Assessment/Plan ... CT with a lot of free air. Will discuss with [MD 7’s] partner regarding takeback to OR for question of leak.” During a review of Patient 16’s “Operative Report (surgery report),” dated 7/29/2025, the “Operative Report” indicated, Patient 16 had exploratory laparotomy (an open surgery requiring large incision in the abdomen to directly view and examine the organs) with small bowel resection and colectomy (surgical removal of part or all of the colon), and mesenteric angiography (special procedure to visualize the blood vessels supplying the small and large intestines to locate bleeding or ischemia [reduced blood flow to the organ and tissues]) on 7/29/2025. The “Operative Report” also indicated, “findings: purulence (the state of containing, discharging or forming pus indicating infection, severe inflammation or a wound that is not healing properly) throughout the abdomen. Small anastomotic leak at the ileocolic (region where the small intestine joins the large intestine) anastomosis ... An ABThera (Advance Open Abdomen Dressing, negative pressure wound therapy system designed to treat open abdominal wound) was placed. The patient (Patient 16) was transferred back to the ICU.” During a review of Patient 16’s “Discharge Summary,” dated 11/4/2025, the “Discharge Summary” indicated, “on 7/29 (7/29/2025): Patient (Patient 16) expressed that he (Patient 16) was not feeling well in the morning, CT chest showed free air but not PE (pulmonary embolism). Patient (Patient 16) underwent cardiac arrest (sudden, fatal electrical malfunction causing heart to stop beating) headed PEA arrest ... surgery will be consulted ... Family discussed the case with surgery ... and they decided to change the code status (level of medical interventions a person wishes to have started if their heart or breathing stops) to DNR/DNI (do not resuscitate/do not intubate, a medical order written by a doctor to instruct health care providers not to do cardiopulmonary resuscitation [CPR, an emergency lifesaving procedure performed when the heart stops beating] if a patient’s breathing or heart stops) Full Medical Treatment ... 7/30 (7/30/2025): the patient (Patient 16) expired (died) on 7/30/2025 at 4:38 a.m.” During a review of the facility’s “Medical Staff Bylaws,” dated 2/2020, the “Medical Staff Bylaws” indicated, “Each practitioner exercising any privileges under these Bylaws shall: 3.5-1 provide patients with continuous care at the generally recognized professional level of quality and efficiency; manage and coordinate the patient’s care, treatment and services. 3.5-2 abide by the Medical Staff Bylaws and all other lawful standards, policies and rules of the Hospital ... 3.5-15 work cooperatively with members, nurses, Hospital administrative staff and others so as not to adversely affect patient care or Hospital operations.””

“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: 46238 Based on interview and record review, the facility failed to: 1. Ensure that registered nurses supervised and evaluated the nursing care for four (4) of 34 sampled patients (Patient 2, Patient 5, Patient 15, and Patient 27) who were experiencing uncontrolled pain (defined as pain that remains above the patient’s acceptable level, persists despite reported assessments, or is not addressed with timely interventions or reassessments), in accordance with the facility’s policy regarding pain assessment and management, when: 1.a. The RN assessed Patient 2’s pain repeatedly as 10/10 (indicates severe pain on a numeric scale; 0-no pain, 1 to 3-mild pain, 4 to 6-moderate pain, 7 to 10-severe pain), but did not provide timely interventions, did not reassess pain within 30 minutes after medication administration, and did not notify the provider of persistent severe pain. This deficient practice resulted in unrelieved pain for Patient 2 and the potential for prolonged discomfort and psychological distress. In addition, this deficient practice violated Patient 2’s right (the patient’s entitlement to safe, timely, and appropriate care) to receive timely and appropriate care. 1.b. Nursing staff failed to assess Patient 5’s pain level hourly per physician’s order, reassess pain level post (after) medication administration, or escalate care to a provider, even though Patient 5 experienced persistent severe pain rated 8-10/10 on a numeric scale (indicating severe to the worst possible pain on the standard 0-10 pain scale), despite receiving analgesics (medications used to relieve pain), throughout Patient 5’s ED (Emergency Department, a hospital department that provides urgent and unscheduled medical care) stay. This deficient practice resulted in unrelieved pain for Patient 5 and placed Patient 5 at risk for delayed recognition of changes in their condition, prolonged severe discomfort, and potential deterioration of clinical status. 1.c. Nursing staff failed to evaluate/assess Patient 15’s pain level, every 2 hours, during vital signs check to determine the need for appropriate pain management. This deficient practice had the potential to result in unrelieved pain for Patient 15 and had the potential to place Patient 15 at risk of delayed recognition of changes in Patient 15’s condition. In addition, this deficient practice violated Patient 15’s right (the patient’s entitlement to safe, timely, and appropriate care) to receive timely and appropriate management of pain. 1.d. Nursing staff assessed/evaluated Patient 27’s pain level but did not provide interventions to relieve pain prior to Patient 27’s discharge from the emergency department (ED, a hospital department that provides urgent and unscheduled medical care). This deficient practice had the potential to result in unrelieved pain for Patient 27 and violated Patient 27’s right to receive timely pain management. 2. The facility failed to ensure adequate monitoring and safe nursing care for four of 34 sampled patients (Patient 4, Patient 5, Patient 6, and Patient 15) in the Red Zone (APOT area, meaning Ambulance Patient Offload Time area where EMS, Emergency Medical Services, transfers patients to the hospital when no ED beds are available) area of the facility’s Emergency Department (ED). Patients in the red zone area experienced missed vital signs (VS, meaning measurements such as heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation) checks, missed pain assessments, lack of patient monitoring, lack of pain management, and one patient (Patient 6) was found unresponsive (unconscious, meaning they do not react to voice, touch, or pain, and cannot be woken up. It indicates a medical emergency where the person is completely still and unresponsive to stimulation) without nursing oversight or monitoring. This deficient practice resulted in the risk of serious harm or death for Patient 4, Patient 5, Patient 6, and Patient 15, as well as all facility patients requiring urgent and emergent care who continued to be offloaded by ambulance into the Red Zone areas in the facility. 3. Ensure one (1) of 34 sampled patients (Patient 7), who was admitted to the facility with stroke symptoms (sudden weakness, trouble speaking, vision problems, dizziness, or severe headache), received an initial NIHSS (National Institutes of Health Stroke Scale, a standardized tool used to measure stroke severity) or a completed neurological examination (a medical assessment of the nervous system), in accordance with the facility’s “Stroke” policy and procedures. This deficient practice had the potential to delay the recognition of a change in condition for Patient 7 and for patients who presented to the facility’s Emergency Department (ED, area in the hospital where people go when they need immediate medical care for sudden or serious health problems) with stroke symptoms. Findings: 1.a. During a review of Patient 2’s Emergency Documentation (the medical record created during an emergency department visit) dated 8/12/2025, the record indicated that Patient 2 was seen in the emergency department (ED, a hospital department that provides urgent and unscheduled medical care) due to a moderate headache, with a gradual onset, that began 8 hours prior to ED arrival. Patient 2 stated she (Patient 2) took “one Percocet (a prescription pain medication that contains oxycodone [a strong pain?relieving drug] and acetaminophen) for the pain but felt no relief.” During a review of Patient 2’s Emergency Documentation, dated 8/12/2025, the record indicated that Patient 2 was diagnosed with low potassium levels (2.6, a critically low electrolyte level that can affect heart and muscle function) and low hemoglobin (Hgb, the protein in red blood cells that carries oxygen). Patient 2 was given potassium replacement medication (treatment used to increase potassium levels in the blood) and a blood transfusion (a procedure in which donated blood is given to a patient through a vein to replace lost or low blood components). During a concurrent interview and record review on 3/3/2026 at 3:08 p.m. with the Quality Clinical Safety Coordinator (SC), Patient 2’s pain assessment (a measurement of how much pain a patient reports using a numeric scale; 0-no pain, 1 to 3-mild pain, 4 to 6-moderate pain, 7 to 10-severe pain) record, dated 8/12/2025, and Medication Administration Record (MAR, a record that shows what medications were given and when), dated 8/12/2025, were reviewed. The record indicated that Patient 2’s pain level on 8/12/2025 were as follows: -at 5:04 a.m., head pain level was 10 (10/10 indicates the worst possible pain on a standard pain scale); -at 5:19 a.m., head pain level was 10; -at 6:17 a.m., head pain level was 10; -at 8:26 a.m., (over two hours later) head pain level was 6 (moderate pain); -at 10:34 a.m., head pain level was 5 (moderately strong pain); -at 12:35 p.m., head pain level was 4 (moderate pain); -and at 4:14 p.m., head pain level was 5 (moderately strong pain) again. -The record also indicated that Patient 2’s documented acceptable pain level was 0 (meaning no pain is the goal for the patient). -SC verified the information and stated that according to the MAR, on 8/12/2025 at 6:18 a.m., Patient 2 was administered 15 milligrams (mg, a measuring unit for medication) of ketorolac (a non?steroidal anti-inflammatory medication used for pain) intramuscularly (IM, meaning injected into the muscle) and 1000 mg of Tylenol (acetaminophen, a medication used to reduce pain and fever). SC confirmed that no other medication for pain was administered to Patient 2 during Patient 2’s Emergency Department (ED) visit on 8/12/2025. During a concurrent interview and record review on 3/3/2026 at 3:35 p.m. with the Quality Clinical Safety Coordinator (SC), Patient 2’s Emergency Documentation, dated 8/12/2025, was reviewed. The record indicated that Patient 2 was discharged (on 8/12/2025) at 4:23 p.m. with pain level last assessed at 4:14 p.m. and being 5/10 (5/10 indicates moderately strong pain). SC also verified that Patient 2’s nursing progress notes/comments had no documentation of Patient 2 refusing pain medications. During an interview on 3/5/2026 at 10:28 a.m. with ED manager (NM 1), NM 1 said, “We do vital signs (VS) every 2 hours for patients. We do pain assessments with VS (vital signs, a set of basic body measurements such as temperature, heart rate, breathing rate, and blood pressure), and more often as needed. Pain assessment is important because pain can alter the VS, and we medicate with medicine. The pain assessment is important. Pain may indicate a deterioration (worsening) of condition. If medication is given, the reassessment of pain is done in 30 minutes. When a patient complains of pain (c/o pain), the nurse documents the pain. They are the patient advocate and let the provider know that the patient has pain. The nurse’s role is to advocate.” NM 1 also stated, “We tell the nurses to notify the charge nurses and document if MD (medical doctor) refuses to manage pain, because we advocate (for patients).” During an interview on 3/6/2026 at 11:16 a.m. with Emergency Department (ED) staff registered nurse (RN 14), RN 14 said “Pain assessment is done with vital signs (VS, a set of basic measurements that show how the body is functioning, such as temperature, heart rate, breathing rate, and blood pressure), every two hours. If pain is high, I check for the PRNs (as-needed medications ordered by the provider), for pain scales, and if not, let’s say the patient has not been fully admitted, I alert the MD (medical doctor). If the pain comes back, I reassess every 1 hour, and if it does not help, I ask for more medications. I document patient refusal ... if PRNs (medications) are refused, I document the reason the patient refused, and otherwise, if the MD refuses to address the patient’s pain, I will make a comment ‘MD made aware of patient pain.’ We do every 2 hours (pain assessment) for patients, we do pain assessments with VS, and more often as needed ...” During a review of the facility’s policy titled “Pain Assessment and Management,” dated (date), the policy indicated the following: “Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. It is relatively brief and subsides as healing takes place.” The policy further indicated: “A. Patients are to be screened for pain when visiting the emergency room, upon admission, and alongside routine vital signs based on unit protocols. B. Staff must accept and respect the patient’s self?report of pain using a verbal pain scale, which defines pain levels as: 0: No pain 1-3: Mild pain 4-6: Moderate pain 7-10: Severe pain The policy also states that: The patient, family/caregivers, nurse, physician, and pharmacist shall collaborate to consider the patient’s home pain regimen as part of the treatment plan. C. Staff must establish an agreed-upon comfort goal based on the patient’s expectations and understanding of the pain scale, and document this in the medical record. Goals for pain less or equal to 5 should include functional expectations (e.g., ability to take a deep breath, turn in bed, ambulate). J. Appropriate use of analgesic medications is to be encouraged, with rare exceptions (e.g., initial examination for acute abdomen, head trauma, or conditions where pain medication may mask symptoms such as stroke). K. Interventions shall be made to relieve reported pain using evidence?based multimodal treatment modalities. Consideration should be given to starting with non?pharmacological interventions, then non-opioid medications, and progressing to opioids as indicated. The choice of intervention must be based on current assessment, patient history, and medication tolerance. L. Pain medication administration must be preceded by a pain assessment, including the patient’s rating of pain. Nurses are required to consider subjective and objective factors before administering medications. M. The registered nurse (RN) shall communicate with the physician to coordinate an alternative treatment plan when the patient’s pain remains above the identified comfort goal.” 1.b. During a review of Patient 5’s Emergency Documentation (the medical record created during an emergency department visit), dated 3/3/2026, the record indicated that Patient 5 presented to the emergency department (ED, a hospital department that provides urgent and unscheduled medical care) on 3/3/2026 complaining of testicular pain and swelling (pain and enlargement of one or both testicles). During a concurrent interview and record review on 3/5/2026 at 10:35 a.m. with the Quality Clinical Safety Coordinator (SC), Patient 5’s Vital Signs (VS, the basic physiological measurements, such as temperature, heart rate, respiratory rate, and blood pressure, used to assess a patient’s immediate clinical status) record, dated 3/3/2026, was reviewed. The Vital Signs record indicated that Patient 5 had a system-generated order (an automated electronic order created by the electronic medical record system based on the patient’s triage category or clinical condition) for VS to be performed every hour due to an assigned ESI 1 (Emergency Severity Index level 1, which designates a patient requiring immediate, life-saving intervention and therefore mandates the highest level of monitoring) in triage (the process of sorting and prioritizing patients based on the severity of their condition to determine the order of treatment, prioritizing those in most urgent need) on 3/3/2026 at 5:59 a.m. SC verified that this was the only VS order (to check Patient 5’s vital signs [which includes pain assessment] every hour) in place for Patient 5 throughout the ED visit. During a concurrent interview and record review on 3/5/2026 at 10:35 a.m. with the Quality Clinical Safety Coordinator (SC), Patient 5’s Vital Signs (VS, the basic physiological measurements-such as temperature, heart rate, respiratory rate, and blood pressure, used to assess a patient’s immediate clinical status) flowsheet, dated 3/3/2026, was reviewed. The Vital Signs record, dated 3/3/2026, indicated Patient 5’s pain assessments as follows: -At 5:59 a.m., pain was documented as 10/10 (10/10 represents the highest level of pain on the standard 0-10 pain scale, where 0 = no pain and 10 = the worst possible pain imaginable). -At 6:57 a.m., pain was 10/10. -At 7:37 a.m., pain was 9/10 (indicating severe pain). -At 9:18 a.m., pain was not assessed. -At 12:27 p.m., pain was 9/10. -At 2:30 p.m., pain was 10/10. -At 3:28 p.m., pain was 8/10 (indicating severe pain). -At 5:28 p.m., pain was 10/10. -At 8:49 p.m., pain was not assessed. -SC verified that Patient 5 was discharged on 3/4/2026 at 1:00 a.m., but a discharge pain assessment was not performed. During a concurrent interview and record review on 3/5/2026 at 10:45 a.m. with the Quality Clinical Safety Coordinator (SC), Patient 5’s Medication Administration Record (MAR, the document that shows all medications administered to a patient, including the medication name, dose, time, and route), dated 3/3/2026, was reviewed. The record indicated the following: -At 7:02 a.m., Patient 5 received 1 mg (milligram, a unit of measurement equal to one-thousandth of a gram) of Dilaudid (hydromorphone, a potent opioid analgesic used to treat moderate to severe pain) IM (intramuscularly, meaning the medication was injected directly into the muscle). -At 2:36 p.m., Patient 5 received one tablet of oxycodone-acetaminophen (a combination opioid and non-opioid analgesic used to treat moderate to severe pain). -SC verified that Patient 5 received pain-medication management twice during their visit on 3/3/2026 through 3/4/2026 (during 19 hours of ED stay). SC also verified that Patient 5’s nursing progress notes/comments contained no documentation indicating that Patient 5 refused pain medications, no documentation showing Patient 5 received any other measures for pain relief (despite pain levels between 8-10/10 on a numeric scale from 5:59 p.m. to 8:49 p.m. on 3/3/2026), and no documentation indicating that a medical doctor (MD) refused to order effective pain management. SC further verified that Patient 5’s pain reassessments showed that Patient 5 remained in constant pain throughout the ED stay. During an interview on 3/5/2026 at 10:28 a.m. with ED manager (NM 1), NM 1 said, “We do vital signs (VS) every 2 hours for patients. We do pain assessments with VS (vital signs, a set of basic body measurements such as temperature, heart rate, breathing rate, and blood pressure), and more often as needed. Pain assessment is important because pain can alter the VS, and we medicate with medicine. The pain assessment is important. Pain may indicate a deterioration (worsening) of condition. If medication is given, the reassessment of pain is done in 30 minutes. When a patient complains of pain (c/o pain), the nurse documents the pain. They are the patient advocate and let the provider know that the patient has pain. The nurse’s role is to advocate.” NM 1 also stated, “We tell the nurses to notify the charge nurses and document if MD (medical doctor) refuses to manage pain, because we advocate (for patients).” During an interview on 3/6/2026 at 11:16 a.m. with Emergency Department (ED) staff registered nurse (RN 14), RN 14 said, “Pain assessment is done with vital signs (VS, a set of basic measurements that show how the body is functioning, such as temperature, heart rate, breathing rate, and blood pressure), every two hours. If pain is high, I check for the PRNs (as-needed medications ordered by the provider), for pain scales, and if not, let’s say the patient has not been fully admitted, I alert the MD (medical doctor). If the pain comes back, I reassess every 1 hour, and if it does not help, I ask for more medications. I document patient refusal ... if PRNs are refused, I document the reason the patient refused, and otherwise, if the MD refuses to address the patient’s pain, I will make a comment ‘MD made aware of patient pain.’ We do (vital signs check) every 2 hours for patients, we do pain assessments with VS, and more often as needed ...” During a review of the facility’s policy titled “Pain Assessment and Management,” dated (date), the policy indicated the following: “Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. It is relatively brief and subsides as healing takes place.” The policy further indicated: “A. Patients are to be screened for pain when visiting the emergency room, upon admission, and alongside routine vital signs based on unit protocols. B. Staff must accept and respect the patient’s self-report of pain using a verbal pain scale, which defines pain levels as: 0: No pain 1-3: Mild pain 4-6: Moderate pain 7-10: Severe pain The policy also states that: The patient, family/caregivers, nurse, physician, and pharmacist shall collaborate to consider the patient’s home pain regimen as part of the treatment plan. C. Staff must establish an agreed?upon comfort goal based on the patient’s expectations and understanding of the pain scale, and document this in the medical record. Goals for pain less or equal to 5 should include functional expectations (e.g., ability to take a deep breath, turn in bed, ambulate). J. Appropriate use of analgesic medications is to be encouraged, with rare exceptions (e.g., initial examination for acute abdomen, head trauma, or conditions where pain medication may mask symptoms such as stroke). K. Interventions shall be made to relieve reported pain using evidence?based multimodal treatment modalities. Consideration should be given to starting with non?pharmacological interventions, then non-opioid medications, and progressing to opioids as indicated. The choice of intervention must be based on current assessment, patient history, and medication tolerance. L. Pain medication administration must be preceded by a pain assessment, including the patient’s rating of pain. Nurses are required to consider subjective and objective factors before administering medications. M. The registered nurse (RN) shall communicate with the physician to coordinate an alternative treatment plan when the patient’s pain remains above the identified comfort goal.” 1.c. During a review of Patient 15’s Emergency Documentation (the medical record created during an emergency department visit), dated 3/3/2026, the record indicated that Patient 15 was seen in the emergency department (ED, a hospital department that provides urgent and unscheduled medical care) on 3/3/2026 with non-specific chest pain which started in the morning as a sore, crushing sensation. During a review of Patient 15’s triage (the initial assessment performed when a patient arrives to the emergency department to determine the severity of their condition and prioritize care) documentation, dated 3/3/2026 at 4:45 p.m., the record indicated that Patient 15 arrived to the Emergency Department (ED) complaining of pain rated 8/10 (meaning the patient reported severe pain on a standard 0-10 pain scale, where 0 = no pain and 10 = the worst possible pain). During a concurrent interview and record review on 3/5/2026 at 9:47 a.m. with the Quality Clinical Safety Coordinator (SC), Patient 15’s Vital Signs (VS, the basic physiological measurements, such as temperature, heart rate, respiratory rate, and blood pressure, used to assess a patient’s immediate clinical status) flowsheet, dated 3/3/2026 through 3/4/2026, was reviewed. The record indicated that Patient 15’s VS along with pain level, were assessed at the following dates and times: -4:45 p.m. on 3/3/2026 (upon arrival to the Emergency Department), vital signs were checked and the pain level was documented as 8/10 (severe pain). -8:57 p.m., vital signs were checked; but the pain level was not assessed at that time. -12:43 a.m. on 3/4/2026, prior to discharge, (Pain level was 0 [no pain]) -SC verified that there was no pain reassessment consistently performed along with VS checks, every two hours, during Patient 15’s visit in the Emergency Department (ED). During a concurrent interview and record review on 3/5/2026 at 10:28 a.m. with the Quality Clinical Safety Coordinator (SC), Patient 15’s Medication Administration Record (MAR, the official record showing all medications that were administered to a patient, including the medication name, dose, time, and route of administration), dated 3/3/2026, was reviewed. The MAR indicated that Patient 15 received 1000 mg (milligrams, a unit of measurement for medication) of Tylenol (acetaminophen, a non-opioid analgesic and antipyretic medication used to relieve mild to moderate pain and reduce fever) on 3/3/2026 at 9:39 p.m., for an unknown reason, as the reason for administration was not documented. SC verified the lack of documentation related to the Tylenol administration for Patient 15 and stated that no other pain medications were administered to Patient 15 during their visit on 3/3/2026. During a review of Patient 15’s Emergency Documentation, dated 3/4/2026, the record indicated that Patient 15’s discharge diagnosis was “chest pain (a clinical term used when the cause of the pain has not yet been definitively identified; it describes discomfort or pain felt anywhere along the front of the body between the neck and upper abdomen and can range from benign causes to serious, life-threatening conditions).” During an interview on 3/5/2026 at 10:28 a.m. with ED manager (NM 1), NM 1 said, “We do vital signs (VS) every 2 hours for patients. We do pain assessments with VS (vital signs, a set of basic body measurements such as temperature, heart rate, breathing rate, and blood pressure), and more often as needed. Pain assessment is important because pain can alter the VS, and we medicate with medicine. The pain assessment is important. Pain may indicate a deterioration (worsening) of condition. If medication is given, the reassessment of pain is done in 30 minutes. When a patient complains of pain (c/o pain), the nurse documents the pain. They are the patient advocate and lets the provider know that the patient has pain. The nurse’s role is to advocate.” NM 1 also stated, “We tell the nurses to notify the charge nurses and document if MD (medical doctor) refuses to manage pain, because we advocate (for patients).” During an interview on 3/6/2026 at 11:16 a.m. with Emergency Department (ED) staff registered nurse (RN 14), RN 14 said, “Pain assessment is done with vital signs (VS, a set of basic measurements that show how the body is functioning, such as temperature, heart rate, breathing rate, and blood pressure), every two hours. If pain is high, I check for the PRNs (as-needed medications ordered by the provider), for pain scales, and if not, let’s say the patient has not been fully admitted, I alert the MD (medical doctor). If the pain comes back, I re-assess every 1 hour, and if it does not help, I ask for more medications. I document patient refusal ... if PRNs (medications) are refused, I document the reason the patient refused, and otherwise, if the MD refuses to address the patient’s pain, I will make a comment ‘MD made aware of patient pain.’ We do every 2 hours for patients, we do pain assessments with VS, and more often as needed ...” During a review of the facility’s policy titled “Pain Assessment and Management,” dated (date), the policy indicated the following: “Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. It is relatively brief and subsides as healing takes place.” The policy further indicated: “A. Patients are to be screened for pain when visiting the emergency room, upon admission, and alongside routine vital signs based on unit protocols. B. Staff must accept and respect the patient’s self?report of pain using a verbal pain scale, which defines pain levels as: 0: No pain 1-3: Mild pain 4-6: Moderate pain 7-10: Severe pain The policy also states that: The patient, family/caregivers, nurse, physician, and pharmacist shall collaborate to consider the patient’s home pain regimen as part of the treatment plan. C. Staff must establish an agreed-upon comfort goal based on the patient’s expectations and understanding of the pain scale, and document this in the medical record. Goals for pain less or equal to 5 should include functional expectations (e.g., ability to take a deep breath, turn in bed, ambulate). J. Appropriate use of analgesic medications is to be encouraged, with rare exceptions (e.g., initial examination for acute abdomen, head trauma, or conditions where pain medication may mask symptoms such as stroke). K. Interventions shall be made to relieve reported pain using evidence?based multimodal treatment modalities. Consideration should be given to starting with non?pharmacological interventions, then non-opioid medications, and progressing to opioids as indicated. The choice of intervention must be based on current assessment, patient history, and medication tolerance. L. Pain medication administration must be preceded by a pain assessment, including the patient’s rating of pain. Nurses are required to consider subjective and objective factors before administering medications. M. The registered nurse (RN) shall communicate with the physician to coordinate an alternative treatment plan when the patient’s pain remains above the identified comfort goal.” 1.d. During a review of Patient 27’s Emergency Documentation, dated 1/4/2026, the record indicated that Patient 27 was seen in the ED due to abdominal (stomach area) pain and blood in the stool for one day. During a review of Patient 27’s Discharge documentation, dated 1/5/2026 and timed at 4:58 a.m., the record indicated that Patient 27 was discharged from the ED at 4:57 a.m. During an interview on 3/5/2026 at 10:21 a.m. with License Vocational Nurse (LVN) 1, LVN 1 stated that LVNs or RNs could discharge the patient once an order had been provided. LVN 1 stated that Staff members should take a last set of vitals (vital signs), and ensure the patients understood the discharge instructions. LVN 1 stated that if any problems arose, then it should be escalated to the charge RN or the discharging practitioner (Medical Doctor, Physician Assistant or Nurse Practitioner). During a concurrent interview and record review on 3/5/2026 at 2:49 p.m. with Nurse Manager (NM) 1 and the Director 1 (DIR 1), Patient 27’s Pain assessment, dated 1/5/2026, was reviewed and indicated the following: -at 00:46 (12:46 a.m.), Patient 27 reported a pain level of “10 (indicates severe pain on the numeric scale of 0-10)” and an acceptable pain level of “0.” -at 2:49 a.m., Patient 27 reported a pain level of “8 (indicates severe pain)” and an acceptable pain level of “0.” -at 4:57 a.m. (One minute before discharge), Patient 27 reported a pain level of “10” and an acceptable pain level of “0.” - NM1 stated that Patient 27 should not have been discharged home with a pain level of 10 and interventions should have been implemented and the provider notified, especially if the patient’s chief complaint was abdominal pain. DIR 1 stated that nurses should advocate for the patient and communicate with the physician if the pain medication did not relieve the patient from pain so that the physician can evaluate. During a review of the facility’s policy titled “Pain Assessment and Management,” revised 9/19/25, the policy indicated the following: “Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. It is relatively brief and subsides as healing takes place.” The policy further indicated: “A. Patients are to be screened for pain when visiting the emergency room, upon admission, and alongside routine vital signs based on unit protocols. B. Staff must accept and respect the patient’s self-report of pain using a verbal pain scale, which defines pain levels as: 0: No pain 1-3: Mild pain 4-6: Moderate pain 7-10: Severe pain The policy also indicated that: The patient, family/caregivers, nurse, physician, and pharmacist shall collaborate to consider the patient’s home pain regimen as part of the treatment plan. C. Staff must establish an agreed-upon comfort goal based on the patient’s expectations and understanding of the pain scale, and document this in the medical record. Goals for pain less or equal to 5 should include functional expectations (e.g., ability to take a deep breath, turn in bed, ambulate). J. Appropriate use of analgesic medications is to be encouraged, with rare exceptions (e.g., initial examination for acute abdomen, head trauma, or conditions where pain medication may mask symptoms such as stroke). K. Interventions shall be made to relieve reported pain using evidence-based multimodal treatment modalities. Consideration should be given to starting with non?pharmacological interventions, then non-opioid medications, and progressing to opioids as indicated. The choice of intervention must be based on current assessment, patient history, and medication tolerance. L. Pain medication administration must be preceded by a pain assessment, including the patient’s rating of pain. Nurses are required to consider subjective and objective factors before administering medications. M. The registered nurse (RN) shall communicate with the physician to coordinate an alternative treatment plan when the patient’s pain remains above the identified comfort goal.” 2. During an observation on 3/3/2026 at 11:18 a.m., the high red zone (area where high-risk or urgent patients are taken off the ambulance and brought into the facility for care), was observed to hold up to 12 gurneys (rolling beds used to transport and hold patients) at a time. The following was observed: -Gurneys 17-22 in the red zone were placed very close together, about 1-3 feet apart. -All (17-22) gurneys were occupied with patients. EMS (Emergency Medical Services, ambulance personnel who bring patients to the hospital) continuously brought new patients and offloaded them into gurneys in the hallways, while gurneys 17-22 remained occupied. -Patients were not attached to monitors (machines that track vital signs such as heart rate, breathing, and oxygen level) during the observation. -Each gurney had a curtain meant to separate patients, but all curtains were open. -No staff were observed in the area except for one technician (Tech 1). Tech 1 was sitting at the far end of the high red zone, documenting offload times and patient information as ambulances were bringing patients in. During an interview on 3/3/2026 at 11:23 a.m. with ED tech (Tech 1), Tech 1 confirmed that all the patients in the red zone were the patients brought in by the EMS (Emergency Medical Services, ambulance personnel who bring patients to the hospital) and offloaded in the area (the red zone area) due to a lack of available beds in the ED (Emergency Department, the emergency room where patients receive immediate medical care). During the same interview on 3/3/2026 at 11:23 a.m. with ED tech (Tech 1), Tech 1 stated the following: -Tech 1 confirmed that some offloaded patients were ESI 2 (Emergency Severity Index level 2, meaning very urgent) and some were ESI 3 (Emergency Severity Index level 3, meaning urgent but less critical than level 2). -Tech 1 demonstrated a log that documented the patients’ information (label, meaning the patient’s name or identifying information) and the off?load time (important for APOT [Ambulance Patient Off Load Time, the interval from an ambulance’s arrival at the ED bay to when the patient is transferred to an ED bed/chair, with a standard goal of 30 minutes or less. It measures “wall time”-how long paramedics wait to transfer care] regulated standard because hospitals must track how long it takes to transfer a patient from EMS to hospital care). -Tech 1 explained that the High Red Zone (area that accommodated patients with higher acuity, meaning patients who were sicker or needed more urgent care) included beds from 17 through 22 (12 gurneys in the high red zone area). Tech 1 said there were about 10-13 patients offloaded in the high red zone at that moment (the time of the interview on 3/3/2026). -Tech 1 said that all patients were monitored by the tech, the nurse (RN), and the discharging LVN (Licensed Vocational Nurse) who oversaw the waiting area (inside the emergency department). Tech 1 confirmed that high red zone patients were not attached to monitors. -Tech 1 said: “The process is (for the EMS) to offload (patients), (patients) get seen by the provider, get assessed, get treated, move on and wait until discharged ...” -Tech 1 confirmed that patients were typically not connected to monitors for VS (vital signs, such as heart rate, blood pressure, breathing, and oxygen level) but said he (Tech 1) was responsible for obtaining vital signs every 2 hours as per ED protocol. -Tech 1 also confirmed that none of the patients had call lights (essential communication devices in hospitals that allow patients to alert nurses or staff when they need assistance). During an interview on 3/3/2026 at 11:33 a.m. with the Director of the Emergency Department (DIR 1), DIR 1 said that there were 2 nurses (1 RN and 1 LVN) in the High Red Zone today (3/3/2026). DIR 1 also stated the following: -DIR 1 said that all the patients in the High Red Zone were waiting for an ED bed, but they had already been seen by a provider and had orders placed for labs (laboratory tests), imaging (non-invasive technologies used to create pictures of the inside of the body to diagnose, monitor, and treat medical conditions. Example: Xray), and/or medications. -DIR 1 confirmed that the patients in the High Red Zone were all overseen by the two nurses (1 RN and 1 LVN) and that a tech was present to help monitor the patients and report any changes to the nurses. During further observation on 3/3/2026 at 11:45 a.m., only one registered nurse (RN 25) was observed standing in the hallway between the high and the low red zones. During a concurrent observation and interview on 3/3/2026 at 11:55 a.m. with Registered Nurse (RN 25), RN 25 stated, “I am assigned to 20 patients with the tech. I am unable to monitor all these patients at one time, especially when the ambulance EMT drops off a patient without giving me a report. For example, there was a patient this morning who was dropped off for maybe suicidal ideation (SI, thoughts of self-harm). Eventually, the patient was moved to the pink side (area for psychiatric patients who require a safer and more controlled environment).” No other nurse was observed to be assigned to the hallway gurneys for patient gurneys 6, 8, and 9. During a concurrent observation and interview on 3/3/2026 at 11:55 a.m. with Registered Nurse (RN 25), it was observed that gurneys 6, 8, and 9 were located around the corner from the hallway of the High Red Zone. RN 25 stated that these gurneys (6, 8, and 9) were also assigned to him. During a concurrent observation and interview on 3/3/2026 at 12:05 p.m. with the ED Nurse Manager (NM 1), gurneys were observed to be parked along the walls leading to the nursing stations. Each gurney observed had a location sign on it, such as “gurney #1, gurney #2 ...” -NM 1 stated that the gurneys were all part of the Red Zone area, also called APOT (Ambulance Patient Offload Time, which refers to the period when EMS hands over a patient to the hospital. The APOT area is where patients offloaded when no ED beds are available). -NM 1 also said that the red zone area was designed for the patients who were triaged (checked by a nurse to determine how urgent their condition is) and seen by providers but were waiting for a bed in the emergency department. -NM 1 also stated that the red zone was typically staffed with 2 registered nurses (RNs), 1 LVN (Licensed Vocational Nurse), and 2 EMTS (Emergency Medical Technicians, staff who assist with patient care and transport). -NM 1 further repeated that this red zone area was a hold area, and nurses (assigned to the area) continued obtaining vital signs and receiving and carrying out provider’s orders while patients waited for a bed in the emergency department (ED). During an interview on 3/3/2026 at 12:00 p.m. with Licensed Vocational Nurse (LVN 2), LVN 2 was asked about the patient assignment for the day. LVN 2 stated, “My shift started at 10 a.m. The patients in room 27, with 11 patients, are the ones I am assigned to. I am assigned to follow up on discharge orders. I do not know what beds 6, 8, and 9 are here for. I am not assigned to those beds, but I do keep an eye out.” During an interview on 3/3/2026 at 12:08 p.m. with the ED Director (Dir 1), regarding the assignment for gurneys 6, 8 and 9, DIR 1 stated that the LVN (LVN 2) was assigned to the patients in gurneys 6, 8, and 9. During an interview on 3/5/2026 at 10:28 a.m. with the Emergency Department Manager (NM 1), regarding the monitoring provided to patients in the Red Zones, NM 1 stated the following: -Vital signs: Vital signs were required during triage. After triage, the patient’s ESI level (Emergency Severity Index, a tool used to rate how sick a patient was) determined how often vital signs were taken. Stable patients had vital signs checked every two hours or as needed. Patients who required ICU?level care had vital?sign checks every hour or less, depending on their condition. -Cardiac monitoring: Cardiac monitoring required a provider’s order. When a patient’s condition changed, the physician was required to place an order for cardiac monitoring. -Continuous oxygen monitoring: Continuous oxygen monitoring also required an order, although nursing staff could initiate it in certain circumstances. -Cardiac monitoring decision?making: For an ESI?2 patient, cardiac monitoring was not done automatically. If a patient reported chest pain and an EKG (Electrocardiogram, non-invasive test that records the electrical activity of your heart to determine abnormalities) was ordered, the provider was the one who decided whether to place the patient on a cardiac monitor. After the EKG was completed and the provider evaluated the patient, the provider determined whether cardiac monitoring was necessary. -NM 1 stated, “The facility retains responsibility over the patient. The nurses assigned to the area are responsible for monitoring (the patients).” -NM 1 explained that the Red Zone offloading area existed due to state APOT (Ambulance Patient Offload Time) requirements, which required hospitals to offload EMS patients within 30 minutes. In this area, the technician updated vital signs every two hours, the LVN performed tasks such as administering medications and updating families, and the RN assessed the patient and carried out provider orders. -NM 1 described the area as “organized chaos,” explaining that staff were constantly moving and keeping an eye on patients. According to NM 1, staffing for the Red Zone (high and low) included four RNs (2 RNs each zone) and one LVN on each side, plus one technician on each side. 2.a. During a review of Patient 5’s Emergency Documentation (the medical record created during an emergency department visit), dated 3/3/2026, the record indicated that Patient 5 presented to the emergency department (ED, a hospital department that provides urgent and unscheduled medical care) on 3/3/2026 complaining of testicular pain and swelling (pain and enlargement of one or both testicles). Patient 5 was placed in the offload high red zone area. During a concurrent interview and record review on 3/5/2026 at 10:35 a.m. with the Quality Clinical Safety Coordinator (SC), Patient 5’s Vital Signs (VS, the basic physiological measurements, such as temperature, heart rate, respiratory rate, and blood pressure, used to assess a patient’s immediate clinical status) record, dated 3/3/2026, was reviewed. The Vital Signs record indicated that Patient 5 had a system?generated order (an automated electronic order created by the electronic medical record system based on the patient’s triage [a fast, initial assessment conducted by a nurse, in the Emergency Department, to prioritize patients based on the severity of their condition] category or clinical condition) for VS to be performed every hour due to an assigned ESI 1 (Emergency Severity Index level 1, which designates a patient requiring immediate, life?saving intervention and therefore mandates the highest level of monitoring) in triage area on 3/3/2026 at 5:59 a.m. SC verified that this (referring to the hourly VS check ordered) was the only VS order in place for Patient 5 throughout the ED visit. During a concurrent interview and record review on 3/5/2026 at 10:35 a.m. with the Quality Clinical Safety Coordinator (SC), Patient 5’s Vital Signs (VS, the basic physiological measurements-such as temperature, heart rate, respiratory rate, and blood pressure, used to assess a patient’s immediate clinical status) flowsheet, dated 3/3/2026, was reviewed. The record indicated that on 3/3/2026, Patient 5’s pain assessments showed the following: -At 5:59 a.m., pain was documented as 10/10 (10/10 represents the highest level of pain on the standard 0-10 pain scale, where 0 = no pain and 10 = the worst possible pain imaginable). -At 6:57 a.m., pain was 10/10. -At 7:37 a.m., pain was 9/10 (indicating severe pain). -At 9:18 a.m., pain was not assessed. -At 12:27 p.m., pain was 9/10. -At 2:30 p.m., pain was 10/10. -At 3:28 p.m., pain was 8/10. -At 5:28 p.m., pain was 10/10. -At 8:49 p.m., pain was not assessed. -SC verified that Patient 5 was discharged on 3/4/2026 at 1:00 a.m., but a discharge pain assessment was not performed. During a concurrent interview and record review on 3/5/2026 at 10:45 a.m. with the Quality Clinical Safety Coordinator (SC), Patient 5’s Medication Administration Record (MAR, the document that shows all medications administered to a patient, including the medication name, dose, time, and route), dated 3/3/2026, was reviewed. The record indicated the following: -At 7:02 a.m., Patient 5 received 1 mg (milligram, a unit of measurement equal to one-thousandth of a gram) of Dilaudid (hydromorphone, a potent opioid analgesic used to treat moderate to severe pain) IM (intramuscularly, meaning the medication was injected directly into the muscle). -At 2:36 p.m., Patient 5 received one tablet of oxycodone-acetaminophen (a combination opioid and non?opioid analgesic used to treat moderate to severe pain). -SC verified that Patient 5 received pain-medication management twice during his (Patient 5) visit on 3/3/2026 through 3/4/2026 (during 19 hours of ED stay). SC also verified that Patient 5’s nursing progress notes/comments contained no documentation indicating that Patient 5 refused pain medications, no documentation showing Patient 5 received any other measures for pain relief despite documented persistent pain levels between 8-10/10 (severe pain), and no documentation indicating that a medical doctor (MD) refused to order effective pain management. SC further verified that Patient 5’s pain reassessments showed that Patient 5 remained in constant pain throughout his (Patient 5) ED stay. During a review of the facility’s policy titled “Pain Assessment and Management,” dated (date), the policy indicated the following: “Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. It is relatively brief and subsides as healing takes place.” The policy further indicated: “A. Patients are to be screened for pain when visiting the emergency room, upon admission, and alongside routine vital signs based on unit protocols. B. Staff must accept and respect the patient’s self-report of pain using a verbal pain scale, which defines pain levels as: 0: No pain 1-3: Mild pain 4-6: Moderate pain 7-10: Severe pain The policy also states that: The patient, family/caregivers, nurse, physician, and pharmacist shall collaborate to consider the patient’s home pain regimen as part of the treatment plan. C. Staff must establish an agreed-upon comfort goal based on the patient’s expectations and understanding of the pain scale, and document this in the medical record. Goals for pain less or equal to 5 should include functional expectations (e.g., ability to take a deep breath, turn in bed, ambulate). J. Appropriate use of analgesic medications is to be encouraged, with rare exceptions (e.g., initial examination for acute abdomen, head trauma, or conditions where pain medication may mask symptoms such as stroke). K. Interventions shall be made to relieve reported pain using evidence-based multimodal treatment modalities. Consideration should be given to starting with non?pharmacological interventions, then non-opioid medications, and progressing to opioids as indicated. The choice of intervention must be based on current assessment, patient history, and medication tolerance. L. Pain medication administration must be preceded by a pain assessment, including the patient’s rating of pain. Nurses are required to consider subjective and objective factors before administering medications. M. The registered nurse (RN) shall communicate with the physician to coordinate an alternative treatment plan when the patient’s pain remains above the identified comfort goal.” During a review of the facility’s policy titled “Plan for Provision of Care, Treatment, and Services,” dated 12/2025, the policy indicated the following: “The Emergency Department (ED) will provide an assessment, and any treatment indicated to all patients presenting with any illness or injury. All patients will be triaged according to policy and will receive an appropriate medical screening exam by a physician or mid-level provider. The goal is to deliver high?quality critical, emergent, and urgent care while maintaining a safe, respectful, and non?discriminatory environment. The staff works together to provide optimal patient care; to share health and safety skills and knowledge within the community; to train students in various health care professions (ED residents, paramedics, and nurses); and to advance emergency care through medical and nursing research. Staffing Plan A. “Patient care and treatment shall be provided by Registered Nurses.” “Patient ratio is driven by patient acuity and guided by Title 22 of the California Code of Regulations.” Title 22 is the section of California law that establishes mandatory minimum nurse-to-patient ratios, staffing requirements, and patient safety rules for hospitals. These regulations are enforceable statewide and set the maximum number of patients who may be assigned to one licensed nurse at any one time. The facility policy incorporates the following verbatim regulatory language from California Code of Regulations, Title 22, §70217 - Nursing Service Staff: “Hospitals shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios. Licensed nurse means a registered nurse, licensed vocational nurse and, in psychiatric units only, a psychiatric technician. Staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system. Licensed nurse-to-patient ratios represent the maximum number of patients that shall be assigned to one licensed nurse at any one time. ‘Assigned’ means the licensed nurse has responsibility for the provision of care to a particular patient within his/her scope of practice. There shall be no averaging of the number of patients and the total number of licensed nurses on the unit during any one shift nor over any period of time. Only licensed nurses providing direct patient care shall be included in the ratios.” The Emergency Department-specific minimum ratios required under Title 22 are: -Emergency Department: 1 licensed nurse for every 4 patients -Emergency Department Critical Care: 1 licensed nurse for every 2 patients -Trauma: 1:1 registered nurse ratio The policy further indicated: C. “The ED staffing plan facilitates the maximum resources at maximum demand. Staff resources increase and decrease with patient volume and acuity as they progress through each day.” 2.b. During a review of Patient 15’s Emergency Documentation (the medical record created during an emergency department visit), dated 3/3/2026, the record indicated that Patient 15 was seen in the emergency department (ED, a hospital department that provides urgent and unscheduled medical care) on 3/3/2026 with non-specific chest pain which started in the morning (of 3/3/2026) as a sore, crushing sensation. Patient 15 was placed in the offload red zone, where Patient 15 remained until discharged. During a concurrent interview and record review on 3/5/2026 at 9:47 a.m. with the Quality Clinical Safety Coordinator (SC), Patient 15’s Vital Signs (VS, the basic physiological measurements, such as temperature, heart rate, respiratory rate, and blood pressure, used to assess a patient’s immediate clinical status) flowsheet, dated 3/3/2026 through 3/4/2026, was reviewed. The VS flowsheet indicated the following: -at 4:45 p.m. (upon arrival of Patient 15 to the Emergency Department), the pain level was documented as 8/10 (severe pain). -at 8:57 p.m., there was no pain level assessed at this time. -SC verified that there was no pain reassessment performed (after the initial pain assessment at 4:45 p.m.) along with VS check/monitoring every two hours during Patient 15’s visit in the Emergency Department (ED). SC also verified that there was no record of Patient 15’s cardiac rhythm assessment (cardiac rhythm assessment is the evaluation and documentation of the heart’s electrical pattern to identify irregular, slow, or fast heartbeats) despite Patient 15’s chief complaint of chest pain on arrival to the ED. During a review of the facility’s policy titled “Pain Assessment and Management,” dated (date), the policy indicated the following: “Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. It is relatively brief and subsides as healing takes place.” The policy further indicated: “A. Patients are to be screened for pain when visiting the emergency room, upon admission, and alongside routine vital signs based on unit protocols. B. Staff must accept and respect the patient’s self-report of pain using a verbal pain scale, which defines pain levels as: 0: No pain 1-3: Mild pain 4-6: Moderate pain 7-10: Severe pain The policy also states that: The patient, family/caregivers, nurse, physician, and pharmacist shall collaborate to consider the patient’s home pain regimen as part of the treatment plan. C. Staff must establish an agreed-upon comfort goal based on the patient’s expectations and understanding of the pain scale, and document this in the medical record. Goals for pain less or equal to 5 should include functional expectations (e.g., ability to take a deep breath, turn in bed, ambulate). J. Appropriate use of analgesic medications is to be encouraged, with rare exceptions (e.g., initial examination for acute abdomen, head trauma, or conditions where pain medication may mask symptoms such as stroke). K. Interventions shall be made to relieve reported pain using evidence-based multimodal treatment modalities. Consideration should be given to starting with non-pharmacological interventions, then non-opioid medications, and progressing to opioids as indicated. The choice of intervention must be based on current assessment, patient history, and medication tolerance. L. Pain medication administration must be preceded by a pain assessment, including the patient’s rating of pain. Nurses are required to consider subjective and objective factors before administering medications. M. The registered nurse (RN) shall communicate with the physician to coordinate an alternative treatment plan when the patient’s pain remains above the identified comfort goal.” During a review of the facility’s policy titled “Plan for Provision of Care, Treatment, and Services,” dated 12/2025, the policy indicated the following: “The Emergency Department (ED) will provide an assessment, and any treatment indicated to all patients presenting with any illness or injury. All patients will be triaged according to policy and will receive an appropriate medical screening exam by a physician or mid-level provider. The goal is to deliver high-quality critical, emergent, and urgent care while maintaining a safe, respectful, and non-discriminatory environment. The staff works together to provide optimal patient care; to share health and safety skills and knowledge within the community; to train students in various health care professions (ED residents, paramedics, and nurses); and to advance emergency care through medical and nursing research. Staffing Plan A. “Patient care and treatment shall be provided by Registered Nurses.” “Patient ratio is driven by patient acuity and guided by Title 22 of the California Code of Regulations.” Title 22 is the section of California law that establishes mandatory minimum nurse-to-patient ratios, staffing requirements, and patient safety rules for hospitals. These regulations are enforceable statewide and set the maximum number of patients who may be assigned to one licensed nurse at any one time. The facility policy incorporates the following verbatim regulatory language from California Code of Regulations, Title 22, §70217 - Nursing Service Staff: “Hospitals shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios. Licensed nurse means a registered nurse, licensed vocational nurse and, in psychiatric units only, a psychiatric technician. Staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system. Licensed nurse-to-patient ratios represent the maximum number of patients that shall be assigned to one licensed nurse at any one time. ‘Assigned’ means the licensed nurse has responsibility for the provision of care to a particular patient within his/her scope of practice. There shall be no averaging of the number of patients and the total number of licensed nurses on the unit during any one shift nor over any period of time. Only licensed nurses providing direct patient care shall be included in the ratios.” The Emergency Department-specific minimum ratios required under Title 22 are: -Emergency Department: 1 licensed nurse for every 4 patients -Emergency Department Critical Care: 1 licensed nurse for every 2 patients -Trauma: 1:1 registered nurse ratio The policy further indicated: C. “The ED staffing plan facilitates the maximum resources at maximum demand. Staff resources increase and decrease with patient volume and acuity as they progress through each day.” 2.c. During a review of Patient 4’s Emergency Documentation, dated 3/4/2026, the record indicated that Patient 4 presented to the Emergency Department on 3/4/2026 at 4:05 a.m. complaining of abdominal pain in the epigastrium (the upper central part of the abdomen, located just below the ribs) and Patient 4 was placed in the offload red zone, where Patient 4 remained until discharge. During a review of Patient 4’s Vital Signs (VS, the basic measurements such as temperature, heart rate, breathing rate, and blood pressure used to monitor a patient’s condition) order, dated 3/4/2026, the record indicated that Patient 4 had an order for vital signs to be taken every one hour. During a review of Patient 4’s Triage (the initial rapid assessment used to determine how sick a patient is and how quickly they need care) note, dated 3/4/2026, the record indicated that Patient 4 required a bag-valve mask (a handheld device used to manually deliver breaths to a patient who is not breathing or not breathing adequately). During a concurrent interview and record review on 3/4/2026 at 12:36 p.m. with the Quality Clinical Safety Coordinator (SC), Patient 15’s Vital Signs (VS, the basic measurements such as temperature, heart rate, breathing rate, and blood pressure used to monitor a patient’s clinical status) record, dated 3/4/2026, was reviewed. The record indicated that VS were obtained at the following times: -at 4:05 a.m. - Blood pressure (BP) was 236/114 (a dangerously high range; normal BP is about 120/80). Pain was 10/10 (10/10 indicates the worst possible pain on the standard 0-10 pain scale; severe pain). Heart rate (HR) was 69. Oxygen therapy: bag-valve mask. Oxygen saturation (the percentage of oxygen in the blood that shows how well oxygen is being delivered to the body) was 100%. -at 5:15 a.m. - Pain was 10/10. -at 5:59 a.m. - BP was 235/102, HR 73, Oxygen saturation was 98%, no oxygen therapy documented. -at 7:39 a.m. - BP was 222/91; pain level was not documented, HR was 70, oxygen saturation was 98% -8:50 a.m. - BP was 222/91; pain level was not assessed, heart rate was not documented, oxygen saturation not documented. -9:46 a.m. - BP was 164/73; pain level was not assessed, HR 60, oxygen saturation rate 98%, no documentation if Patient 4 was on room air or receiving oxygen therapy. -at 11:38 a.m. - BP was 183/84; pain level was not documented, HR 87, oxygen saturation rate 97%, no documentation if Patient 4 was on room air or receiving oxygen therapy -SC verified that hourly vital signs and pain assessments were not completed as ordered and, documentation of oxygen therapy use was inconsistent. During a concurrent interview and record review on 3/3/2026 at 2:36 p.m. with the Quality Clinical Safety Coordinator (SC), Patient 4’s cardiac monitoring rhythm record (cardiac rhythm refers to the pattern of the heart’s electrical activity, documented to identify normal or abnormal heartbeats), was reviewed. The record indicated that there was no documentation showing that Patient 4 was monitored, and no cardiac rhythm was recorded. SC verified that there was no documentation for Patient 4’s cardiac rhythm activity. During a review of Patient 4’s Emergency Documentation record, dated 3/4/2026, the record indicated that Patient 4 was diagnosed with small bowel obstruction (a blockage in the small intestine that prevents food, fluids, and gas from passing through), hypertension (high blood pressure), and Patient 4 required a general surgery consultation (an evaluation by a surgeon to determine if surgical treatment is needed), and had an order for a nasogastric tube insertion (NG tube, placement of a tube through the nose into the stomach to remove stomach contents or relieve pressure). During an interview on 3/4/2026 at 2:34 p.m. with the Quality Clinical Safety Coordinator (SC), SC confirmed that there was no documentation of NG tube placement (nasogastric tube insertion) record in Patient 4’s medical record. SC did not provide a comment regarding when the NG tube should be inserted if the order was placed at 9:04 a.m. During a review of the facility’s policy titled “Pain Assessment and Management,” dated (date), the policy indicated the following: “Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. It is relatively brief and subsides as healing takes place.” The policy further indicated: “A. Patients are to be screened for pain when visiting the emergency room, upon admission, and alongside routine vital signs based on unit protocols. B. Staff must accept and respect the patient’s self-report of pain using a verbal pain scale, which defines pain levels as: 0: No pain 1-3: Mild pain 4-6: Moderate pain 7-10: Severe pain The policy also states that: The patient, family/caregivers, nurse, physician, and pharmacist shall collaborate to consider the patient’s home pain regimen as part of the treatment plan. C. Staff must establish an agreed-upon comfort goal based on the patient’s expectations and understanding of the pain scale, and document this in the medical record. Goals for pain less or equal to 5 should include functional expectations (e.g., ability to take a deep breath, turn in bed, ambulate). J. Appropriate use of analgesic medications is to be encouraged, with rare exceptions (e.g., initial examination for acute abdomen, head trauma, or conditions where pain medication may mask symptoms such as stroke). K. Interventions shall be made to relieve reported pain using evidence-based multimodal treatment modalities. Consideration should be given to starting with non-pharmacological interventions, then non-opioid medications, and progressing to opioids as indicated. The choice of intervention must be based on current assessment, patient history, and medication tolerance. L. Pain medication administration must be preceded by a pain assessment, including the patient’s rating of pain. Nurses are required to consider subjective and objective factors before administering medications. M. The registered nurse (RN) shall communicate with the physician to coordinate an alternative treatment plan when the patient’s pain remains above the identified comfort goal.” During a review of the facility’s policy titled “Plan for Provision of Care, Treatment, and Services,” dated 12/2025, the policy indicated the following: “The Emergency Department (ED) will provide an assessment, and any treatment indicated to all patients presenting with any illness or injury. All patients will be triaged according to policy and will receive an appropriate medical screening exam by a physician or mid-level provider. The goal is to deliver high?quality critical, emergent, and urgent care while maintaining a safe, respectful, and non?discriminatory environment. The staff works together to provide optimal patient care; to share health and safety skills and knowledge within the community; to train students in various health care professions (ED residents, paramedics, and nurses); and to advance emergency care through medical and nursing research. Staffing Plan A. “Patient care and treatment shall be provided by Registered Nurses.” “Patient ratio is driven by patient acuity and guided by Title 22 of the California Code of Regulations.” Title 22 is the section of California law that establishes mandatory minimum nurse-to-patient ratios, staffing requirements, and patient safety rules for hospitals. These regulations are enforceable statewide and set the maximum number of patients who may be assigned to one licensed nurse at any one time. The facility policy incorporates the following verbatim regulatory language from California Code of Regulations, Title 22, §70217 - Nursing Service Staff: “Hospitals shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios. Licensed nurse means a registered nurse, licensed vocational nurse and, in psychiatric units only, a psychiatric technician. Staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system. Licensed nurse-to-patient ratios represent the maximum number of patients that shall be assigned to one licensed nurse at any one time. ‘Assigned’ means the licensed nurse has responsibility for the provision of care to a particular patient within his/her scope of practice. There shall be no averaging of the number of patients and the total number of licensed nurses on the unit during any one shift nor over any period of time. Only licensed nurses providing direct patient care shall be included in the ratios.” The Emergency Department-specific minimum ratios required under Title 22 are: -Emergency Department: 1 licensed nurse for every 4 patients -Emergency Department Critical Care: 1 licensed nurse for every 2 patients -Trauma: 1:1 registered nurse ratio The policy further indicated: C. “The ED staffing plan facilitates the maximum resources at maximum demand. Staff resources increase and decrease with patient volume and acuity as they progress through each day.” 2.d. During a review of Patient 6’s Emergency Documentation, dated 10/1/2025, the record indicated that Patient 6 presented to the emergency department complaining of flu-like symptoms (symptoms such as fever, chills, body aches, headache, or fatigue) for one (1) day, cough, SOB (shortness of breath), and congestion. The record also indicated that Patient 6 was usually on 3 L (liters, a unit of measure) of oxygen at home (meaning the patient typically used 3 liters per minute of supplemental oxygen delivered through a nasal cannula [tube] to maintain adequate oxygen levels). During review of Patient 6’s triage record, dated 10/1/2025 at 11:04 p.m., the record indicated that Patient 6 was brought in by ambulance on 10/1/2025 and was triaged (the initial screening and evaluation done at arrival to determine the patient’s condition and priority for care) at 11:04 p.m. The record further indicated that Patient 6 was given ESI 2 priority (meaning the patient required urgent care and was at high risk of clinical deterioration but was not in immediate life?threatening condition; patients at ESI 2 need rapid evaluation and typically require multiple resources). During an interview on 3/4/2025 at 3:28 p.m. with the Quality Clinical Safety Coordinator (SC), SC confirmed that Patient 6 was not placed in a room in the ED but was offloaded in the hallway (Patient 6 was found unresponsive while still in the hallway at 12:07 a.m. on 10/2/2025). During a review of Patient 6’s nursing progress note, dated 10/2/2025 at 12:07 a.m., the note indicated that, “ED tech (Tech 2) informed the nurse ( [RN 26] the nurse who documented the progress note dated 10/2/2025) that patient (Patient 6) did not look good ... the nurse went to assess the patient (Patient 6), and the patient (Patient 6) was not breathing ... CPR (CPR -cardiopulmonary resuscitation, is an emergency procedure used when a patient is not breathing or does not have a pulse) was started ... patient (Patient 6) was taken to the trauma bay (a designated emergency treatment area where critically ill or injured patients receive immediate, intensive medical care).” The record was reviewed with the Quality Clinical Safety Coordinator (SC) who verified that Patient 6 was found unresponsive in the hallway and sustained a cardiac arrest (when the heart stops beating). During an interview on 3/5/2026 at 10:28 a.m. with ED manager (NM 1), NM 1 said, “We do vital signs (VS) every 2 hours for patients. We do pain assessments with VS (vital signs, a set of basic body measurements such as temperature, heart rate, breathing rate, and blood pressure), and more often as needed. Pain assessment is important because pain can alter the VS, and we medicate with medicine. The pain assessment is important. Pain may indicate a deterioration (worsening) of condition. If medication is given, the reassessment of pain is done in 30 minutes. When a patient complains of pain (c/o pain), the nurse documents the pain. They are the patient advocate and lets the provider know that the patient has pain. The nurse’s role is to advocate.” NM 1 also stated, “We tell the nurses to notify the charge nurses and document if MD (medical doctor) refuses to manage pain, because we advocate [for patients].” During an interview on 3/5/2026 at 2:10 p.m. with the Director of the Emergency Department (DIR 1), regarding staffing and monitoring requirements for patients in the Red Zones, DIR 1 stated the following: -DIR 1 said that when EMS brought patients in, they (the EMS) first gave report to the ambulance triage nurse. After that, EMS gave report to the assigned RN or to the off-loading staff in the facility. -DIR 1 said, “The EMS notifies the tech and explains why the patient was there and where the patient was sent from.” -DIR 1 said that the tech wrote down the EMT’s information and the arrival time. DIR 1 also stated that the facility had staff assigned to the off-load area who reviewed the patient’s chart and looked for any orders that needed to be completed. -DIR 1 said that once patients were offloaded, the nurses in the red zone area observed and monitored the patients to make sure there was no deterioration in their condition. -DIR 1 said, “In the event of a code, if a patient deteriorated in the red zone area, the person assigned to the red zone area could check on the patient, communicate with the charge nurse, and move the patient to the trauma room to provide care ...” -DIR 1 added that: -Patients were monitored appropriately. -The standard was to re-assess patients every two hours. -Connecting patients to a monitor was done when needed or when there was a physician’s order. -Nursing judgment was important because nurses used their professional assessment to decide when patients needed monitoring or closer observation. During the same interview on 3/5/2026 at 2:10 p.m. with the Director of the Emergency Department (DIR 1), DIR 1 said, “We had two RNs, two techs, and two LVNs who were constantly monitoring.” Dir 1 also stated the following: -DIR 1 said it was always possible to find patients who were unresponsive. -DIR 1 stated that if patients were not connected to monitors, it was because yesterday (3/3/2026) had been a very busy day. DIR 1 said they tried to anticipate needs, but it was the emergency department, and anything could happen when it was busy. -DIR 1 said they saw an average of 300-400 patients a day. DIR 1 added that “patients received great quality care” because they were not “holding a wall,” they were not ignored, and in the new area (red zone area), nurses were able to initiate treatment. During the same interview on 3/5/2026 at 2:10 p.m. with the Director of the Emergency Department (DIR 1), DIR 1 stated there were no concerns regarding the proximity of patient gurneys, which were placed approximately within 3 feet of each other. DIR 1 explained that staff received reports on patients, knew who was contagious and who was not, and could place contagious patients in isolation rooms with doors, and curtains were also available for separation. During an interview on 3/5/2026 at 2:17 p.m. with the Infection Control Specialist (ICS), ICS stated that “there had been infection control issues in the ER red zone that had been brought to my attention.” ICS stated that the beds were “too close to each other, creating a risk of spreading germs and infections.” ICS stated that beds needed to be at least 6 feet apart, especially when a patient was on droplet precautions. ICS stated they (the facility) were not sure about the specific regulations but confirmed that the gurneys were too close. During an interview on 3/6/2026 at 1:06 p.m. with the Director of Quality (DQ), DQ confirmed that there was no mention or discussion of APOT (Ambulance Patient Offload Time, meaning the time it takes for EMS to transfer a patient into the hospital’s care) in the emergency department minutes for 2024 or 2025. (The term “minutes” refers to the official written record of a meeting, summarizing the topics discussed, decisions made, and actions to be taken). The DQ also said the following: -DQ said that QAPI (Quality Assurance and Performance Improvement, a program used by hospitals to track, evaluate, and improve performance) had not been monitoring this project (use of the red zone area for patients who are offloaded by EMS and are awaiting ED bed assignments), which was initiated in the emergency department sometime in 2024. -DQ stated that the average off-loading time had been about 20 minutes, and that the emergency department had been meeting its targets (referring to the target for the 30-minute patient offloading requirement). During an interview on 3/6/2026 at 1:40 p.m. with Chief Nursing Officer (CNO), The CNO said the hospital had been working hard since early last year (2025) to meet performance benchmarks (off-load times should not exceed 30 minutes), especially related to patient throughput (moving patients efficiently through the ED). The CNO said the following: -The team (ED Leadership and Physicians) created a plan to improve overall flow and reduce ambulance delays, which led to opening the Red Zone area to help offload EMS patients when the ED became full. -The CNO explained that patients were registered on arrival, EMS would give report to the triage nurse, and then patients were directed to the appropriate area based on how sick they were. Very sick patients go to the Blue Zone or critical care rooms with full monitoring. The offload area (red zone) was used only when the ED was saturated. -“In the offload area, a nurse and tech would obtain vital signs, and EMS provided information to the LVN or RN. Providers could see the patients in the tracking system ... Once offloaded, the patients were considered ED patients.” -The CNO stated that staffing in the red zone area was flexible and moved based on need, and included charge nurses, clinical managers, and leadership across shifts. She said the ED had an offload capacity of about 14 patients and tried not to line patients along the walls. -The CNO said multiple providers were available, and nurses escalated concerns as needed. [Cardiac] Monitoring was done only when required, based on the nurse’s clinical judgment, as there was no formal policy or algorithm (regarding monitoring of the red zone patients). The CNO stated there had been minimal issues and no issues when patients were found unresponsive [not that the CNO was aware of] in the offload area and that adverse events, such as seizures, were reviewed when they occurred. The CNO also said that adverse events were not tracked but said that she [the CNO] was not aware of any adverse events involving patients in the Red Zone area (Patient 6 was found unresponsive while still in the hallway [red zone area] on 10/2/2025). -The CNO said that all patient assessments were expected to be done every two hours, with full assessments followed by focused reassessments. The CNO said that that APOT and offload workflows had been discussed informally, and these discussions were not documented in meeting minutes [Emergency Department meeting minutes], though updates were shared with leadership, including the CEO and CMO. During a review of the facility’s policy titled “Pain Assessment and Management,” dated (date), the policy indicated the following: “Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. It is relatively brief and subsides as healing takes place.” The policy further indicated: “A. Patients are to be screened for pain when visiting the emergency room, upon admission, and alongside routine vital signs based on unit protocols. B. Staff must accept and respect the patient’s self?report of pain using a verbal pain scale, which defines pain levels as: 0: No pain 1-3: Mild pain 4-6: Moderate pain 7-10: Severe pain The policy also states that: The patient, family/caregivers, nurse, physician, and pharmacist shall collaborate to consider the patient’s home pain regimen as part of the treatment plan. C. Staff must establish an agreed-upon comfort goal based on the patient’s expectations and understanding of the pain scale, and document this in the medical record. Goals for pain less or equal to 5 should include functional expectations (e.g., ability to take a deep breath, turn in bed, ambulate). J. Appropriate use of analgesic medications is to be encouraged, with rare exceptions (e.g., initial examination for acute abdomen, head trauma, or conditions where pain medication may mask symptoms such as stroke). K. Interventions shall be made to relieve reported pain using evidence-based multimodal treatment modalities. Consideration should be given to starting with non?pharmacological interventions, then non-opioid medications, and progressing to opioids as indicated. The choice of intervention must be based on current assessment, patient history, and medication tolerance. L. Pain medication administration must be preceded by a pain assessment, including the patient’s rating of pain. Nurses are required to consider subjective and objective factors before administering medications. M. The registered nurse (RN) shall communicate with the physician to coordinate an alternative treatment plan when the patient’s pain remains above the identified comfort goal.” During a review of the facility’s policy titled “Plan for Provision of Care, Treatment, and Services,” dated 12/2025, the policy indicated the following: “The Emergency Department (ED) will provide an assessment, and any treatment indicated to all patients presenting with any illness or injury. All patients will be triaged according to policy and will receive an appropriate medical screening exam by a physician or mid-level provider. The goal is to deliver high-quality critical, emergent, and urgent care while maintaining a safe, respectful, and non-discriminatory environment. The staff works together to provide optimal patient care; to share health and safety skills and knowledge within the community; to train students in various health care professions (ED residents, paramedics, and nurses); and to advance emergency care through medical and nursing research. Staffing Plan A. “Patient care and treatment shall be provided by Registered Nurses.” “Patient ratio is driven by patient acuity and guided by Title 22 of the California Code of Regulations.” Title 22 is the section of California law that establishes mandatory minimum nurse-to-patient ratios, staffing requirements, and patient safety rules for hospitals. These regulations are enforceable statewide and set the maximum number of patients who may be assigned to one licensed nurse at any one time. The facility policy incorporates the following verbatim regulatory language from California Code of Regulations, Title 22, §70217 - Nursing Service Staff: “Hospitals shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios. Licensed nurse means a registered nurse, licensed vocational nurse and, in psychiatric units only, a psychiatric technician. Staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system. Licensed nurse-to-patient ratios represent the maximum number of patients that shall be assigned to one licensed nurse at any one time. ‘Assigned’ means the licensed nurse has responsibility for the provision of care to a particular patient within his/her scope of practice. There shall be no averaging of the number of patients and the total number of licensed nurses on the unit during any one shift nor over any period of time. Only licensed nurses providing direct patient care shall be included in the ratios.” The Emergency Department-specific minimum ratios required under Title 22 are: -Emergency Department: 1 licensed nurse for every 4 patients -Emergency Department Critical Care: 1 licensed nurse for every 2 patients -Trauma: 1:1 registered nurse ratio The policy further indicated: C. “The ED staffing plan facilitates the maximum resources at maximum demand. Staff resources increase and decrease with patient volume and acuity as they progress through each day.” 3. During a review of Patient 7’s “ED Provider Note,” dated 9/9/2023, the note indicated Patient 7 had presented with slurred speech (difficulty speaking clearly), left-sided facial droop (weakness of the facial muscles), and left?sided weakness (reduced strength in the arm or leg on one side of the body) that the patient (Patient 7) had noticed the previous morning and that had lasted throughout the day. The note also indicated that, on the morning of 9/9/2023, the patient (Patient 7) noticed the symptoms were still present, which prompted the patient to visit the emergency department (the hospital area where people go for immediate medical care). The patient (Patient 7) also reported nausea (an upset stomach) without vomiting. The note further indicated that Patient 7’s reported last known well time (LKW, the most recent time a stroke patient was observed to be at their normal baseline without any stroke symptoms) was over 24 hours. During a concurrent interview and record review on 3/6/2026 at 9:54 a.m. with the Manager of the Emergency Department (MN 1), Patient 7’s medical record (MR) titled “Neurological Assessment (an assessment of the nervous system),” dated 9/9/2023, from the time Patient 7 was triaged at 11:36 a.m. through 9/21/2026, was reviewed. The MR indicated the first completed neurological assessment was documented on 9/9/2023 at 5:10 p.m. MN 1 confirmed that there was more than a 5-hour delay in assessing Patient 7’s neurological status (the patient’s brain and nerve function). There was no initial NIHSS (National Institutes of Health Stroke Scale, a standardized tool used to measure stroke severity) assessment. MN 1 further stated that for patients who presented with stroke symptoms an initial neurological assessment should have been completed to establish a baseline (the patient’s normal starting point), so that if the patient’s condition changed, nursing staff could alert the provider. MN 1 stated it does not matter if the patient’s LKW time was over 24 hours, a NIHSS must be completed on the initial assessment. During the same concurrent interview and record review on 3/6/2026 at 9:54 a.m. with the Manager of the Emergency Department (MN 1), Patient 7’ MR titled “Order (Physician’s Order),” was reviewed. The order indicated that Patient 7 had an order for every 4 hours neurological checks. During an interview on 3/5/2026 at 3:40 p.m. with the Manager of Stroke Team (NM 6), NM 6 stated that when a patient presented to the ED with stroke symptoms, an initial assessment of neurological status should be completed, and following that, the physician would place an order for the frequency of neurological checks. NM 1 stated Patient 7 had an order for every 4 hours neurological check. During a review of the facility’s policy and procedures (P&P) titled, “Acute Stroke Pathway for Emergency Department,” dated 11/2025, the P&P indicated, “LKW greater than 24 ...Continue to treat per patients’ assessment and current ED policy ...RN to complete NIHSS ...” During a review of the facility’s policy and procedures (P&P) titled, “Initial Patient Assessment and Reassessment,” dated 3/6/20245, the P&P indicated, “A complete assessment shall include physical, psychological, pain management, spiritual needs, social status, medication history with regards to current medications including allergies and sensitivity, as well as educational and discharge preparedness/planning needs ... At the time of admission or as soon as possible thereafter, each patient shall have an initial physical/psychological assessment completed by a registered nurse (RN) ... Initial assessment includes screening information related to other disciplines (e.g., Nutritional screen, functional screen, etc.). Based on the outcome of screening data, other disciplines may be contacted to perform a more comprehensive assessment of the patient as needed. This data shall be used by the multidisciplinary team to establish the information necessary to provide the most comprehensive plan of care for the patient.””

“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: 50516 Based on interview and record review, the facility failed to ensure nursing staff adhered to the facility’s policies and procedures when: 1.a. One of 34 sampled patients (Patient 20), was placed on bilateral (left and right) soft wrist restraints (mechanical device that reduces the ability of a patient to move or access any part of their body) and was not assessed at an interval of every two (2) hours, in accordance with the facility’s policy and procedure titled, “Restraint and Seclusion (involves isolating a patient in a locked room to prevent immediate harm to a patient or others) Guidelines.” This deficient practice had the potential for Patient 20 to suffer from complications of not having his (Patient 20) care needs assessed, while on restraints, which includes impaired skin circulation (blood flow), skin breakdown (damage to the skin), and emotional distress. 1.b. One of 34 sampled patients (Patient 20) was not repositioned every two hours, in accordance with the facility’s policy and procedure titled, “Skin Care Assessment and Treatment.” Patient 20 had a Braden Scale (tool used to evaluate a person’s risk of developing a pressure injury [localized damage to the skin and/or underlying tissue usually over a bony prominence]) score of less than 18, which indicated that Patient 20 was at risk of a skin breakdown (damage to the skin) if not repositioned in a timely manner. This deficient practice had the potential for Patient 20 to develop a pressure injury (localized damage to the skin and underlying soft tissue, usually occurring over bony prominences, caused by prolonged pressure, friction, or shear), which could have caused discomfort, infection and pain. 2. One of 34 sampled patient’s (Patient 2) medication reconciliation (the process of creating the most accurate list of all medications a patient is taking and comparing it to provider orders to ensure that medications are not omitted, duplicated, or contraindicated) form, was not completed, in accordance with the facility’s policy regarding medication reconciliation, during Patient 2’s Emergency Department (a hospital department that provides urgent and unscheduled medical care) visit on 8/12/2025. This deficient practice resulted in Patient 2 being placed at risk for medication errors, including the risk of omitted, duplicated, or contraindicated medications, and potential delays in receiving safe, accurate and appropriate treatment. Findings: 1.a. During a review of Patient 20’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/5/2026, the record indicated Patient 20 was admitted to the facility for generalized weakness, fatigue (tired) and difficulty walking. The record further indicated Patient 20’s medical history included deep vein thrombosis (blood clot in the vein), anemia (low amount of blood cells to carry oxygen throughout the body) and skin cancer. During a record review on 3/4/2026 at 11:12 a.m. with Data Specialist and Administrative Assistant (DS), Patient 20’s “Order Sheet,” dated 1/6/2026, was reviewed. The Order Sheet indicated Patient 20 had an order for soft left and right wrist restraints (mechanical device that reduces the ability of a patient to move or access any part of their body) due to Patient 20 pulling at tubes and lines. During an interview on 3/4/2026 at 3:58 p.m. with Registered Nurse (RN) 6, RN 6 stated there should be an assessment every two hours to release restraints applied on a patient, check the skin and range of motion (movement), capillary refill (test to see how fast blood flows by pinching the fingernail), offer hydration and restroom use. RN 6 further stated the assessment interval could not be more than two hours. During a concurrent interview and record review on 3/6/2026 at 9:50 a.m. with RN 8, Patient 20’s “Restraint View,” dated 1/6/2026 to 1/7/2026, was reviewed. The record indicated on 1/6/2026 at 8:00 a.m., Patient 20 was on restraints. Patient 20 was next assessed at 12:00 p.m. (four hours later). RN 8 acknowledged that the 10:00 a.m. documentation for restraint assessment, was missing. RN 8 stated restraint documentation should be every two hours, and this would include a documentation regarding checking the patient’s skin and circulation, patient activity and if the patient’s behavior improved. RN 8 stated that documentation was a legal record, and that it also indicated a plan for patient safety. During a review of the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion Guidelines,” dated 5/28/2025, the P&P indicated, “Care of the patient, including needs for hygiene, toileting, Skin and Circulation Assessment, comfort, repositioning, and all other medical needs should continue during the restraint period at intervals not to exceed 2 hours.” 1.b. During a concurrent interview and record review on 3/4/2026 at 11:12 a.m. with Data Specialist and Administrative Assistant (DS), Patient 20’s “Integumentary Assessment,” dated 1/5/2026 to 1/7/2026, were reviewed. The Integumentary (Skin) Assessment record indicated that on 1/5/2026, Patient 20 had a Braden Scale (tool used to evaluate a person’s risk of developing a pressure injury [localized damage to the skin and/or underlying tissue usually over a bony prominence]) score of 20 (low or no risk of developing a pressure injury [localized damage to the skin and underlying soft tissue, usually occurring over bony prominences, caused by prolonged pressure, friction, or shear]), and on the succeeding shift assessments and days, Patient 20 had a Braden score of 13 and 14 (moderate risk of developing a pressure injury). During the same concurrent interview and record review on 3/4/2026 at 11:12 a.m. with DS, Patient 20’s “Positioning and Activity Report,” dated 1/6/2026 to 1/8/2026, were reviewed and indicated the following: -On 1/6/2026 at 1:00 a.m., Patient 20 was positioned supine (lying on the back); -On 1/6/2026 at 7:40 a.m., Patient 20 was supine (6 hours later); -On 1/6/2026 at 7:50 p.m., Patient 20 was supine (12 hours later) and; -On 1/6/2026 at 9:34 p.m. Patient 20 was positioned to the right side; -On 1/6/2026 at 11:50 p.m., Patient 20 was positioned to the left side; -On 1/7/2026 at 1:32 a.m., Patient 20 was positioned supine; -On 1/7/2026 at 3:35 a.m., Patient 20 was positioned to the right side; -On 1/7/2026 at 5:29 a.m. Patient 20 was supine; -On 1/7/2026 at 7:21 a.m., Patient 20 was supine; - On 1/7/2026 at 8:00 a.m., Patient 20 was positioned to the left side - On 1/7/2026 at 11:22 a.m., Patient 20 was positioned to the right side (more than two hours later); - On 1/7/2026 at 2:00 p.m., Patient 20 was positioned supine; -On 1/7/2026 at 4:28 p.m., Patient 20 was positioned to the left side; -On 1/7/2026 at 7:29 p.m., Patient 20 was positioned to the right side (three hours later), and; -On 1/7/2026 at 11:06 p.m., Patient 20 was positioned supine (more than three hours later); -On 1/8/2026 at 1:08 a.m., Patient 20 was positioned on the left side; -On 1/8/2026 at 7:31 a.m., Patient 20 was positioned supine (6 hours since the last repositioning at 1:08 a.m.) -On 1/8/2026 at 9:42 a.m., Patient 20 was positioned on the right side. After this time through 1/9/2026, the position change was not documented. -The record further indicated Patient 20 needed two person assistance for bed mobility (ability to move). During an interview on 3/4/2026 at 4:10 p.m. with Registered Nurse (RN) 6, RN 6 stated that when patients were not able to move on their own or had decreased motion (movement), the patient should be turned every two hours, especially if patients had a skin breakdown or redness on the sacrum (a large, triangular bone located at the base of the spine, situated between the two hip bones) or pressure injuries. RN 6 also stated that turning/repositioning the patient was necessary to offload pressure and make sure the patient was not on one side for too long, which could increase the risk of a skin breakdown. During a concurrent interview and record review on 3/6/2026 at 9:50 a.m. with RN 8, Patient 20’s “Integumentary Assessment,” dated 1/6/2026, was reviewed. RN 8 stated that Patient 20’s Braden scale score was 13. RN 8 stated, for a Braden scale score below 18, the patient should be turned/repositioned. RN 8 said that not turning the patient every two hours could have caused the patient to complain of pain. RN 8 also said that documentation was important, including assessing the patient’s skin condition, activity, tolerance, continence (ability to control the bladder and bowel), and pain. During a review of the facility’s policy and procedure (P&P) titled, “Skin Care Assessment and Treatment,” undated, the P&P indicated, “General Interventions - nursing shall implement on all adult patients with Braden scale 18 or less, with existing pressure injuries and/or based off of nursing judgement: A. Off-load pressure, reposition every 2 (two) hours, pad bony prominences.” 2. During a review of Patient 2’s Emergency Documentation (the medical record created during an emergency department visit), dated 8/12/2025, the record indicated that Patient 2 was seen in the emergency department (ED, a hospital department that provides urgent and unscheduled medical care) due to a moderate headache that began “8 hours ago,” with a gradual onset. The record also indicated that Patient 2 stated she (Patient 2) took “one Percocet (a prescription pain medication that contains oxycodone [a strong pain-relieving drug and acetaminophen]) for the pain but felt no relief.” During a review of Patient 2’s Emergency Documentation, dated 8/12/2025, the record indicated that Patient 2 was diagnosed with low potassium levels (2.6, a critically low electrolyte level that can affect heart and muscle function) and low hemoglobin (Hgb, the protein in red blood cells that carries oxygen). The record also indicated that Patient 2 was given potassium replacement medication (treatment used to increase potassium levels in the blood) and a blood transfusion (a procedure in which donated blood is given to a patient through a vein to replace lost or low blood components). During a concurrent interview and record review on 3/3/2026 at 3:35 p.m. with the Quality Clinical Safety Coordinator (SC), Patient 2’s discharge instructions, dated 8/12/2026, were reviewed. The record indicated that the registered nurse reviewed the medications on file but did not update the medication list. SC confirmed that the medication list had no documented last dose (the most recent time the patient took each medication, used to prevent duplicated dosing, missed doses, or unsafe timing) and next dose (the next scheduled time the patient should take each medication, needed to ensure continuity and safe timing of therapy), and that multiple medications repeatedly appeared on the list. The medication list was later documented to be updated by the provider, with an indication to continue all medications unless otherwise noted. During an interview on 3/5/2026 at 10:28 a.m. with the Emergency Department Manager (NM 1), NM 1 stated that medication reconciliation was performed by nursing staff by updating the patient’s medication history, and the physician completing and finalizing the reconciliation (medication reconciliation is the process of creating the most accurate possible list of all medications a patient is taking, including drug name, dosage, frequency, and route, and comparing that list against the physician’s admission, transfer, or discharge orders to ensure medications are not duplicated, omitted, or contraindicated). During the same interview on 3/5/2026 at 10:28 a.m. with the Emergency Department Manager (NM 1), NM 1 stated, “Medication reconciliation is important because the providers need to know what medications the patient is taking, to ensure medications are not contraindicated and none are missed.” During a review of the facility’s policy titled “Medication Reconciliation,” dated 9/2022, the policy indicated that “Medication reconciliation will be initiated at the point of entry and completed across the continuum, including admission, transfers to different levels of care, and discharge. Involve the patient and family in the medication safety process. Medication reconciliation is the collaborative responsibility of physicians, nurses, and pharmacists. Electronic medication reconciliation will be utilized to document the medication reconciliation process for all in-patient admissions, outpatients, and discharges in the electronic medical record. The Medication Reconciliation form (a triplicate form included with the downtime paperwork) will be used when the electronic medical record is down.” The policy further indicated that: “The Medication Reconciliation form will be a permanent part of the medical record.” “The licensed staff will reconcile all documented medications taken prior to hospitalization.” “The licensed nurse takes responsibility for completion of the Medication Reconciliation form. They must fully complete all information for the medications.””

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure its radiologist (MD 19) documented abnormal urgent results communication with the providers, when MD 19 did not document the communication of identified large intraperitoneal free air from Chest x ray (an imaging procedure to create detailed image of the body’s internal structure such as bones, tissues and organs) result on 7/28/2025, for one of 34 sampled patients (Patient 16). This deficient practice resulted in Patient 16’s medical record not reflecting what was being reported, and as to who received the abnormal urgent result from the radiology department and potentially causing delayed diagnosis and worsened patient conditions. Findings: During a review of Patient 16’s “Operative Report (surgery report),” dated 7/24/2025, the “Operative Report” indicated, Patient 16 had partially obstructing hepatic flexure (the sharp bend between the ascending and transverse colon at the right upper quadrant near the live) colon cancer mass. The “Operative Report” also indicated, Patient 16 had robotic (robotic surgery, robot-assisted surgery) converted to open extended right hemicolectomy (a surgery removing the right side of the colon) and partial omentectomy (surgical removal of a fatty layer of tissue in the abdomen) on 7/24/2025. During a review of Patient 16’s physician order (orders written by physicians to direct care and treatment), the physician order indicated that on 7/28/2025 at 2:30 p.m., the physician (MD 3) ordered to perform Chest X Ray (an imaging procedure to create detailed image of the body’s internal structure such as bones, tissues and organs) STAT (a medical abbreviation for immediately or without delay) with indicated reason of elevated (high) heart rate during ambulation (walking). During a review of Patient 16’s “CXR report,” dated 7/28/2025, the “CXR report” indicated, “large intraperitoneal (inside abdominal cavity) free air (presence of gas within the abdominal cavity, could be an indication of perforated hollow viscus [a hole developed in the stomach or intestines], may presence post-operative status). Correlate for acute (on onset) abdomen or recent abdominal surgery. If indicated, computerized tomography (CT, a medical imaging technique to create detailed images of the inside of the body) abdomen pelvis may be performed.” The CXR report indicated the report was signed off on 7/28/2025 at 4:56 p.m. by radiologist (MD 19). During a concurrent observation and interview on 3/6/2025 at 11:22 a.m. with the Chair (MD 9) of Radiology, Patient 16’s chest x ray image, completed on 7/28/2025, was viewed. MD 9 pointed at where the intraperitoneal free air was seen on the chest x ray image. MD 9 stated the CXR image showed large peritoneal free air. During a concurrent interview and record review on 3/6/2025 at 11:23 a.m. with MD 9, Patient 16’s CXR report, dated 7/28/2025, was reviewed. The CXR report did not indicate any communication with Patient 16’s providers or nurses regarding the identified large intraperitoneal free air. MD 9 confirmed it was not on Patient 16’s CXR report. MD 9 stated the radiologist (MD 19) documented the communication in the department internal communication log. During a concurrent interview and record review on 3/6/2025 at 11:25 a.m. with the Chair (MD 9) of Radiology, the radiology department internal communication log titled, “sticky notes,” dated 7/27/2025, was reviewed. The “sticky notes” indicated, on 7/28/2025 at 4:26 p.m. “connect radiologist (MD 19), speak with nurse (STAT), intraperitoneal free air ... at 4:33 p.m. calling [facility’s medical floor] ... at 4:35 p.m. RN (registered nurse) did not answer. Will try again ... at 4:41 p.m. [RN 18] connected to [MD 19] ...” MD 9 stated MD 19 had concern of intraperitoneal free air identified on the CXR and communicated with Patient 16’s nurse (RN 18). MD 9 stated radiology department standard of practice was for the radiologists to document the communication with what finding, to whom, date and time on the official diagnostic report. MD 9 stated, “I do not know why this radiologist (MD 19) did not do it.” MD 9 confirmed the “sticky note” was not part of Patient 16’s medical record. During a review of the facility’s policy and procedure (P&P) titled, “Critical Results and Values Reporting,” dated 10/205, the P&P indicated, “to establish a standard method for recognition and report of critical test, critical results/values ... Documentation - A licensed healthcare provider will document the critical result, the date and time, the result that was received and the name of the individual reporting the result, and to whom the read-back process was conducted. Clinical areas without electronic documentation/during downtime will use the Critical Lab Value Report. All other areas will document in the electronic medical record.””

“SCOPE OF RADIOLOGIC SERVICES CFR(s): 482.26(a) [§482.26 Condition of Participation: Radiologic Services The hospital must maintain, or have available, diagnostic radiologic services...] §482.26(a) Standard: Radiologic Services The hospital must maintain, or have available, radiologic services according to the needs of the patients. This Standard is not met as evidenced by: 46333 Based on interview and record review, the hospital failed to ensure radiologic services (medical imaging services that use X-rays and other imaging technologies to help diagnose or monitor a patient’s condition) were provided according to the needs of the patient when a STAT (immediately required) CT (computed tomography, a medical imaging test that shows cross?sectional pictures of the inside of the body) scan ordered for one (1) of 34 sampled patients (Patient 7), was not completed within a clinically appropriate timeframe and was not performed in accordance with the facility’s “Code Stroke” policy. This deficient practice had the potential to limit the medical team’s ability to promptly determine whether Patient 7 was experiencing an ischemic (caused by blockage of blood flow) or hemorrhagic (bleeding) event, which could affect time?sensitive (requiring prompt action) treatment decisions. This deficient practice places Patient 7 and other patients requiring urgent diagnostic imaging (tests used to identify medical conditions) at risk for delays in diagnosis and necessary medical interventions (treatments). Findings: During a review of Patient 7’s electronic medical record (EMR, a digital version of the patient’s chart), dated 9/9/2023, the initial HPI (History of Present Illness, the first narrative describing the patient’s condition at the time of presentation) indicated left facial droop, left-sided weakness, slurred speech, blurred vision, and decreased left facial sensation, noticed upon waking at 0600 (6:00 a.m.) on 9/8/2023. LKW (last known well, the last time the patient was known to be without stroke symptoms) was documented as 9/7/2023 at 22:30 (10:30 p.m.). The note indicated Patient 7 reported mild headache and nausea. During an interview on 3/6/2026 at 12:41 p.m. with the Manager of Imaging Services (NM 5), NM 5 stated STAT (immediately required) CT (computed tomography, a medical imaging test that shows cross-sectional pictures of the inside of the body) scans should be completed “under two hours, no more than two hours,” and that Patient 7’s CT “should have been done immediately.” NM 5 further stated they could not find any documentation of communication from the Emergency Department (ED) to Imaging explaining the delay. During an interview on 3/6/2026 at 11:31 a.m. with the Emergency Department Physician (MD 16), MD 16 stated that even when the patient was outside the fibrinolytic window (the critical time frame-ideally within 3 to 4.5 hours of symptom onset-during which clot-busting drugs [like alteplase/tPA are safely administered to dissolve clots and restore blood flow in ischemic stroke), “STAT ordered CT should be done within a few minutes” because imaging was necessary to determine treatment direction, rule out hemorrhage, and guide blood pressure management. During an interview on 3/6/2026 at 10:13 a.m. with the Manager of the Emergency Department (NM 1), NM 1 stated suspected stroke patients “should receive CT within 15 minutes,” and confirmed that Code Stroke was not activated for Patient 7. NM 1 stated activation allowed CT to be prioritized and “clears the CT table for the stroke patient.” During an interview on 3/5/2026 at 3:40 p.m. with the Stroke Program Manager (NM 6), NM 6 stated diagnostic brain imaging should be expedited for all suspected stroke patients, and that Code Stroke activation initiates rapid transport and CT preparation. NM 6 confirmed Code Stroke “did not go out” for Patient 7, meaning CT staff were not alerted to prioritize the scan. NM 6 further stated that because Patient 7’s LKW (last known well, the last time the patient was known to be without symptoms) was over 24 hours, the Code Stroke was not activated, and that Patient 7 continued to have signs and symptoms of stroke. During a concurrent interview and record review on 3/5/2026 at 2:56 p.m. with Director of Medical Surgical/Telemetry (DIR 3), Patient 7’s “Orders,” was reviewed. The orders indicated: - A STAT CT brain without contrast was ordered at 12:00 p.m. on 9/9/2023, the details of the order indicated the reason for CT, “Headache, intracranial hemorrhage suspected ...” During the same interview on 3/5/2026 at 2:56 p.m. with DIR 3, Patient 7’s CT results, dated 9/9/2023 at 4:27 p.m., were reviewed. The CT was not completed until 4:27 p.m. DIR 3 stated, “CT for a patient coming into the emergency department for stroke should not have a delay of 4 hours and 27 minutes.” During a review of the Radiologic Schedule with NM 5 on 3/6/26 at 3:20 p.m., the schedule confirmed the STAT CT ordered at 12:00 p.m., was not completed until 4:27 p.m. NM 5 confirmed that there was no documentation of ED staff communicating any delay or acuity to Imaging. During a review of the facility’s policy and procedure (P&P) titled, “Prioritization of Procedure Requests,” dated 8/8/2023, the P&P indicated, “The goal of the Department of Radiology is to respond in a timely and efficient manner to request for service. In consideration of fluctuating volumes, the Radiology Department adheres to the exam prioritization matrix based on medical urgency as stated by the request, i.e., STAT, ASAP, Routine, Date and Time. Requests for procedures received in the Department of Radiology will be attended to according to level of medical urgency and staff availability ...Exam requests from the Emergency Department are considered STAT, unless otherwise specified, and will be prioritized according to urgency with Code Stroke STEMI and Trauma patients being considered critical. If multiple patients are ordered, the referring providers will need to confer and communicate to the Radiologic Technologist which procedures should be performed first ...” During a review of the facility’s policy and procedure (P&P) titled, “Code Stroke,” dated 11/12/2025, the P&P indicated, “Initiation of Code Stroke via mass communication for patients with any sudden or new onset of the following symptoms with (LKW) time within 24 hours of arrival ...Diagnostic brain imaging is to be expedited; CT staff will prepare table availability to facilitate rapid brain imaging. The Code Stroke patient will be monitored and escorted by a Registered Nurse (RN) during all transport.””

“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: 46333 Based on observation, interviews, and record review, the facility failed to ensure a safe surgical environment by not implementing or enforcing a draping method that prevented oxygen (O2, a gas that supports combustion) from accumulating beneath the surgical drapes (sterile sheets covering the patient) during procedures involving supplemental oxygen delivered by face mask and electrocautery (a heat-producing surgical device used to cut tissue or stop bleeding). This unsafe condition was identified during the review of one (1) of 34 sampled patients (Patient 8). Allowing the drapes to lie directly over the patient’s head created tenting (a pocket of trapped air under the drapes), which allowed oxygen to accumulate. This created an oxygen-enriched environment (a space containing higher-than-normal oxygen levels) in proximity to an ignition source (the electrocautery), contributing to a surgical fire and placing surgical patients at risk for fire-related injury. This deficient practice resulted in the contributing factors to the surgical fire not being fully identified and allowed unsafe conditions to persist during Patient 8’s procedure, which may have contributed to the fire and placed the patient and future patients at risk for fire-related harm. Findings: During a review of Patient 8’s medical record, dated 12/19/2025, the document titled, “Operative Report,” was reviewed. The Operative Report indicated that Patient 8 had a cyst (a small fluid-filled lump) on the right side of the neck causing discomfort, for which Patient 8 requested excision (surgical removal). The right neck was prepped and draped in a sterile manner (cleaned and covered to prevent infection) using chlorhexidine solution (an antiseptic cleaning liquid). The team waited over 3 minutes to allow the prep to fully dry. A timeout (a required safety pause to confirm the correct patient, procedure, and site) was then conducted. The patient (Patient 8) was draped in the usual manner using sterile towels and operating table drapes (clean sheets used to cover the patient during surgery). During a review of Patient 8’s medical record, dated 12/19/2025, the document titled, “Operative Report,” also indicated “Some very minor bleeding was appreciated in the subcutaneous tissue (the fat and soft tissue beneath the skin), and this was controlled by application of cautery (a tool that stops bleeding by using heat). At this point, I noted that the patient’s drapes caught on fire from the cautery. We poured water on the field and ripped all the drapes and blankets off immediately, and the fire was put out within a few seconds.” During a review of Patient 8’s medical record, dated 12/19/2025, the intraoperative record indicated the fire risk score was three (3) and listed required interventions including “employ tenting to minimize oxygen buildup under drapes” and “stop supplemental oxygen (O2 delivered through a face mask) at least 1 minute before and during cautery (heat-producing surgical device).” The record indicated oxygen by face mask was used, alcohol-based skin prep was used, and the fire occurred under the drapes during closure when the Bovie (electrosurgical cautery unit [ESU], an ignition source) was activated. During an interview on 3/4/2026 at 10:15 a.m. with Surgical Technician (ST 1, a sterile scrub-side staff member responsible for preparing and managing sterile instruments and draping), ST 1 stated, “Anesthesia usually clips the barrier drapes to the IV (Intravenous) pole to prevent tenting, which is a pocket under the drapes where oxygen can accumulate. For this case the drape was not clipped up and was lying over the patient’s head which created tenting. We announced the Bovie but music was playing and no one responded. When the Bovie was used a flame ignited under the drapes.” During an interview on 3/4/2026 at 10:54 a.m. with RN Circulator (RN 20, a circulating nurse is the non-sterile OR nurse responsible for managing the environment, equipment, and safety), RN 20 stated, “We decided to do MAC, which is monitored anesthesia care (a sedation method where the patient breathes on their own). We used Chlora-prep, which is an alcohol-based skin antiseptic, and waited 3 minutes to dry. Oxygen was by face mask at 6 liters. The drape was not clipped to the IV pole and lay over the patient’s head. A fast flash fire came from under the drapes when the Bovie was used.” During a concurrent observation and interview on 3/4/2026 at 11:36 a.m. in the OR conference room with Surgical Technician (ST 1), the draping supplies used for head and neck cases, were observed. The drapes were observed to require clipping to the IV pole in order to remain elevated during surgery. ST 1 stated, “Anesthesia usually clips the drapes to the pole to prevent tenting, but in the fire case, the drapes were not clipped up and lay over the patient’s head.” During an interview on 3/4/2026 at 3:19 p.m. with Director of Biomed Department (DIR 11) (the department responsible for evaluating and maintaining medical equipment), DIR 11 stated, “On 12/19/2025 around 2 p.m. I got a notification that there was a fire in OR ABC. I went to the room at 2:15 p.m. and noticed the bed and drapes had holes in them and were burned out.” During an interview on 3/4/2026 at 3:42 p.m. with Director of Surgery/Recovery (DIR 9, the leadership position responsible for OR and recovery operations), DIR 9 stated, “Draping is done by the surgical tech because it is a sterile procedure, but the anesthesiologist makes the final decision whether the drapes must be hung up.” During an interview on 3/5/2026 at 11:30 a.m. with Surgeon (MD 12) (the physician performing the procedure), MD 12 stated, “I did not know oxygen was being used because the patient (Patient 16) was sedated. The drapes at the head lay over the patient’s head. An anesthesia-side drape blocked my view of the patient’s face. The fire happened when I used the Bovie.” During an interview on 3/5/2026 at 12:05 p.m. with Surgical Technician (ST 3), ST 3 stated, “For thyroid (a small, butterfly-shaped gland located at the base of the neck) and head or neck cases we usually clip the drapes up to the pole on the anesthesia side. When the drapes are not clipped up, they drape over the patient’s head and create a tent.” During an interview on 3/5/2026 at 2:23 p.m. with Surgical Technician (ST 4), ST 4 stated, “Drapes are typically clipped to the IV pole by anesthesia. When drapes are not clipped up, they lay over the patient’s head and create a tent that may traps oxygen.” During an interview on 3/5/2026 at 3:11 p.m. with Director of Quality, Infection Control, and Regulatory Affairs, the Director (DQ) (the facility leader responsible for oversight of regulatory compliance and safety policies) stated, “There is no policy that addresses how to drape, there is no draping policy and procedure.” During an interview on 3/6/2026 at 12:45 p.m. with Surgeon ENT (MD 14) (ear, nose, and throat surgeon), MD 14 stated, “If the drapes are draped over the oxygen source, then the three ingredients for fire are there because the drapes trap oxygen, there is cautery, and there are flammable drapes.” During an interview on 3/6/2026 at 12:50 p.m. with the Director of Surgery/Recovery (DIR 9), DIR 9 stated, that the fire safety correction plan addressed several issues-communication, Bovie settings, fire-risk scoring education, drying times, oxygen management-but did not address drape position or the risk of drape-related oxygen accumulation. DIR 9 stated: “We did not address the possibility that drape position could create a tent that may trap oxygen underneath and create a risk for fire. DIR 9 stated, “All education will be completed by the end of January.” DIR 9 stated, “The fire safety correction plan recognized several opportunities and we implemented corrective measures. The opportunities were improved communication between anesthesia and surgeon regarding anesthesia and oxygen; improved communication when cautery will be used; lack of awareness of the facility’s policy which is the facility’s fire-risk scoring and prevention policy; no fire-risk education deployed to OR providers for two years; reducing noise levels; providing Bovie education; considering Betadine prep above the chest; adding announcement of Bovie setting during timeout; continuing OR fire drills; providing fire extinguisher training; and considering nonflammable products or drapes when fire score is 3.” During the same interview on 3/6/2026 at 12:50 p.m. with Director of Surgery/Recovery (DIR 9), DIR 9 stated, “The education for fire score 3 included observing prep dry time of 3 minutes, using occlusive draping (sealed draping technique), using FiO2 (fraction of inspired oxygen) less than or equal to 30 percent if possible, stopping supplemental oxygen at least one minute before and during cautery, using wet sponges, keeping sterile water or saline for suppression, having a saline-filled syringe for procedures in the oral cavity, protecting heat sources with a cautery holder, and minimizing electrocautery settings.” DIR 9 stated, “We did not address the possibility that drape position could create a tent that may trap oxygen underneath and create a risk for fire.” During a review of the facility’s policy and procedure (P&P) titled, “Fire Safety Scoring and Prevention in the Operating/Invasive Procedure Area,” dated 3/19/2025, the P&P indicated, “To provide guidance to perioperative personnel in preventing fires during surgical/invasive procedures ...Responsibility for review and maintenance of this policy is assigned to: Chief Nursing Officer or Designee.” Reviewed and approved by the Director of Surgical Services, Environment of Care/Safety Compliance Committee, Department of Anesthesia, Department of Surgery, Quality Management/Clinical Safet Committee, Chief Nursing Officer. During a review of the facility’s policy and procedure (P&P) titled, “Anesthesia Safety Requirements for Providing Care,” dated 5/1/2024, the P&P indicated, “G. The Director of the Division is responsible for overseeing: Development and enforcement of regulations concerning anesthetic safety ... Ensuring retrospective evaluation of the quality of anesthesia care rendered throughout the facility ... Participation in the development of policies relating to anesthesiologists ...” During a review of the facility’s policy and procedure (P&P) titled, “Fire Safety Management Plan,” dated 4/16/2025, the P&P indicated: “To implement systems that protect patients, staff physicians and visitors from exposure to fire, smoke, and other products of combustion ... Flammable Liquids, including Acetone, Alcohol, Benzene and Ether ...d.Do not use open flames or sparking devices around flammable liquids or compressed gases. e. Do not store oxidizers, oxygen or nitrous oxide with any flammable gases or liquids (i.e., Cyclopropane, ethylene, gasoline, etc.) ... a. Oxygen: i. Oxygen does not burn but may accelerate combustion. ii. Oxygen in combination with certain combustible anesthetic agents (i.e., cyclopropane, ether, or ethylene) may cause explosive chemical reactions and must be handled carefully to prevent ignition. iii. Ignition sources include static sparks, faulty electric cords or appliances, and the use of unapproved appliances must be mitigated. During a review of the facility’s policy and procedure (P&P) titled, “Electrosurgery,” dated 3/19/2025, the P&P indicated, “To provide for proper care, handling and use of electrosurgical unit (ESU) ...The active electrode should not be used in an oxygen-enriched environment. Caution should be exercised during surgery on the head and neck near combustible gases. It should be used as far away from the oxygen source as possible. The lowest practical level of oxygen should be administered to the patient ...””

“DELIVERY OF ANESTHESIA SERVICES CFR(s): 482.52(b) Anesthesia services must be consistent with needs and resources. Policies on anesthesia procedures must include the delineation of pre-anesthesia and post-anesthesia responsibilities. The policies must ensure that the following are provided for each patient: This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure anesthesia services identified and corrected an unsafe draping process that created a tent (a pocket of trapped air under the drapes) that allowed oxygen (a gas that supports combustion) to accumulate beneath the surgical drapes during a procedure for one (1) of 34 sampled patients (Patient 8), in which supplemental oxygen and electrocautery (a heat-producing surgical device used to cut tissue or stop bleeding), were used, in accordance with the facility’s policy regarding anesthesia safety requirements. This deficient practice likely contributed to a surgical fire that occurred during the procedure for Patient 8 and placed current and future surgical patients at risk for fire-related harm. Findings: During a review of Patient 8’s medical record, dated 12/19/2025, document titled “Operative Report,” indicated that Patient 8 had a cyst (a small fluid-filled lump) on the right side of the neck causing discomfort, for which Patient 8 requested excision (surgical removal). The report further indicated that Patient 8 was draped in the usual manner using sterile towels and operating drapes. The report indicated that “the patient (Patient 8’s) drapes caught on fire from the cautery,” and the surgical team applied water and removed the drapes to extinguish the fire. During an interview on 3/4/2026 at 10:15 a.m. with Surgical Technician (ST 1), ST 1 stated anesthesia “usually clips the barrier drapes to the IV pole to prevent tenting,” but for this case (involving Patient 8) “the drape was not clipped up and was lying over the patient’s head,” and “when the Bovie was used a flame ignited under the drapes.” During an interview on 3/4/2026 at 10:54 a.m. with Registered Nurse (RN) 20, RN 20 stated anesthesia provided oxygen by face mask at “6 liters (unit of measure),” alcohol-based prep was used, and “the drape was not clipped to the IV pole and lay over the patient’s head.” RN 20 stated “a fast flash fire came from under the drapes when the Bovie was used.” During a concurrent observation and interview on 3/4/2026 at 11:36 a.m. with Surgical Technician (ST 1) in the OR conference room, observed draping demonstrated by ST 1 with the supplies used for head and neck cases. The drapes were observed to require clipping to the IV pole to remain elevated. ST 1 stated the drapes “were not clipped up and lay over the patient’s head” during Patient 8’s procedure. During an interview on 3/4/2026 at 12:25 p.m. with Chair of the Anesthesia Department (MD 10), MD 10 stated that after the fire, the incident was discussed and the fire-safety policy was reviewed. MD 10 stated the time?out included discussion of the kind of anesthesia being used and what the team and surgeon needed to know during the time-out. MD 10 stated five fire-safety precautions were emphasized: oxygen, anesthesia, the type of surgical scrub (prep solution), equipment settings such as Bovie settings, and procedural factors. MD 10 stated changes were made, including switching to using Chlora-prep (an alcohol-based skin antiseptic) or alcohol-only prep below the xiphoid process (the lower portion of the sternum). MD 10 stated equipment used for fire safety included confirming Bovie settings and keeping oxygen as low as possible during certain procedures, such as tracheostomies (a surgical opening made into the windpipe). MD 10 stated fire-risk safety also included ensuring the surgical technician had normal saline (a sterile salt-water solution) available and that a fire extinguisher was present. MD 10 stated this information was provided through in-person training. MD 10 stated all physicians who worked in the operating room and used cautery took a fire-safety course. MD 10 did not identify draping as a potential risk factor in the fire, nor did MD 10 describe any corrective action implemented to prevent future fires related to draping. During an interview on 3/5/2026 at 11:30 a.m. with Surgeon (MD 12), MD 12 stated “I did not know oxygen was being used because the patient was sedated.” MD 12 stated “the drapes at the head lay over the patient’s head,” and an anesthesia?side drape blocked the view of the patient’s face. MD 12 stated “the fire happened when I used the Bovie.” During an interview on 3/6/2026 at 12:50 p.m. with Director of Surgery/Recovery (DIR 9), DIR 9 stated the facility’s fire-safety corrective plan “did not address the possibility that drape position could create a tent that may trap oxygen underneath and create a risk for fire.” During a concurrent observation and interview on 3/4/2026 at 11:36 a.m. with Surgical Technician (ST 1) in the OR conference room, draping supplies used for head and neck cases were observed to require clipping to the IV pole to remain elevated. ST 1 stated “in the fire case the drapes were not clipped up and lay over the patient’s head.” During an interview on 3/5/2026 at 3:00 p.m. with Anesthesiologist (MD 13), MD 13 stated they received education after the fire regarding “all necessary tools to review, including signing the attestation and protocol for the fire safety tool.” MD 13 stated they were responsible for OR fire-safety elements during the time-out, including anesthesia type and oxygen tolerance, especially for head and neck surgeries. MD 13 stated “I hold the drapes up; it is rarely my practice to leave the drapes lying on the patient’s face.” MD 13 stated oxygen becomes trapped under drapes and stated draping “should always include oxygen-tented technique because oxygen can accumulate under the drapes.” During a review of the facility’s policy and procedure (P&P) titled “Anesthesia Safety Requirements for Providing Care,” dated 5/1/2024, the P&P indicated the Director of the Division was responsible for “development and enforcement of regulations concerning anesthetic safety” and “ensuring retrospective evaluation of the quality of anesthesia care.” During a review of the facility’s policy and procedure (P&P) titled “Electrosurgery,” dated 3/19/2025, the P&P indicated “the active electrode should not be used in an oxygen?enriched environment” and “caution should be exercised during surgery on the head and neck near combustible gases.” During a review of the facility’s policy and procedure (P&P) titled “Fire Safety Scoring and Prevention in the Operating/Invasive Procedure Area,” dated 3/19/2025, the P&P indicated perioperative personnel were responsible for preventing fires during surgical or invasive procedures.”

“PRE-ANESTHESIA EVALUATION CFR(s): 482.52(b)(1) [The policies must ensure that the following are provided for each patient:] A pre-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, performed within 48 hours prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure its anesthesiologist (medical doctor specializing in perioperative care, and administering sedation [administering drugs to produce a state of calm or sleep] to patients before, during and after surgery, [MD7]) completed a pre-anesthesia (before sedation) evaluation for one of 34 sampled patients (Patient 16) prior to surgery on 7/29/2025, in accordance with the facility’s policy regarding anesthesia (a controlled, temporary medical state induced by drugs [anesthetics] to prevent pain, discomfort, and memory of medical procedures) safety requirements. This deficient practice had the potential to result in Patient 16 experiencing potential anesthesia problems and complications. Findings: During a review of Patient 16’s “Operative Report,” dated 7/29/2025, the “Operative Report” indicated, Patient 16 had exploratory laparotomy (an open surgery requiring large incision in the abdomen to directly view and examine the organs) with small bowel resection and colectomy (surgical removal of part or all of the colon), and mesenteric angiography (special procedure to visualize the blood vessels supplying the small and large intestines to locate bleeding or ischemia [reduced blood flow to the organ and tissues]) on 7/29/2025. During a concurrent interview and record review on 3/5/2026 at 11:10 a.m. with the Sepsis (a body’s overwhelming and life-threatening response to infection) Coordinator (SC 2), Patient 16’s “Anesthesia Record (medical document detailing a patient’s care before, during and immediately after anesthesia by anesthesiologist),” dated 7/29/2025, was reviewed. The “Anesthesia Record” indicated, anesthesiologist (MD 7) performed general anesthesia (brings on a sleep-like state with the use of a combination of medicines) on Patient 16 with anesthesia start time at 3:55 p.m. and stop time at 5:10 p.m. SC 2 stated Patient 16 received general anesthesia on 7/29/2025. During an interview on 3/6/2026 at 1:32 p.m. with the Director (MD 10) of Anesthesiology (a medical specialty focused on perioperative care, pain management, and critical care medicine), MD 10 stated anesthesiologist must perform pre-anesthesia (before sedation) evaluation prior to surgery. MD 10 stated the purpose of pre-anesthesia evaluation was to look at the patient’s history, make sure all lab (Laboratory) values were reasonable and ready for the surgery and would discuss the type of anesthesia to be used during the surgery. MD 10 stated the anesthesiologist must document pre-anesthesia evaluation in the patient’s medical record. During a concurrent interview and record review on 3/6/2026 at 2:09 p.m. with MD 10, Patient 16’s medical chart, with admission date 7/24/2025, was reviewed. The medical record indicated there was no pre-anesthesia evaluation found. MD 10 stated MD 7 did not complete a pre-anesthesia evaluation for Patient 16. During a review of the facility’s policy and procedure (P&P) titled, “Anesthesia Safety Requirements for Providing Care,” dated 5/2024, the P&P indicated, “Pre-Anesthesia Evaluation (Plan): A. There is a pre-anesthetic evaluation of the patient by an individual qualified to administer anesthesia services. The evaluation is documented in the patient’s record ...””

“POST-ANESTHESIA EVALUATION CFR(s): 482.52(b)(3) [The policies must ensure that the following are provided for each patient:] A post-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures, which have been approved by the medical staff and which reflect current standards of anesthesia care. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure its anesthesiologist (medical doctor specializing in perioperative care, and administering sedation [administering drugs to produce a state of calm or sleep] to patients before, during and after surgery, [MD7]) completed a post-anesthesia (after sedation) evaluation for one of 34 sampled patients (Patient 16) after surgery performed on 7/29/2025, in accordance with the facility’s policy regarding anesthesia safety requirements. This deficient practice had the potential to result in Patient 16’s anesthesia complications not being evaluated and identified. Findings: During a review of Patient 16’s “Operative Report,” dated 7/29/2025, the “Operative Report” indicated, Patient 16 had exploratory laparotomy (an open surgery requiring large incision in the abdomen to directly view and examine the organs) with small bowel resection and colectomy (surgical removal of part or all of the colon), and mesenteric angiography (special procedure to visualize the blood vessels supplying the small and large intestines to locate bleeding or ischemia [reduced blood flow to the organ and tissues]) on 7/29/2025. During a concurrent interview and record review on 3/5/2026 at 11:10 a.m. with the Sepsis (a body’s overwhelming and life-threatening response to infection) Coordinator (SC 2), Patient 16’s “Anesthesia Record (medical document detailing a patient’s care before, during and immediately after anesthesia by anesthesiologist),” dated 7/29/2025, was reviewed. The “Anesthesia Record” indicated, (on 7/29/2025), anesthesiologist (MD 7) performed general anesthesia for Patient 16 with anesthesia start time at 3:55 p.m. and stop time at 5:10 p.m. SC 2 stated Patient 16 received general anesthesia on 7/29/2025. During an interview on 3/6/2026 at 1:32 p.m. with the Director (MD 10) of Anesthesiology (a medical specialty focused on perioperative care, pain management, and critical care medicine), MD 10 stated anesthesiologist must perform post-anesthesia (after sedation) evaluation after surgery. MD 10 stated the purpose of post-anesthesia evaluation was to make sure patient’s vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) were reasonable and patient’s condition was stable with no complication. MD 10 stated anesthesiologist must document post-anesthesia evaluation in the patient’s medical record. During a concurrent interview and record review on 3/6/2026 at 2:09 p.m. with MD 10, Patient 16’s medical chart, with admission date 7/24/2025, was reviewed. The medical record indicated there was no post-anesthesia evaluation found. MD 10 stated MD 7 did not complete a post-anesthesia evaluation for Patient 16. During a review of the facility’s policy and procedure (P&P) titled, “Anesthesia Safety Requirements for Providing Care,” dated 5/2024, the P&P indicated, “Post Anesthesia. A. An anesthesia post-op evaluation will be written following the anesthetic no later than 48 hours after surgery/procedure requiring anesthesia services ... C. A note will be placed in the chart by anesthesiologist at the time of the postoperative visit indicating the progress of the patient with respect to the anesthetic and to any anesthesia complications ... K. The post-anesthesia evaluation indicates the presence or absence of complications.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46238 Based on observation, interview and record review the facility failed to ensure the Condition of Participation for Patient Rights was met, as evidenced by: 1. The facility failed to ensure its staff provided a copy of a signed “An Important Message from Medicare (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights) prior to one of 30 sampled patient’s (Patient 20) discharge, in accordance with the facility’s policy regarding “An Important Message From Medicare.” This deficient practice had the potential for Patient 20 not knowing the rights to appeal a hospital’s discharge decision. (Refer to A-0117) 2. The facility failed to ensure that one of 30 sampled patients (Patient 1), received a respectful, dignified and fair treatment, in accordance with the facility’s policy on patient rights, when Patient 1’s urine toxicology drug screen results (UDS, refers to a laboratory test that analyzes a urine sample to detect the presence of drugs or substance of abuse, used to screen for opioids [a class of natural, semi-synthetic, and synthetic drugs that include both prescription medications and illegal drugs like heroin], amphetamines [stimulant drugs that speed up messages between the brain and body; are prescribed by doctors to treat certain medical conditions or others, like methamphetamine, produced and sold illegally], cocaine [an addictive drug derived from coca or prepared synthetically, used as an illegal stimulant], and other illicit or prescription medications) were positive for amphetamines and opioids. Patient 1 was diagnosed with methamphetamine use (methamphetamine use disorders involve the recreational use of these substances [other than for unapproved medical indication] and are defined by a pattern of substance use leading to clinically significant impairment or distress), solely based on testing positive for amphetamines in urine, without verifying the medication history (all currently and recently prescribed drugs) of Patient 1, who had a documented history of taking Adderall (a combination of amphetamine and dextroamphetamine, two central nervous stimulants that improve focus and reduce impulsivity by increasing dopamine and norepinephrine levels in the brain). Patient 1 also received a diagnosis of opiate overdose, despite the lack of documentation demonstrating that Patient 1 responded to Narcan (naloxone, a medicine that rapidly reverses an opioid overdose) administration. In addition, the facility failed to ensure that Patient 1 was assessed for suicidal ideation (thoughts of harming or inflicting death on one’s self) after presenting to the emergency department (ED) following a suspected overdose on prescription medications (on both consecutive separate visits to the facility’s emergency department on 2/23/2025 and 2/24/2025). This deficient practice had the potential to result in Patient 1 experiencing psychological distress and had the potential to result in worsening of Patient 1’s condition, due to inappropriate treatment and increased risk for complications, which can compromise Patient 1’s safety. (Refer to A-0129) 3. The facility failed to provide considerate and respectful care, in accordance with the facility’s policy on Patient Rights, for one of 30 sampled patients (Patient 19), when Patient 19 was given a discharge instruction on getting car seat after a diagnosis of fetal demise (death of a fetus before it is born), instead of being provided a discharge instruction regarding miscarriage after care that addresses both the physical and emotional well-being of Patient 19. This deficient practice had the potential to cause Patient 19 not to be aware of proper after care for miscarriage (the natural loss of a pregnancy before the 20th week of gestation) and also cause emotional distress (a highly unpleasant emotional reaction resulting from an experience or event). (Refer to A-0129) 4. The facility failed to ensure two of 30 sampled patients’ (Patient 4 and Patient 5) call lights (a device that allows to alert staff when assistance is needed), were placed within reach to be able to summon help when needed without delay, in accordance with the facility’s fall (an unintentional event that results in a person coming to rest on the ground, floor, or other lower surface) prevention policy. Both Patient 4 and Patient 5 were assessed to be a moderate, and a high fall risk, respectively. This deficient practice had the potential for Patient 4 and Patient 5 to sustain harm, such as falls, injuries or had their care needs not being met, compromising their (Patient 4 and Patient 5) recovery and well-being. (Refer to A-0144) 5. The facility failed to ensure its nursing staff utilized rapid response team (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) to assist with expediting the transfer for one of 30 sampled patients (Patient 21), in accordance with the facility’s policy and procedures regarding rapid response, when Patient 21 remained in the Medical-Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery) Unit waiting to be transferred to Progressive Care Unit (PCU, a hospital unit that provides level of care between general medical-surgical unit and the intensive care unit [ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill]) for four (4) hours on 5/20/2024. This deficient practice had the potential to result in Patient 21 not receiving appropriate level of care and monitoring while waiting to be transferred to PCU and may lead to delay in treatment and care, which may result in complications requiring intubation (a medical procedure where a tube is inserted into the windpipe [trachea] to maintain an open airway). (Refer to A-0144) 6. The facility failed to ensure its nursing staff assessed and performed pulse and skin checking every fifteen (15) minutes for one of 30 sampled patients (Patient 11), in accordance with the facility’s policy and procedures regarding restraints use (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), when Patient 11 was restrained with 4-point (both wrists and both ankles) restraints on 4/14/2025. This deficient practice had the potential to put Patient 11 at risk for skin injury or getting out from restraints. (Refer to A-0175) 7. The facility failed to ensure its Behavioral Health Unit (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurse (RN), evaluated the medical condition and taken vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) for one of 30 sampled patients (Patient 11), when performing a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) on 4/14/2025 and 4/28/2025, in accordance with the facility’s restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) guidelines. This deficient practice had the potential for the nursing staff not immediately recognizing Patient 11’s abnormal vital signs and changes in respiratory (breathing) status resulting from the use of restraints and seclusion, which may cause delay in care or treatment. (Refer to A-0179) 8. The facility failed to ensure its Behavioral Health Unit (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurse (RN), consulted the attending physician within an hour after performing face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) on one of 30 sampled patients (Patient 11), in accordance with the facility’s policy regarding face to face assessment. This deficient practice had the potential to result in Patient 11’s physician not knowing Patient 11’s response to the restraints use (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving), the need for continuation of restraint and/or seclusion, and the possible use of alternatives and, therefore, may lead to unnecessary or prolonged restraints use. (Refer to A-0182) 9. The facility failed to ensure one of two Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurse (RN 3), was trained and demonstrated competency in performing correct face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), when RN 3 did not complete the face-to-face assessment training upon hire and annually (every year), in accordance with the facility’s policy and procedures regarding restraints use (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and face-to-face assessment. This deficient practice resulted in RN 3 not evaluating Patient 11’s medical condition and not consulting the attending physician, when performing face-to-face assessments on 4/14/2025 and 4/28/2025, which may result in the delay of necessary medical care or treatment and/or prolonged use of restraints for Patient 11. (Refer to A-0205) 10. The facility failed to ensure three of five sampled registered nurses (RN 2, RN 3 and RN 4), completed their advance directive training (training module that focuses on educating facility staff about patient rights and responsibilities, end-of-life care and decision-making) yearly, in accordance with the facility’s Annual Competency (ability to demonstrate mastery of specific skills and knowledge) Education requirements. This deficient practice had the potential for violations of patient rights, thus causing harm to patients, due to lack of staff training. This deficient practice may also result in the failure to honor patient’s wishes or neglecting to provide necessary information to allow patients to have informed decision-making. (Refer to A-0208) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“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: 46238 Based on observation, interview and record review the facility failed to ensure the Condition of Participation for Nursing Services was met, as evidenced by: 1. The facility failed to ensure one of 30 sampled patient’s (Patient 3) enteral feeding set (the tubing and associated components used to deliver nutrition directly into the stomach through a feeding tube), was changed every 24 hours or once infused (not to exceed 24 hours), in accordance with the facility’s standard practice regarding changing the enteral feeding administration set. This deficient practice had the potential to compromise Patient 3’s safety by increasing the risk of infection, such as bacterial contamination due to improper or inconsistent changing of feeding sets, which may contribute to the increased risk of hospital-acquired infections (HAIs, infections that patients develop while receiving care in a healthcare facility, such as a hospital) and complications for Patient 3. (Refer to A-0395) 2. The facility failed to ensure one of 30 sampled patient’s (Patient 6), two sterile water containers, were signed with the date and time after opening, to ensure that the containers were not used beyond expiration date (the labeled date and time indicate when the container was opened, as sterile water may become contaminated with germs after opening). This deficient practice had the potential for Patient 6 to receive sterile water that could have been contaminated, which might lead to a compromised health status and complications such as hospital-acquired infections (HAI) for Patient 6. (Refer to A-0395) 3. The facility failed to ensure Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurses (RNs), reassessed one of 30 sampled patients (Patient 11), after anti-psychotic (medication injected to a patient’s muscle to treat psychosis [severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality]) injections were given to Patient 11 on multiple occasions on 4/14/2025. This deficient practice resulted in Patient 11 not receiving proper assessment and monitoring to evaluate the effectiveness of the medications received and the potential need for further management. (Refer to A-0395) 4. The facility failed to formulate an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 30 sampled patients (Patient 3), to address Patient 3’s high risk for aspiration (refers to the inhaling of food, liquid, or secretions into the lungs instead of the esophagus [a muscular tube that conveys food from the mouth to the stomach]), in accordance with the facility’s policy regarding care plans. This deficient practice had the potential for the lack implementation of aspiration precautions (aim to prevent food or liquid from entering the lungs while a person is receiving nutrients through a feeding tube) for Patient 3, which could result in aspiration and possible injury or harm such as aspiration pneumonia (a lung infection caused by inhaling food, or stomach contents into the lungs), which can lead to serious respiratory complications, prolonged hospitalization, and even death. (Refer to A-0396) 5. The facility failed to ensure one of 30 sampled patient’s (Patient 3) total intake (refers to the amount of feeding formula consumed by a patient) of feeding formula per 24 hours, was documented, in accordance with the facility’s policy and procedure regarding enteral feeding (a method of providing nutrition directly into the gastrointestinal (GI) tract through a tube) administration documentation. This deficient practice had the potential to compromise Patient 3’s nutritional status and care, by preventing accurate assessment of nutritional and fluid status needs of Patient 3, increasing Patient 3’s risk for dehydration (a condition that occurs when your body loses more fluids than it takes in, resulting in a shortage of water and other necessary fluids), undernutrition (a condition where the body does not receive enough nutrients to meet its needs, often due to insufficient food intake or poor absorption of nutrients), overhydration (the body takes in more water than it loses), and other complications. (Refer to A-0398) 6. The facility failed to ensure one of 30 sampled patients (Patient 21), received a complete neurological assessment (an exam that evaluates brain and nervous system function through test of mental status, reflexes [automatic body response], movements, and speech) following a fall (an unplanned change in position where a patient lands on the floor or a lower surface), in accordance with the facility’s policy and procedures titled, “Fall Prevention and Reduction.” This deficient practice had the potential to delay recognition of serious medical problems such as a head injury or stroke (occurs when blood flow to the brain is interrupted). Signs and symptoms such as brain swelling, bleeding, or damage might not be noticed in time. (Refer to A-0398) 7. The facility failed to ensure staff removed from service a hospital bed with a malfunctioning alarm for one of 30 sampled patients (Patient 21), in accordance with the facility’s policy and procedure titled, “Medical Equipment Management Program.” Specifically, the bed alarm was found to be non-functional, and staff failed to ensure the bed was taken out of commission, resulting in uncertainty whether the same bed continued to be used for patient care. This deficient practice increased the potential for failure to prevent or respond to patient bed exit in a timely manner, placing patients at increased risk of injury due to falls. (Refer to A-0398) 8. The facility failed to ensure that one of 30 sampled patients (Patient 22), received prescribed pain medication, in accordance with the physician’s orders and the facility’s policy and procedure titled “Administration of Medications.” This deficient practice resulted in Patient 22 experiencing unrelieved pain, which had the potential to limit the patient’s ability to walk and begin physical therapy (treatment to help restore movement and strength). (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Medical Record Services was met, as evidenced by: 1. The facility failed to ensure that for one patient of 30 sampled patients (Patient 1), the emergency department (ED, a hospital department that provides immediate medical care to patients experiencing sudden, serious health problems) visit medical record (MR) contained accurately completed documentation on suicidal (SI, plans or intentions to harm self) and homicidal (HI, thoughts or plans to harm others) ideation assessments (an evaluation conducted by healthcare professionals to determine the patient’s risk to harm self or others, involving questions about thoughts, behaviors, and intent), in triage (the process of quickly assessing and prioritizing patients based on the severity of their condition to determine who needs immediate care), in accordance with the facility’s policy and procedure regarding SI/HI screening, when Patient 1 was documented to have arrived at the facility after a possible overdose on medication -Baclofen (a muscle relaxant medications used to treat muscle spasms). This deficient practice had the potential for Patient 1 not to be correctly assessed for risk of harm to self or others, which could lead to inadequate safety measures, failure to implement appropriate interventions, increased risk of self-harm or harm to others, and potentially serious adverse outcomes such as death. (Refer to A-0438) 2. The facility failed to ensure for one of 30 sampled patients (Patient 1), documentation of the response to Narcan (naloxone, an emergency medication used to reverse the effects of opioid overdose) was documented, after Narcan was administered to Patient 1 due to suspected opioid overdose (a medical condition where opioids cause significant respiratory depression [a breathing disorder characterized by slow or shallow breathing], sedation [a state of calmness, relaxation, or sleepiness induced by medications to help manage pain and anxiety], or coma [a state of prolonged unconsciousness where a person is unresponsive to their surroundings and environment], potentially leading to death). This deficient practice had the potential to compromise Patient 1’s well-being and recovery and may lead to delayed recognition of treatment effectiveness or adverse reactions, potentially hindering the effective clinical evaluation in documenting patient progress after an intervention (response to medication administration) when planning patient’s (Patient 1) care. (Refer to A-0449) 3. The facility failed to ensure that one of 30 sampled patient’s (Patient 6), informed consent (a voluntary agreement signed by the patient or their authorized representative that confirms they understand the nature, risks, benefits, and alternatives of a medical procedure before it is performed) form, was completed and indicated the date and time when Patient 6 or Patient 6’s representative (Rep) signed the informed consent for a medically indicated procedure (an intervention that is performed based on clinical judgement to benefit the patient and is necessary for diagnosis, treatment, or management of a medical condition), in accordance with the facility’s informed consent protocol. This deficient practice had the potential to jeopardize Patient 6’s rights to decision-making (refers to the process in which patients are actively engaged in making informed choices about their healthcare options), undermining Patient 6’s autonomy (person’s right to make their own decisions) and compromise the legal validity (refers to legitimacy and enforceability of a document) of the consent due to lack of completeness of the medical record (informed consent form). (Refer to A-0466) 4. The facility failed to ensure one of 30 sampled patient’s (Patient 1) medical reconciliation (process of reviewing and comparing a patient’s current medications, treatments, and medical history to ensure accuracy and continuity of care) was recorded on two consecutive Emergency Department (ED) visits (2/23/2025 and 2/24/2025), in accordance with the facility’s policy and procedure regarding medication reconciliation and assessment. This deficient practice had the potential to compromise Patient 1’s continuity of care and increase the risk of harm to the patient (Patient 1). In addition, this deficient practice had resulted in a gap in Patient 1’s medical record completeness violating Patient 1’s right to transparency, accountability, and accurate and complete medical records. (Refer to A-0467) 5. The facility failed to ensure that one of 30 sampled patient’s (Patient 22), medication reconciliation (involves creating the most complete and accurate list of a patient’s medications-including prescriptions, over-the-counter drugs, vitamins, and supplements-and comparing this list to the medications ordered or prescribed during a transition of care), was reviewed during Emergency Department (ED) visits (from 3/9/2025 and 3/11/2025), in accordance with the facility’s policy and procedure titled, “Medication Reconciliation.” This deficient practice had the potential to result in an incomplete or inaccurate list of Patient 22’s medications. Without this information, doctors and nurses may not have had everything they needed to safely monitor Patient 22’s condition or give the right care, and had the potential for missed doses, drug interactions, receiving the wrong medicine, or serious side effects. (Refer to A-0467) 6. The facility failed to ensure that one of 30 sampled patient’s (Patient 3) total enteral feeding intake (refers to the amount of feeding formula consumed by a patient) of feeding formula, was consistently documented, in accordance with the facility’s policy regarding documentation of enteral feeding (a method of providing nutrition directly into the gastrointestinal [GI] tract through a tube) administration. This deficient practice had the potential to compromise Patient 3’s nutritional status and care, by preventing accurate assessment of nutritional and fluid status needs of Patient 3, increasing Patient 3’s risk for dehydration (a condition that occurs when your body loses more fluids than it takes in, resulting in a shortage of water and other necessary fluids), undernutrition (a condition where the body does not receive enough nutrients to meet its needs, often due to insufficient food intake or poor absorption of nutrients), overhydration (the body takes in more water than it loses), and other complications, hindering interventions necessary to maintain optimal patient (Patient 3) health. (Refer to A-0467) 7. The facility failed to consistently perform and document neurological assessments (a systemic evaluation of a patient’s nervous system function, including mental status, motor and sensory responses, and reflexes to detect abnormalities), every 4 hours as ordered by the physician, for one of 30 sampled patients (Patient 4), after Patient 4 was diagnosed with a stroke (sudden interruption of blood flow to the brain that can cause neurological deficits, impairments, or death), in accordance with the facility’s policy regarding assessments and documentation. This deficient practice had the potential to result in delayed recognition of neurological deterioration of Patient 4’s condition, increasing the risk for adverse outcomes for Patient 4 such as neurological deficits (permanent impairment or loss of function in the nervous system such as difficulty with coordination, paralysis, numbness, inability to speak or understand language) or death. (refer to A-0467) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility’s Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure there was a standardized procedure developed to monitor and reassess patients in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) after receiving anti-psychotic injections (medication injected to a patient’s muscle to treat psychosis [severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality]) to manage their behavior, when there was missing nursing re-assessment for one of 30 sampled patients (Patient 11) after receiving multiple anti-psychotic injections on 4/14/2025. This deficient practice resulted in lack of consistency on re-assessment post anti-psychotic injections putting Patient 11 and other BHU patients at risk for not receiving proper assessment and monitoring to evaluate the effectiveness of the medications received and the potential need for further management thus affecting quality of patient care. Findings: During a review of Patient 11’s “Behavioral Health (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Inpatient Provider Admission Note (psychiatric History and Physical [H&P], a formal and complete assessment of the patient and the problem completed by a psychiatrist [physician specializes in mental health]),” dated 4/13/2025, the psych H&P indicated, Patient 11 was admitted to the facility’s Behavioral Health Unit on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) with diagnoses including but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and cannabis use disorder (a complex condition that involves problematic pattern of cannabis [marijuana] use). During a review of Patient 11’s “Progress notes (nursing narrative notes),” dated 4/14/2025, the progress notes indicated, “At 8:30 a.m., Patient 11 was pacing in the hallway frequently and dismissing staff instruction, Patient 11 also threatening and posturing towards staff ... MD 8 was notified and new orders received. Patient 11 tolerated injections and continued to pace ... At 11:30 a.m. Patient 11 came out of the shower ... upon exiting the shower room, Patient 11 grabbed staff on the buttocks ... MD 8 was notified and new orders received. Patient 11 tolerated injection.” During a review of Patient 11’s “Behavioral Health Forms,” dated 4/14/2025, the Behavioral Health forms indicated, at 5:11 p.m., Patient 11 attempted to forcefully snatch a staff’s badge to exit the unit and lunged at staff member aggressively. The Behavioral Health forms also indicated Patient 11 was placed in seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) and restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) for Patient 11’s and others’ (other patients and staff) safety. During a review of Patient 11’s physician order, dated 4/14/2025, the physician order indicated violent 4-point (both wrists and both ankles) restraints and seclusion ordered on 4/14/2025 at 5:18 p.m. During a concurrent interview and record review on 5/1/2025 at 10:08 a.m. with the Risk Management Coordinator (CQ 3), Patient 11’s “Medication Administration Record (MAR, record of medications given to patients),” dated 4/14/2025, was reviewed. The MAR indicated Patient 11 received the following medications on 4/14/2025: -At 8:40 a.m.: Zyprexa (medication injectable for rapid control of agitation [feeling of severe restlessness, and excessive motor activity such as pacing, rocking, gesturing] and disturbed behavior) 10 milligrams (mg, unit of measure) intramuscular (IM, delivering medication directly into the muscle tissue) injection one time, and Benadryl (medication helps to help calm agitation and anxiety in psychotic [severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality] patient) 50 mg IM one time; -At 11:56 a.m.: Thorazine (medication injectable to treat psychotic disorder) 50 mg IM one time; and -At 5:34 p.m.: Thorazine 50 mg IM one time and Benadryl 50 mg IM one time. During the same interview on 5/1/2025 at 10:08 a.m. with the Risk Management Coordinator (CQ 3), CQ 3 stated these (referring to the Zyprexa, Thorazine and Benadryl medications) were one-time order anti-psychotic injections given to manage Patient 11’s agitated behavior. During an interview on 5/1/2025 at 11:35 a.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated the following: BHU RN should reassess patients after any one-time order anti-psychotic injection was given. It should be done within thirty (30) minutes to an hour after the administration of the injection to check the patient’s response and to evaluate the effectiveness of the medications then determine if patient would require additional interventions. DIR 5 also stated there was no re-assessment done after the anti-psychotic injections were given at 11:56 a.m. and at 5:34 p.m. During an interview on 5/2/2025 at 3:12 p.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated the following: the one-time order anti-psychotic injections were given when a patient was actively a danger to self or others. The purpose of these injections was to manage the patient’s behavior. The BHU RN should perform a reassessment to evaluate patient’s behavior and response to treatment. Currently, the re-assessment was done per nurses’ discretion because there was no policy and procedures to speak to the process. DIR also stated they were trying to develop some standardized process for the BHU RNs to follow. During an interview on 5/2/2025 at 4:24 p.m. with the Clinical Pharmacy Coordinator (CPC), CPC stated the following: nursing staff should perform a reassessment within thirty (30) minutes to an hour after any anti-psychotic injections were given to BHU patients. The reassessment would include evaluating the patient’s response to the medication so the patient could be safely managed and cared for. During an interview on 5/2/2025 at 6:20 p.m. with the Quality Management Patient Safety (QM), QM stated Quality Assessment and Performance Improvement (QAPI, a process by which hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) committee was not aware there was no policy and procedure developed to address reassessment and management of giving one-time order anti-psychotic injections in BHU. During an interview on 5/2/2025 at 6:22 p.m. with the Director of Quality Management and Clinical Safety (ARLM), ARLM stated the governing body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) was ultimately responsible for the facility and providing oversight to the facility’s operation and quality of care. During an interview on 5/2/2025 at 6:49 p.m. with the Director of Medical Staff Services (DMSS), DMSS stated the GB relied on QAPI to communicate with the departments and identify issues then report to GB. During a review of the facility’s policy and procedures (P&P) titled, “Assessments,” dated 6/2023, the P&P indicated, “Purpose: to determine patient’s care through assessment of each patient’s needs; and to provide guidelines for patient assessment activities ... Ongoing assessments will be performed as the need arises to determine the patient’s response to treatment ... Any significant change in a patient’s condition or diagnosis will warrant ongoing assessment by a Registered Nurse ... Re-assessment shall be documented in the patient’s medical record.” During a review of the facility’s “Governing Body Bylaws (GB Bylaws),” dated 1/2023, the GB Bylaws indicated, “Section 3. Quality of Care: the Board of Directors (GB) is ultimately responsible for the quality of care provided by [the facility] ...To fulfill this responsibility, the Board of Directors assures ... (e) Mechanisms and policies designed to ensure the provision of quality patient care.””

“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: 48212 Based on interview and record review, the facility failed to ensure its staff provided a copy of a signed “An Important Message from Medicare (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights) prior to one of 30 sampled patient’s (Patient 20) discharge, in accordance with the facility’s policy regarding “An Important Message From Medicare.” This deficient practice had the potential for Patient 20 not knowing the rights to appeal a hospital’s discharge decision. Findings: During a review of Patient 20’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/25/2025, the “H&P” indicated, Patient 20 was admitted to the facility with diagnoses including but not limited to non-ST elevated myocardial infraction (NSTEMI, a type of heart attack), altered mental status (significant change in a person’s cognitive function [the mental processes involved in thinking, learning, remembering, and problem-solving], level of consciousness [he degree of wakefulness and awareness a person has] and/or behavior) and hypertension (high blood pressure). During a concurrent interview and record review on 5/1/2025 at 3:51 p.m. with the Quality Clinical Safety Coordinator (CQ 2), Patient 20’s “An Important Message from Medicare About Your Rights (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights),” dated 4/26/2025, was reviewed. The IMM indicated it was signed on 4/26/2025. CQ 2 stated that IMM was signed by Patient 20’s representative. During an interview on 5/2/2025 at 11:52 a.m. with the Case Manager (CM 1), CM 1 stated the following: the IMM notified patients of their rights to appeal a discharge. There was information on the IMM to instruct what patient and/or family members would do to file an appeal. The IMM was given to patients once there was a discharge order so that the patient and/or family members would have enough time to file an appeal if they decide to do so. During a review of Patient 20’s “physician order,” dated 4/30/2025, the physician order indicated, discharge Patient 20 home with home health. During an interview on 5/2/2025 at 12:40 p.m. with the Case Management Assistant (CMA), CMA stated the following: there was no documentation that the signed IMM was given to Patient 20 prior to discharge (on 4/30/2025). The signed IMM should be given to Patient 20 so he (Patient 20) would know his (Patient 20’s) rights to appeal the discharge if he (Patient 20) disagreed with the physician’s decision. During a review of the facility’s policy and procedures (P&P) titled, “An Important Message From Medicare,” dated 3/2022, the P&P indicated, “[the facility] will meet requirements of Medicare by issuing ‘An Important Message from Medicare (IMM)’ ... to all Medicare Beneficiaries who are admitted as inpatients to the hospital within two (2) days of admission, and must obtain the signature of the beneficiary or his or her representative. [the facility] case management shall also deliver a copy of the signed notice prior to discharge, but not more than two days before the discharge ... Documentation. Case Management must document timely delivery of the follow-up copy of the IMM in the patient records.””

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to: 1. Ensure that one of 30 sampled patients (Patient 1) received a respectful, dignified and fair treatment, in accordance with the facility’s policy on patient rights when Patient 1’s urine toxicology drug screen results (UDS, refers to a laboratory test that analyzes a urine sample to detect the presence of drugs or substance of abuse, used to screen for opioids [a class of natural, semi-synthetic, and synthetic drugs that include both prescription medications and illegal drugs like heroin]. , amphetamines [stimulant drugs that speed up messages between the brain and body; are prescribed by doctors to treat certain medical conditions or others, like methamphetamine, produced and sold illegally], cocaine [an addictive drug derived from coca or prepared synthetically, used as an illegal stimulant], and other illicit or prescription medications) were positive for amphetamines and opioids. Patient 1 was diagnosed with methamphetamine use (methamphetamine use disorders involve the recreational use of these substances [other than for unapproved medical indication] and are defined by a pattern of substance use leading to clinically significant impairment or distress), solely based on testing positive for amphetamines in urine, without verifying the medication history (all currently and recently prescribed drugs) of Patient 1, who had a documented history of taking Adderall (a combination of amphetamine and dextroamphetamine, two central nervous stimulants that improve focus and reduce impulsivity by increasing dopamine and norepinephrine levels in the brain). Patient 1 also received a diagnosis of opiate overdose, despite the lack of documentation demonstrating that Patient 1 responded to Narcan (naloxone, a medicine that rapidly reverses an opioid overdose) administration. In addition, the facility failed to ensure that Patient 1 was assessed for suicidal ideation (thoughts of harming or inflicting death on one’s self) after presenting to the emergency department (ED) following a suspected overdose on prescription medications (on both consecutive separate visits to the facility’s emergency department [ED] on 2/23/2025 and 2/24/2025). This deficient practice had the potential to result in Patient 1 experiencing psychological distress and had the potential to result in worsening of Patient 1’s condition, due to inappropriate treatment and increased risk for complications, which can compromise Patient 1’s safety. 2. Provide considerate and respectful care, in accordance with the facility’s policy on Patient Rights, for one of 30 sampled patients (Patient 19), when Patient 19 was given discharge instruction on getting car seat after a diagnosis of fetal demise (death of a fetus before it is born), instead of being provided discharge instruction regarding miscarriage after care that addresses both the physical and emotional well-being of Patient 19. This deficient practice had the potential to cause Patient 19 not to be aware of proper after care for miscarriage (the natural loss of a pregnancy before the 20th week of gestation) and also cause emotional distress (a highly unpleasant emotional reaction resulting from an experience or event). Findings: 1. During a review of Patient 1’s medical record (MR) titled, “Emergency Documentation-Physician Note,” dated 2/23/2025, the MR indicated the following: “Patient (Patient 1) found ALOC ([Altered Level of Consciousness, refers to a state where a person’s level of awareness and responsiveness is significantly reduced, ranging from mild confusion or drowsiness to a state of coma [a state of prolonged unconsciousness where a person is unresponsive to their surroundings and environment]) in a hotel room by family ...was combative, and now lethargic per EMS (Emergency Medical Services) report ...potential Baclofen (medication used to treat pain and certain types of muscle spasticity) overdose (to take an overdose = a dangerously large amount) of a drug.” The MR indicated that Patient 1 was not able to provide past medical history (PMH, a record of a patient’s previous illnesses, surgeries, medications, and other health-related events) and/or to participate in medical exam, “at the time of initial assessment ...” The MR further indicated that Patient 1 was described (by family) to be found with a “pile of prescription drugs,” and had markings on abdomen that are “related to being in a hot tub.” During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1’s “Triage (refers to the detailed record of an initial, rapid assessment of a patient’s condition and the prioritization of care needed based on their presenting complaint and urgency),” record, dated 2/23/2025 at 11:38 a.m., was reviewed. The record indicated that the triage registered nurse (RN 1), documented that Patient 1 had a history of being prescribed dextroamphetamine-amphetamine (Adderall, used to treat attention-deficit hyperactivity disorder [ADHD] and narcolepsy [a condition characterized by an extreme tendency to fall asleep]). During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1’s medical record (MR) titled, “Emergency Department Visit” summary, dated 2/23/2025, was reviewed. The QC stated that Patient 1 had a documented past medical history (PMH, a comprehensive record of a patient’s past and present health conditions) of: - ADHD, a neurodevelopmental disorder characterized by persistent symptoms of inattention, hyperactivity, and impulsivity which are excessive, pervasive, and developmentally inappropriate. -Anxiety, a mental condition characterized by excessive apprehensiveness about real or perceived threats. -Carpal tunnel syndrome, a condition caused by compression of the median nerve as it passes through the carpal tunnel in the wrist. - Cholelithiasis, the formation of gallstones. -Chronic pain, persistent pain that lasts for more than three months. -Cognitive disorder, a mental disorder characterized by impaired cognitive [the mental processes involved in thinking, learning, remembering, and problem-solving] abilities and daily functioning, caused by factors that affect brain function. -Fibromyalgia, a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia (difficulty falling asleep or staying asleep). -Hypertension (HTN), a condition where the force of your blood against your artery walls is consistently too high (high blood pressure). -Hypothyroidism, a condition where the thyroid gland doesn’t produce enough thyroid hormones (regulates how the body uses energy) to meet the body’s needs. -Multiple sclerosis (MS), a chronic, inflammatory disease of the central nervous system (brain and spinal cord). -Multilevel Degenerative Disk disease, the breakdown or deterioration of the discs between the vertebrae (bones that make up the spine) in the spine (long, bony structure from the base of the skull to the tailbone) -Muscle spasms, an involuntary, sudden contraction of a muscle, often resulting in pain. -Neuropathy, refers to any condition that affects the nerves outside your brain or spinal cord. -Osteomyelitis- a bone infection, usually caused by bacteria, mycobacteria, or fungi, that can spread through the bloodstream or from a nearby infection. During the same interview on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), the QC 1 said that Patient 1’s ED Visit medical record on 2/23/2025 had no documentation of patient’s (Patient 1) medication reconciliation (the process of creating a list of all medications a patient is taking) being performed, including prescription medications that Patient 1 might have been possibly taking at home for the medical conditions identified. During further review of Patient 1’s “ED Documentation-Physician Note,” dated 2/23/2025, the note indicated that Patient 1 told the ED physician that they (Patient 1) had PMH of Ehlers-Danlos syndrome (a group of inherited connective tissue disorders that affect the skin, joints, and other organs. It can be painful, particularly due to joint hypermobility and the resulting instability). During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1’s emergency department (ED) visits, dated 2/23/2025 and 2/24/2025, were reviewed. The ED visit record indicated that Patient 1’s medication reconciliation was not recorded during both visits [on 2/23/2025 and 2/24/2025]. This was verified with the QC 1 during a concurrent interview. The QC 1 also said that nurses should do medication reconciliation in the emergency department (ED). During an interview on 4/30/2025 at 12:29 p.m. with the Quality Management (QM), QM stated that the Chief Medical Officer (CMO) confirmed (on 4/20/2025) that medical providers should perform medication reconciliation on admission and discharge During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1’s “Triage (refers to the detailed record of an initial, rapid assessment of a patient’s condition and the prioritization of care needed based on their presenting complaint and urgency),” record, dated 2/23/2025 at 11:38 a.m., was reviewed. The record indicated that the triage registered nurse (RN 1), documented the following in Patient 1’s “Triage” record (on 2/23/2025 at 11:28 a.m.): -Thoughts of harming yourself: NO -Thoughts of harming others: NO -Level of consciousness: Drowsy [sleepy, lethargic] -Orientation Assessment (refers to a person’s level of awareness of their surroundings, time, and identity): Unable to assess During the same interview on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), The QC 1 verified the documentation indicating that Patient 1 was documented to be lethargic upon arrival to the emergency department (ED) and was unable to answer questions during the triage assessment regarding Suicidal (SI) and Homicidal ideation (HI, thoughts about or planning to kill another person). During a review of Patient 1’s nursing shift assessments (a systematic and ongoing process where a nurse gathers, analyzes, and interprets data to evaluate a patient’s health status and plan appropriate care) completed during Patient 1’s stay in the Emergency Department on 2/23/2025 from 11:37 a.m. to 5:57 p.m., no record of an additional SI/HI screening was found to be documented in Patient 1’s electronic medical record (EMR, a digital version of a patient’s paper-based chart or medical record within a single healthcare practice). This was verified by the Quality Coordinator (QC 1) during a concurrent interview and record review on 5/1/2025. During a review of Patient 1’s medical record (MR) titled, “Emergency Documentation (ED)-Physician Note,” dated 2/24/2025, the MR indicated the following: (On 2/24/2025 at 11:25 a.m.) “Patient [Patient 1] was brought to the facility by the ambulance (from hotel) for overdose. Patient (Patient 1) was given 4 milligrams (mg, measuring unit) of Narcan (a medicine that rapidly reverses an opioid [a class of natural, semi-synthetic, and synthetic drugs that include both prescription medications and illegal drugs like heroin] overdose) intranasally (within or into the nose) on the way to the hospital. Patient was seen for the same (on 2/23/2025) a day ago.” During a concurrent interview and record review on 5/1/2025 at 10:01 a.m. with the emergency department provider (MD 3), Patient 1’s ED visit medical record (MR), dated 2/24/2025, was reviewed. The “ED Documentation-Provider Note,” dated 2/24/2025, indicated that Patient 1 was diagnosed with opiate overdose, toxic encephalopathy (a brain disorder resulting from exposure to toxic substance), and methamphetamine use (identifying and confirming the use of methamphetamines [a powerful stimulant, known as crystal meth]). The MD 3 stated the following regarding Patient 1’s diagnoses and medication reconciliation: “(On 2/24/2025) Patient (Patient 1) was diagnosed with an opiate overdose because she (Patient 1) responded to an antidote (Narcan) administered during her treatment in the field, on the way to the emergency department, but this was not clearly documented in the patient’s (Patient 1) medical chart. Regarding methamphetamine use, the patient’s history from 2018 ED visit must have automatically generated methamphetamine use history into the (current 2025) record. The Patient’s (Patient 1) visit on 2/23/2025 (prior to the second ED visit on 2/24/2025) demonstrated that she (Patient 1) tested positive for amphetamines and opiates. However, medication reconciliation was not completed for this patient, and it is possible that the positive results were due to prescription medications-such as prescribed opioids and Adderall (amphetamine-containing medication)-which patient (Patient 1) may have been using as a part of her (Patient 1) treatment plan.” MD 3 also stated that urine toxicology cannot differentiate between amphetamine use and methamphetamine use. During an interview on 5/1/2025 at 12:01 p.m. with the director of the Emergency Department (Dir 1), the Dir 1 stated the following regarding medication reconciliation process in the emergency department (ED): “When a patient arrives at the Emergency Department (ED), the expectation is for the nurses to conduct an initial assessment, which includes gathering the patients’ past medical history and medication history. However, there is typically not enough time to review mediations during triage, and the medication reconciliation is typically done by the assigned nurse once the patient is stabilized. The physician also obtains additional medication history information during their assessment of the patient. Medication reconciliation is marked as complete after the physician reviews and verifies the medication list. Not all patients require nurses to complete the medication history, but Patient with ESI level of 3 and above (Patient 1 had an ESI level of 2) are expected to have the medication reconciliation performed during their ED visit.” The Dir 1 also said that it’s important to know what medications patient is currently taking, especially if patient is admitted on overdose.” During a concurrent interview and record review on 5/1/2025 at 10:50 a.m. with the Quality Coordinator (QC 1), Patient 1’s Medication Administration Record (MAR), dated 2/24/2025, was reviewed. QC 1 confirmed that Patient 1’s MAR contained no documentation of Patient 1 being re-assessed for the response to naloxone (Narcan) administration. During an interview on 5/2/2025 at 11:00 a.m. with the Clinical Pharmacy Coordinator (CPC), the CPC stated the following regarding documentation expectations after administering Narcan for a suspected opioid overdose: “Narcan is an opioids reversal agent. I don’t believe we (the facility) have a specific policy stating that the response to Narcan administration must be documented. However, if this medication is given for an actual opioid overdose in the emergency department, the expectation is for the nurses to document the patient’s reaction and response to the medication, but we don’t audit emergency department Narcan administration. We conduct audits for this documentation to monitor for suspected inpatient adverse reactions to opioids. We specifically look for the assessment documentation conducted after Narcan administration to evaluate its effectiveness.” During an interview on 5/1/2025 at 12:09 p.m. with the Director of the Emergency Department (Dir 1), Dir 1 stated the following regarding Suicidal/Homicidal (SI/HI) ideation screening in triage upon a patient’s arrival to the hospital: “The patient must be alert and oriented (a patient who is awake, awake of their surroundings, and able to understand and respond appropriately) to be able to communicate effectively and to answer questions regarding suicidal ideation (SI) or HI.” During a concurrent interview and record review on 5/1/2025 at 12:15 p.m. with the Director of the Emergency Department (Dir 1), Patient 1’s “Triage” record, dated 2/23/2025, was reviewed. The record indicated that Patient 1 presented drowsy and was not able to be assessed for orientation, but the patient (Patient 1) was documented to have answered “NO” to questions regarding thoughts of harming self or others. Dir 1 reviewed the documentation and stated that the most appropriate option in this documentation would be “unable to assess” rather than to record “no” for a patient who was recorded to be lethargic and unable to communicate. Dir 1 also stated that if a nurse was unable to assess SI/HI in triage, the next nurse (bedside nurse) should follow up with a re-assessment. Dir 1 said, “Even if the patient has answered “NO” to SI/HI questions in triage, nurses can still re-assess during the time patient is in the emergency department, especially if the patient was admitted with a possible overdose. We want to make sure that the patient remains safe.” During a review of Patient 1’s nursing shift assessments completed during Patient 1’s stay in the Emergency Department (ED) on 2/24/2025 from 11:25 a.m. through 2/25/2025 at 6:18 a.m. (second ED visit), no record of additional SI/HI screening was found to be documented in Patient 1’s electronic medical record (EMR). This was verified by the Quality Coordinator (QC 1) during a concurrent interview and record review on 5/1/2025 at 12:20 p.m. During an interview on 5/2/2025 at 8:00 a.m. with the registered nurse (RN 6), the nurse who discharged Patient 1 on 2/25/2025, RN 6 stated that Patient 1 refused to sign discharge instructions (guidelines that patients have to follow after discharge to deal with any remaining illnesses that need to be taken care of personally by the patient) because of the diagnosis of methamphetamine use and opiate overdose, which Patient 1 disagreed with. RN 6 said this was communicated to the physician, but the physician said these diagnoses were based on the urine drug screen and being positive for opioids and amphetamines. RN 6 also said that when Patient 1 left the ED, she (Patient 1) was alert and oriented (meaning the patient was aware of person, place, and time), and able to walk independently. RN 6 said that, according to the facility’s policy, medication reconciliation should have been done for Patient 1. RN 6 could not recall whether the medication reconciliation was done for Patient 1 prior to discharge but stated that she [RN 6] did not complete the medication history for Patient 1 prior to Patient 1’s discharge from the ED (on 2/25/2025). During an interview on 5/2/2025 at 3:04 p.m. with the emergency Department physician (MD 4), MD 4 reviewed Patient 1’s ED visits, dated 2/23/2025 (first ED visit) and 2/24/2025 (second ED visit), and stated the following: “Based on the physician’s documentation in the patient (Patient 1) record, it is not possible to determine whether Patient 1 was screened for suicidal ideation and if Patient 1 intentionally or unintentionally overdosed on medications. You would have to ask the physicians.” MD 4 also said that “perhaps methamphetamine use diagnosis was based on 2021 admission records (Patient 1 was last admitted to the facility on 10/8/2021).” MD 4 also said, “Regarding 1 mg of Morphine (an opioid used for pain relief) that was documented to be given to the patient (patient 1) on 2/25/2025 at 4:49 p.m., (only an hour and 20 minutes prior to Patient 1’s discharge from the ED on 2/25/2025), the reason for this medication is unclear; the physician who ordered it can only state the purpose. It’s possible that Patient 1 was in pain after waking up, but the exact rationale is not documented or known.” During an interview on 5/2/2025 at 4:14 p.m. with the Director of Clinical Laboratory Services (Dir 1), the Dir 1 stated the following: “The urine drug screen test conducted in the facility do not differentiate between prescription amphetamines such as Adderall, and illegal drugs like methamphetamine. In fact, taking Adderall can sometimes lower the concentration of amphetamine in the urine, potentially resulting in a false-negative test when the amount taken or the drug has been partially metabolized, is below the test’s detection threshold. To accurately determine if Adderall, specifically, is present in the urine, samples must be sent to an external reference laboratory, as the facility’s current testing process does not include this measurement.” During a review of Patient 1’s previous admission to the facility, dated 10/8/2021 through 10/10/2021, the History and Physical (H&P), dated 10/8/2021, indicated that Patient 1 presented to the facility’s emergency department from a motel, with high fever and body chills and was admitted to the facility with a diagnosis of pyelonephritis (an inflammation of the kidneys caused by a bacterial infection) and urinary tract infection (UTI, an infection that affects any part of the urinary system, including the kidneys, bladder, and urethra). During a review of Patient 1’s “Discharge Documentation,” dated 10/10/2021, the record indicated that Patient 1 was discharged with the following diagnoses: pyelonephritis, UTI, chronic pain, hypothyroid, tobacco use, weakness and fever. The record also indicated that Patient 1 had positive urine drug toxicology screen for amphetamines and opiates ... The record also indicated that Patient 1 was prescribed 5/325 mg oral tablet Percocet (the brand name of a combination medication used to treat moderate to severe pain. Its two main ingredients (5 milligrams [mg, measuring unit] oxycodone and 325 mg of acetaminophen) relieve pain) for pain and was instructed to continue taking Adderall (indication, dose, and frequency not documented). The record also indicated that no medication reconciliation was completed during Patient 1’s visit from 10/8/2021 through 10/10/2021. This information was verified by the quality coordinator (QC 1) during a concurrent interview and record review on 4/30/2025. During a review of the facility’s policy and procedure (P&P) titled, “Patients’ Rights and Responsibilities,” dated 11/24/2024, the P&P indicated that: “A. Persons with mental or substance abuse disorders have the same legal rights and responsibilities guaranteed all other persons by the Federal Constitution and laws of the State of California, unless specifically limited by federal or state law regulations. During a review of the facility’s policy and procedure (P&P) titled, “Patients’ Rights and Responsibilities,” dated 3/21/2022, the P&P indicated: “VIII.STATEMENT OF PATIENT RIGHTS: The patient has the right to: A. Considerate and respectful care, to be made comfortable. To respect for the patient’s cultural, psychosocial, spiritual and personal values, beliefs and preferences. D. Receive information about the patient’s health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms the patient can understand. The right to effective communication and to participate in the development and implementation of the patient’s plan of care. During a review of the facility’s policy and procedure (P&P) titled, “Documentation,” dated 8/2024, the P&P indicated that: “All documentation shall contain accurate, truthful and pertinent documentation ... All measures performed by nursing relating to care and the patient’s response to such measures shall be documented ... All PRN (as needed) medication, the reason for administering and the effectiveness of same shall be documented in the medical record ...” During a review of the facility’s Policy and Procedure (P&P) titled, “Plan for Provision of Care, Treatment, and Services,” dated 10/2024, the P&P indicated the following: “The Emergency Department (ED) will provide an assessment, and any treatment indicated to all patients presenting with any illness or injury. During a review of the facility’s policy and procedure (P&P) titled, “Suicide Risk Assessment,” dated 9/2022, the P&P indicated that all patients admitted to the hospital or in the ED, shall be screened for the presence of suicide risk factors ... All patients who screen positive for suicide risk factors and/or present with a primary complaint of an emotional or behavioral disorder, shall be further assessed using a comprehensive suicide risk assessment tool for the risk of suicide by a mental health professional. Procedure: 1.A licensed healthcare professional will screen every patient for suicide risk during the initial assessment and reassessment by identifying with special emphasis on those who are being evaluated and/or treated for: a. Suicide attempt (overdosing, self-injury) or suspected suicide attempt ... 3. If any of the above screening indicators are present for a patient in ED, the Psychiatric Liaison Nurse or MHRN who has LPS certification will complete a Columbia Suicide Severity Rating Scale (C-SSRS) form...” During a review of the facility’s policy and procedure (P&P) titled, “ Initial Patient Assessment and Re-assessment,” dated 3/24/2025, the P&P indicated the following [The P&P applies to all nursing areas, including the Emergency Department (ED)]: “ At the time of admission or as soon as possible thereafter, each patient shall have an initial physical/psychological assessment completed by a registered nurse (RN). IV. The assessment is structured to identify facilitating factors and possible barriers to the patient reaching his or her goals including presenting problems and needs such as: I. Psychological, emotional, behavioral, suicidal and mental disorders” During a review of the facility’s policy and procedure (P&P), titled “Triage,” dated 12/18/2023, the P&P indicated the following: “IX. Behavioral Health Patients a. Patients who present to triage exhibiting behaviors such as aggressiveness, agitation, or suicidal ideation present a danger to him/herself, or others, including the ED staff, and are considered violent until proven otherwise. b. The patient will be moved to a secured area away from the triage area. After the patient has had a medical screening exam and it is determined to be medically stable, a mental health evaluation may be requested on any person the provider deems appropriate, i.e., homicidal, suicidal, psychotic, etc.” During a review of the facility’s policy and procedure (P&P) titled, “Initial Patient Assessment and Reassessment,” dated 3/6/2024, the P&P indicated that: “The assessment of the care or treatment required to meet the needs of the patient will be ongoing throughout the patient’s hospital stay, with the assessment process individualized to meet the needs of the patient population. Reassessment shall occur when an intervention has taken place or if there is a change in patient condition or status. During a review of the facility’s policy and procedure (P&P) titled, “Medication Reconciliation,” dated 9/2022, the P&P indicated the following: “Medication reconciliation is the collaborative responsibility of physicians, nurses, and pharmacists ... Electronic medication reconciliation will be utilized to document the medication reconciliation process for all in-patient admissions, outpatients, and discharges in the electronic medical record ...Upon discharge, the ED physician and licensed staff will reconcile the medication list in electronic medical record and determine whether the medication list requires a change or not. This information is included in discharge teaching and the patient’s written instructions.” 2. During a review of Patient 19’s “Emergency Documentation (ED notes, medical notes completed by Emergency Department [hospital department provides unscheduled outpatient services to patients whose condition requires immediate care] physician),” dated12/9/2023, the ED notes indicated Patient 19 was diagnosed with fetal demise (death of a fetus before it is born) before twenty (20) weeks with retention of dead fetus (unborn baby). During a concurrent interview and record review on 5/2/2025 at 12:50 p.m. with the Data Analyst (DA 1), Patient 19’s “Discharge Instruction,” dated 12/9/2023, was reviewed. The discharge instructions indicated patient education including (the state) law requirement of getting car seat for children. DA 1 stated car seat requirement was not related to what Patient 19 came in for, which was fetal demise. DA 1 stated the discharge instruction given to Patient 19 should have included teaching about miscarriage (the natural loss of a pregnancy before the 20th week of gestation) aftercare. During an interview on 5/2/2025 at 3:28 p.m. with the Director of Emergency Department (Dir 1), Dir 1 stated the following: discharge instruction was prepared by the provider. The discharge instruction should provide education related to patient’s diagnosis and what they came to ED for. Discharge instruction for patients with fetal demise and miscarriage should include signs and symptoms to return to emergency department including but not limited to severe abdominal pain and vaginal bleeding. During a concurrent interview and record review on 5/2/2025 at 3:50 p.m. with Dir 1, Patient 19’s “Discharge Instruction,” dated 12/9/2023, was reviewed. The discharge instructions indicated patient education including (the state) law requirement of getting car seat for children. Dir 1 stated the following: giving information about car seat for patient with fetal demise could make patient (Patient 19) feel bad and emotional. Dir 1 stated he (Dir 1) would communicate with the ED providers to be more sensitive in the future. During a review of the facility’s policy and procedure (P&P) titled, “Patient Discharge,” dated 7/2023, the P&P indicated, “Patient shall be educated on their diagnosis and/or disease process.” During a review of the facility’s policy and procedures (P&P) titled, “Patient/Family Teaching Plan,” dated 7/2022, the P&P indicated, “Discharge Instruction: Patient and/or family education and discharge planning are interrelated in that discharge planning involves teaching the patient about care after discharge, understanding treatment, making life-style changes, and managing continuing care ... Physicians are responsible for first diagnosis teaching, and other elements of the medical plan of care ... Licensed Nurses may also provide information on medication, self-care, and use of medical equipment, discharge information, and access to community resources ... the licensed nurse is responsible for coordinating the educational needs of the discharged patient.” During a review of the facility’s policy and procedures (P&P) titled, “Patients’ Rights and Responsibilities,” dated 3/2022, the P&P indicated, “All hospital employees, medical staff, members and contracted agency staff performing patient care activities shall observe these patients’ rights ... Statement of Patients’ Rights: the patient has the right to ... A. Considerate and respectful care, to be made comfortable. To respect for the patient’s cultural, psychosocial, spiritual and personal values, beliefs and preferences ... D. Receive information about the patient’s health status, diagnosis, prognosis, course of treatment, prospects for recovering and outcomes of care (including unanticipated outcomes) in terms that patient can understand.””

“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: 46238 Based on observation, interview, and record review, the facility failed to: 1. Ensure two of 30 sampled patients’ (Patient 4 and Patient 5) call lights (a device that allows to alert staff when assistance is needed), were placed within reach to be able to summon help when needed without delay, in accordance with the facility’s fall (an unintentional event that results in a person coming to rest on the ground, floor, or other lower surface) prevention policy. Both Patient 4 and Patient 5 were assessed to be a moderate, and a high fall risk, respectively. This deficient practice had the potential for Patient 4 and Patient 5 to sustain harm, such as falls, injuries or had their care needs not being met, compromising their (Patient 4 and Patient 5) recovery and well-being. 2. Ensure its nursing staff utilized rapid response team (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) to assist with expediting the transfer for one of 30 sampled patients (Patient 21), in accordance with the facility’s policy and procedures regarding rapid response, when Patient 21 remained in the Medical-Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery) Unit waiting to be transferred to Progressive Care Unit (PCU, a hospital unit that provides level of care between general medical-surgical unit and the intensive care unit [ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill]) for four (4) hours on 5/20/2024. This deficient practice had the potential to result in Patient 21 not receiving appropriate level of care and monitoring while waiting to be transferred to PCU and may lead to delay in treatment and care, which may result in complications requiring intubation (a medical procedure where a tube is inserted into the windpipe [trachea] to maintain an open airway). Findings: 1.a. During a review of Patient 4’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/29/2025, the H&P indicated that Patient 4 was admitted to the facility with a diagnosis of paresthesia (an abnormal sensation, typically tingling or pricking [“pins and needles”], caused chiefly by pressure on or damage to peripheral nerves [other than spinal cord and the brain], right-sided weakness, acute cerebrovascular accident [CVA, a medical term for a stroke, a sudden interruption of blood flow to the brain]). The H&P also indicated that Patient 4 was admitted to neuro-telemetry unit (a specialized hospital unit that provides remote monitoring and care for patients with neurological conditions). During an observation on 4/29/2025, at 11:06 a.m., with the Quality Management (QM), in the Emergency Department (ED, a hospital department dedicated to providing immediate medical care to patients whose conditions require urgent attention), Patient 4 was observed resting on a gurney in a room located away from the nurse’s station, and the patient (Patient 4) was alone in the room. The QM asked Patient 4 if they (Patient 4) had a call light (a device that alerts staff when assistance is needed) within reach to call for assistance. Patient 4 said, “No.” The call light was not within Patient 4’s reach and was coiled on the wall, out of Patient 4’s immediate access. The QM placed the call light next to Patient 4 and tested its functionality by pressing the call light, which lit up the light bulb on the wall, outside Patient 4’s room, indicating that the call light was working. During an interview on 5/2/2025 at 10:51 a.m. with the clinical educator (CE 1), the CE 1 stated the following: “Call lights are provided to all patients in the patients’ rooms. Patients need call lights to call for help and contact their nurse whenever they need assistance. Cal lights are also a fall prevention intervention (a strategy or action aimed at reducing the risk of falls and minimizing their impact) and can be documented as a fall prevention strategy intervention for patients identified as a fall risk.” During a concurrent interview and record review on 5/2/2025, at 11:45 a.m. with Clinical Educator (CE 1), Patient 4’s “Fall Risk,” assessment record, dated 4/29/2025, was reviewed. The record indicated that Patient 4 was identified as a moderate risk for fall (It suggests that individuals are at a greater risk than those with low risk but may not require the most stringent fall precautions). CE 1 stated that Patient 4 was assessed to be a moderate risk for fall and required general fall precaution interventions such as keeping belongings near patient’s reach, keeping call light within reach, and educating the patient of fall risk level and prevention interventions. During a review of the facility’s policy and procedure (P&P) titled, “Fall Prevention and Reduction,” dated 8/2024, the P&P indicated the following: “Fall: A patient fall is a sudden change in body position in a downward direction, which may or may not result in a physical injury ... Evidence-based high fall risk interventions will be implemented and documented based on the identified fall risk assessment ... 2. An environmental risk assessment is performed repeatedly throughout each shift or patient stay ensuring universal fall safety precautions are in place including but not limited to: Call light within reach ...Patient education includes, but not limited to: Ensure call light is in easy reach and assess patient’s ability to use it ...Instruct patient to call for help before getting out of bed by using call light ... 1.b. During an observation and interview on 4/29/2025 at 11:15 a.m., in the emergency department (ED), Patient 5 was observed in the room. Patient 5 did not have a call light within reach. Patient 5 stated that nurses keep coming in and out of the room every 10 minutes and said, “I can scream loud and someone will come.” During a review of Patient 5’s “Fall Risk” assessment record (in the Emergency Department), the record indicated that Patient 5 was identified as a high fall risk. The record also indicated that safety planning interventions documented for Patient 5 included: bed in low position, non-slip footwear side rails up, and wheels locked ... During an interview on 5/2/2025 at 10:51 a.m. with the clinical educator (CE 1), CE 1 stated the following: “Call lights are provided to all patients in their rooms. Patients need call lights to call for help and contact their nurse whenever they need assistance. Cal lights are also a fall prevention intervention (a strategy or action aimed at reducing the risk of falls and minimizing their impact]) and can be documented as a fall prevention strategy intervention for patients identified as a fall risk.” During an interview on 5/2/2025 at 11:46 a.m. with the clinical educator (CE 1), CE 1 said that for high fall risk patients, nurses must document all fall prevention strategies implemented for the patient. CE 1 then reviewed the documentation of the “Fall Risk” assessment (in Patient 5’s medical record, documented on 4/29/2025 in the ED), and stated, “Call light was not documented as one of the safety interventions for Patient 5 assessment under “ED Safety Planning for Fall Prevention” (during Patient 5’s visit in the ED on 4/29/2025). During a review of the facility’s policy and procedure (P&P) titled, “Fall Prevention and Reduction,” dated 8/2024, the P&P indicated the following: “Fall: A patient fall is a sudden change in body position in a downward direction, which may or may not result in a physical injury ... Evidence-based high fall risk interventions will be implemented and documented based on the identified fall risk assessment ... 2. An environmental risk assessment is performed repeatedly throughout each shift or patient stay ensuring universal fall safety precautions are in place including but not limited to: Call light within reach ...Patient education includes, but not limited to: Ensure call light is in easy reach and assess patient’s ability to use it ...Instruct patient to call for help before getting out of bed by using call light ... 2. During a review of Patient 21’s “Progress Notes, (physician narrative notes),” dated 5/20/2024, the “Progress Notes” indicated, Patient 21 was admitted to the facility on 5/17/2024 with diagnoses including but not limited to acute (new onset) on chronic respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (deficiency in the amount of oxygen reaching the tissues), Chronic Obstructive Pulmonary Disease (COPD, a lung disease characterized by long-term poor airflow) exacerbation (worsening) and hypertension (high blood pressure). During a review of Patient 21’s “Provider Notification (communication record between nurses and physicians),” dated 5/20/2024, the “Provider Notification” indicated, at 10:05 a.m., Registered Nurse (RN) 5 reported an abnormal arterial blood test (ABG, a blood test that measures the levels of oxygen and carbon dioxide in arterial blood, as well as the blood’s acidity and bicarbonate concentration) result to Patient 21’s physician and received order to place Patient 21 on BIPAP (Bi-level positive airway pressure device, a pressure support ventilation to treat sleep respiratory problems) and transfer Patient 21 to Progressive Care Unit (PCU, a hospital unit that provides level of care between general medical-surgical [Med-Surg, general patient population hospitalized for various causes such as illness and surgery] unit and the intensive care unit [ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill]) for higher level of care (involves greater supervision, frequency, and intensity of care). During an interview on 4/30/2025 at 12:51 p.m. with the Quality Coordinator (CQ 2), CQ 2 stated when a patient had an order to transfer to PCU from Med-Surg Unit, the patient assignment should be adjusted to make sure there was a competent nurse to provide PCU level of care for the patient until the patient was physically transferred to PCU. During a concurrent interview and record review on 4/20/2025 at 2:48 p.m. with CQ 2, Patient 21’s “Location History,” dated from 5/17/2024 to 6/8/2024, was reviewed. The location history indicated Patient 21 was transferred to PCU on 5/20/2024 at 2:25 p.m. CQ 2 stated Patient 21 remained in Med-Surg Unit for about four (4) hours before Patient 21 was transferred to PCU. During an interview with the Director of Quality Management and Clinical Safety (ARLM), ARLM stated the following: nursing staff should have called rapid response team (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) so that the rapid response team nurse could monitor and provide the right level of care for Patient 21 while waiting for PCU transfer. ARLM stated no RRT was called on 5/20/2024 for Patient 21. During a review of the facility’s policy and procedures (P&P) titled, “Rapid Response,” dated 4/2024, the P&P indicated, “It is the policy of [the facility] to provide rapid assessment and intervention when appropriate, in an effort to provide the best possible patient care and optimize outcomes. [the facility] had Rapid Response Team personnel available to assist with condition deterioration and interventions to prevent or avert further deterioration ... the critical care nurse provides clinical expertise, advanced assessment skills and support for the patients’ nurse, patient and patient’s family, as well as facilitates a timelier transfer to a higher level of care when needed ... Procedure ... Critical care/rapid response nurse responsibilities ... assist/facilitate with transfer to higher level of care if indicated. Remain with the patient until she/he can be transferred to the appropriate level of care and during transport unless there are other competent personnel available at the time.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its nursing staff assessed and performed pulse and skin checking every fifteen (15) minutes, for one of 30 sampled patients (Patient 11), in accordance with the facility’s policy and procedures regarding restraints use (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), when Patient 11 was restrained with 4-point (both wrists and both ankles) restraints on 4/14/2025. This deficient practice had the potential to put Patient 11 at risk for skin injury or getting out from restraints. Findings: During a review of Patient 11’s “Behavioral Health (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Inpatient Provider Admission Note (psychiatric History and Physical [H&P], a formal and complete assessment of the patient and the problem completed by a psychiatrist [physician specializes in mental health]),” dated 4/13/2025, the psych H&P indicated, Patient 11 was admitted to the facility’s Behavioral Health Unit on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) with diagnoses including but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and cannabis use disorder (a complex condition that involves problematic pattern of cannabis [marijuana] use). During a review of Patient 11’s “Behavioral Health Forms,” dated 4/14/2025, the Behavioral Health forms indicated, at 5:11 p.m., Patient 11 attempted to forcefully snatch a staff’s badge to exit the unit and lunged at staff member aggressively. The Behavioral Health forms also indicated Patient 11 was placed in seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) and restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) for Patient 11’s and others’ (other patients and staff) safety. During a review of Patient 11’s physician order, dated 4/14/2025, the physician order indicated violent 4-point (both wrists and both ankles) restraints and seclusion ordered on 4/14/2025 at 5:18 p.m. During an interview on 4/30/2025 at 4:32 p.m. with the Risk Management Coordinator (CQ 3), CQ 3 stated the following: nursing staff should perform circulation (assessing blood flow in the body including checking skin color, temperature, and pulse [the heart rate]) and skin check every fifteen (15) minutes to make sure the restraints were not too tight or too loose. Patients could get hurt if restraints were too tight or patients could get out from the restraints if they were too loose. During a concurrent interview and record review on 5/1/2025 at 11:38 a.m. with the Director of Behavioral Health Unit (DIR 5), Patient 11’s “Restraints Information (restraints flowsheet, nursing assessment while a patient is restrained),” dated 4/14/2025, was reviewed. The restraints flowsheet indicated, Patient 11 was restrained on 4/14/2025 from 5:11 p.m. to 8:30 p.m. the restraints flowsheet also indicated “pulse distal to restraint check” and “skin intact under restraints” were blank from 7:15 p.m. to 7:59 p.m. and from 8:15 p.m. to 8:30 p.m. During the same interview on 5/1/2025 at 11:38 a.m. with DIR 5, DIR 5 stated nursing staff should be performing pulse and skin check every 15 minutes. DIR 5 stated the document was missing four (4) checks from 7:15 p.m. to 8:30 p.m. During a review of the facility’s policy and procedures (P&P) titled, “Restraint and Seclusion Guidelines,” dated 7/2022, the P&P indicated, “Assessment, monitoring and documentation of patients in violent/self-destructive restraints: 1. A staff member who is trained and competent monitors the patient continuously from the initiation of restraint until discontinuation and documents every fifteen (15) minutes regarding: i. signs of injury or distress ii. Circulation and color to the affected extremity iii. Level of emotional and behavioral distress or agitation.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its Behavioral Health Unit (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurse (RN) evaluated the medical condition and taken vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level), for one of 30 sampled patients (Patient 11), when performing a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) on 4/14/2025 and 4/28/2025, in accordance with the facility’s restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) guidelines. This deficient practice had the potential for the nursing staff not immediately recognizing Patient 11’s abnormal vital signs and changes in respiratory (breathing) status resulting from the use of restraints and seclusion which may cause delay in care or treatment. Findings: During a review of Patient 11’s “Behavioral Health (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Inpatient Provider Admission Note (psychiatric History and Physical [H&P], a formal and complete assessment of the patient and the problem completed by a psychiatrist [physician specializes in mental health]),” dated 4/13/2025, the psych H&P indicated, Patient 11 was admitted to the facility Behavioral Health Unit on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) with diagnoses including but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and cannabis use disorder (a complex condition that involves problematic pattern of cannabis [marijuana] use). During a review of Patient 11’s “Behavioral Health Forms,” dated 4/14/2025, the Behavioral Health forms indicated, at 5:11 p.m., Patient 11 attempted to forcefully snatch a staff’s badge to exit the unit and lunged at staff member aggressively. The Behavioral Health forms also indicated Patient 11 was placed in seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) and restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) for Patient 11’s and other’s (the other patients and the staff) safety. During a review of Patient 11’s physician order, dated 4/14/2025, the physician order indicated violent 4-point (both wrists and both ankles) restraints and seclusion ordered on 4/14/2025 at 5:18 p.m. During a review of Patient 11’s “Behavioral Health Forms,” dated 4/28/2025, the Behavioral Health forms indicated, at 10:40 a.m. Patient 11 attacked one of the staff members when Patient 11 was redirected. The Behavioral Health forms also indicated Patient 11 was placed in seclusion and restraints for Patient 11’s safety and safety of others. During a review of Patient 11’s physician order, dated 4/28/2025, the physician order indicated violent 4-point restraints and seclusion ordered on 4/28/2025 at 11:00 a.m. During a concurrent interview and record review on 5/1/2025 at 11:27 a.m. with the Director of Behavioral Health Unit (DIR 5), Patient 11’s “Restraint Face To Face (face-to-face assessment form, an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]),” dated 4/14/2025 and 4/28/2025, were reviewed. The face-to-face assessment forms indicated the following: -“On 4/14/2025 at 5:56 p.m. completed by Registered Nurse (RN 3): Restraints Face to Face ... (C) The patient’s medical and behavioral condition: Patient’s (Patient 11’s) respirations are even and unlabored (normal, effortless breathing), no injury noted to patient (Patient 11). Patient (Patient 11) appears agitated (feeling of uneasiness and severe restlessness) and fighting against the restraints;” and -“On 4/28/2025 at 11:27 a.m. completed by Registered Nurse (RN 3): Restraints Face to Face ... (C) The patient’s medical and behavioral condition: Patient (Patient 11) is agitated, yelling, and fighting the restraints.” During the same interview on 5/1/2025 at 11:27 a.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated the following: both face-to-face assessments completed by RN 3 were incomplete. The expectation was for the RN to obtain a set of vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) when performing face-to-face assessment. There were no vital signs documented for both face-to-face assessments. Also, the face-to-face assessment on 4/28/2025 did not address Patient 11’s medical condition at all. A complete face-to-face assessment was to make sure Patient 11 was safe while being restrained, identify and address any abnormality. During a review of the facility’s policy and procedures (P&P) titled, “Restraint and Seclusion Guidelines,” dated 7/2022, the P&P indicated, “A face-to-face evaluation shall occur within one (1) hour of each initiation of seclusion/restraint for violent/self-destructive reason ... and be documented in the medical record by the physician, RN, Physician Assistant (PA), or Nurse Practitioner (NP) that performed the evaluation. The purpose of the assessment is to evaluate: 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the seclusion or restraint.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(14) If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its Behavioral Health Unit (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurse (RN) consulted the attending physician within an hour after performing face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) on one of 30 sampled patients (Patient 11), in accordance with the facility’s policy regarding face to face assessment. This deficient practice had the potential to result in Patient 11’s physician not knowing Patient 11’s response to the restraints use (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving), the need for continuation of restraint and/or seclusion, and the possible use of alternatives and, therefore, may lead to unnecessary or prolonged restraints use. Findings: During a review of Patient 11’s “Behavioral Health (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Inpatient Provider Admission Note (psych H&P, a formal and complete assessment of the patient and the problem completed by a psychiatrist [physician specializes in mental health]),” dated 4/13/2025, the psych H&P indicated, Patient 11 was admitted to the facility’s Behavioral Health Unit on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) with diagnoses including but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and cannabis use disorder (a complex condition that involves problematic pattern of cannabis [marijuana] use). During a review of Patient 11’s “Behavioral Health Forms,” dated 4/14/2025, the Behavioral Health forms indicated, at 5:11 p.m., Patient 11 attempted to forcefully snatch a staff’s badge to exit the unit and lunged at staff member aggressively. The Behavioral Health forms also indicated Patient 11 was placed in seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) and restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) for Patient 11’s safety and safety of others (other patients and the staff). During a review of Patient 11’s physician order, dated 4/14/2025, the physician order indicated violent 4-point (both wrists and both ankles) restraints and seclusion was ordered on 4/14/2025 at 5:18 p.m. During a review of Patient 11’s “Behavioral Health Forms,” dated 4/28/2025, the Behavioral Health forms indicated, at 10:40 a.m., Patient 11 attacked one of the staff members when Patient 11 was redirected. The Behavioral Health forms also indicated Patient 11 was placed in seclusion and restraints for Patient 11’s safety and safety of others. During a review of Patient 11’s physician order, dated 4/28/2025, the physician order indicated violent 4-point restraints and seclusion was ordered on 4/28/2025 at 11:00 a.m. During a concurrent interview and record review on 4/30/2025 at 4:37 p.m. with the Risk Management Coordinator (CQ 3), Patient 11’s “Restraint Face To Face (face-to-face assessment form, an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]),” dated 4/14/2025 and 4/28/2025, were reviewed. The face-to-face assessment forms indicated both face-to-face assessments were completed by Registered Nurse (RN) 3 and there was no documentation that RN 3 consulted the attending physician after the face-to-face assessment on both days (4/14/2025 and 4/28/2025). CQ 3 stated there was no communication with the physician after face-to-face assessment was completed by RN 3. During an interview on 5/1/2025 at 11:05 a.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated the following: there should be provider notification by RN after performing face-to-face assessment. The RN should document which provider was notified along with the date and time of notification. The provider could decide if restraints were needed or not, alternative consideration or give further orders as needed. During a review of the facility’s policy and procedures (P&P) titled, “Restraint and Seclusion Guidelines,” dated 7/2022, the P&P indicated, “A face-to-face evaluation shall occur within one (1) hour of each initiation of seclusion/restraint for violent/self-destructive reason ... and be documented in the medical record by the physician, RN, Physician Assistant (PA), or Nurse Practitioner (NP) that performed the evaluation. The purpose of the assessment is to evaluate: 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the seclusion or restraint. If a trained and competent RN (or NP or PA) conducts the face-to-face evaluation, the RN (or NP or PA) must consult with the attending physician who is responsible for the patient’s care after completing the face-to-face evaluation. This consultation must be documented in the medical record along with the order to use or continue restraint.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(vi) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (vi) Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure one of two Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurse (RN 3), was trained and demonstrated competency in performing correct face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), when RN 3 did not complete the face-to-face assessment training upon hire and annually (every year), in accordance with the facility’s policy and procedures regarding restraints use (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and face-to-face assessment. This deficient practice resulted in RN 3 not evaluating Patient 11’s medical condition and not consulting the attending physician, when performing face-to-face assessments on 4/14/2025 and 4/28/2025, which may result in the delay of necessary medical care or treatment and/or prolonged use of restraints for Patient 11. Findings: During a review of Patient 11’s “Behavioral Health (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Inpatient Provider Admission Note (psychiatric History and Physical [H&P], a formal and complete assessment of the patient and the problem completed by a psychiatrist [physician specializes in mental health]),” dated 4/13/2025, the psych H&P indicated, Patient 11 was admitted to the facility’s Behavioral Health Unit on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) with diagnoses including but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and cannabis use disorder (a complex condition that involves problematic pattern of cannabis [marijuana] use). During a review of Patient 11’s “Behavioral Health Forms,” dated 4/14/2025, the Behavioral Health forms indicated, at 5:11 p.m., Patient 11 attempted to forcefully snatch a staff’s badge to exit the unit and lunged at staff member aggressively. The Behavioral Health forms also indicated Patient 11 was placed in seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) and restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) for Patient 11’s safety and safety of others (other patients and the staff). During a review of Patient 11’s physician order, dated 4/14/2025, the physician order indicated violent 4-point (both wrists and both ankles) restraints and seclusion ordered on 4/14/2025 at 5:18 p.m. During a review of Patient 11’s “Behavioral Health Forms,” dated 4/28/2025, the Behavioral Health forms indicated, at 10:40 a.m., Patient 11 attacked one of the staff members when Patient 11 was redirected. The Behavioral Health forms also indicated Patient 11 was placed in seclusion and restraints for Patient 11’s safety and safety of others. During a review of Patient 11’s physician order, dated 4/28/2025, the physician order indicated violent 4-point restraints and seclusion ordered on 4/28/2025 at 11:00 a.m. During a concurrent interview and record review on 4/30/2025 at 4:37 p.m. with the Risk Management Coordinator (CQ 3), Patient 11’s “Restraint Face To Face (face-to-face assessment form, an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]),” dated 4/14/2025 and 4/28/2025, were reviewed. The face-to-face assessment forms indicated both face-to-face assessments were completed by BHU RN 3 and there was no documentation that RN 3 consulted the attending physician after completing the face-to-face assessment on both days. CQ 3 stated there was no communication with physician after face-to-face assessment was completed by RN 3. During an interview on 5/1/2025 at 11:05 a.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated the following: there should be provider notification by RN after performing face-to-face assessment. The RN should document which provider was notified along with date and time of notification. The provider could decide if restraints were needed or not, alternative considerations or give further orders as needed. During a concurrent interview and record review on 5/1/2025 at 11:27 a.m. with the Director of Behavioral Health Unit (DIR 5), Patient 11’s “Restraint Face To Face (face-to-face assessment form),” dated 4/14/2025 and 4/28/2025, were reviewed. The face-to-face assessment forms indicated the following: -“On 4/14/2025 at 5:56 p.m. completed by BHU Registered Nurse (RN 3): “Restraints Face to Face ... (C) The patient’s medical and behavioral condition: Patient’s (Patient 11’s) respirations are even and unlabored (normal, effortless breathing), no injury noted to patient (Patient 11). Patient (Patient 11) appears agitated (a feeling of irritability and severe restlessness) and fighting against the restraints;” and -“On 4/28/2025 at 11:27 a.m. completed by Registered Nurse (RN 3): “Restraints Face to Face ... (C) The patient’s medical and behavioral condition: Patient (Patient 11) is agitated, yelling, and fighting the restraints.” During the same interview on 5/1/2025 at 11:27 a.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated the following: both face-to-face assessments completed by RN 3 were incomplete. The expectation was for the RN to obtain a set of vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) when performing face-to-face assessment. There were no vital signs documented for both face-to-face assessments (on 4/14/2025 and 4/28/2025). Also, the face-to-face assessment on 4/28/2025 did not address Patient 11’s medical condition at all. A complete face-to-face assessment was to make sure Patient 11 was safe while being restrained and identify and address any abnormality. During a concurrent interview and record review on 05/02/2025 at 10:50 a.m. with the Business Manager of Education (M1), RN 3’s personnel records, specifically, RN 3’s training records titled, “Student and Group Transcript Report,” with date range from 05/1/2023 - 04/30/2025, was reviewed. The records indicated that RN 3 had no records of completing training on face-to-face assessment. This was confirmed by M1. M1 stated that RN 3 should have been trained and educated to perform face-to-face assessment every year. During an interview on 5/2/2025 at 3:19 p.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated all BHU RNs should be trained to perform face-to-face assessment upon hire and every year. During a review of the facility’s policy and procedures (P&P) titled, “Restraint and Seclusion Guidelines,” dated 7/2022, the P&P indicated, “A face-to-face evaluation shall occur within one (1) hour of each initiation of seclusion/restraint for violent/self-destructive reason ... and be documented in the medical record by the physician, RN, Physician Assistant (PA), or Nurse Practitioner (NP) that performed the evaluation. The purpose of the assessment if to evaluate: 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the seclusion or restraint. If a trained and competent RN (or NP or PA) conducts the face-to-face evaluation, the RN (or NP or PA) must consult with the attending physician who is responsible for the patient’s care after completing the face-to-face evaluation. This consultation must be documented in the medical record along with the order to use or continue restraint ... Staff Training Requirements: A. Staff must be trained and demonstrate competency prior to application of restraints, and the implementation of, monitoring, and providing care for the patient in restraint before performing any of these actions, as part of orientation, and subsequently on an annual basis by either skills demonstration and/or electronic educational module ... B. In addition, the hospital must require appropriate staff to have education, training, and demonstrate knowledge based on the specific needs of the patient population in at least the following ... 6. Monitoring the physical and psychosocial well-being of the patient who is restrained or secluded, including but not limited to: i. respiratory and circulatory status ii. Skin integrity iii. Vital signs iv. Behavior observed.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 42937 Based on interview, and record review, the facility failed to ensure three of five sampled registered nurses (RN 2, RN 3 and RN 4) completed their advance directive training (training module that focuses on educating facility staff about patient rights and responsibilities, end-of-life care and decision-making) yearly, in accordance with the facility’s Annual Competency (ability to demonstrate mastery of specific skills and knowledge) Education requirements. This deficient practice had the potential for violations of patient rights, thus causing harm to patients, due to lack of staff training. This deficient practice may also result in the failure to honor patient’s wishes or neglecting to provide necessary information to allow patients to have informed decision-making. Findings: During a concurrent interview and record review on 05/02/2025 at 12 p.m. with the Business Manager of Education (M1), the personnel records, specifically, the training records titled, “Student and Group Transcript Report,” with date range from 05/1/2023 - 04/30/2025, for registered nurses (RN 2, RN 3, and RN 4), were reviewed. The record indicated that RN 2, RN 3 and RN 4, failed to complete yearly training on advance directive (training module that focuses on educating facility staff about patient rights and responsibilities, end-of-life care and decision-making) titled “SQ: Patient Rights, Advance Directive.” The records indicated that RN 2’s last completion of training was 06/24/2023, RN 3’s last completion date was 10/03/2023, and RN 4’s last completion date was 06/14/2023. During the same interview on 5/02/2025 at 12 p.m. with the Business Manager of Education (M1), M1 stated that the training for advance directive was mandatory for all direct patient care registered nurses and must be completed yearly. RN 2, RN 3 and RN 4 were current active employees and should have completed their training on advance directive yearly. This training was important because it helped staff understand the importance of advance directives, and how to ensure that patient wishes were respected and documented. During a review of personnel’s job description titled, “Registered Nurse,” with last revised date 01/14/2022, the record indicated that registered nurses were to complete all mandatory initial and annual training within assigned time frames per established guidelines. During a review of an education list titled, “Annual Competency Education,” undated, the record listed patient rights/advance directive as an annual regulatory education for staff.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 46333 Based on interviews and record review, the facility’s Quality Assurance and Performance Improvement Program (QAPI, a hospital-wide approach used to continuously assess, monitor, and improve processes that impact patient care outcomes) failed to ensure that an adverse event (an unexpected and undesirable medical incident) involving one of 30 sampled patients (Patient 21), related to malfunctioning medical equipment, specifically, a critical monitoring device (bed alarm) was analyzed to determine the cause of the event and that preventive actions were developed and implemented. QAPI failed to analyze the event, track contributing factors, or implement timely corrective actions. This is not in accordance with the hospital’s QAPI requirements or the facility’s “Medical Equipment Management Program” policy. This deficient practice compromised the facility’s ability to reduce medical errors, undermined the safety of patients, and increased the risk of repeated adverse events. Findings: During a review of Patient 21’s medical record (MR) document titled, “Internal Medicine Progress Note,” dated 5/20/2025, the progress note indicated, Patient 21 had past medical history of chronic (a condition that lasts for a long period) hypoxic respiratory failure (occurs when the lungs struggle to deliver sufficient oxygen to the blood, leading to low oxygen levels in the blood), on 2.5 L (liters, a unit of measurement) nasal cannula (a medical device used to deliver supplemental oxygen to a patient through their nostrils) at home, COPD (Chronic obstructive pulmonary, a disease that restrict breathing), hypertension (condition where the force of blood against the walls of the vessels is too high; the blood pressure [top number] of 130 mmHg or higher), who presented with shortness of breath (the feeling of not being able to get enough air into your lungs), cough, congestion (an abnormal or excessive accumulation of fluid, particularly blood or mucus, in a body part or organ), and wheezing (a high-pitched, whistling sound during breathing caused by airflow through narrowed or obstructed airways) for 2 days. During a review of Patient 21’s medical record (MR) document titled, “Nursing Note,” dated 5/20/2025 at 11:00 a.m., documented by Registered Nurse (RN) 5, the note indicated, “No injuries found upon assessment post (after) fall (a sudden change in body position in a downward direction, which may or may not result in a physical injury). Patient (Patient 21) did have blood present on the right forearm from IV (intravenous- through the vein) removal. Appears to be no injury to head, arms, hands, legs, feet, or body. Patient (Patient 21) assisted back into bed and cleaned up.” During a concurrent interview and record review on 5/2/2025 at 4:12 p.m. with the Quality Management Patient Safety (QM), the facility’s event report (a formal document used to record and document any deviation from standard care, including errors, near misses, or other events that could potentially cause harm to patients, staff, or visitors) regarding Patient 21’s fall, dated 5/20/2025, was reviewed. The report indicated the bed alarm was not working and that the nurse was counseled on the need to remove the non-working bed immediately. QM stated she (QM) could not confirm how long Patient 21 remained on the bed and the incident was not reported to the Quality Department. During an interview on 5/2/2025 at 4:16 p.m. with The Director of Medical Surgical and Telemetry (DIR) 6, DIR 6 stated verbal coaching was issued because staff failed to call the Transport Department to remove the bed immediately. DIR 6 stated staff were expected to call Transport, which will then retrieve the bed and place a work order for repair or replacement. DIR 6 confirmed that there was no practice in place to tag malfunctioning bed with signage, which could result in continued use of unsafe equipment and compromise patient safety. During a concurrent interview and record review on 5/2/2025 at 4:12 p.m. with the Quality Management Patient Safety (QM), the facility’s “Performance Improvement” minutes, dated from 4/17/2024 through 3/19/2025, was reviewed. The minutes did not indicate the incident involving a malfunctioning bed alarm occurring in May 2024. QM Confirmed the bed alarm was not working at the time of Patient 21’s fall and that no Root Cause Analysis (RCA, a structured method used to identify the underlying causes of adverse events) was conducted. The incident was also not reported to the Quality Department. During an Interview on 5/2/2025 at 6:05 p.m. with the Quality Management Patient Safety (QM), QM stated QAPI had no formal system in place at that time to track or audit bed alarm functionality. She (QM) further confirmed that the gap between the policy and actual practice on Medical Surgical and Telemetry (T3) was not identified until later audits (QM was unable provide dates). During an interview on 5/2/2025 at 6:20 p.m. with the Director of Medical Staff Services and Board (DMSS), DMSS stated that the incident was not reviewed by the Medical Quality or Executive Board Committees and acknowledged it should have triggered an RCA due to patient safety implications. During a review of the facility policy and procedure (P&P) titled, “Medical Equipment Management Program,” dated 10/10/2023, the P&P indicated: “ The Risk Manager and Designated Biomedical Department Head are responsible for monitoring and reporting incidents in which a medical device is suspected of being involved with any death or serious illness or injury ...Events should be documented through the Electronic Event Reporting process... to support any requirements for Root Cause Analysis and/or reporting... The results of the evaluation are utilized to... identify opportunities for improvement through the replacement of equipment, changes in management procedures... or healthcare worker training.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Management/Clinical Safety Policy and Procedure Manual: Patient Safety Plan,” dated 12/18/2024, the P&P indicated, “In order to reduce the likelihood of patient incidents and negative outcomes, (name of the facility) shall track the frequency and type of medical errors and compile them in order to learn from and prevent future negative occurrences. The Quality Assurance Performance Improvement (QAPI) Program will incorporate data including patient care data and other relevant data such as to identify opportunities for improvement and changes that will lead to improvement of the (QAPI) program ... a. Risk Occurrence reports with database compilation ... proactive risk assessment -An assessment that examines a process in detail including sequencing of events; accesses actual potential risk, failure, points of vulnerability; and through a logical process, priorities areas for improvement based on the actual or potential patient care impact (criticality). ...4. Data Analysis -Analysis of collected data will be undertaken to monitor and identify levels of performance, trends or patterns that vary significantly from expected outcomes and the need for possible change/ improvement in systems or processes. 5. Process Improvement -When undesirable outcomes are identified, the hospital shall involve the personnel, resources, disciplines, and department/services most directly involved with the process to reduce future risk.””

“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: 46238 Based on observation, interview, and record review, the facility failed to: 1. Ensure one of 30 sampled patient’s (Patient 3) enteral feeding set (the tubing and associated components used to deliver nutrition directly into the stomach through a feeding tube), was changed every 24 hours or once infused (not to exceed 24 hours), in accordance with the facility’s standard practice regarding changing the enteral feeding administration set. This deficient practice had the potential to compromise Patient 3’s safety by increasing the risk of infection, such as bacterial contamination due to improper or inconsistent changing of feeding sets, which may contribute to the increased risk of hospital-acquired infections (HAIs, infections that patients develop while receiving care in a healthcare facility, such as a hospital) and complications for Patient 3. 2. Ensure one of 30 sampled patient’s (Patient 6) two sterile water containers, were signed with the date and time after opening to ensure that the containers were not used beyond expiration date (the labeled date and time indicate when the container was opened, as sterile water may become contaminated with germs after opening). This deficient practice had the potential for Patient 6 to receive sterile water that could have been contaminated, which might lead to a compromised health status and complications such as hospital-acquired infections (HAI) for Patient 6. 3. Ensure Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurses (RNs), reassessed one of 30 sampled patients (Patient 11), after anti-psychotic (medication injected to a patient’s muscle to treat psychosis [severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality]) injections were given to Patient 11 on multiple occasions on 4/14/2025. This deficient practice resulted in Patient 11 not receiving proper assessment and monitoring to evaluate the effectiveness of the medications received and the potential need for further management. Findings: 1. During a review of Patient 3’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/24/2025, the H&P indicated that Patient 3 was admitted to the facility with diagnosis of severe sepsis (a stage of sepsis where an infection has caused a severe inflammation and damage to the body’s organs, potentially leading to multiple organ failure). The H&P also indicated that Patient 3 had history of G-tube (a feeding tube that is inserted surgically through the abdomen directly into the stomach). During an observation on 4/29/2025 at 12:08 p.m. with the Quality Management (QM), in Patient 3’s room, Patient 3 was observed resting in bed, connected to the enteral feeding device (a medical device that provides necessary nutrients directly into the stomach). The feeding set was connected to a tube feeding bottle or container [Brand] formula attached to the set (Kangaroo pump- a portable infusion device used to administer fluids, medications, or nutrition through enteral lines) had a label showing the date of 4/26/2025, the start time of 6:30 p.m., and a flow rate of 20 milliliters (ml, measuring unit) [to be infused in 1 hour]. The QM verified that the label observed was dated 4/26/2025. During a concurrent interview on 4/29/2025 at 12:17 p.m. with registered nurse (RN 9), RN 9 stated that the night shift nurse hung the feeding for Patient 3. RN 9 also said that the feeding administration set (components such as the tubing and connectors) must be changed every 24 hours or after the entire container had been infused, whichever occurred first. RN 9 explained that enteral feeding cannot go over 24 hours due to a risk of infection for the patient [Patient 3] (prolonged use of the same feeding set increases the likelihood of bacterial growth or contamination, which can lead to infections such pneumonia [PNA, an infection that inflames the air sacs in one or both lungs] or gastrointestinal infections [infections of the stomach and intestines caused by bacteria, viruses, or parasites]). During a concurrent interview and record review on 5/1/2025 at 2:00 p.m. with the Quality Coordinator (QC 1), the QC 1 verified that Patient 3 had no documentation of how and when the enteral tubing was changed from 4/26/2025 through 4/29/2025. During an interview on 5/2/2025 at 11:24 a.m. with the clinical educator (CE 2), CE 2 stated that the current practice at the facility included changing the enteral tubing administration set every 24 hours or when the feeding container had been fully infused. CE 2 said, “The entire administration set should be replaced to prevent cross-contamination (the transfer of bacteria (germs) between products or patient sites) and to reduce the risk of infection. The date and time should be documented on the label attached to the feeding container when it is opened. The feeding container has labels where patient’s name, date, and time and flow rate and the schedule for water flushes can be documented.” During an interview on 5/2/2025 at 11:15 a.m. with the quality management (QM), QM stated that the facility did not have a written policy or protocol addressing the recommended frequency for changing the enteral feeding administration set. QM presented the current enteral feeding policy, which contained no information regarding the recommended schedule or guidelines for changing enteral feeding administration set. QM also provided the educational material titled, “Feeding Tube-Education,” [no date], which the facility used during new hire orientation to rate the employees on performance of the insertion, assessment, and maintenance of adult feeding tubes, which similarly lacked any information about the facility’s expected practices regarding administration set changes for tube feedings. QM stated that since this was a nursing practice related issue, nursing leadership was ultimately responsible for ensuring that the facility had relevant policies and or protocols in place to guide staff on this matter. During a review of the facility’s policy and procedure (P&P) titled, “Documentation,” dated 8/2024, the P&P indicated that: “All documentation shall contain accurate, truthful and pertinent documentation ... All measures performed by nursing relating to care and the patient’s response to such measures shall be documented.” During a review of published guidelines from Professional organizations like the American Society for Parenteral (administration of nutrients through routes other than gastrointestinal tract, such as through a vein, or muscle) and Enteral Nutrition (ASPEN) titled, “ Guidelines for the Use of Enteral Nutrition in Adult Patients,” dated 2020, the document provided evidence-based nutrition practice guidelines which recommended changing the entire feeding set every 24 hours unless otherwise specified by institutional policies or patient-specific needs to minimize infection risk. 2. During a review of Patient 6’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 3/26/2025, the H&P indicated that Patient 6 was found unresponsive (unable to react or respond to external stimuli like touch, sound, or visual cues, or to express themselves) next to a scooter; was intubated (a tube, typically an endotracheal tube, has been inserted into a patient’s trachea [windpipe] to assist with breathing) in the field and brought to the facility as a trauma patient (someone who has suffered a traumatic injury). During a concurrent observation and interview on 4/29/2025 at 11:56 a.m. with the Quality Management (QM) and the Registered Nurse (RN 8), in Patient 6’s room, four sterile water bottles were observed standing on the bedside table near Patient 6’s bed. Two sterile water containers were still sealed, while the other two had been opened, and sterile water had been used from them. The open containers still contained about half their volume left in them, but there was no date and time marked on them when they were opened. RN 8 stated that sterile water for Patient 6 was used when medications were given through the G-Tube (surgically inserted feeding tube used to deliver nutritionist and medications directly into the stomach, bypassing the mouth). RN 8 also said that the sterile water containers must be signed with a date and time after opening because the solution must be used within 24 hours after opening, to minimize the risk of contamination (growth of harmful germs). During an interview on 5/2/2025 at 11:25 a.m. with the Quality Management (QM), QM stated that the facility did not have a policy or protocol in place regarding the handling and use of sterile water containers once they have been opened. QM also said that nursing practices and protocols within the facility fell under the oversight of nursing leadership, and they were ultimately responsible for ensuring that policies, procedures, and protocols related to nursing practices were in place and followed by nurses’ hospital-wide to ensure consistent and safe implementation of care. 3. During a review of Patient 11’s “Behavioral Health (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders)Inpatient Provider Admission Note (psych H&P, a formal and complete assessment of the patient and the problem completed by a psychiatrist [physician specializes in mental health]),” dated 4/13/2025, the psych H&P indicated, Patient 11 was admitted to the facility’s Behavioral Health Unit on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) with diagnoses including but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and cannabis use disorder (a complex condition that involves problematic pattern of cannabis [marijuana] use). During a review of Patient 11’s “Progress notes (nursing narrative notes),” dated 4/14/2025, the progress notes indicated, “At 8:30 a.m., Patient 11 was pacing in the hallway frequently and dismissing staff instruction, Patient 11 also threatening and posturing towards staff ... MD 8 was notified and new orders received. Patient 11 tolerated injections and continued to pace ... At 11:30 a.m. Patient 11 came out of the shower ... upon exiting the shower room, Patient 11 grabbed staff on the buttocks ... MD 8 was notified and new orders received. Patient 11 tolerated injection.” During a review of Patient 11’s “Behavioral Health Forms,” dated 4/14/2025, the Behavioral Health forms indicated, at 5:11 p.m., Patient 11 attempted to forcefully snatch a staff’s badge to exit the unit and lunged at staff member aggressively. The Behavioral Health forms also indicated Patient 11 was placed in seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) and restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) for Patient 11’s safety and safety of others. During a review of Patient 11’s physician order, dated 4/14/2025, the physician order indicated violent 4-point (both wrists and both ankles) restraints and seclusion was ordered on 4/14/2025 at 5:18 p.m. During a concurrent interview and record review on 5/1/2025 at 10:08 a.m. with the Risk Management Coordinator (CQ 3), Patient 11’s “Medication Administration Record (MAR, record of medications given to patients),” dated 4/14/2025, was reviewed. The MAR indicated Patient 11 received the following medications on 4/14/2025: -At 8:40 a.m.: Zyprexa (medication injectable for rapid control of agitation [feeling of severe restlessness, and excessive motor activity such as pacing, rocking, gesturing] and disturbed behavior) 10 milligrams (mg, unit of measure) intramuscular (IM, delivering medication directly into the muscle tissue) injection one time and Benadryl (medication helps to calm agitation and anxiety in psychotic [severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality] patient) 50 mg IM one time; -At 11:56 a.m.: Thorazine (medication injectable to treat psychotic disorder) 50 mg IM one time; and -At 5:34 p.m.: Thorazine 50 mg IM on time and Benadryl 50 mg IM one time. During the same interview on 5/1/2025 at 10:08 a.m. with the Risk Management Coordinator (CQ 3), CQ 3 stated these (referring to the Thorazine, Zyprexa and Benadryl medications) were one-time order anti-psychotic injections given to manage Patient 11’s agitated behavior. During an interview on 5/1/2025 at 11:35 a.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated the following: BHU RN should re-assess patients after any one-time order anti-psychotic injection was given. It should be done within thirty (30) minutes to an hour after the administration of the injection to check the patient’s response and to evaluate the effectiveness of the medications then determine if patient would require additional interventions. DIR 5 also stated there was no re-assessment done after the anti-psychotic injections were given at 11:56 a.m. and at 5:34 p.m. During an interview on 5/2/2025 at 3:12 p.m. with DIR 5, DIR 5 stated the following: the one-time order anti-psychotic injections were given when a patient was actively a danger to self or others. The purpose of these injections was to manage the patient’s behavior. The BHU RN should perform a reassessment to evaluate patient’s behavior and response to treatment. Currently, the re-assessment was done per nurses’ discretion because there was no policy and procedures to speak the process. DIR also stated they were trying to develop some standardized process for the BHU RNs to follow. During an interview on 5/2/2025 at 4:24 p.m. with the Clinical Pharmacy Coordinator (CPC), CPC stated the following: nursing staff should perform a reassessment within thirty (30) minutes to an hour after any anti-psychotic injections were given to BHU patients. The reassessment would include evaluating the patient’s response to the medication so the patient could be safely managed and cared for. During a review of the facility’s policy and procedures (P&P) titled, “Assessments,” dated 6/2023, the P&P indicated, “Purpose: to determine patient’s care through assessment of each patient’s needs; and to provide guidelines for patient assessment activities ... Ongoing assessments will be performed as the need arises to determine the patient’s response to treatment ... Any significant change in a patient’s condition or diagnosis will warrant ongoing assessment by a Registered Nurse ... Re-assessment shall be documented in the patient’s medical record.””

“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: 46238 Based on interview and record review, the facility failed to formulate an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 30 sampled patients (Patient 3), to address Patient 3’s high risk for aspiration (refers to the inhaling of food, liquid, or secretions into the lungs instead of the esophagus [a muscular tube that conveys food from the mouth to the stomach]), in accordance with the facility’s policy regarding care plans. This deficient practice had the potential for the lack implementation of aspiration precautions (aim to prevent food or liquid from entering the lungs while a person is receiving nutrients through a feeding tube) for Patient 3, which could result in aspiration and possible injury or harm such as aspiration pneumonia (a lung infection caused by inhaling food, or stomach contents into the lungs), which can lead to serious respiratory complications, prolonged hospitalization, and even death. Findings: During a review of Patient 3’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/24/2025, the H&P indicated that Patient 3 was admitted to the facility with diagnosis of severe sepsis (a stage of sepsis where an infection has caused a severe inflammation and damage to the body’s organs, potentially leading to multiple organ failure). The H&P also indicated that Patient 3 had history of G-tube (a feeding tube that is inserted surgically through the abdomen directly into the stomach). During a review of Patient 3’s medical record (MR) titled, “Order Sheet,” dated 4/26/2025, the MR indicated that Patient 3 had an order for continuous administration of enteral feeding (the delivery of nutrition directly into the gastrointestinal (GI) tract using a tube, instead of through normal oral consumption). During a concurrent interview and record review on 5/1/2025 at 2:07 p.m. with the Quality Coordinator (QC 1), Patient 3’s “Care Plans,” dated 5/1/2025, and initiated on 4/26/2025, the Care Plans indicated that there was no initiated care plan to address aspiration risk for Patient 3 related to enteral feeding (the delivery of nutrition directly into the gastrointestinal (GI) tract using a tube, instead of through normal oral consumption). The QC 1 verified, that Patient 3 had no developed care plan for “Risk for Aspiration,” and stated would need to refer to policy regarding this care plan. During an interview on 5/2/2025 at 11:24 a.m. with the Clinical Educator (CE 2), the CE 2 stated that: “Some care plans that can be initiated for patients with G-tubes include “nutritional” care plans and “at risk for aspiration” care plans (that address the potential for stomach contents to enter the lungs), as all patients with G-Tubes have a risk of aspiration.” During further interview on 5/2/2024 at 12:06 p.m. with the Clinical Educator (CE 2), the CE 2 stated that nurses need to develop care plans because care plans serve as structured, individualized guides to delivering patients’ care based on identified patients’ needs. The CE 2 then also said that care plans establish specific goals for the patient to achieve, which were aligned with desired outcomes, such as improved health status, symptoms management, or safety. During a review of the facility’s policy and procedure (P&P) titled, “Adult Feeding Tubes,” dated 3/2022, the P&P indicated that: “Patients with feeding tubes shall be assessed, monitored for risk of aspiration ...Aspiration precautions must be documented .... Care Plan must be developed, as appropriate ...” During a review of the facility’s policy and procedure (P&P) titled, “Patient Care Planning,” dated 4/2024, the P&P indicated the following: “In order to provide care, treatment and rehabilitation to each patient effectively and efficiently, a multidisciplinary plan of care will be initiated for every patient ... The Care Plan is documentation of the plan for the patient’s care, treatment, and services based on needs identified by the admission assessment, reassessment and results of diagnostic testing. It shall be reviewed every 24 hours and updated as needed to ensure an appropriate plan of care individualized to each patient and their unique needs. The plan should be maintained and revised based on the patient’s response ... The Care Plan will be started by the Registered Nurse (RN) responsible for the admission of the patient ... Staff shall evaluate the patient’s progress, based on the goals established in the Care Plan. The Care Plan problems, goals, and actions shall be modified or closed, as clinically appropriate based on reassessment; patient’s need for further care, treatment, and services; or the patient’s achievement of goals and shall be closed at time of discharge.” During a review of the facility’s policy and procedure (P&P) titled, “Documentation,” dated 8/2024, the P&P indicated that: “An admission assessment will be initiated as soon as possible after admission and must be completed within 24 hours of admission. For electronic documentation, Interdisciplinary Plans of Care (IPOC) shall be initiated to include goals & interventions.””

“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: 46333 Based on interview and record review, the facility failed to: 1. Ensure one of 30 sampled patient’s (Patient 3) total intake (refers to the amount of feeding formula consumed by a patient) of feeding formula per 24 hours, was documented, in accordance with the facility’s policy and procedure regarding enteral feeding (a method of providing nutrition directly into the gastrointestinal (GI) tract through a tube) administration documentation. This deficient practice had the potential to compromise Patient 3’s nutritional status and care, by preventing accurate assessment of nutritional and fluid status needs of Patient 3, increasing Patient 3’s risk for dehydration (a condition that occurs when your body loses more fluids than it takes in, resulting in a shortage of water and other necessary fluids), undernutrition (a condition where the body does not receive enough nutrients to meet its needs, often due to insufficient food intake or poor absorption of nutrients), overhydration (the body takes in more water than it loses), and other complications. 2. Ensure one of 30 sampled patients (Patient 21) received a complete neurological assessment (an exam that evaluates brain and nervous system function through test of mental status, reflexes [automatic body response], movements, and speech) following a fall (an unplanned change in position where a patient lands on the floor or a lower surface), in accordance with the facility’s policy and procedures titled, “Fall Prevention and Reduction.” This deficient practice had the potential to delay recognition of serious medical problems such as a head injury or stroke (occurs when blood flow to the brain is interrupted). Signs and symptoms such as brain swelling, bleeding, or damage might not be noticed in time. 3. Ensure staff removed from service a hospital bed with a malfunctioning alarm for one of 30 sampled patients (Patient 21), in accordance with the facility’s policy and procedure titled, “Medical Equipment Management Program.” Specifically, the bed alarm was found to be non-functional, and staff failed to ensure the bed was taken out of commission, resulting in uncertainty whether the same bed continued to be used for patient care. This deficient practice increased the potential for failure to prevent or respond to patient bed exit in a timely manner, placing patients at increased risk of injury due to falls. Findings: 1. During a review of Patient 3’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/24/2025, the H&P indicated that Patient 3 was admitted to the facility with diagnosis of severe sepsis (a stage of sepsis where an infection has caused a severe inflammation and damage to the body’s organs, potentially leading to multiple organ failure). The H&P also indicated that Patient 3 had history of G-tube (a feeding tube that is inserted surgically through the abdomen directly into the stomach). During a concurrent interview and record review on 4/29/2025 at 12:12 p.m. with registered nurse (RN 9), Patient 3’s record of total enteral feeding intake, was reviewed. RN 9 stated that Patient 3 had a G-tube (gastrostomy tube, a surgically placed feeding tube directly into the stomach) and was on continuous enteral (feeding administered into the gastrointestinal tract ( GI Tract, a series of organs that process food from ingestion to excretion), typically through a feeding tube)], that was infused at 50 milliliters (ml, a unit of volume measurement) per hour through the G-Tube. RN 9 said that documentation of total enteral feeding intake (refer to the sum of all) per shift was not required and typically not documented, unless there was a specific order to do so. RN 9 then checked the documentation in Patient 3’s chart and confirmed that no total intake for enteral feeding had been documented for Patient 3 in the past 24 hours. During a review of Patient 3’s medical record (MR) titled, “Order Sheet,” dated 4/26/2025, the MR indicated that Patient 3 had an order for continuous administration of enteral feeding. During a concurrent interview and record review on 5/1/2025, at 2:07 p.m. with the Quality Coordinator (QC 1), Patient 3’s record titled, “GI-Tube,” dated 4/26/2025 through 4/28/2025, was reviewed. The record indicated the following: (documentation of total intake [the overall amount of] of enteral feeding): -On 4/26/2025 from 7:00 a.m. to 7 p.m. -Total intake of tube feeding was not documented. -On 4/26/2025 from 7:00 p.m. through 4/27/2025 at 7:00 a.m.-Total intake of tube feeding infused was not documented. -On 4/27/2025 from 7:00 p.m. through 4/28/2025 at 7 a.m.-Total Intake of tube feeding was not documented. During the same interview on 5/1/2025 at 2:07 p.m. with the Quality Coordinator (QC 1), QC 1 confirmed that Patient 3’s record titled, “GI-Tube,” (dated 4-26/2025 through 4/28/2025) contained only the documented total infused enteral feeding intake on 4/27/2025 (7 a.m. to 7 p.m.), totaling 500 ml for that shift. During an interview on 5/2/2025 at 10:51 a.m. with the clinical educator (CE 2), the CE 2 stated the following: “ ... The amount of enteral feeding infused, should be documented by the nurses, regardless of if there is a physician’s order or not. We want to know if the patient is tolerating the feeding well and to monitor the nutritional status (encompasses the balance between nutrient intake and the body’s needs for optimal health, growth, and function).” During a review of the facility’s policy and procedure (P&P) titled, “Adult Feeding Tubes,” dated 3/2022, the P&P indicated that: “The policy is developed to ensure that patients with feeding tubes shall be assessed, monitored, and maintenance provided. D. Documentation for patients with Enteral Nutrition: 5. Intake and Output (I&O, “intake” refers to the fluids a patient consumes, while “output” refers to the fluids a patient eliminates from the body), including rate and volume of feeding, number of flushes (free water), discarded residuals (refers to the amount of fluid that remains in the stomach after a feeding, must be documented for patients with enteral nutrition, fluid is aspirated from the stomach via the feeding tube to monitor gastric emptying and assess a patient’s tolerance to enteral nutrition ).” During a review of the facility’s policy and procedure (P&P) titled, “Intake and Output (I&O, “intake” refers to the fluids a patient consumes, while “output” refers to the fluids a patient eliminates from the body),” dated 8/2021, the P&P indicated that: “II. When indicated for the patient based upon condition or orders: A. l&O should be routinely recorded every 12 hours with a 24-hour total computed, or more frequently as patient’s status dictates. IV. It is the Registered Nurse’s responsibility to be aware of a positive or negative fluid balance and ensure that l&Os ...are documented when ordered or as appropriate for patient’s condition. Any medically significant positive or negative fluid balances shall be reported to the physician.” 2. During a review of Patient 21’s medical record (MR) document titled, “Internal Medicine Progress Note,” dated 5/20/2025, the progress note indicated, Patient 21 had past medical history of chronic (a condition that lasts for a long period) hypoxic respiratory failure (occurs when the lungs struggle to deliver sufficient oxygen to the blood, leading to low oxygen levels in the blood), on 2.5 L (liters, a unit of measurement) nasal cannula (a medical device used to deliver supplemental oxygen to a patient through their nostrils) at home, COPD (Chronic obstructive pulmonary, a disease that restrict breathing), hypertension (condition where the force of blood against the walls of the vessels is too high; the blood pressure [top number] of 130 mmHg or higher), who presented with shortness of breath (the feeling of not being able to get enough air into your lungs), cough, congestion (an abnormal or excessive accumulation of fluid, particularly blood or mucus, in a body part or organ), and wheezing (a high-pitched, whistling sound during breathing caused by airflow through narrowed or obstructed airways) for 2 days. During a review of Patient 21’s MR document titled, “Nursing Note,” dated 5/20/2025 at 11:00 a.m., documented by Registered Nurse (RN) 5, the note indicated, “No injuries found upon assessment post (after) fall (an unplanned change in position where a patient lands on the floor or a lower surface). Patient did have blood present on the right forearm from IV (intravenous-into the vein) removal. Appears to be no injury to head, arms, hands, legs, feet, or body. Patient assisted back into bed and cleaned up.” During a review of Patient 21’s MR document titled, “Provider Notification,” dated 5/20/2024 at 12:29 p.m., the Provider Notification indicated, “Small bleeding from left side of patient’s (Patient 21) head post fall, no cut noted when examined and cleaned but blood noted on the pillow and gauze.” The document further indicated, “Provider requested intervention: MD said place order for CT (computed tomography, a medical imaging technique that uses X-rays to create detailed cross-sectional images of the body) brain.” During a concurrent interview and record review on 4/30/2025 at 2:00 p.m. with the Sepsis and Quality Coordinator (CQ) 2, Patient 22’s MR document titled, “Neurological” assessment dated from 5/20/2024 through 5/21/2025, was reviewed. The assessment indicated the following: -On 5/20/2024 at 8:38 a.m., Patient 21 was oriented to person (being aware of who you are interacting with, including recognizing and remembering people and understanding their roles and relationships), and oriented to place (having a mental awareness of one’s current location within a known environment, including the ability to understand the spatial relationships between objects and one’s surroundings). -On 5/20/2025 at 11:00 a.m. (following the fall) Patient 21 was oriented to person, and place. -On 5/20/2025 at 2:45 p.m. (3 hours and 45 minutes later after the fall) Patient 21 was disoriented x 4 (a person is confused and unable to accurately identify four aspects of their surroundings: who they are [person], where they are [place], what time it is [time], and what is happening around them [situation]). CQ 2 stated after a fall, the patient neurologic assessment must follow the facility’s protocol, and more frequent assessment should be done if there was a change in neurological (the nervous system, including the brain, spinal cord [a long, tubular structure made of nerve tissue that extends from the brainstem down the center of the back to the tail bone], and nerves throughout the body) status. During an interview on 5/2/2025 at 10:52 a.m. with the Director of Telemetry 3 (DIR) 6, DIR 6 stated the process staff should follow after a patient fall was to notify the physician, Supervisor, and the patient’s family, document the fall, and assess the patient including completing a neurological assessment. DIR 6 confirmed that following a fall, neurological assessment should be completed every two hours 2 times and following every 4 hours for 24 hours. However, if there were signs in mentation decline (gradual loss of thinking abilities), then the nurse should complete neurological assessments more frequently such as every hour. During a review of the facility’s policy and procedure (P&P) titled, “Fall Prevention and Reduction,” dated 10/12/2020, the P&P indicated, “In the event of a patient fall, staff shall take the following actions ...Immediately perform and document a complete head-to-toe assessment including neuro check, vital signs, and assessment for possible injuries ...Attachment E: Record neuro observations if head involved (every 2 hours X2 and every 4 hours X 24 hours).” During a review of the facility’s policy and procedure (P&P) titled, “Initial Patient Assessment and Reassessment,” dated 3/28/2024, the P&P indicated, “Any change in the patient’s condition shall require an immediate reassessment with changes in the plan of care and SBAR (Situation, Background, Assessment, and Recommendation- a structured communication tool used in healthcare to facilitate quick and efficient information exchange, particularly between healthcare professionals) tool reflecting the change in condition.” 3. During a review of Patient 21’s medical record (MR) document titled, “Internal Medicine Progress Note,” dated 5/20/2025, the progress note indicated, Patient 21 had past medical history of chronic (a condition that lasts for a long period) hypoxic respiratory failure (occurs when the lungs struggle to deliver sufficient oxygen to the blood, leading to low oxygen levels in the blood), on 2.5 L (liters, a unit of measurement) nasal cannula (a medical device used to deliver supplemental oxygen to a patient through their nostrils) at home, COPD (Chronic obstructive pulmonary, a disease that restrict breathing), hypertension (condition where the force of blood against the walls of the vessels is too high; the blood pressure [top number] of 130 mmHg or higher), who presented with shortness of breath (the feeling of not being able to get enough air into your lungs), cough, congestion (an abnormal or excessive accumulation of fluid, particularly blood or mucus, in a body part or organ), and wheezing (a high-pitched, whistling sound during breathing caused by airflow through narrowed or obstructed airways) for 2 days. During a review of Patient 21’s medical record (MR) document titled, “Nursing Note,” dated 5/20/2025 at 11:00 a.m., documented by Registered Nurse (RN) 5, the note indicated, “No injuries found upon assessment post fall. Patient (Patient 21) did have blood present on the right forearm from IV removal. Appears to be no injury to head, arms, hands, legs, feet, or body. Patient (Patient 21) assisted back into bed and cleaned up.” During a review of Patient 21’s MR document titled “Provider Notification,” dated 5/20/2024 at 12:29 p.m., the Provider Notification indicated, “Small bleeding from left side of patient’s (Patient 21) head post fall, no cut noted when examined and cleaned but blood noted on the pillow and gauze.” The document further indicated, “Provider requested intervention: MD said place order for CT (computed tomography, a medical imaging technique that uses X-rays to create detailed cross-sectional images of the body) brain.” During a concurrent interview and record review on 5/2/2025 at 4:12 p.m. with the Quality Management Patient Safety (QM) the facility’s event report (a formal document used to record and document any deviation from standard care, including errors, near misses, or other events that could potentially cause harm to patients, staff, or visitors) regarding Patient 21’s fall, dated 5/20/2025, was reviewed. The report indicated the bed alarm was not working and that the nurse was counseled on the need to remove the non-working bed immediately. QM stated she (QM) could not confirm how long Patient 21 remained on the bed (with the bed alarm not working), and the incident was not reported to the Quality Department. During an interview on 5/2/2025 at 4:16 p.m. with the Director of Medical Surgical and Telemetry (DIR) 6, DIR 6 stated verbal coaching was issued because staff failed to call the Transport Department to remove the bed immediately. DIR 6 stated staff were expected to call Transport, which will then retrieve the bed, and place a work order for repair or replacement. DIR 6 confirmed that there was no practice in place to tag malfunctioning bed with signage, which could result in continued use of unsafe equipment and compromise patient safety. During a concurrent interview and record review with the Manager of Transportation Department (MT)1 on 5/2/2025 at 4:32 p.m., the facility’s work orders placed in May 2024, were reviewed. The documents titled, “Corrective Work Order” and “Work Requested details” indicated that no work order had been placed for a bed alarm malfunction on the Medical Surgical and Telemetry unit (Tower 3-T3) or Documentation of order placed for T3 unit regarding a bed alarm malfunction or the status of a bed with malfunctioning alarm. MT 1 confirmed that, due to lack of detail or documentation, the facility could not determine the status of the bed with the malfunctioning alarm. MT 1 added that the staff member who discovered broken equipment was responsible for initiating the work order. During a review of the facility’s policy and procedure (P&P) titled, “Medical Equipment Management Program,” dated 10/10/2023, the P&P indicated, “High-Risk Equipment (Life Support & Critical Equipment) - equipment this is critical to patient health and safety. At a minimum such critical equipment includes, but is not limited to, life-support devices, key resuscitation devices, critical monitoring devices, and other devices whose failure may result in serious injury to or death of patients or associates ... B. The healthcare worker who identifies that a medical device is in need of repair shall 1. Dial the Biomedical extension 4444 (option 2) 2. The Biomedical extension is automatically forwarded to the Engineering Department after hours where an Engineer will assess the request. C. The healthcare worker making the service call shall complete the Defective Equipment (Do Not Use) sticker, ...documenting the time of the service call and attach it to the defective device ... If a piece of equipment is directly involved, or is thought to have been directly involved, the equipment must be removed from service and quarantined with as little disturbance as possible to the settings and other evidence that might aid the investigation.””

“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: 46333 Based on interview and record review, the facility failed to ensure that one of 30 sampled patients (Patient 22), received prescribed pain medication, in accordance with the physician’s orders and the facility’s policy and procedure titled “Administration of Medications.” This deficient practice resulted in Patient 22 experiencing unrelieved pain, which had the potential to limit the patient’s ability to walk and begin physical therapy (treatment to help restore movement and strength). Findings: During a review of Patient 22’s “Emergency Documentation: ED Note Physician,” dated 3/9/2025, the note indicated Patient 22 had a history of congestive heart failure (CHF, a condition where the heart cannot pump blood effectively enough to meet the body’s need), Crohn’s disease (CD, a chronic inflammatory bowel disease that affects the digestive tract), and diabetes (a condition where your body can’t regulate the amount of sugar in your blood). The patient (Patient 22) was admitted with ongoing generalized weakness (reduced muscle strength) and fatigue (lack of energy). The patient (Patient 22) reported being unable to care for himself and requested placement in a care facility. He (Patient 22) had recently suffered a femur (thigh bone) fracture and had not started physical therapy (treatment to help restore movement and strength). During a concurrent interview and record review on 4/30/2025 at 2:00 p.m. with the Sepsis and Quality Coordinator (CQ) 2, Patient 22’s medical record (MR) document titled, “Order Summary,” dated 3/9/2025 through 3/11/2025, was reviewed. The order summary indicated the following: -Acetaminophen-Hydrocodone (prescribed pain medication used to relieve moderate to severe pain) 325 mg (milligrams, a unit of measurement)-5 mg, 2 tablets every 6 hours, PRN (as needed) for pain, for 10 days. During a concurrent interview and record review with CQ 2 on 4/30/2025 at 2:15 p.m., Patient 22’s “Medication Administration Record (MAR, a patient’s record that tracks the medications prescribed and administered to them),” from 3/9/2025 through 3/11/2025, was reviewed. The MAR indicated: -3/9/2025 at 9:41 p.m. - Acetaminophen-Hydrocodone 2 tablets given -3/10/2025 at 7:33 a.m. - Acetaminophen-Hydrocodone 2 tablets (10 hours, 32 minutes after prior dose) -3/10/2025 at 3:06 p.m. - Acetaminophen-Hydrocodone 2 tablets (7 hours, 33 minutes later) - 3/11/2025 at 12:39 a.m. - Acetaminophen-Hydrocodone 2 tablets (9 hours, 33 minutes later) -3/11/2025 at 7:45 a.m. - Acetaminophen-Hydrocodone 2 tablets (7 hours, 6 minutes later) - 3/11/2025 at 5:18 p.m. - Acetaminophen-Hydrocodone 2 tablets (9 hours, 33 minutes later) During the same interview on 4/30/2025 at 2:15 p.m. with the Sepsis and Quality Coordinator (CQ) 2, CQ2 confirmed the medication (Acetaminophen-Hydrocodone), was not administered within the prescribed 6-hour interval and stated nurses should have notified the physician if pain was not relieved. During a concurrent interview and record review with CQ 2 on 4/30/2025 at 2:20 p.m., Patient 22’s “Vital Flowsheet (a structured chart within a patient’s record used to track observations, trends, and data over time),” dated 3/9/2025 through 3/11/2025, was reviewed. The flowsheet indicated the following: -3/9/2025 at 5:31 p.m. - Pain rated 7/10 in the knee; no pain medication administered or reassessment until 9:40 p.m. (4 hours later) -3/10/2025 at 6:30 a.m. - Pain rated 7/10; medication given an hour later -3/10/2025 at 8:08 p.m. - Pain continued to be rated at 7/10 -3/10/2025 at 9:50 a.m. - Pain increased to 10/10; medication not given until 3:06 p.m. (over 5 hours later) -3/11/2025 at 7:35 a.m. - Pain rated 10/10; medication given at 7:45 a.m. -3/11/2025 at 7:44 a.m. - Pain continued to be rated 10/10 -3/11/2025 at 8:15 a.m. - Pain rated 7-8/10 -3/11/2025 at 5:15 p.m. - Pain rated 8/10 During the same interview on 4/30/2025 at 2:20 p.m. with CQ 2, CQ 2 confirmed that Patient 22’s tolerable pain goal was below 3. CQ 2 stated if pain continued more than 9 hours after medication was given, the physician should be notified. This was not done in the case of Patient 22. During a concurrent interview and record review on 4/30/2025 at 2:40 p.m. with the Sepsis and Quality Coordinator (CQ) 2, Patient 22’s medical record document titled, “Communication Flowsheet,” dated from 3/9/2025 through 3/11/2025, was reviewed. The flowsheet indicated there was no documentation that staff notified the physician about Patient 22’s ongoing pain. CQ2 stated that the nurse should have informed the physician when the pain persisted. During a review of the facility’s policy and procedure (P&P) titled, “Administration of Medication,” dated 7/8/2024, the P&P indicated: “Electronic medication records are reviewed at the beginning of each shift for order, dose, and timing...PRN medications... shall be administered within 30 minutes from the time assessment confirms the need ...Medications must be administered in a timely manner so as not to compromise safety or effectiveness.” During a review of the facility’s policy and procedure (P&P) titled, “Pain Assessment and Management,” dated 6/28/2022, the P&P indicated, “Appropriate use of analgesic medications shall be encouraged ... Interventions shall be made to relieve pain when reported with evidence¿-based multi modal treatment modalities; these may be selected as indicated by physician order and patient preference ... Pain medication administration should be preceded by assessment of pain, patient rating of pain. The nurse shall consider subjective and objective factors prior to administration ... Reassessment of pain shall take place within a clinically appropriate time frame based upon the intervention used ... The registered nurse (RN) shall communicate with the physician to coordinate an alternative treatment plan when pain is above the identified comfort goal ...””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that for one patient of 30 sampled patients (Patient 1), the emergency department (ED, a hospital department that provides immediate medical care to patients experiencing sudden, serious health problems) visit medical record (MR) contained accurately completed documentation of suicidal (SI, plans or intentions to harm self) and homicidal (HI, thoughts or plans to harm others) ideation assessments (an evaluation conducted by healthcare professionals to determine the patient’s risk to harm self or others, involving questions about thoughts, behaviors, and intent) in triage (the process of quickly assessing and prioritizing patients based on the severity of their condition to determine who needs immediate care), in accordance with the facility’s policy and procedure regarding SI/HI screening when Patient 1 was documented to have arrived at the facility after a possible overdose on medication -Baclofen (a muscle relaxant medications used to treat muscle spasms). This deficient practice had the potential for Patient 1 not to be correctly assessed for risk of harm to self or others, which could lead to inadequate safety measures, failure to implement appropriate interventions, increased risk of self-harm or harm to others, and potentially serious adverse outcomes such as death. Findings: During a review of Patient 1’s medical record (MR) titled, “Emergency Documentation-Physician Note,” dated 2/23/2025, the MR indicated the following was documented in Patient 1’s emergency visit medical record on 2/23/2025: “Patient [Patient 1] found ALOC (Altered Level of Consciousness, refers to a state where a person’s level of awareness and responsiveness is significantly reduced, ranging from mild confusion or drowsiness to a state of coma [a state of prolonged unconsciousness where a person is unresponsive to their surroundings and environment]) in hotel room by family ...was combative, and now lethargic (a state of drowsiness, sluggishness, and a lack of energy or alertness) per EMS (Emergency Medical Services) report ...potential Baclofen (medication used to treat pain and certain types of muscle spasticity) overdose (to take an overdose = a dangerously large amount) of a drug.” During a review of Patient 1’s Medical Record titled, “Emergency Documentation-Physician Note,” dated 2/23/2025 [time seen 11:44 a.m.], the record indicated that Patient 1 was not able to provide past medical history (PMH, a record of a patient’s previous illnesses, surgeries, medications, and other health-related events) and/or to participate in medical exam, “at the time of initial assessment, patient (Patient 1) is only arousable to painful stimuli (a painful stimulus is used to elicit a response, such as movement, vocalization, or other signs of awareness, when a person is not responding to normal interactions). The MR further indicated that Patient 1 was described (by family) to be found with a “pile of prescription drugs,” and had markings on abdomen that were “related to being in a hot tub.” During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1’s “Triage(refers to the detailed record of an initial, rapid assessment of a patient’s condition and the prioritization of care needed based on their presenting complaint and urgency)” record, dated 2/23/2025 at 11:38 a.m., was reviewed. The record indicated that the triage registered nurse (RN 1), documented the following in Patient 1’s “Triage” record [on 2/23/2025 at 11:28 a.m.]: -Thoughts of harming yourself: NO -Thoughts of harming others: NO -Level of consciousness: Drowsy [sleepy, lethargic] -Orientation Assessment [refers to a person’s level of awareness of their surroundings, time, and identity]: Unable to assess During the same interview on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), the QC 1 verified documentation indicating that Patient 1 was lethargic upon arrival to the emergency department (ED), Patient 1 was lethargic and unable to answer questions during the triage assessment regarding Suicidal (SI) and Homicidal ideation (HI). During an interview on 5/1/2025 at 12:09 p.m., with the Director of the Emergency Department (ED) (Dir 1), Dir 1 stated the following regarding Suicidal/Homicidal (SI/HI) ideation screening in triage upon a patient’s arrival to the hospital: “The patient must be alert and oriented (a patient who is awake, awake of their surroundings, and able to understand and respond appropriately) to be able to communicate effectively and to answer questions regarding suicidal ideation (SI, thoughts of harming or inflicting death on one’s self) or HI (Homicidal ideation, thoughts about or planning to kill another person).” During a concurrent interview and record review on 5/1/2025 at 12:15 p.m. with the Director of the Emergency Department (Dir 1), Patient 1’s “Triage” record, dated 2/23/2025, was reviewed. The record indicated that Patient 1 presented drowsy and was not able to be assessed for orientation, but the patient (Patient 1) was documented to have answered “NO” to questions regarding thoughts of harming self or others. Dir 1 reviewed the documentation and stated that the most appropriate option in this documentation would be “unable to assess” rather than to record “no” for a patient who was recorded to be lethargic and unable to communicate. Dir 1 also stated that if a nurse was unable to assess SI/HI in triage, the next nurse (bedside nurse) should follow up with a re-assessment. Dir 1 said, “Even if the patient has answered “NO” to SI/HI questions in triage, nurses can still re-assess during the time patient is in the emergency department, especially if the patient was admitted with a possible overdose. We want to make sure that the patient remains safe.” During a review of Patient 1’s nursing shift assessments (a systematic and ongoing process where a nurse gathers, analyzes, and interprets data to evaluate a patient’s health status and plan appropriate care) completed during Patient 1’s stay in the Emergency Department on 2/23/2025, from 11:37 a.m. to 5:57 p.m., no record of an additional SI/HI screening was found to be documented in Patient 1’s electronic medical record (EMR, a digital version of a patient’s paper-based chart or medical record within a single healthcare practice). This was verified by the Quality Coordinator (QC 1) during a concurrent interview and record review on 5/1/2025 at 12:20 p.m. During a review of Patient 1’s medical record (MR) titled, “Emergency Documentation (ED)-Physician Note,” dated 2/24/2025, the MR indicated the following: [On 2/24/2025 at 11:25 a.m.] “Patient [Patient 1] was brought to the facility by the ambulance [from hotel] for overdose. Patient [Patient 1] was given 4 milligrams (mg, measuring unit) of Narcan (a medicine that rapidly reverses an opioid [a class of natural, semi-synthetic, and synthetic drugs that include both prescription medications and illegal drugs like heroin] overdose) intranasally (within or into the nose) on the way to the hospital. Patient 1 was seen for the same (on 2/23/2025, first ED visit) a day ago. During a review of Patient 1’s nursing assessments completed during Patient 1’s stay in the Emergency Department (ED) on 2/24/2025 from 11:25 a.m. through 2/25/2025 at 6:18 a.m., no record of additional SI/HI screening was found to be documented in Patient 1’s electronic medical record (EMR). This was verified by the Quality Coordinator (QC 1) during a concurrent interview and record review on 5/1/2025 at 12:20 p.m. During an interview on 5/2/2025 at 3:04 p.m. with the emergency Department (ED) physician (MD 4), MD 4 reviewed Patient 1’s ED visit (2 consecutive ED visits), dated 2/23/2025 and 2/24/2025, and stated the following: “Based on the physician’s documentation in the patient’s (Patient 1) record, it is not possible to determine whether Patient 1 was screened for suicidal ideation and if Patient 1 intentionally or unintentionally overdosed on medications. You would have to ask the physicians.” During a review of the facility’s policy and procedure (P&P) titled, “Documentation,” dated 8/2024, the P&P indicated that: “All documentation shall contain accurate, truthful and pertinent documentation ... All measures performed by nursing relating to care and the patient’s response to such measures shall be documented ...” During a review of the facility’s Policy and Procedure (P&P) titled, “Plan for Provision of Care, Treatment, and Services,” dated 10/2024, the P&P indicated the following: “The Emergency Department (ED) will provide an assessment, and any treatment indicated to all patients presenting with any illness or injury. During a review of the facility’s policy and procedure (P&P) titled, “Suicide Risk Assessment,” dated 9/2022, the P&P indicated that all patients admitted to the hospital or in the ED, shall be screened for the presence of suicide risk factors ... All patients who screen positive for suicide risk factors and/or present with a primary complaint of an emotional or behavioral disorder, shall be further assessed using a comprehensive suicide risk assessment tool for the risk of suicide by a mental health professional. Procedure: 1.A licensed healthcare professional will screen every patient for suicide risk during the initial assessment and reassessment by identifying with special emphasis on those who are being evaluated and/or treated for: a. Suicide attempt (overdosing, self-injury) or suspected suicide attempt ... 3. If any of the above screening indicators are present for a patient in ED, the Psychiatric Liaison Nurse or MHRN who has LPS certification will complete a Columbia Suicide Severity Rating Scale (C-SSRS) form...” During a review of the facility’s policy and procedure (P&P) titled, “ Initial Patient Assessment and Re-assessment,” dated 3/24/2025, the P&P indicated the following [The P&P applies to all nursing areas, including the Emergency Department (ED)]: “ At the time of admission or as soon as possible thereafter, each patient shall have an initial physical/psychological assessment completed by a registered nurse (RN). IV. The assessment is structured to identify facilitating factors and possible barriers to the patient reaching his or her goals including presenting problems and needs such as: I. Psychological, emotional, behavioral, suicidal and mental disorders” During a review of the facility’s policy and procedure (P&P) titled, “Triage,” dated 12/18/2023, the P&P indicated the following: “IX. Behavioral Health Patients a. Patients who present to triage exhibiting behaviors such as aggressiveness, agitation, or suicidal ideation present a danger to him/herself, or others, including the ED staff, and are considered violent until proven otherwise. b. The patient will be moved to a secured area away from the triage area. After the patient has had a medical screening exam and it is determined to be medically stable, a mental health evaluation may be requested on any person the provider deems appropriate, i.e., homicidal, suicidal, psychotic, etc.””

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure for one of 30 sampled patients (Patient 1), documentation of the response to Narcan (naloxone, an emergency medication used to reverse the effects of opioid overdose) was documented, after Narcan was administered to Patient 1 due to suspected opioid overdose (a medical condition where opioids cause significant respiratory depression [a breathing disorder characterized by slow or shallow breathing], sedation [a state of calmness, relaxation, or sleepiness induced by medications to help manage pain and anxiety], or coma [a state of prolonged unconsciousness where a person is unresponsive to their surroundings and environment], potentially leading to death). This deficient practice had the potential to compromise Patient 1’s well-being and recovery and may lead to delayed recognition of treatment effectiveness or adverse reactions, potentially hindering the effective clinical evaluation in documenting patient progress after an intervention (response to medication administration) when planning patient’s (Patient 1) care. Findings: During a review of Patient 1’s medical record (MR) titled, “Emergency Documentation (ED)-Physician Note,” dated 2/24/2025, the MR indicated the following: [On 2/24/2025 at 11:25 a.m.] “Patient (Patient 1) was brought to the facility by the ambulance (from hotel) for overdose. Patient (Patient 1) was given 4 milligrams (mg, measuring unit) of Narcan (a medicine that rapidly reverses an opioid [a class of natural, semi-synthetic, and synthetic drugs that include both prescription medications and illegal drugs like heroin] overdose) intranasally (within or into the nose) on the way to the hospital. Patient (Patient 1) was seen for the same (on 2/23/2025, first of two consecutive ED visits) a day ago. During a review of Patient 1’s Medication Administration Record (MAR), dated 2/24/2025, the MAR indicated that on 2/24/2025, Patient 1 received 0.04 mg of naloxone (Narcan) (intravenously, [IV] given through a vein into the blood), ordered as needed (PRN) at 11:45 a.m. During a concurrent interview and record review on 5/1/2025 at 10:50 a.m. with the Quality Coordinator (QC 1), Patient 1’s Medication Administration Record (MAR), dated 2/24/2025, was reviewed. QC 1 confirmed that Patient 1’s MAR contained no documentation of Patient 1 being re-assessed for the response to naloxone administration. During an interview on 5/1/2025 at 11:00 a.m. with the Clinical Pharmacy Coordinator (CPC), the CPC stated the following regarding documentation expectations after administering Narcan for a suspected opioid overdose: “Narcan is an opioids reversal agent. I don’t believe we (the facility) have a specific policy stating that the response to Narcan administration must be documented. However, if this medication is given for an actual opioid overdose in the emergency department, the expectation is for the nurses to document the patient’s reaction and response to the medication, but we don’t audit emergency department Narcan administration. We conduct audits for this documentation to monitor for suspected inpatient adverse reactions to opioids. We specifically look for the assessment documentation conducted after Narcan administration to evaluate its effectiveness.” During an interview on 5/2/2025 at 11:42 a.m. with the Emergency Department Clinical Educator (CE 1), the CE 1 stated that while some medications, such as pain medication, have prompts to document a patient’s response to medication to evaluate their effectiveness, Narcan does not have any prompts for documentation after its administration. The CE 1 also said that, however, when a medication such as Narcan was administered for a suspected opioid overdose, documenting the patient response to Narcan administration was considered a standard nursing practice. The CE 1 then stated, “If I were the nurse administering Narcan for a possible opioid overdose, I would document the patient’s response to the medication in the patient’s medical record.” During an interview on 5/2/2025 at 12:05 p.m. with the Accreditation, Regulatory and Licensing Manager (ARLM), the ARLM stated that the facility did not have a policy or procedure regarding documentation post (after) Narcan administration to evaluate its effectiveness because this medication (Narcan) was available over the counter (by ordinary retail purchase, with no need for a prescription or license). During a review of the facility’s policy and procedure (P&P) titled, “Documentation,” dated 8/2024, the P&P indicated that: “All documentation shall contain accurate, truthful and pertinent documentation ... All measures performed by nursing relating to care and the patient’s response to such measures shall be documented ... All PRN medication, the reason for administering and the effectiveness of same shall be documented in the medical record ... “ During a review of the facility’s policy and procedure (P&P) titled, “Administration of Medications,” dated 8/2024, the P&P indicated that: “Naloxone is an opioid antagonist ...indicated for the reversal of an opioid overdose ... is intended to ensure naloxone is readily available for patients at risk of experiencing an opioid overdose. The recommended medication regimen is naloxone 0.1 mg IV Push [a process of introducing a medication or fluid substance directly into the bloodstream via the venous system] once PRN [as needed] for drowsiness and notify physician ...” During a review of the facility’s policy and procedure (P&P) titled, “Initial Patient Assessment and Reassessment,” dated 3/2024, the P&P indicated that: “The assessment of the care or treatment required to meet the needs of the patient will be ongoing throughout the patient’s hospital stay, with the assessment process individualized to meet the needs of the patient population. Reassessment shall occur when an intervention has taken place or if there is a change in patient condition or status. All data collected shall be recorded in the nursing assessment record and shall be available to all those disciplines involved in the care of the patient. Based on the outcome of screening data, other disciplines may be contacted to perform a more comprehensive assessment of the patient as needed. This data shall be used by the multidisciplinary team to establish the information necessary to provide the most comprehensive plan of care for the patient.””

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that one of 30 sampled patient’s (Patient 6), informed consent (a voluntary agreement signed by the patient or their authorized representative that confirms they understand the nature, risks, benefits, and alternatives of a medical procedure before it is performed) form, was completed and indicated the date and time when Patient 6 or Patient 6’s representative (Rep) signed the informed consent for a medically indicated procedure (an intervention that is performed based on clinical judgement to benefit the patient and is necessary for diagnosis, treatment, or management of a medical condition), in accordance with the facility’s informed consent protocol. This deficient practice had the potential to jeopardize Patient 6’s rights to decision-making (refers to the process in which patients are actively engaged in making informed choices about their healthcare options), undermining Patient 6’s autonomy (person’s right to make their own decisions) and compromise the legal validity (refers to legitimacy and enforceability of a document) of the consent due to lack of completeness of the medical record (informed consent form). Findings: During a review of Patient 6’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 3/26/2025, the H&P indicated that Patient 6 was found unresponsive (unable to react or respond to external stimuli like touch, sound, or visual cues, or to express themselves), next to a scooter; was intubated (a tube, typically an endotracheal tube, has been inserted into a patient’s trachea [windpipe] to assist with breathing) in the field and brought to the facility as a trauma patient (someone who has suffered a traumatic injury). During a concurrent interview and record review on 4/29/2025 at 12:25 p.m., at the nurses station on a medical-surgical telemetry unit (a hospital floor that provides general medical care with continuous electronic monitoring of heart rate and rhythm), with the Quality Management (QM), Patient 6’s informed consent (a voluntary agreement given by the patient or their legal representative prior to a medical procedure, confirming they understand the risks, benefits, and alternatives) form titled, “Authorization of and Consent to Surgery or Special Diagnostic or Therapeutic Procedures,” [no date], was retrieved from Patient 6’s paper chart. The informed consent form indicated the following minimum elements: -Name of the hospital where the procedure or other type of medical treatment is to take place; -Name of the specific procedure, or other type of medical treatment for which consent is being given; -Name of the responsible practitioner who is performing the procedure or administering the medical treatment; -Statement that the procedure or treatment, including the anticipated benefits, material risks, and alternative therapies, was explained to the patient or the patient’s legal representative ... - Signature of the patient or the patient’s legal representative; - Date and time the informed consent form is signed by the patient or the patient’s legal representative] of informed consent were documented: -Patient [Patient 6] name -The name of the procedure [Right Frontal Burr Hole-a surgical procedure involving drilling a small hole into the frontal lobe of the skull to access the brain] -The name and signature of Patient 6’s legal representative. During the same interview on 4/29/2025 at 12:25 p.m. with the Quality Management (QM), the QM confirmed that the Informed Consent Form lacked the documentation of the following elements: surgeon’s name (performing the procedure), date and time when the consent was obtained, and QM also stated that the name of the surgeon should be documented. The QM also said the facility would need to review the facility’s policy regarding Informed Consent Forms to ensure compliance and completeness of the medical record (Informed Consent form). During an interview on 4/29/2025 at 2:45 p.m. with the Quality Management (QM), the QM stated that according to the facility’s policy and procedure (P&P) regarding informed consent, the date and time should be documented on the informed consent form because the Informed Consent Form was only valid for the duration of the patient’s admission (meaning the consent provides authorization for treatment during the current hospital stay or specific procedure, and it may need to be re-obtained). During an interview on 5/2/2025 at 11:18 a.m. with the Clinical Educator (CE 2), the CE 2 stated that nurses should document the date and time and all other necessary elements of the informed consent when the informed consent form was obtained to demonstrate that the patient agreed to the specific procedure, acknowledging the fact that the physician explained the nature of the procedure/treatment and its expected outcomes at that exact moment. The CE 2 then stated that proper documentation should provide evidence that the patient (or patient’s legal representative) was informed and actively involved in the decision-making process in real time and ensures that the informed consent remains valid for the entire hospital stay. During a review of the facility’s policy and procedure (P&P) titled, “Informed Consent,” dated 8/10/2020, the P&P indicated the following: “ V. Informed consent may be considered to have continuing force and effect until the patient revokes the consent or until circumstances change so as to materially affect the nature of, or the risks of, the procedure/treatment and/or the alternatives to the procedure/treatment to which the patient consented. VI. The role of the hospital is limited to verifying that informed consent has been given. The consents obtained by employees shall not go beyond simply naming the intended procedure/treatment and obtaining the patient acknowledgement that the physician explained the nature of the procedure/treatment, its expected benefits and risks, and possible alternatives and their benefits and possible risks.””

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to: 1. Ensure one of 30 sampled patient’s (Patient 1) medical reconciliation (process of reviewing and comparing a patient’s current medications, treatments, and medical history to ensure accuracy and continuity of care) was recorded on two consecutive Emergency Department (ED) visits (2/23/2025 and 2/24/2025), in accordance with the facility’s policy and procedure regarding medication reconciliation and assessment. This deficient practice had the potential to compromise Patient 1’s continuity of care and increase the risk of harm to the patient (Patient 1). In addition, this deficient practice had resulted in a gap in Patient 1’s medical record completeness violating Patient 1’s right to transparency, accountability, and accurate and complete medical records. 2. Ensure that one of 30 sampled patient’s (Patient 22), medication reconciliation (involves creating the most complete and accurate list of a patient’s medications-including prescriptions, over-the-counter drugs, vitamins, and supplements-and comparing this list to the medications ordered or prescribed during a transition of care), was reviewed during Emergency Department (ED) visits (from 3/9/2025 and 3/11/2025), in accordance with the facility’s policy and procedure titled, “Medication Reconciliation.” This deficient practice had the potential to result in an incomplete or inaccurate list of Patient 22’s medications. Without this information, doctors and nurses may not have had everything they needed to safely monitor Patient 22’s condition or give the right care, and had the potential for missed doses, drug interactions, receiving the wrong medicine, or serious side effects. 3. Ensure that one of 30 sampled patient’s (Patient 3) total enteral feeding intake (refers to the amount of feeding formula consumed by a patient) of feeding formula, was consistently documented, in accordance with the facility’s policy regarding documentation of enteral feeding (a method of providing nutrition directly into the gastrointestinal [GI] tract through a tube) administration. This deficient practice had the potential to compromise Patient 3’s nutritional status and care, by preventing accurate assessment of nutritional and fluid status needs of Patient 3, increasing Patient 3’s risk for dehydration (a condition that occurs when your body loses more fluids than it takes in, resulting in a shortage of water and other necessary fluids), undernutrition (a condition where the body does not receive enough nutrients to meet its needs, often due to insufficient food intake or poor absorption of nutrients), overhydration (the body takes in more water than it loses), and other complications, hindering interventions necessary to maintain optimal patient (Patient 3) health. 4. Consistently perform and document neurological assessments (a systemic evaluation of a patient’s nervous system function, including mental status, motor and sensory responses, and reflexes to detect abnormalities), every 4 hours as ordered by the physician, for one of 30 sampled patients (Patient 4), after Patient 4 was diagnosed with a stroke (sudden interruption of blood flow to the brain that can cause neurological deficits, impairments, or death), in accordance with the facility’s policy regarding assessments and documentation. This deficient practice had the potential to result in delayed recognition of neurological deterioration of Patient 4’s condition, increasing the risk for adverse outcomes for Patient 4 such as neurological deficits (permanent impairment or loss of function in the nervous system such as difficulty with coordination, paralysis, numbness, inability to speak or understand language) or death. Findings: 1. During a review of Patient 1’s medical record (MR) titled, “Emergency Documentation-Physician Note,” dated 2/23/2025, the MR indicated the following: “Patient (Patient 1) found ALOC ([Altered Level of Consciousness],refers to a state where a person’s level of awareness and responsiveness is significantly reduced, ranging from mild confusion or drowsiness to a state of coma [a state of prolonged unconsciousness where a person is unresponsive, unable to react or respond to external stimuli like touch, sound, or visual cues, or to express themselves, to their surroundings and environment]) in hotel room by family ...was combative, and now lethargic (a state of drowsiness, sluggishness, and a lack of energy or alertness) per EMS (Emergency Medical Services) report ...potential Baclofen (medication used to treat pain and certain types of muscle spasticity) overdose (to take an overdose = a dangerously large amount) of a drug.” During a review of Patient 1’s medical record (MR) titled, “Emergency Documentation-Physician Note,” dated 2/23/2025, the MR also indicated that Patient 1 was not able to provide past medical history (PMH, a record of a patient’s previous illnesses, surgeries, medications, and other health-related events) and/or to participate in medical exam, “at the time of initial assessment ...The MR further indicated that Patient 1 was described [by family] to be found with a “pile of prescription drugs,” and had markings on abdomen that were “related to being in a hot tub.” During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1’s “Triage (refers to the detailed record of an initial, rapid assessment of a patient’s condition and the prioritization of care needed based on their presenting complaint and urgency) record, dated 2/23/2025 at 11:38 a.m., was reviewed. The record indicated that the triage registered nurse (RN 1), documented that Patient 1 had history of being prescribed dextroamphetamine-amphetamine (Adderall, used to treat attention-deficit hyperactivity disorder [ADHD] and narcolepsy [a condition characterized by an extreme tendency to fall asleep]). During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1’s medical record (MR) titled, “Emergency Department (ED) Visit” summary, dated 10/23/2024, was reviewed. The QC stated that Patient 1 had documented past medical history of (PMH, a comprehensive record of a patient’s past and present health conditions): - ADHD, a neurodevelopmental disorder characterized by persistent symptoms of inattention, hyperactivity, and impulsivity, which are excessive, pervasive, and developmentally inappropriate. -Anxiety, a mental condition characterized by excessive apprehensiveness about real or perceived threats. -Carpal tunnel syndrome, a condition caused by compression of the median nerve as it passes through the carpal tunnel in the wrist. - Cholelithiasis, the formation of gallstones. -Chronic pain, persistent pain that lasts for more than three months. -Cognitive disorder, a mental disorder characterized by impaired cognitive (the mental processes involved in thinking, learning, remembering, and problem-solving) abilities and daily functioning, caused by factors that affect brain function. -Fibromyalgia, a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia (difficulty falling asleep or staying asleep). -Hypertension (HTN), a condition where the force of your blood against your artery walls is consistently too high. -Hypothyroidism, a condition where the thyroid gland doesn’t produce enough thyroid hormones (regulates how the body uses energy) to meet the body’s needs. -Multiple sclerosis (MS), a chronic, inflammatory disease of the central nervous system (brain and spinal cord [a long, tubular structure made of nerve tissue that extends from the brainstem down the center of the back to the tail bone]). -Multilevel Degenerative Disk disease, the breakdown or deterioration of the discs between the vertebrae (bones that make up the spine) in the spine -Muscle spasms, an involuntary, sudden contraction of a muscle, often resulting in pain. -Neuropathy, refers to any condition that affects the nerves outside your brain or spinal cord. -Osteomyelitis- a bone infection, usually caused by bacteria, mycobacteria, or fungi, that can spread through the bloodstream or from a nearby infection. During the same interview on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), QC 1 o said that Patient 1’s ED Visit medical record on 2/23/2025 had no documentation of patient’s (Patient 1) medication reconciliation (the process of creating a list of all medications a patient is taking) performed, including prescription medications that Patient 1 might have been possibly taking at home for the medical conditions. During further review of Patient 1’s “ED Documentation-Physician Note,” dated 2/23/2025, the note indicated that Patient 1 told the ED physician that they (Patient 1) had PMH of Ehlers-Danlos syndrome (a group of inherited connective tissue disorders that affect the skin, joints, and other organs. It can be painful, particularly due to joint hypermobility and the resulting instability). During a review of Patient 1’s medical record (MR) titled, “Emergency Documentation (ED)-Physician Note,” dated 2/24/2025, the MR indicated the following: [On 2/24/2025 at 11:25 a.m.] “Patient (Patient 1) was brought to the facility by the ambulance (from hotel) for overdose (refers to prescription medications and/or illegal drugs like heroin, overdose). Patient (Patient 1) was seen for the same (on 2/23/2025, first of two consecutive ED visits) a day ago. History (a record of a patient’s previous illnesses) of HTN and MS.” During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1’s emergency department (ED) visit, dated 2/23/2025, was reviewed. The ED visit record indicated that Patient 1’s medication reconciliation was not recorded. This was verified with the QC 1 during a concurrent interview. The QC 1 also said that nurses should do medication reconciliation in the emergency department (ED). During an interview on 4/30/2025 at 12:29 p.m. with the Quality Management (QM), QM stated that the Chief Medical Officer (CMO) confirmed (on 4/30/2025) that medical providers should perform medication reconciliation on admission and discharge. During a concurrent interview and record review on 5/1/2025 at 10:01 a.m. with the emergency department (ED) provider (MD 3), Patient 1’s ED visit medical record (MR), dated 2/24/2025, was reviewed. The “ED Documentation-Provider Note,” dated 2/24/2025, indicated that Patient 1 was diagnosed with opiate overdose, toxic encephalopathy (a brain disorder resulting from exposure to toxic substance), and methamphetamine use (identifying and confirming the use of methamphetamines [a powerful stimulant, known as crystal meth]). The MD 3 stated the following regarding Patient 1’s diagnoses and medication reconciliation: “[On 2/24/2025] Patient (Patient 1) was diagnosed with an opiate overdose because she (Patient 1) responded to an antidote (Narcan) administered during her (Patient 1) treatment in the field, on the way to the emergency department, but this was not clearly documented in the patient’s (Patient 1) medical chart. Regarding methamphetamine use, the patient’s history from 2018 ED visit must have automatically generated methamphetamine use history into the record. The Patient’s (Patient 1) visit on 2/23/2025 demonstrated that she (Patient 1) tested positive for amphetamines and opiates. However, medication reconciliation was not completed for this patient, and it is possible that the positive results were due to prescription medications-such as prescribed opioids and Adderall (amphetamine-containing medication)-which patient [Patient 1] may have been using as a part of her treatment plan.” MD 3 also stated that urine toxicology (a laboratory test that analyzes a urine sample to detect the presence of drugs or other substances) cannot differentiate between amphetamines use and methamphetamine use. During an interview on 5/1/2025 at 12:01 p.m. with the director of the Emergency Department (Dir 1), the Dir 1 stated the following regarding medication reconciliation process in the emergency department (ED): “When a patient arrives at the Emergency Department (ED), the expectation is for the nurses to conduct an initial assessment, which includes gathering the patients’ past medical history and medication history. However, there is typically not enough time to review mediations during triage, and the medication reconciliation is typically done by the assigned nurse once the patient is stabilized. The physician also obtains additional medication history information during their assessment of the patient. Medication reconciliation is marked as complete after the physician reviewed and verifies the medication list. Not all patients require nurses to complete the medication history, but Patients with ESI (Emergency Severity Index, a system that categorizes patients into five levels based on how urgently they need medical attention and the resources required for their care) level of 3 and above (Patient 1 had an ESI level of 2 on both ED visits on 2/23/2025 and 2/24/2025) are expected to have the medication reconciliation performed during their ED visit.” The Dir 1 also said that it’s important to know what medications patient is currently taking, especially if patient is admitted on overdose. During an interview on 5/2/2025 at 8:00 a.m. with the Registered Nurse (RN 6), the nurse who discharged Patient 1 on 2/25/2025, RN 6 stated that Patient 1 refused to sign discharge instructions (guidelines that patients have to follow after discharge to deal with any remaining illnesses that need to be taken care of personally by the patient) because of the diagnosis of methamphetamine use and opioid overdose, which Patient 1 disagreed with. RN 6 mentioned that when Patient 1 left the ED, she (Patient 1) was alert and oriented (meaning the patient was aware of person, place, and time), and able to walk independently. RN 6 also said that, according to the facility’s policy, medication reconciliation should have been done for Patient 1. RN 6 could not recall whether the medication reconciliation was done for Patient 1 prior to discharge but stated that she (RN 6) did not complete medication history for Patient 1 prior Patient 1’s discharge from the ED [on 2/25/2025]. During further review of Patient 1’s “ED Documentation-Physician Note,” dated 2/23/2025, the note indicated the following: [on 2/23/2025] “At 3:27 p.m. Patient 1 returned to baseline neurologic status (the condition of the nervous system, including the brain, spinal cord, and nerves, and how well it is functioning) and was able to answer questions.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Reconciliation,” dated 9/2022, the P&P indicated the following: “Medication reconciliation is the collaborative responsibility of physicians, nurses, and pharmacists. It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain this information from the patient and/or other sources is expected. Medication reconciliation is done at point of entry including all inpatient and outpatient admissions to any nursing unit, department, or area where licensed personnel could, or would have the potential to, administer medications. Electronic medication reconciliation will be utilized to document the medication reconciliation process for all in-patient admissions, outpatients, and discharges in the electronic medical record. Outpatients: In settings where medications are used minimally or prescribed for a short duration, a modified medication reconciliation process can be performed. In these settings, a medication list will be collected, recorded on the Outpatient Services Medication Reconciliation form and then reviewed by the physician and licensed staff. The list should contain all known and current medications. Any changes made to the medication list during the encounter will prompt reconciliation with the previous medications resulting in a revised complete medication list. The dose, route, frequency of use is not required for this area... Upon discharge, the ED physician and licensed staff will reconcile the medication list in electronic medical record and determine whether the medication list requires a change or not. This information is included in discharge teaching and the patient’s written instructions.” 2.During a review of Patient 21’s “Emergency Documentation: ED Note Physician,” dated 3/9/2025, the note indicated Patient 21 had a history of congestive heart failure (CHF, a condition where the heart cannot pump blood effectively), Crohn’s disease (CD, a chronic inflammatory bowel disease that affects the digestive tract), and diabetes (a condition where your body can’t regulate the amount of sugar in your blood). The patient was admitted with ongoing generalized weakness (reduced muscle strength) and fatigue (lack of energy). The patient (Patient 21) reported being unable to care for himself and requested placement in a care facility. He (Patient 21) had recently suffered a femur (thigh bone) fracture (break in the bone) and had not started physical therapy (treatment to help restore movement and strength). During an interview on 4/29/2025 at 11:18 a.m. with Registered Nurse (RN) 13, in the Emergency Department (ED), RN 13 stated it was usually the admitting RN’s responsibility to reconcile a patient’s home medications (review and record the medications the patient was taking at home) when the patient was admitted to the ED, although pharmacy staff may also perform this medication reconciliation (process of reviewing and comparing a patient’s current medications, treatments, and medical history to ensure accuracy and continuity of care). RN 13 further stated that patients arriving from a skilled nursing facility (SNF - a long-term care nursing facility) typically brought a printed list of their current medications. If a patient from a SNF did not have a medication list on arrival, the nurse should call the SNF to obtain the information. RN 13 further stated it was important to reconcile all patient medications to guide treatment decisions. For example, RN 13 stated that in critical cases, such as a patient with a “head bleed (a serious type of brain hemorrhage [bleeding]),” it was vital to know whether the patient was on any blood thinners (anticoagulant drugs that increase bleeding risk). RN 13 said this medication information was essential because it directly impacted how the medical team would manage the patient’s emergency treatment. During a concurrent interview and record review on 4/30/2025 at 2:00 p.m. with the Sepsis and Quality Coordinator (CQ) 2, Patient 22’s medical record (MR) document titled, “Documentation Medication by Hx (history),” for visit date 3/9/2025 through 3/11/2025, was reviewed. The MR had a message that indicated, “Medication history has not yet been documented. Please document the medication history for this patient encounters.” CQ 2 confirmed that Patient 22’s medication had not been reviewed by nursing or pharmacy. During a review of the facility’s policy and procedure (P&P) titled, “Medication Reconciliation,” dated 9/2022, the P&P indicated the following: “Medication reconciliation is the collaborative responsibility of physicians, nurses, and pharmacists. It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain this information from the patient and/or other sources is expected. Medication reconciliation is done at point of entry including all inpatient and outpatient admissions to any nursing unit, department, or area where licensed personnel could, or would have the potential to, administer medications. Electronic medication reconciliation will be utilized to document the medication reconciliation process for all in-patient admissions, outpatients, and discharges in the electronic medical record. 3. During a review of Patient 3’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/24/2025, the H&P indicated that Patient 3 was admitted to the facility with diagnosis of severe sepsis (a stage of sepsis where an infection has caused a severe inflammation and damage to the body’s organs, potentially leading to multiple organ failure). The H&P also indicated that Patient 3 had history of G-tube (a feeding tube that is inserted surgically through the abdomen directly into the stomach). During a concurrent interview on 4/29/2025 at 12:12 p.m. with registered nurse (RN 9), RN 9 stated that patient 3 has a G-tube (gastrostomy tube, a surgically placed feeding tube directly into the stomach) and is on continuous enteral (feeding administered into the gastrointestinal tract ( GI Tract, a series of organs that process food from ingestion to excretion), typically through a feeding tube)], that is infused at 50 milters (ml, a unit of volume measurement) per hour through the G-Tube. RN 9 said that documentation of total enteral feeding intake (refer to the sum of all) per shift is not required and typically not documented, unless there is a specific order to do so. RN 9 then checked the documentation in Patient 3 chart and confirmed that no total intake for enteral had been documented for Patient 3 in the past 24 hours. During a review of Patient 3’s medical record (MR), titled “Order Sheet,” dated 4/26/2025, the MR indicated that Patient 3 had an order for continuous administration of enteral feeding. During a concurrent interview and record review on 5/1/2025, at 2:07 p.m. with Quality Coordinator (QC1), Patient 3’s record, titled “GI-Tube,” dated 4/26/2025 through 4/28/2025 was reviewed. The record indicated the following: [documentation of total intake (the overall amount of) of enteral feeding]: -On 4/26/2025 from 7:00 a.m. to 7 p.m. -Total intake of tube feeding was not documented. -On 4/26/2025 from 7:00 p.m. through 4/27/2025 at 7:00 a.m.-Total intake of tube feeding infused was not documented. -On 4/27/2025 from 7:00 p.m. through 4/28/2025 at 7 a.m.-Total Intake of tube feeding was not documented. QC 1 confirmed that Patient 3’s record, titled “GI-Tube,” [dated 4-26/2025 through 4/28/2025] contained only the documented total infused enteral feeding intake on 4/27/2025 [7 a.m. to 7 p.m.], totaling 500 ml for that shift. During an interview on 5/2/2025 at 10:51 a.m. with the clinical educator (CE 2), the CE 2 stated the following: “I am not sure how often nurses should document the amount of infused enteral feeding on a regular floor, but the amount of enteral feeding infused, should be documented by the nurses, regardless of if there is a physician’s order or not. We want to know if the patient is tolerating the feeding and to monitor the nutritional status [encompasses the balance between nutrient intake and the body’s needs for optimal health, growth, and function].” During a review of the facility’s policy and procedure (P&P), titled “Adult Feeding Tubes,” dated 3/2022, the P&P indicated that: “The policy is developed to ensure that patients with feeding tubes shall be assessed, monitored, and maintenance provided. D. Documentation for patients with Enteral Nutrition: 5. Intake and Output (I&O, “intake” refers to the fluids a patient consumes, while “output” refers to the fluids a patient eliminates from the body), including rate and volume of feeding, number of flushes (free water), discarded residuals [refers to the amount of fluid that remains in the stomach after a feeding, must be documented for patients with enteral nutrition, fluid is aspirated from the stomach via the feeding tube to monitor gastric emptying and assess a patient’s tolerance to enteral nutrition ].” During a review of the facility’s policy and procedure (P&P), titled “Intake and Output (I&O, “intake” refers to the fluids a patient consumes, while “output” refers to the fluids a patient eliminates from the body),” dated 8/2021, the P&P indicated that: “II. When indicated for the patient based upon condition or orders: A. l&O should be routinely recorded every 12 hours with a 24-hour total computed, or more frequently as patient’s status dictates. IV. It is the Registered Nurse’s responsibility to be aware of a positive or negative fluid balance and ensure that l&Os ...are documented when ordered or as appropriate for patient’s condition. Any medically significant positive or negative fluid balances shall be reported to the physician.” During a review of the facility’s policy and procedure (P&P), titled “Documentation,” dated 8/2024, the P&P indicated that: “All documentation shall contain accurate, truthful and pertinent documentation ... All measures performed by nursing relating to care and the patient’s response to such measures shall be documented ... ... Patients requiring Intake and Output documentation will have Intake and Output Recorded in the medical record every twelve hours, or as the physician dictates, and totaled at the end of the shift and every twenty-four (24) hours by the 7P-7A shift. 4. During a review of Patient 4’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem) dated 4/29/2025, the H&P indicated that Patient 4 was admitted to the facility with a diagnosis of paresthesia [an abnormal sensation, typically tingling or pricking (“pins and needles”), caused chiefly by pressure on or damage to peripheral nerves (other than spinal cord and the brain)], right-sided weakness, acute cerebrovascular accident (CVA, a medical term for a stroke, a sudden interruption of blood flow to the brain). The H&P also indicated that Patient 4 was admitted to neuro-telemetry unit (a specialized hospital unit that provides remote monitoring and care for patients with neurological conditions). During a review of Patient 4 medical records (MR), titled “Admitting Orders, (orders specify the patient’s diagnosis, initial treatment plan, and various other details needed for their care while in the hospital),” dated 4/29/2025, the MR indicated that on 4/29/2025 at 7:04 a.m., the admitting physician placed an order to monitor neurological status [of Patient 4] every 4 hours. During a concurrent interview and record review on 5/2/2025 at 11:40 a.m., with the clinical educator (CE 1), Patient 4’s medical record (MR), titled “Neurological Assessment,” dated 4/29/2025 was reviewed. The MR indicated that a complete neurological assessment (a thorough evaluation of a patient’s neurological function, including assessment of mental status, cranial nerves, motor and sensory responses, reflexes, and intracranial pressure signs) was performed and recorded on 4/29/2025 at 6:30 a.m. and 5:17 a.m. The CE 1 verified that Patient 4’s medical record (MR), titled “Neurological Assessment,” contained no documented neurological assessment recorded between 6:30 a.m. and 5:17 p.m. [every 4 hours, as ordered] on 4/29/2025. The CE 1 stated that the neurological assessment for Patient 4, conducted every 4 hours as ordered by the physician, should have been done in accordance with the order to ensure ongoing monitoring of neurological status and early detection of any worsening of signs and symptoms of a stroke. During a review of the facility’s policy and procedure (P&P), titled “Initial Patient Assessment and Reassessment,” dated 3/2024, the P&P indicated that: “The assessment of the care or treatment required to meet the needs of the patient will be ongoing throughout the patient’s hospital stay, with the assessment process individualized to meet the needs of the patient population. Specialty unit’s assessments shall be completed per unit specific criteria.” During a review of the facility’s policy and procedure (P&P), titled “Documentation,” dated 8/2024, the P&P indicated that: “All documentation shall contain accurate, truthful and pertinent documentation ... All measures performed by nursing relating to care and the patient’s response to such measures shall be documented.””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 46238 Based on observation, interview, and record review, the facility’s Governing Body (responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure the Condition of Participation for Governing Body was met as evidenced by: 1. The facility’s Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies and assisting with strategic planning and decision-making), failed to ensure the Nursing Department’s compliance with the facility’s policy regarding the management of one of 30 sampled patients (Patient 5), on 5150 hold (an involuntary psychiatric hold in California for individuals who are considered a danger to themselves or others) outside of the mental health unit. Patient 5 was on a 5585 hold (an involuntary hold for minors under the age of 18 who are deemed a danger to themselves or others or are gravely disabled [unable to meet basic needs such as feeding, hygiene, etc.] due to a mental disorder, allowing for a 72-hour psychiatric evaluation [a mental health assessment to help diagnose and treat mental health problems]) due to suicidal ideation (SI, thoughts of causing one’s own death), which involved thoughts or planning related to self-harm or suicide (death caused by injuring oneself with the intent to die). Patient 5 was not provided a 1:1 sitter (a patient observer or constant observer, is a healthcare staff member assigned to monitor a single patient continuously) per policy. This deficient practice had the potential to compromise patient safety and increase the risk of harm to Patient 5 and other patients and may also result in death. (Refer to A-0063) 2. The facility’s Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure the facility’s contracted Managed Care personnel ensure the discharge planning process (the process of preparing a patient to leave a healthcare facility, and ensuring a smooth and safe transition to the next phase of care such as going home, moving to a rehabilitation center, nursing home, or other healthcare setting) promoted safe, effective patient transition from hospital to their next level of care, for one (Patients 1) of 30 sampled patients. This deficient practice had the potential to result in negative consequences for patients, post-discharge leading to higher patient re-admission rates and worsening of their conditions due to delays in care coordination or inadequate follow-up care set-up. In addition, this deficient practice violates patients’ and their caregivers’ rights when they were not involved in the discharge planning process. (Refer to A-0083) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.”

“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: 46238 Based on interview and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to ensure one of 30 sampled patient’s (Patient 1) physician was notified regarding Patient 1’s change of condition (clinically important deviation from a patient’s baseline in physical, cognitive [anything related to learning, thinking, and understanding], behavioral or functional domains), in accordance with the facility’s policy and procedure regarding physician notification, when Patient 1’s vital signs (the basic physiological measurements that reflect the essential functions of the body) indicated increased respiratory rate (38 and 24 breaths per minute; normal respiratory rate is 20) and a low blood pressure (105/53 mmHg [a unit of measurement]; Normal BP is 120/90) on the day of discharge. The facility also failed to re-assess and document Patient 1’s latest vital signs prior to discharge, in accordance with the facility’s policy and procedure regarding reassessment and documentation. This deficient practice had the potential to result in delay of immediate interventions needed and may result in worsening of Patient 1’s condition including complications such as respiratory distress (a serious lung condition that causes low blood oxygen), severe hypotension (extremely low blood pressure, and/or death. (Refer to A-0395) 2. The facility failed to ensure one of 30 sampled patients (Patient 1) was placed on a specialty bed (a low-air loss mattress a type of air mattress that helps prevent and treat pressure wounds by constantly circulating air and relieving pressure on the body) as per wound care nurse’s recommendations. This deficient practice resulted in Patient 1 developing pressure injury Stage II (a partial-thickness loss of skin that appears as an open wound, blister [a fluid-filled sac that forms on the skin], or abrasion [a minor injury to the skin that occurs when the surface layers of the skin are broken]). (Refer to A-0395) 3. The facility failed to ensure one of 30 sampled patient’s (Patient 12) nursing care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) for chest tube care (a flexible tube that’s inserted into the chest cavity to drain fluid, blood, or air) was initiated, in accordance with the facility’s policy and procedure regarding care plans. This deficient practice had the potential to result in delayed provision of care when the patient’s (Patient 12) needs and risks were not identified. This deficient practice also had the potential to result in complications such as infection, dislodgement of the tube, etc. which may worsen Patient 12’s condition leading to prolonged hospitalization and recovery. (Refer to A-0396) 4. The facility failed to ensure one of 30 sampled patient’s (Patient 13) nursing care plan for aspiration precaution (measures to prevent food, liquid, saliva, or foreign objects from entering the lungs) was initiated, in accordance with the facility’s policy and procedure regarding care plans. This deficient practice had the potential to result in delayed provision of care when the patient’s (Patient 13) needs and risks were not identified. This deficient practice also had the potential to result in complications such as aspiration pneumonia (a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents), etc. which may prolong Patient 13’s hospitalization and recovery. (Refer to A-0396) 5. The facility failed to ensure one of 30 sampled patient’s (Patient 14) nursing care plan regarding the use of incentive spirometry (a treatment that uses a handheld device to help patients improve lung function by breathing in slowly and deeply), was initiated, in accordance with the facility’s policy and procedure regarding care plans. This deficient practice had the potential to result in delayed provision of care when the patient’s (Patient 14) needs and risks were not identified. This deficient practice also had the potential to worsen Patient 14’s condition by not addressing the respiratory care needs, which may result in complications such as respiratory distress, etc. And may lead to prolonged recovery for Patient 14. (Refer to A-0396) 6. The facility failed to ensure one of 30 sampled patient’s (Patient 15) nursing care plan to address cellulitis (a bacterial infection that affects the skin’s deeper layers, including the dermis and subcutaneous fat) such as an infection related care plan, was initiated, in accordance with the facility’s policy and procedure regarding care plans. This deficient practice had the potential to result in delayed provision of care when the patient’s (Patient 15) needs and risks were not identified. This deficient practice may also result in worsening infection, etc. and thus prolonging patient 15’s hospitalization. (Refer to A-0396) 7. The facility failed to ensure staff followed and implemented the nursing care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 30 sampled patients (Patient 21), when staff did not monitor the daily weight of Patient 21, in accordance with the facility’s policy and procedure regarding care planning. This deficient practice had the potential for staff not being able to accurately monitor Patient 21’s weight changes, which may also impact adjustments in treatment regarding Patient 21’s nutritional status. (Refer to A-0396) 8. The facility failed to: 8.a. Ensure that nursing staff re-assessed (a re-evaluation of a patient’s health status) and documented the pain level for one of 30 sampled patients (Patient 6) in accordance with the facility’s policy and procedure regarding pain re-assessment , after the administration of Morphine (a narcotic pain medication used to relieve moderate to severe pain by acting on the central nervous system to alter the perception of pain) to Patient 6. 8.b. Ensure that nursing staff addressed the pain level for one of 30 sampled patients (Patient 6) in accordance with the facility’s policy and procedure on pain management after the patient (Patient 6) reported being in pain. 8.c. Ensure that nursing staff assessed and documented the pain level for one of 30 sampled patients (Patient 6) at a minimum each time Patient 6’s vital signs (includes temperature, blood pressure, respiratory rate, heart rate, pain level) were obtained and recorded, in accordance with the facility’s policy and procedure regarding nursing assessment and vital signs check. These deficient practices had the potential to result in delayed treatment and worsening of pain, negatively impacting the patient’s (Patient 6) comfort and recovery. (Refer to A-0398) 9. The facility failed to: 9.a. Ensure one of 30 sampled patients (Patient 1) and/or their designated representative received the necessary information and resources for safe and effective post-discharge care, when personalized teaching plan to educate Patient 1 and/or designated representative regarding management of G-tube care and medication administration (the process of delivering medication to a patient through a gastrostomy tube [G-tube, a tube that is inserted into the nose or mouth and passed into the stomach or small intestine]) at home, was not developed and provided to Patient 1 and/or designated representative. 9.b. Ensure one of 30 sampled patients (Patient 1) and/or designated representative were provided with written and verbal discharge instructions for managing enteral feedings (a liquid nutritional formula is delivered through a tube that is inserted into the stomach or small intestine) and aspiration precautions (measures taken to minimize the risk of food, liquid, or other materials entering the lungs) to follow at home. 9.c. Ensure one of 30 sampled patients (Patient 1) and/or designated representative were provided with discharge instructions and necessary guidance on wound care and treatment (the process of evaluating and treating wounds to promote healing, prevent infection, and reduce complications). These deficient practices had the potential for Patient 1 and/or designated representative not to receive the necessary education and guidance for managing Patient 1’s complex care needs at home, potentially increasing the risk of complications and or hospital readmission due to insufficient discharge preparation. (Refer to A-0398) 10. The facility failed to ensure two of 30 sampled patients (Patient 3 and Patient 6) had their call light device (a device used by the patient to call for help) within reach, in accordance with the facility’s policy and procedure regarding call light use. This deficient practice had the potential for unmet needs for Patient 3 and Patient 6, as both were unable to call for assistance due to the absence or inaccessibility of the call light. This deficient practice had the potential to result in delayed treatment, potentially negatively impacting the provision of care for both patients. (Refer to A-0398) 11. The facility failed to ensure that two of two sampled rooms (referring to the clean supply room and the medication room that are stocked with intravenous fluids [IV fluids, sterile solutions administered directly into a patient’s veins to provide hydration, deliver medications, or supply essential nutrients and electrolytes] and medications) designated for entry by authorized personnel, were secured and not accessible to unauthorized individuals, in accordance with the facility’s policy and procedure regarding medication storage areas. This deficient practice had the potential to compromise the safety and security of medical supplies due to tampering or theft, as well as the sterility (free from germs) of the environment, increasing the risk of contamination, which could negatively impact patient care and safety. (Refer to A-0398) 12. The facility failed to ensure three of three Security Guards (Security Guard 1, 2, and 3) completed their Restraint training annually, in accordance with the facility’s policy and procedure regarding restraints (devices that limit a patient’s movement). This deficient practice had the potential for security guards 1, 2, and 3 being unable to safely monitor and assist with patients who have restraints, which may result in injury to patient or the staff. (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“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: 46238 Based on interview and record review, the facility failed to ensure the Condition of Participation for Discharge Planning was met as evidenced by: 1. The facility failed to actively engage one of thirty (30) sampled patients (Patient 1) and/or patient’s family/ representative(s) in the development of a discharge plan for Patient 1 as well as failed to document the discharge plan evaluation within 24 hours after patient’s (Patient 1) admission to the facility in accordance with the facility’s policy and procedure regarding the discharge process (the transition of a patient from the hospital to another level of care such as home). This deficient practice had the potential for Patient 1 and Patient 1’s representatives to not fully understand the discharge care needs of Patient 1 which can impact patient outcomes such as compliance with treatment regimen and reduction of unplanned readmission. This deficient practice can also result in the violation of Patient 1’s rights when the patient (Patient 1) and/or Patient 1’s representative were not included in Patient 1’s discharge planning. (Refer to A-0808) 2. The facility failed to ensure that appropriate referrals (wound care services, physical therapy services) were arranged and coordinated with contracted services prior to discharge for one of 30 sampled patients (Patient 1), in accordance with the facility’s policy and procedure regarding discharge planning (the process of preparing a patient to leave the hospital and transition to the next level of care). This deficient practice had the potential for Patient 1’s condition to worsen post-discharge due to lack of aftercare (the care and support that patients receive after hospitalization). This deficient practice may also result in readmission or poor quality of life and/or death. (Refer to A-0813) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 42937 Based on observation, interview, and record review, the facility’s Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies and assisting with strategic planning and decision-making), failed to ensure the Nursing Department’s compliance with the facility’s policy for 1:1 sitter (a patient observer or constant observer, is a healthcare staff member assigned to monitor a single patient continuously) regarding the management of one of 30 sampled patients (Patient 5) on 5150 hold (an involuntary psychiatric hold in California for individuals who are considered a danger to themselves or others) outside of the mental health unit. Patient 5 was on a 5585 hold (an involuntary hold for minors under the age of 18 who are deemed a danger to themselves or others or are gravely disabled [unable to meet basic needs such as feeding, hygiene, etc.] due to a mental disorder, allowing for a 72-hour psychiatric evaluation [a mental health assessment to help diagnose and treat mental health problems]) due to suicidal ideation (SI, thoughts of causing one’s own death), which involved thoughts or planning related to self-harm or suicide (death caused by injuring oneself with the intent to die). Patient 5 was not provided a 1:1 sitter per policy. This deficient practice had the potential to compromise patient safety and increase the risk of harm to Patient 5 and other patients and may also result in death. Findings: During a concurrent observation and interview on 10/29/2024 at 1:55 p.m. in the Emergency Department (ED, provides immediate care for patients with serious illnesses or injuries), in the area/room called the Main area, Patient 5 was observed inside the room, seated on a hospital gurney in the corner, with the gurney partially obscured by a privacy screen. Patient 5 did not have a 1:1 sitter (a patient observer or constant observer, is a healthcare staff member assigned to monitor a single patient continuously) or a security guard stationed next to Patient 5. The registered nurse (RN 3) was seated behind the desk in the room, while two security guards were positioned near the entrance. There were 4 patients in the room. RN 3 stated that Patient 5 was on a 5585 hold) due to suicidal ideation (SI, thoughts of causing one’s own death), which involves thoughts or planning related to self-harm or suicide (death caused by injuring oneself with the intent to die). During a review of Patient 5’s medical record (MR) titled, “Behavioral Health Forms,” dated 10/28/2024, the MR indicated that on 10/28/2024, Patient 5 was brought into the facility’s ED by the Los Angeles Sheriff’s Department (LASD) and placed on a 5585 hold for suicidal ideation (SI) and cutting wrists. The MR also indicated that Patient 5 stated they had a specific suicide plan and that they required to be transferred to an age-appropriate psychiatric facility. During a concurrent interview and record review on 10/30/2024 at 3:35 p.m. with the Clinical Quality Coordinator (CQC), Patient 5’s medical record (MR) titled, “Psychosocial Assessment” flowsheet, dated from 10/28/2024 through 10/31/2024, was reviewed. The CQC verified that the MR did not contain a “Suicidal Ideation Risk Assessment,” completed by ED nurses for Patient 5 to assess and evaluate the patient for present thoughts about self-harm and suicide. During an interview on 10/31/2024 at 3:41 p.m. with the Emergency Department Charge Nurse (CN 2), the CN 2 described the setup for managing psychiatric patients (patients with mental health issues) in the ED. CN 2 stated, “In the ED, we place all psychiatric patients in the same area. We have security guards assigned to that area, typically 2-3 guards, depending on the number of patients, and one or two licensed nurses, also depending on the number of patients in the room. There is not one security guard per patient. They are all tasked with monitoring for any aggression. They are there to de-escalate (to reduce the intensity of a potentially violent situation) situations and assist the nurse as needed.” During an interview on 10/31/2024 at 4:25 p.m. with the Senior Director of Nursing Administration (SDNA) also known as house supervisor, the SDNA outlined the process and requirements for ordering a 1:1 sitter. The SDNA stated, “We usually know all the holds. My team is aware of all the patients-we know when they come in, their details, and if they are on a hold. We proactively check with the charge nurse to determine if a sitter is needed, even before an official hold is placed.” During the same interview on 10/31/2024 at 4:25 p.m. with the SDNA, the SDNA also stated, “A 1:1 sitter assists a specific patient, ensures the area is safe, and does not leave the bedside without someone to relieve them. They work closely with the team and must document every 15 minutes. We have safety attendants, patient observation attendants, and nurse techs (technician). Security guards can also serve as sitters, but they don’t provide clinical care and still need to document every 15 minutes. For patients with suicidal ideation (SI), these patients are evaluated and placed on a hold. We enter the room, secure the environment, immediately assign a sitter within arm’s length, and screen visitors to ensure safety.” During an interview on 10/31/2024 at 4:45 p.m. with the Emergency Department Manager (EDM), the EDM described the facility’s approach to managing patients with psychiatric mental health issues. The EDM stated, “We typically place all patients with psychiatric mental health issues in one room, referred to as the Main area, which has 8 beds with no dividers and no curtains.” The EMD also stated, “Typically we assign 1 RN and 1 LVN for 6 patients, and 2 RNs for 8 patients. Security coverage is determined by security leadership, with a minimum of 2 security guards assigned. We use security to prevent patients from wandering away from the area and to ensure the patients’ safety.” During the same interview on 10/31/2024 at 4:45 p.m. with the EDM, the EDM also stated, “We sometimes call for sitters for patients with suicidal ideation (SI) or homicidal ideation (HI, the act of thinking about, considering, or planning to kill another person). We contact the house supervisor to request a sitter, but they don’t always provide one due to availability issues. If no sitter is available, we then call security to see if they have enough staff to sit with the patient. If neither is available, we assign a technician to sit with the patient. However, not all patients on holds require a 1:1 sitter or receive one.” During the same interview on 10/31/2024 at 4:45 p.m. with the EDM, the EDM reviewed the facility’s policy titled, “Involuntary Detention (Holds), dated 5/2024 and stated, “The policy is correct stating that each patient on a hold must be provided with 1:1 or security supervision. However, we do not follow this exactly. Instead, we place all patients in one room with security because it is considered a ligature-free environment (a space designed to eliminate or minimize potential ligature (something used to bind or tie. Example: belts, shoelaces, etc.) points, such as areas where a person could attach a cord, rope, or other material to inflict self-harm through strangulation (compression of the neck that may lead to unconsciousness or death) or hanging. This type of environment is crucial in healthcare settings, especially in psychiatric units or emergency departments where patients may be at risk of suicide or self-harm).” During an interview on 11/1/2024 at 12:48 p.m. with the Senior Director of Operations (SOD) regarding the facility’s policy titled, “Involuntary Detention (Holds),” dated 5/2021, the SOD stated, “This policy is primarily for inpatient patients, but since it does not differentiate, it applies to all patient care areas.” The SOD explained, “On the inpatient floors, if a patient is on a hold, they are assigned sitters. In behavioral health, it’s managed differently. In the emergency department, we try to keep all patients with psychiatric mental health issues, whether on a hold or not, in the same area called the Main area. These are ED patients, not BHU (Behavioral Health Unit, provides treatment and stabilization for patients with mental health issues) patients, even if they’re on a hold. They are meant to remain under direct observation in the main room, so they’re constantly in sight.” During an interview on 11/1/2024 at 2:21 p.m. with Risk Management (RM) and the Quality Management Manager (QMM) about the facility’s latest performance improvement projects in the Emergency Department (ED), the RM stated that the performance improvement team recently identified a need to strengthen processes for managing patients with suicidal ideation and other high-risk patients in the ED. The RM stated, “We’re looking at how we are screening in triage (categorize patients based on the severity of their injuries), how we protect patients, especially those who are high-risk, how we’re documenting safety checks and addressing ligature risks. We’re also examining our process for obtaining sitters for high-risk patients. We reached out to our electronic health record (HER. Digital version of paper chart) provider to see if they could incorporate built-in tools to help improve our screening process to identify patients with suicidal ideation.” During the same interview on 11/1/2024 at 2:21 p.m., the RM further explained, “A big part of this work is about identifying patients with suicidal ideation (SI). We’ve (Risk Management team) started auditing those SI patients over the past few weeks to identify any gaps, like missed orders or medications. We’re also discussing order sets and looking at ways to proactively push the sitter order, so it doesn’t have to be manually pulled.” The RM added, “We’re revising the policy to ensure it aligns with evidence-based practice because, ultimately, we want to make sure we’re providing the best possible care.” The RM stated that this process is collaborative, with a multidisciplinary team, including ED education, ED leadership, and all key stakeholders. During an interview on 1/11/2024 at 3:58 p.m. with the Chief Executive Officer (CEO), the CEO described the responsibilities of the Board of Directors, stating, “The Board oversees the operations and quality of care at the hospital. Department heads, executives, and the Board are responsible for overseeing policies and their implementation within each department. This oversight ensures that each department follows established guidelines and remains compliant with organizational standards and regulations. The Board holds ultimate accountability, working closely with department leaders and executives to ensure policies are effectively implemented and consistently followed across the organization.” In the same interview on 11/1/2024 at 3:58 p.m. with the Chief Executive Officer (CEO), the CEO described the process and responsibilities for reviewing and implementing policies. The CEO stated, “The policies are reviewed annually, I think. The owner of the policy, the director or the head of the department is responsible for the policies in their departments. If it is nursing, the Director of Nursing signs off on them. Some of the policies go to the Board of Directors, but not all of them.” During an interview on 11/1/2024 at 4:09 p.m. with the Chief Nursing Officer (CNO), regarding the policy titled, “Involuntary Detentions (Holds)”, dated 5/2021, the CNO stated that the policy was current and remained in effect, adding, “Until I know otherwise, it stands. If it’s an involuntary hold, patients are automatically required to have a sitter. For patients on a hold who are identified as dangerous, additional safety measures are put in place. We are contracted with an outside company that provides sitters for each patient on a hold.” During an interview on 11/1/2024 at 4:09 p.m. with the Chief Nursing Officer (CNO) regarding policy implementation in the facility, the CNO stated, “We’re validating implementation of policies through observations and documentation. Although, through our assessments, we’ve identified a need to develop an improvement project that is currently in progress.” During a review of the facility’s policies and procedures (P&P) for the care of patients on 5150 holds, dated 5/2021, the P&P indicated that all patients on a hold require 1:1 sitter or a security guard assigned for direct observation. A review of the facility’s policies also indicated a lack of policies or guidelines outlining the required assessments and documentation for nursing staff when caring for mental health patients on either 5150 (an involuntary psychiatric hold in California for individuals who are considered a danger to themselves or others) or 5585 holds who are awaiting transfer to a psychiatric hospital in the emergency department. During an interview on 11/1/2024 at 4:16 p.m. with the Chief Nursing Officer (CNO), the CNO stated, “We have identified the issues with the way we manage psychiatric patients. We recognize the need for improvement in assessing and identifying gaps to provide the best care possible.” During a review of the facility’s policy and procedure (P&P) titled, “Involuntary Detention (Holds)” dated 5/2021, the P&P indicated that all patients placed on 5150 holds, regardless of diagnosis, are to be assigned to a private or blocked room with a 1:1 observer (security sitter, nurse technician, or patient safety attendant) responsible for ensuring patient safety. The 1:1 observer will be positioned either in the room or directly outside, with a clear view of the patient at all times. If a private or blocked room is unavailable, the patient will remain in the Emergency Department (ED) under the supervision of a security guard, and transfer arrangements to a medical psychiatric facility will be initiated. Additionally, all in-house psychiatric patients located outside the mental health unit are to be assigned both a medical RN and a Mental Health RN to address their medical and mental health needs, along with a 1:1 sitter. If a Mental Health RN is unavailable, the patient will stay in the ED with a security guard to ensure their safety.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 46238 Based on observation, interview, and record review the facility’s Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure the facility’s contracted Managed Care personnel ensure the discharge planning process (the process of preparing a patient to leave a healthcare facility, and ensuring a smooth and safe transition to the next phase of care such as going home, moving to a rehabilitation center, nursing home, or other healthcare setting) promoted safe, effective patient transition from hospital to their next level of care, for one (Patients 1) of 30 sampled patients. This deficient practice had the potential to result in negative consequences for patients, post [after]-discharge leading to higher patient re-admission rates and worsening of their conditions due to delays in care coordination or inadequate follow-up care set-up. In addition, this deficient practice violated patients’ and their caregivers’ rights when they were not involved in the discharge planning process. Findings: During a review of Patient 1’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty breathing), and found to have aspiration pneumonia (a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues). The H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke (clot in the brain) with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall). During a review of Patient 1’s Medical Record (MR) titled, “Discharge Summary,” dated 7/24/2024, the MR indicated that Patient 1 was at high risk for re-aspiration (Re-aspiration refers to the repeated inhalation of food, liquid, saliva, or other foreign material into the lungs, which can lead to serious complications like pneumonia or respiratory distress. Patients at high risk for re-aspiration require careful monitoring and specific care measures to prevent further aspiration events), though the family wanted to take the patient home. The MR also indicated that Patient 1 required tube feeding, home health services, in-home physical therapy (treatment that uses a combination of techniques to help patients improve their movement, relieve pain, and strengthen muscles), supplemental oxygen, durable medical equipment (DME, medical equipment that can be used repeatedly and is intended to be used in a patient’s home for a medical purpose), including a hospital bed. During a concurrent interview and record review on 10/31/2024 at 9:35 a.m. with the Clinical Quality Coordinator (CQC), Patient 1’s medical record was reviewed for discharge planning documentation. The record indicated that no case management notes were recorded in Patient 1’s chart from 7/12/2024 through 7/22/2024, which the CQC confirmed. Additionally, the medical record contained a note titled, “Case Management (CM),” dated 7/22/2024, indicating that a case manager documented their first contact with Patient 1’s family representative on 7/22/2024, only two days before Patient 1’s discharge from the facility with an anticipation to discharge Patient 1 the following day, on 7/23/2024. During an interview on 10/31/2024 at 11:26 a.m. with Registered Nurse (RN 2) regarding the facility’s discharge process, RN 2 stated, “The case manager (CM) is responsible for relaying information about home health services, durable medical equipment (DMEs), and transportation arrangements.” RN 2 further explained that, typically, the CM would call the nurse to inform them about any DMEs, and other arrangements. “Sometimes it’s documented in the patient’s chart and sometimes it’s not,” RN 2 added. “I’m not sure if I typically document this information after receiving a call from the CM.” During the same interview on 10/31/2024 at 11:26 a.m. with Registered Nurse (RN 2) regarding Patient 1’s discharge instructions dated 7/24/2024, RN 2 reviewed the discharge instructions and stated, “Based on what is documented, arrangements were made for blood glucose (sugar) monitoring, an enteral feeding (a liquid nutritional formula is delivered through a tube that is inserted into the stomach or small intestine) pump, and a transfer aid for Patient 1. However, nursing, and physical therapy are noted as ‘none arranged,’ and I cannot recall if I received a call from the CM about those services. I also don’t remember for certain if all the DMEs and services were arranged or which ones, as it’s not documented.” During a review of Patient 1’s MR titled, Case Management,” dated 7/23/2024 at 4:43 p.m., the MR indicated Patient 1’s discharge was delayed because a hospital bed had not yet been delivered. Patient 1’s MR contained no additional notes recorded by the CM on any other days during Patient 1’s hospital stay. The MR contained no recorded confirmation of delivery of the hospital bed and home health services in Patient 1’s medical record either. During an interview on 10/31/2024 at 12:00 p.m. with Director of Case Management services (DCM) regarding the facility’s discharge planning process, the DCM stated that discharge planning begins within 24 hours of admission and involves case managers, nurses, and other healthcare team members. Case managers would complete the discharge planning screening within the first 24 hours and the process would include discussing patient needs post (after)-discharge, such as home health, durable medical equipment (DME), and other supports, and should be documented thoroughly. For instance, orders for home health services (such as nursing or wound care) should include contact information and the service start date. Similarly, DME orders (like oxygen) should specify requirements (e.g., oxygen levels) and coordinate delivery timing. Documentation should include the agency’s contact details, insurance, and patient-specific requirements. During the same interview on 10/31/2024 at 12:00 p.m. with the DCM, the DCM stated that there had been a challenge with documentation by contracted case managers, particularly with two contracted groups, as they often use separate systems for documentation. Although they have access to the facility’s electronic medical records and they should follow hospital policies, documentation had been inconsistent. “We have reached out to contracted groups to improve documentation and facilitate physical visits (both contracted groups only conduct their case management visits remotely by phone and through chart reviews) by case managers. Despite some improvement after meetings with one of the contracted groups (CG 1), documentation continues to remain a concern, especially with the second contracted group (CG 2), who has not responded to meeting requests, including offers for virtual conferences.” During the same interview on 10/31/2024 at 12:00 p.m. with the Director of Case Management (DCM), DCM stated that hospital staff, specifically the facility’s case managers, frequently step in to address patient needs when contracted case managers do not follow through, aiming to prevent any delays in patient care. The DCM noted there was an ongoing effort to enhance compliance and improve documentation practices to ensure patient safety and continuity of care. Additionally, the DCM explained that oversight of contracts with medical groups regarding case management responsibilities lies with either the Senior Director of Operations (SOD) or the DCM, with final approval resting with the Chief Executive Officer (CEO). During an interview on 10/31/2024 at 1:38 p.m., with Senior Director of Operations (SOD), member of the Governing Body, the SOD stated that oversight for contracted case managers was provided by themselves (referring to members of the GB) and the Director of Case Management. Multiple attempts have been made to reach out to the contracted groups, and recently there had been a meeting with CG 1, but there had been no response from CG 2. In addition, the SOD stated that since starting their role in late April/early June (2024), the SOD, along with DCM, had prioritized addressing these case management challenges, which had been ongoing. They had initiated outreach to the medical groups to improve service delivery and have taken steps to address the most urgent needs, particularly during night shifts when many patients arrive through the Emergency Department (ED) and required immediate case management contact. The SOD created two full-time equivalent (FTE) positions specifically to handle these issues. Two case managers had been hired to cover overnight shifts, where many issues arise, ensuring that case management was available during critical hours. During the same interview with the SOD, the SOD mentioned that the contract with CG 2 was expiring, and renewal is uncertain due to service inconsistencies. The SOD emphasized that contracted case managers were expected to follow hospital policies, including documentation in patient charts. However, contracted case managers were currently on-call rather than on-site and do not consistently report their visits. The SOD noted that these case managers were once on-site but moved to remote work during COVID-19 (infectious disease caused by a virus), and requests for them to return to on-site work had been declined. The SOD also stated that the CEO and Chief Financial officer (CFO), both members of the GB, were actively involved in contract negotiations with both CG 1 and CG 2 and were fully aware of the challenges and service issues with these groups. The SOD had kept leadership informed of the difficulties in ensuring adequate case management coverage and documentation. During an interview on 11/1/2024 at 3:38 p.m. with the Chief Executive Officer (CEO), the CEO was interviewed regarding addressing gaps in case management services and efforts to hold contracted case managers accountable with hospital policies and procedures. The CEO stated that as part of the facility’s contract with CG 1 and CG 2, which “we revise every few years due to financial changes, these groups act as a provider network responsible for certain patient care tasks. Although the contract does not explicitly define specific duties, the expectation is for them to follow our facility’s policies and procedures. If they fail to do their job correctly or violate any policies, the responsibility ultimately falls on the facility to ensure the job is completed and policies are adhered to.” The CEO further stated, “As Director, I am responsible for ensuring that CG 1 and CG 2 follow our policies and procedures. If any issues arise regarding their compliance or performance, it remains my duty to address and correct them to maintain our organizational standards.” During the same interview on 11/1/2024 at 3:58 p.m. with the CEO, the CEO stated that department heads, executives, and the governing board were responsible for overseeing the policies and their implementation within each department. This oversight ensures that each department follows established guidelines and maintains compliance with organizational standards and regulations. The board holds the ultimate accountability, working with department leaders and executives to ensure policies are effectively put into practice and consistently followed throughout the organization. During a review of the facility’s policy and procedure (P&P) titled, “Discharge Planning,” dated 9/2024, the P&P indicated that the facility provides Discharge Planning for all patients according to federal and state regulatory requirements. Patients requiring complex discharge planning are referred to the Case Management department, which arranges necessary services and care based on available resources and authorizations. The P&P states that discharge planning should begin at the time of admission. Additionally, case managers from local medical groups are involved in the discharge planning process and are required to document in the facility’s electronic health record. The case manager (CM) is responsible for periodically reassessing patients with complex or high-risk discharge needs and must document these assessments in the patient’s medical record. During a review of the facility’s Governing Body Bylaws (GBB), also known as “District Bylaws,” last reviewed and approved on 2/24/2021, that govern the facility’s [Organization], the GBB indicated that the Board of Directors is ultimately responsible for the quality of care provided by the [organization] such as mechanisms and policies designed to ensure the provision of quality patient care. The CEO of the institution shall have the responsibility to translate the Board of Director’s policies into actual operations and shall have the authority to establish and communicate personnel policies and practices that adequately support sound patients care.”

“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: 46238 Based on interview and record review, the facility failed to: 1. Ensure one of 30 sampled patient’s (Patient 1) physician was notified regarding Patient 1’s change of condition (clinically important deviation from a patient’s baseline in physical, cognitive [anything related to learning, thinking, and understanding], behavioral or functional domains), in accordance with the facility’s policy and procedure regarding physician notification, when Patient 1’s vital signs (the basic physiological measurements that reflect the essential functions of the body) indicated increased respiratory rate (38 and 24 breaths per minute; normal respiratory rate is 20) and a low blood pressure (105/53 mmHg [a unit of measurement]; Normal BP is 120/90) on the day of discharge. The facility also failed to re-assess and document Patient 1’s latest vital signs prior to discharge, in accordance with the facility’s policy and procedure regarding reassessment and documentation. This deficient practice had the potential to result in delay of immediate interventions needed and may result in worsening of Patient 1’s condition including complications such as respiratory distress (a serious lung condition that causes low blood oxygen), severe hypotension (extremely low blood pressure, and/or death. 2. Ensure Patient 1 was placed on a specialty bed (a low-air loss mattress a type of air mattress that helps prevent and treat pressure wounds by constantly circulating air and relieving pressure on the body) as per wound care nurse’s recommendations. This deficient practice resulted in Patient 1 developing pressure injury Stage II (a partial-thickness loss of skin that appears as an open wound, blister [a fluid-filled sac that forms on the skin], or abrasion [a minor injury to the skin that occurs when the surface layers of the skin are broken]). Findings: 1. During a review of Patient 1’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty breathing), and found to have aspiration pneumonia (a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues). The H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall). During a review of Patient 1’s Vital Signs (VS, basic physiological measurements that reflect the essential functions of the body including heartbeat, breathing rate, temperature, blood pressure, and pain level) flowsheet, dated 7/24/2024, the VS flowsheet indicated that on 7/24/2024: At 8:00 a.m., Patient 1’s respiratory rate (RR) was recorded at 38 breaths per minute (bpm) [a normal respiratory rate for an adult at rest is 12 to 20 bpm], blood pressure (BP) was recorded at 137/77 mmHg (BP is measured in millimeters of mercury, with a typical normal adult range around 120/80 mmHg. The systolic value of 137 indicates slightly elevated pressure, while the diastolic value of 77 falls within the normal range), and heart rate (HR) was documented at 81 beats per minute (bpm) [a normal resting heart rate for adults typically ranges from 60 to 100 bpm]. At 9:21 a.m., Patient 1’s RR was recorded at 24 bpm, BP was 125/68 mmHg, and HR was 77 bpm. At 11:30 a.m., Patient 1’s RR was not recorded, BP was 105/53 mmHg, and HR was not recorded. During a concurrent interview and record review on 10/31/2024 at 11:56 a.m. with the Safety and Quality Coordinator (SQC), Patient 1’s medical record was reviewed. The SQC confirmed that Patient 1’s medical chart contained no documentation indicating that the physician was notified about Patient 1’s abnormally elevated respiratory rate and decreased blood pressure. During a concurrent interview and record review on 10/31/2024 at 11:41 a.m. with registered nurse (RN 2) Patient 1’s VS flowsheet was reviewed. The RN 2 stated “I am not sure why there is only the blood pressure that was documented for Patient 1 on 7/24/2024 at 11:30 a.m.” The RN 2 stated that nurses do need to obtain full set of vital signs prior to discharge and any changes in patient’s vital signs should be communicated to the physician. During an interview on 10/31/2024 at 11:56 a.m. with the Director of Oncology and Neuro Departments (Dir 2), after reviewing Patient 1’s vital signs (VS) flowsheet dated 7/24/2024, Dir 2 stated, “The patient’s respiratory rate of 38 bpm, recorded at 8:00 a.m. on 7/24/2024, as well as the decreased blood pressure recorded at 11:30 a.m. on the same day, should have been communicated to the physician. Both indicate a change from the patient’s baseline measurements, and a complete set of VS should have been obtained and recorded by the nurse prior to discharge.” During a review of the facility’s policy and procedure (P&P), titled, “Initial Patient Assessment and Re-assessment,” dated 3/2024, the P&P indicated, “The assessment of the care or treatment required to meet the needs of the patient will be ongoing throughout the patient’s hospital stay, with the assessment process individualized to meet the needs of the patient population. Reassessment shall occur when an intervention has taken place or if there is a change in patient condition or status. IX. Any change in the patient’s condition shall require an immediate reassessment with changes in the plan of care.” During a review of the facility’s policy and procedure (P&P) titled, “Initial Patient Assessment and Reassessment” dated 3/2024, the P&P indicated that vital signs will be recorded in the patient’s electronic health record (EHR) on designated records specified by the nursing unit. Significant variations need to be reported to the charge nurse and physician. During a review of the facility’s policy and procedure (P&P) titled, “Initial Patient Assessment and Reassessment” dated 3/2024, the P&P indicated that a registered nurse (RN) is responsible for collecting and analyzing data about the patient, determining the need for further data collection, identifying the patient’s healthcare treatment needs, and planning appropriate care or treatment. The P&P also indicated that all healthcare disciplines involved in the patient’s care are required to perform assessments and reassessments in compliance with state licensure laws and relevant regulations. Each discipline must conduct these assessments within its specific scope of practice. 2. During a review of Patient 1’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty in breathing), and found to have aspiration pneumonia ( a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues). The H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke (clot in the brain) with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall). During a review of Patient 1’s medical record (MR) titled, “HAPI (Hospital acquired pressure injury, localized injury to the skin or tissue that occurs during a hospital stay) Prevention Checklist,” dated 7/12/2024 at 10:40 p.m., the MR indicated, that on 7/12/2024, Patient 1 had no identified pressure injuries, had middle upper back dry skin tear (traumatic wound that occurs when the skin separates from the underlying layers), redness to sacrum (a triangular bone at the base of the spine)/buttocks area, and both ankles suspected deep tissue injury (DTI, 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 [a mechanical force that occurs when tissue layers move in opposite directions). During a review of Patient 1’s MR, dated 7/13/2024, the MR indicated Patient 1 was evaluated by the wound care nurse on 7/13/2024 at 1:23 p.m. and ordered a specialty bed with low-air loss mattress (designed to help prevent and treat pressure injuries) for Patient 1. During a review of Patient 1’s medical record (MR), under the entry titled, “Wound Note,” dated 7/19/2024, it was documented that the wound care nurse (WCN) reassessed Patient 1 on that date (7/19/2024) and identified a Stage II pressure injury (partial-thickness skin loss with exposed dermis) on the patient’s (Patient 1) left hip. The MR also indicated that the WCN documented the need for Patient 1 to be placed on a low air-loss bed to reduce pressure and promote healing and placed a call to the contracted company to order a specialty bed for Patient 1. During a concurrent interview and record review on 10/31/2024 at 10:00 a.m. with the clinical quality coordinator (CQC), Patient 1’s medical record was reviewed. The CQC verified that Patient 1’s MR contained no documentation indicating that Patient 1 was placed on a specialty bed at any point during their admission from 7/12/2024 through 7/24/2024. During an interview on 10/31/2024 at 10:26 a.m. with the Director of Oncology and Neuro Departments (Dir 2), regarding specialty beds, the Dir 2 stated “If we don’t have a specialty bed in-house, we should call the rental company to order it. While bed delivery may take a few hours, it should not take days to deliver a specialty bed. The primary nurse was responsible for following up on the status of the specialty mattress order to ensure timely delivery and availability for patient care. If there were delays and the bed is not delivered within the expected timeframe, the primary nurse should escalate the issue to higher management, such as the charge nurse or director.” During a review of the facility’s policy and procedure (P&P) titled, “Skin Care Assessment,” dated 7/2023, the P&P stated that all licensed nurses are permitted to perform skin assessments, initiate prevention interventions, implement wound treatment orders, and coordinate multidisciplinary efforts to prevent and optimize the management of pressure injuries. The P&P also indicated that specialty beds, such as low-air-loss mattresses, should be ordered through the Wound Care department or by contacting the manufacturer directly when a patient requires placement on a low-air-loss mattress. During a review of the facility’s policy and procedure (P&P) titled, “Initial Patient Assessment and Reassessment,” dated 3/2024, the P&P indicated that a registered nurse (RN) is responsible for collecting and analyzing data about the patient, determining the need for further data collection, identifying the patient’s healthcare treatment needs, and planning appropriate care or treatment.”

“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: 42937 Based on interview and record review, the facility failed to: 1. Ensure one of 30 sampled patient’s (Patient 12) nursing care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) for chest tube care (a flexible tube that’s inserted into the chest cavity to drain fluid, blood, or air) was initiated, in accordance with the facility’s policy and procedure regarding care plans. This deficient practice had the potential to result in delayed provision of care when the patient’s (Patient 12) needs and risks are not identified. This deficient practice also had the potential to result in complications such as infection, dislodgement of the tube, etc. which may worsen Patient 12’s condition leading to prolonged hospitalization and recovery. 2. Ensure one of 30 sampled patient’s (Patient 13) nursing care plan for aspiration precaution (measures to prevent food, liquid, saliva, or foreign objects from entering the lungs) was initiated, in accordance with the facility’s policy and procedure regarding care plans. This deficient practice had the potential to result in delayed provision of care when the patient’s (Patient 13) needs and risks are not identified. This deficient practice also had the potential to result in complications such as aspiration pneumonia (a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents), etc. which may prolong Patient 13’s hospitalization and recovery. 3. Ensure one of 30 sampled patient’s (Patient 14) nursing care plan regarding the use of incentive spirometry (a treatment that uses a handheld device to help patients improve lung function by breathing in slowly and deeply), was initiated, in accordance with the facility’s policy and procedure regarding care plans. This deficient practice had the potential to result in delayed provision of care when the patient’s (Patient 14) needs and risks are not identified. This deficient practice also had the potential to worsen Patient 14’s condition by not addressing the respiratory care needs, which may result in complications such as respiratory distress, etc. And may lead to prolonged recovery for Patient 14. 4. Ensure on of 30 sampled patient’s (Patient 15) nursing care plan to address cellulitis (a bacterial infection that affects the skin’s deeper layers, including the dermis and subcutaneous fat) such as an infection related care plan, was initiated, in accordance with the facility’s policy and procedure regarding care plans. This deficient practice had the potential to result in delayed provision of care when the patient’s (Patient 15) needs and risks are not identified. This deficient practice may also result in worsening infection, etc. and thus prolonging patient 15’s hospitalization. 5. Ensure staff follow and implemented the nursing care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 30 sampled patients (Patient 21), when staff did not monitor the daily weight of Patient 21, in accordance with the facility’s policy and procedure regarding care planning. This deficient practice had the potential for staff not being able to accurately monitor Patient 21’s weight changes, which may also impact adjustments in treatment regarding Patient 21’s nutritional status. Findings: 1. During a concurrent interview and record review, on 10/30/2024 at 3:16 p.m. with the Quality Coordinator (QC), Patient 12’s electronic medical record (EMR, a digital version of paper charting) indicated that on 10/27/2024, Patient 12 was seen in the emergency department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) with chief complaint of gunshot wound (GSW) to left shoulder and left chest. A chest tube (a flexible tube that’s inserted into the chest cavity to drain fluid, blood, or air) was placed in Patient 12’s left chest on 10/27/2024 at 2:25 a.m. Patient 12 was admitted and moved to the intensive care unit (ICU, for critically ill or injured patients that is staffed by specially trained medical personnel) on 10/27/2024 at 6:58 a.m. with a chest tube to his (Patient 12) left chest. During the same interview on 10/30/2024 at 3:16 p.m. with the Quality Coordinator (QC), the QC stated there was no record in Patient 12’s EMR that a care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) for chest tube care, was initiated. QC also said a care plan for chest tube care under impaired gas exchange (a serious condition that occurs when the lungs and heart are unable to provide enough oxygen to the body’s tissues) should have been initiated upon admission for Patient 12. QC said it was nursing standard of practice and policy that an individualized care plan must be developed, updated, and reviewed daily according to a patient’s individualized care needs. During a review of the facility’s policy and procedure (P&P) titled, “Patient Care Planning,” with last revised date of 4/2024, the P&P indicated the following: Each patient has unique expectations, characteristics, and needs including those dictated by the patient’s age and the severity of disease, condition, impairment or disability for which services were sought. In order to provide care, treatment and rehabilitation to each patient effectively and efficiently, a multidisciplinary plan of care will be initiated for every patient admitted to [Name of the Facility]. The Care Plan is documentation of the plan for the patient’s care, treatment, and services based on needs identified by the admission assessment, reassessment and results of diagnostic testing. It shall be reviewed every 24 hours and updated as needed to ensure an appropriate plan of care individualized to each patient and their unique needs. The plan should be maintained and revised based on the patient’s response. II. The Care Plan is developed and revised in collaboration with the applicable disciplines of the Health Care Team and the patient/family. Every applicable discipline shall refer to the care plan and provide input relevant to their expertise, as appropriate for the patient’s condition and/or needs. III. The Care Plan shall reflect the patient’s unique needs and resources, utilize patient and/or family involvement, and be based on the patient’s goals, including the time frames, settings and services required to meet those goals. IV. Staff shall evaluate the patient’s progress, based on the goals established in the Care Plan. The Care Plan problems, goals, and actions shall be modified or closed, as clinically appropriate based on reassessment; patient’s need for further care, treatment, and services; or the patient’s achievement of goals and shall be closed at time of discharge. 2. During a concurrent interview and record review on 10/30/2024 at 3:30 p.m. with the Quality Coordinator (QC), Patient 13’s electronic medical record (EMR, digital version of paper charting) indicated that Patient 13 was admitted on 10/8/2024 for altered mental status (a general term that describes a change in how well the brain is functioning). A medical order (a directive from a health care provider that instructs how to care for a patient) was given by a doctor to place Patient 13 on aspiration precaution (measures to prevent food, liquid, saliva, or foreign objects from entering the lungs) on 10/8/2024 at 9:06 p.m. QC stated there was no record in Patient 13’s EMR that a care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) for aspiration precaution, was initiated. During the same interview on 10/30/2024 at 3:30 p.m. with the Quality Coordinator (QC), the QC said a care plan for aspiration precaution should have been initiated upon admission for Patient 13. QC said it was a nursing standard of practice and policy that care plan must be developed, updated, and reviewed daily according to patient individualized care needs. During a review of the facility’s policy and procedure (P&P) titled, “Patient Care Planning,” with last revised date of 4/2024, the P&P indicated the following: Each patient has unique expectations, characteristics, and needs including those dictated by the patient’s age and the severity of disease, condition, impairment or disability for which services were sought. In order to provide care, treatment and rehabilitation to each patient effectively and efficiently, a multidisciplinary plan of care will be initiated for every patient admitted to AVMC The Care Plan is documentation of the plan for the patient’s care, treatment, and services based on needs identified by the admission assessment, reassessment and results of diagnostic testing. It shall be reviewed every 24 hours and updated as needed to ensure an appropriate plan of care individualized to each patient and their unique needs. The plan should be maintained and revised based on the patient’s response. II. The Care Plan is developed and revised in collaboration with the applicable disciplines of the Health Care Team and the patient/family. Every applicable discipline shall refer to the care plan and provide input relevant to their expertise, as appropriate for the patient’s condition and/or needs. III. The Care Plan shall reflect the patient’s unique needs and resources, utilize patient and/or family involvement, and be based on the patient’s goals, including the time frames, settings and services required to meet those goals. IV. Staff shall evaluate the patient’s progress, based on the goals established in the Care Plan. The Care Plan problems, goals, and actions shall be modified or closed, as clinically appropriate based on reassessment; patient’s need for further care, treatment, and services; or the patient’s achievement of goals and shall be closed at time of discharge. 3. During a concurrent interview and record review on 10/31/2024 at 9:30 a.m. with the Quality Coordinator (QC), Patient 14’s electronic medical record (EMR, a digital version of the paper chart) indicated that Patient 14 was admitted on 10/29/2024 for Pneumothorax (a medical condition that occurs when air leaks from the lung and fills the space between the lung and chest wall) from an ATV (All-terrain vehicle) accident. A medical order (a directive from a health care provider that instructs how to care for a patient) was given by a doctor to provide Patient 14 an incentive spirometry (a treatment that uses a handheld device to help patients improve lung function by breathing in slowly and deeply) on 10/29/2024 at 8:19 p.m. During the same interview on 10/31/2024 at 9:30 a.m. with the Quality Coordinator (QC), QC stated there was no record in Patient 14’s EMR that a care plan for incentive spirometry was initiated. QC also stated a care plan for incentive spirometry under impaired gas exchange (a serious condition that occurs when the lungs and heart are unable to provide enough oxygen to the body’s tissues) should have been initiated upon admission for Patient 14. QC stated it was nursing standard of practice and policy that care plan must be developed, updated, and reviewed daily according to patient’s individualize care needs. During a review of the facility’s policy and procedure (P&P) titled, “Patient Care Planning,” with last revised date of 4/2024, the P&P indicated the following: Each patient has unique expectations, characteristics, and needs including those dictated by the patient’s age and the severity of disease, condition, impairment or disability for which services were sought. In order to provide care, treatment and rehabilitation to each patient effectively and efficiently, a multidisciplinary plan of care will be initiated for every patient admitted to AVMC The Care Plan is documentation of the plan for the patient’s care, treatment, and services based on needs identified by the admission assessment, reassessment and results of diagnostic testing. It shall be reviewed every 24 hours and updated as needed to ensure an appropriate plan of care individualized to each patient and their unique needs. The plan should be maintained and revised based on the patient’s response. II. The Care Plan is developed and revised in collaboration with the applicable disciplines of the Health Care Team and the patient/family. Every applicable discipline shall refer to the care plan and provide input relevant to their expertise, as appropriate for the patient’s condition and/or needs. III. The Care Plan shall reflect the patient’s unique needs and resources, utilize patient and/or family involvement, and be based on the patient’s goals, including the time frames, settings and services required to meet those goals. IV. Staff shall evaluate the patient’s progress, based on the goals established in the Care Plan. The Care Plan problems, goals, and actions shall be modified or closed, as clinically appropriate based on reassessment; patient’s need for further care, treatment, and services; or the patient’s achievement of goals and shall be closed at time of discharge. 4. During a concurrent interview and record review on 10/31/2024 at 11:22 a.m. with the Quality Coordinator (QC), Patient 15’s electronic medical record (EMR, digital version of paper chart) indicated that Patient 15 was admitted on 5/5/2024 for cellulitis (a bacterial infection that affects the skin’s deeper layers, including the dermis and subcutaneous fat) to his (Patient 15) left lower leg. During the same interview on 10/31/2024 at 11:22 a.m., QC stated there was no record in Patient 15’s EMR that a care plan for infection to address Patient 15’s cellulitis issue, was initiated. QC stated that a care plan related to infection prevention and treatment should have been initiated upon admission for Patient 15. QC also said it was nursing standard of practice and policy that care plan must be developed, updated, and reviewed daily according to patient’s individualized care needs. During a review of the facility’s policy and procedure (P&P) titled, “Patient Care Planning” with last revised date of 4/2024, the P&P indicated the following: Each patient has unique expectations, characteristics, and needs including those dictated by the patient’s age and the severity of disease, condition, impairment or disability for which services were sought. In order to provide care, treatment and rehabilitation to each patient effectively and efficiently, a multidisciplinary plan of care will be initiated for every patient admitted to AVMC The Care Plan is documentation of the plan for the patient’s care, treatment, and services based on needs identified by the admission assessment, reassessment and results of diagnostic testing. It shall be reviewed every 24 hours and updated as needed to ensure an appropriate plan of care individualized to each patient and their unique needs. The plan should be maintained and revised based on the patient’s response. II. The Care Plan is developed and revised in collaboration with the applicable disciplines of the Health Care Team and the patient/family. Every applicable discipline shall refer to the care plan and provide input relevant to their expertise, as appropriate for the patient’s condition and/or needs. III. The Care Plan shall reflect the patient’s unique needs and resources, utilize patient and/or family involvement, and be based on the patient’s goals, including the time frames, settings and services required to meet those goals. IV. Staff shall evaluate the patient’s progress, based on the goals established in the Care Plan. The Care Plan problems, goals, and actions shall be modified or closed, as clinically appropriate based on reassessment; patient’s need for further care, treatment, and services; or the patient’s achievement of goals and shall be closed at time of discharge. 5. During a review of Patient 21’s “Face Sheet,” dated 3/2023, the Face sheet indicated the following: Patient 21 was admitted to the hospital on 3/15/2023 for abdominal pain and was discharged from the hospital on 3/23/2023. During a review of Patient 21’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 3/2023, the “H&P” indicated the following: Patient 21 brought in for abdominal pain. Patient 21 had a history of bowel resection (a surgical procedure that removes a diseased or damaged or blocked part of the small or large intestine). During a concurrent interview and record review on 10/31/2024 at 10:02 a.m. with Quality Manager (QM) 1, Patient 21’s “Physician Orders and Care Plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process)” dated 3/2023, were reviewed. The Physician Orders indicated on 3/14/2023 there was an order to weigh Patient 21 daily. The Care Plan indicated Patient 21’s weight was to be monitored. QM 1 confirmed there was physician order for Patient 21 to be weighed daily and the care plan indicated to monitor Patient 21’s weight. QM 1 said staff should follow the physician order and the care plan selected. During the same interview and record review on 10/31/2024 at 10:02 a.m. with QM 1, Patient 21’s “Assessment Flowsheet,” dated 3/2023, was reviewed. The Assessment Flowsheet indicated Patient 21’s weight was only taken once on 3/15/2023. QM 1 stated the following: Confirmed Patient 21’s weight was only recorded one day on 3/15/2023. Staff was not following the care plan and physician order regarding daily weight. Staff was also not following the care plan policy. Staff will be educated. During an interview on 10/31/2024 at 10:17 a.m. with Director of Med Surg (Medical Surgical, a unit of the hospital that takes care of patients with a variety of medical and surgical conditions), Telemetry (a unit in the hospital where patients undergo continuous cardiac [heart] monitoring), & Oncology (a medical specialty that focuses on cancer) (DMTO) 1, DMTO 1 stated the following: DMTO 1 confirmed checking the electronic medical record (EMR) of Patient 21. Did not find daily weight monitoring done by the staff. Daily weight monitoring was the responsibility of assigned registered nurse. Will educate the staff. Staff did not follow the care plan policy. During a review of the facility policy and procedure (P&P) titled, “Patient Care Planning,” dated 2024, the P&P indicated, “Each patient has unique expectations, characteristics, and needs including those dictated by the patient’s age and the severity of disease, condition, impairment or disability for which services were sought. In order to provide care, treatment and rehabilitation to each patient effectively and efficiently, a multidisciplinary plan of care will be initiated for every patient admitted to [Name of the facility]. The Care Plan is documentation of the plan for the patient’s care, treatment, and services based on needs identified by the admission assessment, reassessment and results of diagnostic testing. It shall be reviewed every 24 hours and updated as needed to ensure an appropriate plan of care individualized to each patient and their unique needs. The plan should be maintained and revised based on the patient’s response.””

“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: 42976 Based on interview and record review the facility failed to: 1.a. Ensure that nursing staff re-assessed (a re-evaluation of a patient’s health status) and documented the pain level for one of 30 sampled patients (Patient 6) in accordance with the facility’s policy and procedure regarding pain re-assessment , after the administration of Morphine (a narcotic pain medication used to relieve moderate to severe pain by acting on the central nervous system to alter the perception of pain) to Patient 6. 1.b. Ensure that nursing staff addressed the pain level for one of 30 sampled patients (Patient 6) in accordance with the facility’s policy and procedure on pain management after the patient reported being in pain. 1.c. Ensure that nursing staff assessed and documented the pain level for one of 30 sampled patients (Patient 6) at a minimum each time Patient 6’s vital signs (includes temperature, blood pressure, respiratory rate, heart rate, pain level) were obtained and recorded, in accordance with the facility’s policy and procedure regarding nursing assessment and vital signs check. These deficient practices had the potential to result in delayed treatment and worsening of pain, negatively impacting the patient’s (Patient 6) comfort and recovery. 2.a. Ensure Patient 1 and/or their designated representative receive the necessary information and resources for safe and effective post-discharge care, when personalized teaching plan to educate Patient 1 and/or designated representative regarding management of G-tube care and medication administration (the process of delivering medication to a patient through a gastrostomy tube [G-tube, a tube that is inserted into the nose or mouth and passed into the stomach or small intestine]) at home, was not developed and provided to Patient 1 and/or designated representative. 2.b. Ensure Patient 1 and/or designated representative were provided with written and verbal discharge instructions for managing enteral feedings (a liquid nutritional formula is delivered through a tube that is inserted into the stomach or small intestine) and aspiration precautions (measures taken to minimize the risk of food, liquid, or other materials entering the lungs) to follow at home. 2.c. Ensure Patient 1 and/or designated representative were provided with discharge instructions and necessary guidance on wound care and treatment (the process of evaluating and treating wounds to promote healing, prevent infection, and reduce complications). These deficient practices had the potential for Patient 1 and/or designated representative not to receive the necessary education and guidance for managing Patient 1’s complex care needs at home, potentially increasing the risk of complications and or hospital readmission due to insufficient discharge preparation. 3. Ensure two of 30 sampled patients (Patient 3 and Patient 6) had their call light device (a device used by the patient to call for help) within reach, in accordance with the facility’s policy and procedure regarding call light use. This deficient practice had the potential for unmet needs for Patient 3 and Patient 6, as both were unable to call for assistance due to the absence or inaccessibility of the call light. This deficient practice had the potential to result in delayed treatment, potentially negatively impacting the provision of care for both patients. 4. Ensure that two of two sampled rooms (referring to the clean supply room and the medication room that were stocked with intravenous fluids [IV fluids, sterile solutions administered directly into a patient’s veins to provide hydration, deliver medications, or supply essential nutrients and electrolytes] and medications) designated for entry by authorized personnel, were secured and not accessible to unauthorized individuals, in accordance with the facility’s policy and procedure regarding medication storage areas. This deficient practice had the potential to compromise the safety and security of medical supplies due to tampering or theft, as well as the sterility of the environment, increasing the risk of contamination, which could negatively impact patient care and safety. 5. Ensure three of three Security Guards (Security Guard 1, 2, and 3) completed their Restraint training annually, in accordance with the facility’s policy and procedure regarding restraints (devices that limit a patient’s movement). This deficient practice had the potential for security guards 1, 2, and 3 being unable to safely monitor and assist with patients who have restraints, which may result in injury to patient or the staff. Findings: 1.a. During a review of Patient 6’s History and Physical (H&P, comprehensive assessment of a patient that includes taking a detailed medical history from the patient, followed by a physical examination to gather information about their current health condition), dated 10/29/2024, the H&P indicated that Patient 6 complained of generalized weakness and pain and was diagnosed with pancreatitis (sudden inflammation of the pancreas [ an organ that aids in digestion of food] that can cause severe abdominal pain, nausea [the urge to vomit], vomiting, and fever). During further review of Patient 6’s Medical Record titled, “VS (Vital signs, includes temperature, blood pressure, respiratory rate, heart rate, pain level) Flowsheet,” dated 10/29/2024, the MR indicated, on 10/29/2024 at 10:19 p.m., Patient 6’s pain level was documented as 7 out of 10 (a pain level 7 out of 10 on numeric scale indicated severe pain). During a review of Patient 6’s Medication Administration Record (MAR), dated 10/29/2024, the MAR indicated that on 10/29/2024, at 10:22 p.m., Patient 6 received 2 milligrams (mg, measuring unit) of Morphine (a narcotic pain medication used to relieve moderate to severe pain by acting on the central nervous system to alter the perception of pain). During a concurrent interview and record review on 10/31/2024 at 4:14 p.m. with the Clinical Quality Coordinator (CQC), Patient 6’s “VS Flowsheet,” dated 10/29/2024, was reviewed. The flowsheet contained no record of a pain reassessment for Patient 6 after the administration of Morphine on 10/29/2024 at 10:22 p.m. In addition, the medical record indicated that Patient 6’s pain level was not assessed or reassessed until a day later, when it was documented 8/10 (severe pain) at 4:10 p.m. on 10/30/2024. The CQC stated that nurses were expected to perform a pain reassessment within an hour after administering pain medication to evaluate its effectiveness and the patient’s response. During a review of the facility’s policy and procedure (P&P) titled, “Pain Assessment and Re-Assessment,” dated 9/2022, the P&P indicated that patients should be screened for pain alongside routine vital signs according to unit protocols. The policy encourages the appropriate use of analgesics and states that interventions should be made to relieve pain when reported. A reassessment of pain should occur within a clinically appropriate time frame based on the intervention used, with a reassessment required no later than 2 hours after the administration of pain medication. 1.b. During a review of Patient 6’s History and Physical (H&P, comprehensive assessment of a patient that includes taking a detailed medical history from the patient, followed by a physical examination to gather information about their current health condition), dated 10/29/2024, the H&P indicated that Patient 6 complained of generalized weakness and pain and was diagnosed with pancreatitis (sudden inflammation of the pancreas [ an organ that aids in digestion of food] that can cause severe abdominal pain, nausea, vomiting, and fever). During a concurrent interview and record review on 10/31/2024 at 4:14 p.m. with the Clinical Quality Coordinator (CQC), Patient 6’s “VS (Vital Signs, includes temperature, blood pressure, respiratory rate, heart rate, pain level) Flowsheet,” dated 10/30/2024, was reviewed. The Flowsheet indicated that on 10/30/2024 at 4:10 p.m., Patient 6’s pain level was documented as 8 out 10 (severe pain). During a review of Patient 6’s MAR, dated 10/30/2024, the MAR indicated that Patient 6 had a standing order for two different pain medications- Morphine (a narcotic pain medication used to relieve moderate to severe pain by acting on the central nervous system to alter the perception of pain) and Norco (pain medication that combines hydrocodone, an opioid pain reliever, with acetaminophen [Tylenol], a non-opioid analgesic) to be administered for pain as needed. The MR also indicated that no pain medication was recorded to have been administered to Patient 6 on 10/30/2024 for pain level at 8 out 10. During an interview on 10/31/2024 at 4:14 p.m. with the Clinical Quality Coordinator (CQC) regarding the facility’s pain management policy, the CQC stated that the nurse should have addressed Patient 6’s reported pain level of 8 out of 10 by providing necessary relief, but the nurse did not. During further review of Patient 6’s “VS Flowsheet,” dated 10/30/2024 through 10/31/2024, the flowsheet indicated that Patient 6 was not assessed or re-assessed for pain until the following day at 6:43 a.m., on 10/31/2024. During a review of the facility’s policy and procedure (P&P) titled, “Pain Assessment and Re-Assessment,” dated 9/2022, the P&P indicated that patients should be screened for pain alongside routine vital signs according to unit protocols. The policy encourages the appropriate use of analgesics and states that interventions should be made to relieve pain when reported. A reassessment of pain should occur within a clinically appropriate time frame based on the intervention used, with a reassessment required no later than 2 hours after the administration of pain medication. During a review of the facility’ policy and procedure (P&P) titled, “Patients’ Rights and Responsibilities,” dated 3/2022, the P&P indicated that that patients have the right to appropriate assessment and management of their pain, access to information about pain and pain relief measures, and the right to participate in pain management decisions. 1.c. During a review of Patient 6’s History and Physical (H&P, comprehensive assessment of a patient that includes taking a detailed medical history from the patient, followed by a physical examination to gather information about their current health condition), dated 10/29/2024, the H&P indicated that Patient 6 complained of generalized weakness and pain and was diagnosed with pancreatitis (inflammation of the pancreas, an organ responsible for producing enzymes that aid in digestion and hormones that help regulate blood sugar). During a review of Patient 6’s medical record (MR) titled, “Vital Signs (VS, includes temperature, blood pressure, respiratory rate, heart rate, pain level) Flowsheet,” dated 10/29/2024 the MR indicated that from 10/29/2024 at 5/52 p.m. through 10/31/2024 at 6:43 a.m., Patient 6’s Pain assessment was only recorded 3 times while VS were recorded with the frequency of every 4 hours. During an interview on 10/31/2024 at 4:14 p.m. with the Clinical Quality Coordinator (CQC), the CQC stated that nurses were expected to perform a pain assessment along with vital signs and more frequently if needed, in accordance with the facility’s policy. During a review of the facility’s policy and procedure (P&P) titled, “Pain Assessment and Re-Assessment,” dated 9/2022, the P&P indicated that patients should be screened for pain alongside routine vital signs according to unit protocols. The policy encourages the appropriate use of analgesics and states that interventions should be made to relieve pain when reported. A reassessment of pain should occur within a clinically appropriate time frame based on the intervention used, with a reassessment required no later than 2 hours after the administration of pain medication. During a review of the facility’ policy and procedure (P&P), titled “Patients’ Rights and Responsibilities,” dated 3/2022, the P&P indicated that that patients have the right to appropriate assessment and management of their pain, access to information about pain and pain relief measures, and the right to participate in pain management decisions. 2.a. During a review of Patient 1’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty breathing), and found to have aspiration pneumonia ( a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues). The H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall). During a concurrent interview and record review on 10/30/2024 at 4:03 p.m. with the Safety and Quality Coordinator (SQC), Patient 1’s medical record was reviewed. The SQC verified, Patient 1’s medical chart contained no documentation of teaching provided to Patient 1 or their family representative on safe G-tube care and medication administration. During a review of Patient 1’s Medical Record (MR) titled, “Discharge Summary,” dated 7/24/2024, the MR indicated that Patient 1’s family wanted to take the patient (Patient 1) home and Patient 1 required 5 days of antibiotic (medication used to treat bacterial infections) administration trough G-tube (gastrostomy tube, is a flexible tube inserted directly into the stomach through a small surgical opening in the abdomen. It is used to provide nutrition, fluids, and medications to patients who cannot take food or medicine by mouth) because of high risk for aspiration (accidental inhalation of food, liquid, or other material into the lungs). During a concurrent interview and record review on 10/30/2024 at 4:03 p.m. with the Safety and Quality Coordinator (SQC), Patient 1’s medical record was reviewed. The SQC verified, Patient 1’s medical chart contained no documentation of teaching provided to Patient 1 or their family representative regarding safe G-tube care and medication administration. During an interview on 10/31/2024 at 11:29 a.m. with Registered Nurse (RN) 2, who discharged Patient 1 on 7/24/2024, RN 2 reviewed Patient 1’s discharge instructions and stated, “I don’t know if teaching was ever provided to Patient 1’s family during the patient’s stay in the facility.” During an interview on 10/31/2024 at 11:49 a.m. with the Director of Oncology and Neuro Departments (Dir 2), Dir 2 stated, “A teaching plan and education on G-tube care and management, as well as enteral feeding (a liquid nutritional formula is delivered through a tube that is inserted into the stomach or small intestine) administration, should be conducted and documented during the patient’s stay to ensure these needs are met at home after discharge.” During a review of the facility’s policy and procedure (P&P) titled, “Admission, Direct Admission, Transfer, and Discharge,” dated 9/20/2022, the P&P indicated that discharged patients and/or their families must receive adequate healthcare education to address their immediate health care needs following discharge. The procedure requires the following steps: 1. Provide Discharge Education: The patient must receive comprehensive discharge education to prepare them for self-care or family support after they leave the facility. During a review of the facility’s policy and procedure (P&P) titled, “Patient/Family Teaching Plan,” dated July 2022, the P&P indicated that the educational needs of patients and their families must be assessed prior to any teaching and continuously throughout hospitalization. This formal assessment is documented in the multidisciplinary care plan and within the patient teaching area of the electronic chart. Teaching interventions may include, but are not limited to, the following areas: 1. Knowledge of Condition: Educating the patient and/or family about the patient’s medical condition. 2. Knowledge of Safe and Effective Use of Medications: Ensuring understanding of prescribed medications, including proper use and potential side effects. 3. Knowledge of Nutrition: Providing guidance on dietary needs as relevant to the patient’s condition. 4. Discharge Instructions: Preparing the patient and/or family for post-discharge care, including understanding treatment plans and managing ongoing care. During a review of the facility’s policy and procedure (P&P) titled, “Patient/Family Teaching Plan,” dated July 2022, the P&P indicated that patient and family education is closely linked to discharge planning, as discharge involves educating the patient on post-care management and reinforcing the physician’s specific discharge instructions. All teaching and discharge planning activities must be documented in the patient’s medical record, ensuring a clear and thorough record of the care and education provided. During a review of the facility’s policy and procedure (P&P) titled, “Documentation,” dated 8/2024, the P&P indicated, “The teaching method or plan used to educate the patient about their condition and treatment must be documented. This includes the approach taken for patient education, helping to ensure that all necessary information was provided to the patient and/or their family.” 2.b. During a review of Patient 1’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty breathing), and found to have aspiration pneumonia (a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues). The H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke (clot in the brain) with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall). During a review of Patient 1’s medical record (MR) titled, “Emergency Documentation,” dated 7/12/2024, the MR indicated that Patient 1 was transported to the facility by ambulance from a congregate health living facility (a residential care facility that provides medical and personal care for individuals with chronic illnesses, disabilities, or complex medical needs) where he resided prior their admission to the hospital on 7/12/2024. During a review of Patient 1’s MR titled “Discharge Summary,” dated 7/24/2024, the MR indicated that Patient 1 was at high risk for re-aspiration (Re-aspiration refers to the repeated inhalation of food, liquid, saliva, or other foreign material into the lungs, which can lead to serious complications like pneumonia or respiratory distress. Patients at high risk for re-aspiration require careful monitoring and specific care measures to prevent further aspiration events.), though the family wanted to take the patient home. During a concurrent interview and record review on 10/30/2024 at 4:03 p.m. with safety and quality coordinator (SQC) Patient 1’s MR titled “Discharge Instructions,” dated 7/24/2024, was reviewed. The MR indicated that Patient 1’s discharge instructions contained no record of information regarding enteral feeding and aspiration precautions instructions when the documents were printed and provided to Patient 1 on 7/24/2024 at 11:30 a.m. The SQC verified that Patient 1’s medical record lacked the documentation of relevant discharge post-care instructions for enteral feeding administration and aspiration precautions to follow at home. During an interview on 10/31/2024 at 11:20 a.m. with Registered Nurse (RN 2) regarding the discharge instructions provided to Patient 1 on 7/24/2024, RN 2 reviewed the instructions and stated, “I recall that this patient left the facility at noon on 7/24/2024, but when I called the designated family member regarding the discharge, they did not answer. I did not include written instructions on enteral feeding and aspiration precautions, and I can’t recall why. I thought the patient was being discharged back to a skilled nursing facility, not to home, but this is also undocumented, and I don’t remember why.” During a review of the facility’s policy and procedure (P&P) titled “Admission Direct Admission, Transfer, and Discharge” (dated 9/20/2022) the P&P indicated that discharged patients and/or their families must receive adequate healthcare education to address their immediate health care needs following discharge. The procedure requires the following steps: 1.Provide Discharge Education: The patient must receive comprehensive discharge education to prepare them for self-care or family support after they leave the facility. 2. Confirm Understanding and Obtain Signatures: Staff must ensure that the patient or their designated representative understands the discharge instructions. Additionally, they must obtain signatures on all relevant discharge forms to confirm comprehension and consent. 2.c. During a review of Patient 1’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty breathing), and found to have aspiration pneumonia (a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues). The H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke (clot in the brain) with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall). During further review of Patient 1’s Medical Record (MR) titled, “Discharge Summary,” dated 7/24/2024, the MR indicated that Patient 1 had multiple skin issues, including but not limited to, pressure injuries (partial-thickness skin loss with exposed dermis) that were acquired and treated during Patient 1’s stay at the facility from 7/12/2024 through 7/24/2024. The MR also contained wound care follow up orders for each identified pressure injury/skin issue. During a concurrent interview and record review on 10/30/2024 at 4:03 p.m. with safety and quality coordinator (SQC) Patient 1’s MR titled, “Discharge Instructions,” dated 7/24/2024, was reviewed. The MR indicated that Patient 1’s discharge instructions printed and provided to Patient 1 on 7/24/2024 at 11:30 a.m. contained no record of Patient 1’s skin wound descriptions and instructions for treatment and care. During an interview on 10/31/2024 at 11:20 a.m. with Registered Nurse (RN 2) regarding the discharge instructions provided to Patient 1 on 7/24/2024, RN 2 reviewed the instructions and stated they could not recall specific details about the absence of wound care documentation for Patient 1. RN 2 stated, “Typically, if I have orders for wound care instructions, I include them in the patient’s discharge instructions. They should be included. I can’t recall why this isn’t documented. I also can’t remember if any teaching was provided to Patient 1’s family member, but I know that if it isn’t documented, it wasn’t done.” During an interview on 10/31/2024 at 4:07 p.m. with the Wound Care Nurse (WCN), the WCN stated, “The family should be informed of treatment orders before discharge to ensure that treatment and related measures are reinforced and continued after discharge.” During a review of the facility’s policy and procedure (P&P) titled, “Admission, Direct Admission, Transfer, and Discharge,” dated 9/20/2022, the P&P indicated that discharged patients and/or their families must receive adequate healthcare education to address their immediate health care needs following discharge. The procedure requires the following steps: 1.Provide Discharge Education: The patient must receive comprehensive discharge education to prepare them for self-care or family support after they leave the facility. 3.a. During a concurrent observation and interview on 10/29/2024 at 3:14 p.m. with Charge Nurse (CN 2) in the Emergency Department (ED, specialized area of the hospital where patients receive urgent care for acute medical conditions or injuries), Patient 3 was observed in the room, asleep in bed. The call light (a device used by the patient to call for help) was coiled and attached to the wall behind Patient 3’s gurney. CN 2 stated, “The call light probably should be with the patient, but perhaps the patient was not alert enough to use it.” During a review of Patient 3’s medical record (MR) titled, “Emergency Documentation,” dated 10/29/2024, it was indicated that Patient 3 was seen in the Emergency Department (ED, a specialized medical facility that provides immediate care for patients with sudden onset illnesses or injuries) on 10/29/2024 due to left foot pain. During an interview on 10/31/2024 at 2:55 p.m. with Registered Nurse (RN 1) regarding Patient 3’s call light, which was observed not within the patient’s reach, RN 1 stated, “I remember the patient (Patient 3); he (Patient 3) was discharged the same day. The radiology technician brought the patient back after a procedure and did not provide a call light.” RN 1 also stated that a call light should have been provided to Patient 3 and should have been placed within the patient’s reach. During a review of the facility’s policy and procedure (P&P) titled, “Fall (an unplanned descent to the floor or another lower level with or without injury to patient) Prevention and Reduction,” dated 7/2023, the P&P indicated that an environment risk assessment shall be performed with basic interventions initiated for all patients to enhance patient safety. The P&P specified that the call light should be kept within patient’s reach. 3.b. During an observation on 10/29/2024 at 2:15 p.m. in the Emergency Department (ED, a specialized medical facility that provides immediate care for patients with sudden onset illnesses or injuries) in the area called “Green Area,” housing patients with less severe condition (not immediately life-threatening), Patient 6 was observed alone in the room without a call light. When asked how they would call for assistance if needed, Patient 6 responded, “I would yell out, ‘Nurse!’” During an interview on 10/29/2024 at 1:50 p.m. with the Chief Nursing Officer (CNO), when asked about the lack of call lights in the Green Area of the ED, the CNO stated, “We do not have call lights in this area. We will actually be closing this area next month and relocating to a new section in the ED that has built-in call lights. I’m not sure how long we’ve been without call lights in the Green Area, but currently, they are not available there. The new West ED will have call lights installed.” The CNO also added that patients should be provided with call lights so they can call for help if needed. During a review of Patient 6’s History and Physical (H&P, comprehensive assessment of a patient that includes taking a detailed medical history from the patient, followed by a physical examination to gather information about their current health condition), dated 10/29/2024, the H&P indicated that Patient 6 complained of generalized weakness and pain was diagnosed with pancreatitis (inflammation of the pancreas, an organ responsible for producing enzymes that aid in digestion and hormones that help regulate blood sugar). During a review of the facility’s policy and procedure (P&P) titled, “Fall Prevention and Reduction,” dated 7/2023, the P&P indicated that an environment risk assessment shall be performed with basic interventions initiated for all patients to enhance patient safety. The P&P specified that the call light should be kept within patient’s reach. 4. During a concurrent observation and interview on 10/29/2024 at 2:51 p.m. with Risk Management (RM), a door to a clean supply room, labeled “Authorized Personnel Only,” was observed to be held open by a trashcan, allowing unrestricted access to anyone in the Emergency Department (ED). The RM stated that the door must be locked because the supply room contained intravenous fluids (IV [through the vein], sterile ‘free from germs] solutions administered directly into a patient’s veins to provide hydration, deliver medications, or supply essential nutrients and electrolytes) and other medical supplies, which should only be accessible to authorized personnel, such as licensed personnel and supply staff. During an interview on 10/29/2024 at 2:53 p.m. with the Emergency Department Manager (EDM), the EDM stated that the lock on the supply room door was not functioning, but an order had been submitted to repair it. The EDM also stated that the clean supply rooms should always be locked as a safety precaution. During an observation on 10/29/2024 at 3:14 p.m. in the Emergency Department area known as the “Blue Zone (which houses critically ill patients),” it was observed that the medication room behind the nurses’ station had no locked doors. The area contained shelves stocked with IV fluids and bins with patient medications. Medications were observed in three different bins, accessible to anyone in the Emergency Department. During an interview on 11/1/2024 at 12:41 p.m. with the Director of Pharmacy (PD) regarding the storage of IV fluids and medications on the nursing units, the PD stated, “IV fluids are considered medications but are treated slightly differently from other medications. They do need to be stored in areas accessible only to authorized licensed personnel.” The PD further explained, “Most of our medications are kept in the dispenser, which is accessed via badge and restricted to licensed pharmacists, pharmacy technicians, and other licensed personnel. In the Blue Zone, the nursing station doesn’t have doors, but it was assumed that only authorized personnel would enter the area.” During a review of the facility’s policy and procedure (P&P) titled, “Security and Inspection of Medication Storage Areas,” dated 3/2022, the P&P indicated that medication rooms and patient bins (used for medication storage) to be locked at all times. Access to locked medication rooms is to be granted only to authorized licensed personnel. Additionally, non-licensed personnel performing tasks such as housekeeping or repairs in these areas must be monitored by licensed personnel. 5. During a concurrent interview and record review on 11/01/2024 at 11:26 a.m. with the Manager of Human Resource Operation (MHRO) 1 and Manager of Education (ME) 1, the “Restraint Training” for Security Guards (1,2, and 3), was reviewed. The “Restraint Training” for all 3 Security Guards indicated their annual training was completed on 9/19/2023. ME 1 stated the following: Confirmed all 3 security guards Restraint Training have expired and they have to take it annually. It is important for security guards to get their restraint training to be updated with the restraint process. During an interview on 11/01/2024 at 12:45 p.m. with the Director of Security and Safety (DSS) 1, DSS 1 stated the following: DSS 1 was aware of the 3 security guards who have expired restraint training. It is important for the security guards to have restraint training annually. DSS 1 takes full responsibility with security guards restraint training, the security guards will be on the restraint training next week. During a review of the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion (involuntary confinement of a patient alone in a room or area where they are physically prevented from leaving) Guidelines,” dated 2022, the P&P indicated, “PURPOSE: To provide guidelines for the provision of a safe patient environment and to minimize the use of restraints to clinically appropriate and adequately justified situations; to ensure a safe practice of patient monitoring and care in order to promote patient safety, protection, and to maintain the patient’s rights and dignity; to maintain maximum safety and prevent patient and personnel injury with using restraints to control patient’s behavior; to identify and use the least restrictive alternatives in the event of an emergency. V.STAFF TRAINING REQUIREMENTS: Staff must be trained and demonstrate competency prior to application of restraints, and the implementation of, monitoring, and providing care for the patient in restraint before performing any of these actions, as part of orientation, and subsequently on an annual basis by either skills demonstration and or electronic educational module.””

“STANDARDS INCORPORATED BY REFERENCE CFR(s): (e) The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Standards for Health Care Facilities Code of the National Fire Protection Association 99, 2012 edition, issued August 11, 2011. (ii) TIA 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011; (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (2) [Reserved] This Standard is not met as evidenced by: 42937 Based on observation, interview and record review, the facility failed to ensure two of two sampled medical shut off valves (medical shut-off valve panel 1 and medical shut-off valve panel 2) remained accessible to facility staff, in accordance with the facility’s policy and procedure regarding Environment of Care Program and Management Plans. This deficient practice had the potential to delay the facility’s response to quickly shut off the gas supply in an emergency situation, that may prevent hazards like gas leaks, fires, or asphyxiation (a life-threatening condition when the body does not get enough oxygen) to patient, staff and visitors in the event of a disaster or fire. Findings: During a concurrent observation and interview on 10/29/2024 at 3:33 p.m. with the assistant clinical manager (ACM), it was observed that two (2) medical gas shutoff valve panels were blocked and not easily accessible to staff. The medical gas shutoff valve panel 1 (Panel 1) located between gurney one and gurney two was blocked by a visitor chair, while the medical gas shutoff valve panel 2 (Panel 2) next to trauma room (where patients that have critical injuries are treated) was blocked by a workstation on wheels. The ACM stated that staff should not have left items that blocked access to the medical gas shutoff valve panel. Access to the mechanical shutoff valves must remain clear and unobstructed so that it can be shut off quickly in the event of a disaster or fire. During a concurrent interview and record review on 11/1/2024 at 3:10 p.m. with the facility safety officer (FSO), the facility’s policy and procedure (P&P) titled, “Environment of Care Program and Management Plans,” last revised date 01/2024, was reviewed. The P&P indicated that main supply valve and the area shutoff valves of piped medical gas systems should be accessible and clearly labeled. The FSO stated that access to medical gas shutoff valve panel should be always clear and unobstructed, there shouldn’t be any items blocking access to the shut off valve. FSO further said easy access to medical gas valves was important in emergency situations because it allows for immediate action to stop the flow of gas, which can reduce the risk of fire.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 46238 Based on interview and record review the facility failed to actively engage one of thirty (30) sampled patients (Patient 1) and/or patient’s family/ representative(s) in the development of a discharge plan for Patient 1 as well as failed to document the discharge plan evaluation within 24 hours after patient’s (Patient 1) admission to the facility in accordance with the facility’s policy and procedure regarding the discharge process (the transition of a patient from the hospital to another level of care such as home). This deficient practice had the potential for Patient 1 and Patient 1’s representatives to not fully understand the discharge care needs of Patient 1 which can impact patient outcomes such as compliance with treatment regimen and reduction of unplanned readmission. This deficient practice can also result in the violation of Patient 1’s rights when the patient (Patient 1) and/or Patient 1’s representative were not included in Patient 1’s discharge planning. Findings: During a review of Patient 1’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty breathing), and found to have aspiration pneumonia (a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues). During a review of Patient 1’s H&P, dated 7/12/2024, the H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke (clot in the brain) with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall). During a review of Patient 1’s medical record (MR) titled, “Emergency Documentation,” dated 7/12/2024, the MR indicated that Patient 1 was transported to the facility by ambulance from a congregate health living facility (a residential care facility that provides medical and personal care for individuals with chronic illnesses, disabilities, or complex medical needs) where he resided prior their admission to the hospital on 7/12/2024.During a review of Patient 1’s MR titled. “Discharge Summary,” dated 7/24/2024, the MR indicated that Patient 1 was at high risk for re-aspiration (Re-aspiration refers to the repeated inhalation of food, liquid, saliva, or other foreign material into the lungs, which can lead to serious complications like pneumonia (lung infection) or respiratory distress (a serious lung condition that causes low blood oxygen). Patients at high risk for re-aspiration require careful monitoring and specific care measures to prevent further aspiration events)., though the family wanted to take the patient home. The MR also indicated that Patient 1 required tube feeding, home health services, in-home physical therapy, supplemental oxygen, durable medical equipment (DME, medical equipment that can be used repeatedly and is intended to be used in a patient’s home for a medical purpose), including a hospital bed. During a concurrent interview and record review on 10/31/2024 at 9:35 a.m. with the Clinical Quality Coordinator (CQC), Patient 1’s medical record was reviewed for discharge planning documentation. The record indicated that no case management notes were recorded in Patient 1’s chart from 7/12/2024 through 7/22/2024, which the CQC confirmed. Additionally, the medical record contained a note titled “Case Management (CM)” dated 7/22/2024, showing that a case manager documented their first contact with Patient 1’s family representative on 7/22/2024, only two days before Patient 1’s discharge from the facility with an anticipation to discharge Patient 1 the following day, on 7/23/2024. During an interview on 10/31/2024 at 12:00 p.m. regarding the discharge planning process (the process of transitioning a patient from one level of care to another), with the Director of Case Management Services (DCM), the DCM stated that discharge planning begins within 24 hours of a patient’s admission and involves case managers, nurses, and other healthcare team members. The DCM stated that nurses conduct the initial assessment, while case managers complete a discharge planning screening within this timeframe, documenting all steps in the patient’s medical record. During the same interview on 10/31/2024 at 12:00 p.m. regarding discharge planning with the DCM, the DCM stated, “Case manager discharge planning practices include communicating with the patient or family to assess living arrangements, such as stairs in the home, and identifying post-discharge needs, including home health services, durable medical equipment (DMEs), and other necessary support. Service coordination is based on patient requirements. For example, if enteral feeding is needed, vendors are contacted. Hands-on training should be provided to the patient and family by the nurse, with documentation to ensure continuity of care. Either the case manager or primary nurse can determine if additional education is necessary, depending on the patient’s discharge destination.” During a review of the facility’s policy and procedure (P&P) titled, “Patient/Family Teaching Plan,” dated 7/2022, the P&P indicated that patient discharge needs are initially assessed on admission. the patient/family will be informed of various resources in the community if needed. Case Managers shall coordinate discharge arrangement and teaching for medical equipment. Any teaching or discharge planning shall be documented in the medical record. During a review of the facility’s policy and procedure (P&P) titled “Discharge Planning,” dated 9/2024, the P&P indicated that the facility provides Discharge Planning for all patients according to federal and state regulatory requirements. Patients requiring complex discharge planning are referred to the Case Management department, which arranges necessary services and care based on available resources and authorizations. The P&P indicated that discharge planning should begin at the time of admission. Additionally, case managers from local medical groups are involved in the discharge planning process and are required to document in the facility’s electronic health record. The case manager (CM) is responsible for periodically reassessing patients with complex or high-risk discharge needs and must document these assessments in the patient’s medical record.”

“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: 46238 Based on interview and record review, the facility failed to ensure that appropriate referrals (wound care services, physical therapy services) were arranged and coordinated with contracted services prior to discharge for one of 30 sampled patients (Patient 1), in accordance with the facility’s policy and procedure regarding discharge planning (the process of preparing a patient to leave the hospital and transition to the next level of care). This deficient practice had the potential for Patient 1’s condition to worsen post-discharge due to lack of aftercare (the care and support that patients receive after hospitalization). This deficient practice may also result in readmission or poor quality of life and/or death. Findings: During a review of Patient 1’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty breathing), and found to have aspiration pneumonia ( a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues). During a review of Patient 1’s H&P, dated 7/12/2024, the H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke (clot in the brain) with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall). During a review of Patient 1’s Medical Record (MR) titled, “Discharge Summary,” dated 7/24/2024, the MR indicated that Patient 1 was at high risk for re-aspiration (Re-aspiration refers to the repeated inhalation of food, liquid, saliva, or other foreign material into the lungs, which can lead to serious complications like pneumonia or respiratory distress. Patients at high risk for re-aspiration required careful monitoring and specific care measures to prevent further aspiration events), though the family wanted to take the patient home. The MR also indicated that Patient 1 required tube feeding (a method to supply nutrients and fluids to the body if someone cannot safely chew or swallow), home health services, in-home physical therapy, supplemental oxygen, durable medical equipment (DME, medical equipment that can be used repeatedly and is intended to be used in a patient’s home for a medical purpose), including a hospital bed. During an interview on 10/31/2024 at 11:26 a.m. with Registered Nurse (RN 2) regarding the facility’s discharge process, RN 2 stated, “The case manager (CM) is responsible for relaying information about home health services, durable medical equipment (DMEs), and transportation arrangements.” RN 2 further explained that, typically, the CM would call the nurse to inform them about any DMEs, and other arrangements. “Sometimes it’s documented in the patient’s chart and sometimes it’s not,” RN 2 added. “I’m not sure if I typically document this information after receiving a call from the CM.” During the same interview on 10/31/2024 at 11:26 a.m. with Registered Nurse (RN 2) regarding Patient 1’s discharge instructions dated 7/24/2024, RN 2 reviewed the discharge instructions and stated, “Based on what is documented, arrangements were made for blood glucose (sugar) monitoring, an enteral feeding pump, and a transfer aid for Patient 1. However, nursing and physical therapy are noted as ‘none arranged,’ and I cannot recall if I received a call from the CM about those services. I also don’t remember for certain if all the DMEs and services were arranged or which ones, as it’s not documented.” During a review of Patent 1’s MR titled “Case Management notes” dated 7/22/2024, the MR indicated that the CM made first contact with Patient 1’s family member on 7/22/2024 and documented and Patient 1 required front wheel walker (FWW, a type of mobility aid designed to help individuals with limited strength, balance, or mobility maintain stability while walking), blood sugar control, and that a family member requested a hospital bed for Patient 1. The MR contained no other record of arrangements made for enteral feeding (a liquid nutritional formula is delivered through a tube that is inserted into the stomach or small intestine) and pump, home health services and in home physical therapy. During a review of Patient 1’s MR titled, Case Management,” dated 7/23/2024 at 4:43 p.m., the MR indicated Patient 1’s discharge was delayed because a hospital bed had not yet been delivered. Patient 1’s MR contained no additional notes recorded by the CM on any other days during Patient 1’s hospital stay. The MR contained no recorded confirmation of delivery of the hospital bed and arrangement for home health services in Patient 1’s medical record either. During an interview on 10/31/2024 at 12:00 p.m. regarding discharge planning with the Director of Case Management (DCM), the DCM stated, “Case manager discharge planning practices include communicating with the patient or family to assess living arrangements, identifying post-discharge needs and home health services, durable medical equipment (DMEs), and other necessary support. Service coordination is based on patient requirements. For home health services, discharge orders should specify the services provided (such as nursing visits or wound care) and contact information for the home health agency should be included in the CM’s documentation, along with delivery schedules for necessary items. DMEs, such as oxygen or a hospital bed, require specific instructions, including the oxygen levels needed. For supplemental oxygen at home, the oxygen company should be contacted, and this includes providing insurance information, diagnosis, and contact details, as well as determining whether items will be delivered to the hospital or directly to the home. For example, if enteral feeding is needed, vendors are contacted. Enteral feeding also requires an order and input from the dietitian, with the case manager responsible for including this information in the chart for prescription purposes. All steps must be documented in the patient’s medical record to ensure continuity of care.” During a review of the facility’s policy and procedure (P&P) titled, “Discharge Planning,” dated 9/2024, the P&P indicated that the facility provides Discharge Planning for all patients according to federal and state regulatory requirements. Patients requiring complex discharge planning are referred to the Case Management department, which arranges necessary services and care based on available resources and authorizations. The P&P indicated that discharge planning should begin at the time of admission. Additionally, case managers from local medical groups are involved in the discharge planning process and are required to document in the facility’s electronic health record. The case manager (CM) is responsible for periodically reassessing patients with complex or high-risk discharge needs and must document these assessments in the patient’s medical record.”