Adventist Health White Memorial

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met, as evidenced by: 1. The facility failed to appropriately respond to one of 30 sampled Behavioral Health Unit (BHU,inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) patient (Patient 30), who manifested intentions of leaving/eloping (leaving the facility without physician’s permission when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility, in accordance with the facility’s policy regarding patients identified as elopement risk. This deficient practice resulted in Patient 30 eloping and putting the 5150 (temporary, involuntary psychiatric [mental health] hold of a person who as a result of a mental disorder is a danger to themselves, danger to other or gravely disabled [unable to care for one’s self due to mental health issues], hold is designed to provide period of professional evaluation and treatment for person in crisis) patient (Patient 30) in danger to harm himself and a potential to harm others. (Refer to A-0144) 2. The facility failed to ensure one of 30 sampled patients (Patient 19), received care in a safe setting, in accordance with the facility’s policy on patient rights (a subset of human rights. Example: the right to considerate and respectful care), when a male visitor for another patient entered Patient 19’s room and opened the shower curtain while Patient 19 was in the shower. This deficient practice resulted in Patient 19 having felt violated and had the potential for Patent 19 to suffer from psychological and physical harm. (Refer to A-0144) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Quality Assurance and Performance Improvement (QAPI, the facility’s program for identifying problems, investigating causes and making improvements) was met, as evidenced by: 1. The facility’s Quality Assurance and Performance Improvement (QAPI, the facility’s program for identifying problems, investigating causes and making improvements) program failed to implement an appropriate action plan, in a timely manner, to prevent medication errors from happening, in accordance with the facility’s performance improvement plan, after a Registered Nurse (RN 1) removed a wrong medication from the Pyxis (automated medication dispensing machine) tower and administered to one of 30 sampled patients (Patient 2) in the Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) department. This deficient practice had the potential to result in the same or similar medication error happening on other nursing units and potentially causing harm to patients. (Refer to A-0286) 2. The facility’s governing body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to provide oversight for the Quality Assurance and Performance Improvement (QAPI, the facility’s program for identifying problems, investigating causes and making improvements), to address and prioritize actions needed to address patient safety issues resulting from a medication error for one of 30 sampled patients (Patient 2), to ensure there was a safe medication removal and administration process for the entire hospital units when nursing staff were retrieving medications from the Pyxis (automated medication dispensing machine) Tower. This deficient practice had the potential to put other patients at risk for medication error. (Refer to A-0309) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met, as evidenced by: 1. The facility failed to ensure the Nursing staff addressed one of 30 sampled patient’s (Patient 7) pain levels of 8/10 and 9/10 based on a pain scale (0-2: Mild pain, 3-4: Moderate pain, 5-6: Severe pain, 7-10: Very severe pain), in accordance with the facility’s policy regarding pain management. This deficient practice had the potential for inadequate pain control, prolonged patient suffering from pain, and psychological distress (Example: anxiety [feeling of unease]), which may lead to prolonged recovery from illness. (Refer to A-0395) 2. The facility failed to ensure Nursing staff notified the physician regarding the new onset of chest pain for one of 30 sampled patients (Patient 7), in accordance with the facility’s policy regarding physician notification. This deficient practice had the potential for delayed diagnosis and treatment which may result in worsening of Patient 7’s condition and/or death. (Refer to A-0395) 3. The facility failed to ensure one of seven sampled nursing staff’s (RN 14) unit-specific competencies (an integrated set of knowledge, skills, abilities, judgment, values, and professional behaviors that enable a nurse to effectively and safely provide patient care, fulfill professional obligations, and adapt to dynamic healthcare environments) was completed and validated before being released to work independently, in accordance with the facility’s policy regarding staff competencies. This deficient practice resulted in RN 14 committing a medication error (wrong dose) and administering lidocaine (medication for local anesthetic [reduce sensation of pain] and antiarrhythmic [treat or prevent abnormal heart rhythms]) 50 milliliters (ml, unit of measure, used to indicate a volume) instead of 50 milligrams (mg, unit of measure, used in medication dosage) to Patient 3 on 7/29/2025. Patient 3 received 1000 mg of lidocaine, went into seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness) and cardiac arrest (sudden loss of heart function) shortly after the medication administration and required cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating). (Refer to A-0397) 4. The facility failed to ensure one of 30 sampled patient’s (Patient 18) physician was notified of two instances wherein there was presence of blood in the tracheostomy (an opening a surgeon makes through the neck and into the patient’s wind pipe to assist with breathing) dressing of Patient 18, in accordance with the facility’s policy and procedure (P&P) regarding physician notification. This deficient practice had the potential to result in a delay in the provision of care and treatment to address the tracheostomy bleed of Patient 18, which may result in patient harm. (Refer to A-0398) 5. The facility failed to ensure the nursing staff assessed the Maternal Fetal Triage (preliminary assessment to determine the urgency of the need for treatment) Index (MFTI, a five-level obstetric [concerned with childbirth and the care of women giving birth] tool for nurses to use when triaging a pregnant person presenting for care. It provides a standard approach to obstetric triage and is used to classify acuity [severity] and prioritize urgency for evaluation by a nurse and a physician) for two of three sampled patients (Patients 5 and 6), who presented to the Labor and Delivery (L&D) Triage area, in accordance with the facility’s policy and procedure regarding L&D triage. This deficient practice had the potential for the acuity level (severity of condition) of patients to be unknown and had the potential for the delay in evaluation and treatment. (Refer to A-0398) 6. The facility failed to inform two of 30 sampled patients (Patients 25 and 27) about the “Care of Patient’s Belongings” Policy, which included the possibility of inspecting the patients’ belongings and asking if any of the patients’ belongings could be considered a contraband (prohibited items, such as weapons, sharp objects, and illicit drugs), when Patients 25 and 28 did not sign their Patient Valuables form upon admission, in acknowledgement of the facility’s policy and procedure regarding Patient belongings. This deficient practice had the potential for improper inventory of patient belongings, lost items, if not confirmed with patients upon admission, and had the potential for patients to be unaware of which items were prohibited from the hospital (such as weapons or illegal drugs). (Refer to A-0398) 7. The facility failed to ensure Nursing staff notified one of 30 sampled patient’s (Patient 11) family after a code blue (the activation of the Emergency Response Team upon discovery of any individual who has suffered a sudden cessation of vital signs [temperature, blood pressure, heart rate, respiratory rate] or is in a sudden and unexpected life-threatening situation) was activated for Patient 11, in accordance with the facility’s policy regarding family notification during a code blue episode. This deficient practice had the potential to cause Patient 11’s family and/or significant other, emotional distress, leading to feelings of anxiety and guilt. (Refer to A-0398) 8. The facility failed to ensure that a nerve block (an injection of medication close to a targeted nerve to provide temporary pain relief) was administered on the correct site (right knee) for one of 30 sampled patients (Patient 12), in accordance with the facility’s policy regarding anesthesia time-out (a critical safety protocol where the entire surgical team pauses before starting an invasive procedure to verify the correct patient, procedure, and site). This deficient practice had the potential to expose the patient (Patient 12) to a greater risk of local anesthetic toxicity, mobility (ability to walk) problems post-surgery (after surgery), and increased length of stay in hospital. (Refer to A-0398) 9. The facility failed to ensure nursing staff followed safe medication administration process for three of 30 sampled patients (Patient 1, Patient 2, and Patient 3), in accordance with the facility’s policy regarding medication administration when: 9.a. Registered Nurses (RN) 12 and RN 13 failed to verify the Pitocin (a form of synthetic oxytocin, medication used to induce labor in pregnant women by stimulating uterine contractions) induction (to start labor contractions [tightening and relaxing of uterus during pregnancy to move the baby into the birth canal] artificially before they would naturally occur) order was in place, and administered to Patient 1, Pitocin 95 milliliters per hour (ml/hr, unit of rate) instead of Pitocin 2ml/hr on 5/16/2025 (wrong order). This deficient practice resulted in Patient 1 experiencing a decreased fetal (unborn baby) heart rate and requiring medical attention and intervention to stop the contraction. (Refer to A-0405) 9.b. RN 1 gave ropivacaine (medication used in epidural [a type of pain relief medication administered through a catheter inserted into the epidural space, the area between the spinal cord and the spinal column]) instead of clindamycin (medication, a type of antibiotics to treat infection) to Patient 2 on 5/23/2025 (wrong medication). This deficient practice resulted in Patient 2 feeling numbness to the body and blurred vision and requiring medical attention and intervention to treat the Local Anesthetic Systemic Toxicity (LAST, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels). (Refer to A-0405) 9.c. RN 14 gave lidocaine (medication for local anesthetic [reduce sensation of pain] and antiarrhythmic [treat or prevent abnormal heart rhythms]) 50 milliliters (ml, unit of measure, used to indicate a volume) instead of 50 milligrams (mg, unit of measure, used in medication dosage) to Patient 3 on 7/29/2025 (wrong dose). This deficient practice resulted in Patient 3 receiving 1000 mg of lidocaine, going into seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness) and cardiac arrest (sudden loss of heart function) shortly after the medication administration and required cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating). These deficient practices also had the potential to put other patients at risk for medication errors and cause harm to patients. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure the Condition of Participation for Medical Record Services was met, as evidenced by: 1. The facility failed to ensure one of 30 sampled patient’s (Patient 7) medical record contained copies of telemetry mounting strips (printed recording of the patient’s heart electrical activity, captured continuously by the telemetry monitor important for reviewing and documenting heart rhythms over time) and copies retained from 1/27/2025 at 4:11 p.m. (the time of admission) to 1/28/2025 at 11:58 a.m., at the required intervals of every 4 hours and as needed, in accordance with the facility’s policy regarding telemetry monitoring (a system that uses small, wearable devices with electrodes attached to a patient’s body to wirelessly transmit their vital signs-such as heart rate, rhythm, and sometimes oxygen saturation and respiratory rate-to a central station for continuous, real-time observation by healthcare providers). This deficient practice had the potential for Patient 7’s safety to be compromised, leading to lack of monitoring, review, and assessment of the patient’s (Patient 7) cardiac (heart) status, potentially delaying identification of arrhythmias (a condition in which the heart beats with an irregular or abnormal rhythm) or other critical changes. (Refer to A-0438) 2. The facility failed to ensure one of 30 sampled patient’s (Patient 24), who was documented as Spanish-speaking only (both verbally and written communication), informed consent (permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits) for blood transfusion (a medical procedure where blood or blood components from a donor are transferred into the bloodstream of a recipient) and esophagogastroduodenoscopy (EGD, a medical procedure that allows a doctor to examine the lining of the upper gastrointestinal tract, including the esophagus, stomach, and first part of the small intestine), was verified by a nurse who was proficient in Spanish and certified by the facility or the process involved the use of the interpreter services (professional medical interpreter), and with documentation of interactions used to communicate with the LEP (Limited English Proficiency) person included as part of the medical record, in accordance with the facility’s established policy and procedures regarding use of interpretation services and documentation. This deficient practice had the potential to compromise Patient 24’s ability to fully understand the course of treatment, procedures, or risks because the patient (Patient 24) was not properly informed in their own language thus had the potential to lead to incorrect decisions, lack of full consent, and affecting patient (Patient 24) autonomy (the capacity to be one’s own person, making free and independent choices based on one’s own judgment and values, rather than being controlled by external forces) and safety. (Refer to A-0438) 3. The facility failed to ensure one of 30 sampled patient’s (Patient 10), language preference, was accurately documented by nursing staff, when the official record indicated that Patient 10’s preferred language was English while all informed consent forms obtained during Patient 10’s admission stay at the facility were in Spanish. This deficient practice had the potential for Patient 10’s actual language needs to not be properly addressed, which could impair effective communication, understanding of medical information, and informed-decision-making. (Refer to A-0438) 4. The facility failed to ensure that for one of 30 sampled patients (Patient 24), the following information was documented to justify Patient 24’s progress and response to treatment plan, in accordance with the facility’s policy regarding documentation, when: 4.a. Nursing staff failed to obtain and document Patient 24’s daily weight in accordance with the physician’s order. This deficient practice had the potential to result in adverse patient outcomes for Patient 24, when complications such as fluid overload and/or dehydration goes undetected due to lack of monitoring and proper documentation, which can lead to delayed diagnosis and treatment. (Refer to A-0467) 4.b. Nursing staff failed to develop, document, and maintain a personalized care plan (a formal, documented roadmap created by nurses that outlines a patient’s specific health needs, goals, and planned nursing actions to achieve those goals) for monitoring fluid balance (the body’s ability to maintain the proper amount of water and hydration) and nutritional status (the body’s current state of nourishment, reflecting the balance between nutrient intake and the body’s needs for growth, repair, and maintenance) for Patient 24. This deficient practice had the potential to result in adverse patient outcomes for Patient 24, when complications such as fluid overload and/or dehydration goes undetected due to lack of monitoring and proper documentation, which can lead to delayed diagnosis and treatment. (Refer to A-0467) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility’s governing body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure there was a safe medication removal and administration process when nursing staff were retrieving medications from three of three sampled Pyxis (an automatic medication dispensing machine) Tower (Pyxis #1), in accordance with the facility’s policy regarding medication administration and with the facility’s performance improvement plan. This deficient practice resulted in Registered Nurse 2 administering a wrong medication to Patient 2 causing Patient 2 to experience numbness to the body and blurry vision, which required medical attention and intervention. This deficient practice also had the potential to have reoccurrence of similar medication errors causing harm to other patients. Findings: During a review of Patient 2’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 5/20/2025, the H&P indicated, Patient 2 was 28 weeks and 2 days pregnant and was admitted to the facility’s Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) department for antepartum (a period before labor and delivery) workup and management of fever. During a review of Patient 2’s physician order, dated 5/21/2025, the physician order indicated, to give clindamycin (medication, a type of antibiotics to treat infection) 900 milligrams (mg, unit of measure) every eight (8) hours intravenously (IV, administered into a vein). During a review of Patient 2’s physician progress notes, dated 5/23/2025, the physician progress notes indicated, physician (MD 1) was notified that Patient 2 was feeling “numb all over her body and has blurry vision” at 0053 (12:53 a.m.) after the administration of clindamycin. The physician progress notes also indicated MD 1 assessed Patient 2. Patient 2 reported episodes of numbness and unable to make eye contact because she (Patient 2) had floaters/flashes in her (Patient 2’s) vision. Patient 2 overall felt very “weird.” MD 1 was then notified Patient 2 received ropivacaine (medication used in epidural [a type of pain relief medication administered through a catheter inserted into the epidural space, the area between the spinal cord and the spinal column]) instead of clindamycin. During an interview on 8/20/2025 at 10:16 a.m. with Registered Nurse (RN) 1, RN 1 stated the following: “on 5/23/2025, I was trying to give the medication on time before I go on break. When I requested clindamycin from the Pyxis (an automatic medication dispensing machine), it prompted me which pocket to get it from, but I mistakenly went to the wrong pocket and took out ropivacaine instead of clindamycin. The pyxis printed a label sticker (pyxis label) for me to scan. I scanned the sticker (pyxis label) instead of the actual medication bag when giving the medication (to Patient 2) at bedside and the system let it pass.” RN 1 also stated, “I should not trust the sticker (pyxis label). I should scan the medication. I wanted to be on time, and I was in a rush before going on break.” RN 1 stated she did not look at the name on the IV medication bag. During an interview on 8/20/2025 at 11:19 a.m. with the Director (DIR 1) of Pharmacy, DIR 1 stated the following: the nurse (RN 2) deviated from the process, she (RN 2) scanned the Pyxis printed label (pyxis label) instead of the bar code on the actual medication. Nurses must scan the bar code on the medication bag not the pyxis label. The purpose of pyxis label was to serve as patient specific label to identify the patient, not replace the barcode on the medication. If the nurse scanned the pyxis printed label, the system would not be able to detect the medication error (wrong medication). During an interview on 8/20/2025 at 11:25 a.m. with DIR 1, DIR 1 stated after the incident that the pharmacy turned on “scan removal” feature on the pyxis in L&D department to force the L&D nurses to scan the medication bag before closing Pyxis door. The medications with the scan removal feature were only limited to the medications used in L&D department. During an interview on 8/21/2025 at 5:37 p.m. with physician (MD 1), MD 1 stated ropivacaine could cause seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness [often described as “fainting” or “passing out”]), lidocaine toxicity (LAST, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug is absorbed into the bloodstream at toxic levels) and affect the heart and affect the patient neurologically. During a review of Patient 2’s “Discharge Summaries Notes (DC Summary),” dated 5/25/2025, the DC Summary indicated, Ancef (medication, antibiotics to treat infection) and clindamycin started for presumed chorioamnionitis (bacterial infection and inflammation of the placenta [a temporary organ that forms inside the uterus during pregnancy connecting the mother and the developing baby], amniotic fluids [clear watery substance that surrounds and protects the developing baby during pregnancy], and the membranes [a thin protective layers that surround and cushion the developing baby during pregnancy]). The DC Summary also indicated, “(on 5/23/2025) overnight (Patient 2) noted to receive ropivacaine through IV instead of clindamycin due to nursing error resulting in whole body numbness and blurry vision. Patient (Patient 2) noted to have concern for LAST (Local Anesthetic Systemic Toxicity, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug is absorbed into the bloodstream at toxic levels) - anesthesia (physician who specialized in planning and administering anesthetic medications to manage pain and consciousness during surgical and medical procedures) called and 2 bags of lipid emulsion therapy (medical treatment to reverse the effects from local anesthetic systemic toxicity) was administered with resolution of patient (Patient 2) symptoms.” During a concurrent observation and interview on 8/21/2025 at 10:05 a.m., to demonstrate the retrieval of medication from the Pyxis, with RN 2 in Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) medication room, RN 2 put in a request of Cardene (medication to treat high blood pressure) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with twelve (12) pockets with different medications: 0.9% normal saline (type of IV fluid to treat fluid imbalance, phenylephrine (medication to treat low blood pressure) 20 mg per 250 milliliters (ml, unit of measure), vancomycin (type of antibiotics to treat infection) 1.25 grams (g, unit of measure) vial, mupirocin (antibiotic ointment to treat bacterial skin infection) ointment 2%, sevelamer carbonate (medication to treat high blood phosphate levels) oral suspension 0.8 g, potassium 10 milliequivalent (mEq, unit of measure) per 100 ml, epinephrine (medication to treat allergic reaction and to restore cardiac rhythm) 1mg/10ml, micafungin (medication to treat fungal infection) 100 mg vial, norepinephrine (medication to treat low blood pressure) 8 mg per 250 ml, Cardene 20mg/200ml, venofer (medication to treat iron deficiency anemia [a condition in which there are not enough red blood cells (RBCs) or hemoglobin in the blood. Hemoglobin is an iron-rich protein in RBCs that carries oxygen throughout the body]) 100mg/5ml, nystatin (medication to treat fungal infection) powder bottle in the same drawer. RN 2 removed a box of IV Cardene from Pyxis pocket number 10 and closed the Pyxis door without the need for scanning the medication. The Pyxis machine printed a label sticker (pyxis label) when RN 2 closed the pyxis door. RN 2 stated she (RN 2) could scan either the bar code on the medication (the medication itself) or the barcode on the pyxis label when giving the medication to a patient (The correct process is to scan the barcode on the actual medication and not the pyxis label). During a concurrent observation and interview on 8/21/2025 at 10:32 a.m., to demonstrate the retrieval of medication from the pyxis, with RN 3 in Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit medication room, RN 3 put in a request of Merrem (medication, type of antibiotics to treat infection) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with seven (7) pockets with different medications: 0.9% normal saline 250 ml, 0.9% normal saline 50 ml, amiodarone (medication to treat heart dysrhythmia [abnormal heart rhythm]) 360 mg/200 ml, Merrem 1 gram vial, magnesium sulfate (medication to treat low magnesium in blood) 2 gram/50 ml, PEG-3350 and electrolytes (laxative solution to clear bowel) for oral solution jar, and nafcillin 2 gram vial, in the same drawer. RN 3 removed a vial of Merrem from Pyxis pocket number 45 and closed the Pyxis door without the need for scanning the medication. RN 3 stated once the Pyxis drawer door opened, she (RN 3) had access to all the medications in the same drawer (drawer number 4). RN 3 stated she (RN 3) could scan either the bar code on the medication (the medication itself) or the pyxis printed label (the barcode) when giving the medication to a patient. During a concurrent interview and record review on 8/22/2025 at 3:27 p.m. with the Chief Nursing Officer (CNO), facility’s apparent cause analysis (a focused investigation used to identify the immediate causes of adverse patient safety events and develop action plan) report titled, “Cause Analysis Report (CAR report),” dated 5/23/2025, was reviewed. The CAR report indicated the medication error incident took place on 5/23/2025 involving the Primary RN (RN 1) who took the wrong medication from the Pyxis because RN (RN 1) did not pay attention to detail and did not validate the medication. The CAR report also indicated the action plan section was blank. CNO stated the CAR report was incomplete because the action plan was missing. During an interview on 8/22/2025 at 3:28 p.m. with the Chief Medical Officer (CMO), the CMO stated cause analysis was to identify the cause so the team could put in measures to improve the system by providing education or interventions and holding people accountable. CMO further stated there should be an action plan in place to prevent it (medication error incident) from happening again. During an interview on 8/22/2025 at 3:30 p.m. with the Operation Executive (OE), OE stated the following: the facility was aware there was a break in the system, but it took time to work with the vendor (Pyxis) to figure out how to selectively de-activate the label printing function without interrupting another workflow before implementing the new process hospital-wide. The facility did see there was potential to have the same error happen on other units. OE also stated, “we figured it out (Pyxis label printing function) yesterday (8/21/2025).” During an interview on 8/22/2025 at 3:38 p.m. with the CMO, CMO stated Quality Assurance and Performance Improvement (QAPI, the facility’s program for identifying problems, investigating causes and making improvements) was responsible to improve consistency of care, quality of care, patient safety and maximize patient outcomes. During an interview on 8/22/2025 at 3:45 p.m. with OE, OE stated the governing body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) was responsible for patient safety and clinical quality oversight for the whole hospital. OE further stated the medication error incident was reported to GB in June. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration - Inpatient (Nursing),” dated 7/2024, the P&P indicated, “To ensure the safe and accurate administration of drugs to patients at [the facility] by using barcode technology ... Administration ... 6. Before administering a medication, the LIP (Licensed Independent Practitioner) should perform the following ... verify that the medication selected for administration is the correct one based on the medication order and product label ... 7. For the nursing staff ... bring meds (medications) to bedside. Scan all medications and verify. Remove the packaging of the medication at the bedside ... use 2 patient identifiers and follow 6 rights of medication administration. i. right patient (with 2 patient identifiers), ii. Right time, iii. Right drug, iv. Right dose, v. right route, vi. Right documentation... Safe Practices on Medication Administration ... Prior to administration of medication, the licensed staff will verify: 1. Use of two (2) patient identifiers 2. Name of drug 3. Route 4. Dosage 5. Frequency 6. Indication.” During a review of the facility’s QAPI plan titled, “[the facility] Performance Improvement Plan 2025,” dated 6/2025, the QAPI plan indicated, “The purpose of the Performance Improvement Efforts at [the facility] is to ensure the delivery of safe patient care and to strive to be a benchmark for excellence in medical care and services. This is accomplished in a proactive approach by assessing patient care and other support processes in a systemic, ongoing manner in order to identify, analyze improvement opportunities and to act on those opportunities in a timely manner ... The Community Governing Board (GB) strives to assure quality patient care and customer service by requiring and supporting the establishment and maintenance of an effective hospital-wide continuous performance improvement initiative ... The overall authority for the direction of the Performance Improvement Program rests with the Community Governing Board ... Performance Improvement Methodology ... 2. Any of these performance improvement strategies may be used in response to ongoing measurement, staff suggestions, Medical Staff suggestions, Council/Committee suggestions, and from other sources. Specifically, assessment is triggered ... i. by all significant medication errors ... Proactive Analyses to Reduce Risks to Patients. 1. The organization’s Patient Safety Committee is responsible for any ongoing, proactive program for identifying and reducing unanticipated adverse events and safety risks to patients. The Committee’s approach includes ... c. identify the ways in which the process could breakdown or fail to perform its desired function; d. identify the possible effects that a breakdown or failure of the process could have on patients and the seriousness of the possible effects ... g. re-designing the process and/or underlying systems to minimize risk of the effects on patients; once the identification of the severity, notability, detectability and critically of the process failure has been prioritized.””

“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: 50515 Based on observation, interview and record review, the facility failed to: 1. Appropriately respond to one of 30 sampled Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) patient (Patient 30), who manifested intentions of leaving/eloping (leaving the facility without physician’s permission when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility, in accordance with the facility’s policy regarding patients identified as elopement risk. This deficient practice resulted in Patient 30 eloping and putting the 5150 (temporary, involuntary psychiatric [mental health] hold of a person who as a result of a mental disorder is a danger to themselves, danger to other or gravely disabled [unable to care for one’s self due to mental health issues], hold is designed to provide period of professional evaluation and treatment for person in crisis) patient (Patient 30) in danger to harm himself and a potential to harm others. 2. Ensure one of thirty sampled patients (Patient 19), received care in a safe setting, in accordance with the facility’s policy on patient rights (a subset of human rights. Example: the right to be treated with courtesy and respect), when a male visitor (MV) for another patient entered Patient 19’s room and opened the shower curtain while Patient 19 was in the shower. This deficient practice resulted in Patient 19 having felt violated and had the potential for Patent 19 to suffer from psychological and physical harm. On 8/20/2025 at 5:29 p.m., the survey team called an immediate Jeopardy (a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment or death to a patient) in the presence of the Associate Chief Nursing Operator (ACNO), Regulatory Specialist Organization Performance (RSO), Director of Accreditation, Licensing and Regulatory (DALR), Chief Nursing Officer (CNO), Operation Executive (OE) and Administrative Director of Emergency Department (ED, provides immediate medical care to patients experiencing serious or life-threatening conditions), Intensive Care Unit and Behavioral Health Unit (ADBHU). The facility failed to appropriately respond to a patient who manifested intentions of leaving/eloping (leaving the facility without physician’s permission when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility. This most likely put the 5150 (temporary, involuntary psychiatric hold of a person who as a result of a mental disorder is a danger to themselves, danger to other or gravely disabled, hold is designed to provide period of professional evaluation and treatment for person in crisis) Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) patient in danger to harm himself and a potential to harm others. A review of the facility’s security footage indicated the following: on 7/29/2025, a BHU patient (Patient 30), on a 5150 got up out of bed with an intravenous (IV, into the vein) pole attached to his (Patient 30) arm, walked to the emergency department hallway and out of the facility’s emergency room exit with the Patient Safety Attendant (PSA) and the Charge Nurse (CN 2) walking behind him resulting in Patient 30 eloping in the presence of several facility staff members. During an interview on 8/19/2025 at 12:59 with the Security Manager (SM), SM stated all security and nursing staff were trained to intervene in events where a patient was attempting to leave, staff were trained to de-escalate (reduce the intensity of a conflict or potentially violent situation) and if necessary, safely place hands on patient to be taken back to room or safely restrain or medicate as medically necessary. During an interview on 8/19/2025 at 3:46 pm with the ACNO, the ACNO stated code grey (an emergency situation involving an aggressive or combative patient) was delayed and should have been called the moment Patient 30 got up out of bed and began to ambulate (to walk) in the hallway. ACNO further stated a code green was called at 12:54 a.m., and that emergency department staff made no intentions to intervene with Patient 30 from leaving facility while waiting for security to arrive. This deficient practice placed Patient 30’s and others safety at risk, exposing Patient 30 to traffic, accidents, injury and/or death. On 8/22/2025 at 2:29 p.m. the IJ was removed in the presence of the OE, DALR, CNO, and CMO 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 by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that immediate action taken by the facility were the following: starting 8/20/2025, charge nurse and patient safety attendant involved in the incident would be re-educated on what to do if a patient attempt to elope: steps to follow during attempt to elope included call code green (emergency alert for patient elopement) via STAT (emergency) line, attempt verbal de-escalation, hands on approach (Get a patient’s attention with a gentle touch on the arm or shoulder to guide them, while maintaining a calm voice and direct eye contact), use restraints (any physical device, chemical substance, or environmental factor used to restrict a patient’s freedom of movement or normal body function without their consent, typically to prevent harm to themselves or others), call physician, review of behavioral health patients in the emergency department (TEAM advanced), verbal de-escalation and interventions including behavioral health emergency types, early recognition, interventions hands-on approach included team essential skills lab (skills laboratory- a controlled, simulated environment where healthcare professionals practice foundational clinical skills), safe working positions, defense and escape techniques, escort techniques and application of restraints. Immediate activation of code grey by calling STAT line 88888, the process of calling the STAT line was revised, labeling with the 88888-emergency call number for [name of Facility] campus two and 22222 for [Name of Facility] main campus. The IJ removal plan also included the following: Starting 8/20/2025, emergency staff charge nurses, registered nurses, emergency medical technicians, patient safety attendants, security and unit secretary received in person education on interventions and expectation when any patient on a hold attempted to leave. Security staff received education and expectations of responding to code green. The nursing director and designee would validate emergency department and behavior health unit staff understanding at both campuses (Main campus and secondary campus) including knowledge of behavioral health emergency, early recognition, interventions such as verbal de-escalation, TEAM advanced training process and care for patient on hold. Emergency manager or designee would conduct five staff interviews per day to validate knowledge on the prevention of 5150 elopement for the first week or until 100% compliance was achieved for three consecutive months. PBX (a telephone system for managing calls) manager or designee would perform five random test calls per week on the STAT line to validate functionality and confirm if the revised process was working as intended. Audit continues until 100% compliance for three consecutive months. PBX manager or designee would also conduct five daily observations of phones in patient care areas to verify Emergency Code call number stickers were in place. Audit to continue until 100% compliance was achieved for three consecutive months. Findings: 1. During a review of Patient 30’s “Emergency Physician Note,” dated 7/28/2025, the note indicated Patient 30 was brought to the facility by local enforcement on 7/28/2025. Patient 30 was on a 5150 hold for being a danger to others. Patient 30 was acting erratically and making threats to kill the president. Patient 30 arrived in the Emergency Room in 4-point restraints (involves securing a patient’s wrist and ankles to prevent movement used in emergency situations involving violent or self-destructive behavior) with a spit hood (disposable mesh device that fit over the head) in place. During a review of Patient 30’s “Elopement Risk Assessment Tool,” dated 7/28/2025 and timed at 1830 (6:30 p.m.), the Elopement Risk Assessment Tool, indicated Patient 30’s elopement score was 22 (score of 7 or higher indicated a high risk of elopement). During an interview on 8/19/2025 at 12:40 p.m. with the Emergency Department Charge Nurse (CN 1), CN 1 stated, patients with elopement risk were assessed, and depending on the score, interventions were taken. For Patients with a score of 7 or higher or on a legal hold, the following precautions were taken: patient in green gown, patient placed away from the exit, patient safety attendant assigned, restroom in hallways: two person assisting patients and restrict ambulation to the room (no hallway ambulation). During an interview on 8/19/2025 at 12:59 p.m. with the Security Manager (SM), SM stated, all security and nursing staff were trained to intervene in events where a patient was attempting to leave, staff were trained to de-escalate and if necessary, safely place hands on patient to be taken back to room or safely restrain or medicate as medically necessary. During an interview on 8/19/2025 at 10:22 a.m. with the SM, the SM stated, the assigned Emergency Department’s main door security guard could have moved with more sense of urgency once code green was announced overhead and via radio. During an interview on 8/19/2025 at 2:51p.m. with Associate Chief Nursing Operator (ACNO), ACNO stated the charge nurse (CN 2) did not attempt to intervene in stopping Patient 30 from leaving because she (the charge nurse) did not want to get hurt and security guards were not sure about hands on intervention, also CN 2 verbalized her (CN 2) understanding that she (CN 2) was not to touch Patient 30. During a concurrent observation, interview and video footage record review on 8/19/2025 at 3:24 p.m. with the Patient Safety Attendant (PSA 1), Patient 30’s “Video Footage-Charge Nurse Station (A Side),” date stamped 7/29/2025 at 12:52 a.m., was reviewed. The video footage indicated, Patient 30 wearing a green gown exiting Room 9 with IV pole in right hand walking towards the emergency exit. PSA 1 and Charge Nurse 2 (CN 2) were seen walking behind Patient 30, Patient 30 continued to walk at a slow pace and exited the emergency room through the emergency exit. PSA 1, CN 2 and Emergency Medical Technician (EMT) did not follow Patient 30 out the door. The PSA1 stated she (PSA 1) did not attempt to intervene when Patient 30 got out of bed and began to walk in the hallway because the charge nurse told her (PSA 1) not to touch the patient (Patient 30). During a concurrent observation, interview and video footage record review on 8/19/2025 at 3:34 p.m. with the SM and the ACNO, the security footage from 7/29/2025, was reviewed. The recorded events were observed and validated with the SM and the ACNO, at the indicated timestamps in the videos: View 1 (Charge Nurse Station) -Timed stamped:7/29/2025 at 12:52 a.m. -Patient 30 wearing a green gown exited Room 9 with IV pole in right hand walking towards the emergency exit. PSA 1 and CN 2 were seen walking behind Patient 30, Patient 30 continued to walk at a slow pace and exited the emergency room through the emergency exit. PSA 1, CN 2 and EMT did not follow Patient 30 out the door. View 2 (Ambulance/Emergency exit) -Timed stamped: 7/29/2025 at 12:52 a.m., Patient 30 was seen walking towards emergency exit with PSA 1 and CN 2 following behind. EMT 1 approached Patient 30, EMT 1 reached for Patient 30’s arm and Patient 30 maneuvered arm up and away from EMT 1’s grasp and continued walking and exited through the door out of the video’s frame. View 3 (Exterior view of ED) -Timed stamped: 7/29/2025 at 12:53 a.m. Patient 30 outside Emergency Room running towards Beverly Blvd. with no shoes or socks. View 4 (ER room entrance) -Timed stamped: 7/29/2025 at 12:54 a.m. Security guard 1 was seen standing up from his chair and slowly (no urgency) walking toward the Emergency Room door (where Patient 30 exited). During an interview on 8/19/2025 at 3:40 p.m. with the SM, the SM stated staff members should have used the TEAM advance techniques (training techniques used to manage psychiatric patients in crisis) and taken Patient 30 back to Room 9, The SM further added that in this case (involving Patient 30) the advance training techniques were not deployed. During an interview on 8/19/2025 at 3:46p.m. with the ACNO, ACNO stated code grey was delayed and should have been called the moment Patient 30 got up out of bed and began to ambulate in the hallway. ACNO further stated a code green was called at 12:54 a.m., and that emergency department staff made no intentions to intervene with Patient 30 from leaving facility while waiting for security to arrive. During an interview on 8/19/2025 at 4:45 p.m. with the Unit Associate (UA), UA stated she (UA) made two attempts to reach the facility operator by dialing the stat line 88888, allowing the phone to ring about 10 times on first attempt and on second attempt was able to reach the operator to overhead page for a code green (code used to activate staff discovering a high risk patient who is missing or suspected of elopement or who witnesses the patient leave the unit). During an interview on 8/19/2025 at 5:10 p.m. with the ACNO, ACNO stated she reviewed the stat line calls made on 7/29/2025 and that there were no calls made to operator using the emergency stat-line no. 88888. The Emergency Room (ER) unit associate probably dialed “0,” the non-emergency line to operator, during the elopement incident of Patient 30. The ACNO said it was important that staff utilized emergency stat-line number “88888” for all emergency code, including code blue (a hospital term for a medical emergency, most often indicating a patient is in cardiac arrest [when the heart stops beating] or experiencing respiratory failure [when a patient stops breathing], requiring immediate medical attention and resuscitation efforts [interventions to keep the heart beating and the patient breathing]) and elopement incident, to avoid delay of interventions. During an interview on 8/20/2025 at 11:52 a.m. with the ACNO, ACNO stated Patient 30 returned to the facility two days after eloping from facility to retrieve his (Patient 30) belongings. Patient 30 was being aggressive and making threats towards staff. Local law enforcement was called, and Patient 30 was placed on another 5150 hold. Patient 30 was admitted and transferred to the sister facility’s Behavioral Health Unit. During an interview on 8/20/2025 at 3:05 p.m. with the ACNO, ACNO stated that hospital staff can refer to the emergency operator number (example: 88888) in the phone extension list that was posted next to the phone. The hospital had no process of updating and posting of the extension list. During an interview on 8/20/2025 at 3:50 p.m. with Charge Nurse 3 (CN 3), CN 3 stated that the phone extension list in the telemetry unit (Tower 3) did not include the operator emergency line (example: 88888) and was not posted anywhere else in the unit. During a review of the facility’s Policy and Procedure (P&P) titled, “Code Green-Patient Elopement-Missing High-Risk Patients,” revised 6/18/2024, the P&P indicated “All reasonable measures will be taken to prevent the elopement of high-risks patients from the hospital.” However, in the case of Patient 30, the protocol for 5150 hold patients was not implemented and this finding was validated by the ACNO. 2. During a review of Patient 19’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/10/2024, the H&P indicated Patient 19 was admitted to the facility for Uterine Contractions (uterine [ relating to womb] muscles tighten and relax to prepare for childbirth). During an interview on 8/20/2025 at 8:53 a.m. with Charge Nurse (CN) 3, CN 3 stated security would walk around and check the unit a couple of times a day. During a concurrent interview and record review on 8/20/2025 at 9:02 a.m. with CN 3, Patient 19’s “Flowsheet -Clinical Note Nursing,” dated 12/12/2024, was reviewed. CN 3 said the flowsheet indicated Patient 19 called to inform the staff that a man (a male visitor for another patient) had walked in the room looking for his (the male visitor) wife while Patient 19 was in the shower. During the same interview on 8/20/2025 at 8:53 a.m. with Charge Nurse (CN) 3, CN 3 stated Patient 19 was showering, Patient 19 heard the shower curtain open a little bit, and it was not Patient 19’s spouse. Furthermore, CN 3 stated Patient 19 was upset, did not want to talk to anybody and called the spouse (Patient 19’s spouse) to be picked up. During an interview on 8/20/2025 at 9:37 a.m. with Security Shift Supervisor (SS) 1, SS 1 stated the male visitor who entered Patient 19’s room was the spouse of another patient who was in a different room. SS 1 said, the visitor mix up was explained to Patient 19, but Patient 19 stated she (Patient 19) felt violated and was upset because someone else other than her spouse entered the room and opened the shower curtain, while she (Patient 19) was in the shower. During an interview on 8/20/2025 at 10:26 a.m. with the Director of Risk Management (DRM) 1, DRM 1 stated it was important to ensure safety and privacy of patients. Furthermore, DRM 1 stated it was expected for the staff to know who was in the unit, to ensure patient privacy was protected and ensure a healing environment, where patients can feel safe, was provided. During a review of the facility’s policy and procedure (P&P) titled, “Standard Policy: Conditions of Registration (COR),” revised in 12/6/2024, the P&P indicated, “The COR provides important information including but not limited to ...Patient Rights ...Patient Rights You have the right to: Considerate and respectful care, and to be made comfortable ...Receive care in a safe setting.” During a review of the facility’s policy and procedure (P&P) titled, “Policy: Visitor Policy, Patient-Directed Visitation,” revised in 6/18/2024, the P&P indicated, “In addition, [the facility’s name] desires to maintain an atmosphere that is safe for patients, visitors, and staff ...Visitor: A visitor is defined as a guest of the patient.””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility’s Quality Assurance and Performance Improvement (QAPI, the facility’s program for identifying problems, investigating causes and making improvements) program failed to implement an appropriate action plan, in a timely manner, to prevent medication errors from happening, in accordance with the facility’s performance improvement plan, after a Registered Nurse (RN 1) removed a wrong medication from the Pyxis (automated medication dispensing machine) tower and administered to one of 30 sampled patients (Patient 2) in the Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) department. This deficient practice had the potential to result in the same or similar medication error happening on other nursing units and potentially causing harm to patients. Findings: During a review of Patient 2’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 5/20/2025, the H&P indicated, Patient 2 was 28 weeks and 2 days pregnant and was admitted to the facility’s Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) Department for antepartum (a period before labor and delivery) workup and management of fever. During a review of Patient 2’s physician order, dated 5/21/2025, the physician order indicated to give clindamycin (medication, a type of antibiotics to treat infection) 900 milligram (mg, unit of measure) every eight (8) hours intravenously (IV, administered into a vein). During a review of Patient 2’s physician progress notes, dated 5/23/2025, the physician progress notes indicated, physician (MD 1) was notified that Patient 2 was feeling “numb all over her body and has blurry vision” at 0053 (12:53 a.m.) after the administration of clindamycin. The physician progress notes also indicated MD 1 assessed Patient 2. Patient 2 reported episodes of numbness and unable to make eye contact because she (Patient 2) had floaters/flashes in her (Patient 2’s) vision. Patient 2, overall, felt very “weird.” MD 1 was then notified Patient 2 received ropivacaine (medication used in epidural [a type of pain relief medication administered through a catheter inserted into the epidural space, the area between the spinal cord and the spinal column]) instead of clindamycin. During an interview on 8/20/2025 at 10:16 a.m. with Registered Nurse (RN) 1, RN 1 stated the following: “on 5/23/2025, I was trying to give the medication on time before I go on break. When I requested clindamycin from the Pyxis (an automatic medication dispensing machine), it prompted me which pocket to get it from, but I mistakenly went to the wrong pocket and took out ropivacaine instead of clindamycin. The pyxis printed a label sticker (pyxis label) for me to scan. I scanned the sticker (pyxis label) instead of the actual medication bag when giving the medication (to Patient 2) at bedside and the system let it pass.” RN 1 also stated, “I should not trust the sticker (pyxis label). I should scan the medication. I wanted to be on time, and I was in a rush before going on break.” RN 1 stated she (RN 1) did not look at the name on the IV medication bag. During an interview on 8/20/2025 at 11:19 a.m. with the Director (DIR 1) of Pharmacy, DIR 1 stated the following: the nurse (RN 2) deviated from the process, she (RN 2) scanned the Pyxis printed label (pyxis label) instead of the bar code on the actual medication. Nurses must scan the bar code on the medication bag not the pyxis label. The purpose of pyxis label was to serve as patient specific label to identify the patient, not replace the barcode on the medication. If the nurse scanned the pyxis printed label, the system would not be able to detect the medication error (wrong medication). During an interview on 8/20/2025 at 11:25 a.m. with DIR 1, DIR 1 stated after the incident that the pharmacy turned on the “scan removal” feature on the pyxis in L&D department to force the L&D nurses to scan the medication bag before closing Pyxis door. The medications with the scan removal feature were only limited to the medications used in the L&D department. During an interview on 8/21/2025 at 5:37 p.m. with physician (MD 1), MD 1 stated ropivacaine could cause seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness [often described as “fainting” or “passing out”]), lidocaine toxicity (LAST, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels) and affect the heart and affect the patient neurologically. During a review of Patient 2’s “Discharge Summaries Notes (DC Summary),” dated 5/25/2025, the DC Summary indicated, Ancef (medication, antibiotics to treat infection) and clindamycin started for presumed chorioamnionitis (bacterial infection and inflammation of the placenta [a temporary organ that forms inside the uterus during pregnancy connecting the mother and the developing baby], amniotic fluids [clear watery substance that surrounds and protects the developing baby during pregnancy], and the membranes [a thin protective layers that surround and cushion the developing baby during pregnancy]). The DC Summary also indicated, “(on 5/23/2025) overnight (Patient 2) noted to receive ropivacaine through IV instead of clindamycin due to nursing error resulting in whole body numbness and blurry vision. Patient (Patient 2) noted to have concern for LAST (Local Anesthetic Systemic Toxicity, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels) - anesthesia (physician who specialized in planning and administering anesthetic medications to manage pain and consciousness during surgical and medical procedures) called and 2 bags of lipid emulsion therapy (medical treatment to reverse the effects from local anesthetic systemic toxicity) was administered with resolution of patient (Patient 2) symptoms.” During a concurrent observation and interview on 8/21/2025 at 10:05 a.m., to demonstrate the retrieval of medication from the Pyxis, with RN 2 in the Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) medication room, RN 2 put in a request of Cardene (medication to treat high blood pressure) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with twelve (12) pockets with different medications: 0.9% normal saline (type of IV fluid to treat fluid imbalance, phenylephrine (medication to treat low blood pressure) 20 mg per 250 milliliters (ml, unit of measure), vancomycin (type of antibiotics to treat infection) 1.25 grams (g, unit of measure) vial, mupirocin (antibiotic ointment to treat bacterial skin infection) ointment 2%, sevelamer carbonate (medication to treat high blood phosphate levels) oral suspension 0.8 g, potassium 10 milliequivalent (mEq, unit of measure) per 100 ml, epinephrine (medication to treat allergic reaction and to restore cardiac rhythm) 1mg/10ml, micafungin (medication to treat fungal infection) 100 mg vial, norepinephrine (medication to treat low blood pressure) 8 mg per 250 ml, Cardene 20mg/200ml, Venofer (medication to treat iron deficiency anemia [a condition in which there are not enough red blood cells (RBCs) or hemoglobin in the blood. Hemoglobin is an iron-rich protein in RBCs that carries oxygen throughout the body]) 100mg/5ml, nystatin (medication to treat fungal infection) powder bottle in the same drawer. RN 2 removed a box of IV Cardene from Pyxis pocket number 10 and closed the Pyxis door without the need for scanning the medication. The Pyxis machine printed a label sticker (pyxis label) when RN 2 closed the pyxis door. RN 2 stated she (RN 2) could scan either the bar code on the medication (the medication itself) or the barcode on the pyxis label when giving the medication to a patient (The correct process is to scan the barcode on the actual medication and not the pyxis label). During a concurrent observation and interview on 8/21/2025 at 10:32 a.m., to demonstrate the retrieval of medication from the pyxis, with RN 3 in the Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit medication room, RN 3 put in a request of Merrem (medication, type of antibiotics to treat infection) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with seven (7) pockets with different medications: 0.9% normal saline 250 ml, 0.9% normal saline 50 ml, amiodarone (medication treat heart dysrhythmia [abnormal heart rhythm]) 360 mg/200 ml, Merrem 1 gram vial, magnesium sulfate (medication to treat low magnesium in blood) 2 gram/50 ml, PEG-3350 and electrolytes (laxative solution to clear bowel) for oral solution jar, and nafcillin 2 gram vial), in the same drawer. RN 3 removed a vial of Merrem from Pyxis pocket number 45 and closed the Pyxis door without the need for scanning the medication. RN 3 stated once the Pyxis drawer door opened, she (RN 3) had access to all the medications in the same drawer (drawer number 4). RN 3 stated she (RN 3) could scan either the bar code on the medication (the medication itself) or the pyxis printed label (the barcode) when giving the medication to a patient. During a concurrent interview and record review on 8/22/2025 at 3:27 p.m. with the Chief Nursing Officer (CNO), facility’s apparent cause analysis (a focused investigation used to identify the immediate causes of adverse patient safety events and develop action plan) report titled, “Cause Analysis Report (CAR report),” dated 5/23/2025, was reviewed. The CAR report indicated the medication error incident took place on 5/23/2025 involving the Primary RN (RN 1) who took the wrong medication from the Pyxis because RN (RN 1) did not pay attention to detail and did not validate the medication. The CAR report also indicated the action plan section was blank. CNO stated the CAR report was incomplete because the action plan was missing. During an interview on 8/22/2025 at 3:28 p.m. with the Chief Medical Officer (CMO), CMO stated cause analysis was to identify the cause so the team could put in measures to improve the system by providing education or interventions and holding people accountable. CMO further stated there should be an action plan in place to prevent it (the medication error incident involving Patient 2) from happening again. During an interview on 8/22/2025 at 3:30 p.m. with the Operation Executive (OE), OE stated the following: the facility was aware there was a break in the system but it took time to work with the vendor (Pyxis) to figure out how to selectively de-activate the label printing function without interrupting another workflow, before implementing the new process hospital-wide. The facility did see there was potential to have the same error happen on other units. OE also stated, “we figured it out (Pyxis label printing function) yesterday (8/21/2025).” During an interview on 8/22/2025 at 3:38 p.m. with the CMO, CMO stated Quality Assurance and Performance Improvement (QAPI, the facility’s program for identifying problems, investigating causes and making improvements) was responsible to improve consistency of care, quality of care, patient safety and maximize patient outcomes. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration - Inpatient (Nursing),” dated 7/2024, the P&P indicated, “To ensure the safe and accurate administration of drugs to patients at [the facility] by using barcode technology ... Administration ... 6. Before administering a medication, the LIP (Licensed Independent Practitioner) should perform the following ... verify that the medication selected for administration is the correct one based on the medication order and product label ... 7. For the nursing staff ... bring meds (medications) to bedside. Scan all medications and verify. Remove the packaging of the medication at the bedside ... use 2 patient identifiers and follow 6 rights of medication administration. i. right patient (with 2 patient identifiers), ii. Right time, iii. Right drug, iv. Right dose, v. right route, vi. Right documentation... Safe Practices on Medication Administration ... Prior to administration of medication, the licensed staff will verify: 1. Use of two (2) patient identifiers 2. Name of drug 3. Route 4. Dosage 5. Frequency 6. Indication.” During a review of the facility’s QAPI plan titled, “[the facility] Performance Improvement Plan 2025,” dated 6/2025, the QAPI plan indicated, “The purpose of the Performance Improvement Efforts at [the facility] is to ensure the delivery of safe patient car and to strive to be a benchmark for excellence in medical care and services. This is accomplished in a proactive approach by assessing patient care and other support processes in a systemic, ongoing manner in order to identify, analyze improvement opportunities and to act on those opportunities in a timely manner ... Performance Improvement Methodology ... 2. Any of these performance improvement strategies may be used in response to ongoing measurement, staff suggestions, Medical Staff suggestions, Council/Committee suggestions, and from other sources. Specifically, assessment is triggered ... i. by all significant medication errors ... Proactive Analyses to Reduce Risks to Patients. 1. The organization’s Patient Safety Committee is responsible for any ongoing, proactive program for identifying and reducing unanticipated adverse events and safety risks to patients. The Committee’s approach includes ... c. identify the ways in which the process could breakdown or fail to perform its desired function; d. identify the possible effects that a breakdown or failure of the process could have on patients and the seriousness of the possible effects ... g. re-designing the process and/or underlying systems to minimize risk of the effects on patients; once the identification of the severity, notability, detectability and critically of the process failure has been prioritized.””

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility’s governing body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to provide oversight for the Quality Assurance and Performance Improvement (QAPI, the facility’s program for identifying problems, investigating causes and making improvements), to address and prioritize actions needed to address patient safety issues resulting from a medication error for one of 30 sampled patients (Patient 2), to ensure there was a safe medication removal and administration process for the entire hospital units when nursing staff were retrieving medications from the Pyxis (automated medication dispensing machine) Tower. This deficient practice had the potential to put other patients at risk for medication error. Findings: During a review of Patient 2’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 5/20/2025, the H&P indicated, Patient 2 was 28 weeks and 2 days pregnant and was admitted to the facility’s Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) department for antepartum (a period before labor and delivery) workup and management of fever. During a review of Patient 2’s physician order, dated 5/21/2025, the physician order indicated to give clindamycin (medication, a type of antibiotics to treat infection) 900 milligrams (mg, unit of measure) every eight (8) hours intravenously (IV, administered into a vein). During a review of Patient 2’s physician progress notes, dated 5/23/2025, the physician progress notes indicated, physician (MD 1) was notified that Patient 2 was feeling “numb all over her body and has blurry vision” at 0053 (12:53 a.m.) after the administration of clindamycin. The physician progress notes also indicated MD 1 assessed Patient 2. Patient 2 reported episodes of numbness and unable to make eye contact because she (Patient 2) had floaters/flashes in her (Patient 2’s) vision. Patient 2 overall felt very “weird.” MD 1 was then notified that Patient 2 received ropivacaine (medication used in epidural [a type of pain relief medication administered through a catheter inserted into the epidural space, the area between the spinal cord and the spinal column]) instead of clindamycin. During an interview on 8/20/2025 at 10:16 a.m. with Registered Nurse (RN) 1, RN 1 stated the following: “on 5/23/2025, I was trying to give the medication on time before I go on break. When I requested clindamycin from the Pyxis (an automatic medication dispensing machine), it prompted me which pocket to get it from, but I mistakenly went to the wrong pocket and took out ropivacaine instead of clindamycin. The pyxis printed a label sticker (pyxis label) for me to scan. I scanned the sticker (pyxis label) instead of the actual medication bag when giving the medication (to Patient 2) at bedside and the system let it pass.” RN 1 also stated, “I should not trust the sticker (pyxis label). I should scan the medication. I wanted to be on time and I was in a rush before going on break.” RN 1 stated she (RN 1) did not look at the name on the IV medication bag. During an interview on 8/20/2025 at 11:19 a.m. with the Director (DIR 1) of Pharmacy, DIR 1 stated the following: the nurse (RN 2) deviated from the process, she (RN 2) scanned the Pyxis printed label (pyxis label) instead of the bar code on the actual medication. Nurses must scan the bar code on the medication bag not the pyxis label. The purpose of pyxis label was to serve as patient specific label to identify the patient, not replace the barcode on the medication. If the nurse scanned the pyxis printed label, the system would not be able to detect the medication error (wrong medication). During an interview on 8/20/2025 at 11:25 a.m. with DIR 1, DIR 1 stated after the incident, the pharmacy turned on the “scan removal” feature on the pyxis in the L&D department to force the L&D nurses to scan the medication bag before closing Pyxis door. The medications with the scan removal feature were only limited to the medications used in L&D department. During an interview on 8/21/2025 at 5:37 p.m. with physician (MD 1), MD 1 stated ropivacaine could cause seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness), lidocaine toxicity (LAST, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels) and affect the heart and affect the patient neurologically. During a review of Patient 2’s “Discharge Summaries Notes (DC Summary),” dated 5/25/2025, the DC Summary indicated, Ancef (medication, antibiotics to treat infection) and clindamycin started for presumed chorioamnionitis (bacterial infection and inflammation of the placenta [a temporary organ that forms inside the uterus during pregnancy connecting the mother and the developing baby], amniotic fluids [clear watery substance that surrounds and protects the developing baby during pregnancy], and the membranes [a thin protective layers that surround and cushion the developing baby during pregnancy]). The DC Summary also indicated, “(on 5/23/2025) overnight (Patient 2) noted to receive ropivacaine through IV instead of clindamycin due to nursing error resulting in whole body numbness and blurry vision. Patient (Patient 2) noted to have concern for LAST (Local Anesthetic Systemic Toxicity, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels) - anesthesia (physician who specialized in planning and administering anesthetic medications to manage pain and consciousness during surgical and medical procedures) called and 2 bags of lipid emulsion therapy (medical treatment to reverse the effects from local anesthetic systemic toxicity) was administered with resolution of patient (Patient 2) symptoms.” During a concurrent observation and interview on 8/21/2025 at 10:05 a.m., to demonstrate the retrieval of medication from the Pyxis, with RN 2 in Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) medication room, RN 2 put in a request of Cardene (medication to treat high blood pressure) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with twelve (12) pockets with different medications: 0.9% normal saline (type of IV fluid to treat fluid imbalance, phenylephrine (medication to treat low blood pressure) 20 mg per 250 milliliters (ml, unit of measure), vancomycin (type of antibiotics to treat infection) 1.25 grams (g, unit of measure) vial, mupirocin (antibiotic ointment to treat bacterial skin infection) ointment 2%, sevelamer carbonate (medication to treat high blood phosphate levels) oral suspension 0.8 g, potassium 10 milliequivalent (mEq, unit of measure) per 100 ml, epinephrine (medication to treat allergic reaction and to restore cardiac rhythm) 1mg/10ml, micafungin (medication treat fungal infection) 100 mg vial, norepinephrine (medication to treat low blood pressure) 8 mg per 250 ml, Cardene 20mg/200ml, venofer (medication to treat iron deficiency anemia) 100mg/5ml, nystatin (medication to treat fungal infection) powder bottle in the same drawer. RN 2 removed a box of IV Cardene from Pyxis pocket number 10 and closed the Pyxis door without the need for scanning the medication. The Pyxis machine printed a label sticker (pyxis label) when RN 2 closed the pyxis door. RN 2 stated she (RN 2) could scan either the bar code on the medication (the medication itself) or the barcode on the pyxis label when giving the medication to a patient (The correct process is to scan the barcode on the actual medication and not the pyxis label). During a concurrent observation and interview on 8/21/2025 at 10:32 a.m., to demonstrate the retrieval of medication from the pyxis, with RN 3 in Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit medication room, RN 3 put in a request of Merrem (medication, type of antibiotics to treat infection) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with seven (7) pockets with different medications: 0.9% normal saline 250 ml, 0.9% normal saline 50 ml, amiodarone (medication treat heart dysrhythmia [abnormal heart rhythm]) 360 mg/200 ml, Merrem 1 gram vial, magnesium sulfate (medication to treat low magnesium in blood) 2 gram/50 ml, PEG-3350 and electrolytes (laxative solution to clear bowel) for oral solution jar, and nafcillin 2 gram vial), in the same drawer. RN 3 removed a vial of Merrem from Pyxis pocket number 45 and closed the Pyxis door without the need for scanning the medication. RN 3 stated once the Pyxis drawer door opened, she (RN 3) had access to all the medications in the same drawer (drawer number 4). RN 3 stated she (RN 3) could scan either the bar code on the medication (the medication itself) or the pyxis printed label (the barcode) when giving the medication to a patient. During a concurrent interview and record review on 8/22/2025 at 3:27 p.m. with the Chief Nursing Officer (CNO), the facility’s apparent cause analysis (a focused investigation used to identify the immediate causes of adverse patient safety events and develop action plan) report titled, “Cause Analysis Report (CAR report),” dated 5/23/2025, was reviewed. The CAR report indicated the medication error incident took place on 5/23/2025 involving the Primary RN (RN 1), who took the wrong medication from the Pyxis because RN (RN 1) did not pay attention to detail and did not validate the medication. The CAR report also indicated the action plan section was blank. CNO stated the CAR report was incomplete because the action plan was missing. During an interview on 8/22/2025 at 3:28 p.m. with the Chief Medical Officer (CMO), the CMO stated cause analysis was to identify the cause so the team could put in measures to improve the system by providing education or interventions and holding people accountable. The CMO further stated there should be an action plan in place to prevent it (the medication error incident involving Patient 2) from happening again. During an interview on 8/22/2025 at 3:30 p.m. with the Operation Executive (OE), OE stated the following: the facility was aware there was a break in the system, but it took time to work with the vendor (Pyxis) to figure out how to selectively de-activate the label printing function without interrupting another workflow before implementing the new process hospital-wide. The facility did see there was potential to have the same error happen on other units. OE also stated, “we figured it out (Pyxis label printing function) yesterday (8/21/2025).” During an interview on 8/22/2025 at 3:38 p.m. with the CMO, CMO stated the Quality Assurance and Performance Improvement (QAPI, the facility’s program for identifying problems, investigating causes and making improvements) was responsible to improve consistency of care, quality of care, patient safety and maximize patient outcomes. During an interview on 8/22/2025 at 3:45 p.m. with OE, OE stated the governing body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) was responsible for patient safety and clinical quality oversight for the whole hospital. OE further stated the medication error incident was reported to GB in June. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration - Inpatient (Nursing),” dated 7/2024, the P&P indicated, “To ensure the safe and accurate administration of drugs to patients at [the facility] by using barcode technology ... Administration ... 6. Before administering a medication, the LIP (Licensed Independent Practitioner) should perform the following ... verify that the medication selected for administration is the correct one based on the medication order and product label ... 7. For the nursing staff ... bring meds (medications) to bedside. Scan all medications and verify. Remove the packaging of the medication at the bedside ... use 2 patient identifiers and follow 6 rights of medication administration. i. right patient (with 2 patient identifiers), ii. Right time, iii. Right drug, iv. Right dose, v. right route, vi. Right documentation... Safe Practices on Medication Administration ... Prior to administration of medication, the licensed staff will verify: 1. Use of two (2) patient identifiers 2. Name of drug 3. Route 4. Dosage 5. Frequency 6. Indication.” During a review of the facility’s QAPI plan titled, “[the facility] Performance Improvement Plan 2025,” dated 6/2025, the QAPI plan indicated, “The purpose of the Performance Improvement Efforts at [the facility] is to ensure the delivery of safe patient car and to strive to be a benchmark for excellence in medical care and services. This is accomplished in a proactive approach by assessing patient care and other support processes in a systemic, ongoing manner in order to identify, analyze improvement opportunities and to act on those opportunities in a timely manner ... The Community Governing Board (GB) strives to assure quality patient care and customer service by requiring and supporting the establishment and maintenance of an effective hospital-wide continuous performance improvement initiative ... The overall authority for the direction of the Performance Improvement Program rests with the Community Governing Board ... Performance Improvement Methodology ... 2. Any of these performance improvement strategies may be used in response to ongoing measurement, staff suggestions, Medical Staff suggestions, Council/Committee suggestions, and from other sources. Specifically, assessment is triggered ... i. by all significant medication errors ... Proactive Analyses to Reduce Risks to Patients. 1. The organization’s Patient Safety Committee is responsible for any ongoing, proactive program for identifying and reducing unanticipated adverse events and safety risks to patients. The Committee’s approach includes ... c. identify the ways in which the process could breakdown or fail to perform its desired function; d. identify the possible effects that a breakdown or failure of the process could have on patients and the seriousness of the possible effects ... g. re-designing the process and/or underlying systems to minimize risk of the effects on patients; once the identification of the severity, notability, detectability and critically of the process failure has been prioritized.””

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility’s medical staff failed to demonstrate accountability for the quality of medical care provided to patients when the facility’s physicians failed to perform a medical screening exam (MSE, a medical evaluation to determine if an emergency condition exits ) for two (2) of three (3) sampled patients (Patients 5 and 6) who presented to the Labor and Delivery triage area (L&D [a specialized hospital unit that provides care to pregnant individuals, from onset of labor and throughout the entire process of childbirth] where a nurse conducts a quick assessment to identify those patients requiring immediate medical care and a physician performs a medical screening exam [MSE, an initial evaluation to determine if a patient has an emergency medical condition]), in accordance with the facility’s policies and procedures regarding Patient Triage in the Labor and Delivery Department and the Medical Staff Rules and Regulations. This deficient practice resulted in a lack of a medical screening exam performed by a physician to determine Patient 5 and 6’s medical status and to determine whether an emergency medical condition existed, which may have the potential to result in patient harm. Findings: During an interview on 8/19/2025 at 1:16 p.m. with Registered Nurse (RN) 7, in the Emergency Department (ED, provides immediate medical care to patients experiencing serious or life-threatening conditions), RN 7 stated patients who presented to the ED, check in with him (RN 7) first. If a patient, who was over 20 weeks pregnant, presented to the ED for pregnancy related concerns, the patient was escorted to the Labor and Delivery (L&D) triage area (L&D [a specialized hospital unit that provides care to pregnant individuals, from onset of labor and throughout the entire process of childbirth] where a nurse conducts a quick assessment to identify those patients requiring immediate medical care and a physician performs a medical screening exam [MSE, an initial evaluation to determine if a patient has an emergency medical condition]) for evaluation. During an interview on 8/19/2025 at 1:28 p.m. with the triage intake Registered Nurse (RN 5) in L&D Triage 1 (an area where a nurse conducts a quick assessment to identify those patients requiring immediate medical care and determines who can wait in the waiting room or who needs to be seen immediately), RN 5 stated the following: RN 5 performed a quick assessment of patients, including vital signs (temperature, blood pressure, heart rate, respiratory rate) and used a doppler ultrasound (a non-invasive test that uses sound waves to exam blood flow) to assess for a fetal (unborn baby) heart rate. The patients’ acuity level (the severity, complexity, and urgency of a patient’s condition, and level of care and resources required), was assessed. Then the patient will either wait in the waiting room or be taken to the adjacent Triage 2 area, where patients were placed in a bed, hooked up to a fetal monitor (a medical device used during pregnancy, labor, and delivery to track a baby’s heart rate and strength or duration of uterine contractions [a shortening or uterine muscles occurring at intervals before and during childbirth) and evaluated by a physician. During an interview on 8/19/2025 at 1:38 p.m., with RN 6, in Triage 2, RN 6 stated the following: Patients were brought to Triage 2, for fetal (baby) monitoring for a minimum of 20 minutes to determine the status of the baby and contractions. The physician will perform a medical screening exam and may conduct additional tests to determine the patients’ status and course of treatment. 1. During a concurrent interview and record review on 8/20/2025 at 10:47 a.m. with RN 4, Patient 5’s medical record, was reviewed. RN 4 stated the following: On 8/16/2025 at 8:20 p.m., Patient 5, who was 28 weeks pregnant, presented to L&D triage due to abdominal pain and contractions for three (3) days. On 8/16/2025 at 11:47 p.m., a physician’s order was placed to admit Patient 5 to the Labor and Delivery Department. RN 4 stated Patient 5 was admitted due to antepartum high risk (increased monitoring and specialized care due to health conditions, or pregnancy complications, aiming to prevent complications for both mother and baby). RN 4 stated an order was placed for Patient 5 to be admitted to the L&D unit, however, there was no physician progress note documented in the L&D triage. RN 4 stated patients should be evaluated by a physician during L&D triage to make medical decisions, such as treatment or decision to admit patients. RN 4 verified that the facility’s policy regarding L&D triage indicated that a medical screening exam would be conducted by a physician. During a review Patient 5’s L&D Triage note, dated 8/16/2025 at 8:20 p.m., the L&D Triage note indicated the following: Patient 5 presented to the L&D triage. Patient 5 was 28 weeks and 3 days pregnant and complained of abdominal pains and contractions. Patient 5 was placed on a fetal monitor, and vital signs were taken. Patient 5 had a history of anemia (blood does not have enough healthy red blood cells to carry oxygen throughout the body) and diabetes (high blood sugar). During a review of Patient 5’s Order Requisition, dated 8/16/2025 at 11:47 p.m., the Order indicated the following: Procedure: Admission Status. Admission Type: Inpatient. Level of Care: Obstetrics (medical specialty focused on childbirth and the care of mother and baby). During a review of Patient 5’s History and Physical (H&P, a comprehensive assessment of a patient’s health status) dated 8/17/2025 at 2:14 a.m., the H&P indicated the following: Patient 5 presenting for abdominal pain and pressure ...Admitted to antepartum service for rule out preterm labor (labor contractions that occur before 37 weeks of gestation [pregnancy]). During a review of the facility’s policy and procedure (P&P) titled, “Patient Triage in the Labor & Delivery Unit,” dated 4/19/2024, the P&P indicated the following: Policy Summary/Intent: To provide all birth persons presenting in the Labor and Delivery Triage area a nursing assessment and a medical screening examination ...Definitions: MSE: Medical Screening Examination is the process reached to determine whether or not an emergency medical condition exists. Triage: An assessment and classification of prioritization for which birthing persons will be provided with an MSE by a physician. Triage is not the equivalent of an MSE ... Timing of initial and ongoing physician/RN assessment will be determined by the status of the mother and the fetus (unborn baby). The RN will communicate with the appropriate physician regarding the condition of the patients. a. MSE will be performed by a physician. During a review of the facility’s “Medical Staff Rules and Regulations,” approved by the Governing Body on 9/17/2024, the Medical Staff Rules and Regulations indicated the following: 7.7 - Screening Examinations. 7.7.1 - Emergency Services - Only emergency room physicians and physician assistants will perform the medical screening examination. 7.7.2 - Obstetrics - Only qualified medical persons (Physician or Resident, or labor and delivery registered nurse) will perform the medical screening exam to determine labor status. 2. During a concurrent interview and record review on 8/20/2025 at 11:26 a.m. with RN 4, Patient 6’s medical record, was reviewed. RN 4 stated the following: On 8/18/2025 at 12:02 p.m., Patient 6, who was 39 weeks and 5 days pregnant, presented to the L&D triage for cramping. An order to admit Patient 6 to the L&D unit was placed on 8/18/2025 at 2:02 p.m. A history and physical examination was started on 8/18/2025 at 2:05 p.m., after Patient 6 was admitted to the L&D unit. There were no physician progress notes documented while Patient 6 was in the L&D triage. RN 4 verified that the facility’s policy regarding L&D triage indicated that a medical screening exam would be conducted by a physician. During a review Patient 6’s L&D Triage note, dated 8/18/2025 at 12:02 p.m., the Triage note indicated the following: Patient 6 was 39 weeks and 5 days pregnant. Patient 6 complained of cramping. During a review of Patient 6’s Admission Order, dated 8/18/2025 at 2:04 p.m., the Admission order indicated to admit to L&D for induction of labor (using medical treatment to start labor before it begins naturally). During a review of Patient 6’s History and Physical (H&P, a comprehensive assessment of a patient’s health status) dated 8/18/2025 at 2:05 a.m., the H&P indicated the following: Patient 6 presenting for contractions ...Plan: Admit to L&D for indicated induction. During a review of the facility’s policy and procedure (P&P) titled, “Patient Triage in the Labor & Delivery Unit,” dated 4/19/2024, the P&P indicated the following: Policy Summary/Intent: To provide all birth persons presenting in the Labor and Delivery Triage area a nursing assessment and a medical screening examination ...Definitions: MSE: Medical Screening Examination is the process reached to determine whether or not an emergency medical condition exists. Triage: An assessment and classification of prioritization for which birthing persons will be provided with an MSE by a physician. Triage is not the equivalent of an MSE ... Timing of initial and ongoing physician/RN assessment will be determined by the status of the mother and the fetus (unborn baby). The RN will communicate with the appropriate physician regarding the condition of the patients. a. MSE will be performed by a physician. During a review of the facility’s “Medical Staff Rules and Regulations,” approved by the Governing Body on 9/17/2024, the Medical Staff Rules and Regulations indicated the following: 7.7 - Screening Examinations. 7.7.1 - Emergency Services - Only emergency room physicians and physician assistants will perform the medical screening examination. 7.7.2 - Obstetrics - Only qualified medical persons (Physician or Resident, or labor and delivery registered nurse) will perform the medical screening exam to determine labor status.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to: 1. Ensure the Nursing staff addressed one of 30 sampled patient’s (Patient 7) pain levels of 8/10 and 9/10 based on a pain scale (0-2: Mild pain, 3-4: Moderate pain, 5-6: Severe pain, 7-10: Very severe pain), in accordance with the facility’s policy regarding pain management. This deficient practice had the potential for inadequate pain control, prolonged patient suffering from pain, and psychological distress (Example: anxiety [feeling of unease]), which may lead to prolonged recovery from illness. 2. Ensure Nursing staff notified the physician regarding the new onset of chest pain for one of 30 sampled patients (Patient 7), in accordance with the facility’s policy regarding physician notification. This deficient practice had the potential for delayed diagnosis and treatment which may result in worsening of Patient 7’s condition and/or death. Findings: 1. During a review of Patient 7’s History and Physical (H&P, a formal, comprehensive clinical evaluation by a healthcare provider to gather information about a patient’s condition ), dated 1/27/2025, the H&P indicated the following: Patient 7 was admitted to the facility on 1/27/2025 due to abdominal pain, nausea (the urge to throw up), and vomiting. Patient 7 also had documented past medical history (PMH, a patient’s previous medical conditions, treatments, surgeries, hospitalizations, and medications) of cardiomegaly (enlarged heart), polysubstance drug abuse (the repeated, non-prescribed use of three or more different types of drugs [or drug categories] for non-medical or recreational purposes, often resulting in harm or impairment) and schizophrenia (a chronic mental illness that affects a person’s thoughts, feelings, and behavior). Patient 7’s cardiac troponin (found only in the heart muscle and is a crucial biomarker for diagnosing heart damage, including heart attacks) level was 5030 nanogram/Liter (ng/L, measuring unit) which was significantly elevated and indicated extensive cardiac muscle injury (heart attack). The H&P also indicated that Patient 7 was diagnosed with NSTEMI (Non-ST Segment Elevation Myocardial Infarction, a type of heart attack where there is damage to the heart muscle [myocardium] without significant elevation of the ST segment [an indicator for various conditions such as heart attack or lack of blood flow] on an electrocardiogram [ECG, a non-invasive medical test that records the electrical activity of the heart]) and was admitted to telemetry unit (a hospital floor for remote cardiac monitoring, or a portable device that collects and transmits data from a patient’s body to a central location for real-time observation). During a concurrent interview and record review on 8/19/2025 at 2:15 p.m. with the Director of Risk Management (DRM) and the Program Specialist Informatics Nurse (RNPSI), Patient 7’s “Nursing Documentation-Flowsheet,” dated 1/28/2025, was reviewed. The record indicated that on 1/28/2025 at 3:00 a.m., the primary registered nurse (Nurse 1) documented that Patient 7 had a pain level of 8/10 (on a 0-10 scale, an 8/10 pain level represents very strong to intense pain that is significantly limiting and possibly unbearable, making it hard to do anything but focus on the pain, with physical activity and even conversation severely restricted) in his back. The record also indicated that at 7:10 a.m. [on 1/28/2025], Nurse 2 documented that Patient 7 had pain level of 9/10 in the chest. The RNPSI verified that neither entry in Patient 7’s record included a follow-up action (assess and reassess pain after interventions given to reduce pain, notify the physician if pain is unrelieved or if medication order may be necessary) to address Patient 7’s pain. The DRM confirmed that neither nurse (Nurse 1 or Nurse 2) documented follow-up actions/interventions to address Patient 7’s pain. During an interview on 8/29/2025 at 3:06 p.m. with the Clinical Nurse Educator (CNE), the CNE said that new onset pain, especially when rated as 8 out of 10 (severe pain) or 9 out of 10 (severe pain), required a follow-up. The CNE said that both nurses (Nurse 1 and Nurse 2) should have addressed Patient 7’s reported pain level of 8/10 and 9/10 on 1/28/2025, but they (Nurse 1 and Nurse 2) did not. During a review of the facility’s policy and procedure (P&P) titled, “ Opioid (a class of drugs that acts on the nervous system to relieve pain) Analgesia (the absence or reduction of pain), Assessment and Monitoring,” dated 1/2025, the P&P indicated that “Patients will be assessed for pain and managed per the facility’s policy or online standardized procedure manual ...Screening for pain will be documented in the electronic medical records (EMR, digital version of paper chart) when completed...” During a review of the facility’s policy and procedure (P&P) titled, “OPIOID PRESCRIBING AND PAIN MANAGEMENT THERAPY,” dated 11/2024, the P&P indicated that, “Patient pain treatment plan is based on evidenced-based practices and the patient’s clinical condition, past medical history, and pain management goals. This may include non-pharmacologic, pharmacologic, or a combination of approaches ... When appropriate, based upon individual patient circumstances the healthcare team may consider non¿pharmacological pain treatment... If the non-pharmacological alternatives are ineffective for pain management, the attending physician will be notified... the provider may consider non-narcotic or narcotic pain treatment modalities for pain management ...Once ordered, progress with the policy...” During a review of the facility’s adopted “Patient Rights” template, dated 11/2024, the template indicated that, “The patient has the right to receive the appropriate assessment and management of the pain, information about pain, pain relief measures and participate in pain management decisions. They may request or reject the use of any or all modalities to relieve pain...” 2. During a review of Patient 7’s History and Physical (H&P, a formal, comprehensive clinical evaluation by a healthcare provider to gather information about a patient’s condition ), dated 1/27/2025, the H&P indicated the following: Patient 7 was admitted to the facility on 1/27/2025 due to abdominal pain, nausea (the urge to throw up), and vomiting. Patient 7 also had documented past medical history (PMH, a patient’s previous medical conditions, treatments, surgeries, hospitalizations, and medications) of cardiomegaly (enlarged heart), polysubstance drug abuse (the repeated, non-prescribed use of three or more different types of drugs [or drug categories] for non-medical or recreational purposes, often resulting in harm or impairment) and schizophrenia (a chronic mental illness that affects a person’s thoughts, feelings, and behavior). Patient 7’s cardiac troponin (found only in the heart muscle and is a crucial biomarker for diagnosing heart damage, including heart attacks) level was 5030 nanogram/Liter (ng/L, measuring unit) which was significantly elevated and indicated extensive cardiac muscle injury (heart attack)]. The H&P also indicated that Patient 7 was diagnosed with NSTEMI (a type of heart attack where there is damage to the heart muscle [myocardium] without significant elevation of the ST segment on an electrocardiogram [ECG, a non-invasive medical test that records the electrical activity of the heart]) and was admitted to telemetry unit (a hospital floor for remote cardiac monitoring, or a portable device that collects and transmits data from a patient’s body to a central location for real-time observation). During a concurrent interview and record review on 8/19/2025 at 2:15 p.m. with the Director of Risk Management (DRM) and the Program Specialist Informatics Nurse (RNPSI), Patient 7’s “Nursing Documentation-Flowsheet,” dated 1/28/2025, was reviewed. The DRM also confirmed that registered nurse (Nurse 2) did not notify the physician regarding Patient 7’s new onset of chest pain, which was rated 9/10 (severe pain on a scale of 0-10), despite documentation indicating that a message was left for the physician regarding the chest pain. There was no follow-up made by Nurse 2 to ensure that the physician received the message and find out what the treatment course would be for Patient 7’s chest pain of 9/10. During an interview on 8/19/2025 at 2:56 p.m. with the Director of Risk Management (DRM), the DRM said that the facility had investigated this incident and reported it to the Department of Public Health (Regulatory Agency) because the patient (Patient 7) had a major heart attack a few hours after the reported chest pain of 9/10 [at 7:10 a.m. on 1/28/2025]. The DRM said the internal investigation was conducted to examine why nursing staff did not notify the physician about Patient 7’s chest pain rated as 9 out of 10 on 1/28/2025 at 7:10 a.m., and why there was no follow-up action taken. The DRM said that, at that time (on 1/28/2025), although Patient 7 was admitted to the telemetry unit, the patient (Patient 7) was physically located in the Emergency Department (ED), in the area designated for patients waiting for a bed (called “holds” or holding area- admitted patients waiting for a bed in the hospital). The DRM also stated that the investigation found the nurse who documented the chest pain of 9/10 did not follow the facility’s policy regarding a change of condition and did not report the new onset of chest pain to the physician. During an interview on 8/29/2025 at 3:06 p.m. with the Clinical Nurse Educator (CNE), the CNE said that new onset chest pain, especially when rated as 9 out of 10 (severe pain), was considered a change in the patient’s condition and required the nurse to notify the physician promptly. The CNE said that according to the facility’s protocol for change of condition notification and escalation policy (outlines the procedures for elevating a patient’s care, resources, or a problematic situation up the chain of command or to higher levels of authority until a resolution is achieved), the nurse should have called the attending physician “on call (the physician responsible for the patient’s care who is available outside of regular hours),” and if the physician did not answer or call back, the nurse had to call again in 15-30 minutes. The CNE also stated that after repeated attempts, and there was still no response from the attending physician, the nurse was authorized to escalate the matter by following the chain of commands (which included contacting the charge nurse and ultimately the chair of the department). During a review of Patient 7’s “Physician Progress Note,” dated 1/28/2025, the note indicated that Patient 7 was seen and examined by the resident physician on 1/28/2025. The resident physician documented that Patient 7 had complained of chest pain for the first time during the exam (on 1/28/2025 around 9:30 a.m.).The note also indicated that “About 10 minutes after the exam, patient’s (Patient 7’s) condition worsened significantly, and the patient (Patient 7) experienced a cardiac emergency (called Code Blue, meaning the patient’s heart stopped and/or they stopped breathing) and a code STEMI (heart attack caused by a blockage of blood flow to the heart) was called ...patient (Patient 7) then was rushed to the catheterization lab (Cath lab, a specialized hospital area with advanced technology for performing minimally invasive diagnostic and therapeutic procedures on the heart and blood vessels) to get urgent help for the blocked heart artery.” During a review of Patient 7’s “Death Note,” dated 1/28/2025, the note indicated that Patient 7 expired on 1/28/2025 at 9:26 p.m. The note indicated the cause of death was due to STEMI and drug-induced cardiomyopathy (DICM, heart muscle disease caused by the toxic effects of a drug, resulting in weakened heart function that can lead to heart failure). During a review of Patient 7’s “Nursing Documentation Flowsheet” record, dated 1/28/2025 at 7:09 a.m., the record indicated that Nurse 2 documented that the attending physician was notified regarding “Patient (Patient 7) is having chest pain 9/10, -phone message left; follow-up required.” The record contained no documented follow-up with the attending physician. This information was verified during record review on 8/19/2025 with the Program Specialist Informatics Nurse (RNPSI). During an interview on 8/19/2025 at 4:02 p.m. with the Chief Nursing Executive (CNE), the CNE said, “We investigated the incident following an internal report indicating that the physician did not return the call regarding Patient 7’s chest pain documented on 1/28/2025 at 7:10 a.m. During the review of the patient’s (Patient 7) case, we found that Nurse 2 did not call the physician directly, but rather asked the emergency department secretary to page the physician and did not follow the facility’s protocol for reporting a change in patient’s condition-specifically, the new onset of chest pain. The physician had never been notified of the patient’s (Patient 7) chest pain rated 9/10.” During a review of the facility’s policy and procedure (P&P) titled, “Contacting Physician for Patient Care,” dated 6/17/2025, the P&P indicated that “Effective and timely communication is critical to safe patient care. The facility is committed to ensuring hospital associates are able to contact physicians and/or their affiliated allied health providers to communicate the need for additional information, relay pertinent diagnostic test results, and/or changes in the patient’s condition. Associates utilize their critical thinking skills to categorize communication as either Urgent or Routine. The physician will assume the communication is Routine unless the call-back extension entered is followed by “911” or the message left at the service as described as Urgent. 1. Escalation: all clinical issues must be resolved in a timely manner to prevent delay of treatment. If the situation cannot be resolved at the lowest possible level, the next level should be accessed. All urgent communication is expected to be followed up with a second attempt within 10 min. If no return telephone call within 30 min, associates are to escalate the issue to his/her leadership ...Documentation: Contacting a physician requires documenting date, time, name of doctor and, what was discussed. All attempts to call doctor should be documented.””

“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: 48212 Based on observation, interview and record review, the facility failed to ensure one of seven sampled nursing staff’s (RN 14) unit -specific competencies (an integrated set of knowledge, skills, abilities, judgment, values, and professional behaviors that enable a nurse to effectively and safely provide patient care, fulfill professional obligations, and adapt to dynamic healthcare environments) was completed and validated before being released to work independently, in accordance with the facility’s policy regarding staff competencies. This deficient practice resulted in RN 14 committing a medication error (wrong dose) and administering lidocaine (medication for local anesthetic [reduce sensation of pain] and antiarrhythmic [treat or prevent abnormal heart rhythms]) 50 milliliters (ml, unit of measure, used to indicate a volume) instead of 50 milligrams (mg, unit of measure, used in medication dosage) to Patient 3 on 7/29/2025. Patient 3 received 1000 mg of lidocaine, went into seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness) and cardiac arrest (sudden loss of heart function) shortly after the medication administration and required cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating). Findings: During a review of Patient 3’s “Cardiology (heart) Procedure (procedure notes, completed by a physician who performed a special procedure)” notes, dated 7/29/2025, the procedure note indicated Patient 3 was admitted to the facility with diagnoses including but not limited to severe heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body’s needs) and coronary artery disease (CAD, a condition where fats build up in the coronary arteries [major blood vessels supplying oxygen and nutrients to the heart muscle] narrowing and restricting blood flow in the heart). Patient 3 was scheduled for high-risk PCI (percutaneous coronary intervention, a minimally invasive procedure to treat narrowed or blocked coronary arteries) with Impella (a minimally invasive, catheter-based blood pump designed to temporarily support the heart’s pumping function) support. During further review of Patient 3’s “Cardiology (heart) Procedure (procedure notes, completed by a physician who performed a special procedure)” notes, dated 7/29/2025, The procedure notes indicated the following: “ ... patient (Patient 3) was at this point noted to have runs of VT (Ventricular tachycardia, life-threatening heart rhythm disorder that lead to inadequate blood supply to the body and potentially cardiac arrest [(sudden loss of heart function]) ... she (Patient 3) was given 50 milligrams (mg, unit of measure) lidocaine (medication for local anesthetic [reduce sensation of pain] and antiarrhythmic [treat or prevent abnormal heart rhythms]) IV (IV, administered into a vein) for suppression (to stop) and did have normalization of the rhythm, however, subsequently was noted to have absent pulsatility (rhythmic, nature of blood flow and pressure caused by a beating heart). Unlike previous episodes during the case where patient (Patient 3) was still awake, conversant, alert during loss of pulsatility, this time patient (Patient 3) was subsequently noted to be unresponsive (does not react to sounds, touch or pain), with seizure-like/tonic-clonic (jerking) activity, and foaming at the mouth ... A Code Blue (hospital emergency code use to summon help when a patient is in need of resuscitation [CPR, an emergency lifesaving procedure performed when the heart stops beating]) was immediately called and chest compressions were commenced (started).” During a review of Patient 3’s procedure report titled, “Hemodynamic (evaluation of physiological [function and mechanism of a living organism] parameters of cardiovascular [heart and blood vessels] systems) Procedure Report,” dated 7/29/2025, the procedure report indicated, Registered Nurse (RN) 14 administered 2% lidocaine 50 milliliters (ml, unit of measure) IV to Patient 3. The procedure report also indicated, “at 18:35:32 (6:35:32 p.m.) 2% lidocaine 50 ml IV was verbally ordered with readback by [physician name] (MD 2), verified and given by [nurse name] (RN 14) per physician order.” During an interview on 8/20/2025 at 1:54 p.m. with the Director (DIR 1) of Pharmacy, DIR 1 stated RN 14 removed ten (10) vials of 2% lidocaine (100 milligrams per 5 milliliters) from the Pyxis (automatic medication dispensing machine) machine during Patient 3’s procedure on 7/29/2025. During an interview on 8/20/2025 at 2:10 p.m. with an interventional cardiologist (MD 3, cardiologist who specialized in performing minimally invasive, catheter-based procedures to diagnose and treat heart and blood vessels conditions), MD 3 stated a high dose of lidocaine could cause severe complication and lead to cardiac arrest. During a concurrent observation and interview on 8/20/2025 at 2:33 p.m. with the Pharmacy Manager (PM 1) and Registered Nuse (RN) 16 at the facility’s cardiac catheterization laboratory (cath lab, a hospital unit to perform minimally invasive, catheter-based procedures to diagnose and treat heart and blood vessels conditions) procedure room, PM 1 opened the Pyxis drawer and showed stocked 2% lidocaine vial. There were two (2) 2% lidocaine 100 milligrams per 5 milliliters vials stocked in the Pyxis machine. RN 16 stated the cath lab nurses (nurses who have special training in assisting the minimally invasive, catheter-based procedures to diagnose and treat heart and blood vessels conditions) had access to the Pyxis machine, to retrieve and administer medication per physician order. During an interview on 8/20/2025 at 3:37 p.m. with the interventional cardiologist (MD 2), MD 2 stated the following: on day of procedure (7/29/2025), Patient 3 had some runs of ventricular tachycardia (VT) and he (MD 2) asked RN 14 to give 50 mg of lidocaine. RN 14 for some reason misheard and gave 50 ml which was equivalent to 1000 mg (20 times than the ordered dose). Patient 3 had seizure and lost pulsatility one to two minutes later. A Code Blue was called after. MD 2 further stated he (MD 2) would give medication dosage order in “milligrams (mg)” not in “milliliters (ml)” because “ml” was a unit of volume (amount of liquid) not a dose (amount of the medicine within the liquid). During an interview on 8/20/2025 at 4:03 p.m. with RN 14, RN 14 stated the following: when MD 2 ordered lidocaine 50 milligrams for Patient 3’s ventricular tachycardia, he (RN 14) misheard it as 50 milliliters. He (RN 14) readback “50 ml” but did not think MD 2 heard him (RN 14) clearly because he (MD 2) was busy with Patient 3. RN 14 also stated it was his (RN 14’s) first time giving lidocaine and he (RN 14) was not familiar with it. RN 14 further stated, “I did not read back appropriately. It should be in milligrams.” During a concurrent interview and record review on 8/22/2025 at 11:24 a.m. with the Manager (NM 6) for Clinical Education and RN Clinical Educator (RNE 2) for Critical Care and Special Procedure, RN 14’s nursing competency titled, “Initial Department/Unit Specific Orientation & Skills Competency Checklist,” was reviewed. The nursing competency indicated, the medications under section “Pharmacologic Adjuncts in Cath Lab”: Glucophage (medication to treat high blood sugar), Class I Antiarrhythmic - sodium channel blockers - lidocaine & procainamide (type of medication to treat abnormal heart rhythm), Class II, Class III, Class IV, and Class V antiarrhythmic medications were not checked off. NM 6 stated the following: the validator should check off the medications when he or she went over with the orientee. The clinical educator was responsible for making sure the completeness of competency validation to ensure the employee/orientee was fully competent before being released to work independently. During a review of the facility’s policy and procedure (P&P) titled, “Giving/Receiving/Authenticating Verbal Orders and Telephone Orders, Inpatient CPOE,” dated 7/2022, the P&P indicated, “Verbal orders ... If a verbal order is necessary, use the following processes to ensure accuracy: a. Ordering Provider: i. to ordering provider shall dictate verbal orders slowly, clearly, and in an articulate manner to avoid confusion. b. Recipient: i. the licensed professional shall repeat back the entire verbal order to the ordering provider to ensure accuracy.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration - Inpatient (Nursing),” dated 7/2024, “Administration ... the pharmacist and/or nurse should contact the prescriber to discuss concerns and issues relating to medication orders and obtain clarification as needed ... Safe Practices on Medication Administration ... C. prior to administration of medication, the licensed staff will verify 1. Use of two (2) patient identifiers 2. Name of drug 3. Route 4. Dosage 5. Frequency 6. Indication D. the licensed staff must know the purpose and effect of medications.” During a review of the facility’s policy and procedure (P&P) titled, “Nursing Division - Overall Scope, Standards, and Structure,” dated 6/2022, the P&P indicated, “Standard X - Competency. i. The patient can expect to be cared for by professional nursing staff who take responsibility for maintain current licensure and level of knowledge specific to their specialty through attendance at workshops, seminars and team conferences ... Staff Development/Competency 1. [the facility] is committed to improving the professional development staff and leadership to ensure staff is competent and well-trained to perform within the scope of their job descriptions. 2. Staff development is accomplished through: a. Providing orientation to job responsibilities/requirements of personnel. b. facilitating improved job performance and professional development of associates. This will be accomplished through assessment of learning needs, development of effective learning opportunities and evaluation of associate learning through testing, skills demonstration and on-the-job performance. c. updating nursing knowledge and clinical skills of nursing services personnel through in-services and staff development programs ... f. mechanisms utilized to validate competencies include: i. self-assessment ii. orientation skills validation iii. Annual competency review iv. Annual performance evaluation v. observation.””

“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: 50594 Based on interview and record review, the facility failed to: 1. Ensure one of 30 sampled patient’s (Patient 18) physician was notified of two instances wherein there was presence of blood in the tracheostomy (an opening a surgeon makes through the neck and into the patient’s windpipe to assist with breathing) dressing of Patient 18, in accordance with the facility’s policy and procedure (P&P) regarding physician notification. This deficient practice had the potential to result in a delay in the provision of care and treatment to address the tracheostomy bleed of Patient 18, which may result in patient harm. 2. Ensure the nursing staff assessed the Maternal Fetal Triage (preliminary assessment to determine the urgency of the need for treatment) Index (MFTI, a five-level obstetric [concerned with childbirth and the care of women giving birth] tool for nurses to use when triaging a pregnant person presenting for care. It provides a standard approach to obstetric triage and is used to classify acuity [severity] and prioritize urgency for evaluation by a nurse and a physician) for two of three sampled patients (Patients 5 and 6), who presented to the Labor and Delivery (L&D) Triage area, in accordance with the facility’s policy and procedure regarding L&D triage. This deficient practice had the potential for the acuity level of patients to be unknown and had the potential for the delay in evaluation and treatment. 3. Inform two of 30 sampled patients (Patients 25 and 27) about the “Care of Patient’s Belongings” Policy, which included the possibility of inspecting the patient’s belongings and asking if any of the patient’s belongings could be considered contraband (prohibited items, such as weapons, sharp objects, and illicit drugs), when Patients 25 and 28 did not sign their Patient Valuables form upon admission, in acknowledgement of the facility’s policy and procedure regarding Patient belongings. This deficient practice had the potential for improper inventory of patient belongings, lost items, if not confirmed with patients upon admission, and had the potential for patients to be unaware of which items were prohibited from the hospital (such as weapons or illegal drugs). 4. Ensure Nursing staff notified one of 30 sampled patient’s (Patient 11) family after a code blue (the activation of the Emergency Response Team upon discovery of any individual who has suffered a sudden cessation of vital signs [temperature, blood pressure, heart rate, respiratory rate] or is in a sudden and unexpected life-threatening situation) was activated for Patient 11, in accordance with the facility’s policy regarding family notification during a code blue episode. This deficient practice had the potential to cause Patient 11’s family and/or significant other, emotional distress, leading to feelings of anxiety and guilt. 5. Ensure that a nerve block (an injection of medication close to a targeted nerve to provide temporary pain relief) was administered on the correct site (right knee) for one of 30 sampled patients (Patient 12), in accordance with the facility’s policy regarding anesthesia time-out (a critical safety protocol where the entire surgical team pauses before starting an invasive procedure to verify the correct patient, procedure, and site). This deficient practice had the potential to expose the patient (Patient 12) to a greater risk of local anesthetic toxicity, mobility (ability to walk) problems post-surgery (after surgery), and increased length of stay in the hospital. Findings: 1. During a review of Patient 18’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 3/21/2025, the H &P indicated, Patient 18 was admitted to the facility for worsening muscle weakness and headache. During a concurrent interview and record review on 8/20/2025 at 2:28 p.m. with Nurse Manager (NM) 1, Patient 18’s “Operation/Procedure Report,” dated 4/3/2025, was reviewed. NM 1 stated Patient 18 had a tracheostomy (an opening a surgeon makes through the neck and into the patient’s wind pipe to assist with breathing) insertion. During the same concurrent interview and record review on 8/20/2025 at 2:28 p.m. with Nurse Manager (NM) 1, Patient 18’s “Nursing Documentation; Tracheostomy site drainage description,” dated 4/4/2025 and 4/5/2025, were reviewed. NM1 stated on 4/4/2025 at 5:35 a.m. and on 4/5/2025 at 12:15 p.m., Patient 18’s Tracheostomy site drainage description was documented as bloody. NM 1 stated physician should have been notified for the presence of blood in the tracheostomy dressing to check Patient 18 for any complications that needed to be addressed. During a review of the facility’s policy and procedure (P&P) titled, “Policy: Tracheostomy care, stoma (an artificial opening created through surgery) care and trach change,” revised on 1/18/2022, the P&P indicated, “Policy summary/Intent: To minimize risks of infection and other complications associated with tracheostomy care and tracheostomy tube ...Report any swelling, redness, bleeding, discomfort, drainage, and/or signs of infection related to the tracheostomy to physician and document in the progress notes.” 2. During an interview on 8/19/2025 at 1:28 p.m. with the Triage (preliminary assessment to determine the urgency of the need for treatment) Intake Registered Nurse (RN 5) in the Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) Triage 1 (an area where a nurse conducts a quick assessment to identify those patients requiring immediate medical care and determines who can wait in the waiting room or who needs to be seen immediately), RN 5 stated the following regarding what happens in the L&D triage area: RN 5 performs a quick assessment of patients, including vital signs (temperature, blood pressure, heart rate, respiratory rate) and uses a doppler ultrasound (a non-invasive test that uses sound waves to exam blood flow) to assess for a fetal (unborn baby) heart rate. The patients’ acuity level (the severity, complexity, and urgency of a patient’s condition, and level of care and resources required), is assessed using the Maternal Fetal Triage Index (MFTI, is a five-level obstetric [concerned with childbirth and the care of women giving birth] tool for nurses to use when triaging a pregnant person presenting for care. It provides a standard approach to obstetric triage and is used to classify acuity and prioritize urgency for an evaluation by the physician). The MFTI was used to determine whether the patient will wait in the waiting room or be taken to the adjacent Triage 2 area, where patients were placed in a bed, hooked up to a fetal monitor (a medical device used during pregnancy, labor, and delivery to track a baby’s heart rate and strength or duration of uterine contractions [a shortening or uterine muscles occurring at intervals before and during childbirth) and evaluated by a physician. During a concurrent interview and record review on 8/20/2025 at 10:47 a.m. with RN 4, Patient 5’s medical record, was reviewed. RN 4 stated the following: On 8/16/2025 at 8:20 p.m., Patient 5, who was 28 weeks pregnant, presented to L&D triage due to abdominal pain and contractions for three (3) days. Patient 5’s vital signs and the fetal heart rate (unborn baby’s heart rate) were checked, however, the MFTI assessment was not documented by the Intake RN. In addition, there was no evaluation by the physician in the L&D triage area. Patient 5 was eventually admitted to the Antepartum (a period before labor and delivery) High-Risk area of the Labor and Delivery Unit on 8/17/2025 at 12:06 a.m. RN 4 verified that the facility’s policy required the Triage Intake RN to assess the MFTI to prioritize which patients needed to be seen most urgently, and who can wait in the waiting room. During a review Patient 5’s L&D Triage note, dated 8/16/2025 at 8:20 p.m., the L&D Triage note indicated the following: Patient 5 presented to the L&D triage. Patient 5 was 28 weeks and 3 days pregnant and complained of abdominal pains and contractions. Patient 5 was placed on a fetal monitor, and vital signs were taken. Patient 5 had a history of anemia (blood does not have enough healthy red blood cells to carry oxygen throughout the body) and diabetes (high blood sugar). The MFTI was not documented. This was verified by RN 4. During a concurrent interview and record review on 8/20/2025 at 11:26 a.m. with RN 4, Patient 6’s medical record, was reviewed. RN 4 stated the following: On 8/18/2025 at 12:02 p.m., Patient 6, who was 39 weeks and 5 days pregnant, presented to the L&D triage for cramping. The MFTI assessment was not documented. Patient 6 was not evaluated by the physician in the L&D triage area. Patient 6 was admitted to the Labor and Delivery Unit on 8/18/2025 at 2:04 p.m. for induction of labor (using medical treatment to start labor before it begins naturally). During a review Patient 6’s L&D Triage note, dated 8/18/2025 at 12:02 p.m., the Triage note indicated the following: Patient 6 was 39 weeks and 5 days pregnancy. Patient 6 complained of cramping. The MFTI assessment was not documented. This was verified by RN 4. During a review of the facility’s policy and procedure (P&P) titled, “Patient Triage in the Labor & Delivery Unit,” dated 4/19/2024, the P&P indicated the following: Policy Summary/Intent: To provide all birth persons presenting in the Labor and Delivery Triage area a nursing assessment and a medical screening examination (MSE, mandated evaluation performed by a qualified medical person to determine if a patient has an emergency medical condition)) ...Definitions: RN: Registered Nurse MFTI: Maternal Fetal Triage Index is a five-level obstetric tool for nurses to use when triaging a pregnant person presenting for care. It provides a standard approach to obstetric triage and is used to classify acuity and prioritize urgency for provide evaluation. Triage: An assessment and classification of prioritization for which birthing persons will be provided with an MSE by a physician. Triage is not the equivalent of an MSE ... Triage Intake RN: responsible for assessing and determining (MFTI) Triage RN: Responsible for post MFTI nursing assessment in the triage area ... Patients will arrive to the unit via Birthing Center elevator. The Triage Intake RN will complete MFTI assessment and then proceed with the registration process ...All patients will promptly be evaluated by the Triage Intake RN for: 1. Chief Complaint, or reason for coming to the L&D Unit. 2. Determination of acuity and urgency prioritization utilizing the Material Fetal Triage Index. 3.a. During an interview on 8/19/2025 at 2:21 p.m. with certified nurse assistant (CNA) 1 in the Telemetry unit, CNA 1 stated the following: When patients were admitted, usually a CNA would ask patient about which belongings were brought in. The CNA would check the patient’s belongings with permission from the patient and would document the belongings in the medical record. The CNA reviews the belongings with the patient, and the patient signs the form regarding patient valuables, in acknowledgement that the patient agrees with the inventory and was informed about the policy. CNA 1 stated that patients in the Telemetry unit were not stripped searched (a physical search where a person is required to remove their clothing), only patients who were admitted to the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) were stripped or searched for any contraband. During a concurrent interview and record review on 8/20/2025 at 1:49 p.m. with Nurse Manager (NM) 4, Patient 25’s medical record, was reviewed. NM 4 stated the following: Patient 25 was admitted to the facility’s Telemetry Unit (a unit dedicated to patients who require continuous cardiac [heart] monitoring) on 3/23/2025 at 12:28 a.m. Patient 25’s belongings were checked on 3/23/2025 at 6:54 a.m. Patient 25’s belongings included a cane, a belt, pants, shoes, socks, and a cellphone with charger. Patient 25 did not bring a backpack. NM 4 verified that the patient valuables form was not signed by Patient 25. The patient valuables form should have been signed by Patient 25 to acknowledge that Patient 25 reviewed the items, and was informed of the facility’s belongings policy, which included consent to search belongings, and agreed that any items illegal in nature should be removed or disposed. During the same interview on 8/20/2025 at 1:49 p.m. with Nurse Manager (NM) 4, NM 4 said Patient 25 was transferred to the Intensive Care Unit (a specialized hospital section providing constant monitoring and life-sustaining treatment for patients with severe, life-threatening illness or injuries) on 3/24/2025 at 11:38 a.m., due to changes in mental status, including eyes rolling back, delirium (a temporary state of mental confusion and disorientation), unintelligible speech (verbal communication that others cannot understand). NM 4 stated an unlabeled vial containing a small amount of unknown pink liquid was found in Patient 25’s underwear. The vial had not been seen before, and it was unclear if Patient 25 ingested it (pink liquid). Patient 25 tested negative for methadone (a long-acting synthetic opioid medication used to treat drug addiction, and severe and chronic pain) upon admission on 3/22/2025, however, Patient 25 tested positive for methadone on 3/24/2025 at 1:20 a.m. During an interview on 8/20/2025 at 2:45 p.m. with the Risk Manager (RM), the RM stated the amount of pink substance in the bottle found in Patient 25’s underwear, was less than 5 milliliters (ml) and not enough to send to the lab for identification. Per a social worker’s note, Patient 25 said the pink substance was methadone. The RM stated that patients in the telemetry units were not strip-searched, only patients who were admitted to the Behavior Health Unit were strip-searched for contraband (prohibited items, such as weapons, sharp objects, and illicit drugs). During an interview on 8/20/2025 at 3:02 p.m. with Registered Nurse (RN) 15, RN 15 stated that RN 15 cared for Patient 25 in the Telemetry unit on 3/24/2025. An RRT (Rapid Response Team, a hospital team that intervenes for patient deterioration) was called for Patient 25 at 10:52 a.m. because he (Patient 25) looked sleepy and had tremors (shaking). During that time, Patient 25 wanted to urinate. RN 15 assisted Patient 25 with using the urinal and found a small clear container with a small amount of light pink liquid when Patient 25’s underwear was pulled down. Patient 25 was transferred to the ICU for a change of condition. During a review of Patient 25’s History and Physical (H&P, a formal, comprehensive clinical evaluation by a healthcare provider to gather information about a patient’s condition), dated 3/23/2025, the H&P indicated the following: Patient 25 “was brought by paramedics from home for nausea (urge to throw up)/vomiting with blood last night ...Patient (Patient 25) had a past medical history of cirrhosis (cirrhosis of the liver, chronic liver damage from a variety of causes leading to scarring and liver failure) and alcohol abuse (a pattern of drinking that interferes with day to day activities) and was presenting with hematemesis (vomiting blood) since yesterday ...Patient denied using drugs however has positive urine drug screen for amphetamines (potent central nervous system stimulants with both medical and recreational uses) and opiates (class of natural or synthetic drugs that include both prescription and illegal drugs, such as heroin).” During a review of Patient 25’s Progress Note, dated 3/23/2025, the progress note indicated Patient 25 tested negative for Methadone (a long-acting synthetic opioid medication used to treat opioid use disorder) on 3/22/2025 at 10:50 p.m. During a review of Patient 25’s Physician Progress Note, dated 3/24/2025 at 8:25 a.m., the progress note indicated the following: “An RRT (Rapid Response Team, a hospital team that intervenes for patient deterioration) was initiated due to concerns about patient’s (Patient 25) mentation ...During the assessment, the nursing staff discovered an unlabeled vial containing small amounts of a pink liquid substance in Patient 25’s underwear. They were unsure of its contents and had not seen it before. It is also unclear if Patient 25 ingested this substance ...Given patient’s (Patient 25) decline, the ICU team was notified for further evaluation and management ...” During a review of Patient 25’s H&P dated 3/24/2025 at 2:40 p.m., the H&P indicated the following: “Patient (Patient 25) in ICU (intensive care unit) after rapid response called secondary to AMS (altered mental status). Patient (Patient 25) may have ingested substance that contributed to presentation but was brought to ICU for further monitoring given patients’ risk for decompensation. Patient (Patient 25) exhibited respiratory distress (difficulty breathing) needing emergency intubation (a tube is inserted into the airway, to keep it open and allows for the delivery of oxygen).” During a review of Patient 25’s document titled, “CM (case Management)-/ -SW (Social Work), dated 3/27/2025 at 12:17 p.m., the document indicated the following: Patient 25 explained he (Patient 25) had a history of smoking heroin (a highly addictive drug once used to treat severe pain but is now illegal to use or sell) and was now receiving methadone. Patient 25 stated the pink liquid was methadone. Patient 25 stated it was given from a clinic which provided medication-assisted treatment for opioid use disorder (drug addiction). During a review of Patient 25’s report titled, “Valuables / Medications Disposition,” dated 3/24/2025 at 12:44 p.m., the report indicated the following: No medications brought from home. Valuables were reviewed on 3/23/2025 at 6:55 a.m. Valuables at bedside included: cane. Clothing at bedside included: belt, jacket, pants, shirt, shoes, socks, undershorts, hat. Electronics devices at bedside included: cell phone with charger. The report also indicated the following: “We recommend personal belongings be sent home with family or placed in the hospital’s fireproof safe. The hospital cannot assume liability for items you choose to keep at the bedside, including money ...or eyeglasses ...I agree to hospital staff inventorying my personal belongings in my presence. I agree that any items of an illegal nature should be removed and disposed of, and that such items may be provided to law enforcement for safety or if required by law.” There was no documentation indicating the Patient 25 reviewed the medications, valuables, or informed or educated about the “Care of Patient’s Belongings” policy. There was no signature by Patient 25’s in acknowledgement of the policy. This was verified by NM 4. During a review of the facility’s policy and procedure (P&P) titled, “Care of Patient Belongings, Nursing,” dated 5/24/2022, the P&P indicated the following. Because patient care units may not have a safe place to keep valuables, patients are discouraged from bringing expensive items ...Additionally, to maintain the security and patient safety, certain belongings and items are deemed contraband/prohibited or unauthorized (e.g., weapons, illegal or unauthorized drugs ...and other items that can pose a threat of physical harm to the patient ...Inventory searches may be conducted for the following reasons: 1. There is a probable cause to believe that the person has his/her possession a weapon or contraband and there is no less intrusive way of handling the situation. 2. To protect the staff and others from potential dangers. -Procedure: 1. Inform the patients about the “Care of Patient’s Belongs” Policy ... 2. Perform hand hygiene ... 3. Confirm the patient’s identity ... 4. Ask the patient if s/he has any valuables or other items that could be considered prohibited (contraband). 5. Inspect the patient’s belongings. -Patient Education: 1. Inform the patient that because there are typically no locks on the doors to the patient’s rooms, valuables cannot be considered safe in the room ... -Documentation: 1. Document that the Policy on Care of Patient’s Belongings was explained to the patient and the described patient’s response. 2. The items being stored as well as the items remaining with the patient. 3. Document the presence of eyeglasses ...or medical devices ... 4. Note whether any of the patient’s valuables ...were given to family members ... 5. If any items remain in the patient’s possession, include an itemized list in the patient’s medical record ... 6. Ask the patient or Representative to review and sign the form before putting valuables away ... 7. Observe items being removed, if patient permits. 3.b. During a concurrent interview and record review on 8/21/2025 at 1:18 p.m., with Nurse Manager (NM) 5, Patient 27’s medical record, was reviewed. NM 5 stated the following: Patient 27 was admitted to the Telemetry unit on 8/20/2025 for epigastric (upper middle portion of the abdomen) pain. Patient 27 did not sign the Patient Valuables report. The report needed to be signed to verify the belongings were listed correctly and for Patient 27 to acknowledge having been informed of the facility’s policy regarding patient belongings. During a review of Patient 27’s Face Sheet (a concise, printable document or digital view containing a patient’s essential demographic, contact, insurance, and medical summary information for quick access by healthcare providers), the Face Sheet indicated Patient 27 was admitted to the facility on 8/20/2025 for abdominal pain. During the review of Patient 27’s report titled, “Valuables/Medications Disposition,” dated 8/20/2025 at 4:48 p.m., the report indicated the following: “No medications brought to the hospital. Yes, brought valuables from home. Yes, patient (Patient 27) responsible for valuables. Yes, clothing discarded with patient’s (Patient 27) permission. Valuables clothing at bedside included: pants, shirt, slippers (crocs). Money at bedside, $21. The wallet, cell phone and keys were at bedside.” The form also indicated the following: - “We recommend personal belongings be sent home with family or placed in the hospital’s fireproof safe. The hospital cannot assume liability for items you choose to keep at the bedside, including money ...or eyeglasses ...I agree to hospital staff inventorying my personal belongings in my presence. I agree that any items of an illegal nature should be removed and disposed of, and that such items may be provided to law enforcement for safety or if required by law.” -There was no documentation indicating the Patient 27 was informed or educated about the “Care of Patient’s Belongings” policy. Additionally, there was no signature by Patient 27 to indicate acknowledgement of the policy. This was verified by NM 5. During a review of the facility’s policy and procedure (P&P) titled, “Care of Patient Belongings, Nursing,” dated 5/24/2022, the P&P indicated the following. Because patient care units may not have a safe place to keep valuables, patients are discouraged from bringing expensive items ...Additionally, to maintain the security and patient safety, certain belongings and items are deemed contraband/prohibited or unauthorized (e.g., weapons, illegal or unauthorized drugs ...and other items that can pose a threat of physical harm to the patient ...Inventory searches may be conducted for the following reasons: 1. There is a probable cause to believe that the person has his/her possession a weapon or contraband and there is no less intrusive way of handling the situation. 2. To protect the staff and others from potential dangers. -Procedure: 1. Inform the patients about the “Care of Patient’s Belongs” Policy ... 2. Perform hand hygiene ... 3. Confirm the patient’s identity ... 4. Ask the patient if s/he has any valuables or other items that could be considered prohibited (contraband). 5. Inspect the patient’s belongings. -Patient Education: 1. Inform the patient that because there are typically no locks on the doors to the patient’s rooms, valuables cannot be considered safe in the room ... -Documentation: 1. Document that the Policy on Care of Patient’s Belongings was explained to the patient and the described patient’s response. 2. The items being stored as well as the items remaining with the patient. 3. Document the presence of eyeglasses ...or medical devices ... 4. Note whether any of the patient’s valuables ...were given to family members ... 5. If any items remain in the patient’s possession, include an itemized list in the patient’s medical record ... 6. Ask the patient or Representative to review and sign the form before putting valuables away ... 7. Observe items being removed, if patient permits. 4. During a review of Patient’s 11’s “History and Physical (H&P),” dated 04/28/2025, the H&P indicated that Patient 11 had history of hypertension (high blood pressure), hyperlipidemia (high cholesterol), status post (after) pacemaker (a battery-powered device implanted in the chest to regulate an abnormal heart rhythm) insertion. Patient 17 was brought to the emergency room complaining of left groin pain and left-sided chest pain. The H&P indicated that Patient 11 would be admitted to the Telemetry (a hospital level of care where patients undergo continuous cardiac [heart] monitoring) floor for further evaluation and management of chest pain. During a concurrent interview and record review on 08/21/2025 at 2:47 p.m. with Registered Nurse (RN) 8, Patient 11’s medical record titled, “Nursing Flowsheet,” dated 05/2/2025, was reviewed. The Nursing Flowsheet indicated that the patient (Patient 11) was found unresponsive (does not react to sounds, touch or pain) and code blue (when someone’s heart stops beating or someone stops breathing) was activated on 5/2/2025at 2:20 a.m., and at 2:54 a.m., Patient 11’s spouse, granddaughter, and son were not called. RN 8 stated that it was the facility’s policy and practice that family be called immediately once a code blue was activated on a patient. During a concurrent interview and record review on 08/21/2025 at 3:22 p.m. with Registered Nurse (RN) 8, Patient 11’s medical record titled, “CPR (Cardiopulmonary Resuscitation, an emergency treatment that’s done when someone’s breathing or heartbeat has stopped) Record,” dated 05/2/2025, was reviewed. Patient 11’s CPR record indicated that five (5) subsequent code blue was called on Patient 11. Code blue was activated at the following times on 5/2/2025: 2:20 a.m., 2:28 a.m., 2:38 a.m., 2:43 a.m., and at 2:49 a.m. Patient 11 expired(died) at 2:51 a.m. RN 8 stated that staffing may have been the issue why the nurses failed to notify family the first time a code blue was called on Patient 11. RN 8 further stated the nurses only called Patient 11’s family at 2:54 a.m. after the Patient 11 died. There was no documentation expectation on the CPR Record Sheet that the family be notified, it only asked for the nurse to document what time the attending doctor was notified. During a review of the facility’s Policy and Procedure (P&P) titled, “Emergency Response to Adult (Code Blue) and Pediatric (Code White) Cardiac Or Respiratory,” with last revised date of 07/17/2024, the document indicated the following: In the event of a code blue, the Primary Nurse of the patient shall remain at the bedside to provide relevant history, pertinent clinical information and for notifying the attending physician and the patient’s family, as appropriate. 5. During a review of Patient’s 12’s “History and Physical (H&P),” dated 12/16/2024, the H&P indicated that Patient 12 presented with complaint of right knee pain which had been present for approximately 3 years. Patient 12 had attempted treatment with activity modification, medication, physical therapy, and corticosteroid injection (a medical treatment that delivers potent, artificial steroid hormones to reduce inflammation and pain in a specific area of the body). Unfortunately, this treatment had not alleviated the patients’ symptoms and was limited to even simple activities such as walking and going up and down the stairs. The H&P also indicated Patient 12 completed preoperative clearance (a medical evaluation that takes place before a surgical procedure) and would like to proceed with total knee arthroplasty (TKA, or total knee replacement, is a surgical procedure that replaces a damaged knee joint with artificial components made of metal and plastic) surgery. During a concurrent interview and record review on 08/19/2025 at 4:57 p.m. with Nurse Manager (NM 3), Patient 12’s medical record titled, “Post-Anesthesia (a medical intervention that temporarily induces a loss of sensation, consciousness, and/or muscle relaxation to allow for surgical procedures or other medical interventions to be performed without pain or discomfort) Note,” dated 12/16/2024, was reviewed. The Post-Anesthesia Note indicated that a discussion of wrong site nerve block (an injection of medication close to a targeted nerve to provide temporary pain relief) happened between Patient 12 and anesthesiologist (A1). The H&P also indicated that the surgery was performed on the correct side (right knee). During the same interview on 08/19/2025 at 4:57 p.m. with Nurse Manager (NM 3), NM 3 stated that Patient 12 was scheduled for a right TKA and was mistakenly given a left side nerve block instead of a right-side nerve block. The mistake was caught right after the administration of the nerve block. The incident happened prior to Patient 12’s TKA surgery. NM3 added that although an anesthesia time out (a critical safety protocol where the entire surgical team pauses before starting an invasive procedure to verify the correct patient, procedure, and site) was called, it was later identified that the circulating nurse (a nurse in the operating room who manages the overall flow and logistics of a surgical procedure by coordinating communication and ensuring safety protocols are followed) was interrupted by the surgical technician (a staff who prepares the operating room and assists the surgical team during procedures) during the anesthesia time out process. As a result, the circulating nurse was not able to observe and verify the correct site. During a review of the facility’s Policy and Procedure (P&P) titled, “Universal Protocol for Eliminating Wrong Site, Wrong Procedures, And Wrong Patient Surgery,” with last revised date of 04/21/2022, the P&P indicated the following: A Time-out is performed immediately before starting the operation/procedure a. Anesthesia time-out is performed and documented in the EMR in the operating room and other areas where general anesthesia is administered. i. Anesthesia time-out is performed before induction of general anesthesia or administration of sedation. ii. The circulating nurse correctly identifies the patient by calling the name on the ID band and the medical record number while the anesthesiologist is verifying it with the patient label on the consent form. iii. The team verifies the procedure and the surgical site.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure nursing staff followed safe medication administration process for three of 30 sampled patients (Patient 1, Patient 2, and Patient 3), in accordance with the facility’s policy of medication administration when: 1. Registered Nurses (RN) 12 and RN 13 failed to verify the Pitocin (a form of synthetic oxytocin, medication used to induce labor in pregnant women by stimulating uterine contractions) induction (to start labor contractions [tightening and relaxing of uterus during pregnancy to move the baby into the birth canal] artificially before they would naturally occur) order was in place, and administered to Patient 1, Pitocin 95 milliliters per hour (ml/hr, unit of rate) instead of Pitocin 2ml/hr on 5/16/2025 (wrong order). This deficient practice resulted in Patient 1 experiencing a decreased fetal (unborn baby) heart rate and requiring medical attention and intervention to stop the contraction. 2. RN 1 gave ropivacaine (medication used in epidural [a type of pain relief medication administered through a catheter inserted into the epidural space, the area between the spinal cord and the spinal column]) instead of clindamycin (medication, a type of antibiotics to treat infection) to Patient 2 on 5/23/2025 (wrong medication). This deficient practice resulted in Patient 2 feeling numbness to the body and blurred vision and requiring medical attention and intervention to treat the Local Anesthetic Systemic Toxicity (LAST, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels). 3. RN 14 gave lidocaine (medication for local anesthetic [reduce sensation of pain] and antiarrhythmic [treat or prevent abnormal heart rhythms]) 50 milliliters (ml, unit of measure, used to indicate a volume) instead of 50 milligrams (mg, unit of measure, used in medication dosage) to Patient 3 on 7/29/2025 (wrong dose). This deficient practice resulted in Patient 3 receiving 1000 mg of lidocaine, going into seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness) and cardiac arrest (sudden loss of heart function) shortly after the medication administration and required cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating). These deficient practices also had the potential to put other patients at risk for medication errors and cause harm to patients. On 8/21/2025 at 4:08 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Operation Executive (OE), Director of Accreditation, Licensing and Regulatory (DALR), Program Manager Regulatory (PMR), Director of Patient Experience and Nurse Clinical Outcomes (DIR 2), and with the following attendees via conference call: Chief Nursing Officer (CNO), Associate Chief Nursing Officer (ACNO) and System Director Regulatory (SDR). The facility failed to ensure nursing staff followed safe medication administration process and failed to ensure there was a safe process to prevent nursing staff from removing the wrong medication from the Pyxis tower (an automatic medication dispensing machine). These deficient practices resulted in Patient 2 receiving a wrong medication, receiving ropivacaine (medication used in epidural [a type of pain relief medication administered through a catheter inserted into the epidural space, the area between the spinal cord and the spinal column]) instead of clindamycin (medication, a type of antibiotics to treat infection), on 5/23/2025. As a result, Patient 2 experienced numbness all over her (Patient 2) body and blurry vision and required medical attention and intervention. On 5/23/2025, a Registered Nurse (RN 1) removed a bag of ropivacaine instead of clindamycin from the wrong pocket in the Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) department Pyxis tower. The Pyxis machine printed a label sticker (pyxis label) with the information of clindamycin for RN 1. RN 1 scanned the barcode on the pyxis label instead of the barcode on the actual medication and administered ropivacaine to Patient 2. Patient 2 was later found having numbness to her (Patient 2’s) body and blurry vision. On 8/20/2025, the Director (DIR 1) of Pharmacy stated the pyxis label was to serve as patient specific label (a label contains patient’s name, medication name and strength) to identify the patient, not to replace the barcode on the medication. If the nurse scanned the pyxis label, the system would not be able to detect the medication error (wrong medication). DIR 1 further stated after the incident, the pharmacy turned on the “scan removal” feature on the pyxis tower in the L&D department to force the L&D nurses to scan the medication bag before closing pyxis door. The medications with the scan removal feature were only limited to the medications used in L&D department. On 8/21/2025, nursing staff (RN 2 and RN 3) from Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) and Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit were able to remove medications from pyxis tower without the need for scanning the medications before closing the pyxis door. RN 2 and RN 3 both stated it was ok to scan either the barcode on the medication or the pyxis label when giving the medication to a patient. On 8/22/2025 at 2:30 p.m., the IJ was removed in the presence of the Chief Medical Officer (CMO), OE, DALR, and CNO, 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 by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that immediate actions taken by the facility were as follows: on 8/21/2025 at 5:45 p.m., the pharmacy department modified the Pyxis tower configuration and disabled label printing functionality for all nursing units. A barcode verification upon medication removal was being enabled for medications not stored in lidded Pyxis pockets for all nursing units. A revised nursing Pyxis tower medication removal and administration processes were implemented. During the medication removal process, nursing staff must visually validate the correct medication was pulled and scan the manufacturer’s barcode with the Pyxis to confirm the correct medication had been removed. Nursing staff would affix an IV medication label and a patient specific label onto the intravenous (IV, administered into a vein) medication bag. During the bedside medication administration process, the nursing staff would validate the six (6) rights: right (correct) patient, right drug, right dose, right route, right time and right documentation. Nursing staff would scan the manufacturer’s barcode again at bedside prior to medication administration. Education of revised processes began on 8/21/2025 for night shift nursing staff working in the units with Pyxis tower by nursing managers, educators and charge nurses. Education will continue at the beginning of the shift until 100% of staff have completed their education. Pharmacy director and nursing director will be performing weekly audits to ensure Pyxis tower label printing function remained disabled and compliance with the Pyxis tower medication removal and administration processes. Findings: 1. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 5/15/2025, the H&P indicated, Patient 1 was 40 weeks and 5 days pregnant and was admitted to the Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) Department for induction labor (to start labor contractions [tightening and relaxing of uterus during pregnancy to move the baby into the birth canal] artificially before they would naturally occur). During a review of Patient 1’s “Obstetrics/Gynecology (OB, medical specialty that focuses on the health of women’s reproductive systems, including pregnancy childbirth and related conditions) nursing flowsheet (OB nursing flowsheet),” dated 5/16/2025, the OB nursing flowsheet indicated, Patient 1 delivered a baby on 5/16/2025 at 12:08 p.m. via Cesarean section (C-section, a surgical procedure to deliver a baby by making an incision in the mother’s abdomen and uterus). During an interview on 8/19/2025 at 12:34 p.m. with a Labor & Delivery (L&D) Registered Nurse (RN) 9, RN 9 stated the following: Pitocin could be given for two (2) different indications. Titratable (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) Pitocin infusion, given at 1milliunit per minute (milliUnit/min, unit of dosage is equivalent to 1 milliliters per hour [ml/hr, unit of rate] in 30 units (unit, unit of measure) per 500 milliliters (ml, unit of measure) concentration bag), which was used for labor induction while postpartum (after childbirth) Pitocin infusion, was given at 95 ml/hr after a bolus (a single large dose of fluid infusion) and was for postpartum to prevent postpartum hemorrhage (excessive bleeding after childbirth). Physician order would indicate the indication and dosage for each Pitocin infusion. RN 9 also stated Pitocin was a high-risk medication and required two RNs’ verification (checking). During an interview on 8/19/2025 at 12:51 p.m. with the L&D charge nurse (CN 4), CN 4 stated the following: the RN must choose the correct Pitocin infusion order in the system when associating (programming) the IV (Intravenous, administered into a vein) pump (a medical device allowing medical personnel to set the amount of fluids of medications to be delivered to a patient over a specific time frame) to deliver the correct rate. A second RN verifier was needed to confirm prior to Pitocin administration. During a concurrent interview and record review on 8/19/2025 at 3:25 p.m. with the Clinical Educator of Perinatal (RN 6), Patient 1’s “Medication Administration Record (MAR, record of medications given to patients),” dated 5/16/2025, was reviewed. The MAR indicated, RN 12 administered Pitocin at rate of 95 ml/hr at 5:35 a.m. and witnessed by RN 13. RN 6 stated the dose rate was for postpartum but Patient 1 had not delivered the baby at that time. Patient 1 should have received the Pitocin induction dose. RN 6 stated RN 12 administered the wrong Pitocin dose (higher dose) because the pump was set up incorrectly. During a concurrent interview and record review on 8/19/2025 at 3:35 p.m. with RN 6, Patient 1’s physician orders (physician order 1 and 2), dated 5/15/2025 and 5/16/2025, were reviewed. The physician orders indicated the following: -Physician order 1 was ordered on 5/15/2025 at 9:45 a.m. for oxytocin (same as Pitocin) 30 units [5.7 units/hr] with order comments, “AFTER DELIVERY OF INFANT’S SHOULDER: Program continuous infusion at dose of 5.7 units/hr (rate of 95 ml/hr).” -Physician order 2 ordered on 5/16/2025 at 7:21 a.m. for oxytocin 30 units [2 milliUnit/min] with order comments, “START oxytocin at 2 milliUnit/min Titrate by 2 milliUnit/min at an interval no sooner than every thirty (30) minutes but within forty (40) minutes is acceptable, to maintain regular uterine contractions of moderate to strong intensity by palpation (examining the body by touch) and patient perception.” -RN 6 stated there were two (2) Pitocin orders with two (2) different indications. RN 12 chose the wrong order because the induction order (physician order 2) was not entered at time of administration. RN 6 further stated RN 13 was the second witness when RN 12 administered Pitocin for Patient 1. Both RN 12 and RN 13 did not follow the medication administration process to verify right order and right dose for Patient 1 thus resulting in the medication error. During an interview on 8/19/2025 at 3:58 p.m. with RN 6, RN 6 stated Pitocin could cause hyperstimulation (too much stimulation) to the uterus and cause fetal heart rate to decelerate (drop). During an interview on 8/20/2025 at 9:49 a.m. with RN 12, RN 12 stated the following: on 5/16/2025 when she (RN 12) scanned (process of scanning to prevent medication error) the Pitocin, the system selected the postpartum order, and she (RN 12) did not read the order. She (RN 12) associated the IV pump with the wrong order. She (RN 12) did not look at the IV pump to verify the rate. During an interview on 8/20/2025 at 5:15 p.m. with RN 13, RN 13 stated the following: when she (RN 13) walked into Patient 1’s room, the computer screen was on, and the pump was ready to start by RN 12. She (RN 13) entered her (RN 13’s) credentials (login name and password) as second witness without reading the order then left the room. RN 13 further stated she (RN 13) was called to the room later because of the fetal heart rate deceleration. She (RN 13) noticed the rate was incorrect when she (RN 13) turned off the IV pump. During a review of Patient 1’s “Discharge Summaries Notes (DC Summary),” dated 5/21/2025, the DC Summary indicated, “(on 5/16/2025) Pitocin was started at 0540 (5:40 a.m.) and one minute after starting Pitocin, patient (Patient 1) had a prolonged deceleration of seven (7) minutes with nadir (the lowest point or slowest rate of fetal heart rate deceleration during labor) in 70s. Pitocin was immediately discontinued and patient (Patient 1) was repositioned to the right lateral decubitus position (lying on the right side) ...IUPC (Intrauterine Pressure Catheter, a thin, flexible tube inserted into the uterus during labor to monitor uterine contractions) picked up contractions two minutes apart with FHR (fetal heart heart) in 80s-90s after 5 minutes, terbutaline (medication used to stop or slow down contractions) was given. Prolonged deceleration resolved in left lateral decubitus position (lying on the left side) and Trendelenburg position (the body was flat on back on a 15-30 degrees incline with the feet elevated above the head). After the above events, it was identified that the patient (Patient 1) received the postpartum rate of Pitocin rather than the starting dose of 2 milliUnit/min.” During a review of the facility’s policy and procedure (P&P) titled, “Oxytocin: Administration of Oxytocin for Induction or Augmentation of Labor (medical process of speeding up an ongoing labor),” dated 10/2024, the P&P indicated, “A physician’s order if required prior to induction or augmentation of labor ... Nursing Responsibilities During Labor Induction/Augmentation: 1. Prior to the start or re-start of Oxytocin two (2) RN’s must check and document the following ... infusion is started at the ordered dose 1 or 2 milliUnits/min.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration - Inpatient (Nursing),” dated 7/2024, the P&P indicated, “To ensure the safe and accurate administration of drugs to patients at [the facility] by using barcode technology ... Administration ... 1. Medication should be administered only upon the order of a clinician who has been granted clinical privileges by the Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital) to prescribe the medications ... 6. Before administering a medication, the LIP (Licensed Independent Practitioner) should perform the following ... verify that the medication selected for administration is the correct one based on the medication order and product label. c. Verify the medication dose with the physician order in the MAR and product label, to assure that the correct drug is administered in the prescribed dose, by the correct toute, and at the proper time ... 7. For the nursing staff ... use 2 patient identifiers and follow 6 rights of medication administration. i. right patient (with 2 patient identifiers), ii. Right time, iii. Right drug, iv. Right dose, v. right route, vi. Right documentation... Orders. A. A physician’s order must be obtained before administration of medication ... Safe Practices on Medication Administration ... Prior to administration of medication, the licensed staff will verify: 1. Use of two (2) patient identifiers 2. Name of drug 3. Route 4. Dosage 5. Frequency 6. Indication.” 2. During a review of Patient 2’s “History and Physical (H&P),” dated 5/20/2025, the H&P indicated, Patient 2 was 28 weeks and 2 days pregnant and was admitted to the facility Labor and Delivery (L&D) Department for antepartum (a period before labor and delivery) workup and management of fever. During a review of Patient 2’s physician order, dated 5/21/2025, the physician order indicated to give clindamycin (medication, a type of antibiotics to treat infection) 900 milligram (mg, unit of measure) every eight (8) hours intravenously (IV, administered into a vein). During a review of Patient 2’s physician progress notes, dated 5/23/2025, the physician progress notes indicated, physician (MD 1) was notified that Patient 2 was feeling “numb all over her body and has blurry vision” at 0053 (12:53 a.m.) after the administration of clindamycin. The physician progress notes also indicated MD 1 assessed Patient 2. Patient 2 reported episodes of numbness and unable to make eye contact because she (Patient 2) had floaters/flashes in her (Patient 2’s) vision. Patient 2 overall felt very “weird.” MD 1 was then notified that Patient 2 received ropivacaine (medication used in epidural [a type of pain relief medication administered through a catheter inserted into the epidural space, the area between the spinal cord and the spinal column]) instead of clindamycin (thus wrong medication was given). During an interview on 8/20/2025 at 10:16 a.m. with Registered Nurse (RN) 1, RN 1 stated the following: “on 5/23/2025, I was trying to give the medication on time before I go on break. When I requested clindamycin from the Pyxis (an automatic medication dispensing machine), it prompted me which pocket to get it from, but I mistakenly went to the wrong pocket and took out ropivacaine instead of clindamycin. The pyxis printed a label sticker (pyxis label) for me to scan. I scanned the sticker (pyxis label) instead of the actual medication bag when giving the medication (to Patient 2) at bedside and the system let it pass.” RN 1 also stated, “I should not trust the sticker (pyxis label). I should scan the medication. I wanted to be on time, and I was in a rush before going on break.” RN 1 stated she did not look at the name on the IV medication bag. During an interview on 8/20/2025 at 11:19 a.m. with the Director (DIR 1) of Pharmacy, DIR 1 stated the following: the nurse (RN 2) deviated from the process, she (RN 2) scanned the Pyxis printed label (pyxis label) instead of the bar code on the actual medication. Nurses must scan the bar code on the medication bag not the pyxis label. The purpose of pyxis label was to serve as patient specific label to identify the patient, not replace the barcode on the medication. If the nurse scanned the pyxis printed label, the system would not be able to detect the medication error (wrong medication). During an interview on 8/20/2025 at 11:25 a.m. with DIR 1, DIR 1 stated after the incident that the pharmacy turned on “scan removal” feature on the pyxis in L&D department to force the L&D nurses to scan the medication bag before closing Pyxis door. The medications with the scan removal feature were only limited to the medications used in L&D department. During an interview on 8/21/2025 at 5:37 p.m. with physician (MD 1), MD 1 stated ropivacaine could cause seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness), lidocaine toxicity (LAST, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels) and affect the heart and affect the patient neurologically. During a review of Patient 2’s “Discharge Summaries Notes (DC Summary),” dated 5/25/2025, the DC Summary indicated, Ancef (medication, antibiotics to treat infection) and clindamycin started for presumed chorioamnionitis (bacterial infection and inflammation of the placenta [a temporary organ that forms inside the uterus during pregnancy connecting the mother and the developing baby], amniotic fluids [clear watery substance that surrounds and protects the developing baby during pregnancy], and the membranes [a thin protective layers that surround and cushion the developing baby during pregnancy]). The DC Summary also indicated, “(on 5/23/2025) overnight (Patient 2) noted to receive ropivacaine through IV instead of clindamycin due to nursing error resulting in whole body numbness and blurry vision. Patient (Patient 2) noted to have concern for LAST (Local Anesthetic Systemic Toxicity, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels) - anesthesia (physician who specialized in planning and administering anesthetic medications to manage pain and consciousness during surgical and medical procedures) called and 2 bags of lipid emulsion therapy (medical treatment to reverse the effects from local anesthetic systemic toxicity) was administered with resolution of patient (Patient 2) symptoms.” During a concurrent observation and interview on 8/21/2025 at 10:05 a.m., to demonstrate the retrieval of medication from the Pyxis, with RN 2 in the Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) medication room, RN 2 put in a request of Cardene (medication to treat high blood pressure) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with twelve (12) pockets with different medications: 0.9% normal saline (type of IV fluid to treat fluid imbalance, phenylephrine (medication to treat low blood pressure) 20 mg per 250 milliliters (ml, unit of measure), vancomycin (type of antibiotics to treat infection) 1.25 grams (g, unit of measure) vial, mupirocin (antibiotic ointment to treat bacterial skin infection) ointment 2%, sevelamer carbonate (medication to treat high blood phosphate levels) oral suspension 0.8 g, potassium 10 milliequivalent (mEq, unit of measure) per 100 ml, epinephrine (medication to treat allergic reaction and to restore cardiac rhythm) 1mg/10ml, micafungin (medication to treat fungal infection) 100 mg vial, norepinephrine (medication to treat low blood pressure) 8 mg per 250 ml, Cardene 20mg/200ml, venofer (medication to treat iron deficiency anemia) 100mg/5ml, nystatin (medication to treat fungal infection) powder bottle in the same drawer. RN 2 removed a box of IV Cardene from Pyxis pocket number 10 and closed the Pyxis door without the need for scanning the medication. The Pyxis machine printed a label sticker (pyxis label) when RN 2 closed the pyxis door. RN 2 stated she (RN 2) could scan either the bar code on the medication (the medication itself) or the barcode on the pyxis label when giving the medication to a patient (The correct process is to scan the barcode on the actual medication and not the pyxis label). During a concurrent observation and interview on 8/21/2025 at 10:32 a.m., to demonstrate the retrieval of medication from the pyxis, with RN 3 in the Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit medication room, RN 3 put in a request of Merrem (medication, type of antibiotics to treat infection) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with seven (7) pockets with different medications: 0.9% normal saline 250 ml, 0.9% normal saline 50 ml, amiodarone (medication treat heart dysrhythmia [abnormal heart rhythm]) 360 mg/200 ml, Merrem 1 gram vial, magnesium sulfate (medication to treat low magnesium in blood) 2 gram/50 ml, PEG-3350 and electrolytes (laxative solution to clear bowel) for oral solution jar, and nafcillin 2 gram vial), in the same drawer. RN 3 removed a vial of Merrem from Pyxis pocket number 45 and closed the Pyxis door without the need for scanning the medication. RN 3 stated once the Pyxis drawer door opened, she (RN 3) had access to all the medications in the same drawer (drawer number 4). RN 3 stated she (RN 3) could scan either the bar code on the medication (the medication itself) or the pyxis printed label (the barcode) when giving the medication to a patient. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration - Inpatient (Nursing),” dated 7/2024, the P&P indicated, “To ensure the safe and accurate administration of drugs to patients at [the facility] by using barcode technology ... Administration ... 6. Before administering a medication, the LIP (Licensed Independent Practitioner) should perform the following ... verify that the medication selected for administration is the correct one based on the medication order and product label ... 7. For the nursing staff ... bring meds (medications) to bedside. Scan all medications and verify. Remove the packaging of the medication at the bedside ... use 2 patient identifiers and follow 6 rights of medication administration. i. right patient (with 2 patient identifiers), ii. Right time, iii. Right drug, iv. Right dose, v. right route, vi. Right documentation... Safe Practices on Medication Administration ... Prior to administration of medication, the licensed staff will verify: 1. Use of two (2) patient identifiers 2. Name of drug 3. Route 4. Dosage 5. Frequency 6. Indication.” 3. During a review of Patient 3’s “Cardiology (heart) Procedure (procedure notes, completed by a physician who performed a special procedure)” notes, dated 7/29/2025, the procedure note indicated Patient 3 was admitted to the facility with diagnoses including but not limited to severe heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body’s needs) and coronary artery disease (CAD, a condition where fats build up in the coronary arteries [major blood vessels supplying oxygen and nutrients to the heart muscle] narrowing and restricting blood flow in the heart). Patient 3 was scheduled for high-risk PCI (percutaneous coronary intervention, a minimally invasive procedure to treat narrowed or blocked coronary arteries) with Impella (a minimally invasive, catheter-based blood pump designed to temporarily support the heart’s pumping function) support. The procedure notes further indicated the following: “ ... patient (Patient 3) was at this point noted to have runs of VT (Ventricular tachycardia, life-threatening heart rhythm disorder that lead to inadequate blood supply to the body and potentially cardiac arrest [(sudden loss of heart function]) ... she (Patient 3) was given 50 milligrams (mg, unit of measure) lidocaine (medication for local anesthetic [reduce sensation of pain] and antiarrhythmic [treat or prevent abnormal heart rhythms]) IV (IV, administered into a vein) for suppression (to stop) and did have normalization of the rhythm, however, subsequently was noted to have absent pulsatility (rhythmic, nature of blood flow and pressure caused by a beating heart). Unlike previous episodes during the case where patient (Patient 3) was still awake, conversant, alert during loss of pulsatility, this time patient (Patient 3) was subsequently noted to be unresponsive (does not react to sounds, touch or pain), with seizure-like/tonic-clonic (jerking) activity, and foaming at the mouth ... A Code Blue (hospital emergency code use to summon help when a patient is in need of resuscitation [CPR, an emergency lifesaving procedure performed when the heart stops beating]) was immediately called and chest compressions were commenced (started).” During a review of Patient 3’s procedure report titled, “Hemodynamic (evaluation of physiological [function and mechanism of a living organism] parameters of cardiovascular [heart and blood vessels] systems) Procedure Report,” dated 7/29/2025, the procedure report indicated, Registered Nurse (RN) 14 administered 2% lidocaine 50 milliliters (ml, unit of measure) IV to Patient 3. The procedure report also indicated, “at 18:35:32 (6:35:32 p.m.) 2% lidocaine 50 ml IV was verbally ordered with readback by [physician name] (MD 2), verified and given by [nurse name] (RN 14) per physician order” During an interview on 8/20/2025 at 1:54 p.m. with the Director (DIR 1) of Pharmacy, DIR 1 stated RN 14 removed ten (10) vials of 2% lidocaine (100 milligrams per 5 milliliters) from Pyxis (automatic medication dispensing machine) machine during Patient 3’s procedure on 7/29/2025. During an interview on 8/20/2025 at 2:10 p.m. with an interventional cardiologist (MD 3, cardiologist who specialized in performing minimally invasive, catheter-based procedures to diagnose and treat heart and blood vessels conditions), MD 3 stated a high dose of lidocaine could cause severe complication and lead to cardiac arrest. During a concurrent observation and interview on 8/20/2025 at 2:33 p.m. with the Pharmacy Manager (PM 1) and Registered Nuse (RN) 16 at the facility’s cardiac catheterization laboratory (cath lab, a hospital unit to perform minimally invasive, catheter-based procedures to diagnose and treat heart and blood vessels conditions) procedure room, PM 1 opened the Pyxis draw and showed stocked 2% lidocaine vial. There were two (2) 2% lidocaine (100 milligrams per 5 milliliters) 5 ml vials stocked in the Pyxis machine. RN 16 stated the cath lab nurses (nurses who have special training in assisting the minimally invasive, catheter-based procedures to diagnose and treat heart and blood vessels conditions) had access to the Pyxis machine, to retrieve and administer medication per physician order. During an interview on 8/20/2025 at 3:37 p.m. with the interventional cardiologist (MD 2), MD 2 stated the following: on day of procedure (7/29/2025), Patient 3 had some runs of ventricular tachycardia (VT), and he (MD 2) asked RN 14 to give 50 mg of lidocaine. RN 14 for some reason misheard and gave 50 ml which was equivalent to 1000 mg (20 times than the ordered dose). Patient 3 had seizure and lost pulsatility one to two minutes later. A Code Blue was called after. MD 2 further stated he would give medication dosage order in “milligrams (mg)” not in “milliliters (ml)” because “ml” was a unit of volume (amount of liquid) not a dose (amount of the medicine within the liquid). During an interview on 8/20/2025 at 4:03 p.m. with RN 14, RN 14 stated the following: when MD 2 ordered lidocaine 50 milligrams for Patient 3’s ventricular tachycardia, he (RN 14) misheard it as 50 milliliters. He (RN 14) readback “50 ml” but did not think MD 2 heard him (RN 14) clearly because he (MD 2) was busy with Patient 3. RN 14 also stated it was his (RN 14’s) first time giving lidocaine and he (RN 14) was not familiar with it. RN 14 further stated, “I did not read back appropriately. It should be in milligrams.” During a review of the facility’s policy and procedure (P&P) titled, “Giving/Receiving/Authenticating Verbal Orders and Telephone Orders, Inpatient CPOE,” dated 7/2022, the P&P indicated, “Verbal orders ... If a verbal order is necessary, use the following processes to ensure accuracy: a. Ordering Provider: i. the ordering provider shall dictate verbal orders slowly, clearly, and in an articulate manner to avoid confusion. b. Recipient: i. the licensed professional shall repeat back the entire verbal order to the ordering provider to ensure accuracy.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration - Inpatient (Nursing),” dated 7/2024, “Administration ... the pharmacist and/or nurse should contact the prescriber to discuss concerns and issues relating to medication orders and obtain clarification as needed ... Safe Practices on Medication Administration ... C. prior to administration of medication, the licensed staff will verify 1. Use of two (2) patient identifiers 2. Name of drug 3. Route 4. Dosage 5. Frequency 6. Indication D. the licensed staff must know the purpose and effect of medications.””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to: 1. Ensure one of 30 sampled patient’s (Patient 7) medical record contained copies of telemetry mounting strips (printed recording of the patient’s heart electrical activity, captured continuously by the telemetry monitor important for reviewing and documenting heart rhythms over time) and copies retained from 1/27/2025 at 4:11 p.m. (the time of admission) to 1/28/2025 at 11:58 a.m., at the required intervals of every 4 hours and as needed, in accordance with the facility’s policy regarding telemetry monitoring (a system that uses small, wearable devices with electrodes attached to a patient’s body to wirelessly transmit their vital signs-such as heart rate, rhythm, and sometimes oxygen saturation and respiratory rate-to a central station for continuous, real-time observation by healthcare providers). This deficient practice had the potential for Patient 7’s safety to be compromised, leading to lack of monitoring, review, and assessment of the patient’s (Patient 7) cardiac (heart) status, potentially delaying identification of arrhythmias (a condition in which the heart beats with an irregular or abnormal rhythm) or other critical changes. 2. Ensure one of 30 sampled patient’s (Patient 24), who was documented as Spanish-speaking only (both verbally and written communication), informed consent (permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits) for blood transfusion (a medical procedure where blood or blood components from a donor are transferred into the bloodstream of a recipient) and esophagogastroduodenoscopy (EGD, a medical procedure that allows a doctor to examine the lining of the upper gastrointestinal tract, including the esophagus, stomach, and first part of the small intestine), was verified by a nurse who was proficient in Spanish and certified by the facility or the process involved the use of the interpreter services (professional medical interpreter), and with documentation of interactions used to communicate with the LEP (Limited English Proficiency) person included as part of the medical record, in accordance with the facility’s established policy and procedures regarding use of interpretation services and documentation. This deficient practice had the potential to compromise Patient 24’s ability to fully understand the course of treatment, procedures, or risks because the patient (Patient 24) was not properly informed in their own language thus had the potential to lead to incorrect decisions, lack of full consent, and affecting patient (Patient 24) autonomy (the capacity to be one’s own person, making free and independent choices based on one’s own judgment and values, rather than being controlled by external forces) and safety. 3. Ensure one of 30 sampled patient’s (Patient 10), language preference, was accurately documented by nursing staff, when the official record indicated that Patient 10’s preferred language was English while all informed consent forms obtained during Patient 10’s admission stay at the facility were in Spanish. This deficient practice had the potential for Patient 10’s actual language needs to not be properly addressed, which could impair effective communication, understanding of medical information, and informed decision-making. Findings: 1. During a review of Patient 7’s History and Physical (H&P, a formal, comprehensive clinical evaluation by a healthcare provider to gather information about a patient’s condition ), dated 1/27/2025, the H&P indicated the following: Patient 7 was admitted to the facility on 1/27/2025 due to abdominal pain, nausea (the urge to throw up), and vomiting. Patient 7 also had documented past medical history (PMH, a patient’s previous medical conditions, treatments, surgeries, hospitalizations, and medications) of cardiomegaly (enlarged heart), polysubstance drug abuse (the repeated, non-prescribed use of three or more different types of drugs [or drug categories] for non-medical or recreational purposes, often resulting in harm or impairment) and schizophrenia (a chronic mental illness that affects a person’s thoughts, feelings, and behavior). The H&P further indicated that Patient 7’s cardiac troponin (a measurable substance [a biomarker] found only in the heart muscle, crucial for diagnosing heart damage, including heart attacks) level was 5030 nanogram/Liter (ng/L, measuring unit which was [significantly elevated and indicated extensive cardiac muscle injury (heart attack)]. The H&P also indicated that Patient 7 was diagnosed with NSTEMI (Non ST Elevated Myocardial Infarction, a type of heart attack where there is damage to the heart muscle [myocardium] without significant elevation of the ST segment [an indicator for various conditions such as heart attack or lack of blood flow] on an electrocardiogram (ECG, a non-invasive medical test that records the electrical activity of the heart) and was admitted to telemetry unit (a hospital floor for remote cardiac monitoring, or a portable device that collects and transmits data from a patient’s body to a central location for real-time observation). During a concurrent interview and record review on 8/19/2025 at 2:15 p.m. with the Director of Risk Management (DRM) and the Program Specialist Informatics Nurse (RNPSI), Patient 7’s “Nursing Documentation-Flowsheet,” dated 1/28/2025, was reviewed. The record indicated that at 7:10 a.m. [on 1/28/2025], Nurse 2 documented that Patient 7 had pain level of 9/10 (on a pain scale from 0 [no pain] to 10 [worst pain ever], typically signifies severe, excruciating pain) in the chest and cardiac rhythm was documented as sinus arrhythmia (a normal, physiological variation in the heart’s rhythm where the heart rate speeds up slightly during inhalation and slows down during exhalation, resulting in irregular beat-to-beat intervals). During a review of Patient 7’s electronic medical record (EMR, is a digital version of a patient’s medical history, containing all relevant information about their health, treatments, and medications) uploaded telemetry strips (which are recorded images of the patient’s heart rhythm stored in the electronic system) in Patient 7’s EMR for the period from 1/27/2025 at 4:11 p.m. (admission time) to 1/28/2025 at 9:26 p.m. [expired time), were requested to be reviewed. The EMR indicated that there were no telemetry strips that had been uploaded into the EMR to demonstrate Patient 7’s recorded electrical activity from 1/27/2025 [at 4:11] p.m. to 1/28/2025 at 11:28 a.m. This information was verified with the Program Specialist Informatics Nurse (RNPSI) on 8/19/2025 at 4:11 p.m., who confirmed that Patient 7’s medical record did not contain retained copies of telemetry strips (from 1/27/2025 at 4:11 p.m. to 1/28/2025 at 11:28 a.m.). During an interview on 8/19/2025 at 4:12 p.m. with the Telemetry Nurse Manager (NM 4), the NM 4 said that a primary nurse (a nurse responsible for the continuous management of a specific patient) was responsible for printing telemetry strips upon admission, every 4 hours, and as needed for all telemetry patients, and then placing these strips into the patients’ chart, in accordance with the facility’s policy regarding telemetry monitoring and retention of records. During a review of the facility’s policy and procedure (P&P) titled, “Telemetry Monitoring and Trouble Shooting,” dated 3/15/2022, the P&P indicated that, “The RN (Registered Nurse) trained in basic EKG monitoring will be responsible for documentation of the measurements and interpretation on all routine and PRN [as needed] rhythm strip records. Strips are ran at the beginning of each shift, as a baseline... subsequent readings will be run and interpreted every 4 hours and as needed...the interpreted strips will be placed in the mounting sheet or will be printed.... Licensed nurse measures and interprets the patient’s rhythm strip and signs in each rhythm strip.... Licensed nurse is responsible for placing mounting strips in the patients’ chart.” 2. During a review of Patient 24’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 8/17/2025, the H&P indicated that Patient 24 was admitted due to dark blood coming from the rectum and weakness. The H&P also indicated that Patient 24 had past medical history (PMH, the record of a patient’s previous health conditions, illness, surgeries and medical issues that have occurred before the current health concern) of gastrointestinal (GI, the digestive system, encompassing all the organs involved in digestion, from the mouth to the anus) bleeding with blood transfusions (a medical procedure where blood or blood components from a donor are transferred into the bloodstream of a recipient), anemia (a condition characterized by a low level of red blood cells (erythrocytes) or hemoglobin in the blood), and edema (swelling caused by an abnormal accumulation of fluid in the body’s tissues, often affecting the feet, ankles, and legs due to gravity). During further review of Patient 24’s History and Physical (H&P), dated 8/17/2024, the H&P indicated that Patient 24 required a consultation with gastroenterologist (GI, stomach and intestine doctor) and a possible test called, EGD (esophagogastroduodenoscopy, a procedure to look inside the digestive system and identify any issues such as the source of bleeding) and was made NPO (nothing by mouth, meaning not allowed to eat or drink), and an order was placed upon admission to check and record Patient 24’s weight every day to monitor Patient 24’s fluid status and overall health (daily weight fluctuations are an early indicator of a patient’s worsening condition). During an interview on 8/20/2025 at 3:13 p.m. with the nurse manager (NM 7), the NM 7 said the following regarding verified consents and the process of obtaining them (the process of confirming that an individual has a full understanding of a medical procedure or research study before voluntarily agreeing to it, and signing a consent form as a voluntary agreement to proceed with the treatment or a medical procedure): “If the patient’s primary language is Spanish, the interpreter used to translate should provide their identification number, which must be documented on the consent form. A nurse can also translate without using an interpreter if the nurse is certified through the facility. We have a list of certified nurses, which we can use to provide interpretation.” The NM 7 also said that for the accuracy of documentation, patient language preferences should be respected, and the patient should fully understand what they are signing to make informed decisions about their treatment and care. During a concurrent interview and record review on 8/21/2025 at 11:30 a.m. with the Clinical Informatics Specialist Nurse (CISN), Patient 24’s verified informed consents for the EGD, dated 8/17/2025, and 2 verified informed consents for Blood Transfusions, dated 8/16/2025 and 8/18/2025, were reviewed. All three consents were verified in the presence of nursing staff, who signed the consent forms as a witness. The CISN said that not one consent form had a documentation regarding the use of interpreter services. All three informed consents were in Spanish language and sighed by the patient (Patient 24). All three nurses, who were used to interpret, were also not listed among the qualified/certified Spanish interpreters list provided by the facility’s Director of Accreditation, Licensing, and Regulatory Services (DARL) on 8/21/2025 at 11:00 a.m. During a review of the facility’s policy and procedure (P&P) titled, “Language Assistance Program-Interpretation and Hearing Impaired,” dated 1/2025, the P&P indicated that, the facility “...will ensure that persons requiring language assistance services (such as oral language assistance or written translation) and who have limited English proficiency (LEP) will have meaningful access and an equal opportunity to participate and understand services, activities, programs, and other benefits involving medical conditions and treatment ...Language assistance will be provided using competent bilingual staff, providers, staff interpreters, or technology and telephonic interpretation services... Initial assessment of communication needs will be made during the admission process...Staff will identify the language and communication needs of the LEP person. In addition, the records are kept of past interactions with patients, the language used to communicate with the LEP person will be included as a part of the record ...Staff who have a limited familiarity (not deemed competent or qualified) with language interpreter skills should interpret only in emergency situation for a brief time...” During a review of the facility’s policy and procedure (P&P) titled, “Consent and Informed Consent-California,” dated 5/2025, the P&P indicated that, “The consent form should include ...Name and signature of interpreter and an attestation that the consent has been translated, if applicable... If the patient cannot communicate with the practitioner because of language barrier, the practitioner, with the health care facility’s assistance, should arrange for an interpreter. The interpreter’s responsibilities include translating the information regarding the recommended medical treatment that the patient or the patient’s legal representative needs to receive before deciding whether to give consent, as well as instructions regarding medical care...” 3. During a review of Patient 10’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 11/29/2024, the H&P indicated that Patient 10 was admitted due to weakness and abdominal pain. The H&P indicated that Patient 10 had past medical history (PMH, a comprehensive record of a person’s health information before their current visit or illness, detailing past and present illnesses, hospitalizations, surgeries, injuries, allergies, medications, and health habits like diet, exercise, alcohol, and drug use) of End-Stage Renal Disease (ESRD, a medical condition in which a person’s kidneys cease functioning on a permanent basis), hypertension (high blood pressure), recent (11/21/2024) placement of peritoneal catheter (a flexible tube, that is surgically implanted into the abdomen to facilitate peritoneal dialysis, a treatment for kidney failure), alcohol and substance abuse. During a concurrent interview and record review on 8/20/2025 at 3:24 p.m. with Nurse Manager (NM 6), Patient 10’s signed informed consents (the process by which an individual agrees to undergo a medical procedure, participate in a clinical study, or a specific course of action after receiving and understanding all the relevant information, including potential risks and benefits) for the following procedures were reviewed: 1. Esophagogastroduodenoscopy (EGD, medical procedure that allows a doctor to examine the lining of the upper gastrointestinal tract, including the esophagus, stomach, and first part of the small intestine) and Colonoscopy, dated 12/2/2024 e, colonoscopy- a medical procedure that involves examining the large intestine (colon) using a thin, flexible tube called a colonoscope. 2. Placement of Peritoneal Dialysis (PD, a treatment for kidney failure that uses the lining of the abdomen [peritoneum] as a filter to remove waste products and excess fluid from the blood) Catheter, possible Laparoscopy (minimally invasive surgical procedure to insert a tube [catheter] into the abdomen, with a camera, into the abdomen), dated 11/21/2024. 3. Laparoscopic drainage possible open procedure all other indicated procedures, retrieval of peritoneal dialysis (removing peritoneal dialysis catheter using a minimally invasive, laparoscopic approach with small incisions and a camera),” dated 12/05/2024. -All three consents were obtained in Spanish (Patient 10 reviewed and signed all three consent forms written in Spanish). The NM 6 verified that Patient 10’s documented preferred language (spoken and written) at the time of admission (11/29/2024) was English. The NM 6 also said that if Patient 10’s preferred language was English, then all the consents should have been obtained in English, not in Spanish. The NM 6 then said, “The reason why the consents should be obtained in the patient’s preferred language is because we want the patient to fully understand what they are signing.” During a review of the facility’s policy and procedure (P&P) titled, “Language Assistance Program-Interpretation and Hearing Impaired,” dated 1/2025, the P&P indicated that, the facility “...Will ensure that persons requiring language assistance services (such as oral language assistance or written translation0 and who have Limited English Proficiency (LEP) will have meaningful access and an equal opportunity to participate and understand services, activities, programs, and other benefits involving medical conditions and treatment...Language assistance will be provided using competent bilingual staff, providers, staff interpreters, or technology and telephonic interpretation services... Initial assessment of communication needs will be made during the admission process...Staff will identify the language and communication needs of the LEP person. In addition, the records are kept of past interactions with patients, the language used to communicate with the LEP person will be included as a part of the record...” During a review of the facility’s policy and procedure (P&P) titled, “Consent and Informed Consent-California,” dated 5/2025, the P&P indicated that, “The consent form should include...Name and signature of interpreter and an attestation that the consent has been translated, if applicable... If the patient cannot communicate with the practitioner because of language barrier, the practitioner, with the health care facility’s assistance, should arrange for an interpreter. Vital documents, including consent forms, presented by the healthcare facility staff to a patient must be written in a language that the patient can understand, or translated into such a language with an appropriate qualified interpreter.””

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that for one of 30 sampled patients (Patient 24), the following information was documented to justify Patient 24’s progress and response to treatment plan, in accordance with the facility’s policy regarding documentation, when: 1. Nursing staff failed to obtain and document Patient 24’s daily weight in accordance with the physician’s order. 2. Nursing staff failed to develop, document, and maintain a personalized care plan (a formal, documented roadmap created by nurses that outlines a patient’s specific health needs, goals, and planned nursing actions to achieve those goals) for monitoring fluid balance (the body’s ability to maintain the proper amount of water and hydration) and nutritional status (the body’s current state of nourishment, reflecting the balance between nutrient intake and the body’s needs for growth, repair, and maintenance) for Patient 24. These deficient practices had the potential to result in adverse patient outcomes for Patient 24, when complications such as fluid overload and/or dehydration goes undetected due to lack of monitoring and proper documentation, which can lead to delayed diagnosis and treatment. Findings: 1. During a review of Patient 24’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 8/17/2025, the H&P indicated that Patient 24 was admitted due to dark blood coming from the rectum and weakness. The H&P also indicated that Patient 24 had past medical history (PMH, the record of a patient’s previous health conditions, illness, surgeries and medical issues that have occurred before the current health concern) of gastrointestinal (GI, the digestive system, encompassing all the organs involved in digestion, from the mouth to the anus) bleeding with blood transfusions (a medical procedure where blood or blood components from a donor are transferred into the bloodstream of a recipient), anemia (a condition characterized by a low level of red blood cells [erythrocytes] or hemoglobin in the blood), and edema (swelling caused by an abnormal accumulation of fluid in the body’s tissues, often affecting the feet, ankles, and legs due to gravity). During further review of Patient 24’s History and Physical (H&P), dated 8/17/2024, the H&P indicated that Patient 24 required a consultation with gastroenterologist (GI, stomach and intestine doctor) and a possible test called EGD (esophagogastroduodenoscopy, a procedure to look inside the digestive system and identify any issues such as the source of bleeding) and was made NPO (nothing by mouth, meaning not allowed to eat or drink) and an order was placed upon admission to check and record Patient 24’s weight every day to monitor their (Patient 24) fluid status and overall health (daily weight fluctuations are an early indicator of a patient’s worsening condition). During a review of Patient 24’s “Physician Orders” set, dated 8/16/2025, the Physician Orders indicated that Patient 24 had a standing order for “Daily Weight at 0600 (Monitoring weight every day at 6:00 a.m.), placed on 8/16/2025 at 6:32 p.m., upon Patient 24’s admission to the facility. During a concurrent interview and record review on 8/21/2025 at 11:10 a.m. with Clinical Informatics Specialist Nurse (CISN), Patient 24’s “Daily Weight -Nursing Flowsheet,” dated from 8/17/2025 through 8/21/2025, was reviewed. The CISN confirmed that Patient 24’s medical record titled, “Daily Weight -Nursing Flowsheet,” dated from 8/17/2025 through 8/21/2025, did not include documented weights at 6 a.m. [from 8/17/2025 through 8/21/2025] as ordered by physician. The CISN confirmed that the daily weight should have been obtained and documented as ordered. During a review of the facility’s policy and procedure (P&P), titled “Assessment and Reassessment Nursing Services,” dated 4/2025, the P&P indicated that “Documentation-The electronic medical record (EMR) is used for clinical documentation throughout the hospital. The complete medical record is viewed as the integrated document. The EMR and the written medical record are reflections of the patient’s care.” During a review of the facility’s policy and procedure (P&P), titled “Clinical Record Documentation Guidelines,” dated 4/2024, the P&P indicated that “The basic purpose of the clinical record is to record and communicate the following information: ...Patient condition, care, treatment and services received...Clinical record documentation is used for: ...Providing clinically relevant data...a means of communication between physicians and other healthcare team members...” During a review of the facility’s policy and procedure (P&P) titled, “NURSING ASSESSMENT, DOCUMENTATION USING POWERCHART, IVIEW, DYNAMIC CHARTING FORMS,” dated 4/2024, the P&P indicated that, “Professional documentation by clinical staff is an integral part of practice to ensure safe and effective care. Documentation is a record of the care provided and reflects the judgment and critical thinking of the nurse. Documentation should reflect the patient-centered and evidence-based plan of care and indicate patient outcomes for all inpatients. Nursing care should be documented as closely as possible to the time delivered...” 2. During a review of Patient 24’s History and Physical (H&P), dated 8/17/2025, the H&P indicated that Patient 24 was admitted due to dark blood coming from the rectum and weakness. The H&P also indicated that Patient 24 had past medical history (PMH, the record of a patient’s previous health conditions, illness, surgeries and medical issues that have occurred before the current health concern) gastrointestinal (GI, the digestive system, encompassing all the organs involved in digestion, from the mouth to the anus) bleeding with blood transfusions (a medical procedure where blood or blood components from a donor are transferred into the bloodstream of a recipient), anemia (a condition characterized by a low level of red blood cells [erythrocytes] or hemoglobin in the blood), and edema (swelling caused by an abnormal accumulation of fluid in the body’s tissues, often affecting the feet, ankles, and legs due to gravity). During further review of Patient 24’s History and Physical (H&P), dated 8/17/2024, the H&P indicated that Patient 24 required a consultation with gastroenterologist (GI, stomach and intestine doctor) and a possible test called EGD (esophagogastroduodenoscopy, a procedure to look inside the digestive system and identify any issues such as the source of bleeding) and was made NPO (nothing by mouth, meaning not allowed to eat or drink) and an order was placed upon admission to check and record Patient 24’s weight every day to monitor Patient 24’s fluid status and overall health (daily weight fluctuations are an early indicator of a patient’s worsening condition). During a concurrent interview and record review on 8/21/2025 at 11:02 a.m. with the Clinical Informatics Specialist Nurse (CISN), Patient 24’s care plans (nursing care plan outline a patient’s individualized care goals and nursing actions needed to meet those goals), dated 8/21/2025, was reviewed. The nursing care plan did not reflect a care plan developed or documented to guide nurses to maintain proper fluid and electrolyte balance (the body’s process of maintaining stable levels of both water and charged minerals [electrolytes like sodium [salt], potassium [for blood pressure control], calcium [strengthen bones], and magnesium- essential for nerve and muscle function] within specific concentrations to ensure proper body’s function, and preventing complications such as fluid overload and retention) and nutritional status. The CISN said that a built-in nutritional care plan was available for the nurses to initiate; however, it was marked inactive. During a review of the facility’s policy and procedure (P&P) titled, Nursing Division-Overall Scope, Standards, and Structure,” dated 4/2025, the P&P indicated that: “c. Standard Ill - Plan of Care i. A registered nurse will analyze the admission assessment data and establish a plan of nursing care. v. The plan of care will be individualized and based on the nursing assessment, diagnostic results, and the patient’s goals. The nurse will collaborate with the interdisciplinary team, the patient, patient’s family, and significant others to help establish the plan of care and goals based on patient’s needs.” During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment Nursing Services,” dated 4/2025, the P&P indicated that, “B. A registered nurse will implement the individualized plan of care...The RN retains the responsibility for interpreting the data and identifying patient needs. C. Documentation-The electronic medical record (EMR) is used for clinical documentation throughout the hospital. The complete medical record is viewed as the integrated document. The EMR and the written medical record are reflections of the patient’s care...” During a review of the facility’s policy and procedure (P&P) titled, “Clinical Record Documentation Guidelines,” dated 4/2024, the P&P indicated that “The basic purpose of the clinical record is to record and communicate the following information: ...Patient condition, care, treatment and services received...Clinical record documentation is used for: ...Providing clinically relevant data...a means of communication between physicians and other healthcare team members...””

“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: 42937 Based on interview and record review, the facility failed to ensure proper completion of a pre procedure checklist (a tool used by surgical teams to improve patient safety by ensuring essential steps, tasks and assessment are completed before surgery) for one of 30 sampled patients (Patient 14), in accordance with the facility’s policy regarding pre-operative operation. This deficient practice had the potential to create serious risks, including surgical errors, complications, and/or death. In addition, it can also potentially lead to medical errors, inefficient use of resources, and costly delays or cancellations that can cause significant patient anxiety and inconvenience for Patient 14 and other patients undergoing surgery. Findings: During a review of Patient’s 14’s “Orthopedic (a branch of medicine that focuses on the musculoskeletal system, including bones, joints, muscles, tendons, and ligaments) SOAP (standardized, four-part progress note [Subjective, Objective, Assessment, Plan] used by healthcare providers to document a patient’s condition and treatment during their hospitalization) Note,” dated 08/12/2025, the record indicated that Patient 14 sustained a right hand injury on 8/4/2025. Patient 14 reported he (Patient 14) was walking his dogs outside when he (Patient 14) slipped and fell. Radiographs (X-ray imagery) of the right hand showed evidence of fourth and fifth metacarpal (any of the five long bones that form the palm of the hand) fractures (a break in the bone). The note indicated a Plan to schedule Patient 14 for a Closed Reduction Percutaneous Pinning (CRPP, a surgical procedure for bone fractures where the bone is manipulated back into alignment and then held in place with internal pins or screws) versus Open reduction and internal fixation (ORIF, a surgical procedure used to treat severe fractures or dislocations by realigning the broken bones and stabilizing them with internal hardware) for Patient 14’s right fourth and fifth metacarpal fractures. During a concurrent interview and record review on 08/22/2025 at 3:00 p.m. with Registered Nurse Educator (RNE), Patient 14’s medical record titled, “Pre Procedure Checklist (a tool used by surgical teams to improve patient safety by ensuring essential steps, tasks and assessment are completed before surgery),” dated 8/20/2025 at 6:47 a.m., was reviewed. Patient 14’s pre procedure checklist indicated “Holding” for the following questions: Consult note needed, H&P (History and Physical, a formal and complete assessment of the patient and the problem) available, H&P interval update, informed consent (A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment), pre-anesthesia (a medical intervention that temporarily induces a loss of sensation, consciousness, and/or muscle relaxation to allow for surgical procedures or other medical interventions to be performed without pain or discomfort) evaluation documented, surgical site marked by MD (Medical Doctor), and surgical site verified by patient. During the same interview on 08/22/2025 at 3:00 p.m. with Registered Nurse Educator (RNE), RNE stated that the pre procedure checklist was considered incomplete. RNE said that the only acceptable answer was either Yes or Not Applicable (NA). RNE added that he (RNE) was not sure what “Holding” meant based on what was documented, but RNE stated “it seems to suggest that the nurse in the Holding Unit (a hospital area where patients are prepared for surgery before being taken to the operating room) will do a follow up and complete the pre-procedure checklist.” RNE further stated it was important for nurses to complete the pre-procedure checklist correctly to make sure that patient was safe and prepared for surgery. During a review of the facility’s Policy and Procedure (P&P) titled, “Surgery - Pre-Operative Preparation,” with last review date of 03/18/2025, the P&P indicated the following: Responsibility of RN (registered Nurse) Review the pre-operative checklist to see that preparation is complete. Check if the patient is wearing an identification band. Key Points: Complete the pre-operative checklist. Ensure consent signed, lab work done, valid history and physical in chart, etc. Document in nursing note’s exact location of patient’s valuables.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Patients Rights was met as evidenced by: 1. The facility failed to inform the legal guardian and obtain consent for care and treatment from the legal guardian for one of 30 sampled patients (Patient 3) before providing care to Patient 3, in accordance with the facility’s policy and procedure regarding Condition of Registration- Hospital Services and Informed Consent (a process in which patients are given important information, including possible risks and benefits about a medical procedure or treatment so that they can make well-considered decisions about their care), when Patient 3, who was identified as a minor (children under age of 18), signed the facility’s Condition of Registration (COR, legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service). Patient 3 was 17 years old (considered a minor). This deficient practice resulted in a violation of Patient 3’s and Patient 3’s legal representative’s right to receive information regarding patients’ rights (ethical principles that apply to patient care such as the right to receive information about any proposed treatment, etc.) as hospital patient and had the potential to result in Patient 3’s and/or Patient 3’s legal guardian’s inability to effectively make decisions regarding Patient 3’s care or treatment. (Refer to A-0117) 2. The facility failed to ensure one of 30 sampled patient’s (Patient 25’s) Condition of Registration form (legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service) was followed- up by the registration staff to ensure completion and include documentation of attempts made to obtain Patient 25’s signature to indicate that Patient 25 received the form, in accordance with the facility’s policy and procedure regarding Condition of Registration process. This deficient had the potential for Patient 25 to not receive information regarding his (Patient 25) Patients’ rights as well as to participate and make effective decisions regarding his (Patient 25) care and treatment, which may negatively affect Patient 25’s compliance with care and treatment resulting in prolonged recovery and hospitalization. (Refer to A-0117) 3. The facility failed to indicate the correct state regulatory agency phone number for two of two sampled facility’s Patients’ Rights Poster posted in the emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) and in the facility’s admission booklet titled, “Welcome! (Patient Handbook, a patient welcome guide designed to assist patients with simple questions on key care topics and explains patient rights and responsibilities),” for three of 30 sampled patients (Patient 3, 6 and 7), in accordance with the facility’s policy and procedure regarding complaint and grievance (written or oral expression of dissatisfaction regarding the quality of care provided to a patient) management. This deficient practice had the potential to result in Patients 3, 6 and 7, not knowing who to contact when filing a grievance, which may prevent the patients from expressing concerns they may have regarding their care and treatment, thus leading to poor compliance with treatment regimen and delayed recovery. (Refer to A-0118) 4. The facility failed to ensure for one of 30 sampled patients (Patients 19) the following: 4.a. Patient 19’s environmental safety checklist (a tool that help nursing staff identify and abate environmental hazards that could increase the chance of patient suicide [thoughts of taking one’s own life] or self-harm) for suicide precaution was completed, after Patient 19 was diagnosed with suicidal ideation (when a patient thinks about, consider or feel preoccupied with the idea of death and suicide), in accordance with the facility’s policy and procedure regarding suicide prevention. 4.b. Patient 19’s re-assessment of Columbia-Suicide Severity Rating Scale ([C-SSRS] a risk assessment intended to help establish a person’s immediate risk of suicide and is used in hospital care settings) was completed, after it was determined that Patient 19 exhibited a change in condition (Patient 19 informed other ED staff members that he was suicidal), in accordance with the facility’s policy and procedure regarding suicide prevention. These deficient practices had the potential to result in self-harm or harm to others, for patients who are seen in the Emergency Department (ED, provides immediate care for patients with acute [sudden and severe in onset] illnesses or injuries) and diagnosed with suicidal ideation. (Refer to A-0144) 5. The facility failed to ensure its nursing staff developed and implemented a 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) care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) upon restraints initiation, for one of 30 sampled patients (Patient 5), in accordance with the facility’s policy and procedure for restraints, when Patient 5 was placed on 5-point restraints in the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care). This deficient practice had the potential to result in lack of nursing intervention and monitoring while Patient 5 was restrained, which may put Patient 5 at risk for injury such as strangulation (when a person’s breathing or blood circulation is impeded by applying pressure to the neck or throat), skin tear, dehydration, etc. (Refer to A-0166) 6. The facility failed to ensure the physician performed face to face assessment (in-person evaluation documented by a licensed independent practitioner or their designee to evaluate patient’s response to treatment/intervention) within an hour after initiation of a violent or self-destructive 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 for restraints, on one of 30 sampled patients (Patient 5), when Patient 5 was placed on 5-point (bilateral wrists, bilateral ankles and waist) restraints in the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care). This deficient practice had the potential to result in lack of evaluation of Patient 5’s response to the behavioral restraints initiated including assessment for continued need for the restraints and/or other interventions, which may result in unnecessary use of restraints and other complications such as strangulation (when a person’s breathing or blood circulation is impeded by applying pressure to the neck or throat), skin tear, dehydration, etc. (Refer to A-0178) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment, potentially placing patients at risk for a delay in care and treatment, injury, and/or death.”

“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: 48212 Based on interview and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to ensure for one out of 30 sampled patients (Patient 8), nursing care was provided when: 1.a. Patient 8’s admission orders were not carried out timely while waiting in the Emergency Department (ED, provides immediate care to patients with acute [sudden and severe in onset] illnesses or injuries) to be admitted in the Medical-Surgical/Telemetry unit (MST, a specialized unit for the patients that needed continuous heart monitoring), in accordance with the facility’s policy on Provision of Patient Care Services. 1.b. Patient 8 did not have a complete physical assessment (head to toe evaluation) by a Registered Nurse (RN) while in the ED, in accordance with the facility’s policy regarding Provision of Patient Care Services and Emergency Department Triage. 1.c. Patient 8’s high Blood Pressure (BP, amount of force the blood needs to move through the vessels) readings in the ED were not addressed, in accordance with the facility’s policy regarding Provision of Patient Care Services. These deficient practices resulted in delayed treatment and also had the potential to cause a delay in determining Patient 8’s change of condition and/or provision of care needed, which could worsen the patients’ condition and may result in death. (Refer to A-0395) 2. The facility failed to initiate and develop an individualized care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 30 sampled patients (Patient 4), to address Patient 4’s diaper rash, in accordance with the facility’s policy and procedure regarding care planning. This deficient practice had the potential to result in the delay of care and evaluation of Patient 4’s response to treatment and intervention, by not identifying Patient 4’s needs and risks, which may result in worsening of Patient 4’s condition and may prolong hospitalization. (Refer to A-0396) 3. The facility failed to develop and implement an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) related to dialysis (procedure that cleans the blood by removing extra fluids and waste), for one of 30 sampled patients (Patient 14), in accordance with the facility’s policy and procedure regarding care planning. This deficient practice had the potential to result in delayed provision of treatment by not identifying Patient 14’s needs and risks pertaining to dialysis, which may result in complications for Patient 14 such as difficulty in breathing due to excessive fluids in the body, irregular heartbeat, confusion, and/or death. (Refer to A-0396) 4. The facility failed to develop and implement an individualized nursing care plan to address issues with bleeding for one of 30 sampled patients (Patient 16), in accordance with the facility’s policy and procedure regarding care planning. This deficient practice had the potential to result in delayed treatment by not identifying Patient 16’s needs and risks pertaining to bleeding, which may result in excessive blood loss, hypotension (low blood pressure), and/or death. (Refer to A-0396) 5. The facility failed to implement the care plan developed regarding seizure (a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person’s behavior, movements, and level of consciousness [a person’s awareness and understanding of what is happening in his or her surroundings]) precautions for one of 30 sampled patients (Patient 25), in accordance with the facility’s policy regarding care planning, when seizure pads were not documented being placed on Patient 25’s bed’s siderails. This deficient had the potential for Patient 25 to sustain an injury in case of a seizure episode, which may include fracture (break in the bone), contusion (bruise), etc., and may result in prolonged hospitalization and recovery. (Refer to A-0396) 6. The facility failed to ensure staff followed the facility’s “Central Venous Catheter Management Policy,” for one of 30 sampled patients (Patient 24), when Patient 24 had a PICC line (Peripheral Inserted Central Catheter, is an intravenously [into the vein] placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava [a large vein that carries blood from the head, neck, arms, and chest], and used for intravenous treatment that is required over a long period) placement done and staff did not obtain an order that it was okay to use the PICC line prior to using the PICC line for medication administration. This deficient practice had the potential for misplaced PICC line to lead to serious complications like infection, bleeding, pneumothorax (when air leaks from the lung into the space between the lung and the chest wall), or arrythmias (abnormal heart rhythm). (Refer to A-0398) 7. The facility failed to ensure one of 30 sampled patient’s (Patient 12) Code Status (type of lifesaving emergency treatment someone wants, which can or cannot include chest compressions, a breathing tube, and medications) was verified and physician was notified regarding the absence of documented order for Patient 12’s code status, and ensure documentation of code status order in Patient 12’s medical record, within 24 hours after admission, in accordance with the facility’s policy and procedure regarding Code status. This deficient practice had the potential for Patient 12 to receive inappropriate emergency life sustaining measures, and/or delay the care for Patient 12, which could lead to serious harm and/or death. (Refer to A-0398) 8. The facility failed to ensure one of 30 sampled patients (Patients 17) operating room nursing staff adhered to the facility’s policy and procedure regarding chain of command (a formal process that hospital staff use to escalate concerns about patient safety or other issues to the appropriate levels of authority), when it was identified that the surgeon continued and completed surgical skin closure (the final step in a surgical procedure that involves repairing the skin and deeper layers of tissue to promote healing) after being told that the surgical count (a crucial procedure that ensures no surgical items are left behind in a patient after surgery) was incorrect. This deficient practice resulted in Patient 17 having to undergo another surgical procedure to retrieve a surgical sponge that was left unintentionally inside Patient 17’s abdominal cavity. This deficient practice also had the potential to cause complications such as infection, uncontrolled bleeding, and psychological distress for Patient 17. (Refer to A-0398) 9. The facility failed to ensure for two of 30 sampled patients (Patients 8 and 9), the following: 9.a. For Patient 8, Amlodipine (medication used to lower blood pressure [BP, amount of force blood uses to move through the body]) was given as ordered by the physician. This deficient practice had the potential for Patient 8’s blood pressure to remain elevated, which may result in complications such as heart attack and stroke (formation of blood clots in the brain), leading to paralysis (loss of function in part or all of the body) and/or death. (Refer to A-0405) 9.b. For Patient 8, Hydralazine (medication used to lower BP) was given as ordered by the physician. This deficient practice had the potential for Patient 8’s blood pressure to remain elevated, which may result in complications such as heart attack and stroke (formation of blood clots in the brain), leading to paralysis (loss of function in part or all of the body) and/or death. (Refer to A-0405) 9.c. For Patient 8, Lactated Ringers (LR, intravenous fluid given through the vein to help balance electrolyte [minerals that carry an electric charge found in the body which are important for bodily functions such as heart rate and rhythm, blood pressure, etc.] levels) was given as ordered by the physician. This deficient practice had the potential for Patient 8 to have a low blood volume or low blood pressure, which may result in complications such as hypovolemic shock (a life-threatening medical condition where a significant loss of blood or bodily fluids prevents the heart from pumping enough blood to adequately supply the body with oxygen, leading to organ dysfunction and potentially causing death if not treated promptly), thus leading to prolonged hospitalization and/or death. (Refer to A-0405) 9.d. For Patient 9, Lamotrigine (a medication to prevent seizures [a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person’s behavior, movements, feelings, and level of consciousness- used to describe a person’s awareness and understanding of what is happening in his or her surroundings]) was given as ordered by the physician. This deficient practice had the potential to result in persistent seizure episodes, which may lead to permanent injury or death for Patient 9. (Refer to A-0405) 10. The facility failed to ensure one of 30 sampled patient’s (Patient 13) vital signs (VS, set of blood pressure, temperature, heart rate, breathing rate, and oxygen measurements), were frequently checked and monitored during blood transfusions (critical procedure that moves blood or blood products into a person who has low blood levels, and can carry risks such as an allergic reaction, heart and lung problems, and death), in accordance with the facility’s policy and procedure regarding blood administration. This deficient practice had the potential to cause a delay in determining Patient 13’s change of condition such as the presence of an allergic reaction, irregular heart rhythm, etc. and/or a delay in the provision of emergent treatment needed which could worsen Patient 13’s condition and may result in 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: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 42976 Based on interview and record review, the facility failed to: 1. Inform the legal guardian and obtain consent for care and treatment from the legal guardian for one of 30 sampled patients (Patient 3) before providing care to Patient 3, in accordance with the facility’s policy and procedure regarding Condition of Registration- Hospital services and Informed Consent (a process in which patients are given important information, including possible risks and benefits about a medical procedure or treatment so that they can make well-considered decisions about their care), when Patient 3, who was identified as a minor (children under age of 18), signed the facility’s Condition of Registration (COR, legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service). Patient 3 was 17 years old. This deficient practice resulted in a violation of Patient 3’s and/or Patient 3’s legal representative’s right to receive information regarding patients’ rights (ethical principles that apply to patient care such as the right to receive information about any proposed treatment, etc.) as hospital patients and had the potential to result in Patient 3’s and/or Patient 3’s legal guardian’s inability to effectively make decisions regarding Patient 3’s care or treatment. 2. Ensure one of 30 sampled patient’s (Patient 25’s) Condition of Registration form (legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service) was followed- up by the registration staff to ensure completion and include documentation of attempts made to obtain Patient 25’s signature to indicate that Patient 25 received the form, in accordance with the facility’s policy and procedure regarding Condition of Registration process. This deficient had the potential for Patient 25 to not receive information regarding his (Patient 25) Patients’ rights as well as to participate and make effective decisions regarding his care and treatment, which may negatively affect Patient 25’s compliance with care and treatment resulting in prolonged recovery and hospitalization. Findings: 1. During a review of Patient 3’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/6/2024, the H&P indicated Patient 3 was a 17-year-old patient admitted to the facility’s Pediatrics (Peds, hospital unit with patients from very young infant to teenagers who require hospital admission for a variety of medical illnesses) unit for acute (new onset) colitis (a digestive disease that causes swelling of large intestine or colon). During an interview on 11/14/2024 at 9:58 a.m. with the Director of Patient Access (DPAR), DPAR stated the form titled “Condition of Registration (COR, legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service),” was given to all patients to give medical consent, nursing care and authorization for the facility to treat and provide service. DPAR stated the COR also covered the personal valuables, consent for photography, non-discrimination, financial agreement and responsibility, patients’ rights (ethical principles that apply to patient care such as the right to receive information about any proposed treatment, etc.) and consent for email or phone communication. During a concurrent interview and record review on 11/14/2024 at 2:50 p.m. with the Chief Nursing Officer (CNO), Patient 3’s signed copy of “Condition of Registration (COR),” dated 11/5/2024, was reviewed. The COR indicated the form was signed by Patient 3 with Patient 3’s signature, printed name and indication of “I am the patient.” CNO stated Patient 3 should not sign the COR since he (Patient 3) was still a minor. CNO stated a minor was considered as anyone below age of 18. CNO stated the COR form should be signed by Patient 3’s legal guardian or parents. During a review of the facility’s policy and procedure (P&P) titled, “Condition of Registration - Hospital Services,” dated 11/2021, the P&P indicated, “Consent is necessary prior to any treatment or procedure ... All facility admissions require the Condition of Registration (COR) form signed by patient or their authorized representative at the time of each hospital outpatient visit or bedded admission encounter ... The patient’s or authorized representative’s signature is obtained confirming consent for care, receiving notification of his/her Patient Rights and Responsibilities, knowledge of billing information, financial assistance ... Legal Representative ... a parent or legal guardian of a minor child.” During a review of the facility’s policy and procedure (P&P) titled, “Consent and Informed Consent - [the state],” dated 1/2023, the P&P indicated, “Definitions ... minors - all persons under 18 years of age ... Conditions of Registration: upon admission or as soon as thereafter as reasonably possible the patient or a patient’s legal representative will be asked to give consent to the general medical care and the general terms and conditions for receiving care from the health care facility.” 2. During review of Patient 25’s “Face Sheet (a document that summarizes a patient’s key personal and medical information, including their name, address, date of birth, insurance details, allergies, medical history, and current medications),” dated November 2024, the Face Sheet indicated the following: Patient 22 was admitted to the hospital on 11/10/2024 for seizure (a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person’s behavior, movements, feelings, and level of consciousness [a person’s degree of awareness and responsiveness to their surroundings]) and discharged from the hospital on 11/12/2024. During review of Patient 25’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/2024, the “H&P,” indicated the following: Patient 25 was brought to the hospital for witnessed seizure at the gym. During a concurrent interview and record review on 11/13/2024 at 2:57 p.m. with the Associate Patient Care Executive (APCE), Patient 25’s “Condition of Registration Form (CORF, legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service),” dated November 2024, was reviewed. The “CORF” indicated Patient 25 was “unable to sign due to medical condition.” APCE stated the following: Confirmed Patient 25 did not sign “CORF” due to medical condition. APCE stated there were no other “CORF” in the medical chart indicating Patient 25 signed his (Patient 25) “CORF.” During an interview on 11/14/2024 at 9:58 a.m. with the Director of Patient Access Rep (DPAR), DPAR stated the following: Confirmed DPAR was responsible for the registration staff. Patient 25’s CORF form was not completed correctly. The registration staff should have documented what condition patient had since Patient 25 was unable to sign. Registration staff will run a missing signature report and put in the patients account notes about attempting to get a signature from the patient. At least once a day, staff need to go timely and see the patient to get a signature and come back to document in the log if patient did not sign. There will be a time stamp. DPAR Confirmed registration staff did not document in the registration flow log that registration staff attempted to get a signature from Patient 25. DPAR will educate staff on following up with Patients regarding CORF. It was important to make sure patients know their patient rights and responsibilities. During a review of the facility’s policy and procedure (P&P) titled, “Condition of Registration - Hospital Services,” dated November 2021, the “P&P” indicated the following: 1. Conditions of Registration (COR): The COR is a legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical services. A. Conditions of Registration 1. All Patient Access associates must be informed and understand the principles and requirements for completing the COR document. 2. Every patient has a legal right to decide upon the medical treatment that they are to receive. The COR provides important information including but not limited to Consent to Treatment, Patient Rights, Patient Privacy Practices, Assignment of Insurance Benefits and Permission to Bill for Services. D. If a patient’s medical/mental condition prevents the patient from being able to sign the document, the patient’s legal representative or family member may sign on the patient’s behalf. If no legal representative or family member is available, Patient Access is responsible to follow up and obtain signatures prior to patient discharge if possible. All attempts to obtain signatures will be documented in the patient record.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to indicate the correct state regulatory agency phone number for two of two sampled facility’s Patients’ Rights Poster posted in the emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) and in the facility’s admission booklet titled, “Welcome! (Patient Handbook, a patient welcome guide designed to assist patients with simple questions on key care topics and explains patient rights and responsibilities),” for three of 30 sampled patients (Patient 3, 6 and 7), in accordance with the facility’s policy and procedure regarding complaint and grievance (written or oral expression of dissatisfaction regarding the quality of care provided to a patient) management. This deficient practice had the potential to result in Patients 3, 6 and 7, not knowing who to contact when filing a grievance, which may prevent the patients from expressing concerns they may have regarding their care and treatment, thus leading to poor compliance with treatment regimen and delayed recovery. Findings: During a review of Patient 3’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/6/2024, the H&P indicated Patient 3 was a 17-year-old patient admitted to the facility’s Pediatrics (Peds, hospital unit with patients from very young infant to teenagers who require hospital admission for a variety of medical illnesses) unit for acute (new onset) colitis (a digestive disease that causes swelling of large intestine or colon). During a review of Patient 6’s “History and Physical (H&P),” dated 11/12/2024, the H&P indicated Patient 6 was admitted to the facility with diagnoses including but not limited to sepsis (a body’s overwhelming and life-threatening response to infection) and cholecystitis (inflammation of gallbladder). During a review of Patient 7’s “History and Physical (H&P),” dated 11/12/2024, the H&P indicated, Patient 7 was admitted to the facility with diagnoses including but not limited to anaphylaxis (a severe, lift-threatening allergic reaction), hypotension (low blood pressure) and acute (new onset) renal failure (the sudden and rapid loss of kidney’s ability to filter waste and balance fluid in blood). During an observation on 11/12/2024 at 1:15 p.m. in the emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) lobby, there were two posters titled, “Patients’ Rights” posted in the lobby, one in English and one in Spanish. The posters listed an address and phone number under item number 23 “File a complaint with the [state] Department of Public Health (a state regulatory agency) regardless of whether you use the hospital’s grievance (written or oral expression of dissatisfaction regarding the quality of care provided to a patient) process.” During a concurrent observation and interview on 11/12/2024 at 1:16 p.m. in the ED lobby with the Nursing Data Strategist (NDS), surveyor called the phone number listed on the posters, heard a person answer the phone and stated, “This is the Department of Public Health Laboratory.” NDS stated the phone number listed on the posters was incorrect. NDS stated it was not the right phone number for patients to call to file complaints with the state regulatory agency. During an interview on 11/12/2024 at 1:37 p.m. with the charge nurse (CN 2) in ED, CN 2 stated the Patient Access Representative (staff responsible for processing patients when they arrive at the hospital) was responsible to provide patients’ rights information to the patients during registration. During an interview on 11/12/2024 at 2:01 p.m. with the Patient Access Representative (PAR 1), PAR 1 stated she (PAR 1) was not sure what was included in patients’ rights. During an interview on 11/14/2024 at 9:58 a.m. with the Director of Patient Access (DPAR), DPAR stated the Patient Access Representative was responsible to provide patients’ rights information by providing the facility’s admission booklet titled, “Welcome! (Patient Handbook, a patient welcome guide designed to assist patients with simple questions on key care topics and explains patient rights and responsibilities),” to all patients admitted to the facility. During a concurrent record review and interview on 11/14/2024 at 10:10 a.m. with DPAR, the facility’s admission booklet titled, “Welcome! (Patient Handbook), undated, was reviewed. The “Patient Handbook” indicated, on page 10, patients’ rights and responsibilities ... file a complaint with the [state] Department of Public Health regardless of whether you use the hospital’s grievance process. The “Patient Handbook” also indicated a phone number of the [state] Department of Public Health. DPAR stated all patients had rights to file complaint to the state regulatory agency if they were not happy with the care provided by the facility. DPAR stated it was important to have the correct information on the “Patient Handbook.” During a concurrent observation and interview on 11/14/2024 at 10:12 a.m. with the Manager of Accreditation & Regulatory Compliance (MARC) at the facility’s conference room, MARC called the phone number listed on the Patient Handbook, page 10 for the [state] Department of Public Health and received a voice message of “you have reached [a person name] voicemail.” MARC stated this was not the correct phone number for the [state] Department of Public Health. MARC also stated patients would not be able to file complaint with the [state] Department of Public Health with the wrong phone number. During a review of the facility’s policy and procedure (P&P) titled, “Patient-Related Complaint and Grievance Management,” dated 11/2022, the P&P indicated, “[the facility] is committed to providing patients and the patient’s legal representative a complaint and grievance mechanism within the facility designed to promptly resolve patient complaints and grievances regarding the care and service they have received. It was the goal that these complaints and grievances are thoroughly addressed in a timely manner and handled in a way that supports the patient’s right to receive respectful and supportive care ... notifying the patient of their right to file a complaint or grievance. A patient or their legal representative will be notified of their right ... to express complaints or grievances regarding patient care, abuse or neglect. Issues related to the facility’s compliance ... file a grievance with the State Agency responsible for licensing the facility.””

“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: 42937 Based on interview and record review, the facility failed to ensure for one of 30 sampled patients (Patients 19) the following: 1. Patient 19’s environmental safety checklist (a tool that help nursing staff identify and abate environmental hazards that could increase the chance of patient suicide [thoughts of taking one’s own life] or self-harm) for suicide precaution was completed, after Patient 19 was diagnosed with suicidal ideation (when a patient thinks about, consider or feel preoccupied with the idea of death and suicide), in accordance with the facility’s policy and procedure regarding suicide prevention. 2. Patient 19’s re-assessment of Columbia-Suicide Severity Rating Scale ([C-SSRS] a risk assessment intended to help establish a person’s immediate risk of suicide and is used in hospital care settings) was completed, after it was determined that Patient 19 exhibited a change in condition (Patient 19 informed other ED staff members that he was suicidal), in accordance with the facility’s policy and procedure regarding suicide prevention. These deficient practices had the potential to result in self-harm or harm to others for patients who are seen in the Emergency Department (ED, provides immediate care for patients with acute [sudden and severe in onset] illnesses or injuries) and diagnosed with suicidal ideation. Findings: 1. During a review of Patient 19’s “ED (Emergency Department) Physician Notes,” dated 11/12/2024, the “ED Note” indicated, Patient 19 was a 29 year old male with past medical history of schizophrenia (a chronic mental disorder that impacts how a person thinks, perceives reality, and interacts socially) that presented to the Emergency Department with chief complaint of headache for the past 10 hours. Patient initially told triage (process used to assess patient’s injuries or illnesses and determine the priority of care) nurse that he (Patient 19) lost his medication and wants a refill for his Vistaril (a medication used as a sedative to treat anxiety [a feeling of fear or uneasiness] and tension) and Depakote (medication used to treat seizure disorders [a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person’s behavior, movements, and level of consciousness [a person’s awareness and understanding of what is happening in his or her surroundings]). Patient 19 then stated that he (Patient 19) was hearing voices and asked to be put on a 5150 hold (also known as a 72-hour hold, is a legal process that allows for the involuntary detention of an adult in a psychiatric [branch of medicine that focuses on mental, emotional, and behavioral disorders] hospital for up to 72 hours) because he (Patient 19) was also suicidal (thoughts of taking one’s own life). During a concurrent observation and interview on 11/12/2024 at 2:38 p.m. with the Registered Nurse 5 (RN5), Patient 19 was observed in the emergency department (ED) room 10. RN5 stated that Patient 19 was identified as suicidal and that the patient (Patient 19) was moved from room 14 to room 10 at around 6:42 a.m. this morning (11/12/2024). RN5 added that an environmental safety checklist was completed for when Patient 19 was in room 14, but there was no environmental safety checklist done when Patient was moved to room 10. It was the facility’s policy and practice that an environmental safety checklist must be done every time a suicidal patient was transferred or moved to a different room. The environmental safety checklist guides the nurse to identify environmental hazard that may be in the room that a suicidal patient may use to self-harm or harm others. During a review of the facility’s policy and procedure (P&P) titled, “Suicide Prevention,” last revised 4/27/2020, the P&P indicated the following: Interventions for Moderate Risk: Document the plan/actions used to mitigate the risk for suicide for the patient to include at minimum: II. Physical environment. Clinician or PSA will use an environmental checklist to document risk items removed. See Attachment G for an example of the minimum information that should be documented. Items that remain will be justified, for example, oxygen tubing due to pulmonary Issues. - Remove ligature risks (any item that can be used to tie or bind something tightly. Example: Shoelaces, belts, etc.) that can be removed and are not required for the patient’s care. - Identify ligature risks that cannot be removed and ensure they are part of the risk status report during hand-off. Ill. Remove medications, needles, sharps and other potentially dangerous objects from the patient’s area/room. - Inventory and secure patient’s belongings ensuring there are no potentially dangerous Items in the patient’s area/room. - Verify items brought into the patient’s area/room by visitors that may be used for self-harm by the patient. Explain to visitors the items deemed at risk must be removed. Visitors deemed to exacerbate or antagonize the patient’s mental status may lose their ability to visit the patient. - Notify Nutritional Services to serve finger foods on disposable/paper products. 2. During a review of Patient 19’s “ED (Emergency Department) Physician Notes,” dated 11/12/2024, the “ED Note” indicated, Patient 19 was a 29 year old male with past medical history of schizophrenia (a chronic mental disorder that impacts how a person thinks, perceives reality, and interacts socially) that presented to the Emergency Department with chief complaint of headache for the past 10 hours. Patient initially told triage (process used to assess patient’s injuries or illnesses and determine the priority of care) nurse that he (Patient 19) lost his medication and wants a refill for his (Patient 19) Vistaril (a medication used as a sedative to treat anxiety [a feeling of fear or uneasiness] and tension) and Depakote (medication used to treat seizure disorders [a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person’s behavior, movements, and level of consciousness [a person’s awareness and understanding of what is happening in his or her surroundings]). Patient 19 then stated that he (Patient 19) was hearing voices and asked to be put on a 5150 hold (also known as a 72-hour hold, is a legal process that allows for the involuntary detention of an adult in a psychiatric [branch of medicine that focuses on mental, emotional, and behavioral disorders] hospital for up to 72 hours) because he (Patient 19) is also suicidal (thoughts of taking one’s own life). During a concurrent interview and record review on 11/13/2024 at 3:26 p.m. with the Nurse Manager 5 (NM5), Patient 19’s electronic medical record (EMR, a digital version of paper charting), was reviewed. Patient 19’s EMR indicated that an initial CSSRS (Columbia-Suicide Severity Rating Scale ([C-SSRS] a risk assessment intended to help establish a person’s immediate risk of suicide and is used in hospital care settings) screen was completed by the ED (Emergency Department) RN (Registered Nurse) on 11/12/2024 at 12:46 a.m., identifying patient (Patient 19) not at risk for suicide. That same nurse (ED RN) indicated later at 3:54 a.m., that patient (Patient 19) told a provider and other staff members of having suicidal thoughts. Patient (Patient 19) was placed with 1:1 sitter (also known as a one-on-one attendant, provides continuous monitoring and is used to reduce the risk and incidence of harm to patient). NM5 stated that there was no re-screen of a CSSRS at 3:54 a.m., EDRN should have done a reassessment of a CSSRS screen after documenting that there had been a change in behavior (at 3:54 a.m.) where patient (Patient 19) was now determined to be suicidal. During a record review of the facility’s policy and procedure (P&P) titled, “Suicide Prevention,” last revised 4/27/20, the P&P indicated the following: Rescreen: If there is a moderate or high risk of suicide Identified, rescreen using the C-SSRS Frequent Screener tool every shift. In addition, rescreen any time there are changes in the patient’s behavior. Re-screening risk level may increase the interventions. Notify the LIP of any increase in risk level. Interventions should only be decreased using clinical judgement after collaboration with LIP. The LIP must authorize and document any change to the interventions. If patient was initially low risk but changes in behavior led to rescreening that identified a higher risk, refer to E. Lifetime/Recent Assessment and ensure assessment is completed appropriately.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure its nursing staff developed and implemented a 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) care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) upon restraints initiation, for one of 30 sampled patients (Patient 5, in accordance with the facility’s policy and procedure for restraints, when Patient 5 was placed on 5-point restraints in the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care). This deficient practice had the potential to result in lack of nursing intervention and monitoring while Patient 5 was restrained, which may put Patient 5 at risk for injury such as strangulation (when a person’s breathing or blood circulation is impeded by applying pressure to the neck or throat), skin tear, dehydration, etc. Findings: During a concurrent observation and interview on 11/12/2024 at 1:40 p.m. with the Emergency Medical Technician (EMT 1) in the facility’s Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care), Patient 5 was observed sleeping in the gurney with eyes closed. EMT 1 stated Patient 5 had 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) earlier but he (Patient 5) was sedated (medications was given to calm someone or to make someone sleep) now. During an interview on 11/12/2024 at 1:45 p.m. with Registered Nurse (RN) 7, RN 7 stated Patient 5 was on restraints and was given injectable medications of Haldol (medication treats mental disorder) 5 milligrams (mg, unit of measurement), Benadryl (medication causes drowsiness) 50 mg and Versed (a medication that helps someone relax or sleep) 5 mg. During a review of Patient 5’s “Emergency Department Reports (ED report, ED physicians progress notes including patient assessment and care provided),” dated 11/12/2024, the ED report indicated, Patient 5 was brought to the facility’s Emergency Department via law enforcement for the complaint of 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to suicidal (killing self) ideation. The ED report also indicated Patient 5 presented harm to himself (Patient 5) as he (Patient 5) was given injectable medications of Versed, Haldol and Benadryl and was started on physical restraints in the ED. During a concurrent interview and record review on 11/13/2024 at 11:07 a.m. with the Emergency Department Supervisor (EDS), Patient 5’s “Violent or Self Destructive Behavior Restraints - Assessment Flow Sheet, (behavioral restraints flowsheet),” dated 11/12/2024, was reviewed. The behavioral restraints flowsheet indicated, Patient 5 was placed on locked 5-points restraints on 11/12/2024 at 11:50 a.m. with injectable medications of Haldol 5 mg, Benadryl 50 mg and Versed 5 mg given on 11/12/2024 at 12:22 p.m. EDS stated the following: the locked 5-points restraints was applied to Patient 5’s bilateral wrists, bilateral ankles and waist. Patient 5 was chemically restrained with the injectable medications. EDS stated there was no care plan related to restraints initiated and developed for Patient 5. EDS stated care plan was used to identify nursing intervention to resolve a problem. During a concurrent interview and record review on 11/14/2024 at 11:20 a.m. with the Nursing Director of ED (ND 1), the facility’s policy and procedure (P&P) titled, “Patient Plan of Care,” dated 5/2022, was reviewed. The P&P indicated, “All in-patients will have a plan of care developed that includes assessment based on comprehensive patient needs, treatment and goals ... Plans of Care will also be developed (initiate, implemented and evaluated) in the following areas: Emergency Department.” ND 1 stated care plan could be initiated in ED per facility’s policy. During a review of the facility’s policy and procedure (P&P) titled, “Restraint Management (Mechanical, Chemical, Seclusion),” dated 1/2021, the P&P indicated, “General considerations - restraints/ seclusion (the involuntary confinement of a patient alone in a room where they are physically prevented from leaving) ... assessment/ re-assessment ... use of restraint and/or seclusion are in accordance with initiation and modification(s) to patient’s plan of care ... ongoing monitoring/documentation ... documentation of restraint and/or seclusion episode(s) to include, but not limited to: assessments/re-assessments, interventions, care plan/ plan of care modifications, response to interventions, criteria met for discontinuation.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure the physician performed face to face assessment (in-person evaluation documented by a licensed independent practitioner or their designee to evaluate patient’s response to treatment/intervention) within an hour after initiation of violent or self-destructive 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 for restraints, on one of 30 sampled patients (Patient 5), when Patient 5 was placed on 5-point (bilateral wrists, bilateral ankles and waist) restraints in the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care). This deficient practice had the potential to result in lack of evaluation of Patient 5’s response to the behavioral restraints initiated including assessment for continued need for the restraints and/or other interventions, which may result in unnecessary use of restraints and other complications such as strangulation (when a person’s breathing or blood circulation is impeded by applying pressure to the neck or throat), skin tear, dehydration, etc. Findings: During a concurrent observation and interview on 11/12/2024 at 1:40 p.m. with the Emergency Medical Technician (EMT 1) in the facility’s Emergency Department (ED, hospital department that provides unscheduled outpatient services to patients whose condition requires immediate care), Patient 5 was observed sleeping in the gurney with eyes closed. EMT 1 stated Patient 5 had 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) earlier but he (Patient 5) was sedated (medications was given to calm someone or to make someone sleep) now. During an interview on 11/12/2024 at 1:45 p.m. with Registered Nurse (RN) 7, RN 7 stated Patient 5 was on restraints and was given with injectable medications of Haldol (medication treats mental disorder) 5 milligrams (mg, unit of measurement), Benadryl (medication causes drowsiness) 50 mg and Versed (a medication that helps someone relax or sleep) 5 mg. During a review of Patient 5’s “Emergency Department Reports (ED report, ED physicians progress notes including patient assessment and care provided),” dated 11/12/2024, the ED report indicated, Patient 5 was brought to the facility’s Emergency Department via law enforcement for the complaint of 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to suicidal (killing self) ideation. The ED report also indicated Patient 5 also presented harm to himself (Patient 5) as he (Patient 5) was given injectable medications of Versed, Haldol and Benadryl and was started on physical restraints in the ED. During a concurrent interview and record review on 11/13/2024 at 11:07 a.m. with the Emergency Department Supervisor (EDS), Patient 5’s “Violent or Self-Destructive Behavior Restraints - Assessment Flow Sheet, (behavioral restraints flowsheet),” dated 11/12/2024, was reviewed. The behavioral restraints flowsheet indicated, Patient 5 was placed on locked 5-points restraints on 11/12/2024 at 11:50 a.m. along with injectable medications of Haldol 5 mg, Benadryl 50 mg and Versed 5 mg given on 11/12/2024 at 12:22 p.m. EDS stated the following: the locked 5-points restraints was applied to Patient 5’s bilateral wrists, bilateral ankles and waist. Patient 5 was also chemically restrained with the injectable medications. During an interview on 11/14/2024 at 11:09 a.m. with EDS, EDS stated the ED physician would be the one to perform the face-to-face assessment (in-person evaluation documented by a licensed independent practitioner or their designee to evaluate patient’s response to treatment/intervention) on patients placed on violent or self-destructive behavioral restraints to assess patient’s behavior, need for continuation of restraints or alternatives, and patient’s response to the restraints. During a concurrent interview and record review on 11/14/2024 at 11:15 a.m. with the Nursing Director of ED (ND 1), Patient 5’s Emergency Department Reports (ED Reports), dated 11/12/2024, was reviewed. The ED Reports indicated, at 11:45 a.m. “patient (Patient 5) now moved from EMS (Emergency Medical Services, ambulance crew) to now ED gurney physical restraints applied at approximately this time as well.” ND 1 stated there was no documentation from the ED physician that a face-to-face assessment was conducted after initiation of restraints for Patient 5. During a review of the facility’s policy and procedure (P&P) titled, Restraint Management (Mechanical, Chemical, Seclusion),” dated 1/2021, the P&P indicated, “Restraints considerations - violent/self-destructive ... this type of restraint/seclusion order is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others ... after the initial intervention, patients shall be seen face-to-face within one hour by a quailed licensed independent practitioner (LIP), registered nurse or physician assistant who has received education in accordance with requirements to evaluate: a. patient’s immediate situation, b. reaction to intervention, c. medical and behavioral condition, d. need to continue or terminate the restraint(s) or seclusion.””

“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: 50516 Based on interview and record review, the facility failed to ensure for one out of 30 sampled patients (Patient 8), nursing care was provided when: 1. Patient 8’s admission orders were not carried out timely while waiting in the Emergency Department (ED, provides immediate care to patients with acute [sudden and severe in onset] illnesses or injuries) to be admitted in the Medical-Surgical/Telemetry unit (MST, a specialized unit for the patients that needed continuous heart monitoring), in accordance with the facility’s policy on Provision of Patient Care Services. 2. Patient 8 did not have a complete physical assessment (head to toe evaluation) by a Registered Nurse (RN) while in the ED, in accordance with the facility’s policy regarding Provision of Patient Care Services and Emergency Department Triage. 3. Patient 8’s high Blood Pressure (BP, amount of force the blood needs to move through the vessels) readings in the ED were not addressed, in accordance with the facility’s policy regarding Provision of Patient Care Services. These deficient practices resulted in delayed treatment and had the potential to cause a delay in determining Patient 8’s change of condition and/or provision of care needed, which could worsen the patients’ condition and may result in death. Findings: During a review of Patient 8’s “ED (Emergency Department) Depart Summary,” dated 7/17/2024, the record indicated Patient 8 presented to the ED on 7/16/2024 for abdominal pain, nausea (the urge to throw up), vomiting and headache for two weeks. The record further indicated Patient 8 had a medical history of pneumonia (lung infection) and hypertension (HTN, high BP [blood pressure]). The record indicated Patient 8 was triaged (first evaluation of the patient to determine the level and urgency of care needed) on 7/16/2024 at 1:12 p.m. During a review of Patient 8’s “Admission Status” order, dated 7/16/2024 at 4:21 p.m., the order indicated Patient 8 was admitted as an “Inpatient (patient will be admitted to the facility for further care),” to the Medical-Surgical/Telemetry unit (MST, a specialized unit for the patients that needed continuous heart monitoring) unit. 1. During a review of Patient 8’s order for “Telemetry Monitoring (device used for continuous remote measurements of the heart’s activity),” dated 7/16/2024 at 4:22 p.m., the order indicated for Patient 8 to be placed on a telemetry monitoring. During a concurrent interview and record review on 11/14/2024 at 9:58 a.m. with the Emergency Department Supervisor (EDS), the EDS stated when Patient 8 had an order to be admitted in the MST unit, ED did not have an open bed and Patient 8 was placed in the ED waiting room while waiting for a bed in the MST unit. In the same interview and record review on 11/14/2024 at 9:58 a.m., the EDS stated Patient 8’s telemetry monitoring was not initiated as ordered because Patient 8 was placed in the ED waiting room until a bed was available for the patient’s (Patient 8) admission to the MST unit. The EDS also stated that when a patient in the ED needed a bed, the House Supervisor (HS) should be notified by the nursing staff so that the HS would arrange a bed for the patient. There was no documented evidence the HS arranged a bed for Patient 8 when the patient (Patient 8) had an order to be admitted to the MST unit and needed to be on telemetry monitoring. During a review of the facility’s policy and procedure (P&P) titled, “Admission of Patient Nursing,” dated 5/24/2022, the P&P indicated, “Inpatient and Observation Patients: Initiate continuous cardiac (heart) monitoring for patients with orders for telemetry or ICU (Intensive Care Unit [provides critical care and life support for patients with life-threatening injuries or illnesses]) admissions.” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for the Provision of Patient Care Services,” dated 7/18/2024, the P&P indicated, “Goals for patient care are...provide timely and appropriate services including assessments, procedures, interventions, and reassessments to the individualized needs of the patients.” 2. During a concurrent interview and record review on 11/14/2024 at 9:58 a.m. with the Emergency Department Supervisor (EDS), the EDS verified Patient 8’s “System Assessments,” dated 7/16/2024 through 7/17/2024 did not have Patient 8’s complete physical assessment by an RN (Registered Nurse). In the same interview and record review on 11/14/2024 at 9:58 a.m., the EDS stated a complete physical assessment (head to toe evaluation) should be done every two hours to monitor for changes while the patient was in the ED (Emergency Department). The EDS verified Patient 8 did not have a complete physical assessment done by the nurse, from the time Patient 8 was triaged (a system used to prioritize patients based on the severity of their condition and the need for immediate care) in the ED (7/16/2024 at 12:36 p.m.) to when Patient 8 was discharged (released) from the ED (7/17/2024 at 4:16 a.m.). Patient 8 did not have a complete physical assessment for 15 hours while in the ED. During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for the Provision of Patient Care Services,” dated 7/18/2024, the P&P indicated, “Goals for patient care are...provide timely and appropriate services including assessments, procedures, interventions, and reassessments to the individualized needs of the patients.” During a review of the facility’s policy and procedure (P&P) titled, “Emergency Department Triage,” dated 11/14/2024, the P&P indicated “Reassessment of patients in the waiting room should occur approximately every two (2) hours or sooner if indicated by changes in the patient condition. Any change in patient status while waiting shall be documented in the medical record.” During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment Nursing Services,” dated 8/28/2024, the P&P indicated, “On admission, patients will receive a comprehensive physical and psychosocial assessment by a Registered Nurse (RN) ...Reassessment: The minimum timeframes for nursing reassessment are as follows: ED, every 2 hours or as needed.” During a review of the facility’s policy and procedure (P&P) titled, “Admission of Patient, Nursing,” dated 5/24/2022, the P&P indicated, “Inpatient and Observation Patients ...Physical assessment (initial upon admission) ...Perform a physical assessment with a focus on the areas of complaints ...Perform a complete skin/body check and document findings.” 3. During a concurrent interview and record review on 11/14/2024 at 9:58 a.m. with the Emergency Department Supervisor (EDS), the EDS verified Patient 8’s “Vital Signs (BP, heart rate, temperature, and oxygen levels),” dated 7/16/2024 through 7/17/2024, indicated Patient 8’s BP readings were: - On 7/16/2024 at 1:12 p.m., Patient 8’s BP was 174/78 millimeters of mercury (mmHg, a unit of measurement; Normal BP range is 120/90); At 4:31 p.m., Patient 8’s BP was 179/87 mm/Hg; At 8:08 p.m., Patient 8’s BP was 178/78 mm/Hg; At 11:40 p.m., Patient 8’s BP was 184/77 mm/Hg. - On 7/17/2024 at 1:00 a.m., Patient 8’s BP was 168/78 mm/Hg. The EDS stated Patient 8’s BP was high and not in an acceptable range. The EDS verified Patient 8’s record had no documentation notifying the physician of Patient 8’s high BP. In the same interview and record review on 11/14/2024 at 9:58 a.m., the EDS stated Patient 8 had two BP medication (Amlodipine and Hydralazine, both used to lower and control BP) orders that were not given to Patient 8. The EDS verified Patient 8’s record had no documentation as to why the patient’s (Patient 8) BP medication were not given as ordered. During a review of the facility’s “Policy and Procedure (P&P),” titled, “Hospital Plan for the Provision of Patient Care Services,” dated 7/18/2024, the P&P indicated, “Goals for patient care are...provide timely and appropriate services including assessments, procedures, interventions, and reassessments to the individualized needs of the patients.” During a review of the facility’s “Policy and Procedure (P&P)” titled, “Assessment and Reassessment Nursing Services,” dated 8/28/2024, the P&P indicated, “The scope and intensity of the assessment will be determined by: The level of care needed; The patient’s desire for care and interventions; The patient’s response to treatments, care, and interventions...Documentation: Every effort should be made to document assessments and interventions in a timely manner.”

“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: 50516 Based on interview and record review, the facility failed to: 1. Initiate and develop an individualized care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 30 sampled patients (Patient 4), to address Patient 4’s diaper rash, in accordance with the facility’s policy and procedure regarding care planning. This deficient practice had the potential to result in the delay of care and evaluation of Patient 4’s response to treatment and intervention, by not identifying Patient 4’s needs and risks, which may result in worsening of Patient 4’s condition and may prolong hospitalization. 2. Develop and implement an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) related to dialysis (procedure that cleans the blood by removing extra fluids and waste), for one of 30 sampled patients (Patient 14), in accordance with the facility’s policy and procedure regarding care planning. This deficient practice had the potential to result in delayed provision of treatment by not identifying Patient 14’s needs and risks, which may result in complications for Patient 14 such as difficulty in breathing due to excessive fluids in the body, irregular heartbeat, confusion, and/or death. 3. Develop and implement an individualized nursing care plan to address issues with bleeding for one of 30 sampled patients (Patient 16), in accordance with the facility’s policy and procedure regarding care planning. This deficient practice had the potential to result in delayed treatment by not identifying Patient 16’s needs and risks, which may result in excessive blood loss, hypotension (low blood pressure), and/or death. 4. Implement the care plan developed regarding seizure (a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person’s behavior, movements, and level of consciousness [a person’s awareness and understanding of what is happening in his or her surroundings]) precautions for one of 30 sampled patients (Patient 25), in accordance with the facility’s policy regarding care planning, when seizure pads were not documented being placed on Patient 25’s bed’s siderails. This deficient had the potential for Patient 25 to sustain an injury in case of a seizure episode, which may include fracture (break in the bone), contusion (bruise), etc., and may result in prolonged hospitalization and recovery. Findings: 1. During a review of Patient 4’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/6/2024, the H&P indicated, Patient 4 was an 11-day-old infant (baby) admitted to the facility with diagnosis of diaper dermatitis (diaper rash). The H&P also indicated Patient 4 had extensive erythema (reddening of the skin) on convex (curved or rounded) skin surfaces of his (Patient 4’s) buttocks and groin, and clusters of papules (inflammatory form of acne)/pustules (blister-like sores) on the right and left inner thigh. During a concurrent interview and record review on 11/13/2024 at 4:12 p.m. with the Nurse Manager (NM2) of Pediatrics (Peds, hospital unit with patients from very young infant to teenagers who require hospital admission for a variety of medical illnesses) and Neonatal Intensive Care Unit (NICU, hospital unit that provides specialized care for sick or premature newborn babies), Patient 4’s “Care plans (care plan, provides a framework for evaluating and providing patient care needs related to the nursing process),” dated 11/6/2024, was reviewed. The care plan indicated a care plan related to problems of infection, fall (unplanned descent to the floor with or without injury to the patient) risk and knowledge deficit (lack of) related to discharge, were developed on 11/6/2024. NM2 stated there was no care plan developed to address Patient 4’s problem with diaper rash or skin issue that Patient 4 came in with. NM 2 stated the care plan should be customized to Patient 4’s active problem to provide nursing intervention focusing on the skin issue and to evaluate the wound or rashes healing. NM2 stated lack of care plan development to address the active problem could cause delay of care due to lack of wound healing monitoring and may prolong hospital stay. During a review of the facility’s policy and procedure (P&P) titled, “Patient Plan of Care,” dated 5/2022, the P&P indicated, “All in-patient will have a plan of care developed that includes assessment based on comprehensive patient needs, treatment and goals ... The care plan must be initiated within the first eight (8) hours after admission by the Registered Nurse ... It is the responsibility of the RN to develop the plan of care ... the problems will be based on the nursing admission assessment and additional data contributed by other members of the health care team and the patient.” 2. During a review of Patient 14’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/8/2024, the H&P indicated Patient 14 was admitted to the facility for a right foot wound and gangrene (dead tissue due to the lack of blood supply). The H&P further indicated Patient 14 had a medical history of End Stage Renal Disease (ESRD, irreversible kidney failure) on hemodialysis (HD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Patient 14’s “Care Plans: Medical,” the record indicated Patient 14 received HD on 11/9/2024 and 11/12/2024. During a concurrent interview and record review on 11/13/2024 at 10:30 a.m. with Nurse Manager 4 (NM 4) and the Program Specialist (PS), NM 4 and the PS both verified that Patient 14’s “Care Plans” did not include a plan for Patient 14’s management and needs for HD. NM 4 stated there should have been a care plan related to Patient 14’s HD. NM 4 stated Patient 14’s care plan was for everyone to know what the plan was for Patient 14’s management of HD. During a review of the facility’s “Policy and Procedure (P&P)” titled, “Patient Plan of Care,” dated 5/24/2022, the P&P indicated, “The care plan must be initiated within the first 8 hours after admission by the Registered Nurse ...It is the responsibility of the RN to develop the plan of care ...Nursing Services: Plan of care are reviewed every shift, revised as needed, and when there is a change in the patient’s condition, level of care, outcomes, problems or needs.” 3. During a review of Patient 16’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/5/2024, the H&P indicated Patient 16 was admitted to the facility for weakness and dizziness for six days, and lower leg swelling and rectal bleeding (bleeding from the lower colon or rectum) for two months. The H&P further indicated Patient 16 had a medical history of anemia (condition where the body does not have enough healthy red blood cells), alcohol abuse (when a person continuous to consume alcohol despite the adverse consequences. Example: liver disease, mental and behavioral problems), and anxiety (a feeling of fear or uneasiness). During a review of Patient 16’s “Order Information for Transfusion (procedure that moves whole or partial blood parts into the body),” dated 11/5/2024 and 11/11/2024, the orders indicated the following: - On 11/5/2024, Patient 16 had an order to receive six units (bags) of red blood cell (important part of the blood that carries oxygen throughout the body) transfusions and one unit of plasma (liquid part of the blood). Patient 16 received the blood transfusions. -On 11/11/2024, Patient 16 had an order to receive one unit of platelets (part of the blood that forms a clot to stop bleeding). Patient 16 received the blood transfusion. During a concurrent interview and record review on 11/13/2024 at 11:06 a.m. with Nurse Manager 4 (NM 4) and the Program Specialist (PS), NM 4 and the PS both verified Patient 16’s “Care Plans,” did not have a plan related to bleeding or blood transfusions. The PS stated a “Risk for Bleeding/Hemorrhage” care plan should have been added. NM 4 stated it was important to know what the plan and interventions were to manage Patient 16’s bleeding. During a review of the facility’s “Policy and Procedure (P&P)” titled, “Patient Plan of Care,” dated 5/24/2022, the P&P indicated, “The care plan must be initiated within the first 8 hours after admission by the Registered Nurse ...It is the responsibility of the RN to develop the plan of care ...Nursing Services: Plan of care are reviewed every shift, revised as needed, and when there is a change in the patient’s condition, level of care, outcomes, problems or needs.” 4. During review of Patient 25’s “Face Sheet (a document that summarizes a patient’s key personal and medical information, including their name, address, date of birth, insurance details, allergies, medical history, and current medications ),” dated November 2024, the Face Sheet indicated the following: Patient 22 was admitted to the hospital on 11/10/2024 for seizure (a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person’s behavior, movements, and level of consciousness [a person’s awareness and understanding of what is happening in his or her surroundings]) and was discharged from the hospital on 11/12/2024. During review of Patient 25’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated November 2024, the “H&P,” indicated the following: Patient 25 was brought to the hospital for witnessed seizure at the gym. During a concurrent interview and record review on 11/13/2024 at 3:10 p.m. with the Associate Patient Care Executive (APCE), Patient 25’s “ADL (Activities of Daily Living, basic self-care tasks that people perform regularly such as toileting, hygiene, feeding, etc.) Flow Sheet,” dated November 2024, was reviewed. The ADL Flowsheet indicated the following: On 11/10/2024 at 3 p.m. to 11/11/2024 at 10 p.m., there was no documentation that seizure pads were used for Patient 25’s safety. APCE confirmed that there was no documentation seizure padded equipment was used for Patient 25. APCE also said the staff need to document the use of seizure pads in the medical chart for patients with seizure to indicate implementation of the seizure precaution (which includes the application of seizure pads on side rails) for patient. APCE stated it was important to utilize the seizure pads to protect the patient from injuring self during a seizure episode. APCE also said the staff should document the use of the seizure pads as part of the seizure precaution care plan implementation. During a review of Patient 25’s “Care Plan,” dated November 2024, the Care Plan indicated the following: Patient 25 had a care plan selected for Seizure that indicated to initiate seizure precautions which included padded side rails/suction device (a medical device used to remove fluids such as vomit, mucus, blood, etc.) and Oxygen at bedside. During a review of the facility’s policy and procedure (P&P) titled, “Patient Plan of Care,” dated 5/2022, the “P&P” indicated the following: Patient Plan of Care: The patient’s plan of care and goals are developed with the patient/family and reflect individualized care and treatment provided by the multidisciplinary team. A. The patient record, in its entirety, reflects the plan of care for the patient. All in-patients will have a plan of care developed that includes assessment based on comprehensive patient needs, treatments and goals. Qualified members of the Health Care team will be responsible for documenting the plan of care whenever a need is identified. Revisions, updates or resolutions will also be documented whenever there is a significant change in the patient’s diagnosis or condition. 1.Nursing Services: Plan of care are reviewed every shift, revised as needed, and when there is a change in the patient’s condition, level of care, outcomes, problems or needs.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 42976 Based on interview and record review, the facility failed to: 1. Ensure staffed followed the facility’s “Central Venous Catheter Management Policy,” for one of 30 sampled patients (Patient 24), when Patient 24 had a PICC line (Peripheral Inserted Central Catheter, is an intravenously [into the vein] placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava [a large vein that carries blood from the head, neck, arms, and chest], and used for intravenous treatment that is required over a long period) placement done and staff did not obtain an order that it was okay to use the PICC line prior to using the PICC line for medication administration. This deficient practice had the potential for misplaced PICC line to lead to serious complications like infection, bleeding, pneumothorax (when air leaks from the lung into the space between the lung and the chest wall), or arrythmias (abnormal heart rhythm). 2. Ensure one of 30 sampled patient’s (Patient 12) Code Status (type of lifesaving emergency treatment someone wants, which can or cannot include chest compressions, a breathing tube, and medications) was verified and physician was notified regarding the absence of documented order for Patient 12’s code status, and ensure documentation of code status order in Patient 12’s medical record, within 24 hours after admission, in accordance with the facility’s policy and procedure regarding Code status. This deficient practice had the potential for Patient 12 to receive inappropriate emergency life sustaining measures, and/or delay the care for Patient 12, which could lead to serious harm and/or death. 3. Ensure one of 30 sampled patients (Patients 17) operating room nursing staff adhered to the facility’s policy and procedure regarding chain of command (a formal process that hospital staff use to escalate concerns about patient safety or other issues to the appropriate levels of authority), when it was identified that the surgeon continued and completed surgical skin closure (the final step in a surgical procedure that involves repairing the skin and deeper layers of tissue to promote healing) after being told that the surgical count (a crucial procedure that ensures no surgical items are left behind in a patient after surgery) was incorrect. This deficient practice resulted in Patient 17 having to undergo another surgical procedure to retrieve a surgical sponge that was left unintentionally inside Patient 17’s abdominal cavity. This deficient practice also had the potential to cause complications such as infection, uncontrolled bleeding, and psychological distress for Patient 17. Findings: 1. During a review of Patient 24’s “Face Sheet (a document that summarizes a patient’s key personal and medical information, including their name, address, date of birth, insurance details, allergies, medical history, and current medications),” dated November 2024, the Face Sheet indicated Patient 24 was admitted to the facility unit on 11/11/2024. During a review of Patient 24’s “ED (Emergency Department, provides immediate care for patients with acute [sudden and severe in onset] illnesses or injuries) Physician Notes ,” dated November 2024, the ED Physician Notes indicated the following: Patient 24 was brought in by ambulance for generalized weakness with abdominal pain, vomiting, and hypotension (low blood pressure). Patient 24 had a history of gastric cancer (cancer of the stomach) and had a PICC (Peripheral Inserted Central Catheter, is an intravenously [into the vein] placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is positioned in a location at the superior vena cava [a large vein that carries blood from the head, neck, arms, and chest], and used for intravenous treatment that is required over a long period) line. Medical plan was to admit Patient 24 to the Intensive Care Unit (ICU, provides critical care and life support for patients who are very sick or injured). During a review of Patient 24’s “Chest X Ray (an imaging test to create pictures of the organs and structures in the chest) Report ,” dated November 2024, the Chest X-ray report indicated the following: Patient 24 with PICC line terminating in the right atrium (the upper chamber on the right side of the heart that receives oxygen-poor blood from the body and then pumps it into the right ventricle to be sent to the lungs for oxygenation). During a concurrent interview and record review on 11/12/2024 at 1:55 p.m. with the Associate Patient Care Executive (APCE), Patient 24’s “Medication Administration Record (MAR),” dated November 2024, was reviewed. The “MAR” indicated the following: On 11/11/2024 at 12:41 p.m., gastrointestinal (refers to the stomach and the intestines) bleed medication “Octreotide” was administered to Patient 24 at 1:58 p.m., pain medication “Hydromorphone” and nausea medication “Zofran,” was administered to Patient 24. APCE confirmed the 3 medications (Octreotide, Hydromorphone, & Zofran) were administered by staff using the PICC line without obtaining an “okay to use” order from the physician. APCE said the staff should not administer the 3 medications to Patient 24, using the PICC line, without an okay to use PICC line order from the doctor. APCE confirmed the X ray report for Patient 24 did not say okay to use PICC line and during the times 3 medications were administered, there was no okay to use PICC line order or documentation. APCE stated it was dangerous to give medication using the PICC line without knowing or confirming the location because it can cause harm to the patient if not in the correct location for use. APCE said staff did not follow the policy regarding PICC line use and will provide education to the staff. During a review of the facility’s policy and procedure (P&P) titled, “Central Venous Catheter Management,” dated December 2024, the “P&P” indicated following: POLICY SUMMARY/INTENT: To provide evidence-based and standardized practices for central venous catheter insertion. management and maintenance aimed at the prevention of central line-associated bloodstream Infections (CLABSI). This policy does not intend to replace critical decision-making by the provider inserting the central venous catheter; consideration should be given to the entire clinical circumstance and the goals to prevent potential harm or infection. 8. Peripherally Inserted Central Catheter (PICC): A type of long catheter that is inserted through a peripheral vein, often In the arm, into a larger vein in the body, used when intravenous treatment is required over a long period. Because of tip location, PICC lines are considered central vascular access devices. E. Verification of line placement: 1. All central lines should have an ‘insertion’ or ‘may use’ order (e.g., “May use central line’), which documents necessity. 2. If a patient arrives to the hospital with a central line in place - A. Notify provider of line presence. B. Obtain an order from provider to confirm placement for central venous catheter above the diaphragm via chest x-ray. C. Obtain an order from provider to access line (e.g., “May use central line’), which documents necessity. 2. During a review of Patient 12’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/12/2024, the H&P indicated Patient 12 was admitted on 11/11/2024, to the facility, for nausea (urge to throw up), vomiting, and diarrhea (loose stool). The H&P further indicated Patient 12 had a medical history of diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN, high blood pressure [BP, amount of force the blood needs to move through the vessels]). During a concurrent interview and record review on 11/13/2024 at 2:00 p.m. with the Nursing Director 2 (ND 2) and the Nurse Manager 3 (NM 3), ND 2 and NM 3 both verified that Patient 12’s record did not have the patient’s (Patient 12) code status (type of lifesaving emergency treatment someone wants, which can or cannot include chest compressions, a breathing tube, and medications) and was documented as, “Code Status: Not Ordered (Patient 12 had been admitted to the facility for more than 24 hours). In the same interview on 11/13/2024 at 2:00 p.m., ND 2 stated the nurses were responsible for notifying the physician that Patient 12 did not have a Code Status order. ND 2 stated the patient’s code status was important to know the patient’s wishes for medical treatment. During a review of the facility’s policy and procedure (P&P) titled, “Code Status and Philosophy of Care Regarding Life-Sustaining Measures,” dated 6/21/2023, the P&P indicated, “A patient’s code status is to be confirmed by a physician within the first 24 hours of his/her care ...The patient’s code status and philosophy of care is documented in writing by the physician in the Medical Record.” 3. During a concurrent interview and record review on 11/12/2024 at 1:30 p.m. with the Associate Patient Care Executive (APCE), Patient 17’s medical record (MR), was reviewed. Patient 17’s medical record indicated that on 7/9/2024, Patient 17 was brought in by paramedics (highly trained health care professionals who respond to emergencies to provide advanced life support and transport patients to medical facilities) for abdominal pain. Patient 17 was diagnosed with perforated gastric ulcer (also known as a ruptured ulcer, is a serious condition that occurs when an untreated stomach ulcer eats through the stomach lining and creates a hole) and underwent exploratory laparotomy (a surgical procedure that allows a doctor to examine the abdominal organs by making a cut in the abdomen) that same day (7/9/2024). During the same interview on 11/12/2024 at 1:30 p.m. with the Associate Patient Care Executive (APCE), APCE stated that back in July 2024, the facility reported a retention of foreign object (RFO, a medical procedure unintentionally left a surgical tool or material, like a sponge or a piece of equipment, inside a patient’s body after surgery, essentially leaving a foreign object behind) incident involving a patient (Patient 17). Patient 17 had exploratory laparotomy surgery on 7/9/2024. It was noted that one (1) lap sponge (also known as a laparotomy sponge or abdominal pad, is a sterile, absorbent pad used to control bleeding and keep surgical areas clear of fluids during surgical procedures) was missing, but medical doctor 5 (MD 5) continued and completed surgical skin closure (the final step in a surgical procedure that joins the edges of a wound to help it heal). An x-ray (a plain radiographs that provide doctors a way to get pictures of the inside of a patient body) was ordered, and it was found that one (1) lap sponge was left in Patient 17’s abdomen. MD5 had to reopen Patient 17’s surgical site and retrieve the surgical sponge. APCE said the incident was reportable and against hospital policy because the surgical count was not verified as complete, prior to the surgical skin closure. APCE stated that the operating room (OR) nursing staff was reluctant to tell MD 5 to stop surgical skin closure despite knowing and informing the surgical team that the count was not correct, and that one lap sponge was missing. During a concurrent interview and record review on 11/12/2024 at 4:00 p.m. with the Registered Nurse 4 (RN 4), Patient 17’s medical record titled, “Surgery and Procedure Reports,” dated 7/9/2024 7:57 p.m., was reviewed. The report indicated “final lap sponge count’s incorrect, surgeon notified. Portable x-ray ordered, lap sponge found in abdominal cavity, lap sponge removed from abdominal cavity by surgeon and final sponge count correct.” RN 4 stated that MD5 started initiating skin closure at the start of the surgical count. MD5 was notified that the count was incorrect, there was a missing lap sponge. RN 4 said MD5 continued and completed surgical skin closure. RN 4 also stated MD5 should have waited until surgical count was verified as correct prior to completing the surgical skin closure. RN 4 further said that an X-ray was ordered, and it confirmed a lap sponge was left inside Patient 17’s abdomen. MD5 had to reopen the surgical site and retrieved the lap sponge. RN 4 added that, MD5 continued to close even with an incorrect count because MD5 did not believe the lap sponge was left inside Patient 17’s abdomen. Patient 17 was an emergency add-on case. During a concurrent interview and record review on 11/13/2024 at 11:53 a.m. with the Nurse Manager 6 (NM6), Patient 17’s medical record titled, “Surgery and Procedure Reports,” dated 7/9/2024 7:57 p.m., was reviewed. The report indicated “final lap sponge counts incorrect, surgeon notified. Portable x-ray ordered, lap sponge found in abdominal cavity, lap sponge removed from abdominal cavity by surgeon and final sponge count correct.” NM6 stated that she (NM6) was made aware of RFO (Retention of Foreign Object) incident involving Patient 17 on the next day post procedure on 7/10/2024. NM6 said, the facility identified the issue of not following the “chain of command,” RN 4 was the assigned circulating nurse at the time of the surgery and should have reported to house supervisor that the surgeon did not stop and completed surgical skin closure even after being informed that surgical count was incorrect, and a lap sponge was missing. During a review of the facility’s policy and procedure (P&P) titled, “Chain of Command,” last revised 12/22/21, the P&P indicated the following: Clinical Issues a. The chain of command for clinical issues must be accessed in a timely manner to prevent delay of treatment. If the situation cannot be resolved at the lowest possible level, the next level should be accessed. b. Any licensed caregiver who has reason to doubt the appropriateness of the medical care being provided to a patient should discuss the situation starting with the first individual listed below: Step 1: Discuss with individual directly involved (Resident / Physician Assistant or Nurse Practitioner, if involved). Step 2: If Step 1 was with someone other than Attending and it is unresolved, discuss with Attending. Step 3: If the problem cannot be resolved by Steps 1 or 2, the staff member should notify the Shift Leader (i.e., Shift Coordinator, Charge Nurse, etc.). The Shift Leader will then assume responsibility. Step 4: Discuss with Residency Program Director (only when Resident is involved). In the event that the Residency Program Director is notified, the Shift Leader should also notify his/her Manager or Department Director (or House Supervisor). Step 5: Discuss with Medical Director. If there is not Medical Director, go to Step 6. In the event that the Medical Director is notified, the Shift Leader should also notify his/her Department Director (or House Supervisor).”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 50516 Based on interview and record review, the facility failed to ensure for two of 30 sampled patients (Patients 8 and 9), the following: 1.a. For Patient 8, Amlodipine (medication used to lower blood pressure [BP, amount of force blood uses to move through the body]) was given as ordered by the physician. This deficient practice had the potential for Patient 8’s blood pressure to remain elevated, which may result in complications such as heart attack and stroke (formation of blood clots in the brain), leading to paralysis (loss of function in part or all of the body) and/or death. 1.b. For Patient 8, Hydralazine (medication used to lower BP) was given as ordered by the physician. This deficient practice had the potential for Patient 8’s blood pressure to remain elevated, which may result in complications such as heart attack and stroke (formation of blood clots in the brain), leading to paralysis (loss of function in part or all of the body) and/or death. 1.c. For Patient 8, Lactated Ringers (LR, intravenous fluid given through the vein to help balance electrolyte [minerals that carry an electric charge found in the body which are important for bodily functions such as heart rate and rhythm, blood pressure, etc.] levels) was given as ordered by the physician. This deficient practice had the potential for Patient 8 to have a low blood volume or low blood pressure, which may result in complications such as hypovolemic shock (a life-threatening medical condition where a significant loss of blood or bodily fluids prevents the heart from pumping enough blood to adequately supply the body with oxygen, leading to organ dysfunction and potentially causing death if not treated promptly), thus leading to prolonged hospitalization and/or death. 2. For Patient 9, Lamotrigine (a medication to prevent seizures [a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person’s behavior, movements, feelings, and level of consciousness- used to describe a person’s awareness and understanding of what is happening in his or her surroundings]) was given as ordered by the physician. This deficient practice had the potential to result in persistent seizure episodes, which may lead to permanent injury or death for Patient 9. Findings: 1. During a review of Patient 8’s “ED (Emergency Department) Depart Summary,” dated 7/17/2024, the record indicated Patient 8 presented to the ED on 7/16/2024 for abdominal pain, nausea (urge to throw up), vomiting and headache for two weeks. The record further indicated Patient 8 had a medical history of pneumonia (lung infection) and hypertension (HTN, higher BP ranges than the normal BP of less than 120/80). During a concurrent interview and record review on 11/13/2024 at 9:58 a.m. with the Emergency Department Supervisor (EDS), the EDS verified that on 7/16/2024 at 4:21 p.m., Patient 8 was admitted to the facility as an “Inpatient (patient will be admitted to the facility for further care),” to the “Medical-Surgical/Telemetry unit (MST, a specialized unit for the patients that need continuous heart monitoring).” The EDS stated Patient 8 remained in the ED while waiting for an inpatient bed. 1.a. During a concurrent interview and record review on 11/14/2024 at 9:58 a.m. with the EDS, the EDS verified Patient 8’s “Vital Signs (BP, heart rate, temperature, and oxygen levels),” dated 7/16/2024 through 7/17/2024, indicated Patient 8’s BP readings were: - On 7/16/2024 at 1:12 p.m., Patient 8’s BP was 174/78 millimeters of Mercury (mmHg, a unit of measurement; Normal BP range is 120/80); at 4:31 p.m., Patient 8’s BP was 179/87 mmHg; at 8:08 p.m., Patient 8’s BP was 178/78 mmHg; at 11:40 p.m., Patient 8’s BP was 184/77 mmHg. - On 7/17/2024 at 1:00 a.m., Patient 8’s BP was 168/78 mmHg. In the same interview and record review on 11/14/2024 at 9:58 a.m., the EDS verified Patient 8’s “Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient),” dated 7/16/2024, included a physician’s order of Amlodipine (medication to lower blood pressure) 5 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount) to be given orally once a day, with a start date of 7/16/2024 at 8:19 p.m. Subsequently, the EDS verified Patient 8’s MAR, dated 7/17/2024 at 2:51 a.m., indicated the Amlodipine was not given, and was documented as “Not done: start with next dose,” (Amlodipine was ordered to be given on 7/16/2024 at 8:19 p.m.). During the same interview on 11/14/2024 at 9:58 a.m. with the EDS, the EDS stated Patient 8’s Amlodipine was not given as ordered by the physician. The EDS stated Patient 8’s BP was high and not in an acceptable range. The EDS verified Patient 8’s record had no documentation as to why the patient’s BP medication was not given as ordered. During a review of the facility’s policy and procedures (P&P) titled, “Medication Administration - In-Patient (Nursing),” dated 07/16/2024, the P&P indicated, “For the nursing staff ...follow the 6 rights of medication administration: Right patient (with 2 patient identifiers);Right time; Right drug; Right dose; Right route; Right documentation ...If a medication is not given, the reason must be documented on the MAR (Medication Administration Record), and communicated to the prescriber.” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for the Provision of Patient Care Services,” dated 7/18/2024, the P&P indicated, “Goals for patient care are...provide timely and appropriate services including assessments, procedures, interventions, and reassessments to the individualized needs of the patients.” 1.b. During a concurrent interview and record review on 11/14/2024 at 9:58 a.m. with the Emergency Department Supervisor (EDS), the EDS verified Patient 8’s “Vital Signs (BP, heart rate, temperature, and oxygen levels),” dated 7/16/2024 through 7/17/2024, indicated Patient 8’s BP readings were: - On 7/16/2024 at 1:12 p.m., Patient 8’s BP was 174/78 millimeters of Mercury (mmHg, a unit of measurement; Normal BP range is 120/80; At 4:31 p.m., Patient 8’s BP was 179/87 mmHg; At 8:08 p.m., Patient 8’s BP was 178/78 mmHg; At 11:40 p.m., Patient 8’s BP was 184/77 mmHg. - On 7/17/2024 at 1:00 a.m., Patient 8’s BP was 168/78 mmHg. In the same interview and record review on 11/14/2024 at 9:58 a.m., the EDS verified Patient 8’s “Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient),” dated 7/16/2024, included a physician’s order of Hydralazine (medication to lower blood pressure) 25 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount) to be given by mouth three times a day, with a start date and time of 7/16/2024 at 9:00 p.m. Subsequently, the EDS verified Patient 8’s MAR, dated 7/17/2024 at 2:51 a.m., indicated the Hydralazine was not given, and was documented as “Order discontinued/duplicated.” During the same interview on 11/14/2024 at 9:58 a.m. with the EDS, the EDS stated Patient 8’s Hydralazine order was not duplicated and should have been given as ordered. The EDS stated Patient 8’s BP was high and not in an acceptable range. The EDS verified Patient 8’s record had no documentation as to why the patient’s BP medication was not given as ordered. During a review of the facility’s policy and procedures (P&P) titled, “Medication Administration - In-Patient (Nursing),” dated 07/16/2024, the P&P indicated, “For the nursing staff ...follow the 6 rights of medication administration: Right patient (with 2 patient identifiers);Right time; Right drug; Right dose; Right route; Right documentation ...If a medication is not given, the reason must be documented on the MAR (Medication Administration Record), and communicated to the prescriber.” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for the Provision of Patient Care Services,” dated 7/18/2024, the P&P indicated, “Goals for patient care are...provide timely and appropriate services including assessments, procedures, interventions, and reassessments to the individualized needs of the patients.” 1.c. During a concurrent interview and record review on 11/14/2024 at 9:58 a.m. with the Emergency Department Supervisor (EDS), the EDS verified Patient 8’s “Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient),” dated 7/16/2024, included a physician’s order of LR (Lactated Ringer’s, intravenous fluid given through the vein to help balance electrolyte [minerals that carry an electric charge found in the body which are important for bodily functions such as heart rate and rhythm, blood pressure, etc.] levels) intravenous (IV, through the veins) fluids to be given continuously at 80 milliliters per hour (mL/hr, a unit of measurement), with a start date of 7/16/2024 at 7:27 p.m. The EDS verified Patient 8’s LR IV fluids was initiated on 7/17/2024 at 5:15 a.m. (a total of 9 hours and 48 minutes after LR was ordered to be given). In the same interview and record review, on 11/14/2024 at 9:58 a.m., the EDS stated, when Patient 8 had an order to be admitted in the MST (Medical-Surgical Telemetry) unit, ED did not have an open bed and Patient 8 was placed in the ED waiting room while waiting for a bed in the MST unit. In the same interview on 11/14/2024 at 9:58 a.m., the EDS stated patients in the ED waiting room were not allowed to have IV fluids and/or medications. The EDS verified Patient 8 did not receive the LR IV fluid until Patient 8 was transferred to the MST unit on 7/17/2024 at 4:16 a.m. During a review of the facility’s policy and procedures (P&P) titled, “Medication Administration - In-Patient (Nursing),” dated 07/16/2024, the P&P indicated, “For the nursing staff ...follow the 6 rights of medication administration: Right patient (with 2 patient identifiers);Right time; Right drug; Right dose; Right route; Right documentation ...If a medication is not given, the reason must be documented on the MAR (Medication Administration Record), and communicated to the prescriber.” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for the Provision of Patient Care Services,” dated 7/18/2024, the P&P indicated, “Goals for patient care are...provide timely and appropriate services including assessments, procedures, interventions, and reassessments to the individualized needs of the patients.” 2. During a review of Patient 9’s “Emergency Department (ED) Physician Notes,” dated 11/12/2024, the record indicated, Patient 9 was seen in the ED for a possible unwitnessed seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), noted by abnormal behavior during dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). The note further indicated that Patient 9 had a medical history of End Stage Renal Disease (ESRD, irreversible kidney failure) and seizures. During a review of Patient 9’s “ED Physician Notes,” dated 11/12/2024, the record indicated, on 11/12/2024 at 7:03 a.m., Patient 9 had an order to be admitted to the Medical-Surgical/Telemetry unit (MST, a specialized unit for the patients that need continuous heart monitoring). During an interview on 11/14/2024 at 9:58 a.m., with the Emergency Department Supervisor (EDS), the EDS stated, if a patient was in ED waiting for an inpatient bed, the ED nurses were responsible for carrying out the inpatient orders. During a concurrent interview and record review on 11/14/2024 at 10:35 a.m. with the EDS, the EDS verified Patient 9’s “Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient),” dated 11/12/2024, included a physician’s order of Lamotrigine (a medication to prevent seizures) 150 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount) to be given by mouth twice a day, with a start date and time of 11/12/2024 at 10:41 a.m. In the same interview and record review on 11/14/2024 at 10:35 a.m., the EDS verified Patient 9’s MAR dated 11/12/2024 at 4:21 p.m., indicated Lamotrigine was not given, and “Patient [was] not available/off unit,” (a total of six hours after Lamotrigine was ordered to be given). During the same interview on 11/14/2024 at 10:35 a.m., the EDS stated Patient 9 should have received Lamotrigine. The EDS stated the Registered Nurse (RN) responsible for Patient 9’s care should have notified the physician of the late or missed dose, and/or should have the medication rescheduled. The EDS verified Patient 9’s record did not have documentation the physician was notified of the late or missed dose of Lamotrigine. During a review of the facility’s “Policy and Procedure (P&P)” titled, “Medication Administration - In-Patient (Nursing),” dated 07/16/2024, the P&P indicated, “For the nursing staff ...follow the 6 rights of medication administration: Right patient (with 2 patient identifiers);Right time; Right drug; Right dose; Right route; Right documentation ...If a medication is not given, the reason must be documented on the MAR (Medication Administration Record), and communicated to the prescriber.””

“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: 50516 Based on interview and record review, the facility failed to ensure one of 30 sampled patient’s (Patient 13) vital signs (VS, set of blood pressure, temperature, heart rate, breathing rate, and oxygen measurements), were frequently checked and monitored during blood transfusions (critical procedure that moves blood or blood products into a person who has low blood levels, and can carry risks such as an allergic reaction, heart and lung problems, and death), in accordance with the facility’s policy and procedure regarding blood administration. This deficient practice had the potential to cause a delay in determining Patient 13’s change of condition such as the presence of an allergic reaction, irregular heart rhythm, etc. and/or a delay in the provision of emergent treatment needed which could worsen Patient 13’s condition and may result in death. Findings: During a review of Patient 13’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/11/2024, the H&P indicated Patient 13 was admitted to the facility on 11/10/2024 for a rectal bleed (lower colon or rectum bleeding). The H&P further indicated Patient 13 had a medical history of Gastrointestinal (GI, digestive system) bleed. During a review of the physician’s order, dated 11/12/2024, the order indicated for Patient 13 to have 2 units (bags) of Packed Red Blood Cells (PRBC, part of the blood that carries oxygen from the lungs to the body tissue) transfused for a Hemoglobin (Hgb, part of the red blood cell that carries oxygen) level of less than 7. 1.a. During a concurrent interview and record review on 11/14/2024 at 3:53 p.m. with the Nurse Manager 3 (NM 3), NM 3 verified Patient 13’s “Blood Product Administration,” dated 11/12/2024, Patient 13 received one unit of PRBC (first bag) from 11:03 a.m. through 3:01 p.m. In the same interview and record review on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13’s vital signs (VS) for Patient 13’s first blood transfusion was taken on 11/12/2024 at the following times: - at 11:03 a.m. (the beginning of PRBC transfusion); - at 11:30 a.m. (27 minutes after the start of PRBC transfusion); - at 11:34 a.m. (31 minutes after the start of PRBC transfusion); and, - at 3:02 p.m. (the end of PRBC transfusion). NM 3 stated when a patient was being transfused, the patient’s VS should be checked before the blood transfusion starts; at the time when the blood transfusion started; 15 minutes after the blood transfusion started; an hour after the blood transfusion started; and when the blood transfusion was completed. During the same interview on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13’s VS were not checked on 11/12/2024, before starting the blood transfusion, fifteen minutes after the blood transfusion started, and an hour after the blood transfusion started. NM 3 stated it was important to check and monitor the patient’s VS for signs and symptoms of a blood transfusion reaction. During a review of the facility’s policy and procedure (P&P) titled, “Blood Administration,” dated 10/20/2021, the P&P indicated, “The patient’s vital signs (temperature, pulse, respiration, and blood pressure) are taken and recorded: i. Within 30 minutes prior to starting the transfusion ii. Fifteen (15) minutes after initiating the transfusion iii. One (1) hour after initiating the transfusion, unless the patient’s condition requires more frequent checks. iv. When the transfusion ends ... vi. Check the vital signs before each blood component is transfused.” 1.b. During a concurrent interview and record review on 11/14/2024 at 3:53 p.m. with Nurse Manager (NM) 3, NM 3 verified Patient 13’s “Blood Product Administration,” dated 11/12/2024, Patient 13 received the second unit (second bag) of PRBC from 4:05 p.m. through 8:11 p.m. In the same interview and record review on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13’s vital signs (VS) for Patient 13’s second blood transfusion was taken on 11/12/2024 at the following times: -At 4:05 p.m. (the beginning of the blood transfusion); -at 4:48 p.m. (43 minutes after the start of the blood transfusion); -at 7:06 p.m., and 7:07 p.m., (3 hours after the start of the blood transfusion); and, - at 8:20 p.m. (the end of the blood transfusion). NM 3 stated when a patient was being transfused, the patient’s VS should be checked before the blood transfusion starts; at the time when the blood transfusion started; 15 minutes after the blood transfusion started; an hour after the blood transfusion started; and when the blood transfusion was completed. During the same interview on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13’s VS were not checked on 11/12/2024 (for the second blood transfusion), before starting the blood transfusion, fifteen minutes after the blood transfusion started, and an hour after the blood transfusion started. NM 3 stated it is important to check and monitor the patient’s VS for signs and symptoms of a blood transfusion reaction. During a review of the facility’s policy and procedure (P&P) titled, “Blood Administration,” dated 10/20/2021, the P&P indicated, “The patient’s vital signs (temperature, pulse, respiration, and blood pressure) are taken and recorded: i. Within 30 minutes prior to starting the transfusion ii. Fifteen (15) minutes after initiating the transfusion iii. One (1) hour after initiating the transfusion, unless the patient’s condition requires more frequent checks. iv. When the transfusion ends ... vi. Check the vital signs before each blood component is transfused.””

“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: 42937 Based on interview and record review, the facility failed to ensure one of 30 sampled patient’s (Patient 13) vital signs (VS, set of blood pressure, temperature, heart rate, breathing rate, and oxygen measurements), were frequently checked and monitored during blood transfusions (critical procedure that moves blood or blood products into a person who has low blood levels, and can carry risks such as an allergic reaction, heart and lung problems, and death), in accordance with the facility’s policy and procedure regarding blood administration. This deficient practice had the potential to cause a delay in determining Patient 13’s change of condition such as the presence of an allergic reaction, irregular heart rhythm, etc. and/or a delay in the provision of emergent treatment needed which could worsen Patient 13’s condition and may result in death. Findings: During a review of Patient 13’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/11/2024, the H&P indicated Patient 13 was admitted to the facility on 11/10/2024 for a rectal bleed (lower colon or rectum bleeding). The H&P further indicated Patient 13 had a medical history of Gastrointestinal (GI, digestive system) bleed. During a review of the physician’s order, dated 11/12/2024, the order indicated for Patient 13 to have 2 units (bags) of Packed Red Blood Cells (PRBC, part of the blood that carries oxygen from the lungs to the body tissue) transfused for a Hemoglobin (Hgb, part of the red blood cell that carries oxygen) level of less than 7. 1.a. During a concurrent interview and record review on 11/14/2024 at 3:53 p.m. with the Nurse Manager 3 (NM 3), NM 3 verified Patient 13’s “Blood Product Administration,” dated 11/12/2024, Patient 13 received one unit of PRBC (first bag) from 11:03 a.m. through 3:01 p.m. In the same interview and record review on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13’s vital signs (VS) for Patient 13’s first blood transfusion was taken on 11/12/2024 at the following times: - at 11:03 a.m. (the beginning of PRBC transfusion); - at 11:30 a.m. (27 minutes after the start of PRBC transfusion); - at 11:34 a.m. (31 minutes after the start of PRBC transfusion); and, - at 3:02 p.m. (the end of PRBC transfusion). NM 3 stated when a patient was being transfused, the patient’s VS should be checked before the blood transfusion starts; at the time when the blood transfusion started; 15 minutes after the blood transfusion started; an hour after the blood transfusion started; and when the blood transfusion was completed. During the same interview on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13’s VS were not checked on 11/12/2024, before starting the blood transfusion, fifteen minutes after the blood transfusion started, and an hour after the blood transfusion started. NM 3 stated it was important to check and monitor the patient’s VS for signs and symptoms of a blood transfusion reaction. During a review of the facility’s policy and procedure (P&P) titled, “Blood Administration,” dated 10/20/2021, the P&P indicated, “The patient’s vital signs (temperature, pulse, respiration, and blood pressure) are taken and recorded: i. Within 30 minutes prior to starting the transfusion ii. Fifteen (15) minutes after initiating the transfusion iii. One (1) hour after initiating the transfusion, unless the patient’s condition requires more frequent checks. iv. When the transfusion ends ... vi. Check the vital signs before each blood component is transfused.” 1.b. During a concurrent interview and record review on 11/14/2024 at 3:53 p.m. with Nurse Manager (NM) 3, NM 3 verified Patient 13’s “Blood Product Administration,” dated 11/12/2024, Patient 13 received the second unit (second bag) of PRBC from 4:05 p.m. through 8:11 p.m. In the same interview and record review on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13’s vital signs (VS) for Patient 13’s second blood transfusion was taken on 11/12/2024 at the following times: -At 4:05 p.m. (the beginning of the blood transfusion); -at 4:48 p.m. (43 minutes after the start of the blood transfusion); -at 7:06 p.m., and 7:07 p.m., (3 hours after the start of the blood transfusion); and, - at 8:20 p.m. (the end of the blood transfusion). NM 3 stated when a patient was being transfused, the patient’s VS should be checked before the blood transfusion starts; at the time when the blood transfusion started; 15 minutes after the blood transfusion started; an hour after the blood transfusion started; and when the blood transfusion was completed. During the same interview on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13’s VS were not checked on 11/12/2024 (for the second blood transfusion), before starting the blood transfusion, fifteen minutes after the blood transfusion started, and an hour after the blood transfusion started. NM 3 stated it is important to check and monitor the patient’s VS for signs and symptoms of a blood transfusion reaction. During a review of the facility’s policy and procedure (P&P) titled, “Blood Administration,” dated 10/20/2021, the P&P indicated, “The patient’s vital signs (temperature, pulse, respiration, and blood pressure) are taken and recorded: i. Within 30 minutes prior to starting the transfusion ii. Fifteen (15) minutes after initiating the transfusion iii. One (1) hour after initiating the transfusion, unless the patient’s condition requires more frequent checks. iv. When the transfusion ends ... vi. Check the vital signs before each blood component is transfused.””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 36206 Based on observation, interview, and record review the facility failed to ensure the Condition of Participation CFR 482.12 for Governing Body (GB) was met when: 1.The facility’s Governing Body failed t to ensure a Physician provided ongoing monitoring and supervision of medical care for one (1) of 30 sampled Patients (Patient 1) and assured Patient1 received medical care in a safe and effective manner. Patient 1’s baby was born nonviable at the facility and had the potential to place all neonatal (unborn babies)patients at risk for serious injury, harm, or death. (Refer to A-0068). 2.The facility’s Governing Body failed to ensure a Registered Nurse was competent in the hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency) for one (1) out of 30 sampled patients. (Refer to A-0084) The cumulative effect of these deficient practices resulted in the facility’s inability to provide appropriate oversight on quality health care rendered to the facility’s patients.”

“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 observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to follow State and Federal regulatory standards regarding safe patient care assignments for one (1) of two (2) charge nurses (CN 2) by assigning CN 2 to the Labor & Delivery (L&D, the facility ’ s birthing center) unit, Obstetric (OB, a branch of medicine concerned with childbirth) Triage (preliminary assessment in order to determine the urgency of patients ’ need or treatment) Area, Antepartum (period before childbirth) Unit, the Operating Room and assigning CN 2 to perform individual patient care. This deficient practice had the potential to result in patient needs not being met to assure patient safety especially when there is an emergency situation, and the charge nurse is not readily available to assist staff. (Refer to A - 0392) 2. The facility ’ s nursing staff failed to perform an initial admission assessment (a comprehensive physical examination that shines a light on a patient ’ s needs and problems) and reassessments to determine a patient ’ s status and progression of labor (the process by which the fetus [unborn baby] leaves the uterus) for one of thirty sampled patients (Patient 1). In addition, nursing staff failed to take vital signs (Temperature, blood pressure, heart rate, respiratory rate, and pain) at least every hour and report abnormal findings, such as the inability to detect Patient 1 ’ s Fetal Heart Rate (FHR, baby ’ s heart rate), elevated blood pressures, severe abdominal pain, and complaints of headache to the physician (attending physician). These deficient practices resulted in the facility ’ s inability to identify and treat potential complications and the inability to determine the progression of Patient 1 ’ s labor resulting in the death of Patient 1 ’ s baby. (Refer to A-0395) 3. The facility failed to ensure that a comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed and implemented for one of 30 sampled patients (Patient 13) in accordance with the facility ’ s policy and procedure regarding care plan development and implementation when Patient 13 was admitted with hypertensive crisis (very high blood pressure) and peritoneal dialysis (PD, a treatment for kidney failure that uses the lining of the abdomen to filter the blood via a catheter [tube]) catheter dysfunction . This deficient practice had the potential to delay provision of care to Patient 13 by not identifying the patient ’ s needs and risks, which may result in patient harm or death. (Refer to A-0396) 4. The facility failed to ensure nursing staff adhered to the facility ’ s policies and procedures for three of thirty (30) sampled patients (Patient 13, Patient 11, and Patient 1) when: a. Patient 13 ’ s cardiac activity was not continuously monitored with a cardiac device that monitors and records heart rate and rhythm (the heart beats too fast or too slow) as per physician ’ s order and in accordance with the facility ’ s policy and procedure regarding cardiac monitoring. This deficient practice had the potential to result in Patient 13 ’ s abnormal heart rate and rhythm to be not properly monitored and detected, which may result in patient harm and/or death when left untreated. (Refer to A-0398) b. Skin assessment was not performed and documented for one of 30 sampled patients (Patient 11) in accordance with the facility ’ s policy and procedure regarding assessment and reassessment. This deficient practice had the potential to result in the delay of implementation of interventions to prevent skin breakdown (tissue damage caused by friction, moisture, and pressure) for Patient 11. (Refer to A-0398) c. Pain reassessment was not performed after administering a medication (acetaminophen [Tylenol, over the counter pain reliever]) to treat a headache for one of thirty (30) sampled patients (Patient 1) in accordance with the facility ’ s policy and procedure regarding pain assessment and management. This deficient practice resulted in the nurses ’ inability to determine whether the pain medication was effective and also had the potential for Patient 1 ’ s pain to remain unrelieved. (Refer to A-0398) 5. The facility failed to administer oxytocin (a hormone given to strengthen labor contractions [periodic tightening and relaxing of the uterine muscles] and control bleeding after childbirth) as ordered by the physician for one of thirty (30) sampled patients (Patient 1). This deficient practice had the potential for the non-progression of labor (the process by which the fetus [unborn baby] leaves the uterus [a female organ that plays a critical role in pregnancy]) and excessive bleeding after childbirth. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“CARE OF PATIENTS - RESPONSIBILITY FOR CARE CFR(s): 482.12(c)(4) [ ...the governing body must ensure that the following requirements are met:] A doctor of medicine or osteopathy is responsible for the care of each Medicare patient with respect to any medical or psychiatric problem that-- (i) Is present on admission or develops during hospitalization; and (ii) Is not specifically within the scope of practice of a doctor of dental surgery, dental medicine, podiatric medicine, or optometry; a chiropractor; or clinical psychologist, as that scope is-- (A) Defined by the medical staff; (B) Permitted by State law; and (C) Limited, under paragraph (c)(1)(v) of this section, with respect to chiropractors. This Standard is not met as evidenced by: 31993 Based on interview and record review, the facility’s Governing Body failed to ensure a Physician provided ongoing monitoring and supervision of medical care for one (1) of 30 sampled Patients (Patient 1) and assured Patient1 received medical care in a safe and effective manner. This deficient practice resulted to Patient 1’s baby being born nonviable (infant did not survive/dead) at the facility and had the potential to place all neonatal patients at risk for serious injury, harm, or death. Findings: A review of a facility document for Patient 1’s History and Physical, dated 11/1/23 at 9:37 AM, indicated Patient1 was admitted to obstetrics (OB) Triage ( Medical care unit where Pregnant Patients are urgently evaluated for Pregnancy related concerns) Unit for uterine contractions and pain. Patient 1 Pelvic exam indicated Cervical Dilation ( Opening that allows Baby to descend into the Birth canal)of 4 cm, and Station (where Baby head is positioned) -1. Patient 1was diagnosed in in early labor with irregular contractions. Fetal well-being verified as category one ( Normal)Patient1 had diagnosis including gestational hypertension( Hypertension occurring during pregnancy) diagnosed on admission and plan included admit to Labor and Delivery (L&D, the facility’s birthing center) for management of early labor continuous fetal heart monitoring (FHR,monitoring device to measure Baby heart rate and rhythm during pregnancy). Physicians admit orders included “Continuous fetal monitoring and to notify Provider for significant changes including abnormal FHR monitor findings and non-progression of labor.” The record indicated Patient1 remained in triage for about 6 hours after admission to Labor and Delivery. On 11/14/23 at 2:49 pm, during an interview and concurrent chart review with Nurse Manager 1(NM 1) and Perinatal Education Director (PED) of Patient1 medical records and FHR monitor, NM 1 and PED confirmed Patient was off FHR monitoring up to 15 min at a time due to movement and discomfort from labor contractions. NM 1 and PED confirmed there were no communication with a Physician about the repeated difficulty obtaining continuous FHR monitoring. On 11/17/23 at 12:05 pm during an interview and concurrent chart review with PED of Patient 1’s medical record titled Medication order, dated 11/1/23 at 2:14 pm, indicated a physician order to start Oxytocin (medication given to assist during uterine contraction during labor). PED confirmed Patient 1 was not started on Oxytocin. PED explained Oxytocin was not administered in Triage Unit. PED stated Patient 1 would have to be in Labor and Delivery room to administer Oxytocin. PED confirmed there was no Physician notification that Oxytocin had not been administered to Patient1 as ordered. A review of the facility document for Patient 1’s OB Delivery Note dated 11/1/23 completed at 4:21 pm, indicated Patient 1 was off the FHR monitoring due to mom moving around from painful contractions while in Triage Unit, and was off FHM for one hour when brought to the delivery room from the Triage Unit. At 3:42 PM Patient1 had a normal spontaneous vaginal delivery and membranes (layers of tissue with fluid [amniotic] surrounding fetus [baby] inside the womb) ruptured. There was thick meconium (baby first bowl movement inside the womb). The infant was non-viable (infant did not survive/dead) at 41-week-old and the APGARS (quick test performed on a baby at 1 and 5 minutes after birth) score were zero at one minute and zero at five minutes. The NICU (neonatal intensive care unit - area of the hospital specializing in the care if newborns needing round the clock care) team was called for resuscitative measures (a set of Emergency intervention measures taken to assist baby in breathing and circulation) for the Baby. A review of a facility notes for Patient 1, dated 11/1/23 completed at 5:23 pm, titled clinical note respiratory therapy indicated Neonatal Intensive Care Unit Medical Doctor (NICUMD) intubated (tube inserted in the airway to assist with breathing) infant, and an umbilical line (medication given by the umbilical cord) was placed. Epinephrine (emergency medication used to restart the heart) was administered two times. The note indicated after 20 minutes of resuscitative intervention, Patient 1’s baby was pronounced dead. A review of Patient 1’s History and Physical, dated 11/2/23 at 10:04 am completed by MD 1, indicated MD 1 was contacted on 11/1/23 at 9 am that Patient 1 was admitted for early labor. MD1 indicated “I did not get a call until time of delivery.” There was no documentation that Patient 1 was examined or reassessed by a Physician after admission to Labor and Delivery on 11/1/23 at 9:50 am. There is no documentation that the Triage Nurses communicated difficulty in continuously monitoring of FHR or attempted to reassess and examined Patient 1’s progression of labor (the development of the different stages of giving birth). There was no documentation that a Physician did examine and reassess Patient 1 after each contraction occurred from 9:50 am to 3:30 pm. A review of the facility document title rules and regs of the medical staff dated July 18, 2023, under section 10 indicates, “General responsibilities of physician practitioner - the patient’s admitting physician shall be responsible for the medical care and treatment of each patient in the hospital for the prompt completeness and accuracy of records necessary special instructions.” A review of this facility document titled medical staff bylaws dated September 21, 2021, indicated ongoing responsibilities of each member of the medical staff included providing patients with the quality of care that meets the professional standard of the medical staff. A review of a facility document titled bylaws of Community Board dated April 28, 2022, indicated the Community board is responsible to ensure “high quality medical care practice and patient care “and “ensuring a safe environment within the hospital for patients.””

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 31993 Based on observation, interview, and record review, the facility’s Governing Body failed to ensure registered nurses working with patients on a dialysis procedure (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) were competent in the hemodialysis ( emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency) for one (1) out of 30 sampled patients (Patient 6). This deficient practice had the potential to result in inadequate return of blood from the machine to one of thirty sampled Patients (Patient 6) which could lead to harm or even death during hemodialysis treatment. Findings: A review of Patient 6’s, History and Physical (H&P), dated 11/13/23, indicated Patient 6 was admitted for Hemodialysis (a treatment to filter wastes and water from your blood.) On 11/14/23 at 11:05 am, during a concurrent observation and interview on six (6) North with manager of 6 North (Registered Nurse, RN 7) and Dialysis RN(RN 11), RN 11 confirmed there was a sign posted in the dialysis machine regarding instructions on how to shut off the Hemodialysis machine safely in case of an emergency. RN 7 was asked for documentation of training in-service provided to the facility’s RNs on how to shut off the Hemodialysis machine in case of an emergency. RN 7 was not able to provide training in-service for facility’s RN on how to shut off Hemodialysis machine in case of an emergency. During an interview, on 11/17/23 at 4 pm, with Director Nurse Educator (RN 9) and Nurse Educator telemetry (RN 10), RN 9 and RN 10 stated hemodialysis was being provided hospital wide and registered nurses had not received in-service on how to shut off the hemodialysis machine in case of an emergency such as during a power outage or an incapacitated dialysis nurse during dialysis. Both (RN 9 and RN 10) stated facility did not have a Policy and Procedure (P&P) regarding emergency termination of dialysis by a non-dialysis staff, and there was no record of Registered Nurses training or in-service for emergencies during hemodialysis including safely shutting shut off dialysis in case of an emergency. A review of a facility document titled, Bylaws of Community Board, dated April 28, 2022, indicated the Community board was responsible to ensure, “High quality medical care practice and patient care,” and “Ensuring a safe environment within the hospital for patients.””

“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: 36206 Based on observation, interview, and record review, the facility failed to: 1. Ensure One of two crash carts (Crash Cart 1, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) in the Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) was checked to ensure emergency supplies, equipment, and medications were readily available in the event of an emergency. This deficient practice had the potential for emergency supplies to not be readily available in case of an emergency and had the potential to result in a delayed provision of emergency care needed by patients, which may lead to patient harm and/or death. 2. Ensure one of two crash carts (Crash Cart 2) in the Emergency Department (ED) was equipped with a backboard (a rigid plastic backboard or cardiac [heart] board used for the administration of chest compressions by providing a firm surface). This deficient practice had the potential to negatively affect the quality of chest compression depth provided to the patient which may result in poor outcome such as patient death. 3. Ensure one out of four oxygen cylinders (a metal cylinder [tanks] containing oxygen under pressure used to deliver supplemental oxygen when patients have a lung condition or difficulty breathing) in the Emergency Department ’ s (ED) patient care area was not empty. This deficient practice had the potential for oxygen to not be readily available in case of an emergency which may result in the delay of patient care delivery. 4. Ensure one of one Malignant Hyperthermia Carts (a storage space for supplies such as intravenous [IV, through the vein] fluids, syringes, etc.) in the Labor and Delivery (L&D, the facility ’ s birthing center) Operating Room (OR) Suite, was checked daily to ensure the integrity of the cart was maintained and all supplies and medications were readily available in the event a patient suffered from malignant hyperthermia (a rare and severe reaction to certain drugs used for anesthesia, without prompt treatment complications could be fatal) after receiving anesthesia. This deficient practice had the potential for the integrity of the cart to be compromised and the medications and supplies not to be readily available in the event a patient suffered malignant hyperthermia after receiving anesthesia. This deficient practice also had the potential to result in patient harm and/or death. Findings: 1. During an observation on 11/14/2023 at 11:16 a.m., in the Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care), one of two Crash Cart ’ s (Crash Cart 1, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) Log was reviewed. There was no documentation to indicate that the crash cart was checked for emergency medications, supplies, and equipment on 11/14/2023. During an interview on 11/14/2023, at 11:16 a.m., with the Director of the ED (DED), the DED stated, the crash carts should be checked by a Charge Nurse or a designated nurse around 5 a.m. daily. The DED verified the “Crash Cart Log” was not checked on 11/14/2023 by the designated person at 5:00 a.m. on 11/14/2023. A review of the “Crash Cart Log,” dated 9/2023, the Crash Cart log indicated, there was no documented check of the crash cart for expiration of medications, and emergency supplies such as, oxygen tanks, back board ... on 11/14/2023. This lack of documentation was verified with the DED during an interview on 11/14/2023. A review of the facility ’ s policy and procedure (P&P) titled, “Crash Cart Checks,” dated 10/21/2020, the P&P indicated, “An assigned licensed nurse will check and document a complete Crash Cart Log Sheet daily. The following items should be checked daily: Medications and/or supply items such as backboard attached to the back of the cart including an Ambu-bag (a hand-held device used to force air into the lungs of a patient who has either completely ceased breathing or struggling to breathe properly and in need of assistance), intubation (insertion of a flexible tube into the airway to assist with breathing) box, defibrillator (a device used to restore the heart ’ s normal heartbeat) and cables, portable suction (used to clear the airway of secretions), oxygen cylinder, and transvenous pacemaker (a small electronic device that keeps the heart beating at a regular rate). 2. During an observation, on 11/14/2023 at 11:21 a.m., another crash cart (Crash Cart 2, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency), in the Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) did not have a backboard. During a concurrent interview and record review on 11/14/2023 at 11:21 a.m., with the Director of the ED (DED), the Crash Cart Log,” dated 11/2023 was reviewed. The record indicated, the crash cart (Crash Cart 2) was checked on 11/14/2023 and the backboard attached to back of cart was marked as “Yes” (indicating present during inspection). During a concurrent observation and record review, on 11/14/2023 at 11:21 a.m., with the Director of Emergency Department (DED), the second crash cart was observed not equipped with the backboard. The DED stated, the backboard must be stored on the back of the crash cart because the crash cart should be always equipped with all supplies and equipment, in case of emergency. A review of the facility ’ s P&P titled, “Crash Cart Checks,” dated 10/21/2020, the P&P indicated, “An assigned licensed nurse will check and document a complete Crash Cart Log Sheet daily. The following items should be checked daily: Medications and/or supply items such as backboard attached to the back of the cart including an Ambu-bag, intubation box, defibrillator, and cables, portable suction , oxygen cylinder, and transvenous pacemaker. 3. During an observation, on 11/14/2023 at 10:00 a.m., in the Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care), in the rapid patient management (RPM) area, an area designated for quickly stabilizing patients in distress (patients with health issues such as difficulty breathing, chest pain, etc.), four oxygen cylinders stored in a rack were observed. One oxygen cylinder indicated the dial was within the red zone (red zone means that the cylinder is close to empty or empty and needs to be refilled with oxygen) and indicated empty. During an interview on 11/14/2023 at 10:00 a.m. with the Emergency Department Technician (EMT), the EMT stated, empty oxygen cylinders (tanks) must be stored separately from Active (full of oxygen, readily available for use) cylinders in the dirty utility room. The EMT also said, “It has been very busy this morning in the ED, and all the tanks in this area need to be full. I did not have time to check.” During an interview on 11/14/2023 at 1:05 a.m., with the Director of the ED (DED), the DED stated, the rack with stored oxygen tanks in the RPM area should only contain full oxygen tanks because the area is designated for rapid stabilization of patients in distress. A review of the facility ’ s P&P titled, “Oxygen Storage and Transportation,” dated 03/08/2023, the P&P indicated, “All cylinders must be identified in the storage areas with placards labeled as; Active or Empty. Active cylinders that are full and partially full can be stored in the same location in the tank holder designated as Active. Empty tanks must be stored separately from Active tanks. All associates working in patient care areas are oriented to the location, storage, handling, and dispensing of Oxygen in the hospital.” 4. During an observation on 11/13/2023 at 11:08 a.m., with the Perinatal (period immediately before and after birth) Educator (PED), Nurse Manager (NM 1) for the Labor and Delivery (L&D, the facility ’ s birthing center) Unit, the following was observed: There was a cart labeled “Malignant Hyperthermia (MH, a rare and severe reaction to certain drugs used for anesthesia, without prompt treatment complications could be fatal),” in the L&D operating room suite. There was a log on top of the MH cart (a storage space for supplies such as intravenous [IV, through the vein] fluids, syringes, etc.) titled, “Malignant Hyperthermia Cart, Nursing Daily Medication Drawer Check Log,” dated 11/2023. The log indicated the following: Daily RN (registered nurse) Check: RN to check if (1) yellow lock is intact, (2) the yellow lock number matches with the number on the log, (3) any medication is missing in the 2nd tray, (4) meds (medications) not expired on the earliest expiration sticker ...” The log indicated that the cart was not checked on November 4, 5, 6, 8, 9 and 10th of 2023. During an interview on 11/13/2023 at 11:08 a.m. with the PED, the PED stated the MH Cart contained emergency medications and supplies used to treat patients who suffered from malignant hyperthermia after receiving anesthesia. The PED stated the cart should be checked every day to ensure all the supplies and medications were readily available for use. The PED verified that the MH cart had not been checked on November 4, 5, 6, 8, 9 and 10th of 2023. A review of the facility ’ s policy and procedure (P&P) titled, “Management of Anesthetic - Induced Malignant Hyperthermia - Peri-Operative Services,” dated 7/20/2022, indicated the following: General supplies: Stocked in the malignant hyperthermia cart ... A review, on 11/13/2023 at 11:08 am., in the L&D operating room suite, the log titled, “Malignant Hyperthermia Cart, Nursing Daily Medication Drawer Check Log,” dated 11/2023, was reviewed. The log indicated the following: Daily RN (registered nurse) Check: RN to check if (1) yellow lock is intact, (2) the yellow lock number matches with the number on the log, (3) any medication is missing in the 2nd tray, (4) meds (medications) not expired on the earliest expiration sticker ...” The log indicated that the cart was not checked on November 4, 5, 6, 8, 9 and 10th of 2023.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to follow State and Federal regulatory standards regarding safe patient care assignments for one of two charge nurses (CN 2) by assigning CN 2 to the Labor & Delivery (L&D, the facility ’ s birthing center) unit, Obstetric (OB, a branch of medicine concerned with childbirth) Triage (preliminary assessment in order to determine the urgency of patients ’ need or treatment) Area, Antepartum (period before childbirth) Unit, the Operating Room and assigning CN 2 to perform individual patient care. This deficient practice had the potential to result in patient needs not being met to assure patient safety especially when there is an emergency situation, and the charge nurse is not readily available to assist staff. Findings: During an interview on 11/15/2023 at 3:02 p.m. with Charge Nurse (CN) 2, CN 2 stated she (CN 2) was assigned as the charge nurse for the OB (OB, a branch of medicine concerned with childbirth) Triage (preliminary assessment in order to determine the urgency of patients ’ need or treatment) Area, the Labor and Delivery (L&D, the facility’s birthing center) unit, the Antepartum (period before childbirth) Unit and was also assigned to care for two (2) L&D patients on 11/1/2023. CN 2 also said charge nurse duties included, making the unit assignments, making rounds (monitoring and re-assessment to ensure patient safety) on all patients, checking crash (emergency) carts (a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) and equipment, assisting other nurses with patient care, moving patients from OB Triage to the L&D unit, and giving report of all patients to the incoming charge nurse at change of shift. During an interview on 11/15/2023 at 1:44 p.m. with the Director of Women and Children ’ s Services (DWCS), the DWCS stated the following: CN 2 was assigned to be the charge nurse on 11/1/2023 during the day shift (6:30 a.m. to 7 p.m.). The DWCS was unable to provide the nursing assignment on 11/1/2023 for the OB Triage Area, L&D Unit, Antepartum Unit, and Operating room. During an interview on 11/15/2023 at 3:54 p.m. with the Director of Risk Management (DRM), the DRM stated the facility followed State and Federal mandatory staffing ratios (maximum number of patients assigned to a Registered Nurse [RN] during one shift). The DRM also said charge nurses could take care of patients (which means the charge nurse has her designated patients). However, charge nurses should not be assigned to perform charge nurse duties when the charge nurse already has her designated patient assignment. A review of the facility ’ s policy and procedure (P&P) titled, “Staffing Assignment By Acuity (severity of a patient ’ s illness),” dated 2/14/2023, the P&P indicated the following: “The facility adopts the following policy to standardize the process of defining patient acuity and need as they are used for determining staffing assignments, in addition to any State mandated ratio requirements ...General Parameters: The staffing assignment is prepared by the charge nurse/ shift leader or designee ...Additional Staffing Factors: ...State specific staffing requirements.””

“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 ’ s nursing staff failed to perform an initial admission assessment (a comprehensive physical examination that shines a light on a patient ’ s needs and problems) and reassessments to determine a patient ’ s status and progression of labor (the process by which the fetus [unborn baby] leaves the uterus [a female organ that plays a critical role in pregnancy]) for one of thirty sampled patients (Patient 1). In addition, the nursing staff failed to take vital signs (Temperature, blood pressure, heart rate, respiratory rate, and pain) at least every hour and report abnormal findings, such as the inability to detect Patient 1 ’ s Fetal Heart Rate (FHR, baby ’ s heart rate), elevated blood pressures, severe abdominal pain, and complaints of headache to the physician (attending physician). These deficient practices resulted in the facility ’ s inability to identify and treat potential complications and the inability to determine the progression of Patient 1 ’ s labor resulting in the death of Patient 1’s baby. On 11/16/2023 at 3:35 p.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, a serious injury, harm, impairment, or death to a patient) in the presence of the Manager of Accreditation & Regulatory Compliance (MARC), Systems Director of Accreditation & Licensing (SDAL), Retiring Patient Care Executive (PCE 1), and Incoming Patient Care Executive (PCE 2), Operations Executive (OE), and the President (Pres). On 11/1/2023 at 7:26 a.m., Patient 1 presented to the facility ’ s Obstetrics (OB, a branch of medicine concerned with childbirth and the care of women given birth) Triage (preliminary assessment in order to determine the urgency of patients ’ need or treatment) area on 11/1/2023 at 7:26 a.m. for uterine contractions (periodic tightening and relaxing of the uterine muscles that force the fetus [unborn baby] out of the uterus [a female organ that plays a critical role in pregnancy]). Patient 1 arrived at the facility from home and alone. Patient 1 was found to be four (4) centimeters (cm, a unit of measurement) dilated (lower part of the uterus is open at 4 out of 10 cm). Patient 1 had an order to be admitted to the Labor and Delivery (L&D, the facility ’ s birthing center) unit on 11/1/2023 at 9:50 a.m. However, Patient 1 continued to physically remain in the OB Triage area on 11/1/2023 from 9:50 a.m. to 3:32 p.m. During this time (9:50 a.m., to 3:32 p.m.), Patient 1 ’ s fetal heart rate (FHR, baby ’ s heart rate) was undetectable for periods ranging from 4 to 9 minutes on multiple occasions, Patient 1 ’ s blood pressure and heart rate were elevated, Patient 1 complained of pain to the abdomen and head rated at 10 of 10 (zero means no pain, 10 means severe). These abnormal signs and symptoms were not reported to the physician. In addition, nursing staff did not perform a head-to-toe assessment (a comprehensive physical examination that shines a light on a patient ’ s needs and problems) for Patient 1 after the physician ordered Patient 1 to be admitted and nursing staff did not assess the progression of Patient 1 ’ s labor (the process by which the fetus [unborn baby] leaves the uterus). On 11/1/2023 at 3:32 a.m., Patient 1 was transferred to the L&D unit and found to be fully dilated (10 cm, the cervix [lower portion of the uterus] is fully open for the baby to pass through during delivery) and ready to deliver (to give birth). On 11/1/2023 at 3:42 p.m., Patient 1 delivered the baby. The baby was limp (without muscle tone), cyanotic (bluish color due to lack of oxygen), was not breathing and did not have a heart rate. The baby was pronounced dead after twenty (20) minutes of resuscitative (an attempt to revive) efforts. These deficient practices resulted in the facility ’ s inability to identify and treat potential complications and the inability to determine the progression of Patient 1 ’ s labor resulting in the death of Patient 1 ’ s baby. On 11/17/2023 at 6:14 p.m., the IJ was removed in the presence of the MARC, SDAL, PCE 1, PCE 2, OE, Pres, and the Chief Medical Officer (CMO) 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 IJ Removal Plan indicated all L&D staff would be re-educated on assessment (within 1 hour of admission) and reassessment (progression of labor) of patients and escalating abnormal signs and symptoms, including vital signs (Temperature, blood pressure, heart rate, respiratory rate, and pain) and the loss of fetal heart rate to the physician. The Plan also included assigning an L&D nurse to patients who had an order to be admitted to the L&D unit but remained in the OB Triage area. In addition, a new monitoring process was developed under which the Lead nurse or designee will perform rounds (monitoring and re-assessment to ensure patient safety) every two hours to ensure timely initial assessments (evaluation of a patient ’ s state of health) are completed for newly admitted patients, progression of labor is monitored, and abnormal findings are reported to the physician. Findings: A review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/1/2023 at 9:37 a.m., the H&P indicated the following: Patient 1 presented to the Obstetrics (OB, branch of medicine concerned with childbirth and the care of women who have given birth) Triage (preliminary assessment in order to determine the urgency of patients ’ need or treatment) area, alone and complaining of uterine contractions (periodic tightening and relaxing of the uterine muscles that force the fetus [unborn baby] out of the uterus [a female organ that plays a critical role in pregnancy]). Patient 1 was 41 weeks plus 2 days pregnant (past due, full-term pregnancy is 40 weeks). Dilation was 4 cm (4 - 6 cm indicates early labor [the process by which the fetus leaves the uterus], 10 cm indicates the cervix [lower portion of the uterus] is fully dilated or open). Effacement (the cervix stretches and gets thinner) was 90 % (90 of 100 % indicates the cervix is almost ready for delivery) and Station was -1 (the position of the baby ’ s head in relation to its position to the mother ’ s pelvis, - 1 means one (1) cm above the pelvis). Patient 1 ’ s blood pressure was 147/91 (elevated, normal is 120/90). Gestational hypertension (a woman with elevated blood pressure during pregnancy) was diagnosed on admission. “Plan: Admit to Labor and Delivery (L&D) unit for management of early labor. Continuous fetal monitoring ...” During a review of a physician ’ s order, dated 11/1/2023 at 9:50 a.m., the order indicated the following: 1. An order for Admission Status. “Inpatient level of care: Labor and Delivery.” 2. Continuous order for fetal monitoring. Notify provider of significant changes. 3. To notify physician for rapid changes or non-progression in labor. 4. Vital signs (blood pressure [BP], Temperature [T], pulse [or heart rate, HR) check, pain, and fetal heart rate (FHR, baby ’ s heart rate) check, every four hours (Q4H) and PRN (as needed) as the patient ’ s (Patient 1) condition warrants. A review of Patient 1’s “Nursing Documentation - Flowsheet,” dated 11/1/2023, indicated the following: At 7:30 a.m., Temperature (T) was 98.2 degrees Fahrenheit (normal level from 97 degrees Fahrenheit [F] to 99 degrees F), Blood pressure was 148/97 millimeters of mercury (mmHg, unit of measurement) (high, normal blood pressure 120/80 mmHg to 120/80 mmHg), Pulse was 92 beats per minute (normal was 60 beats per minute [BPM] to 100 BPM), pain was 10 (10 of 10, zero indicates no pain, 10 indicates severe pain). Patient 1 complained of uterine contractions. At 8:17 a.m., blood pressure (BP) was 150/89 mmHg (high), and maternal heart rate (MHR) was 85 BPM. At 8:32 a.m., BP was 147/85 mmHg (high), and MHR was 86 BPM. At 8:47 a.m., BP was 147/91 mmHg (high), and MHR was 82 BPM. At 9 a.m., BP was 151/92 mmHg (high). MHR was 95 BPM. At 9:13 a.m., cervical dilation (the cervix opening, zero [0] centimeter [cm, unit of measurement] closed to 10 cm [full dilation/open] ) was 4 centimeter (cm, unit of measurement), cervical effacement was 90 % (measured in percentages from zero (0) to 100 percent, zero is closed to 100 % open [cervix is ready for delivery]). At 2:23 p.m., Patient 1 complained of headache rated at a level 10 (severe pain). At 3:31 p.m., Registered Nurse (RN) 4 handed off (exchanged) Patient 1 to RN 5. RN 4 gave report to RN 5. At 3:36 p.m., Resident Physician and Attending Physician were notified that Patient 1 was ready to deliver. Patient 1 was 10 cm dilated (fully), cervical effacement 100 %, and + 2 station (baby ’ s head was 2 cm below the pelvis). At 3:39 p.m., Patient ready to deliver ...Resident Physician at bedside, informed unable to detect fetal heart rate. At 3:42 p.m., Psychosocial/bonding issues: Fetal demise (death of a baby) ... During a review of Patient 1 ’ s “Fetal Monitoring Strips and Annotations (comment or explanation),” dated 11/1/2023 from 7:48 a.m. through 3:48 p.m., indicated the following: At 9:06 a.m., The TOCO (tocotransducer, round monitors [leads] placed on the belly, held in place with belts, that monitor fetal heart rate and uterine contractions) was not detected from 9:06 a.m. to 9:11 a.m. At 9:20 a.m., RN (registered nurse) at bedside: Strip review; Position change; Toco/US (ultrasound) adjusted, loss of signal due to maternal frequent position changed, non-compliant to keep monitor on. At 10:32 a.m., BP was 142/92 mmHg (high), and MHR was 93 BPM. At 11:02 a.m., BP was 150/77 mmHg (high), and MHR was 98 BPM. At 11:32 a.m., BP was 144/69 mmHg (high), and MHR was 101 (high) BPM. At 11:47 a.m., BP was 156/84 mmHg (high), and MHR was 98 BPM. At 11:57 a.m., the TOCO lead was not detected from 11:57 a.m. to 12:06 p.m. At 12:07 p.m., BP was 151/99 mmHg (high), and MHR was 95 BPM. At 12:12 p.m., Patient 1 refuses to lay back to get baby on the monitor due to her (Patient 1) pain. At 12:17 p.m., BP was 169/87 mmHg (high), and MHR was 97 BPM. At 12:19 p.m., BP was 152/89 mmHg (high), and MHR was 99 BPM. At 12:32 p.m., BP was 155/95 mmHg (high), MHR was 96 BPM. At 12:48 p.m., BP was 176/88 mmHg (high), and MHR was 99 BPM. At 12:54 p.m., BP was 165/77 mmHg (high), and MHR was 94 BPM. At 1:02 p.m., The TOCO lead was not detected from 1:03 p.m. to 1:06 p.m. At 2:03 p.m., BP was 162/104 mmHg (severely high), and MHR was 104 BPM (high). At 2:08 p.m., BP was 138/82 mmHg (high), and MHR was 111 BPM (high). At 2:23 p.m., BP was 147/86 mmHg (high), and MHR was 102 BPM (high). At 3:02 p.m., strip review, frequent loss of signal, Patient 1 unable to keep still due to labor pain. At 3:04 p.m., the TOCO lead was not detected. At 3:10 p.m., up to BR (bathroom) and voided. At 3:18 p.m., Patient 1 remained in the BR called her attention to go back to bed and patient did. At 3:29 p.m., Patient has been disassociated (disconnected from the fetal monitor). At 3:32 p.m., Patient 1 associated (placed on a fetal monitor). At 3:36 p.m. Station: + 2, Effacement: 100 %, Dilation: 10 cm. At 3:38 p.m., AROM (artificial rupture of membrane, or “breaking of the bag of water,” (when the provider intentionally breaks a pregnant person ’ s amniotic sac [holds fluid that surround the baby in the womb]). At 3:39 p.m., OB provider (Resident Physician) at bedside. OB provider (Attending Physician) notified. A review Patient 1 ’ s “Fetal Monitoring Data,” dated 11/1/2023, the data indicated that fetal heart rate baseline was unable to be determined at 3 p.m. and at 3:45 p.m. A review of Patient 1 ’ s vital signs (Temperature [T], blood pressure [BP], heart rate [HR], respiratory rate [RR] and pain), dated 11/1/2023 from 7:30 a.m. to 3:46 p.m., indicated that a full set of vital signs were only assessed once, as follows: At 7:30 a.m., T was 98.2 degrees F, HR was 92 BPM, BP was 148/97 mmHg (high), RR was 18 (normal range 12 respiration per minute [RPM] - 18 RPM), and pain to abdomen rated at 10 out of 10 (severe pain). A review of Patient 1’s head to toe assessments (a comprehensive physical examination that shines a light on a patient ’ s needs and problems) dated 11/1/2023, the assessments indicated that Patient 1 had an initial head to toe assessment at 4:30 p.m., over six (6) hours after Patient 1 was ordered to be admitted to the L&D unit (at 9:50 a.m.). A review of Patient 1 ’ s physician “Progress Note,” dated 11/1/2023 at 4:21 p.m., the progress note indicated the following: Patient 1’s infant was non-viable (unable to survive). Complications: “Patient (Patient 1) admitted to L&D at approximately 10 a.m. for eLabor (early labor) ...While in triage, baby falling off monitor for prolonged periods due to mother moving around from painful contractions ...When moved to labor room, baby had been off the monitor for 1 (one) hour ...Patient was checked and found to be 10 cm dilated, and + 2 station (2 cm below the pelvis). I (Resident Physician) was called to room for delivery. Patient was instructed to push. Membranes were ruptured during pushing with thick mec (meconium, a newborn ’ s first poop) noted. Baby was delivered within two minutes of pushing. Poor tone was noted, and cord was immediately clamped and cut. Baby was brought to the warmer, where resuscitative measures (life-saving measures, such as chest compression (a life-saving procedure performed when someone ’ s heart stops beating) and respiratory support and management) were started by the L&D team. NICU (Neonatal Intensive Care Unit, a unit of the hospital that specializes in the treatment of newborns with health problems or difficult births) was emergently called ...Please see NICU note for details on resuscitative efforts.” A review of Patient 1’s, “CPR (cardiopulmonary resuscitation, a life-saving procedure performed when someone ’ s heart stops beating) Record,” for Patient 1’s baby, dated 11/1/2023 at 3:45 p.m., indicated the following: CPR started at 3:43 p.m. by the L&D. Initial signs of arrest (heart stops beating): Apnea (breathing has stopped), absence of pulse, cyanosis (bluish discoloration of the skin from inadequate oxygenation of the blood), and unresponsive (not reacting in a quick or positive way). Code Team (a team that responds to the patient ’ s bedside when patient is in need of resuscitation (to revive) such as cases of heart attack, etc.) arrival time was, on 11/1/2023 at 3:45 p.m. Patient 1’s baby was intubated (a tube is inserted into the mouth or airway to allow air to get through) and emergency medications were given. The record indicated under Event End, Patient 1’s baby expired (died), on 11/1/2023 at 4:03 p.m. A review of Patient 1’s “H&P” dated 11/2/2023 at 10:04 a.m., indicated the following, “This is a 22-year-old female who is a primigravida (pregnant for the first time) presented at 40 weeks gestation (pregnant) complaining of uterine contractions ...I (Attending Physician) was called at 9:00 in the morning. The patient (Patient 1) was noted to be in early labor of 4 cm (dilated) and 90 % (effacement). At that time, orders were given to admit the patient for labor management. Subsequently, I did not get a call until the time of delivery where I was called for the delivery. Upon my presentation to the labor and delivery suite along with the resident, I delivered a nonviable (not capable of living) infant. Neonatal team was present in order to perform resuscitation, however despite our aggressive resuscitation, the newborn had expired ...” A review of Patient 1’s “Clinical Pathway/Care Plan (provides a framework for evaluating and providing patient care needs),” dated 11/1/2023 at 9:50 a.m., indicated to notify MD for the following admission findings: Temperature 100.4 (F) or higher, pulse less than 60 or greater than 120, Respiration less than 12 and greater than 24, BP equal to or greater than 140 mmHg or greater than 90 diastolic (pressure the blood is exerting against the artery [blood vessels that deliver oxygenated blood to the body] walls of the heart while the heart muscles are resting) BP, BP less than 90/50, non-reassuring FHR, abnormal labor progress (no change in dilation or station less than or equal to 2 hours), abnormal vital signs, abnormal FHR ...” During a concurrent interview and record review, on 11/14/2023 at 1:29 p.m., with the Perinatal Educator (PED) and the Nurse Manager (NM 1) for Labor & Delivery Unit, Patient 1’s Nursing Flowsheets and Fetal Heart Monitoring Strips and annotations were reviewed. The PED and NM 1 stated the following: Patient presented to OB triage on 11/1/2023 at 7:26 a.m., with a chief complaint of uterine contractions. Patient 1 was 4 cm dilated, 90% effaced, and -2 station. Patient 1 had an order to be admitted to the L&D unit at 9:50 a.m. However, Patient 1 remained in the OB triage area until 3:32 p.m. During this time (9:50 to 3:32 p.m.) the PED and NM 1 verified Patient 1 ’ s blood pressures were elevated and would require BP monitoring every 15 minutes. If the blood pressure was over or equal to 140/90, the physician should be notified. If the BP was equal to or greater than 160/110, the physician should be notified immediately to evaluate the patient and to determine the course of treatment, if any. High blood pressure could be associated with preeclampsia (persistently high blood pressure that develops during pregnancy), which could lead to seizures (convulsions, uncontrolled electrical activity between the brain cells that causes temporary abnormality in muscle tone and movements) or stroke (when blood flow to the brain is blocked). During an interview, on 11/14/2023 at 1:29 p.m., the PED and the NM 1 verified Patient 1 ’ s BP was consistently elevated, as follows: at 12:19 p.m., BP was 152/89. At 12:32 p.m., BP was 155/95. At 12:48 p.m., BP was 176/88 (high). At 12:54 p.m., BP was 165/77 (high). At 2:03 p.m., BP was 162/104 (severely high), and MHR was 104 (high). At 2:08 p.m., BP was 138/82 (high) and MHR was 111 (high). At 2:23 p.m., BP was 147/86 (high) and MHR was 102 (high). The PED stated that the BPs over 160/110 (176/88, 165/77, and 162/104) were severely high and should have been reported immediately. The MHR over 100 (102, 111, and 104) were not reported to the physician. The PED and the NM 1 stated Patient 1 ’ s FHR and contractions were being monitored. However, there were multiple times when the FHR signal was not able to be detected, ranging from 4 to 9 minutes, therefore the FHR was unable to be determined. The PED stated if there was a concern or issues with the inability to determine the fetal heart rate, the issues should have been communicated to the physician so the physician could evaluate the FHR by performing an ultrasound (an imaging test that uses sound waves to make pictures of organs, tissues, and other structures inside the body). During an interview, on 11/14/2023 at 1:29 p.m., the PED and the NM 1 also verified Patient 1 complained of abdominal pain rated at a 10 (severe) at 7:30 a.m., and at 2:23 p.m., Patient 1 complained of a headache rated at a 10. The PED and the NM 1 verified that there was no documentation in the medical record that the physician was notified of the pain. Moreover, the PED stated that pain should be assessed every hour, but was only assessed twice between 7:30 a.m. and 3:32 p.m. In addition, the PED and the NM 1 verified that there was no documentation indicating that nursing staff had performed an initial (admission) assessment after Patient 1 was ordered to be admitted to the L&D unit, nor was there documentation of the reassessment of the progression of labor from 9:50 a.m. to 3:32 p.m. while Patient 1 physically remained in the OB triage area. The PED stated it was important to conduct these assessments to determine the health status of Patient 1 and Patient 1 ’ s baby and identify any potential complications. During an interview on 11/15/2023 at 12:16 p.m., with Registered Nurse (RN) 3, in OB triage, RN 3 stated the following: RN 3 cared for Patient 1 on 11/1/2023 from 7:30 a.m. to approximately 11:30 a.m. in the OB triage area. Patient 1 was placed on monitor to detect FHR and MHR. Patient 1 had persistently elevated BPs and severe pain to the abdomen. The elevated BP and pain were not reported to the physician. A full set of vital signs should be taken every hour, and RN 3 verified this was not documented in the medical record. Patient 1 had an order to be admitted to the L&D unit, but physically remained in the OB Triage area. RN 3 stated, generally, an L&D nurse is assigned to an “admitted” patient in the Triage area and carries out admission orders. Patient 1 was not assigned a L&D nurse and remained under the care of the Triage nurses (RN 3, RN 4). RN 3 stated she (RN 3) was triaging other patients and was not able to perform an admission assessment, but RN 3 continued to monitor FHR, MHR, and BPs. At approximately 11:30 a.m., RN 3 endorsed Patient 1 to RN 4 (who is not available for interview). During an interview, on 11/15/2023 at 3:02 p.m. with Charge Nurse (CN) 2, she (CN 2) said that she (CN 2) was assigned as the charge nurse and was also assigned to care for two (2) L&D patients on 11/1/2023. Patient 1 remained in the OB triage area after being admitted by the physician, because patients were brought to the L&D unit according to acuity (urgency for clinical intervention). Patient 1 remained under the care of the Triage nurse after the physician ordered for Patient 1 to be admitted. CN 2 said OB triage nurses should perform initial nursing assessments, reassessments, and perform VS at minimum of every hour. Patient 1 was moved to the L&D unit at approximately 3:36 p.m. CN 2 stated she (CN 2) was taking her break when she was called to assist in code (Code Blue, a term used to indicate a patient requires resuscitation or immediate attention, mostly as a result of a respiratory or cardiac arrest [when the heart stops beating]) for Patient 1 ’ s baby. CN 2 stated “I coded the baby.” NICU staff was called and attempted to resuscitate the baby. The baby did not survive. During a second interview and record review of Patient 1 ’ s Nursing Flow Sheets on 11/17/2023 at 10:15 a.m., with the PED and the NM 1, the PED and the NM 1 stated the following: On 11/1/2023 at 3:42 p.m., Patient 1 delivered her (Patient 1) baby. Thick meconium (baby ’ s first stool) was noted. The umbilical cord was observed around the baby ’ s neck and reduced (removed) prior to delivery. The baby ’ s Apgar scores (based on baby ’ s heart rate, muscle tone, grimace, color, respiration, ranges from 0 to 10) were assessed at 1 minute and 5 minutes of birth. The baby ’ s scores were 0 at 1 minute and at 5 minutes, indicating there were no signs of life. L&D and NICU staff attempted to resuscitate the baby for 20 minutes. The baby was pronounced dead at 4:03 p.m. A review of the facility ’ s policy and procedure (P&P) titled, “Standards of the Nursing Practice Labor and Delivery,” dated 3/17/2021, the P&P indicated the following: “Maternal and Fetal Assessment: Initial assessment and intervention for intra-partum (during labor) patient may occur concurrently and may include: Determining fetal and maternal status, vital signs and pain assessment ..., and completing a systems assessment (head to toe assessment). Ongoing assessment may include: Identifying maternal physical and psychological response to labor and plan nursing care from data obtained. Identify fetal response to labor, recognizing normal and abnormal fetal heart tracing or non-reassuring characteristics ...Identify progress of labor, recognizing normal and abnormal rate of cervical effacement (the cervix stretches and gets thinner), dilatation, descent of presenting parts and notification of MD. Identity complications diverting from the normal labor process ... Maternal and Fetal Surveillance: Fetal heart rate (FHR) will be continuously monitored, or fetal heart tone auscultation will be done. Nurse will document FHR and uterine contractions electronically. General Interventions... Nursing will observe and document abnormal fetal heart rate pattern, notify MD, and apply appropriate nursing interventions, according to Labor and Delivery (L&D) policies and procedures ... Obtain blood pressure, pulse, respiratory rate every hour or more often if indicated (i.e., hypertension (high blood pressure), abnormal bleeding etc.). Report any abnormal findings to MD. Obtain and document temperature every 4 hours normally ... Perform sterile vaginal examination, as necessary, to determine progression of labor and document. Notify MD of any signs of abnormal labor progress.” A review of the facility ’ s policy and procedure (P&P) titled, “Assessment/Reassessment of Patients, Interdisciplinary,” dated 10/20/2021, the P&P indicated the following: Nursing, Assessment Time frames: Labor & Delivery/Maternity - ante (before)/intra (during)/Post (after) - partum (childbirth), physical assessment within one (1) hour of admission. Labor assessment frequency per phase. Scope (of assessment) includes, vital signs, basic physical assessment, assessments if necessary, and pain ... Reassessment Time frames: Labor & Delivery: Per standards of care for labor patients. At a minimum of hourly until delivery. Scope (of reassessment), in general assessment, address the following. review of physical and psychosocial status, changes in condition, response to treatment and interventions, and need for additional referrals/communication to member of the multidisciplinary team. A review of the facility ’ s policy and procedure (P&P) titled, “Admission of Patient to Labor and Delivery,” dated 10/21/2021, the P&P indicated to “Follow Standards of Nursing Practice in Labor & Delivery Policy ...Receive and carry out admission orders ...” A review of the facility ’ s policy and procedure (P&P) titled, “Hypertensive Disorders of Pregnancy,” dated 9/16/2022, the P&P indicated the following: Screening process includes ...Preeclampsia Early Recognition Tool (PERT) and the following: A. Notify provider (within 60 minutes or sooner, 30 is minutes is preferred) of worrisome “yellow” BPs (blood pressures) greater than or equal to 155 mmHg systolic AND/OR greater than or equal to 105 mmHg (taken at least 15 minutes apart on two occasions). B. Notify provider (within 60 minutes) if 2 more worrisome “yellow” triggers are present. C. Notify provider (within 30 minutes) if 1 or more “red” triggers are present. Preeclampsia (condition in pregnancy characterized by high blood pressure, sometimes with fluid retention, and protein in the urine) Early Recognition Tool (PERT), indicated the following: Worrisome (Yellow) triggers included, but not limited to the following; agitation, confusion, mild headache, nausea (uneasiness in the stomach), vomiting, Systolic (measures the pressure in the arteries when the heart beats) BP (mmHg) over or equal to 155 - 159, Diastolic (pressure the blood is exerting against the artery [blood vessels that deliver oxygenated blood to the body] walls of the heart while the heart muscles are resting) BP (mmHg) between 90 - 109, HR between 110 - 120, abdominal pain, and fetal signs - non-reactive NST (non-stress test)... Severe (Red) triggers included, but not limited to the following: unresponsiveness, unrelieved headache, Systolic BP (mmHg) over 160, Diastolic BP (mmHg) over 110, Heart rate over 120, and abdominal pain ... Yellow=Worrisome: Increase assessment frequency: 1 trigger, to do: Notify provider. More than 1 trigger, to do: Notify charge nurse, in-person evaluation ... Red=Severe: Trigger, 1 of any type: Immediate evaluation, transfer to higher level of care, 1:1 staff ratio ...”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 46238 Based on interview, and record review, the facility failed to ensure that a comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed and implemented for one (1) of 30 sampled patients (Patient 13) in accordance with the facility’s policy and procedure regarding care plan development and implementation when Patient 13 was admitted with a hypertensive crisis (very high blood pressure) and peritoneal dialysis (PD, a treatment for kidney failure that uses the lining of the abdomen to filter the blood via a catheter [tube]) catheter dysfunction. This deficient practice had the potential to delay provision of care to Patient 13 by not identifying the patient ’ s needs and risks, which may result in patient harm or death. Findings: During a review of Patient 13’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 11/13/2023, indicated, on 11/13/2023, Patient 13 was admitted to the facility’s telemetry unit (a hospital unit where patients are under cardiac monitoring [use of a device that continuously watches the electrical activity of the heart]) with a principal problem of hypertensive crisis (very high blood pressure) and peritoneal dialysis (PD, a treatment for kidney failure that uses the lining of the abdomen to filter the blood via a catheter [tube]) catheter malfunction. The H&P further indicated, Patient 13 ’ s plan of treatment included peritoneal dialysis catheter dysfunction requiring a surgical interference and hypertensive urgency (severely elevated blood pressure without evidence of organ damage). During a concurrent interview and record review on 11/14/2023 at 9:42 a.m. with the manager of the Emergency Department and ICU (MEDICU), Patient 13 ’ s nursing care plan (NCP), dated 11/13/2023 to 11/15/2023 was reviewed. Patient 13 ’ s NCP indicated, no care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed for hypertensive urgency and peritoneal dialysis. The MEDICU stated, nursing staff should develop a plan of care for each patient based on presenting and identified patient ’ s health issues as per facility’s policy since care plans serve to facilitate coordination and communication of care specific to problems identified. A review of the facility ’ s policy and procedures (P&P) titled, “Patient Plan of Care,” dated 5/2022, the P&P indicated, “The patient’s plan of care and goals are developed and documented in Power Chart [Electronic Medical Record], which includes the patient’s problems, expected outcomes, and intervention. The care plan must be initiated within first 8 hours after admission by the Registered Nurse. The plan of care for the patient includes assessment based on comprehensive patient needs, treatments, and goals. Patient response to care plan must be documented.””

“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: 46238 Based on observation, interview and record review, the facility failed to ensure nursing staff adhered to the facility’s policies and procedures for three (3) of thirty (30) sampled patients (Patient 13, Patient 11, and Patient 1) when: 1. Patient 13’s cardiac activity was not continuously monitored with a cardiac device that monitors and records heart rate and rhythm (the heart beats too fast or too slow) as per physician ’ s order and in accordance with the facility ’ s policy and procedure regarding cardiac monitoring. This deficient practice had the potential to result in Patient 13 ’ s abnormal heart rate and rhythm to be not properly monitored and detected, which may result in patient harm and/or death when left untreated. 2. Skin assessment was not performed and documented for one of 30 sampled patients (Patient 11) in accordance with the facility ’ s policy and procedure regarding assessment and reassessment. This deficient practice had the potential to result in the delay of implementation of interventions to prevent skin breakdown (tissue damage caused by friction, moisture, and pressure) for Patient 11. 3. Pain reassessment was not performed after administering a medication (acetaminophen [Tylenol, over the counter pain reliever]) to treat a headache for one of thirty (30) sampled patients (Patient 1) in with the facility ’ s policy and procedure regarding pain assessment and management. This deficient practice resulted in the nurses ’ inability to determine whether the pain medication was effective and also had the potential for Patient 1 ’ s pain to remain unrelieved. Findings: 1. During a review of Patient 13’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 11/13/2023, the H&P indicated, on 11/13/2023, Patient 13 was admitted to the facility ’ s telemetry unit (a hospital unit where patients are under cardiac monitoring [use of a device that continuously watches the electrical activity of the heart]) with a principal problem of hypertensive crisis (a very high blood pressure) and peritoneal dialysis (PD, a treatment for kidney failure that uses the lining of the abdomen to filter the blood via a catheter [tube]) catheter malfunction. The H&P further indicated, Patient 13 ’ s principal problems included peritoneal dialysis catheter dysfunction (malfunction in the catheter) and hypertensive urgency (severely elevated blood pressure without evidence of organ damage). During a concurrent observation and interview, on 11/14/2023 at 10:28 a.m. with Patient 13, in the emergency department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) patient care room, Patient 13 was observed in bed, with no cardiac electrodes (small, plastic patches that stick to the skin on chest to connect the wires to a monitor detecting heart ’ s electric activity) and lead wires attached to Patient 13 ’ s chest connecting Patient 13 to a cardiac monitor (a device that continuously watches the electrical activity of the heart) in the room. The cardiac monitor in Patient 13 ’ s room, indicated, Patient 13 ’ s heart electrical activity was not continuously monitored on 11/14/2023 at 10:28 a.m. Patient 13 stated, the cardiac monitor was not always connected to his (Patient 13) chest. A review of Patient 13 ’ s physician orders, dated 11/13/2023, at 1:16 p.m., the order indicated, Patient 13 required continuous cardiac monitoring with Telemetry level of care. During a concurrent observation and interview on 11/14/2023 at 10:54 a.m., with Patient 13 ’ s primary nurse, at the ED nurses ’ station, the monitor displaying patient 13 ’ s cardiac activity [in real time] and most recent vital signs ([VS], temperature, blood pressure, respiratory rate, heart rate that indicates the state of a patient’s essential body functions) was observed. The monitor displaying Patient 13 ’ s cardiac activity and VS indicated, Patient 13 ’ s heart rhythm was not displayed. The primary nurse stated, Patient 13 was admitted to a telemetry unit on 11/13/2023, with continuous cardiac monitoring orders, but there were no inpatient hospital beds available, so Patient 13 was occupying the ED bed. The primary nurse further stated, Patient 13 appeared to be disconnected from the monitor but could not say how long Patient 13 ’ s cardiac activity was not monitored. During an interview on 11/17/2023 at 10:17 a.m. with the Manager of ED and ICU (MEDICU), the MEDICU stated, patients with orders for continuous telemetry monitoring must always be connected to a cardiac monitor and nurses should have a physician order if patient requires to be off the monitor. Nursing should continuously monitor patients on telemetry in case the cardiac activity change and requires an immediate assessment and intervention. A review of the facility’s policy and procedure (P&P) titled, “Telemetry Monitoring and Trouble Shooting,” dated 3/2022, the P&P indicated, “Telemetry monitoring requires the monitor tech to continuously monitor the electrical activity of the heart, and the trained Registered Nurse is responsible for documenting the measurements and interpretation on all routine rhythms recordings. For the telemetry area being remotely monitored, the primary nurse is responsible for ensuring that the patient ’ s monitor alarm is audible on the monitor screens of the units.” 2. A review of Patient 11’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 10/5/2023, the H&P indicated, Patient 11 presented to the facility ’ s Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) on 10/5/2023 with complaints of weakness, a fall (unintentional event resulting in a person coming to rest on the ground or another lower level) at home, with lacerations/skin tears on the left forearm and left leg. The record indicated Patient 11 ’ s wounds were not amenable to suture (threads or strands used to close a wound) repair and the wounds were cleaned and dressed per ED staff on 10/5/2023. A review of Patient 11 ’ s nursing assessment documentation (NAD), dated 10/5/2023, the NAD indicated, Patient 11 ’ s skin lacerations was recorded by the primary nurse. The NAD further indicated, there was no documentation of any intervention for the skin lacerations identified in Patient 11 ’ s H&P on 10/5/2023. During a concurrent interview and record review, on 11/17/2023 at 11:13 with the manager of the ED and ICU (MEDICU), Patient 11 ’ s skin assessment record, dated 10/5/2023 was reviewed. The skin assessment record indicated, there was no documentation of skin issues identified for Patient 11 on 10/5/2023.The MEDICU stated, nursing should document all identified skin issues and document the assessment in the patient ’ s skin assessment medical records. The MEDICU further stated, nursing should document all interventions for all identified skin issues, but the primary nurse did not. During a review of the facility ’ s policy and procedures (P&P) titled, “Assessment/Reassessment of Patients, Interdisciplinary [IDT],” dated 10/20/2021, the P&P indicated, “The initial assessment will be performed by a Registered Nurse within 60 minutes of receipt of a patient into the ED. Depth of assessment is based on patient care needs and the scope of services provided in a particular care area. The assessment should be documented in the patient ’ s medical record.” 3. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/1/2023 at 9:37 a.m., the H&P indicated the following: Patient 1 presented to the Obstetrics (OB, branch of medicine concerned with childbirth and the care of women given birth) Triage (preliminary assessment in order to determine the urgency of their need or treatment), alone and complaining of uterine contractions (periodic tightening and relaxing of the uterine muscles that force the fetus [unborn baby] out of the uterus [a female organ that plays a critical role in pregnancy]). A review of Patient 1 ’ s physician ’ s order, dated 11/1/2023 at 10:50 a.m., the order indicated, to give acetaminophen (Tylenol, over the counter pain reliever) 650 milligrams (mg, a unit of measurement) by mouth, every six (6) hours as needed for headache. A review of Patient 1 ’ s “Medication Administration Record (MAR),” dated 11/1/2023 at 2:23 p.m., the MAR indicated, Patient 1 was given acetaminophen 650 mg by mouth for a headache, pain intensity level was 10. During a concurrent interview and record review of Patient 1 ’ s physician ’ s orders and medication administration record (MAR), on 11/17/2023 at 10:15 a.m., with the Perinatal Educator (PED), the PED stated the following: Patient 1 was given Tylenol 650 mg for a headache, rated at 10 out of 10 (severe pain) pain scale, on 11/1/2023 at 2:23 p.m. The PED verified that there was no documentation in the medical record indicating that Patient 1 ’ s pain was reassessed. The PED stated the pain should have been reassessed within 1 hour of administration of pain medication to determine for effectiveness. The PED stated that unrelieved headache can be a sign of preeclampsia (high blood pressure in pregnant women) and can lead to seizures (convulsions, (uncontrolled electrical activity between the brain cells that causes temporary abnormality in muscle tone and movements) or stroke (when blood flow to the brain is blocked). A review of the facility ’ s policy and procedure (P&P) titled, “Pain Assessment and Management,” dated 6/22/2022, the P&P indicated the following: Reassessment: Patient will be reassessed after each pain management intervention to evaluate effectiveness, to recognize undesirable side effects and document in the electronic medical record (EMR). Pharmacological and non-pharmacological interventions will be reassessed within approximately 60 minutes. A review of the facility’s P&P titled, “Triage and Medical Screening Procedure, Labor & Delivery,” dated 4/21/2022, indicated all patients will be promptly evaluated by triage for ...All patients presenting to Labor & Delivery / Triage are evaluated for hypertension ...Symptoms of pre-eclampsia / eclampsia (seizures during pregnancy) are headache (not relieved with medication) ...”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to administer oxytocin (a hormone given to strengthen labor contractions [periodic tightening and relaxing of the uterine muscles] and control bleeding after childbirth) as ordered by the physician for one (1)of thirty (30) sampled patients (Patient 1). This deficient practice had the potential for the non-progression of labor (the process by which the fetus [unborn baby] leaves the uterus [a female organ that plays a critical role in pregnancy]) and excessive bleeding after childbirth. Findings. A review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/1/2023 at 9:37 a.m., the H&P indicated the following: Patient 1 presented to the Obstetrics (OB, branch of medicine concerned with childbirth and the care of women given birth) Triage (preliminary assessment in order to determine the urgency of their need or treatment), alone and complaining of uterine contractions (periodic tightening and relaxing of the uterine muscles that force the fetus [unborn baby] out of the uterus [a female organ that plays a critical role in pregnancy]). A review of Patient 1’s physician order dated 11/1/2023 at 9:50 a.m., the order indicated: oxytocin (a hormone given to strengthen labor contractions and control bleeding after childbirth) 30 units 95 ml/hour, comment: “After delivery of infant ’ s shoulders: Program continuous infusion at dose of 5.7 units/hour (rate 95 milliliter [mL, unit of measurement]/hour [hr.]), then using the bolus function within the pump, deliver 10 units over duration of 30 minutes (333 mL/hr.). Following completion of bolus, continue at dose of 5.7 units/hr. (rate 95 mL/hr.) for 3 hours and 30 minutes. The record indicated to notify provider for excessive vaginal bleeding. A review of Patient 1’s physician order dated 11/1/2023 at 3:14 p.m., the order indicated: oxytocin 30 units ... for labor induction or augmentation (the process of stimulating the uterus to increase the frequency, duration and intensity of contractions after the onset of spontaneous labor) ... Order Comment; Start oxytocin at 2 milliunit/minute (min), Titrate (to adjust the dose) by 2 milliunit/min every 30 minutes to maintain regular uterine contractions of moderate to strong intensity by palpation (method of feeling with hands during assessment) and patient perception ... A review of Patient 1’s physician order dated 11/1/2023 at 4:24 p.m., the order indicated: oxytocin 30 units, Postpartum (after childbirth) Vaginal Delivery ...Order Comment: Stop or hold main line infusion (intravenous [through the vein] administration of medication). The record indicated after delivery of infant’s shoulder: infuse oxytocin at 334 mL/hr. for 167 mL (delivers 10 units over 30 minutes). Then reduce rate to 95 mL/hr. to finish the bag. The record indicated to notify provider for excessive vaginal bleeding. During a concurrent interview and record review of Patient 1’s physician orders and Medication Administration Record (MAR) on 11/17/2023 at 10:15 a.m., with the Perinatal Educator (PED), the PED stated the following: Patient 1 had orders for Oxytocin on 11/1/2023. The PED stated oxytocin was usually given prior to delivery to augment the patient ’ s labor and given to prevent excessive bleeding after delivery. The PED stated Patient 1 gave birth on 11/1/2023 at 3:42 p.m. The PED verified that there was no documentation in the medical record indicating the Oxytocin had been administered to Patient 1 or the reasons why it (oxytocin) was not administered. A review of the facility’s policy and procedures (P&P) titled, “Admission of Patient to Labor and Delivery,” dated 10/21/2021, the P&P indicated the following: Receive and carry out admission orders.”