Sharp Memorial Hospital

“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: 28183 Based on interview and record review, the hospital failed to ensure a Registered Nurse (RN) 1 documented an accurate and valid cardiac assessment for 1 of 30 sampled patients (Patient 1). Findings: Patient 1 was admitted to the hospital on 2/18/26 with diagnoses that included congestive heart failure and interstitial lung disease (condition involving inflammation or scarring of the lung tissue), per the History and Physical dated 2/18/26. On 4/7/26 at 10:11 A.M., the Director of Critical Care (DCC) was interviewed. According to the DCC, Patient 1 was admitted to the Progressive Care Unit (PCU) from the Emergency Department (ED) on 2/18/26 after suffering a fall at home. RN 1 was Patient 1’s primary care nurse on the PCU, and the nurse who conducted the admission nursing assessment, which included placing telemetry leads on Patient 1. However, RN 1 did not verify with the Central Monitoring Unit (CMU) that Patient 1 was connected with the heart rhythm showing on the monitor, per policy. The DCC stated that around 8 P.M., the night shift nurse went in to see Patient 1 and found him unresponsive, with his high flow oxygen nasal cannula (HFNC) off. There were no alarms to alert staff because the patient was not connected to telemetry. The DCC stated that a Code Blue was called, but resuscitation efforts were unsuccessful, and the patient expired. A joint interview and record review was conducted on 4/7/26 at 2:25 P.M. with Clinical Nurse Specialist (CNS) 3 and the Nurse Manager (NM). RN 1 documented on 2/18/26 at 3:41 P.M. on the nursing assessment flowsheet dated 2/18/26, that Patient 1 was on telemetry. RN 1 further documented Patient 1’s heart rhythm was V-paced (ventricular paced- a pacemaker rhythm) on Lead 2. However, there were no telemetry strips uploaded to the clinical record. The night shift nurse (RN 2) documented in a nursing note on 2/18/26 at 8:35 P.M., that Patient 1 was alert, oriented, and speaking upon the start of shift. RN 2 further documented that when she went to check vital signs around 8 P.M., she found Patient 1 with his HFNC off and not responding. According to the note, “Primary RN could not feel a pulse, confirmed by charge nurse. Code blue was called.” The Discharge Summary by the physician, dated 2/19/26, indicated, “Cardiac arrest was suspected due to hypoxia as he was found without his HFNC on for an unknown period of time.” On 4/8/26 at 7:46 A.M., RN 2 was interviewed. RN 2 stated that she saw Patient 1 and finished handoff report with RN 1. The patient was alert and talking at that time. About 15 minutes later, RN 2 returned to see Patient 1 and check vital signs, but found him unresponsive with no pulse, and his HFNC off. A Code Blue was called but resuscitative efforts were unsuccessful. During an interview on 4/8/26 at 8:15 A.M. the DCC acknowledged that RN 1 wrongly documented a cardiac telemetry assessment on Patient 1 when the patient was not on telemetry. The DCC stated, “Any falsification is concerning; to document rhythm under assessment when there was no telemetry.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 28183 Based on interview and record review, Registered Nurse (RN) 1 failed to ensure a telemetry box was verified and connected in order to enable continuous heart monitoring for 1 of 30 sampled patients (Patient 1). As a result, there was no alarm system mechanism in place to alert staff when the patient experienced respiratory distress. In addition, the hospital did not ensure there was a physician order for telemetry for 1 of 30 sampled patients (Patient 13). As a result, Patient 13 had telemetry for two days without a valid physician order. Findings: 1. Patient 1 was admitted to the hospital on 2/18/26 with diagnoses including congestive heart failure and interstitial lung disease (condition involving inflammation or scarring of the lung tissue), per the History and Physical dated 2/18/26. On 4/7/26 at 10:11 A.M., the Director of Critical Care (DCC) was interviewed. According to the DCC, Patient 1 was admitted to the Progressive Care Unit (PCU) from the Emergency Department (ED) on 2/18/26 after suffering a fall at home. RN 1 was identified as Patient 1’s primary care nurse on the PCU, and the nurse who conducted the admission nursing assessment on 2/18/26, which included placing telemetry leads on Patient 1. However, RN 1 did not verify with the Central Monitoring Unit (CMU) that Patient 1 was connected with the heart rhythm showing on the monitor, per policy. The DCC stated that around 8 P.M., the night shift nurse went in to see the patient and found him unresponsive, with his high flow oxygen nasal cannula (HFNC) off. There were no alarms to alert staff because the patient was not connected to telemetry. The DCC stated that a Code Blue was called but resuscitation efforts were unsuccessful, and the patient expired. A joint interview and record review was conducted on 4/7/26 at 2:25 P.M. with Clinical Nurse Specialist (CNS) 3 and the Nurse Manager (NM). RN 1 documented on 2/18/26 at 3:41 P.M. on the nursing assessment flowsheet dated 2/18/26, that Patient 1 was on telemetry. RN 1 further documented Patient 1’s heart rhythm was V-paced (ventricular paced- a pacemaker rhythm) on Lead 2. However, there were no telemetry strips uploaded to the clinical record. The night shift nurse (RN 2) documented in a nursing note on 2/18/26 at 8:35 P.M., that Patient 1 was alert, oriented, and speaking upon the start of shift. RN 2 further documented that when she went to check vital signs around 8 P.M., she found Patient 1 with his HFNC off and not responding. According to the note, “Primary RN could not feel a pulse, confirmed by charge nurse. Code blue was called.” The Discharge Summary by the physician, dated 2/19/26, indicated, “Cardiac arrest was suspected due to hypoxia as he was found without his HFNC on for an unknown period of time.” On 4/8/26 at 7:46 A.M., RN 2 was interviewed. RN 2 stated that she briefly saw Patient 1 and finished handoff report with RN 1 around 7:40 P.M. Patient 1 was alert and talking at that time. About 15 minutes later, RN 2 returned to see Patient 1 and check vital signs, but found him unresponsive with no pulse, and his HFNC off. A Code Blue was called but resuscitative efforts were unsuccessful. According to the hospital’s Nursing Guidelines of Care, updated 2/6/26, “Continuous Cardiac Monitoring ...Verification with Central Monitoring; While at the bedside, verify with the central monitoring unit: -Correct patient using two patient identifiers -Room number -Telemetry box number -Cardiac rhythm -Resuscitation status.” 2. Patient 13 was admitted to the hospital on 4/6/26 with diagnoses including congestive heart failure and atrial fibrillation, per the History and Physical, dated 4/6/26. On 4/10/26 at 9:10 A.M., a joint interview and record review was conducted with the Director of Acute Care (DAC) and the Telemetry Manager (TM). According to the nursing flowsheets dated April 2026, Patient 13 was on telemetry for continuous heart monitoring upon admission, 4/6/26. Telemetry strips were saved to the clinical record since the patient’s admission. Patient 13’s physician orders were reviewed. There was no physician order for Patient 13’s telemetry until 4/8/26, two days after the patient was admitted to the hospital. The TM stated, “I don’t see a telemetry order until 4/8.” The DAC and TM acknowledged that Patient 13 should have had a valid physician order (on 4/6/26) for the patient’s telemetry.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 28183 Based on interview and record review, the hospital failed to ensure nursing staff uploaded telemetry strips into the clinical record per hospital policy for 10 of 30 sampled patients (5, 13, 14, 16, 20, 21, 22, 24, 27, 28 ) Findings: 1. On 4/7/26 at 12:20 P.M. a joint interview and record review was conducted with the Director of Acute Care (DAC) and the Charge Nurse (CN) for the Progressive Care Unit (PCU). Patient 5 was admitted to the hospital on 4/7/26 with diagnoses that included history of kidney stones, per the Patient Demographics form. The clinical record indicated the patient was admitted to the PCU and an admission nursing assessment was completed on 4/7/26 at 2 A.M. However, there was no telemetry strip uploaded with the admission nursing assessment. The CN stated, “I don’t see one.” The DAC stated the first telemetry strip was not uploaded until day shift, on 4/7/26 at 11:56 A.M. The DAC acknowledged a telemetry strip should have been uploaded on the night shift with the nursing assessment upon admission, and then once every shift thereafter. According to the hospitals Nursing Guidelines of Care, last updated 2/6/26, “Continuous Cardiac Monitoring ...Interpret and document ECG intervals using a 6-second strip at a minimum ...Frequency: Every shift.” 2. On 4/10/26 at 9:10 A.M., a joint interview and record review was conducted with the Director of Acute Care (DAC) and the Telemetry Manager (TM). Patient 13 was admitted to the hospital on 4/6/26 with diagnoses that included congestive heart failure and atrial fibrillation, per the History and Physical, dated 4/6/26. The clinical record indicated Patient 13 was admitted to the PCU and an admission nursing assessment was completed on 4/6/26 at 12 P.M. However, there was no telemetry strip uploaded with the admission nursing assessment. The first telemetry strip was not uploaded until the night shift on 4/6/26 at 7:40 P.M. The TM acknowledged there should have been a telemetry strip uploaded on the day shift with the nursing assessment. According to the hospitals Nursing Guidelines of Care, last updated 2/6/26, “Continuous Cardiac Monitoring ...Interpret and document ECG intervals using a 6-second strip at a minimum ...Frequency: Every shift.” 3. On 4/10/26 at 9:11 A.M., a joint interview and record review was conducted with the Director of Acute Care (DAC) and the Telemetry Manager (TM). Patient 14 was admitted to the hospital on 2/27/26 with diagnoses that included aortic dissection (a serious condition in which there is a tear in the major artery carrying blood out of the heart), per the History and Physical, dated 2/27/26. The patient’s telemetry strips were reviewed. There was no telemetry strip uploaded on the night shift on 4/6/26. The TM stated, “I’m not seeing one.” According to the hospitals Nursing Guidelines of Care, last updated 2/6/26, “Continuous Cardiac Monitoring ...Interpret and document ECG intervals using a 6-second strip at a minimum ...Frequency: Every shift.” 51631 4. On 4/8/26 at 12:36 P.M., a joint interview and record review was conducted with Registered Nurse (RN) 31 and the Director of Nursing (DON). Patient 16 was admitted to the facility on 3/31/26 with diagnoses including shortness of breath and diastolic Congestive Heart Failure (CHF; condition where the heart cannot pump blood efficiently), per the History and Physical dated 3/31/26. A review of Patient 16’s medical record was conducted. There were no telemetry strips uploaded for both the day and night shifts on 4/1/26. The DON confirmed there was no telemetry strip uploaded on 4/1/26 for Patient 16, and stated it was his expectation that the nurses assigned to patients on telemetry monitoring, completed a cardiac rhythm analysis every shift. According to the hospitals Nursing Guidelines of Care, last updated 2/6/26, “Continuous Cardiac Monitoring ...Interpret and document ECG intervals using a 6-second strip at a minimum ...Frequency: Every shift.” 50175 5. On 4/9/26 at 11:10 A.M., a joint interview and record review was conducted with Director of Critical Care (DCC) and Clinical Nurse Specialist (CNS) 16. Patient 20 was admitted to the hospital on 3/26/26 with diagnoses including a stroke (medical emergency when blood supply to the brain is decreased due to blockage or bleeding), per Patient 20’s history and physical (physician’s assessment) dated 3/26/26. A review of Patient 20’s medical record indicated there were no telemetry strips (a reading of heart rhythms) uploaded on the night shifts of 3/27/26, 3/30/26, 3/31/26, 4/1/26, and on the day shift of 4/5/26. DCC and CNS 16 acknowledged that a telemetry strip should have been uploaded on every shift. DCC stated it was important to upload telemetry strips to the medical record on every shift to make sure the heart rhythm was analyzed and there were no changes in Patient 20’s heart rhythm. According to the hospitals Nursing Guidelines of Care, last updated 2/6/26, “Continuous Cardiac Monitoring ...Interpret and document ECG intervals using a 6-second strip at a minimum ...Frequency: Every shift.” 6. On 4/9/26 at 11:30 A.M., a joint interview and record review was conducted with Director of Critical Care (DCC) and Clinical Nurse Specialist (CNS) 16. Patient 21 was admitted to the hospital on 3/28/26 with diagnoses including acute renal failure (kidney failure), per Patient 21’s history and physical (physician’s assessment) dated 3/28/26. A review of Patient 21’s medical record indicated there were no telemetry strips (a reading of heart rhythms) uploaded on the day shift of 3/30/26. DCC and CNS 16 acknowledged that a telemetry strip should have been uploaded. According to the hospitals Nursing Guidelines of Care, last updated 2/6/26, “Continuous Cardiac Monitoring ...Interpret and document ECG intervals using a 6-second strip at a minimum ...Frequency: Every shift.” 7. On 4/9/26 at 11:40 A.M., a joint interview and record review was conducted with Director of Critical Care (DCC) and Clinical Nurse Specialist (CNS) 16. Patient 22 was admitted to the hospital on 4/4/26 with diagnoses including a fall with possible subdural hematoma (bleeding in the brain), per Patient 22’s history and physical (physician’s assessment), dated 4/4/26. A review of Patient 22’s medical record indicated there were no telemetry strips (a reading of heart rhythms) uploaded on the day shift of 4/5/26 and 4/6/26. DCC and CNS 16 acknowledged that a telemetry strip should have been uploaded on every shift. According to the hospitals Nursing Guidelines of Care, last updated 2/6/26, “Continuous Cardiac Monitoring ...Interpret and document ECG intervals using a 6-second strip at a minimum ...Frequency: Every shift.” 8. On 4/9/26 at 2:17 P.M., a joint interview and record review was conducted with Director of Critical Care (DCC) and Clinical Nurse Specialist (CNS) 16. Patient 24 was admitted to the hospital on 3/29/26 with diagnoses including multiple fractures following a motor vehicle accident, per Patient 24’s history and physical (physician’s assessment) dated 3/29/26. A review of Patient 24’s medical record indicated there were no telemetry strips (a reading of heart rhythms) uploaded on the night shift of 4/2/26 and 4/5/26, and on the day shift of 4/6/26. DCC and CNS 16 acknowledged that a telemetry strip should have been uploaded on every shift. According to the hospitals Nursing Guidelines of Care, last updated 2/6/26, “Continuous Cardiac Monitoring ...Interpret and document ECG intervals using a 6-second strip at a minimum ...Frequency: Every shift.” 9. On 4/9/26 at 2:57 P.M., a joint interview and record review was conducted with Director of Critical Care (DCC) and Clinical Nurse Specialist (CNS) 16. Patient 27 was admitted to the hospital on 4/6/26 with diagnoses including low back pain, per Patient 27’s history and physical (physician’s assessment) dated 4/6/26. A review of Patient 27’s medical record indicated there were no telemetry strips (a reading of heart rhythms) uploaded on the day shift of 4/7/26. DCC and CNS 16 acknowledged that a telemetry strip should have been uploaded. According to the hospitals Nursing Guidelines of Care, last updated 2/6/26, “Continuous Cardiac Monitoring ...Interpret and document ECG intervals using a 6-second strip at a minimum ...Frequency: Every shift.” 10. On 4/9/26 at 3:07 P.M., a joint interview and record review was conducted with Director of Critical Care (DCC) and Clinical Nurse Specialist (CNS) 16. Patient 28 was admitted to the hospital on 3/27/26 with diagnoses including respiratory failure (a condition when lungs cannot adequately supply oxygen to the blood), per Patient 28’s history and physical (physician’s assessment) dated 3/27/26. A review of Patient 28’s medical record indicated there were no telemetry strips (a reading of heart rhythms) uploaded on the day shift of 4/1/26. DCC and CNS 16 acknowledged that a telemetry strip should have been uploaded. According to the hospitals Nursing Guidelines of Care, last updated 2/6/26, “Continuous Cardiac Monitoring ...Interpret and document ECG intervals using a 6-second strip at a minimum ...Frequency: Every shift.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 45909 Based on interview and record review, the hospital failed to ensure staff followed its policy and procedure related to monitoring patient with high risk for suicidal ideation (SI- taking own life) for one of 30 sampled patients (Patient 24). This failure had the potential to cause Patient 24 to possibly harm herself. Finding: Review of Patient 24’s admission record dated 9/16/24, indicated Patient 24 was in the Emergency Department (ED) with medical diagnoses including, SI, methamphetamine (drug that affects mood) abuse. Review of Patient 24’s Columbia Suicide Severity Rating Scale (assessment tool) dated 9/16/24, indicated Patient 24 was “high risk” for suicide. During a concurrent interview and interview conducted with an observer staff (OS) on 11/4/24 at 11:10 A.M., The OS stated when an OS was assigned to a high-risk patient, the OS should monitor the patient continuously inside the room and wherever the patient was. The OS further stated this was done to provide a safe environment for the patient. The OS also stated, it was a requirement for them to fill out a form titled, SMH ED Observer Workflow Log (EDOWL) or to enter the activities in the patient’s electronic medical record (EMR) under Patient Observation. The OS further stated the form would have to be filled out hourly by the OS who was assigned to that patient. The EDOWL will then have to be submitted to the charge nurse at the end of the shift. During an interview with registered nurse (RN) 24 on 11/6/24 at 11:30 A.M., RN 24 stated high-risk patients were identified when patients in the ED who needed continuous monitoring. RN 24 further stated, the OS would have been assigned and should have been documenting patient with high risk at least hourly on the EDOWL or in the patient’s observation section of the EMR. During a concurrent interview and record review with the Clinical Nurse Specialist (CNS) 24 on 11/6/24 at 3:15 PM., CNS 24 stated, Patient 24 did not have an OS EDOWL on file and there was no documented evidence in the EMR charting indicating Patient 24 was observed hourly. CNS 24 further stated, the OS who was assigned to Patient 24 should have filled out the EDOWL form or entered Patient 24’s activities in the EMR to indicate that Patient 24 was continuously monitored for safety. This was not done for Patient 24. A review of the hospital’s policy titled, Safety Observer Instructions, (undated), indicated, “...During Shift:..2. Note patient behaviors every 60 minutes and notify RN with any changes or concerns. 3. Document patient activity, ADL’s, safety precautions at a minimum of every 2 hours in the EMR.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 43674 Based on interview and record review the hospital did not ensure the use of restraint for 1 of 1 patient (Patient 15) were in accordance with physician order when Patient 15’s was placed on left upper extremities soft restraint on 2/18/24 and 2/19/24. This failure had the potential risk for Patient 15’s care and well-being. Finding: Patient 15 was admitted to the hospital on 2/11/24 for diagnoses which included intracranial hemorrhage (bleeding in the brain) and altered mental status (confusion) per history and physical (H&P) dated 2/11/24. A review of Patient 15’s Restraint Evaluation and Monitoring form dated 2/18/24 and 2/19/24 indicated that Patient 15 was on left upper extremities soft restraint from 2/18/24 at 12 A.M. until 2/19/24 at 11:59 P.M. A review of Patient 15’s Physician Orders on restraint indicated that Patient 19 did not have an order for left upper extremities soft restraint on 2/18/24 and 2/19/24. A concurrent interview and record review of Patient 15’s Restraint Evaluation and Monitoring, and Restraint orders were conducted on 11/7/24 at 8:30 A.M., with the Director of Critical Care (DCC). The DCC stated Patient 15 was placed on left upper extremities soft restraint from 2/18/24 at 12 A.M., until 2/19/24 at 11:59 P.M. The DCC further stated Patient 15 did not have a valid physician order for restraint on 2/18/24 and 2/19/24. The DCC stated it was important to ensure Patient 15 had an order for restraint to ensure appropriateness of restraint and patient safety. The DCC acknowledged that Patient 15 should have a physician order for restraint but did not. A review of hospital’s policy and procedure titled, Restraint and Seclusion Use last revised 7/8/22 indicated “ ...III. Policy: ...G. The use of restraint and seclusion will be in accordance with the order of a physician or other LIP who is responsible for the care of the patient and authorized to order restraint or seclusion ...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 43674 Based on interview and record review the hospital did not ensure that 1 of 30 patient (Patient 15) were consistently assessed and monitored while placed on soft restraint. This failure had the potential risk for Patient 15’s care and well-being. Findings: Patient 15 was admitted to the hospital on 2/11/24 for diagnoses which included intracranial hemorrhage (bleeding in the brain) and altered mental status (confusion) per history and physical (H&P) dated 2/11/24. A review of Patient 15’s Restraint Evaluation and Monitoring indicated that Patient 15 was placed on left upper extremities soft restraint from 2/12/24 at 7 A.M., until 3/16/24 at 8 A.M. Further review indicated there were no evidence of documentation that Patient 15 were consistently monitored and reassessed every 2 hours while on restraint per hospital policy. A concurrent interview and record review of Patient 15’s Restraint orders, and Monitoring/Assessment forms were conducted on 11/7/24 at 8:30 A.M., with the Director of Critical Care (DCC). The DCC stated Patient 15 had an order for left upper extremities soft restraint on 2/13, 2/28 and 2/29/24. The DCC stated Patient 15’s Monitoring/Assessment forms did not indicate he was monitored/reassessed on these dates and times: 2/13/24 at 12 and 2 P.M. 2/28/24 at 12, 2, 4 and 6 A.M. 2/29/24 at 2, 4, and 6 P.M. The DCC further stated it was important to ensure restraint monitoring and reassessment were conducted every 2 hours for patient safety. The DCC acknowledged that Patient 15 should have been monitored and assessed every 2 hours while on restraint but was not. A review of hospital’s policy and procedure titled, Restraint and Seclusion Use last revised 7/8/22 indicated “ ...IV. Procedure: ...G. Monitoring/Reassessment 1. Monitor and document the patient’s physical, psychological, and comfort status at least every two (2) hours ...””

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 43674 Based on interview and record review the hospital staff did not ensure the policies and procedures (P&P) were followed for 2 of 30 patients (Patient 8 and Patient 9) when: 1. Patient 8’s surgical specimen was not sent from Operating room (OR) to Pathology. 2. Patient 9’s miscellaneous surgical device was retained after the surgery. These failures had the potential to affect Patient 8 and Patient 9 health and well-being. Findings: 1. Patient 1 was admitted to the hospital on 10/23/24 for diagnoses which included Intrauterine fetal demise (IUFD) and for procedure which included Dilation and Evacuation (D&E - removal of products of conception) per history and physical (H&P). An interview was conducted on 11/4/24 at 10:46 A.M., with the Director of Perioperative and Obstetrics and Gynecology Services (DPOBS). The DPOBS stated Patient 8 had a D&E procedure and Patient 8’s products of conception specimen were not transported or directed from OR to pathology. The DPOBS further stated, the specimen went to Post Anesthesia Care Unit (PACU) instead. An interview and record review were conducted on 11/6/24 at 2:05 P.M., with the Manager of Perioperative Services (MPS). The MPS stated the hospital policy on handling of surgical specimen indicated, “all anatomical parts, tissue and foreign objects removed in the operating room shall be sent to the pathologist for examination ...” The MPS stated the policy was not followed when he transported and directed Patient 8’s product of conception specimen from the OR to PACU. The MPS stated the staff followed his instructions and opened Patient 8’s product of conception specimen container. The MPS acknowledged that it was important to ensure the interpretation of the policy and procedure was clarified to protect everyone including the staff. A review of the hospital’s policy and procedure titled, Specimen - Handling of - Surgical Care last revised 7/7/2021 indicated “ ...III. Text. A. ALL anatomical parts, tissue and foreign objects removed in the operating room shall be sent to the pathologist for examination ...” 50175 2. A review of Patient 9’s Admission Record indicated Patient 9 was in the hospital on 4/22/24 with a diagnosis of a left ovarian cyst (a fluid filled sac on or inside the left ovary, a part of a woman’s reproductive system). A review of Patient 9’s Authorization for and Consent to Surgery, signed by Surgeon 8 and Patient 9 on 4/22/24 at 11:22 A.M., indicated Patient 9 agreed to a robotic assisted left cystectomy (removal of part of the bladder), possible left oophorectomy (removal of ovarian tissue using surgical tools). A review of the progress note written by Surgeon 8, dated 4/22/24, indicated after removal of the cyst, “ ...The speculum (an instrument inserted into the vaginal cavity to help visualize the cervix, the birth canal) was then reinserted, the uterine manipulator (a device used during surgery to help reposition the uterus, the organ where the baby develops inside a woman’s body) was removed from the cervix ...” A review of the progress note written by Surgeon 8, dated 5/1/24, indicated Surgeon 8 had a discussion with Patient 9 “regarding ...the tip of the acorn manipulator was inadvertently left inside during the surgery ...” An interview was conducted with Licensed Nurse (LN) 8 on 11/5/24 at 9:13 A.M. LN 8 demonstrated the use of the [Brand] uterine manipulator device. The uterine manipulator came in a package sealed with a clear film so the instrument and its parts can be seen. There were two different sized “acorns” (cone shaped device) and a probe (surgical instrument) in the package. The surgeon would choose which acorn to use and screw it onto the probe. The surgeon would then use a speculum to visualize the cervix and complete the procedure. LN 8 stated the acorn could get loosened from the instrument during the procedure because the instrument was moved in many different directions during the procedure. LN 8 stated the acorns should have been counted before and after the procedure to make sure all parts of the device was removed from Patient 9. An interview was conducted with the Director of Perioperative and Obstetrics Services (DPO) on 11/6/24 at 9:02 A.M. The DPO stated she was aware of the situation indicated in the progress note written by Surgeon 8 on 5/1/24. The DPO stated the acorns were miscellaneous surgical items and should have been counted before and after the procedure. The DPO stated there was no itemized list in the packaging of the [Brand] uterine manipulator device. It was the responsibility of both the surgeon and surgical technician (assistant during surgeries) and/or circulating nurse (a registered nurse who works in the operating room) to count the acorns before and after the procedure to confirm all instruments and parts used during the procedure were removed from Patient 9. A review of the policy titled, Intraoperative Counts, revised 10/29/24, “ ...I. Purpose. To provide a method to systematically and accurately account for the items placed on the sterile field for use on a surgical procedure; when the depth and location of the wound is such that the item could be lost or left in the patient ...C. Other Miscellaneous Items includes items that ...have the potential for being retained in the surgical wound ...D. Instruments - surgical tools or devices ...E. Incorrect Counts - Any intraoperative count that reveals a number inconsistent ...on the running count on the whiteboard or instrument sheet ...A. Dual Responsibilities ...1 ...miscellaneous item and instrument counts are the dual responsibility of the scrub person and the RN Circulator with full accountability for the process. 2. The RN Circulator and scrub person will conduct a systematic and accurate accounting of all counted items. This is important to help prevent patient injury as a result of a foreign body ...5. When adding items to the sterile field both team members shall verbally verify and visually verify the count and white board documentation ...””