Community Hospital of Huntington Park

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to provide appropriate stabilizing treatment for one (1) of 20 sampled patients (Patient 1), when Patient 1 presented to the Emergency Department (ED, a hospital facility providing 24/7, unscheduled medical care for acute, severe, or life-threatening conditions using triage to prioritize critical patients and offering immediate stabilization, diagnosis [labs, imaging], and treatment) with vaginal bleeding and nausea (strong urge to vomit). Patent 1’s ultrasound (non-invasive imaging technique that uses high-frequency sound waves to create real-time pictures of organs, tissues, and blood flow inside the body helping doctors diagnose problems and guide treatments) results indicated suspected ruptured ectopic pregnancy (a life-threatening medical emergency where a fertilized egg implants outside the uterus [usually in a fallopian tube] and grows, causing the tube to burst, leading to severe internal bleeding and requiring immediate surgery). The provider advised Patient 1 to leave the facility against medical advice (AMA) and seek care at a larger hospital for better management, rather than initiating appropriate stabilizing treatment and arranging a compliant EMTALA (Emergency Medical Treatment and Labor Act, a federal law that requires anyone coming to an emergency department to be treated and stabilized, regardless of their insurance status or ability to pay) transfer, in accordance with the facility’s policy regarding EMTALA guidelines. This deficient practice placed Patient 1 at risk for serious harm, including fallopian tube rupture, severe internal bleeding, infection, shock (a life-threatening emergency where the circulatory systems fails, meaning tissues and organs do not get enough oxygen-rich blood, leading to cell dysfunction, organ failure, and potentially death if not treated immediately), and possible death. Findings: During a review of Patient 1’s “ED Triage (sorting and prioritizing patients based on the urgency of their medical condition, using a nurse’s rapid assessment of vital signs and symptoms to determine who needs immediate, critical care versus who can wait, ensuring the sickest are seen first, regardless of arrival time)” note, dated 9/24/2025 at 9:17 p.m., the note indicated Patient 1 presented to the Emergency Department (ED) with complaints of vaginal bleed for 2 weeks and nausea. Last menstrual period was 8/10/2025. During a review of Patient 1’s “ED Note,” dated 9/24/2025 at 11:03 p.m., the note indicated Patient 1 presented to the Emergency Department (ED) with complaints of vaginal bleed for 2 weeks and nausea. Last menstrual period was 8/10/2025. Labs (Laboratory results) were reviewed and indicated a positive Beta HCG (positive for pregnancy). White Blood Count was 13.1 (elevated, could indicate infection or inflammation). Diagnosis: ectopic pregnancy (fertilized egg plants itself outside the uterus [womb], most commonly in the fallopian tube, poses risk of rupture and internal bleeding for the mother). The ED Note also indicated “Medical Decision Making: 19-year-old female (Patient 1) came with complaint of vaginal bleeding, abdominal ultrasound reveals concern for possible left-sided ectopic pregnancy ... Care discussed with OBGYN (Obstetric Gynecologist, a medical doctor specializing in comprehensive women’s healthcare, covering both pregnancy/childbirth [obstetrics] and the female reproductive system [gynecology]) on call who advised patient (Patient 1) sign AMA (against medical advice) and go to the nearest big hospital capable of managing patient (Patient 1) ... patient (Patient 1) needs to go somewhere else where they (Patient 1) can be better managed. Care also discussed with Attending ED Physician (MD 2) who is aware of plan. Ultrasound of pelvis result indicated: Abnormal pelvic ultrasound. Complex pelvic free fluid and a 4.7 centimeter (cm) left adnexal mass suspicious for ruptured ectopic pregnancy.” During a review of Patient 1’s Nurse’s “Progress Note Report,” dated 9/24/2025 at 11:08 p.m., the note indicated the following: Upon receiving Patient 1, Nurse Practitioner (NP) 1 spoke with OBGYN consult and stated Patient 1 needed to go to another Hospital (Hospital B) and had to sign AMA. NP 1 explained to Patient 1 the diagnosis and the reason for signing the AMA form. NP 1 explained to Patient 1 she (Patient 1) needed to sign AMA and needed to go to Hospital B STAT (immediately). The report indicated Patient 1 verbalized understanding of the reason why Patient 1 needed to sign AMA form. Patient 1 verbalized understanding of risk of signing AMA. Patient 1 signed AMA with NP 1. Patient 1 was provided copy of results, lab (laboratory) and US (ultrasound), radiology and copy of CD (Compact Disc) imaging (diagnostic images). The note further indicated Patient 1 left the ER (Emergency Room). During a review of Patient 1’s document titled, “Leaving Hospital Against Medical Advice,” dated 9/24/2025 at 3:15 p.m., the document indicated Patient 1 and Nurse Practitioner (NP 1) signed the form. The form indicated that Patient 1 was leaving the hospital against the advice of NP 1 and “was told about the risk and consequences involved in leaving the hospital at this time.” During an interview on 1/6/2026 at 3:15 p.m. with Registered Nurse 1 (RN 1), RN 1 stated the following: -RN 1 stated that an ectopic pregnancy was a medical emergency, and risks included bleeding and possible infection. -RN 1 stated that he (RN 1) was told by NP 1 that Patient 1 needed to leave AMA and go immediately to another hospital. -RN 1 stated that he (RN 1) did not feel that Patient 1 should leave AMA. During a concurrent interview and record review on 1/6/2026 at 3:46 p.m. with the Director of Emergency Department (DED), the DED said the following: -DED stated that the situation (involving Patient 1) was not escalated properly and there were protocols in place that should have been followed. -DED stated that the nurses should have advocated for Patient 1 and their documentation should have reflected it. -DED reviewed Patient 1’s medical records and verified that there were no treatments ordered, only labs and ultrasounds. During a concurrent interview and record review on 1/7/2026 at 10:02 a.m. with the Medical Director of the Emergency Department (MD 1), MD 1 stated the following: An ectopic pregnancy can be serious if the ectopic pregnancy ruptured. Patients who present to the Emergency Department (ED) with an ectopic pregnancy should be treated. The facility was expected to provide treatment, such as methotrexate (a medication to end pregnancy in early stages) or surgery, if it ruptured. The rupture can cause a patient to hemorrhage (excessive bleeding) and can be life-threatening. MD 1 reviewed Patient 1’s medical record and ultrasound results and stated that Patient 1 had a ruptured ectopic pregnancy and OBGYN doctor was consulted and per the ED Note, dated 9/24/2025, OBGYN advised that Patient 1 sign AMA (against medical advice) and go to the nearest big hospital capable of managing Patient 1. Care also discussed with ED physician (MD 2) who was aware of plan. MD 1 stated Patient 1 had a ruptured ectopic pregnancy, and it was not appropriate to advise Patient 1 to sign AMA and go to another hospital. Patient 1 should have been taken to the operating room to address the ectopic pregnancy. If the hospital was not capable of providing care, the facility should have arranged to transfer Patient 1 to another hospital capable of providing care. During an interview on 1/7/2026 at 11:30 a.m. with the Emergency Department Physician (MD 2), MD 2 stated that he (MD 2) was the attending physician on 9/24/2025 and stated the following: Nurse Practitioner (NP) 1 evaluated Patient 1 and consulted with the OBGYN physician (OBGYN) on call. “The OBGYN refused to come and evaluate Patient (Patient 1).” The OBGYN did not order any treatment for Patient 1. The OBGYN instructed NP 1 to have Patient 1 sign that she (Patient 1) was leaving against medical advice (AMA). Patient 1 was instructed to go to another hospital, given copies of medical records and imaging, and instructed on what to say when Patient 1 arrived at the other hospital. It was not safe for Patient 1 to leave the hospital because the ultrasound results indicated Patient 1 had a suspected ruptured ectopic pregnancy. A ruptured ectopic pregnancy could result in death of the Patient 1. MD 2 stated the hospital could not transfer Patient 1 to another hospital because the facility had the capacity to treat Patient 1, however, the OBGYN refused to go to the hospital and evaluate Patient 1. During an interview on 1/7/2026 at 12:00 p.m. with NP 1, NP 1 stated the following: -NP 1 stated that Patient 1 was a critical patient and as an NP she usually did not see critical patients. -NP stated that she received guidance from MD 2 regarding Patient 1’s care and MD 2 advised her to call the on call OBGYN. -NP 1 stated that when she called the OBGYN, she (NP 1) read Patient 1’s vital signs and ultrasound results, OBGYN stated that the patient (Patient 1) was stable and should go to another hospital. -NP 1 stated that a complication of leaving the Emergency Department AMA, with a ruptured ectopic pregnancy, was death. During a review of the facility’s policy and procedure (P&P) titled, EMTALA Guidelines for Emergency Department, dated 8/2025, the P&P indicated ... “A. It is policy of the Hospital: 2. If it is determined that the individual has an emergency medical condition, provide a medical examination and treatment required to stabilize the medical condition, within the capabilities of the hospital, or arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below ... E. “Stabilization or to Stabilize” means: b. To provide such material treatment of the condition as is necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the Hospital ... I. “Treatment to Stabilize” or “Stabilizing Treatment” means: Treatment of the emergency condition within the capabilities of the hospital such that, within reasonable medical probability, no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the Hospital ...””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to provide appropriate stabilizing treatment for one (1) of 20 sampled patients (Patient 1), when Patient 1 presented to the Emergency Department (ED, a hospital facility providing 24/7, unscheduled medical care for acute, severe, or life-threatening conditions using triage to prioritize critical patients and offering immediate stabilization, diagnosis [labs, imaging], and treatment) with vaginal bleeding and nausea (strong urge to vomit). Patent 1’s ultrasound (non-invasive imaging technique that uses high-frequency sound waves to create real-time pictures of organs, tissues, and blood flow inside the body helping doctors diagnose problems and guide treatments) results indicated suspected ruptured ectopic pregnancy (a life-threatening medical emergency where a fertilized egg implants outside the uterus [usually in a fallopian tube] and grows, causing the tube to burst, leading to severe internal bleeding and requiring immediate surgery). The provider advised Patient 1 to leave the facility against medical advice (AMA) and seek care at a larger hospital for better management, rather than initiating appropriate stabilizing treatment and arranging a compliant EMTALA (Emergency Medical Treatment and Labor Act, a federal law that requires anyone coming to an emergency department to be treated and stabilized, regardless of their insurance status or ability to pay) transfer, in accordance with the facility’s policy regarding EMTALA guidelines. This deficient practice placed Patient 1 at risk for serious harm, including fallopian tube rupture, severe internal bleeding, infection, shock (a life-threatening emergency where the circulatory systems fails, meaning tissues and organs do not get enough oxygen-rich blood, leading to cell dysfunction, organ failure, and potentially death if not treated immediately), and possible death. On 1/08/2026 at 9:21 a.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Chief Nursing Officer (CNO), the Quality Coordinator (QC), the Director of the Emergency Department (DED) and the Senior Director of Quality (SDOQ). Patient 1 presented to the Emergency Department (ED) with complaints of vaginal bleed for 2 weeks and nausea (strong urge to vomit). Last menstrual period was 8/10/2025. Laboratory test indicated a positive Beta HCG (positive for pregnancy). White Blood Count was 13.1 (elevated, could indicate infection or inflammation). Patient 1 was diagnosed with an ectopic pregnancy (when fertilized egg plants itself outside the uterus [womb], most commonly in the fallopian tube, poses risk of rupture and internal bleeding for the mother). Patient 1’s ultrasound indicated a suspicious ruptured ectopic pregnancy (a life-threatening medical emergency where a fertilized egg, usually in the fallopian tube, bursts the structure, causing internal bleeding). The Nurse Practitioner (NP 1) providing care for Patient 1 consulted with the On-Call Obstetrician-Gynecologist (OBGYN, a medical doctor specializing in women’s reproductive health, pregnancy, and childbirth). The OBGYN did not go to the facility to evaluate Patient 1. Patient 1 was not treated for the ruptured ectopic pregnancy. Instead OBGYN advised that Patient 1 leave the hospital against medical advice (AMA) and seek treatment at a bigger hospital which could manage Patient 1. Patient 1 was informed of the risks and benefits of leaving AMA, given copies of medical records and imaging (various non-invasive, often painless, technologies used by healthcare providers to view the inside of the body to diagnose, monitor, and treat medical conditions) and instructed on what to say upon arriving at the other hospital (Hospital B). Patient 1 left the Emergency Department after signing the Leaving Against Medical Advice (AMA) form. On 1/09/2026 at 3:44 p.m., the IJ was removed in the presence of the CNO, DED, Director of Quality (DOQ) and the Chief Executive Officer (CEO) after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record reviews. The hospital implemented a directive prohibiting any physician, nurse practitioner, or physician assistant from recommending, initiating, or directing an AMA discharge for any patient. The AMA can only be initiated by the patient. The hospital must provide mandatory stabilizing treatment or EMTALA-Compliant Transfer for life-threatening obstetric emergencies or other emergency conditions if the service is not available. Failure of an on-call physician to respond to an emergency consult now requires the charge nurse and house supervisor to be notified. The charge nurse and house supervisor will escalate to the Administrator on Call, Chief of Staff, and Medical Director of the Emergency Department. The ED attending physician retains full authority to activate operating room, initiate stabilization, or arrange an EMTALA transfer. Any medical staff member or employee who notices an inappropriate or unsafe transfer of a patient or has any concerns must report to the house supervisor immediately. The charge nurse will review all AMAs and must have a conversation with the patient to confirm the patient’s wishes. All ED transfers must be reviewed by the charge nurse and the house supervisor before the patient is transferred to ensure all the components of the EMTALA form are completed. Re-education was provided to all applicable staff to include but not limited to ED providers, ED staff (nursing, emergency technicians etc.), House Supervisors and Management. Findings: During a review of Patient 1’s “ED Triage (sorting and prioritizing patients based on the urgency of their medical condition, using a nurse’s rapid assessment of vital signs and symptoms to determine who needs immediate, critical care versus who can wait, ensuring the sickest are seen first, regardless of arrival time)” note, dated 9/24/2025 at 9:17 p.m., the note indicated Patient 1 presented to the Emergency Department (ED) with complaints of vaginal bleed for 2 weeks and nausea. Last menstrual period was 8/10/2025. During a review of Patient 1’s “ED Note,” dated 9/24/2025 at 11:03 p.m., the note indicated Patient 1 presented to the Emergency Department (ED) with complaints of vaginal bleed for 2 weeks and nausea. Last menstrual period was 8/10/2025. Labs (Laboratory results) were reviewed and indicated a positive Beta HCG (positive for pregnancy). White Blood Count was 13.1 (elevated, could indicate infection or inflammation). Diagnosis: ectopic pregnancy (fertilized egg plants itself outside the uterus [womb], most commonly in the fallopian tube, poses risk of rupture and internal bleeding for the mother). The ED Note also indicated “Medical Decision Making: 19-year-old female (Patient 1) came with complaint of vaginal bleeding, abdominal ultrasound reveals concern for possible left-sided ectopic pregnancy ... Care discussed with OBGYN (Obstetric Gynecologist, a medical doctor specializing in comprehensive women’s healthcare, covering both pregnancy/childbirth [obstetrics] and the female reproductive system [gynecology]) on call who advised patient (Patient 1) sign AMA (against medical advice) and go to the nearest big hospital capable of managing patient (Patient 1) ... patient (Patient 1) needs to go somewhere else where they (Patient 1) can be better managed. Care also discussed with Attending ED Physician (MD 2) who is aware of plan. Ultrasound of pelvis result indicated: Abnormal pelvic ultrasound. Complex pelvic free fluid and a 4.7 centimeter (cm) left adnexal mass suspicious for ruptured ectopic pregnancy.” During a review of Patient 1’s Nurse’s “Progress Note Report,” dated 9/24/2025 at 11:08 p.m., the note indicated the following: Upon receiving Patient 1, Nurse Practitioner (NP) 1 spoke with OBGYN consult and stated Patient 1 needed to go to another Hospital (Hospital B) and had to sign AMA. NP 1 explained to Patient 1 the diagnosis and the reason for signing the AMA form. NP 1 explained to Patient 1 she (Patient 1) needed to sign AMA and needed to go to Hospital B STAT (immediately). The report indicated Patient 1 verbalized understanding of the reason why Patient 1 needed to sign AMA form. Patient 1 verbalized understanding of risk of signing AMA. Patient 1 signed AMA with NP 1. Patient 1 was provided copy of results, lab (laboratory) and US (ultrasound), radiology and copy of CD (Compact Disc) imaging (diagnostic images). The note further indicated Patient 1 left the ER (Emergency Room). During a review of Patient 1’s document titled, “Leaving Hospital Against Medical Advice,” dated 9/24/2025 at 3:15 p.m., the document indicated Patient 1 and Nurse Practitioner (NP 1) signed the form. The form indicated that Patient 1 was leaving the hospital against the advice of NP 1 and “was told about the risk and consequences involved in leaving the hospital at this time.” During an interview on 1/6/2026 at 3:15 p.m. with Registered Nurse 1 (RN 1), RN 1 stated the following: -RN 1 stated that an ectopic pregnancy was a medical emergency, and risks included bleeding and possible infection. -RN 1 stated that he (RN 1) was told by NP 1 that Patient 1 needed to leave AMA and go immediately to another hospital. -RN 1 stated that he (RN 1) did not feel that Patient 1 should leave AMA. During a concurrent interview and record review on 1/6/2026 at 3:46 p.m. with the Director of Emergency Department (DED), the DED said the following: -DED stated that the situation (involving Patient 1) was not escalated properly and there were protocols in place that should have been followed. -DED stated that the nurses should have advocated for Patient 1 and their documentation should have reflected it. -DED reviewed Patient 1’s medical records and verified that there were no treatments ordered, only labs and ultrasounds. During a concurrent interview and record review on 1/7/2026 at 10:02 a.m. with the Medical Director of the Emergency Department (MD 1), MD 1 stated the following: An ectopic pregnancy can be serious if the ectopic pregnancy ruptured. Patients who present to the Emergency Department (ED) with an ectopic pregnancy should be treated. The facility was expected to provide treatment, such as methotrexate (a medication to end pregnancy in early stages) or surgery, if it ruptured. The rupture can cause a patient to hemorrhage (excessive bleeding) and can be life-threatening. MD 1 reviewed Patient 1’s medical record and ultrasound results and stated that Patient 1 had a ruptured ectopic pregnancy and OBGYN doctor was consulted and per the ED Note, dated 9/24/2025, OBGYN advised that Patient 1 sign AMA (against medical advice) and go to the nearest big hospital capable of managing Patient 1. Care also discussed with ED physician (MD 2) who was aware of plan. MD 1 stated Patient 1 had a ruptured ectopic pregnancy, and it was not appropriate to advise Patient 1 to sign AMA and go to another hospital. Patient 1 should have been taken to the operating room to address the ectopic pregnancy. If the hospital was not capable of providing care, the facility should have arranged to transfer Patient 1 to another hospital capable of providing care. During an interview on 1/7/2026 at 11:30 a.m. with the Emergency Department Physician (MD 2), MD 2 stated that he (MD 2) was the attending physician on 9/24/2025 and stated the following: Nurse Practitioner (NP) 1 evaluated Patient 1 and consulted with the OBGYN physician (OBGYN) on call. “The OBGYN refused to come and evaluate Patient (Patient 1).” The OBGYN did not order any treatment for Patient 1. The OBGYN instructed NP 1 to have Patient 1 sign that she (Patient 1) was leaving against medical advice (AMA). Patient 1 was instructed to go to another hospital, given copies of medical records and imaging, and instructed on what to say when Patient 1 arrived at the other hospital. It was not safe for Patient 1 to leave the hospital because the ultrasound results indicated Patient 1 had a suspected ruptured ectopic pregnancy. A ruptured ectopic pregnancy could result in death of the Patient 1. MD 2 stated the hospital could not transfer Patient 1 to another hospital because the facility had the capacity to treat Patient 1, however, the OBGYN refused to go to the hospital and evaluate Patient 1. During an interview on 1/7/2026 at 12:00 p.m. with NP 1, NP 1 stated the following: -NP 1 stated that Patient 1 was a critical patient and as an NP she usually did not see critical patients. -NP stated that she received guidance from MD 2 regarding Patient 1’s care and MD 2 advised her to call the on call OBGYN. -NP 1 stated that when she called the OBGYN, she (NP 1) read Patient 1’s vital signs and ultrasound results, OBGYN stated that the patient (Patient 1) was stable and should go to another hospital. -NP 1 stated that a complication of leaving the Emergency Department AMA, with a ruptured ectopic pregnancy, was death. During a review of the facility’s policy and procedure (P&P) titled, EMTALA Guidelines for Emergency Department, dated 8/2025, the P&P indicated ... “A. It is policy of the Hospital: 2. If it is determined that the individual has an emergency medical condition, provide a medical examination and treatment required to stabilize the medical condition, within the capabilities of the hospital, or arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below ... E. “Stabilization or to Stabilize” means: b. To provide such material treatment of the condition as is necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the Hospital ... I. “Treatment to Stabilize” or “Stabilizing Treatment” means: Treatment of the emergency condition within the capabilities of the hospital such that, within reasonable medical probability, no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the 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: 36206 Based on observation, interview and record review, the facility failed to meet the Condition of Participation of Patient’s Rights (The Patient’s Bill of Rights is a document that outlines what patients can expect when receiving health care) as evidenced by: 1. The facility failed to ensure the patient’s right (a subset of human rights) to make informed decisions regarding their care, including their right to be involved in their treatment and receive communication in their preferred language, in accordance with the facility’s policy and procedure regarding the use of interpreter services (facilitates communication between healthcare workers and non-English speaking patients to ensure the best possible quality of care), for four of 30 sampled patients (Patient 11, Patient 15, Patient 19, and Patient 20) when: 1.a. A documented “Condition of Admission (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)” provided in the patient’s preferred language of Spanish was not completed for Patient 11 and Patient 20. 1.b. A documented “COA” and a documented “Important Message from Medicare (IM - a notice inpatients receive to inform them of their rights)” was not completed for Patient 15. 1.c. A documented “COA” and a documented surgical procedure consent provided in the patient’s preferred language of Russian was not completed for Patient 19. 1.d. A documented blood transfusion (administration of blood or blood components through an intravenous [IV- through the vein] line into a patient’s vein) informed consent provided in the patient’s preferred language of Spanish was not completed for Patient 20. These deficient practices had the potential for Patient 11, Patient 15, Patient 19, and Patient 20 not being able to fully understand and exercise their rights as patients during their respective hospitalizations, which could have negatively affected the patients’ rights to be involved in their own care and treatment in the facility. (Refer to A-0131) 2. The facility failed to ensure personal privacy was provided for one of 30 sampled patients (Patient 14), when Patient 14’s room curtains and door were not closed to ensure Patient 14’s privacy during a medical procedure, in accordance with the facility’s policy and procedure regarding Patient’s Rights (a subset of human rights). This deficient practice resulted in Patient 14’s personal privacy and dignity not being maintained during the delivery of care and exposing Patient 14’s vulnerable state to anyone coming into the respective facility care area, which could have negatively affected Patient 14’s right to receive respectful care and maintain their psychosocial well-being. (Refer to A-0143) 3. The facility failed to provide Abuse (intentional maltreatment of an individual that may cause physical or psychological injury) training for two of six sampled staff members (Registered Nurses [RN] 1, and RN 6), in accordance with the facility’s policies and procedures regarding abuse. This deficient practice had the potential for staff not to be informed of abuse, neglect, related reporting requirements, including prevention, intervention, and detection, which could potentially compromise patient safety. (Refer to A-0145) 4. The facility failed to ensure patients will be free from unnecessary 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), in accordance with the facility’s policy and procedure regarding restraints use for one of 30 sampled patients (Patient 26), when Patient 26 was placed in bed with four bed side rails up. This deficient practice resulted in restricting Patient 26 from getting out of bed freely and had potential to put Patient 26 at risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level) when attempting to get out of bed. (Refer to A-0164) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe setting.”

“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: 36206 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 provide registered nurse’s oversight over licensed vocational nurses’ assessments for six of 30 sampled patients (Patients 1, 3, 4, 28, 29 and 30) in accordance with the facility’s policy and procedure regarding assessment (in depth evaluation conducted by a registered nurse that evaluates a patient’s current physical, mental and emotional state) and reassessment and professional standards of practice. This deficient practice resulted in assessments documented by LVNs without RN oversight and had the potential for an inaccurate assessment of patients’ condition, which may result in the delay of provision of immediate care needed by the patients. (Refer to A-0395) 2. The facility failed to ensure nursing staff provided patient care, in accordance with accepted standards of nursing practice and hospital policy, for two of 30 sampled patients (Patient 17 and Patient 18), when Patient 17’s and Patient 18’s assessed responses to care interventions were not documented, as per facility policy and procedure regarding assessment and re-assessment. This deficient practice had the potential for Patient 17 and Patient 18 not receiving the necessary documented assessments and interventions regarding their individualized care needs, which can cause a delay in treatment and worsening of patient condition. (Refer to A-0395) 3. The facility failed to evaluate and validate competency (ability to perform skilled learned) for one of one nursing staff (Registered Nurse [RN] 6) on performing a procedure requiring moderate sedation (a drug-induced state where a patient is asleep but can be awakened by verbal command or light touch used to help relieve anxiety during certain medical or surgical procedure), in accordance with facility’s policy and procedure regarding moderate sedation before taking care of one of 30 sampled patients (Patient 27) for cardioversion (a medical procedure that restores a normal heart rhythm by delivering an electrical shock to the chest). This deficient practice resulted in RN 6 not performing required vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) and sedation monitoring (monitor for patient’s conscious and agitation level) for a patient (Patient 27) during and post (after) procedure and put Patient 27 at risk for respiratory distress (difficulty breathing) and death. (Refer to A-0397) 4. The facility failed to ensure there was a written order that was signed by a licensed practitioner for medications administered for one of 30 sampled (Patient 27), in accordance with the facility’s general rules and regulations regarding medication orders by a member of the medical staff, when Propofol (an intravenous [inject directly to vein] anesthetic [a drug that causes a temporary loss of feeling or awareness] used to induce and maintain anesthesia [a medical procedure that temporarily and intentionally causes loss of sensation or awareness to prevent pain during a medical procedure] and sedation [state of relaxation, sleepiness, or calmness caused by certain drugs]) was given during electrical cardioversion (a medical procedure that restores a normal heart rhythm by delivering an electrical shock to the chest). This deficient practice resulted in Propofol given to Patient 27 without written order by a licensed prescriber, which had the potential to result in lack of patient monitoring regarding response to the Propofol medication that may lead to complications such as respiratory issues and/or death. (Refer to A-0409) 5. The facility failed to ensure nursing staff provided proper vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) and sedation monitoring (monitor for patient’s conscious and agitation level) for two of 30 sampled patients (Patient 25 and 27) in the emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care), in accordance with the facility’s policy and procedure regarding moderate sedation when: 5.a. Patient 25 received Ketamine (an intravenous [inject directly to vein] anesthetic [a drug that causes a temporary loss of feeling or awareness] used medically for induction and maintenance of anesthesia [a medical procedure that temporarily and intentionally causes loss of sensation or awareness to prevent pain during a medical procedure]) and Versed (an intravenous [inject directly to vein] injection that helps the patient relax or sleep before a procedure) for right shoulder reduction (a procedure of returning a dislocated shoulder to its normal position). 5.b. Patient 27 received Propofol (an intravenous [inject directly to vein] anesthetic [a drug that causes a temporary loss of feeling or awareness] used to induce and maintain anesthesia [a medical procedure that temporarily and intentionally causes loss of sensation or awareness to prevent pain during a medical procedure] and sedation [state of relaxation, sleepiness, or calmness caused by certain drugs]) prior to an electrical cardioversion (a medical procedure that restores a normal heart rhythm by delivering an electrical shock to the chest). This deficient practice had the potential to result in not identifying oversedation of Patient 25 and Patient 27 and put Patient 25 and Patient 27 at risk for respiratory distress (a condition that occurs when the body needs more oxygen, and can be caused by a number of factors, including infections, chronic illness, or a blocked airway) and death. (Refer to A-0410) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50515 Based on interview and record review, the facility failed to ensure the patient’s right (a subset of human rights) to make informed decisions regarding their care, including their right to be involved in their treatment and receive communication in their preferred language, in accordance with the facility’s policy and procedure regarding the use of interpreter services (facilitates communication between healthcare workers and non-English speaking patients to ensure the best possible quality of care), for four of 30 sampled patients (Patient 11, Patient 15, Patient 19, and Patient 20) when: 1. A documented “Condition of Admission (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)” provided in the patient’s preferred language of Spanish was not completed for Patient 11 and Patient 20. 2. A documented “COA” and a documented “Important Message from Medicare (IM - a notice inpatients receive to inform them of their rights)” was not completed for Patient 15. 3. A documented “COA” and a documented surgical procedure consent provided in the patient’s preferred language of Russian was not completed for Patient 19. 4. A documented blood transfusion (administration of blood or blood components through an intravenous [IV- through the vein] line into a patient’s vein) informed consent provided in the patient’s preferred language of Spanish was not completed for Patient 20. These deficient practices had the potential for Patient 11, Patient 15, Patient 19, and Patient 20 not being able to fully understand and exercise their rights as patients during their respective hospitalizations, which could have negatively affected the patients’ rights to be involved in their own care and treatment in the facility. Findings: 1.a. During a review of Patient 11’s “Face Sheet (a document containing a patient’s medical and demographic information),” (undated), the “Face Sheet” indicated, Patient 11 was admitted to the facility on 9/2/2024 at 8:58 a.m., with a medical diagnosis of Acute Renal Failure (a condition in which the kidneys suddenly cannot filter waste from the blood), and vomiting. Patient’s 11’s “Face Sheet” further indicated, Patient 11’s preferred language was Spanish. During an interview on 9/3/2024 at 2:30 p.m. with Patient 11 and Patient 12, Patient 11 stated, she (Patient 11) was admitted to her patient room (bed 20B) and was not offered nor provided interpreter service or translation services (facilitates communication between healthcare workers and non-English speaking patients to ensure the best possible quality of care). Patient 12(bed 20A), roommate to Patient 11, stated she (Patient 12) translated in Spanish for Patient 11 and her (Patient 11) nurse all night when she (Patient 11) was admitted. During an interview on 9/3/2024 at 2:35 p.m. with Registered Nurse 2 (RN 2), RN 2 stated, when there was a language barrier with a patient, nurses were expected to use “Martti (Martti is a rolling iPad or tablet with an application that asked for patient’s language and provides interpreter service).” RN 2 stated, nurses would be aware of a patient’s language barrier or preferred language when getting report, through the patient’s demographic profile, and upon the admission assessment. During a concurrent interview and record review on 9/3/2024 at 3:00 p.m. with the Director of Medical/Surgical (provides care for patients who are recovering from surgery or with acute [sudden or severe] medical conditions)/Telemetry (where patients are monitored for heart activity) (DMST), Patient 11’s “Admission Inquiry Flowsheet (also known as the ‘Admission Assessment’),” dated 9/2/2024, was reviewed. The “Admission Inquiry Flowsheet” indicated, on 9/2/2024 at 11:22 a.m., Patient 11’s preferred spoken and written language was Spanish, and no interpreter use was documented. The DMST stated, no interpreter use was documented on Patient 11’s “Admission Inquiry Flowsheet.” The DMST further stated, the facility does not have qualified interpreters, so nurses were required to use “Martti” to do their assessments on patients with preferred languages other than English, as indicated in their patient profiles, and document the interpreter identification in the respective patient’s progress notes. During a concurrent interview and record review on 9/4/2024 at 10:21 a.m. with the Clinical Informatics Analyst (CIA) and the Director of Quality (DOQ), Patient 11’s “Condition of Admission (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.),” dated 9/2/2024, was reviewed. Patient 11’s “COA” documentation was signed on 9/2/2024 at 11:17 a.m. in English, with no interpreter use documented. The DOQ stated, Patient 11’s “COA” should have been in Spanish, because Patient 11 needed to understand what she (Patient 11) signed. During an interview on 9/4/2024 at 10:41 a.m. with the Admitting Director (AD) and the CIA, the AD stated, when a patient did not speak English, the facility tried to look for someone who spoke the language and the patient needed to request documents in their preferred language. The AD further stated, the facility did not have a language line for interpreter services and had not witnessed admitting employees using the translation service. The CIA stated, “Martti” was available, and could travel throughout the facility, including within the admitting department for interpreter service. During a review of the facility’s policy and procedure (P&P) titled, “Interpreter Services,” revised February 2024, the P&P indicated, “Consistent with ethical principles including respect for persons, the critical importance of communication, and state and federal regulations, the facility provide interpreters and translators for patients with limited proficiency (LEP). Staff will identify and document a patient’s primary language and dialect as well as the provision of interpreter and translation services.” 1.b. During a review of Patient 20’s “Face Sheet,” (undated), the “Face Sheet” indicated, Patient 20 was admitted to the facility on 9/3/2024 at 8:58 a.m., with a medical diagnosis of Acute Renal Failure (a condition in which the kidneys suddenly cannot filter waste from the blood) and anemia (condition when there’s low levels of red blood cells to carry oxygen to the body). Patient’s 20 “Face Sheet” further indicated, Patient 20’s preferred language was Spanish. During a concurrent interview and record review on 9/5/2024 at 1:36 p.m. with the Director of Medical Surgical/Telemetry (DMST) and the Clinical Informatics Analyst (CIA), Patient 20’s “COA (Condition of Admission- a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.),” dated 9/2/2024 was reviewed. Patient 20’s “COA” documentation was signed on 9/2/2024 at 1:58 p.m. in English, with no interpreter use documented. The DMST stated, no interpreter use was documented on Patient 20’s “COA.” The DMST further stated, the expectation was for nurses or admitting staff to make sure the patient’s informed consent (process in which a healthcare provider educates a patient about the risks, benefits, and alternatives of a procedure or intervention) was completed in the respective patient’s preferred language, because the patient needed to know what they signed. During a review of the facility’s policy and procedure (P&P) titled, “Interpreter Services,” revised February 2024, the P&P indicated, “Consistent with ethical principles including respect for persons, the critical importance of communication, and state and federal regulations, the facility provide interpreters and translators for patients with limited proficiency (LEP). Staff will identify and document a patient’s primary language and dialect as well as the provision of interpreter and translation services.” 2. During a review of Patient 15’s “Face Sheet,” (undated), the “Face Sheet” indicated, Patient 15 was admitted to the facility on 9/2/2024 at 9:00 a.m., with a medical diagnosis of urinary tract infection (UTI - infection in the urine tract). Patient 15’s “Face sheet” further indicated, Patient 15’s preferred language was Spanish. During a concurrent interview and record review on 9/5/2024 at 9:33 a.m. with the DMST and the CIA, Patient 15’s electronic health record (EHR - a digital health record accessed through a facility’s computer system), dated 9/2/2024 through 9/5/2024, was reviewed. Patient 15’s EHR was reviewed for Patient 15’s “COA (Condition of Admission- a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)” documentation and for their “Important Message from Medicare (IM - a notice inpatients receive to inform them of their rights).” The “COA” documentation and the “IM” documentation were not found for Patient 15. The DMST stated, does she did not know why Patient 15’s “COA” and “IM” were not in Patient 15’s EHR. During an interview on 9/5/2024 at 11:02 a.m. with the Admitting Director (AD) and the Director of Quality (DOQ) on the phone, the AD stated, the facility failed to follow-up for Patient 15’s incomplete “COA” or “IM” documentation until 9/5/2024, the day of the interview. During a review of the facility’s P&P titled, “Admission Consent Forms,” revised July 2021, the P&P indicated, “Upon admission/registration, all Consent Forms must be explained to the patient and their signature. Signatures on applicable Consent Forms are required prior to hospital services rendered. Within 24 hours of admission a follow up or second attempt will be made by the appropriate hospital designee to obtain patient signatures on admission consents.” 3. During a review of Patient 19’s “Face Sheet,” (undated), the “Face Sheet” indicated, Patient 19 was admitted to the facility on 9/1/2024 at 8:33 a.m., with a medical diagnosis of right foot cellulitis (painful skin infection that affects feet or legs). Patient 19’s “Face Sheet” further indicated, Patient 19’s preferred language was Russian. During a concurrent interview and record review on 9/5/2024 at 2:02 p.m. with the Director of Medical Surgical/Telemetry (DMST) and the Clinical Informatics Analyst (CIA), Patient 19’s “Condition of Admission (COA),” dated 9/1/2024 was reviewed. Patient 19’s “COA (Condition of Admission- a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)” documentation was signed on 9/1/2024 in English, with no interpreter use documented. The DMST stated, the patient needed to know what they were signing, and an interpreter should have been used for Patient 19. During a concurrent interview and record review on 9/5/2024 at 2:02 p.m. with the DMST and CIA, Patient 19’s “Consent to Surgery/Special Procedure/Anesthesia (a medical procedure that prevents patients from feeling pain during medical procedures or surgery)/Procedural Sedation (used to calm a patient during a procedure. This involves administration of medications to ease pain, discomfort or anxiety [a feeling of fear or uneasiness]) - with Physician Verification (also known as ‘consent for surgery’ - informed consent is a process that involves a patient and medical provider),” dated 9/3/2024 at 7:50 a.m., was reviewed. The document indicated, it was provided and completed in English, and no interpreter use was documented. The DMST and the CIA stated, an interpreter should have been used for Patient 19, as Patient 19 needed to understand what they signed. During a review of the facility’s policy and procedure (P&P) titled, “Interpreter Services,” revised February 2024, the P&P indicated, “Consistent with ethical principles including respect for persons, the critical importance of communication, and state and federal regulations, the facility provide interpreters and translators for patients with limited proficiency (LEP). Staff will identify and document a patient’s primary language and dialect as well as the provision of interpreter and translation services.” 4. During a review of Patient 20’s “Face Sheet,” (undated), the “Face Sheet” indicated, Patient 20 was admitted to the facility on 9/3/2024 at 8:58 a.m., with a medical diagnosis of Acute Renal Failure (a condition in which the kidneys suddenly cannot filter waste from the blood). Patient 20’s “Face Sheet” further indicated, Patient 20’s preferred language was Spanish. During a concurrent interview and record review on 9/5/2024 at 1:36 p.m. with the DMST and the CIA, Patient 20’s “Consent to Blood Transfusion/Blood Products (blood transfusion is the process of receiving blood or blood products intravenously [through the vein]),” dated 9/2/2024, was reviewed. Patient 20’s “Consent for Blood Transfusion/Blood Products” indicated, the completed document was printed in English, with no interpreter use documented. The DMST stated, the expectation was for nurses or admitting staff to make sure the informed consent was in Patient 20’s respective language and the patient understood what they signed. The DMST further stated, they were unable to locate a copy of an informed consent printed in Spanish within Patient 20’s EHR (Electronic Health Record- a digital health record accessed through a facility’s computer system). During a review of the facility’s policy and procedure (P&P) titled, “Interpreter Services,” revised February 2024, the P&P indicated, “Vital documents must be translated for those populations comprising 5% or 1000, whichever is less, individuals in the hospital’s geographic area. These include but are not limited to: consent and complaints form; (footnote) if the patient or the patient’s legal representative’s primary language is not one which a consent form has been prepared, an interpreter who is fluent in that language should prepare a written translation of the form that the patient can be given.””

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 50515 Based on observation, interview, and record review, the facility failed to ensure personal privacy was provided for one of 30 sampled patients (Patient 14), when Patient 14’s room curtains and door were not closed to ensure Patient 14’s privacy during a medical procedure, in accordance with the facility’s policy and procedure regarding Patient’s Rights (a subset of human rights). This deficient practice resulted in Patient 14’s personal privacy and dignity not being maintained during the delivery of care and exposing Patient 14’s vulnerable state to anyone coming into the respective facility care area, which could have negatively affected Patient 14’s right to receive respectful care and maintain their psychosocial well-being. Findings: During a review of Patient 14’s “Face Sheet (a document containing a patient’s medical and demographic information),” (undated), the “Face Sheet” indicated, Patient 14 was admitted to the facility on 8/29/2024 at 5:03 a.m., with a medical diagnosis of Chronic Obstructive Pulmonary Disease (COPD - lung disease that causes breathing difficulties and restricted airflow), Hypoxia (medical condition that occurs when there is not enough oxygen in the body), and Respiratory Failure (medical condition that occurs when the lungs are unable to properly absorb oxygen). During an observation on 9/3/2024 at 2:13 p.m. on the Intensive Care Unit (ICU - a hospital unit that provides specialized care for patients who are seriously ill), the door to patient room two was observed to be wide open, with the room curtains drawn in the open position. A Dialysis Nurse (DN - a Registered Nurse trained to perform dialysis, a life-sustaining procedure that filters waste and excess fluid from the blood) was observed inside patient room two with Patient 14, collecting blood from Patient 14 with the room door open and the curtains drawn open, exposing Patient 14’s vulnerable state to anyone walking into the ICU. During a concurrent observation and interview on 9/3/2024 at 2:13 p.m. with the Risk and Regulatory Management (RRM) and the ICU Charge Nurse (ICUCN), on the ICU in front of patient room two, the RRM observed the doorway of patient room two and stated, Patient 14’s privacy was not protected, and the expectation was for the room curtains to be drawn closed during the performance of a medical procedure. The ICUCN stated, the patient room curtains should have been drawn closed to protect Patient 14’s privacy during a medical procedure. During a review of the facility’s patient admission document titled, “Patient Rights,” (undated), the document indicated, “You have the right to: Have personal privacy respected.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights,” revised February 2024, the P&P indicated, “Full consideration of privacy regarding the medical care program. Case discussion, consultation, examination, and treatments are confidential and should be conducted discretely, including the right to be advised of the reason for the presence of any individual.””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to provide Abuse (intentional maltreatment of an individual that may cause physical or psychological injury) training for two of six sampled staff members (Registered Nurses [RN] 1, and RN 6), in accordance with the facility’s policies and procedures regarding abuse. This deficient practice had the potential for staff not to be informed of abuse, neglect, related reporting requirements, including prevention, intervention, and detection, which could potentially compromise patient safety. Findings: During a concurrent interview and record review on 9/6/2024 at 11:29 a.m., with the Human Resources Business Partner (HRBP) and the Clinical Educator (CED), the HRBP and CED reviewed RN 1 and RN 6’s personnel file and stated the following: Both RN 1 and RN 6 were contracted through a nursing registry. RN 1 and RN 6 did not have evidence of Abuse (intentional maltreatment of an individual that may cause physical or psychological injury) training in the personnel files. Abuse training should be provided upon hire and annually via the facility’s “Annual Update” (online study module that includes training on topics including, patient rights, patient safety, and identifying and reporting victims of abuse). The CED stated that all healthcare workers were required to have Abuse training to ensure staff could recognize signs and symptoms of abuse and help the patients. During a review of RN 1’s personnel file, the file indicated RN 1 was a contracted nurse and hired on 8/19/2023. RN 1 did not have evidence of completing the facility’s Abuse training. This was confirmed by HRBP and CED. During a review of RN 6’s Personnel file, the personnel file indicated RN 6 was a contracted nurse and hired on 1/16/2023. RN 6 did not have evidence of completing the facility’s Abuse training. This (lack of evidence of training) was confirmed by the HRBP and CED. During a review of the facility’s, “2023 Annual Update,” the Updated included topics, including, Patient Rights, Patient Safety, Identifying and Reporting Victims of Abuse, Identifying Potential Child Abuse, Neglect, and Potential Elder Abuse. During a review of the facility’s policy and procedure (P&P) titled, “Reporting of Alleged Abuse - Adult or Pediatric Patients,” dated 7/2022, the P&P indicated the following. Purpose: Establish guidelines in the reporting of alleged abuse or neglect, whether sexual or physical, known or suspected. The P&P did not indicate the frequency of training. This was confirmed by the CED.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure patients will be free from unnecessary 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), in accordance with the facility’s policy and procedure regarding restraints use, for one of 30 sampled patients (Patient 26), when Patient 26 was placed in bed with four bed side rails up without a physician order for restraints use. This deficient practice had resulted in restricting Patient 26 from getting out of bed freely and had potential to put Patient 26 at risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level) when attempting to get out of bed. Findings: During a review of Patient 26’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 8/31/2024, the H&P indicated, Patient 26 was admitted to the facility with diagnoses of non-ST-elevation myocardial infarction (NSTEMI, a type of heart attack) and congestive heart failure (CHF, a chronic condition in which a weakness of the heart leads to a buildup of fluid in the lungs). During a concurrent observation and interview on 9/3/2024 at 3:09 p.m. with the Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) Charge Nurse (ICUCN) at Patient 26’s room, Patient 26 was in bed with four bed side rails up. ICUCN stated there should be no more than three bed side rails up. ICUCN stated having all four bed side rails up would be considered as 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) because Patient 26 would not be able to get out of bed easily. ICUCN stated Patient 26 did not have any physician order for restraints and did not require any restraints. During a concurrent interview and record review on 9/4/2024 at 2:50 p.m. with the Clinical Informatics Specialist (CIS), Patient 26’s “Daily Assessment (nursing assessment, patient’s head to toe assessment performed by Registered Nurse),” dated 9/3/2024, was reviewed. The nursing assessment indicated, Patient 26 was awake, alert and oriented (a person’s level of awareness of self, place, time, and situation) with calm behavior. CIS stated there was no documentation showing Patient 26 was restless or getting out of bed. CIS stated having all four bedside rails up was not necessary for Patient 26. During a review of the facility’s policy and procedure (P&P) titled, “Restraints,” dated 7/2022, the P&P indicated, “Use of Side Rails ... side rails are frequently not used as a method to prevent patient from falling out of bed, but instead, used to restrict the patient’s freedom to exit the bed. The use of side rails to prevent the patient from exiting the bed would be considered a restraint ... All patients have the right to be free from restraint, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff.””

“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: 36206 Based on interview and record review, the facility failed to: 1. Provide registered nurse’s oversight over licensed vocational nurses’ assessments for six of 30 sampled patients (Patients 1, 3, 4, 28, 29 and 30) in accordance with the facility’s policy and procedure regarding assessment (in depth evaluation conducted by a registered nurse that evaluates a patient’s current physical, mental and emotional state) and reassessment and professional standards of practice. This deficient practice resulted in assessments documented by LVNs without RN oversight and had the potential for an inaccurate assessment of patients’ condition, which may result in the delay of provision of immediate care needed by the patients. 2. Ensure nursing staff provided patient care, in accordance with accepted standards of nursing practice and hospital policy, for two of 30 sampled patients (Patient 17 and Patient 18), when Patient 17’s and Patient 18’s assessed responses to care interventions were not documented, as per facility policy and procedure regarding assessment and re-assessment. This deficient practice had the potential for Patient 17 and Patient 18 not receiving the necessary documented assessments and interventions regarding their individualized care needs, which can cause a delay in treatment and worsening of patient condition. Findings: 1.a. During a review of Patient 1’s “ED (Emergency Department) Note,” dated 3/6/2024 at 3:04 p.m., the ED Note indicated the following. Patient 1’s chief complaint: “Laceration (a cut caused by a sharp object) and avulsion (a separation or detachment) to left 3rd and 4th finger while cooking today ...” During a review of Patient 1’s Nurse’s assessment titled, “Ambulatory Assessment/History Report,” dated 3/6/2024 at 3:46 p.m., the assessment indicated Licensed Vocational Nurse (LVN) 1 performed the Patient 1’s assessment. LVN 1’s documented assessments for the following body systems; Cardiovascular (heart), respiratory (lungs), neurological (relating to the brain, spinal cord, and nerves), and the integumentary (skin). There was no registered nurse’s co-signature on the LVN 1’s assessment of Patient 1 to validate that LVN 1’s assessment was correct. This was confirmed by the Director of Quality (DOQ) and the Pharmacy Informatics Specialist (PHIS). During a concurrent interview and record review, on 9/4/2024 at 2:34 p.m., with the Pharmacy Informatics Specialist (PHIS), the PHIS verified that LVN 1 performed Patient 1’s assessment in the Emergency Department on 3/6/2024 at 3:46 p.m. and verified there was no Registered Nurse’s co-signature to validate that LVN 1’s assessment was correct. During a concurrent interview and record review, on 9/4/2024 at 2:54 p.m., with the Director to Quality (DOQ), the DOQ stated the following: LVN can perform assessment with the co-signature of a registered nurse (RN) validating that the RN agrees with the LVN’s assessment and ensure the assessment is correct. An RN needs to co-sign the LVN’s assessment. The DOQ verified that there was no RN co-signature for LVN 1’s assessment. During an interview on 9/5/2024 at 11:01 a.m., with the Director of Emergency Department and Intensive Care unit (DIR), the DIR stated the following: It was not within the LVN’s scope of practice to perform assessments. LVNs collect data and work with the RN. If the RN agrees with the data collected, the RN is supposed to co-sign the data collected and documented by the LVN. The RN co-signature indicates that the RN agrees with LVN’s collected and documented data. During a review of the facility’s policy and procedure (P&P) titled, “Assessment/ Reassessment, Nursing Documentation,” dated 7/2022, the P&P indicated, “the process and mechanism by which [the facility] determines the care, treatment, and services that will meet the patient’s initial and continuing needs ... Data base: data collection of the admission assessment may be completed by a licensed vocational nurse with the Registered Nurse retaining responsibility for interpreting the data, completing all other aspects of the assessment and identifying patient care needs.” 1.b. During a review of Patient 3’s “ED (Emergency Department, provides immediate care for patients with serious illnesses and injuries) Note,” dated 9/3/2024, the ED Note indicated Patient 3 presented to the ED due to shortness of breath (difficulty breathing) and cough. During a review of Patient 3’s Nurse’s assessment titled, “Ambulatory Assessment/History Report” dated 9/3/2024, the nurse’s assessment indicated LVN 2 performed Patient 3’s assessment. LVN 2 documented assessments for the following body systems: Respiratory, Neurological, Musculoskeletal, and Integumentary. There was no registered nurse’s co-signature on the LVN 2’s assessment of Patient 1 to validate that LVN 2’s assessment was correct. This was confirmed by the DOQ. During a concurrent interview and record review on 9/4/2024 at 10:23 a.m., with the DOQ and the PHIS, the PHIS and DOQ verified that Patient 3’s assessment in the ED was performed by LVN 2 and not co-signed by a RN. During a review of the facility’s policy and procedure (P&P) titled, “Assessment/ Reassessment, Nursing Documentation,” dated 7/2022, the P&P indicated, “the process and mechanism by which [the facility] determines the care, treatment, and services that will meet the patient’s initial and continuing needs ... Data base: data collection of the admission assessment may be completed by a licensed vocational nurse with the Registered Nurse retaining responsibility for interpreting the data, completing all other aspects of the assessment and identifying patient care needs.” 1.c. During a review of Patient 4’s “ED (Emergency Department) Note,” dated 9/2/2024 at 6:58 p.m., the ED Note indicated the following: Patient 4 was brought by ambulance secondary to fever, shortness of breath, left upper quadrant pain for several days. During a review of Patient 4’s “Admission Assessment Report,” dated 9/3/2024 at 12:05 a.m., the assessment indicated LVN 3 performed Patient 4’s assessment, when Patient 4 was admitted to the Medical/Surgical Unit (provides care for patients who are recovering from surgery or have acute medical conditions). LVN 3 documented an assessment for the following body systems: Neurological ... Cardiovascular, Respiratory, Eye, Ear, Nose, Throat, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary, and a VTE (venous thromboembolism, blood clot formation in a vein) Risk Assessment ... There was no registered nurse’s co-signature for LVN 3’s assessment of Patient 4 to validate that LVN 3’s assessment was correct. This was confirmed by the DOQ. During a concurrent interview and record review on 9/4/2024 at 10:58 a.m., with the DOQ and the PHIS, the PHIS and DOQ verified that Patient 4’s assessment in the Medical/Surgical Unit was performed by LVN 3 and not co-signed by a RN to validate LVN 3’s assessment. During a review of the facility’s policy and procedure (P&P) titled, “Assessment/ Reassessment, Nursing Documentation,” dated 7/2022, the P&P indicated, “the process and mechanism by which [the facility] determines the care, treatment, and services that will meet the patient’s initial and continuing needs ... Data base: data collection of the admission assessment may be completed by a licensed vocational nurse with the Registered Nurse retaining responsibility for interpreting the data, completing all other aspects of the assessment and identifying patient care needs.” 1.d. During a review of Patient 28’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/2/2024, the H&P indicated, Patient 28 was admitted to the facility with diagnosis of acute (new onset) appendicitis (an inflammation of the appendix, a small organ in the large intestine). During a concurrent interview and record review on 9/5/2024 at 10 a.m. with the Clinical Informatics Specialist (CIS), Patient 28’s “Daily Assessment (nursing assessment, patient’s head to toe assessment performed by Registered Nurse),” dated from 9/2/2024 to 9/3/2024, was reviewed. The nursing assessment indicated Licensed Vocational Nurse (LVN 5) recorded the assessment on the following days: 9/2/2024 at 8 p.m. completed by LVN 5 9/3/2024 at 8 p.m. completed by LVN 5 CIS stated there should be a Registered Nurse (RN) to co sign LVN 5’s nursing assessment on 9/2/2024 and 9/3/2024. During an interview on 9/5/2024 at 10:29 a.m. with CIS, CIS stated the following: it was not within the Licensed Vocational Nurse (LVN) scope of practice to perform assessment. LVN could perform data collection in assessment, but the Registered Nurse (RN) needed to validate and sign off the assessment for LVN’s patients. RN assessment was needed to identify patient’s change of condition, address problems and provide interventions as needed. During a review of the facility’s policy and procedure (P&P) titled, “Assessment/ Reassessment, Nursing Documentation,” dated 7/2022, the P&P indicated, “the process and mechanism by which [the facility] determines the care, treatment, and services that will meet the patient’s initial and continuing needs ... Data base: data collection of the admission assessment may be completed by a licensed vocational nurse with the Registered Nurse retaining responsibility for interpreting the data, completing all other aspects of the assessment and identifying patient care needs.” 1.e. During a review of Patient 29’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/3/2024, the H&P indicated, Patient 29 was admitted to the facility with diagnoses of dizziness and rule out cerebral infarct (stroke, when blood flow to the brain is interrupted, damaging or killing the brain tissue). During a concurrent interview and record review on 9/5/2024 at 11:55 a.m. with the Clinical Informatics Specialist (CIS), Patient 29’s “Daily Assessment (nursing assessment, patient’s head to toe assessment performed by Registered Nurse),” dated on 9/3/2024, was reviewed. The nursing assessment indicated Licensed Vocational Nurse (LVN) 4 recorded the nursing assessment at 7:47 a.m. CIS stated Registered Nurse’s co-signature was needed to validate LVN 4’s entry. CIS stated there was no RN oversight provided for Patient 29. During a review of the facility’s policy and procedure (P&P) titled, “Assessment/ Reassessment, Nursing Documentation,” dated 7/2022, the P&P indicated, “the process and mechanism by which [the facility] determines the care, treatment, and services that will meet the patient’s initial and continuing needs ... Data base: data collection of the admission assessment may be completed by a licensed vocational nurse with the Registered Nurse retaining responsibility for interpreting the data, completing all other aspects of the assessment and identifying patient care needs.” 1.f. During a review of Patient 30’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/1/2024, the H&P indicated, Patient 30 was admitted to the facility with diagnoses of cholelithiasis (gallstones) and dehydration (a harmful reduction in the amount of water in the body). During a concurrent interview and record review on 9/5/2024 at 12:11 p.m. with the Director of Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery)/ Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) Unit (DMST), Patient 30’s “Daily Assessment (nursing assessment, patient’s head to toe assessment performed by Registered Nurse),” dated 9/3/2024, was reviewed. The nursing assessment indicated Licensed Vocational Nurse (LVN) 3 recorded the nursing assessment at 7:45 a.m. DMST stated the following: only Registered Nurse (RN) could perform head to toe assessment for patients. LVN could only perform data collection. The expectation was for the RN to sign off LVN 3’s entry. It was important for the RN to validate the nursing assessment in order to know Patient 30’s condition, identify any change of condition and to adjust treatment plan accordingly. During a review of the facility’s policy and procedure (P&P) titled, “Assessment/ Reassessment, Nursing Documentation,” dated 7/2022, the P&P indicated, “the process and mechanism by which [the facility] determines the care, treatment, and services that will meet the patient’s initial and continuing needs ... Data base: data collection of the admission assessment may be completed by a licensed vocational nurse with the Registered Nurse retaining responsibility for interpreting the data, completing all other aspects of the assessment and identifying patient care needs.” 2.a. During a review of Patient 17’s “Face Sheet (a document containing a patient’s medical and demographic information),” (undated), the “Face Sheet” indicated, Patient 17 was admitted to the facility on 9/3/2024 at 5:01 a.m., with a medical diagnosis of Facial Trauma (Damage to the face’s soft tissue/bone). During a review of Patient 17’s “Vital Sign (includes temperature, heart rate, respiratory rate, blood pressure) Report,” dated 9/3/2024 through 9/4/2024, the “Vital Sign Report” indicated, Patient 17 reported pain at a pain level of eight out of ten (8/10 - a pain level of 8 out of 10, on a pain scale of 1 through 10, with 10 representing the highest level of pain imaginable, would indicate a high level of experienced pain) on 9/3/2024 at 6:11 a.m. During a review of Patient 17’s “Medication Administration History Report (MAR),” dated 9/3/2024 at 12:00 a.m. through 9/3/2024 at 11:59 p.m., the “MAR” indicated, Patient 17 received Hydrocodone-Acetaminophen (Medical drug used to relive moderate-to-severe pain) 5-325 mg (milligram, a unit of measure) tablet by mouth, on 9/3/2024 at 6:11 a.m. During a concurrent interview and record review on 9/5/2024 at 11:28 a.m. with the Director of Medical/Surgical/Telemetry (DMST) and the Clinical Informatics Analyst (CIA), Patient’s 17’s “Vital Sign Report,” dated 9/3/2024 through 9/4/2204, was reviewed. The “Vital Sign report” indicated, no pain reassessments were documented for Patient 17, after Patient 17 received his pain medication on 9/3/2024 at 6:11 a.m. The DMST stated, patient pain reassessment was important, and it was expected from nurses to document and evaluate the effectiveness of a patient’s pain treatment. During an interview on 9/6/2024 at 10:13 a.m. with the Clinical Educator (CED), the CED stated, once medication was administered to a patient, nurses were expected to reassess the patient within 30 minutes to one hour after oral medication, and 15 minutes to 30 minutes after intravenous medication administration, and it needed to be documented. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment-Emergency Department,” revised January 2019, the P&P indicated, “assessment and care are documented as soon as possible after they are performed. Including response to medication, adverse reactions, vital signs, etc. Additional reassessment will be done and documented according to the following: To determine the patient’s response to care, treatment, and services.” 2.b. During a review of Patient 18’s “Face Sheet,” (undated), the “Face Sheet” indicated, Patient 18 was admitted to the facility on 9/2/2024 at 9:44 p.m., with a medical diagnosis of nausea (a feeling of sickness or discomfort in the stomach) and vomiting. During a concurrent interview and record review on 9/5/2024 at 11:49 a.m. with the DMST and the CIA, Patient’s 18’s “Medication Administration History Report (MAR),” dated 8/4/2024 at 3:15 p.m. through 9/4/2024 at 11:15 p.m., was reviewed. The “MAR” indicated, Patient 18 received Ondansetron (also known as Zofran, a medical drug used to prevent nausea and vomiting) 4 mg intravenously (through vein) on 9/2/2024 at 11:02 p.m. The DMST and the CIA stated, no reassessment was documented after Patient 18 received their Ondansetron medication. The DMST further stated, the expectation was that after patients received medication or treatments, there needed to be a documented patient reassessment. During an interview on 9/6/2024 at 10:13 a.m. with the Clinical Educator (CED), the CED stated, once medication was administered to a patient, nurses were expected to reassess the patient within 30 minutes to one hour after oral medication, and 15 minutes to 30 minutes after intravenous medication administration, and it needed to be documented. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment-Emergency Department,” revised January 2019, the P&P indicated, “Assessment and care are documented as soon as possible after they are performed. Including response to medication, adverse reactions, vital signs, etc. Additional reassessment will be done and documented according to the following: To determine the patient’s response to care, treatment, and services.””

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to evaluate and validate competency (ability to perform skilled learned) for one of one nursing staff (Registered Nurse [RN] 6) on performing a procedure requiring moderate sedation (a drug-induced state where a patient is asleep but can be awakened by verbal command or light touch used to help relieve anxiety during certain medical or surgical procedure), in accordance with facility’s policy and procedure regarding moderate sedation before taking care of one of 30 sampled patients (Patient 27) for cardioversion (a medical procedure that restores a normal heart rhythm by delivering an electrical shock to the chest). This deficient practice resulted in RN 6 not performing required vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) and sedation monitoring (monitor for patient’s conscious and agitation level) for a patient (Patient 27) during and post (after) procedure and put Patient 27 at risk for respiratory distress (difficulty breathing) and death. Findings: During a review of Patient 27’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/3/2024, the H&P indicated Patient 27 was admitted to the facility with diagnosis of atrial flutter (A flutter, a common type of irregular heartbeat that occurs when the heart’s upper chamber beat too quickly) with supraventricular tachycardia (SVT, a condition that caused the heart beat abnormally fast with a rate of 150 per minutes or higher). During an interview on 9/5/2024 at 10:08 a.m. with Registered Nurse (RN) 6, RN 6 stated the following: He (RN 6) took care of Patient 27 on 9/3/2024. Patient 27 received cardioversion (a medical procedure that restores a normal heart rhythm by delivering an electrical shock to the chest) in the emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) on 9/3/2024. Patient 27 received a dose of Propofol (an intravenous [inject directly to vein] anesthetic [a drug that causes a temporary loss of feeling or awareness] used to induce and maintain anesthesia [a medical procedure that temporarily and intentionally causes loss of sensation or awareness to prevent pain during a medical procedure] and sedation [state of relaxation, sleepiness, or calmness caused by certain drugs]) prior to cardioversion. RN6 did not provide vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) and sedation monitoring (monitor for patient’s conscious and agitation level) for Patient 27 during and after the moderate sedation (a drug-induced state where a patient is asleep but can be awakened by verbal command or light touch used to help relieve anxiety during certain medical or surgical procedure) procedure. He (RN6) did not know it was a moderate sedation. RN6 only found out today (9/5/2024) when speaking with the charge nurse. RN6 did not receive any moderate sedation training at this facility. During an interview on 9/5/2024 at 10:46 a.m. with the Director of Emergency Department and Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) (DIR), DIR stated the following: cardioversion was a moderate sedation procedure and it required the Registered Nurse (RN6) to provide vital signs and sedation monitoring before, during and after the procedure to ensure Patient 27 was not overly sedated. Lack of monitoring after the procedure could put Patient 27 at risk for life threatening result including respiratory distress (difficulty breathing) and death. During a concurrent interview and record review on 9/6/2024 at 11:28 a.m. with the Clinical Educator (CED), RN 6’s “Registry Self-Assessment and Unit Specific Competency (ability to perform skilled learned) Check List Emergency Department, Registered Nurse (competency check list),” dated 1/16/2023, was reviewed. The competency check list indicated, there was no evaluator sign off on the method of evaluation and evaluation outcome under the topics including but not limited to “recognizing unusual and unstable condition... moderate/ procedural sedation” The competency check list also indicated there was no evaluator name, signature and date. CED stated there was no evaluator to validate RN 6’s skills and competency. During a review of the facility’s policy and procedure (P&P) titled, “Cardioversion,” dated 7/2022, the P&P indicated, “to outline the nursing management of the patient for cardioversion ... equipment: medication to sedate per physician order. Bedside monitoring including electrocardiogram (EKG, a quick, painless test that measures the electrical activity of the heart) noninvasive blood pressure and pulse. Oximetry (non-invasive technique to measures the amount of oxygen in a person’s blood) ... post-cardioversion: refer to IV [intravenous, into the vein] Moderate Sedation Policy for post-medication treatment and recovery period ... Documentation: documentation heart rhythm and blood pressure before and after cardioversion ... patient response... vital signs per time frame as indicated in IV Moderate Sedation Policy.” During a review of the facility’s policy and procedure (P&P) titled, “Moderate Sedation by Non-Anesthesiology Personnel,” dated 7/2022, the P&P indicated, “During the procedure: sedated patients shall be subject to ongoing observation by a registered nurse with ACLS (advanced cardiovascular life support, management of cardiopulmonary arrest and emergencies) and demonstrated competency in the identification of respiratory failure (difficulty breathing), cardiac changes, and other potential complications ...blood pressure, pulse, respiratory rate and oxygen saturation (measure amount of oxygen in blood) shall be monitored and recorded by an appropriately-trained care giver and record at least every fifteen (15) minutes until the patient has reached their pre-sedation score for level of sedation ... After Sedation: blood pressure, pulse, respiratory rate, oxygen saturation, and level of consciousness shall be monitored and record at least every fifteen (15) minutes until the patient has been assessed to have recovered.””

“ORDERS FOR DRUGS AND BIOLOGICALS CFR(s): Orders for drugs and biologicals may be documented and signed by 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. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure there was a written order that was signed by a licensed practitioner for medications administered for one of 30 sampled (Patient 27), in accordance with the facility’s general rules and regulations regarding medication orders by a member of the medical staff, when Propofol (an intravenous [inject directly to vein] anesthetic [a drug that causes a temporary loss of feeling or awareness] used to induce and maintain anesthesia [a medical procedure that temporarily and intentionally causes loss of sensation or awareness to prevent pain during a medical procedure] and sedation [state of relaxation, sleepiness, or calmness caused by certain drugs]) was given during electrical cardioversion (a medical procedure that restores a normal heart rhythm by delivering an electrical shock to the chest). This deficient practice resulted in Propofol given to Patient 27 without written order by a licensed prescriber, which had the potential to result in lack of patient monitoring regarding response to the Propofol medication that may lead to complications such as respiratory issues and/or death. Findings: During a review of Patient 27’s “Emergency Department Notes (ED note, a formal and complete assessment of the patient and the problem performed by ED physician),” dated 9/3/2024, the ED note indicated Patient 27 presented to facility’s emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) for supraventricular tachycardia (SVT, a condition that caused the heart beat abnormally fast with a rate of 150 per minutes or higher). The ED note also indicated Patient 27 received procedure sedation with medication of Propofol (an intravenous [inject directly to vein] anesthetic [a drug that causes a temporary loss of feeling or awareness] used to induce and maintain anesthesia [a medical procedure that temporarily and intentionally causes loss of sensation or awareness to prevent pain during a medical procedure] and sedation [state of relaxation, sleepiness, or calmness caused by certain drugs]) for electrical cardioversion (a medical procedure that restores a normal heart rhythm by delivering an electrical shock to the chest). During an interview on 9/5/2024 at 9:50 a.m. with the Director of Pharmacy (DOP), DOP stated Propofol could be used for sedation, and it required a physician order. DOP stated nursing staff should document the Propofol administration on the Medication Administration Record (MAR, record of medications given to patients). During an interview on 9/5/2024 at 10:08 a.m. with Registered Nurse (RN) 6, RN 6 stated the following: He (RN 6) took care of Patient 27 on 9/3/2024. Patient 27 received cardioversion in the ED on 9/3/2024. ED physician (MD 1) ordered to give Propofol prior to the procedure. Patient 27 received a dose of Propofol prior cardioversion. He (RN 6) stated he (RN 6) should document the verbal order and the administration of the Propofol but he (RN 6) did not. During an interview on 9/5/2024 at 10:31 a.m. with the Director of Emergency Department and Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) (DIR), DIR stated physician could give verbal order to the registered nurse to administer the medication but the registered nurse should document the order in the patient’s medical record. During an interview on 9/6/2024 at 12:20 p.m. with the Director of Quality Improvement (DOQ), DOQ stated there was no written Propofol order found in Patient 27’s medical record even though Patient 27 received a dose of Propofol in the ED on 9/3/2024. DOQ stated there should be written order and administration record documented so that Propofol could be accounted for and prevent drug diversion. During a review of the facility’s medical staff “General Rules and Regulations,” dated 8/2024, the “General Rules and Regulations” indicated, “All drugs and medications administered to patients shall be ordered by a member of the Medical Staff ... orders by the physician must be entered electronically ... all orders for treatment or medication shall be in writing and reviewed daily. A verbal order may be received from a licensed prescriber and recorded on the medical record by any one of the following: registered nurse ... verbal orders are to be electronically authenticated promptly with signature, date, and time within 48 hours.” During a review of the facility’s policy and procedure (P&P) titled, “Intravenous [IV, inject directly to vein] Therapy,” dated 7/2022, the P&P indicated, “Registered Nurse ...shall be responsible to maintain all policies relative to intravenous therapy ... orders will be filled upon receipt of a doctor’s order ... All IV fluids, IV push medications, and IV piggybacks (a method of administering medication through an IV line by attaching a smaller bad of medication to the primary IV line) will be documented in the MAR.””

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure nursing staff provided proper vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) and sedation monitoring (monitor for patient’s conscious and agitation level) for two of 30 sampled patients (Patient 25 and 27) in the emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care), in accordance with the facility’s policy and procedure regarding moderate sedation when: 1. Patient 25 received Ketamine (an intravenous [inject directly to vein] anesthetic [a drug that causes a temporary loss of feeling or awareness] used medically for induction and maintenance of anesthesia [a medical procedure that temporarily and intentionally causes loss of sensation or awareness to prevent pain during a medical procedure]) and Versed (an intravenous [inject directly to vein] injection that helps the patient relax or sleep before a procedure) for right shoulder reduction (a procedure of returning a dislocated shoulder to its normal position). 2. Patient 27 received Propofol (an intravenous [inject directly to vein] anesthetic [a drug that causes a temporary loss of feeling or awareness] used to induce and maintain anesthesia [a medical procedure that temporarily and intentionally causes loss of sensation or awareness to prevent pain during a medical procedure] and sedation [state of relaxation, sleepiness, or calmness caused by certain drugs]) prior to an electrical cardioversion (a medical procedure that restores a normal heart rhythm by delivering an electrical shock to the chest). This deficient practice had the potential to result in not identifying oversedation indicated by excessive drowsiness, inappropriate movement, etc.) of Patient 25 and Patient 27 and put Patient 25 and Patient 27 at risk for respiratory distress (a condition that occurs when the body needs more oxygen, and can be caused by a number of factors, including infections, chronic illness, or a blocked airway) and death. Findings: 1. During a review of Patient 25’s “Emergency Department Notes (ED note, a formal and complete assessment of the patient and the problem performed by ED physician),” dated 7/8/2024, the ED note indicated Patient 25 presented to the facility’s emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) for right shoulder dislocation. The ED note also indicated Patient 25 received procedure sedation with medication of Ketamine 70 milligrams (mg, unit of measure) intravenously (IV, inject directly to vein) and Versed 2mg IV for shoulder reduction. During a review of Patient 25’s “Medication Administration Record (MAR, record of medications given to patients),” dated 7/8/2024, the MAR indicated Versed 2mg IV was given on 7/8/2024 at 3:10 p.m. and Ketamine 70mg IV was given on 7/8/2024 at 3:24 p.m. During a concurrent interview and record review on 9/5/2024 at 10:38 a.m. with the Director of Emergency Department and Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) (DIR), Patient 25’s “Vital Signs Record (VS record, record of measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level),” dated 7/8/2024, was reviewed. The VS record indicated Registered Nurse (RN 5) recorded the following: On 7/8/2024 at 3:10 p.m.: complete vital signs with Richmond Agitation-Sedation Scale (RASS, sedation monitoring tool to rank agitation and possibility for sedation from -5 being unarousable to +4 combative) score of “+1 (RASS score +1 means restless, anxious but movement not aggressive vigorous).” On 7/8/2024 at 3:25 p.m.: complete vital signs with no RASS score On 7/8/2024 at 4:18 p.m.: complete vital signs with no RASS score DIR stated RN 5 did not follow facility policy and procedure to perform ongoing assessment including vital signs monitoring and doing RASS score on Patient 25 every fifteen (15) minutes after procedure to make sure Patient 25 return to pre-procedure state to ensure safety. DIR stated it was the RN’s responsibility to perform assessment and monitoring post (after) procedure. DIR stated lack of monitoring could put Patient 25 at risk for respiratory distress and death. During a review of the facility’s policy and procedure (P&P) titled, “Moderate Sedation by Non-Anesthesiology Personnel,” dated 7/2022, the P&P indicated, “During the procedure: sedated patients shall be subject to ongoing observation by a registered nurse with ACLS [advanced cardiovascular life support, management of cardiopulmonary arrest and emergencies] and demonstrated competency in the identification of respiratory failure [difficulty breathing], cardiac changes, and other potential complications ...blood pressure, pulse, respiratory rate and oxygen saturation [measure amount of oxygen in blood] shall be monitored and recorded by an appropriately-trained care giver and record at least every fifteen (15) minutes until the patient has reached their pre-sedation score for level of sedation ... After Sedation: blood pressure, pulse, respiratory rate, oxygen saturation, and level of consciousness shall be monitored and record at least every fifteen (15) minutes until the patient has been assessed to have recovered.” 2. During a review of Patient 27’s “Emergency Department Notes (ED note, a formal and complete assessment of the patient and the problem performed by ED physician),” dated 9/3/2024, the ED note indicated Patient 27 presented to facility’s emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) for supraventricular tachycardia (SVT, a condition that caused the heart beat abnormally fast with a rate of 150 per minutes or higher). The ED note also indicated Patient 27 received procedure sedation with medication of Propofol (an intravenous [inject directly to vein] anesthetic [a drug that causes a temporary loss of feeling or awareness] used to induce and maintain anesthesia [a medical procedure that temporarily and intentionally causes loss of sensation or awareness to prevent pain during a medical procedure] and sedation [state of relaxation, sleepiness, or calmness caused by certain drugs]) for electrical cardioversion (a medical procedure that restores a normal heart rhythm by delivering an electrical shock to the chest). During an interview on 9/5/2024 at 9:50 a.m. with the Director of Pharmacy (DOP), DOP stated Propofol could be used for sedation and it required nursing staff to monitor patient’s vital signs and sedation monitoring using Richmond Agitation-Sedation Scale (RASS, sedation monitoring tool to rank agitation and possibility for sedation from -5 being unarousable to +4 combative) after it was given because it could put patient in respiratory distress. During an interview on 9/5/2024 at 10:08 a.m. with Registered Nurse (RN) 6, RN 6 stated the following: He (RN 6) took care of Patient 27 on 9/3/2024. Patient 27 received cardioversion in the ED on 9/3/2024. Patient 27 received a dose of Propofol prior to cardioversion. He (RN6) did not provide vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) checking and sedation monitoring (monitor for patient’s conscious and agitation level) for Patient 27 during and after the moderate sedation (a drug-induced state where a patient is asleep but can be awakened by verbal command or light touch used to help relieve anxiety during certain medical or surgical procedure) procedure. He (RN6) did not know it was a moderate sedation. He (RN6) only found out today (9/5/2024) when speaking with the charge nurse. During a concurrent interview and record review on 9/5/2024 at 10:46 a.m. with the Director of Emergency Department and Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) (DIR), Patient 27’s “Ambulatory Assessment (ED nurse note, ED nurse patient assessment) and “Vital Signs Record (VS record, record of measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level),” dated 9/3/2024, were reviewed. The ED nurse note indicated, “at 11:53 a.m., procedure explained to patient and patient consented. With physician and respiratory therapist at bedside, synchronized (occur at the same time) cardioversion performed at 50 joules (unit of measure).” The VS record indicated RN 6 recorded the following: On 9/3/2024 at 10:34 a.m.: complete vital signs with no RASS score On 9/3/2024 at 11:53 a.m.: complete vital signs with no RASS score On 9/3/2024 at 12:05 p.m.: complete vital signs with no RASS score During an interview on 9/5/2024 at 10:46 a.m. with DIR, DIR stated the following: Patient 27 had cardioversion at around 11:53 a.m. cardioversion required moderate sedation. RN 6 should perform frequent vital signs checking and sedation monitoring before, during and after the procedure to ensure Patient 27 was not overly sedated. RN 6 should be monitoring vital signs and RASS score every fifteen (15) minutes after procedure to ensure Patient 27 return to pre-procedure state. RN 6 did not follow the facility’s policy and procedure to provide proper monitoring. Lack of monitoring after the procedure could put Patient 27 at risk for life threatening result including respiratory distress and death. During a review of the facility’s policy and procedure (P&P) titled, “Cardioversion,” dated 7/2022, the P&P indicated, “to outline the nursing management of the patient for cardioversion ... equipment: medication to sedate per physician order. Bedside monitoring including electrocardiogram [EKG, a quick, painless test that measures the electrical activity of the heart] noninvasive blood pressure and pulse. Oximetry [non invasive technique to measures the amount of oxygen in a person’s blood] ... post-cardioversion: refer to IV [intravenous, into the vein] Moderate Sedation Policy for post-medication treatment and recovery period ... Documentation: documentation heart rhythm and blood pressure before and after cardioversion ... patient response... vital signs per time frame as indicated in IV Moderate Sedation Policy. During a review of the facility’s policy and procedure (P&P) titled, “Moderate Sedation by Non-Anesthesiology Personnel,” dated 7/2022, the P&P indicated, “During the procedure: sedated patients shall be subject to ongoing observation by a registered nurse with ACLS [advanced cardiovascular life support, management of cardiopulmonary arrest and emergencies] and demonstrated competency in the identification of respiratory failure [difficulty breathing], cardiac changes, and other potential complications ...blood pressure, pulse, respiratory rate and oxygen saturation [measure amount of oxygen in blood] shall be monitored and recorded by an appropriately-trained care giver and record at least every fifteen (15) minutes until the patient has reached their pre-sedation score for level of sedation ... After Sedation: blood pressure, pulse, respiratory rate, oxygen saturation, and level of consciousness shall be monitored and record at least every fifteen (15) minutes until the patient has been assessed to have recovered.””

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 36206 Based on interview and record review the facility failed to make transfer arrangements for one of 30 sampled patients (Patient 1). Patient 1 sustained an amputation (loss of a body part) to the left 3rd fingertip and a laceration (cut to the skin) to the 4th finger, while cooking. Patient 1 was discharged from the Emergency Department (ED) and instructed to go directly to another hospital (Hospital B) to seek treatment from a hand specialist, without making any transfer arrangements. This deficient practice had the potential for a delay in care, as Patient 1 had to make her own travel arrangements to go to another hospital to seek treatment from a hand specialist. Findings: During a review of Patient 1’s Face Sheet, the Face sheet indicated Patient 1 walked into the Emergency Department (ED) on 3/6/2024 at 1:22 p.m. During a review of Patient 1’s “ED Triage Note,” dated 3/6/20244 at 1:43 p.m., the ED Triage note indicated Patient 1 arrived on foot, from home. Chief complaint: Laceration (cut on the skin) and avulsion (a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone) to the left 3rd and 4th finger with blender while cooking ...sustained on her kitchen blender when Patient 1 stuck her hand in to move food around. Fingertip amputation (loss of a body part) and 4th finger laceration (cut to the skin). During a review of provider note for Patient 1 titled, “ED Note,” dated 3/6/2024 at 4:52 p.m., the note indicated the following diagnosis: Left 3rd fingertip amputation. Left 4th finger tufts fracture (tip of finger), and Left 4th finger laceration. Medical Decision Making: ED course: Plan is to discharge Patient (Patient 1). Advised to go directly to outside hospital for hand specialist. Wound care given with appropriate dressing and cleansing. Antibiotics, pain medication, and tetanus (a vaccine to prevent a bacterial disease marked by rigidity and spasms of the muscles) given prior to discharge. During a review of an untitled document for Patient 1, dated 3/6/2024, the documented indicated the following: The Patient was given access to the following documents on March 6, 2024. Finger Amputation - After care instructions. Special instructions. Plan to discharge patient. Advised to go directly to an outside hospital for hand specialist... During a concurrent interview and record review on 9/04/2024 at 2:34 p.m., with the Pharmacy Informatics Specialist (PHIS), the PHIS stated Patient 1 arrived by foot and walked into the Emergency Department (ED) on 3/6/2024 at 1:22 p.m., due to a laceration and avulsion to the left 3rd and 4th finger. Patient 1 was seen by a physician. Patient 1 was discharged and advised to go directly to an outside hospital (Hospital B) to see a hand specialist. The PHIS verified the facility did not arrange for Patient 1 to be transported to Hospital B, nor did the facility arrange for Patient 1 to seen by a hand specialist at Hospital B. During a concurrent interview and record review, on 9/04/2024 at 2:54 p.m., with the Director of Quality, the DOQ stated the following: Patient 1 was discharged and advised to go directly to an outside hospital to see a hand specialist for further care. The facility did not make any arrangements for Patient 1 to see a hand specialist or for transfer to Hospital B. There was no evidence of physician-to-physician communication, or the name of an accepting physician. There was no evidence that transportation had been arranged. The DOQ stated that the discharge instructions were vague and did not specify where to seek care in Hospital B. The DOQ stated Patient 1 would have to go to Hospital B’s Emergency Department. It was unknown if a hand specialist was available to treat Patient 1. This was unsafe and could possibly result in a delay of care. During a review of the facility’s policy and procedure (P&P) titled, “Transfer of Patient to Another Facility,” dated 7/2022, the P&P indicated the following ...All patients shall be evaluated by the Emergency Department ...If a provider determines, through the hospital policy, that the patient should be transferred to another facility for further care, EMTALA (Emergency Medical Treatment and Labor Act) standards should be followed: The patient must: Have not life-threatening condition ...Not require immediate need for surgery, Be medically stable, Agree to the transfer. Acceptance to the receiving facility must be made physician to physician, with documentation of the receiving facility’s physician’s name. Patient shall be informed of the reason for transfer: ...Continued care not offered at this hospital, High Level of Care, Specialty Care. During a review of the facility’s policy and procedure (P&P) titled, “EMTALA Guidelines for Emergency Department,” dated 7/2022, the P&P indicated the following. Transfers: Transfers/referrals of patients who do not have an emergency medical condition but who, in the medical opinion of the Qualified Medical Person, require immediate care outside of the hospital ...should conform with the requirements of Patient Transfers. F. Patient Transfer: It is the responsibility of the Physician to ensure that all transfer for immediate care of an individual to another care facility (including a physician’s office will be carried out in accordance with the following: 1. Medical Treatment... 2. Informed Consent: ...Where the transfer is medically recommended, the hospital will notify the individual ...in writing of the recommended transfer and the reasons therefore... 3. Informed Request: ... 4. Contact Receiving Facility - a representative of the receiving facility must have confirmed that: a. The receiving facility has available space and qualified personnel to treat the individual; and b. The receiving facility has agreed to accept transfer of the individual and to provide appropriate medical treatment... 5. Copies of Medical Records/Consents /Certification. The Hospital will send the receiving facility copies of all pertinent medical records available at time of transfer... 6. Transfer by Qualified Personnel... 7. Reporting On-Call Physician... 8. Complete Transfer Summary: The physician shall ensure that a completed “Transfer Summary Form,” signed by the patient...Where a physician is consulted by the ED Physician and the physician has assumed significant responsibility for the care of the individual, the physician shall also sign the “Transfer Summary Form.””