Providence St. Joseph Hospital

“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: 29798 Based on interview and record review, the hospital failed to ensure the patients received care in a safe environment for two of four sampled patients (Patients 1 and 2) as evidenced by: 1. For Patient 1: a. The nursing staff failed to perform an ongoing accurate assessment and evaluations of Patient 1 related to frequency of the patient’s RASS assessment, the use of restraint, and self-extubation when the patient was intubated with continuous sedation being titrated or as needed for any changes in mental status as per the hospital’s P&P. b. The nursing staff failed to ensure the Confusion Assessment Method was completed for Patient 1 every shift and as needed, to determine if delirium was present while the patient was on a ventilator and/or with a RASS greater or equal to -2 as per the hospital’s P&P. 2. For Patient 2, the nursing staff failed to follow Patient 2 physician’s order for titration of the medication being administered as per the hospital’s P&P. These failures created the risk of substandard health outcomes for the patients. Findings: Review of the hospital’s P&P titled Critical Care Standards of Practice dated 06/2026 showed in part: * Purpose: The policy is to establish the standards for nursing practice in the Intensive Care Unit (ICU) and Critical Care Unit (CCU) beds 311-320 at the hospital. - Nursing Plan of Care is assessed, updated, and documented in the electronic medical record (EMR) every shift. - Patients on mechanical ventilation: ICU Liberation ABCDEF Bundle adherence with Respiratory Therapist (RT) collaboration: A: Assess and treat pain B: Both Spontaneous Awakening Trials (SAT), “Sedation Vacation” and Spontaneous Breathing Trials (SBT) C: Choice of sedation and analgesia D: Delirium monitoring and management E: Early progressive mobility and exercise using mobility guidelines F: Family engagement - Ventilator Associated Pneumonia (VAP) Bundle:...Delirium - Assess, Prevent & Manage (CAM-ICU) - Richmond Agitation-Sedation Scale (RASS) Assessment: Every 2 hours for patients who are on the ventilator receiving intermittent or continuous sedation. Every 15 minutes for the ventilated patient with continuous sedation being titrated. PRN for any change in mental status. Standard work: Assessment, prevention and treatment of Delirium, PC-342. - Confusion Assessment Method for ICU (CAM-ICU) is completed every shift, and PRN, to determine if delirium is present for patients on a ventilator and/or with a RASS greater or equal -2. 1. Review of the hospital’s P&P titled Restraint for Non-Violent Non-Self-Destructive Behavior dated 5/2025 showed in part: * Scope: ...This policy applies to restraint use for non-violent/non-self-destructive behavior in the acute care setting in areas where restraint is used to support physical safety of the patient. The policy applies to all patients for whom restraint is utilized, regardless of age, and involves all disciplines. * Purpose: To describe care of the patient and use of restraint for non-violent/non-self-destructive behavior and requirements for alternative methods, ordering restraints, documentation, monitoring, caregiver training and regulatory reporting. * Definitions: - Restraint - is any method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely (generally, if a patient can easily remove a device, it would not be considered as restraint). - Restraint for non-violent, non-self-destructive behavior may include, but are not limited to: a. Hand Mitts are a restraint if one of the following conditions are met: 1. The patient is pinned or tied down in such a way that movement is restricted. 2. Hand Mitt is designed to restrict finger or hand movement... 3. Hand Mitt is used in conjunction with wrist restraints. * Policy: The hospital recognizes that use of restraints is a high-risk intervention with the potential for causing harm and this policy supports a culture which limits the use of restraints through promoting alternative strategies to protect patients from harm. - Restraint use for non-violent/non-self-destructive behavior - The following criteria specific to the patient population and services are used as a guideline for assessment and identification of situations, which are based on the patients’ individual needs and may clinically justify restraint application. These include the following: a. Patient actions resulting in unsafe interference with medically necessary devices or treatments. b. Patient actions resulting in serious imminent physical risk or injury to self or others that outweigh the risk associated with restraint use. - Monitoring and reassessment of well-being, patient needs, and continued need of restraint - To ensure the well-being of the patient and continued need for restraint, an ongoing process including assessment, intervention, evaluation, and re-intervention will be carried out: a. Upon initiation, and not greater than every 2 hours thereafter, the RN will perform an assessment that includes: proper application of restraints...Physical needs, exercise, elimination, nutrition, hydration, and range of motion. - Documentation - Each episode of restraint will be documented in the patient’s medical record and will include the following elements: a. The RN documents in the medical record: ...Patient’s plan of care will include restraint use and will be modified when restraints are applied or discontinued... b. ...Skin and circulation assessment with Range of Motion (ROM). Review of the hospital’s P&P titled Restraint for Violent/Seclusion/Self-Destructive Behavior dated 5/2025 showed in part: * This policy applies to restraint and seclusion use for violent and or self-destructive behavior in the acute care setting in areas where restraint is used to ensure physical safety of the patient, caregiver(s), or others. The policy applies to all patients for whom restraint is utilized, regardless of age, and involves all disciplines. * Definitions: - Restraints may include...Hand Mitt used in conjunction with wrist restraints. - Chemical Restraint: A drug or medication when it is used as a restraint to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. If the overall effect of a drug or medication, or combination of drugs or medications, is to reduce the patient’s ability to interact with the world around the patient, then the drug or medication is not being used as a standard treatment or dosage for the patient’s condition and is considered a restraint. All violent restraint requirements apply. - Special category: Self-destructive behaviors are those engaged in by patients who intentionally engage in behaviors that cause injury to themselves. For patients engage in self-destructive behaviors, orders for restraint and/or seclusion require the one (1) hours face to face evaluation... In very rare cases, a patient may demonstrate uncontrollable, repetitive, self-mutilating behaviors. Such disorders include but not limited to...Autism Spectrum Disorder... - Assess and Monitor the Patient:...Frequency of RN assessment/monitoring and documentation of patients in Restraint and/or Seclusion - Frequency of assessment and monitoring should be individualized, taking into consideration variables such as the patient’s condition, cognitive status, risks associated with the use of the chosen intervention, and other relevant factors. In some cases, check every 15 minutes or vital signs taken every 2 hours may not be sufficient to ensure the patient’s safety...Similarly, depending on the patient’s needs and situational factors, the use of restraint or seclusion may require either periodic (e.g. every 15 minutes, every 30 minutes, etc.) or continual (i.e., moment to moment) monitoring and assessment. 1. The recommended timeframe for reassessment is every 15-30 minutes... 3. Restraints are removed one limb at a time for at least fifteen minutes, unless is medically or psychiatrically contraindicated to assist with range of motion/exercise, and/body re-positioning. - The patient plan of care is modified to include restraint and/or seclusion during the shift when restraints and/or seclusion are initiated; the plan of care is reviewed every shift and revised as necessary. On 7/14/26 at 1255 hours, an interview with concurrent record review of Patient 1’s medical record was conducted with the Risk and Patient Safety Manager. Patient 1’s medical record showed on 4/27/26 Patient 1 was presented to the hospital’s ED. Patient 1 was admitted to the ICU on 5/2/26. Review of the ED Provider 1 note dated 4/27/26 at 1348 hours, showed chief complaint-psychiatric evaluation. The provider note also showed Patient 1 presented with 5150 for DTS. The patient’s past medical history was autism, developmental delay, and anxiety. On 4/2726 at 1411 hours, the ED Provider 1 note showed “Patient has been evaluated and found to be medically cleared at this time. Ready to transfer to ECDU. Will receive further evaluation and final disposition.” Review of ED Provider 2 note dated 5/2/26 at 0708 hours, showed “CT Abdomen Pelvis wo IV Contrast ... Final Result ... Patchy airspace disease of the visualized lung bases consistent with pneumonia and/or aspiration.” Further review of the ED Provider 2 note showed the following: * On 5/2/26 at 0709 hours, the patient noted to be agitated and potentially a danger to self and others. In the provider’s medical judgment, it was necessary and appropriate to place the patient in restraints to safely protect self and others. * On 5/2/26 at 0711 hours, brought back from CDU for continued aggressive behavior. Patient was not redirectable. * On 5/2/26 at 0836 hours, sleeping but tachycardic after ketamine (a general anesthetic used to induce and maintain unconsciousness, provide sedation for procedure, and manage pain). * On 5/2/26 at 0844 hours, Agitated again. Would give Haldol (an antipsychotic medication). * On 5/2/26 at 0935 hours, after Haldol, the patient was still agitated, punching a nurse in face. Would start Precedex (a fast-acting sedative medication used in hospitals and clinics. It primarily keeps patients calm, relaxed, and lightly asleep during surgical or diagnostic procedures, or for patients on breathing machines [ventilators] in the ICU). * On 5/2/26 at 1006 hours, patient became more agitated prior to Precedex treatment being started. The patient became very violent. Decision was made to intubate. Patient was intubated with no complications. The patient was now sedated and comfortable on propofol (it is primarily used to induce and maintain general anesthesia for surgeries, provide conscious sedation during minor procedures, and sedate critically ill patients on mechanical ventilators in the ICU) and fentanyl (a powerful synthetic opioid). * On 5/2/26 at 1158 hours, would get a CT of the brain due to persistent worsening mental status change. Decision was made to admit. On 5/2/26 at 1052 hours, patient admitted to the ICU. a. Review of Patient 1’s medical record showed bilateral soft wrist restraints to the patient’s upper extremities for violent behavior was initiated on 4/29/26 at 1715 hours, 5/1/26 at 1546 and 1932 hours, and 5/2/26 at 0709 hours; and restraint for non-violent behavior on 5/4/26. Review of the night shift RN documentation dated 5/4/26 at 0659 hours, showed “Pt self extubated while on multiple sedation (propofol, fentanyl, precedex), restraints in place ... Patient was extremely agitated, kicking and biting at staff, pulled out all IV’s, monitors and other medical equipment, attempting to get out of bed...was ultimately reintubated safely and sedated.” Review of the nursing RASS assessment documentation dated 5/4/26 at 0130 to 5/5/26 at 2353 hours, showed the following: * On 5/4/26 at 0100 hours, Patient 1’s RASS was documented as +1 (restless) At 0130 hours, the RASS was documented as -5 (unarousable). At 0145 hours, there was no documented evidence to show Patient A’s RASS assessment was performed as per the hospital’s P&P. At 0200 hours, the nursing RASS assessment was documented as -5 (unarousable). However, the nursing documentation showed at 0200 hours, Patient 1 self-extubated, and was re-intubated, and at 0300 hours, the patient’s RASS assessment showed as -5. The next nursing RASS assessment of Patient 1 was performed on 5/4/26 at 0500, 0600, 0700, 0800, 0900, 1000, 1300, 1400, 1500, 1600, 1700, 2000, 2100, 2200, 2248, and 2353. On 5/4/26 at 1850 hours, Patient 1 self-extubated for the second time. Patient 1’s RASS assessment was not completed as per the hospital’s P&P. On 7/15/26 at 1155 hours, an interview with concurrent record review was conducted with RN 1. RN 1 stated Patient 1 was very agitated, on multiple sedations which were titrated per the provider’s order. When asked, RN 1 stated did not recall how Patient 1 self-extubated during the night shift. On rounds Patient 1 was calm throughout the shift and became agitated on turning and repositioning. Patient 1 was on continuous drips that were titrated per the provider’s order. The patient’s RASS was monitored every 2 hours. Patient 1 had soft wrist restraints on bilateral upper and lower extremities. When asked if Patient 1’s soft wrist restraints to bilateral upper and lower extremities were used in conjunction with hand mittens. RN 1 stated soft wrist restraints do not necessarily come with hand mittens. RN 1 further stated the patient’s bilateral soft wrist restraints were monitored every 2 hours, and vital signs every 15 minutes. Patient was calm at 1800 hours, rounds. When asked if the use of hand mittens could have prevented the patient to self-extubate for the second time, RN 1 stated it was possible. RN 1 was asked Patient 1 self-extubated during the night shift what RN 1 could have done differently to prevent the patient from self-extubate for the second time. RN 1 stated “would have not done anything different.” b. Review of the nursing flowsheet documentation failed to show Patient 1’s Confusion Assessment Method was completed every shift and as needed, to determine if delirium was present while the patient was on a ventilator and/or with a RASS greater or equal to -2 (light sedation) as per the hospital’s P&P. 2. On 7/16/26 at 0905 hours, an interview with concurrent record review of Patient 2’s medical record was conducted with the Patient Safety Officer. Patient 2’s medical record showed on 7/12/26, Patient 2 was admitted to the hospital. Review of the ED provider note dated 7/12/26 at 1107 hours, showed Patient 2 was obtunded and was intubated for airway protection. Patient 2 was admitted to the ICU. Review of the provider’s order dated 7/12/26 at 1154 hours, showed propofol 20 mcg/kg/min increase by 5-10 every 5 minutes to reach RASS 0 (alert and calm) to -2 (light sedation - alert & calm). Review of the nursing documentation showed the propofol infusion was started on 7/12/26 at 1154 hours, at 20 mcg/kg/min. The nursing documentation showed the following: - On 7/12/27 at 1154 hours, Patient 2’s RASS was documented as -4 - On 7/12/26 at 1415 hours, the nursing documentation showed Patient 2’s RASS as -3, the propofol infusion rate was increased to 50 mcg/kg/min. - On 7/12/26 at 1700 hours, the nursing documentation showed Patient 2’s RASS as -2, the infusion rate was increased to 70 mcg/kg/min. Patient 2’s infusion rate was not titrated per the provider’s order, and Patient 2’s RASS assessment was not completed every 15 minutes for the ventilated patient with continuous sedation being titrated as per the hospital’s P&P. - On 7/12/26 at 2230 hours, the nursing documentation showed the propofol infusion was restarted at the rate of 20 mcg/kg/hr. On 7/20/26 at 1310 hours, the above findings were verified by the Patient Safety Officer.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 29798 Based on interview and record review, the hospital failed to ensure the nursing staff adhered to the hospital’s P&P related to the use of restraints for two of four sampled patients (Patients 1 and 2) as evidenced by: 1. For Patient 1: * The frequency of assessment and monitoring of the bilateral soft wrist restraints was not individualized taking into consideration Patient 1’s condition as per the hospital’s P&P. * Restraints were not removed one limb at a time for at least 15 minutes unless was medically or psychiatrically contraindicated to assist with range of motion/exercise, and/body re-positioning as per the hospital’s P&P. 2. For Patient 2, range of motion was not performed while the patient was in restraints as per the hospital’s P&P. These failures posed the potential risk for poor health outcomes for the patient. Findings: Review of the hospital’s P&P titled Restraint for Non-Violent Non-Self-Destructive Behavior dated 5/2025 showed in part: * Scope: ...This policy applies to restraint use for non-violent/non-self-destructive behavior in the acute care setting in areas where restraint is used to support physical safety of the patient. The policy applies to all patients for whom restraint is utilized, regardless of age, and involves all disciplines. * Purpose: To describe care of the patient and use of restraint for non-violent/non-self-destructive behavior and requirements for alternative methods, ordering restraints, documentation, monitoring, caregiver training and regulatory reporting. * Definitions: - Restraint - is any method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely (generally, if a patient can easily remove a device, it would not be considered as restraint). - Restraint for non-violent, non-self-destructive behavior may include, but are not limited to: a. Hand Mitts are a restraint if one of the following conditions are met: 1. The patient is pinned or tied down in such a way that movement is restricted. 2. Hand Mitt is designed to restrict finger or hand movement... 3. Hand Mitt is used in conjunction with wrist restraints. * Policy: The hospital recognizes that use of restraints is a high-risk intervention with the potential for causing harm and this policy supports a culture which limits the use of restraints through promoting alternative strategies to protect patients from harm. - Restraint use for non-violent/non-self-destructive behavior - The following criteria specific to the patient population and services are used as a guideline for assessment and identification of situations, which are based on the patients’ individual needs and may clinically justify restraint application. These include the following: a. Patient actions resulting in unsafe interference with medically necessary devices or treatments. b. Patient actions resulting in serious imminent physical risk or injury to self or others that outweigh the risk associated with restraint use. - Monitoring and reassessment of well-being, patient needs, and continued need of restraint - To ensure the well-being of the patient and continued need for restraint, an ongoing process including assessment, intervention, evaluation, and re-intervention will be carried out: a. Upon initiation, and not greater than every 2 hours thereafter, the RN will perform an assessment that includes: proper application of restraints...Physical needs, exercise, elimination, nutrition, hydration, and range of motion. - Documentation - Each episode of restraint will be documented in the patient’s medical record and will include the following elements: a. The RN documents in the medical record: ...Patient’s plan of care will include restraint use and will be modified when restraints are applied or discontinued... b. ...Skin and circulation assessment with Range of Motion (ROM). Review of the hospital’s P&P titled Restraint for Violent/Seclusion/Self-Destructive Behavior dated 5/2025 showed in part: * This policy applies to restraint and seclusion use for violent and or self-destructive behavior in the acute care setting in areas where restraint is used to ensure physical safety of the patient, caregiver(s), or others. The policy applies to all patients for whom restraint is utilized, regardless of age, and involves all disciplines. * Definitions: - Restraints may include...Hand Mitt used in conjunction with wrist restraints. - Chemical Restraint: A drug or medication when it is used as a restraint to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. If the overall effect of a drug or medication, or combination of drugs or medications, is to reduce the patient’s ability to interact with the world around the patient, then the drug or medication is not being used as a standard treatment or dosage for the patient’s condition and is considered a restraint. All violent restraint requirements apply. - Special category: Self-destructive behaviors are those engaged in by patients who intentionally engage in behaviors that cause injury to themselves. For patients engage in self-destructive behaviors, orders for restraint and/or seclusion require the one (1) hours face to face evaluation... In very rare cases, a patient may demonstrate uncontrollable, repetitive, self-mutilating behaviors. Such disorders include but not limited to...Autism Spectrum Disorder... - Assess and Monitor the Patient:...Frequency of RN assessment/monitoring and documentation of patients in Restraint and/or Seclusion - Frequency of assessment and monitoring should be individualized, taking into consideration variables such as the patient’s condition, cognitive status, risks associated with the use of the chosen intervention, and other relevant factors. In some cases, check every 15 minutes or vital signs taken every 2 hours may not be sufficient to ensure the patient’s safety...Similarly, depending on the patient’s needs and situational factors, the use of restraint or seclusion may require either periodic (e.g. every 15 minutes, every 30 minutes, etc.) or continual (i.e., moment to moment) monitoring and assessment. 1. The recommended timeframe for reassessment is every 15-30 minutes... 3. Restraints are removed one limb at a time for at least fifteen minutes, unless is medically or psychiatrically contraindicated to assist with range of motion/exercise, and/body re-positioning. - The patient plan of care is modified to include restraint and/or seclusion during the shift when restraints and/or seclusion are initiated; the plan of care is reviewed every shift and revised as necessary. 1. On 7/14/26 at 1255 hours, an interview with concurrent record review of Patient 1’s medical record was conducted with the Risk and Patient Safety Manager. Patient 1’s medical record showed on 4/27/26, Patient 1 was presented to the ED. On 5/2/26, Patient 1 was admitted to the ICU. Review of the ED Provider 1 documentation dated 4/27/26 at 1348 hours, showed chief complaint - Psychiatric evaluation. The provider notes also showed the patient presented with 5150 for DTS. The patient’s past medical history was autism, developmental delay, and anxiety. On 4/27/26 at 1411 hours, the ED Provider 1 documented “Patient has been evaluated and found to be medically cleared at this time. Ready to transfer to ECDU. Will receive further evaluation and final disposition.” Review of Patient 1’s physician’s orders dated 4/29/26 at 1715 hours, 5/1/26 at 1546 and 1932 hours, and 5/2/26 at 0709 hours, showed bilateral soft restraints to upper and lower extremities - pulling on lines/drains/airways. - The frequency of assessment and monitoring of the bilateral soft wrist restraints was not individualized taking into consideration Patient 1’s condition as per the hospital’s P&P. - Restraints were not removed one limb at a time for at least 15 minutes unless was medically or psychiatrically contraindicated to assist with range of motion...as per the hospital’s P&P. 2. On 7/16/26 at 1110 hours, Patient 2’s medical record was reviewed with the Patient Safety Officer. Patient 2’s medical record showed the patient was admitted to the hospital on 7/12/26. Review of Patient 1’s provider’s order dated 7/13/26 at 0637 hours, showed bilateral soft restraints to upper and lower extremities - pulling on lines/drains/airways. However, the nursing flowsheet failed to show hand the range of motion was performed for the patient. On 7/20/26 at 1310 hours, the above findings were verified by the Patient Safety Officer.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 29558 Based on interview and record review, the hospital failed to implement its P&P for staffing, the staffing matrix, and the required nurse-to-patient ratios for the Pulmonary Renal Unit (3 East and 3 West, a telemetry unit) on the night shift of 3/7/26 and 3/8/26. This had the potential to compromise patient safety due to insufficient nursing coverage. Findings: During a review of the hospital’s P&P titled, “Staffing, GEN-700,” dated 4/2023, the P&P showed staffing levels are designed to provide an adequate number of Registered Nurses who are qualified to make decisions for care ... Staffing will be increased or decreased to accommodate fluctuating volume and patient acuity. Each nursing unit identifies the scheduling process based on established guidelines ... and reflects appropriate staff for each shift to ensure skill mix required to maintain the unit’s patient care requirements. During a review of the hospital’s P&P titled “Scope of Service Admission Transfer Discharge: Pulmonary Renal Unix,” updated 7/2023, the P&P showed the unit provided skilled personnel for monitoring, observation and treatment of diverse illnesses ... Department goals include guiding the patient care by written standards that meet regulatory and practice criteria including, JCAHO, Title 22, AACN and etc. To monitor, indemnify problems, plan, implement solutions and evaluate the quality of patient care provided to move to wellness. 1. Review of the Staffing Matrix for Patient Care Unit Pulmonary Renal (also known as 3 East and 3 West, a telemetry unit) showed the following for night shift: a census of 36 patients had 9 Registered Nurses (RN’s), 0.66 of a break nurse, and 1 Charge Nurse A review of the Patient Care Unit, Pulmonary Renal staff schedule dated 3/7/26, night shift with a beginning census of 36 showed the following RN staffing assignments: 9 Registered nurses, 1 charge nurse, and no assigned break nurse. During a review of the night assignments dated 3/7/26, the night shift assignments showed RN 1 had been assigned to 6 Medical/Surgical patients at the beginning of the night shift. These included: Patient 1 who was assigned to RN 1 at the start of the shift at 1900 hours. During a review of Patient 1’s plan of care dated 3/7/26 at 1526 hours, the plan of care showed Patient 1 was to be discharged by ambulance home. A Note showed the ambulance scheduled to arrive at 1930 hours. During a review of Patient 1’s nursing progress note dated 3/7/26, the nursing progress note showed Patient 1 was discharged by RN 1 home at 2000 hours. Patient 2 who was assigned to RN 1 at the start of the shift at 1900 hours and remained RN 1’s patient throughout the night shift. Patient 3 who was assigned to RN 1 at the start of the shift at 1900 hours and remained RN 1’s patient throughout the night shift. Patient 4 who was assigned to RN 1 at the start of the shift at 1900 hours and remained RN 1’s patient throughout the night shift. Patient 5 who was assigned to RN 1 at the start of the shift at 1900 hours and remained RN 1’s patient throughout the night shift. Patient 6 who was assigned to RN 1 at the start of the shift at 1900 hours and remained RN 1’s patient throughout the night shift. During an interview and concurrent review of the hospital documentation on 4/23/26 at 1500 hours and on 4/24/26 at 0810 hours, with the Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring, the Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring stated the Pulmonary Renal Unit admitted patients who were classified as medical, surgical, and telemetry patients. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring stated the expectation was for RNs with medical or surgical patients (no telemetry patients) could have up to 5 patients, with 5 being the maximum number of patients assigned to them. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring stated the unit also used their staffing matrix as guidelines for staffing based on the acuity of patients, the California ratios and the patient census. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring reviewed the schedule and verified on 3/7/26, night shift, the nurse staffing schedule did not follow the requirements of the nurse matrix for a patient census of 36 and 9 scheduled Registered Nurses 0.66 break nurses and 1 Charge Nurse. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring stated per the staffing matrix, 9 RN’s, 1 break nurse and 1 charge nurse should have been scheduled for the shift. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring verified the schedule that showed no break nurse was assigned for the shift. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring stated she was unaware of this occurrence. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring stated one solution was to have the charge nurse assigned to Patient 1’s care until the scheduled ambulance came to pick up the patient. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring verified the assigned charge nurse did not take any patients per the schedule. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring verified the above documents showed RN 1 was given an initial assignment of 6 patients which was out of the required California ratios on 3/7/26 from 1900 hours till discharge of Patient 1 at 2000 hours on the night shift. 2. Review of the Staffing Matrix for Patient Care Unit Pulmonary Renal (also known as 3 East and 3 West, a telemetry unit) showed the following for a census of 34 patients, with 9 Registered Nurses (RN’s), 0.66 of a break nurse, and 1 Charge Nurse. A review of the Patient Care Unit, Pulmonary Renal staff schedule dated 3/8/26, night shift with a beginning census of 34 showed the following RN staffing assignments: the night assignments showed that RN 2 had been assigned 5 total patients, with 3 telemetry patients and 2 Medical/Surgical Patients at the beginning of the night shift. These included: Patient 7, a patient with a telemetry order who was assigned to RN 2 at the start of the shift on 3/8/26 at 1900 hours and remained RN 2’s patient throughout the night shift until shift change at 0700 hours on 3/9/26. Patient 8 who was assigned to RN 2 at the start of the shift on 3/8/26 at 1900 hours and remained RN 2’s patient throughout the night shift until shift change at 0700 hours on 3/9/26. Patient 9 a patient with a telemetry order who was assigned to RN 2 at the start of the shift on 3/8/26 at 1900 hours and remained RN 2’s patient throughout the night shift until shift change at 0700 hours on 3/9/26. Patient 10 who was assigned to RN 2 at the start of the shift on 3/8/26 at 1900 hours and remained RN 2’s patient throughout the night shift until shift change at 0700 hours on 3/9/26. Patient 11, a patient with a telemetry order who was assigned to RN 2 at the start of the shift on 3/8/26 at 1900 hours and remained RN 2’s patient throughout the night shift until shift change at 0700 hours on 3/9/26. A review of the hospital form titled Department’s Out of Ratio Report Form showed the following: Unit Pulmonary Renal on 3/8/26 had a unit census of 33 with 8 nurses and 1 charge nurse and listed 28 telemetry patients. A change in ratio due to post surgery needs acuity level or change in patients’ conduction was marked. As well as the box other was marked, showing a nurse sick call. Efforts made to maintain required staffing levels showed the department had called both day and night shift staff roster and/or the on-call list. However, it did not show the Charge Nurse was pulled into staffing and taken patients. On 4/23/26 at 1500 hours and 4/24/26 at 0810 hours, an interview and concurrent hospital document review was conducted with the Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring stated the Pulmonary Renal Unit admitted patients who were classified as medical, surgical and telemetry patients. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring defined telemetry patients as those patients who had a provider order for cardiac monitoring. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring stated the unit has two shifts, day shift and night shift. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring stated the unit followed the California title 22 ratios for the unit’s patient care requirements. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring stated the purpose for following the California ratios was partly due to the Title 22 requirement, but also for patient safety and acuity. The ratios were followed to ensure patients with higher acuity get the nursing care they need. Telemetry was considered a higher acuity as those patients need cardiac monitoring. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring stated the unit also used their staffing matrix as guidelines for staffing based on the acuity of patients, the California ratios and the patient census. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring stated per the required California ratios, the expectation was for RNs to have no more than a total of 4 patients if they have even 1 patient with provider ordered cardiac monitoring (telemetry patients). RNs with medical or surgical patients (no telemetry patients) could have up to 5 patients assigned to them. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring reviewed the schedule and assigned patients for RN 2. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring reviewed and verified on 3/8/26, night shift, the nurse staffing schedule did not follow the requirements of the nurse matrix for a patient census of 34 and 9 scheduled Registered Nurses 0.66 break nurses and 1 Charge Nurse. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring stated per the staffing matrix, 9 RN’s, 1 break nurse and 1 charge nurse should have been scheduled for the shift. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring verified the schedule showed 8 RN’s and 1 Charge Nurse were assigned to this shift. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring verified no break nurse was assigned for the shift. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring verified the assigned Charge Nurse did not take any patients per the schedule. The Nurse Manager of Oncology, Pulmonary Renal and Centralized Monitoring verified the above documents showed RN 2 was given an assignment of 5 patients, 3 of those patients with cardiac monitoring (telemetry) orders. Pulmonary Renal and Centralized Monitoring verified the assigned schedule was out of the required California ratios of 1 nurse to 4 patients for telemetry patients on 3/8/26 from 1900 hours till shift change at 0700 on 3/9/26. During an interview with the Relief House Supervisor and Relief Charge Oncology on 4/24/26 at 1001 hours. The Relief House Supervisor and Relief Charge Oncology stated staffing did have a Registered Nurse float from the Pulmonary Renal Unit to the ICU at 1700 hours, removing one of the original scheduled nurses for the unit. The Relief House Supervisor and Relief Charge Oncology stated the hospital was very short-staffed that night. The Relief House Supervisor and Relief Charge Oncology stated a call out occurred on the Pulmonary Renal unit on 3/8/26 at 1800 hours, after staffing had been completed. The Relief House Supervisor and Relief Charge Oncology stated once staffing had been completed, the expectation was for the unit to find a replacement registered nurse. The Relief House Supervisor and Relief Charge Oncology stated the unit was expected to also use all unit scheduled nurses including any break nurses and charge nurses to take patients to maintain correct California mandated staffing ratios. The Relief House Supervisor and Relief Charge Oncology stated staffing was not required to send the unit any extra nursing staff or float someone to their floor if they still have a charge nurse who is available to take patients. During an interview with the Accreditation Program Manager on 4/28/26 at 1435 hours, the Accreditation Program Manager was made aware of the above staffing concerns.”

“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: 38660 Based on interview and record review, the hospital failed to ensure the medication was administered as per the hospital’s P&P for one of three sampled patients (Patient 1). The nurse staff failed to administer blood pressure medication to Patient 1 and did not inform the physician. The physician increased the dose of blood pressure medication, causing Patient 1’s BP dropped suddenly, requiring the Medical Emergency Team’s intervention. This failure resulted in poor health outcomes for the patient. Findings: During a review of the hospital’s P&P titled, “Medication/IV Administration, RX-444” dated 6/2024, the P&P showed: * Scheduled medications will be administered within one hour before or one hour after their scheduled administration time. * The Medication Administration section showed - Monitor the patient’s response to medications for any adverse or unexpected reactions. - When unable to administer a dose based on the patient’s condition (e.g., not administering a blood pressure medication due to the patient’s blood pressure being abnormally low), notify the prescriber that the medication was not administered and why, document the medication omission, why the medication was not administered, and that the licensed independent practitioner (LIP) was notified, and determine if there are any follow-up orders or interventions from the prescriber. During a review of Patient 1’s medical record with the Medical Telemetry Manager on 9/25/25, the medical record showed Patient 1 was admitted to the hospital on 6/25/25, with left hemiparesis and hypertensive emergency. During a review of the Hospitalist Progress Note dated 6/27/25, the Hospitalist Progress Note showed Patient 1 experienced several hours of left-sided weakness and tingling in the face, arm, and leg. These symptoms resolved with blood pressure control but recurred with uncontrolled hypertension. The plan on 6/27/25 included increasing lisinopril (blood pressure medication) to 40 mg daily, continuing HCTZ (blood pressure medication) 25 mg daily, starting amlodipine (blood pressure medication) 5 mg daily in the morning, and prazosin (blood pressure medication) 1 mg nightly. Review of Patient 1’s Flowsheet on 6/27/25 showed BP readings of 177/122 mmHg at 1958 hours, 165/112 mmHg at 2000 hours, and 157/106 mmHg at 2034 hours. At 2000 hours, Patient 1 was anxious and restless. At 2039 hours, the nurse informed the physician of the patient’s hypertension, anxiety, and left arm numbness, stating all PRNs were exhausted. Review of the physician’s order dated 6/27/25 at 2048 hours, showed the order for prazosin capsule 1 mg oral nightly, starting on 6/27/25 at 2115 hours. Review of the MAR dated 6/27/25, showed prazosin 1 mg was documented “Not Given” at 2300 hours, with the RN’s note showed “Pt finally asleep after having anxiety and HTN. Letting him sleep since the two symptoms are coupled”. Review of the physician’s order dated 6/28/25 at 1030 hours, showed the order for prazosin capsule 2 mg orally nightly, starting on 6/28/25 at 2100 hours. Review of the physician’s order dated 6/28/25 at 1031 hours, showed the order for metoprolol (a medication used to treat high blood pressure) 25 mg orally two times daily, starting on 6/28/25 at 1100 hours. Review of Patient 1’s Flowsheet on 6/28/25, showed the patient’s BP was 200/119 mmHg at 2026 hours and 153/106 mmHg at 2029 hours. Review of the MAR on 6/28/25, showed Patient 1 received metoprolol 25 mg orally at 2030 hours and prazosin 2 mg orally at 2034 hours. Review of Patient 1’s Flowsheet on 6/28/25 at 2139 hours, the Flowsheet showed Patient 1’s BP was 91/44 mmHg. During a review of the Medical Emergency Team (MET) dated 6/28/25 at 2152 hours, showed the MET was called for Patient 1 with low blood pressure after receiving metoprolol 25 mg and prazosin 2 mg. Patient 1 had been experiencing hypertension with readings of 150-200/100-110 mmHg throughout the day and had tolerated HCTZ 25 mg, lisinopril 40 mg, and metoprolol 25 mg administered in the morning. According to the family present at the bedside, the patient was sitting up on the couch and ambulating prior to the evening medication administration. The MAR showed that the patient had not received prazosin the previous night (6/27/25), making the dose administered on 6/28/25 new for the patient. On assessment, Patient 1’s BP was in the 90s/50s mmHg range, the patient was lethargic but arousable to voice and complained of dizziness. Patient 1’s pupils were dilated, equal, and reactive, with no focal deficits observed, and generalized weakness and slight diaphoresis were noted. Lung sounds were diminished. Patient 1 received a 500 ml normal saline (NS, an IV solution or mixture of water and salt) bolus and reported feeling better. At 0130 hours, Patient 1’s systolic blood pressure (SBP) remained below 100 mmHg, and Patient 1 continued to be lethargic and complained dizziness. Patient 1 received an additional 500 ml NS bolus. At 0255 hours, the patient was still lethargic and complained of dizziness. Glucagon (medication to treat severe low blood sugar) was administered as ordered by the physician. Patient 1’s BP was recorded at 110/60 mmHg, and the patient reported feeling a little better. During a concurrent interview and record review on 9/25/25 at 1400 hours, with the Medical Telemetry Manager, the Medical Telemetry Manager stated prazosin was ordered 1 mg on 6/27/25 for Patient 1. The Medical Telemetry Manager stated the nurse held the prazosin and did not notify the physician. As a result, Patient 1’s BP remained uncontrolled, the physician increased the dose of the prazosin to 2 mg on 6/28/25, which resulted in Patient 1 experiencing hypotension requiring MET intervention.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 40483 Based on interview and record review, the hospital failed to follow their P&P, staffing matrix, and California Required Ratios for Patient Care Unit, Critical Decision Unit Overflow (a unit known as 2 South, a telemetry unit) on 2/14/25 (for the night shift) and 2/15/25 (for both day and night shifts). This failure created the risk of substandard health outcomes to the patients. Findings: Review of the hospital’s P&P titled Staffing, GEN-700, last approved dated April 2023 showed the staffing levels are designed to provide the adequate number of registered nurses who are qualified to make decisions for care. The staffing will be increased or decreased to accommodate the fluctuating volume and patient acuity. Each nursing unit identifies the scheduling process based on established guidelines and reflects the appropriate staff for each shift to ensure the skill mix is required to maintain the unit’s patient care requirements. The California Code of Regulations, Title 22, Division 5, Chapter 1, Article 3, §70217(a)(10) showed the licensed nurse-to-patient ratio in a telemetry unit shall be 1:4 or fewer at all times. Review of the Staffing Matrix for Patient Care unit 2 South showed the following for night shift: - A census of 16 patients has 4 Registered Nurses (RN’s) and 1 Charge Nurse - A census of 18 patients has 5 RN’s, 1 Break Nurse and 1 Charge Nurse - A census of 22 patients has 5 RN’s, 1 Break Nurse and 1 Charge Nurse On 3/13/25 at 0835 hours, a review of the staffing schedule was conducted with the Patient Safety Officer and the Nurse Manager of Critical Decision Unit Overflow (2 South). Review of the 2 South Nursing staff schedule dated 2/14/25, night shift with a beginning census of 16 showed the following RN staffing assignments: - 1 scheduled Charge Nurse. - RN 2 was assigned 5 patients, one who was admitted from the ER at 0027 hours with cardiac monitoring ordered and was a telemetry patient. - RN 3 was assigned 5 patients, one patient who was a direct admit at 2232 hours and one patient who was admitted from the ER at 0027 hours. All 5 assigned patients had cardiac monitoring ordered and were telemetry patients. - RN 4 was assigned 5 patients, one who was admitted from the ER at 0111 hours. All 5 assigned patients had cardiac monitoring ordered and were telemetry patients. - RN 5 was assigned 5 patients, one who was admitted from the ER at 0031 hours with cardiac monitoring ordered and was a telemetry patient. Review of the 2 South Nursing staff schedule, dated 2/15/25, day shift with a beginning census of 22 showed the following RN staffing assignments: - RN 6 was assigned 5 patients, one patient who was admitted from the ER at 0850 hours with cardiac monitoring ordered and one patient was admitted from the ER at 1846 hours. Review of the 2 South Nursing staff schedule dated 2/15/25, night shift with a beginning census of 18 showed the following RN staffing assignments: - 1 scheduled Charge Nurse - RN 2 was assigned 5 patients, one who was admitted from the ER at 0038 hours with cardiac monitoring ordered and was a telemetry patient. - RN 1’s assignment was 5 patients, 4 of which were on cardiac monitoring. - RN 7 was assigned 5 patients, one who was admitted from the ER at 1846 hours with cardiac monitoring ordered and was a telemetry patient. Another patient was admitted from the ER at 0028 hours. RN 7’s assignment was 5 patients, 4 of which were on cardiac monitoring. - RN 8 was assigned 5 patients, one who was admitted from the ER at 2326 hours with cardiac monitoring ordered and was a telemetry patient. RN 8’s assignment was 5 patients, 4 of which were on cardiac monitoring. - RN 9 was assigned 5 patients, one who was admitted from the ER at 1846 hours with cardiac monitoring ordered and was a telemetry patient. RN 9’s assignment was 5 patients, 1 of which was admitted on cardiac monitoring. No time documented for when the patient was admitted from the ED. On 3/13/25 at 0835 hours, an interview was conducted with the Nurse Manager of Critical Decision Unit Overflow (2 South). The Nurse Manager of Critical Decision Unit Overflow (2 South) stated the unit admitted patients who were classified as medical, surgical, and telemetry patients. The Nurse Manager of Critical Decision Unit Overflow (2 South) defined telemetry patients as those patients who had a provider order for cardiac monitoring. The Nurse Manager of Critical Decision Unit Overflow (2 South) stated the unit had two shifts, day shift and night shift. The Nurse Manager of Critical Decision Unit Overflow (2 South) stated the unit followed the California title 22 ratios for the unit’s patient care requirements. The Nurse Manager of Critical Decision Unit Overflow (2 South) stated the purpose for following the California ratios was partly due to the Title 22 requirement, but also for patient safety and acuity. It was followed to ensure patients with higher acuity got the nursing care they needed. Telemetry was considered a higher acuity as those patients needed the monitoring. The Nurse Manager of Critical Decision Unit Overflow (2 South) stated the unit also followed a staffing matrix based on the California ratios and the patient census. The Nurse Manager of Critical Decision Unit Overflow (2 South) stated per the required California ratios, the expectation was for RNs to have no more than a total of 4 patients if they have even 1 patient with cardiac monitoring (telemetry patients). RNs with medical or surgical patients (no telemetry patients) could have up to 5 patients assigned to them. The Nurse Manager of Critical Decision Unit Overflow (2 South) verified on 2/15/25 night shift, the nurse staffing schedule did not follow the requirements of the nurse matrix for a patient census of 18 and 4 scheduled nurses and 1 Charge Nurse. The Nurse Manager of Critical Decision Unit Overflow (2 South) stated per the staffing matrix, 5 RN’s, 1 break nurse, and 1 charge nurse should have been scheduled for the shift. The Nurse Manager of Critical Decision Unit Overflow (2 South) also verified the above documents showed the RNs were given assignments out of the required California ratios on 2/14/25 night shift and on 2/14/25 both day and night shift.”

“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: 22553 Based on interview and record review, the hospital failed to ensure the bed alarm was set for one of 19 sampled patients (Patient 1) who was identified to be high risk for falls. This failure created the risk of substandard health outcomes for the patient. Findings: The hospital’s P&P titled Fall Risk Assessment and Interventions, PC-168 revised on June 2022 showed patients admitted for an acute hospital stay will be assessed for fall risk by the RN every shift. Fall precaution strategies are to be initiated based on the assessment findings. For patients assessed to be at Moderate/High Fall risk, the fall prevention interventions include activation of the bed alarm. On 3/12/25 at 1402 hours, review of Patient 1’s closed medical record was conducted with Risk Management Analyst. Patient 1 was admitted to the hospital on 1/26/25, for a chest pain. Review of the Cardiovascular and Thoracic Surgery Progress Note dated 1/30/25, showed Patient 1 had a Coronary Artery Bypass Grafting Times Four. The patient had a left chest tube, secured pacer wires, and sternal incision. Review of the nursing assessment dated 1/30/25 at 1345 hours, showed Patient 1 was high risk for falls with a Morse Fall Risk of “60” (a total of 15 for Secondary Diagnosis, 15 for Ambulatory Aids, 20 for IV or IV Access, and 10 for Gait/Transferring). Review of the nursing assessment dated 1/30/25 at 1427 hours, showed Patient’s mobility was independent, needed minimum assistance for mobility and transfer, and patient used a “2 wheeled walker”. The Enhanced Safety Measures included bed alarm set. Review of RN 1’s notes dated 1/30/25 at 1836 hours, showed at approximately 1418 hours, the CNA reported to the RN that Patient 1 had fallen on the floor. Patient 1 was found faced down on the floor with the feet a couple of feet from the foot of the patient’s bed and the head towards the entrance of the room. Per the CNA, when the CNA approached the door of the room, the CNA heard the patient fall. The patient was unresponsive with no verbal response to any prompts. The patient was breathing at 22 breaths per minute. With the assistance of the surrounding staff, the patient was turned on the side and after the airway was cleared, the patient regained consciousness and was fully oriented to questions. On 3/12/25 at 1340 hours, CNAs 1 and 2 were interviewed about Patient 1’s fall on 1/30/25. Both CNAs were able to recall the fall episode. The CNAs stated because Patient 1 was ambulating, they turned off the bed alarm. The Risk Management Analyst and Director of Risk confirmed the findings on 3/12/25 at 1516 hours.”

“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: 29798 Based on interview and record review, the hospital failed to ensure the nursing staff adhered to the hospital’s P&P for one of two sampled patients (Patient 2) when Patient 2’s change of condition was not addressed in the patient’s plan of care. This failure posed the risk of adverse health outcomes to the patient. Findings: Review of hospital’s P&P titled Critical Care Standards of Practice dated March 2024 showed the policy is to establish the standards for nursing practice in the Medical Intensive Care Unit (MICU) and Cardiovascular Intensive Care Unit (CVICU) (beds 7-12) at the hospital. Nursing Plan of Care is assessed, updated, and documented in the electronic medical record every shift. On 1/16/25 at 0910 hours, Patient 2’s medical record review was initiated with the Patient Safety Officer. Patient 2’s medical record showed Patient 2 was brought into the ED on 12/21/24, with the chief complaint of lactic acidosis and acute pancreatitis. Review of the Nurse Practitioner’s order dated 1/5/25 at 0755 hours, showed to transfuse one unit of Red Blood Cells (PRBC); the indication was for the Hgb less than 7 g/dl or Hct less than 21% in stable patient. Review of the document titled Single Transfusion Record showed the PRBC transfusion was started on 1/5/25 at 1431 hours, and completed on 1/5/25 at 1545 hours. Review of Patient 2’s Plan of Care failed to show documented evidence the patient’s plan of care dated 12/21/24 at 1554 hours was updated with Patient 2’s change of condition related to active bleeding. The above finding was verified with the Patient Safety Officer.”

“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: 39199 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff followed the hospital’s P&P on administering the medications enterally for one of two sampled patients (Patient 1). This failure posed the risk of adverse health outcomes to the patient. Findings: Review of the hospital’s P&P titled Enteral Feeding Administration dated April 2024 showed under the section Medication Delivery: - Do not mix medications together due to the risks for physical and chemical incompatibilities, tube obstructions, and altered therapeutic drug responses. - Each medication should be administered separately using a clean 30 ml or larger enteral syringe. On 1/16/25 at 0911 hours, an observation of the medication administration for Patient 1 by RN 1 was conducted. RN 1 was observed crushing the following three medications together and administered them via Patient 1’s NG tube (not separately as per the hospital’s P&P): - One tablet of amiodarone (an anti-arrhythmic drug) 200 mg, - One tablet of midodrine (a medication to treat low blood pressure) 5 mg, and - One capsule of rifampin (an antibiotic) 300 mg. On 1/16/25, RN 1 verified the findings following the medication administration observation. On 1/16/25 at 1530 hours, the Patient Safety Officer acknowledged the findings.”