Saint Francis Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38310 Based on observation, interview, and record review the facility failed to ensure the Condition of Participation for Patient’s Rights was met as evidenced by: 1. The facility failed to ensure for four of 35 sampled patients (Patients 2, 3, 36, and 37), the patients’ right to be free from all forms of abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse) was implemented when: 1. Appropriate safety measures and interventions were not in place for Patient 1, with known aggressive and assaultive behavior, to prevent Patient 1’s physical assault against Patients 2 and 3. 2. Appropriate safety measures and interventions were not in place for Patient 12, with known aggressive and assaultive behavior, to prevent Patient 12’s physical assault to Patients 36, 37, and another patient (no known patient identifier). This deficient practice resulted in the following: a. Patient 2, who was physically assaulted by Patient 1, with unknown injury because the facility did not investigate and report incident to local law enforcement and local health department, was not assessed and provided necessary patient care needed from the assault (Refer to A-0145) b. Patient 3 was physically assaulted by Patient 1, which resulted in Patient 3 to suffer fracture (broken bone) on the nose. (Refer to A-0145) c.) Patients 36 and 37 were punched by Patient 12 In addition, the deficient practice had the potential for other patients to suffer physical abuse from Patients 1 and 12 that may cause harm/injury/death. (Refer to A-0145) 2. The facility failed to ensure for two (2) of 35 sampled patients (Patients 32 and 33), Patient 32 and 33’s nursing care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) for the use of restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) was developed. This deficient practice had the potential to result in harm to Patients 32 and 33’s safety by not identifying the patients’ needs and risks. (refer to A-0166) 3. The facility failed to ensure for two of 35 sampled patients (Patients 5 and 28), the use of restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) was ordered by the physician when, all four side-rails for Patients 5 and 28 were raised. This deficient practice resulted in an inappropriate use of restraints and had the potential for Patients 5 and 28 to have compromised patient safety with complications such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia [lack of oxygen]), skin tear, etc. (refer to A-0168) 4. The facility failed to ensure for one of 35 sampled patients (Patients 33), Patient 33’s condition was assessed and have the assessment documented in the patient’s record after Patient 33 was put on restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely). This deficient practice had the potential to result in inappropriate, unnecessary, and prolonged use of restraints. (Refer to A-0175) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe setting, potentially placing patients at risk for a delay in care and treatments, abuse, self-harm, harm to others, 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: 38310 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 for two of 35 sampled patients (Patient 7 and 22), nursing care was provided when: 1.a. Patient 7’s strict intake and output (I&O - monitoring is a clinical care process that measures and records fluid balance to help caregivers understand a patient’s condition and guide their daily care) was not monitored as ordered by the physician. This deficient practice had the potential to cause adverse health outcomes which could negatively affect Patient 7’s health and safety due to inaccurate intake and output monitoring that that may lead to prolonged hospitalization and/or death of the patient. (Refer to A-0395) 1.b. Patient 22’s call light (device use by patient to call for assistance from facility staff) was not responded timely in accordance with the facility’s protocol regarding call lights. This deficient practice had the potential for Patient 22’s needs to not be met and may result in delayed treatment that could have a negative effect on Patient 22’s provision of care. (Refer to A-0395) 2. The facility failed to ensure for five of 35 sampled patients (Patients 4, 25, 29, 34, and 35) the following: 2.a. Patient 4’s nursing care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) was developed upon admission for seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain), in accordance with the facility’s policy and procedure regarding care plans. 2.b. Patient 25’s nursing care plan for care of central line (Hemodialysis [(HD, a mechanical way to treat advanced kidney failure by removing waste products and excess fluid from blood] Access line, a device inserted to patient bloodstream that can be used for dialysis [a lifesaving procedure to clean the blood]) was developed after Patient 25’s insertion of the Hemodialysis Access line, in accordance with the facility’s policy and procedure regarding care plans. 2.c. Patient 34’s nursing care plan was developed upon admission for skin impairment, in accordance with the facility’s policy and procedure regarding care plans. 2.d. Patients 29 and 35’s nursing care plan was developed upon admission for pain management, in accordance with the facility’s policy and procedure regarding pain management. These deficient practices had the potential to result in the delayed provision of care to the patients (Patients 4, 25, 29, 34, and 35) by not identifying the patients’ needs and risks. (Refer to A-0396) 3. The facility failed to ensure for five of 35 sampled patients (Patients 11, 22, 30, 31, and 34), the facility’s policies and procedures (P&P) were implemented when: 3.a. Patient 11, who was at risk for skin impairment, was not provided and kept on appropriate support surface, a waffle overlay (a non-powered air support surface that is placed on top of a mattress to help prevent and treat pressure injuries. It’s designed to redistribute pressure on bony areas of the body and has venting holes to allow for air circulation, which can help keep patients cool, dry, and comfortable) that would help ensure maintenance of the patient’s skin integrity, in accordance with the facility’s policy and procedure regarding Skin Integrity. This deficient practice had the potential to cause pressure injuries (PI, localized damage to the skin and underlying tissue caused by prolonged pressure) which could negatively affect Patient 11’s provision of care and that may lead to prolonged hospitalization and/or death of the patient. (Refer to A-0398) 3.b. Patient 22’s Heparin (a medication that stops your blood from forming blood clots) intravenous (IV - in the vein) drip did not have a medication label. In addition, two RNs verified Patient 22’s Heparin drip prior to administering the medication without a medication label, in accordance with the facility’s policy and procedure regarding Heparin Therapy Protocol. This deficient practice had the potential to cause adverse health outcomes which could negatively affect the patient’s health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death. (Refer to A-0398) 3.c. Patients 31 and 34’s wound and PI (Pressure Injuries) were not assessed and measured weekly, in accordance with the facility’s policy and procedure regarding Wound care. This deficient practice had the potential for Patients 31 and 34’s wound and/or PI assessment to be inaccurate and may cause delay in treatment that could result in patient harm. (Refer to A-0398) 3.d. Registered Nurse 14 (RN 14), who was assigned to the care of Patient 30, did not perform hand hygiene after providing patient care to Patient 30 with PureWick (a female external catheter is intended for non-invasive urine output management in adults uses with female anatomy for conditions such as urinary incontinence), in accordance with the facility’s policy and procedure regarding Hand Hygiene. This deficient practice had the potential for the introduction of pathogens (a microorganisms such as bacteria or virus that can cause a disease process) from RN 14 not performing hand hygiene and the potential for risk of transmission of microorganism to other patients in the same unit or hospital setting. (Refer to A-0398) 3.e. One of four sampled Emergency Cart (Emergency Cart 1, mobile cart unit stocked with emergency medical equipment, supplies, and drugs use by medical personnel for life threatening emergency), Emergency Cart 1 was not checked daily for all the necessary equipment and supplies that are readily available during an emergency in accordance with the facility’s policy and procedure regarding Emergency Crash Carts. This deficient practice had the potential to delay patient care and to improve patient outcomes following an emergency medical condition or in a crisis event. (Refer to A-0398) 4.The facility failed to ensure for two of 35 sampled patient (Patients 22 and 35) the following: 4.a. Morphine (medication to help relieve moderate to severe pain) was administered to Patient 22 in accordance with the physician’s order. 4.b. Tylenol (pain medication used to treat mild pain (pain score of 1-3 is mild pain) was administered to Patient 35 in accordance with the physician’s order. These deficient practices resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect the patients’ health and safety due to unsafe medication administration and may lead to prolonged hospitalization. (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 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: 38310 Based on observation, interview and record review, the facility’s Governing Body (responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure the Nursing Services, in the psychiatric unit (BHU - specialized unit for inpatient treatment of individuals with psychiatric conditions), followed established policies and procedures for the safety for one of 35 sampled patients (Patient 1), in the psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) unit, who had a long history of aggressive and violent behavior, requiring one-to-one monitoring (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) to prevent physical and verbal abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) to other patients. This deficient practice resulted in Patient 1 physically abusing two patients (Patient 2 and Patient 3), in the psychiatric unit (BHU), with injury to one patient (Patient 3). Findings: During an observation on 7/22/2024 at 3:01 P.M. with Charge Nurse (Chg Nse), in the Behavioral Health Unit (BHU - a hospital unit that provides inpatient care for people with mental health issues), Patient 1 was observed asleep in one of the three seclusion rooms (quiet rooms, away from the other patient rooms, used by the facility for patients who are high risk for aggressive/assaultive behaviors and are requiring emergency intramuscular [IM - administered through the muscles] medications and close monitoring of behavior, by assigned staff) with bedsheets covering face and body. There was no BHU staff within line-of-sight (the patient will always be in the vision of the staff) of Patient 1. The Chg Nse stated that Patient 1 likes to be away from other patients and likes to sleep in the seclusion room. During an interview on 7/22/2024 at 4:02 P.M. with Registered Nurse 2 (RN 2), RN 2 stated he (RN 2) was assigned to the care of Patient 1, for the first time, with a trainee (RN 3), today (7/22/2024). RN 2 stated he (RN 2) was not aware that Patient 1 assaulted another patient. RN 2 stated he (RN 2) only heard that Patient 1 struck a patient (Patient 2) last March (2024) and was not aware of another incident after that. During a concurrent interview and record review on 7/23/2024 at 10:30 A.M. with telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) supervisor (Sup 1), Patient 1’s face sheet (a document that gives a patient’s information at a quick glance and includes the patient’s name, date of birth, address, etc.), dated 2/21/2024, was reviewed. Sup 1 stated patient (Patient 1) was brought to the facility, by law enforcement, with an involuntary psychiatric 72-hour hold (5150 is the number of the section of the Welfare and Institutions Code [establishes programs and public social services for promoting the public welfare], which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) because of a danger to others and a danger to self. Sup 1 stated prior to being brought into the facility, Patient 1 assaulted staff from a previous facility, left the previous facility, and ran into oncoming traffic, and was a danger to self and to others. As a result, local law enforcement was called and brought Patient 1 to the current facility. Concurrently, Sup 1 stated Patient 1 was admitted to the emergency department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) on 2/21/2024, at 4:08 P.M., was agitated (A feeling of irritability or severe restlessness) and uncooperative, was placed in 4-point restraints (device used on all four limbs simultaneously for violent behaviors) and was medicated with intramuscular medications (IM - medication administered into a muscle for rapid absorption) for aggressive behavior. Concurrently, Sup 1 stated Patient 1 was admitted to facility’s psychiatric unit (BHU - behavioral health unit that provides inpatient care for people with mental health issues), on 2/21/2024, at 10:59 P.M. Concurrently, Sup 1 stated Patient 1 received additional emergency IM medications, for aggressive behavior on the following dates and times: 1. 2/21/2024, at 4:25 P.M. and at 4:59 P.M., in the ED. 2. 2/22/2024, at 12:01 A.M., and at 10:57 A.M., in BHU. 3. 2/27/2024, at 2:41 A.M., in BHU. 4. 3/4/2024, at 6:12 P.M., in BHU. 5. 3/21/2024, in BHU. During an interview on 7/23/2024, at 11:19 A.M., with clinical supervisor of BHU (Sup 2), Sup 2 stated “BHU staff must “keep an extra eye on all their BHU patients” because of the high risk for aggressive and/or assaultive behaviors towards other patients and staff. Concurrently, Sup 2 stated BHU staff keep their patients safe by doing 15-minute rounds (best practice intervention of checking in on patients to meet patient care needs) on all their patients. Sup 2 said BHU staff do not do one-to-one (1:1 observation or continuous observation - a type of care that involves a registered nurse or health care worker providing close supervision to a patient for a period to ensure patient safety) monitoring and/or use 1:1 sitter for their patients, unless the patients meet a certain criterion, including a suicidal (ending one’s own life) patient with an active plan. On 7/23/2024, at 12:02 P.M., during concurrent interview with Sup 2 and record review of BHU’s emergency IM medication log and Patient 1’s nursing notes, Sup 2 stated Patient 1 received IM injections on the following dates and times: 1. 2/22/2024, at 11:17 A.M., Haldol (used to treat mental/mood disorders), lorazepam (used to treat anxiety), and Benadryl (used as a sedative [cause sleepiness] in the psychiatric unit), for threatening BHU staff. 2. 2/27/2024, at 2:45 A.M., Haldol, Benadryl, and lorazepam, for throwing objects at staff. 3. 3/4/2024, at 6:20 P.M., Thorazine (used to treat mental health conditions) and lorazepam, for punching BHU walls and doors and threatening staff. 4. 3/21/2024, at 2:40 P.M., Thorazine, for throwing water at another patient and yelling at BHU staff. 5. 3/28/2024, at 1:52 P.M., Thorazine and lorazepam, for hitting a male patient (Patient 2), in the common area, unprovoked. 6. 3/30/2024, at 7:35 A.M., Thorazine and lorazepam, for threatening BHU staff and other patients. 7. 7/9/2024, at 10:57 P.M., Thorazine and lorazepam, for hitting a female patient (Patient 3), who was wheelchair-bound, in the common area, unprovoked, which resulted in injury to Patient 3, requiring emergency care in the ED. Concurrently, Sup 2 stated after the incidents with Patient 1 hitting Patient 2 and Patient 3, there were no additional interventions done to ensure Patient 1 does not hit another patient, besides every 15-minute rounds, which was done for all BHU patients. Sup 2 stated even with 15-minute rounds for all patients, including Patient 1, there is a possibility that Patient 1 could hit another patient. On 7/23/2024, at 3:26 P.M., during interview with director of BHU (BHU Dir), regarding Patient 1, BHU Dir stated the following: 1. BHU staff ensure patient safety by doing 15-minute rounds on all patients, which is accomplished by licensed nurses and mental health workers. 2. Licensed nurses document assaultive behaviors every shift and as needed, in their nursing notes. 3. BHU staff create update and individualized care plans for the patients, which is done by the registered nurses (RN), every shift. 4. After an assaultive behavior by a patient, RN can create a new care plan or update a current care plan. 5. After an assaultive behavior by a patient, BHU staff are informed of the incident during staff huddles. 6. All BHU staff monitor all patients with every 15-minute rounds or by keeping the psychiatric patients within the staff’s line-of-site. 7. All psychiatric patients have daily evaluations by psychiatric physicians. 8. Patient 1 has a history of being developmentally delayed and was being followed by regional center. On 7/24/2024, at 4:08 P.M., during concurrent interview with Sup 1 and record review of Patient 2’s face sheet, dated 3/13/2024, Sup 1 stated patient was admitted to the facility with a chief complaint of suicidal ideation (suicidal thoughts - when a person is thinking about killing him/herself, with or without a plan to die by suicide). On 7/24/2024, at 9:36 A.M., during interview with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the following: 1. She worked on 3/28/2024 and was assigned to the care of Patient 1. 2. On 3/28/2024, she heard Patient 1 leave her room while responding to internal stimuli because she heard the patient was talking to herself. 3. She did not witness Patient 1 hit another patient (Patient 2) in the common area. 4. She cannot remember the staff members who witnessed the incident between Patients 1 and 2. 5. After the incident, she interviewed Patient 1, but patient refused to answer any questions. 6. She called Patient 1’s physician and received orders for emergency IM medications. 7. RN 2 put Patient 1 into seclusion room, for observation, and gave the patient the emergency IM injections. On 7/24/2024, at 10:01 A.M., during interview with LVN 2 and Sup 2, Sup 2 stated after the 3/28/2024 incident with Patient 1 hitting Patient 2, there was no investigation done. Sup 2 stated he (Sup 2) did not know if an incident report was made, after the 3/28/2024 incident between Patient 1 and Patient 2, because he (Sup 2) was not working, that day. On 7/24/2024, at 11:10 A.M., during an interview with social worker (SW) 1 and BHU Dir, SW 1 stated she (SW 1) did not know about the 3/28/2024 incident of Patient 1 hitting Patient 2, unprovoked because BHU staff did not report incident to supervisor and did not file an incident report. SW1 stated she (SW 1) was assigned to Patient 1, and not assigned to Patient 2. Concurrently, BHU Dir stated the following: 1. She was not aware the incident that happened on 3/28/2024, between Patient 1 and Patient 2, either, because her staff did not report the incident to any supervisors. 2. There was no investigation done, after the patient-to-patient incident, until recently, on 7/23/2024. 3. She stated she reviewed the medical records, dated 3/28/2024, for Patient 1 and Patient 2 and did not find any notes about the incident on Patient 2’s medical records. 4. She stated she interviewed Patient 2’s physician and psychiatrist after reviewing patients’ medical records, dated 3/28/2024 regarding the incident. She stated during interview with Patient 2’s physicians, they were not aware of the incident that happened between Patient 2 and Patient 1 because they were not notified of the incident. 5. She stated she interviewed the staff who worked on 3/28/2024, and nobody, but one staff member, stated an incident happened between Patient 1 and Patient 2, with Patient 1 hitting Patient 2, unprovoked. 6. She stated, on 3/28/2024, RN 2 was assigned to the care of Patient 2. 7. She stated RN 2 did not document on Patient 2’s medical records, that Patient 2 was struck by Patient 1, did not file an incident report, after Patient 2 was struck by Patient 1. 8. She stated Patient 2’s medical records, dated 3/28/2024, are inaccurate because the incident of Patient 1 hitting Patient 2 was not documented anywhere in the patient’s records. 9. She stated that BHU staff are expected to fill out an incident for all adverse events and/or unusual occurrences (including incidents with patients hitting another patient), to notify the physician, to notify the nursing supervisor, and document the incident in the patient’s medical records (nursing notes). On 7/23/2024, at 3:45 P.M., during telephone interview with registered nurse (RN) 1, RN 1 stated the following: 1. He worked on 7/9/2024, night shift when Patient 1 hit Patient 3, who was wheelchair-bound. 2. Prior to 7/9/2024 incident of Patient 1 assaulting Patient 3, he was not aware of Patient 1’s history of assaultive behavior. 3. On 7/9/2024, he was not assigned to Patient 1 - another licensed nurse was assigned to Patient 1. 4. On 7/9/2024, he heard Patient 3 scream, but did not see the incident. He stated he could not remember who was present when Patient 1 hit Patient 3. 5. After the 7/9/2024 incident between Patient 1 and Patient 3, he called and notified the physician, who ordered emergency IM medications. 6. No other interventions were ordered for Patient 1, to ensure the safety to other patients. 7. Patient 1 was taken to the seclusion room. 8. He interviewed Patient 1, but patient refused to answer questions regarding incident. 9. BHU staff received training on de-escalation techniques for aggressive patients. 10. BHU staff were trained to report assaultive behavior to the supervisor and the physician, and then fill out an incident report. On 7/23/2024, at 4:17 P.M., during telephone interview with licensed vocational nurse (LVN) 1, LVN 1 stated the following: 1. She worked 7/9/2024, night shift, and was assigned to Patient 1. 2. Patient 1 was unpredictable and responds to internal stimuli and was restless. 3. She observed Patient 1 pacing the floor and walking and talking to herself. 4. She did not witness Patient 1 hitting Patient 3 and did not remember who was present during the incident. 5. After the incident, she offered to help Patient 1, who refused any help from her. 6. After the incident, RN 1 called Patient 1’s physician, who ordered patient to be placed in the seclusion room, and emergency IM injection medications. 7. There were no additional interventions for Patient 1, after the incident, including 1:1 monitoring or 1:1 sitter assigned to Patient 1. A review of Patient 3’s face sheet, dated 6/27/2024, indicated patient was admitted to the emergency department (ED) with a chief complaint of anxiety with suicidal ideation (SI - suicidal thoughts; when you think about killing yourself with or without a plan to die by suicide). A review of Patient 3’s psychiatric consultation, dated 6/27/24, indicated patient was admitted voluntarily to the psychiatric unit (BHU - a hospital unit that provides inpatient care for people with mental health issues) for danger to self. A review of Patient 3’s 72-Hour Assessment, dated 6/28/2024, indicated the following: 1. Patient was evaluated by the psychiatric Emergency Team (PET - mobile teams operated by psychiatric hospitals and approved by the department of mental health to provide 5150 evaluations) to be gravely disabled. 2. 72-hour hold for patient who was confused and disoriented due to altered mental condition. A review of Patient 3’s Observation Record, dated 7/9/2024, indicated the following: 1. At 10 P.M., patient (Patient 3) was attacked by room mate in the common area, while receiving medications. 2. At 12 A.M., patient (Patient 3) went to get a computed tomography (CT Scan - medical imaging technique that uses x-rays and a computer to create detailed cross-sectional images of the inside of the body. 3. At 2 A.M., patient (Patient 3) was interviewed by law enforcement. 4. At 5 A.M., patient (Patient 3) was interviewed. A review of Patient 3’s nursing notes, dated 7/9/2024, indicated the following: 1. At 10 P.M., patient was in the medication window receiving medication, while sitting in her wheelchair. 2. Patient’s room mate approached patient without provocation, yelled at her, and began punching her in the face. 3. Afterwards, patient was observed to have swelling in the nose and bleeding from the nostrils. Patient complained of pain in the left eye, with a pain score of 6/10 (moderate pain). 4. Patient was taken to get a CT scan of the head and face. A review of Patient 3’s CT scan of the head, dated 7/11/2024, indicated the following: 1. Fractured (broken) left nasal bone. 2. Fractured right nasal bone. 3. Mildly deviated nasal septum (off-centered position of the wall between the nostrils). During an interview on 7/26/2024 at 4:35 P.M. with a member of the facility’s governing body’s (GB - a group of people that has the authority to exercise governance over an organization), Chief Financial Officer (CFO - a senior executive who manages all aspect of the company’s finances) stated the GB meets monthly to review staff credentials and quarterly. CFO stated she (CFO) was not aware of patients in the BHU requiring 1:1 monitoring or 1:1 sitter, until after 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) on 7/24/2024. A review of the facility’s GB minutes - Medical Executive Committee minutes, dated, 4/15/2024, 5/13/2024, 6/17/2024, did not reflect documentation of the GB’s oversight to ensure the safety of patients from aggressive and assaultive patients, in the BHU, who needed one-to-one (1:1) monitoring and/or 1:1 sitter. Patients were not provided 1:1 monitoring, until the survey team called an IJ on 7/24/2024. A review of the facility’s One-to-One (1:1) Observation policy, dated 6/14/2021, indicated the following: 1. Patients may be placed on a 1:1 observation, upon a physician’s order and shall include a staff member always remaining with the patient(s). 2. Patients may be placed on a 1:1 observation, if, in the judgement of the staff, they may be suicidal, exhibit impaired judgement, or may be in danger of elopement (when a patient leaves a healthcare facility without authorization and without being noticed, especially when they are unable to make safe decisions for themselves). 3. A staff member will always maintain visual contact with the patient, no more than 4 feet away. 4. Patients who are at high risk for self-harm or injury to others may require more intensive observation. The observation requires the staff to be always within arm’s length. A review of the facility’s Observation Attendant (Sitter) policy, dated 7/2023, indicated the following: 1. Observation Attendant (OA) used to protect the patient from harm or injury in a safe healing environment. 2. Levels of observation included: every 15-minute observation, line-of-sight observation, director constant observation and one-to-one (1:1). a. Every 15-minute observation - OA is dedicated to one or more patients; OA documents patient’s behaviors and activities; observation every 15 minutes is the maximum amount of time for a gap in observation of the patient. b. Line-of-Sight observation means OA is in direct line of sight with one or more patients; patients can be always seen by staff - either directly or by video. c. Direct Constant observation - OA is within direct line-of-sight in a risk reduced environment with patient not actively attempting or actively verbalizing intent to self-harm. d. 1:1 in an at-risk environment - OA is within sight and proximity to the patient - close enough for OA to react to patient’s behavior, without delay, with no physical barriers and in the same room/area with a 360-degree view of the patient and surroundings.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 38310 Based on observation, interview, and record review, the facility failed to ensure for four of 35 sampled patients (Patients 2, 3, 36, and 37), the patients’ right to be free from all forms of abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse) was implemented when: 1. Appropriate safety measures and interventions were not in place for Patient 1, with known aggressive and assaultive behavior, to prevent Patient 1’s physical assault against Patients 2 and 3. 2. Appropriate safety measures and interventions were not in place for Patient 12, with known aggressive and assaultive behavior, to prevent Patient 12’s physical assault to Patients 36, 37, and another patient (no known patient identifier). This deficient practice resulted in the following: a. Patient 2, who was physically assaulted by Patient 1, with unknown injury because the facility did not investigate and report incident to local law enforcement and local health department, was not assessed and provided necessary patient care needed from the assault b. Patient 3 was physically assaulted by Patient 1, which resulted in Patient 3 to suffer fracture (broken bone) on the nose. c. Patients 36 and 37 were punched by Patient 12 In addition, the deficient practice had the potential for other patients to suffer physical abuse from Patients 1 and 12 that may cause harm/injury/death. On 7/24/2024, at 5:24 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) situation in the presence of the Chief Nursing Officer (CNO), Director of Performance Improvement (Dir PI), and the Quality Assurance/Survey Coordinator (QA Coord). 1. The facility failed to provide two patients (Patient 2 and Patient 3) their rights to be free from abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) from another patient (Patient 1) who hit them (Patients 2 and 3), in the psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) unit (BHU, Behavioral Health Unit that specializes in the care of people with serious mental illness). 2. The facility failed to provide additional safety measures to prevent Patient 1 from hurting other patients, in the Behavioral Health Unit (BHU). The CNO and Dir PI were informed of the immediate jeopardy situation regarding the failure to provide a safe environment, in the psychiatric unit, with their patients free from physical abuse from patients who exhibit assaultive and aggressive behavior. On 7/26/2024, at 3:58 P.M., the IJ was removed in the presence of the CNO, and the Dir PI, 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 the following: 1. Assaultive patients were placed in private rooms with a one-to-one (1:1) sitter (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed), who is assigned at a safe distance, but within 3 arms’ length. These patients will be accompanied by the sitter always including the common areas and when patient is outside the department. 2. Re-educating all staff in the BHU on: escalation process (initiating the chain of command to resolve problems/concerns related to patient care); importance of reporting all patient-to-patient assaults to clinical supervisor, charge nurse, house supervisor, or director of BHU; completing an event audit tool for each patient-to-patient assault incident; debriefing (to improve clinical outcomes by learning through discussion and reflection of events and then transferring that learning into clinical practice) of each patient-to-patient assault (intentional act that puts another person in reasonable apprehension of imminent harmful or offensive contact) incident; facility’s use of Epic Smart Phrase (tool to document patient-to-patient assaults, in the patient’s medical record, including description of event, debrief documentation, asking victim if he/she wants to press charges, notification of provider/physician, notification of patient’s family and law enforcement, new orders/treatment plan - reviewed for possible changes, care plan, and face-to-face assessment for assailant and victim to be completed by clinical supervisor/charge nurse). 3. BHU staff will contact the physician/provider for active assaultive patients for 1:1 observation order; BHU will assign staff to be a sitter for assaultive patient and accompany patient everywhere, at all times; sitter breaks will be covered by another assigned BHU staff member; sitters will use de-escalation techniques when they recognize signs of agitation (attacking objects, irritability, verbal threats, physical threats, boisterousness); BHU staff will review patient’s plan of care and will update interventions, according to the patient’s needs; staff will complete escalation process to report incidents of assaultive behavior; director of BHU will audit active assaultive patient’s care plans daily. Findings: 1. During an observation on 7/22/2024 at 3:01 P.M. with Charge Nurse (Chg Nse), in the Behavioral Health Unit (BHU - a hospital unit that provides inpatient care for people with mental health issues), Patient 1 was observed asleep in one of the three seclusion rooms (quiet rooms, away from the other patient rooms, used by the facility for patients who are high risk for aggressive/assaultive behaviors and are requiring emergency IM medications and close monitoring of behavior, by assigned staff) with bedsheets covering face and body. There was no BHU staff within line-of-sight (the patient will always be in the vision of the staff) of Patient 1. The Chg Nse stated that Patient 1 likes to be away from other patients and likes to sleep in the seclusion room. During an interview on 7/22/2024 at 4:02 P.M. with Registered Nurse 2 (RN 2), RN 2 stated he (RN 2) was assigned to the care of Patient 1, for the first time, with a trainee (RN 3), today (7/22/2024). RN 2 stated he (RN 2) was not aware that Patient 1 assaulted another patient. RN 2 stated he (RN 2) only heard that Patient 1 struck a patient (Patient 2) last March (2024) and was not aware of another incident after that. During a concurrent interview and record review on 7/23/2024 at 10:30 A.M. with telemetry supervisor 1 (Sup 1), Patient 1’s face sheet (a document that gives a patient’s information at a quick glance and includes the patient’s name, date of birth, address, etc.), dated 2/21/2024, was reviewed. Patient 1’s face sheet indicated Patient 1 was brought to the facility, by law enforcement, with an involuntary psychiatric 72-hour hold (5150 is the number of the section of the Welfare and Institutions Code [establishes programs and public social services for promoting the public welfare], which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled]) because of a danger to others and a danger to self. Sup 1 stated Patient 1’s record indicated Patient 1 assaulted staff from a previous facility, left the previous facility, and ran into the oncoming traffic. In the same interview and record review, on 7/23/2024 at 10:30 A.M., Sup 1 verified Patient 1’s record indicated Patient 1 was presented to the emergency department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) on 2/21/2024 at 4:08 P.M., agitated and uncooperative, was placed in a 4-point restraints,(use of restraints on all four limbs simultaneously for violent behaviors) and was medicated with psychiatric medications (ziprasidone 20 milligrams [mg, a unit of measure] intramuscular [IM, medication administered into a muscle for rapid absorption] injection and lorazepam [used to treat anxiety] 2 mg IM) for extreme agitation (feeling of irritability or severe restlessness). Patient 1 was admitted to BHU on 2/21/2024 at 10:59 P.M. 1.a. During a concurrent interview and record review on 7/23/2024 at 12:02 P.M. with Sup 2, The BHU’s emergency IM log (a record of emergency medications administered to BHU patients), was reviewed. Sup 2 stated the log indicated Patient 1 received intramuscular (IM) injections on the following dates and times: -On 2/22/2024, at 11:17 A.M., Patient 1 was administered lorazepam (medication used for anxiety) and ziprasidone (medication used to treat mental disorders). The corresponding nurse’s notes indicated Patient 1 was given the IM injection for threatening BHU staff. -On 2/27/2024, at 2:54 A.M., Patient 1 was administered Haldol (medication to treat nervous, emotional and mental conditions), Benadryl (medication used for sedation), and lorazepam. The corresponding nurse’s notes indicated Patient 1 was given the IM injection for throwing objects at staff. -On 3/4/2024, at 6:20 P.M., Patient 1 was administered Thorazine (medication used to treat mental health conditions) and lorazepam. The corresponding nurse’s notes indicated Patient 1 was given the IM injection for punching BHU walls and doors and threatening staff. -On 3/21/2024, at 2:40 P.M., Patient 1 was administered Thorazine. The corresponding nurse’s notes indicated Patient 1 was given the IM injection for throwing water at another patient and yelling at BHU staff. -On 3/28/2024, at 1:52 P.M., Patient 1 was administered Thorazine and lorazepam. The corresponding nurse’s notes indicated Patient 1 was given the IM injection for hitting a male patient (Patient 2), in the common area, unprovoked. A review of Patient 1’s nursing notes, dated 3/28/2024, at 1:40 P.M., indicated Patient 1 was administered IM medications, at 1:40 P.M., after an incident of hitting another patient (Patient 2), in the face, without provocation, in the hallway. Patient 1’s physician was notified of the incident and ordered IM medications of Thorazine and lorazepam. Patient 1 was taken to the seclusion room and given the IM medications. During a concurrent interview and record review on 7/24/2024 at 4:08 P.M., with Sup 1, Sup 1 verified Patient 2’s face sheet dated 3/13/2024, indicated Patient 2 was admitted to the facility with a chief complaint of suicidal ideation (suicidal thoughts - when a person is thinking about killing him/herself, with or without a plan to die by suicide). During an interview on 7/24/2024, at 11:10 A.M., with Social Worker 1 (SW 1) and the Director of BHU (DBHU), SW 1 stated she did not know about the 3/28/2024 incident of Patient 1 hitting Patient 2, unprovoked, because the incident was not reported to the supervisor and an incident report was not filed. In the same interview on 7/24/2024, at 11:10 A.M., the DBHU stated there was no incident report made regarding Patient 2 being assaulted by Patient 1. She (DBHU) stated she (DBHU) just found out of the incident on 7/23/2024. The DBHU stated there was no incident report received, no documentation on Patient 2’s record regarding the incident. The DBHU stated they were not aware if Patient 2 had an injury from the assault since there was no incident report, it was not investigated. 1.b. A review of Patient 1’s nursing notes, dated 7/9/2024, at 10:57 P.M., indicated Patient 1 was observed pacing the common area and talking to herself, when she (Patient 1) punched her roommate (Patient 3), who was sitting in a wheelchair, in the common area. Registered Nurse 1 (RN 1) called the physician, who ordered emergency IM (Intramuscular, medication administered into a muscle for rapid absorption) medications for Thorazine (medication used to treat mental health conditions) and lorazepam (medication used for anxiety). Patient 1 was taken to the seclusion room, emergency IM medications were administered. Patient 1 was monitored every 15 minutes for safety and behavioral changes. A review of Patient 3’s nursing notes, dated 7/9/2024, at 11:04 P.M., indicated Patient 3, in a wheelchair, was at the medication window receiving medication when Patient 3’s roommate (Patient 1) approached the patient (Patient 3), without provocation, started yelling and punching Patient 3 in the face. Patient 3 was observed with swelling and bleeding from the nose, complained of pain in the left eye. Patient 3 was taken to ED for head CT scan (Computerized Tomography Scan, a type of imaging that uses X-ray techniques to create detailed images of the body). A review of Patient 3’s CT scan of the head, dated 7/11/2024, indicated Patient 3 had a fractured left nasal(nose) bone with soft tissue edema (swelling), non-displaced fracture (break in the bone) of right nasal bone, and mild rightward deviation of the nasal septum (the thin wall that separates the right and left nasal passages). A review of Patient 3’s face sheet, dated 6/27/2024, indicated patient(Patient 3) was admitted to the emergency department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) with a chief complaint of anxiety (a feeling of fear, dread, and uneasiness) with suicidal ideation (SI - suicidal thoughts; when you think about killing yourself with or without a plan to die by suicide). During an interview on 7/23/2024, at 11:19 A.M., with clinical supervisor of BHU (Sup 2), Sup 2 stated BHU staff keep an “extra eye” on all their BHU patients because of the high risk for aggressive and/or assaultive behaviors towards other patients and staff. Sup 2 stated BHU staff keep their patients safe by doing 15-minute rounds (best practice intervention of checking in on patients to meet patient care needs) on all their patients. Sup 2 stated BHU staff does not do one-to-one (1:1) observation or continuous observation (involves a health care worker providing close supervision to a patient for a period to ensure patient safety) monitoring and/or use 1:1 sitter for their patients, unless the patient is a suicidal patient with an active plan. In a follow-up interview on 7/23/2024, at 12:19 P.M., with Sup 2, Sup 2 stated when Patient 1 assaulted Patient 3, there were no other safety interventions placed to ensure the safety of other patients, other than the 15-minute rounding of staff for all the patients in the psychiatric unit. Sup 2 agreed that there was a possibility for Patient 1, with known aggressive and assaultive behavior, to harm other patients in between the 15-minutes staff rounding. During an interview on 7/23/2024, at 3:45 P.M., with RN 1, RN 1 stated he (RN 1) worked on 7/9/2024, night shift (7PM to 7 AM) when Patient 1 hit Patient 3, who was wheelchair-bound, unprovoked, in the common area, in front of the medication window. RN 1 stated he (RN 1) heard Patient 3 scream but did not see the incident. RN 1 stated he (RN 1) was not aware of Patient 1’s history of assaultive behavior. In the same interview on 7/23/2024, at 3:45 P.M., RN 1 stated the physician was notified of Patient 1 assaulting Patient 3, emergency IM medications were ordered and given to Patient 1. RN 1 stated Patient 1 was taken to the seclusion room. RN 1 stated there were no other safety measures implemented for Patient 1 to ensure safety for other patients. Patient 1 did not have one-to-one monitoring after the incident. A review of facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 6/2022, the P&P indicated, “The patient has the right to receive care in a safe setting. The patient has the right to be free from all forms of abuse and harassment. A review of facility’s policy and procedure (P&P) titled, “One-to-One (1:1) Observation,” dated 6/14/2021, indicated the following: -Patients may be placed on a 1:1 observation, if, in the judgement of the staff, they may be suicidal, exhibit impaired judgement, or may be in danger of elopement (when a patient leaves a healthcare facility without authorization and without being noticed, especially when they are unable to make safe decisions for themselves). - A staff member will always maintain visual contact with the patient, no more than 4 feet away. - Patients who are at high risk for self-harm or injury to others may require more intensive observation. The observation requires the staff to be always within arm’s length. 2. A review of Patient 12’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/15/2024 at 10:32 P.M., indicated Patient 12 was on a 5150 hold (is the number of the section of the Welfare and Institutions Code [establishes programs and public social services for promoting the public welfare], which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) for DTO (danger to others). Patient 12 reported hearing voices and seeing shadows believed to be demons trying to attack. Patient 12 physically assaulted another person at the previous group home. 2.a. A review of Patient 12’s “Nursing Note,” dated 4/9/2024 at 10:23 A.M., indicated Patient 12 was watching television (TV) and without cause, Patient 12 was seen chasing Patient 36 into the dining area and began striking and kicking Patient 36 with a closed fist. Patient 12 reported paranoia (the irrational and persistent feeling that people are out to get you) and voices were telling Patient 12 to inflict (cause) harm to peers (friends/other patients). A review of Patient 12’s “Psychiatry Progress Note,” dated 4/9/2024 at 10:41 A.M., indicated Patient 12 became agitated (a feeling of uneasiness or severe restlessness) and paranoid. Patient 12 “attacked” (try to hurt or kill) Patient 36 and required emergency medication(s). A review of Patient 36’s “Nursing Note,” dated 4/9/2024 at 12:00 P.M., indicated Patient 36 was attacked and punched from behind by Patient 12 for no reason. Patient 36 complained of pain to the left side of the head causing Patient 36 to become angry and require emergency medication. 2.b. A review of Patient 12’s “Nursing Note” dated 4/23/2024 at 5:17 P.M., indicated Patient 12 became physically combative (ready to fight) to another patient, unprovoked. Patient 12 was removed (from the presence of other patients). Patient 12’s behavior continued to become worse causing Patient 12 to threaten (tell someone or something of a wish to harm) staff and provoke (try to make someone angry) fighting with other patients. Patient 12 was given emergency intramuscular (IM, medication administered into a muscle for rapid absorption) medications for combative behavior and escorted (go with) to the observation room. During an interview on 7/25/2024 at 4:33 P.M. with the Director of the Behavioral Health Unit (DBHU), the DBHU stated she (DBHU) was not aware of Patient 12’s assault of another patient that occurred on 4/23/2024. The DBHU stated the incident was not reported and no incident report filed causing inability to identify the patient assaulted by Patient 12. The DBHU stated she (DBHU) only became aware of the incident on 7/25/2024 after reviewing Patient 12’s record that indicated the incident of Patient 12’s assault towards another patient. The DBHU stated there was no patient identifier provided in Patient 12’s record to assist with the identification of the other patient assaulted on 4/23/2024. The DBHU further stated documentation and reporting was important to allow appropriate follow up. Failure to assess and/or report may result in missed opportunities, safety concerns, and/or serious injuries. The DBHU stated a lack of assessment following a physical altercation may lead to overlooked injuries with potential for serious harm and/or potential for others to be harmed. The DBHU was unable to verify if any injuries occurred due to the lack of knowledge of the events and the inability to identify all parties involved. 2.c. A review of Patient 12’s “Nursing Note,” dated 5/2/2024 at 7:00 P.M., indicated Patient 12 was observed (seen) pacing (walking back and forth) and mumbling (quietly talking) to self. Without provocation (cause), Patient 12 jumped out the seat, started yelling (speak loudly), and abruptly (quickly) began punching (hitting) another patient (Patient 37). A review of Patient 37’s “Nursing Note,” dated 5/2/2024 at 10:42 P.M., indicated report (information about the patient and care) received included Patient 37’s location, mood, and actions. There was no documentation (written information) of the physical altercation (fight) between Patient 12 and Patient 37 on 5/2/2024. There was no assessment (look at/check) of potential injury documented. During an interview on 7/25/2024 at 4:33 P.M. with the DBHU, the DBHU stated she (DBHU) was not aware of Patient 12’s assault of another patient (Patient 37) that occurred on 5/2/2024. The DBHU stated Patient 12’s record indicated Patient 37 was the patient assaulted by Patient 12 on 5/2/2024. The DBHU stated there was no documentation of Patient 37’s assessments following the assault from Patient 12. The DBHU stated there was no incident report filed for this incident. The DBHU further stated documentation and reporting was important to allow appropriate follow up. Failure to assess and/or report may result in missed opportunities, safety concerns, and/or serious injuries. The DBHU stated a lack of assessment following a physical altercation may lead to overlooked injuries with potential for serious harm and/or potential for others to be harmed. The DBHU was unable to verify if any injuries occurred due to the lack of knowledge of the events and the inability to identify all parties involved. In the same interview on 7/25/2024 at 4:33 P.M., the DBHU stated no new interventions or treatment plan for Patient 12 was developed following multiple occurrences of assault to other patients. The DBHU stated it was the physician’s responsibility to make adjustments to a treatment plan for repeated behaviors which may include medication adjustment(s). The DBHU stated the lack of awareness caused missed opportunity for discussion with the physician to make adjustments/changes on Patient 12’s treatment plan to help prevent multiple occurrences of Patient 12’s assault to other patients A review of the facility’s policy and procedure (P&P) titled, “One-to-One Observation,” dated 09/2023, indicated “patients who are at high risk for self-harm and/or injury to others may require a more intensive observation (watch). Fifteen-minute rounding (check status, location, and mood of the patients) is an intervention (task) used for all BHU patients to promote safety. This task is performed every 15 minutes by staff. No new safety plans or interventions are implemented (started) for Patient 12 that would prevent further physical altercations following multiple occurrences. Patient 12 was not placed with a sitter (someone assigned to closely watch a patient and keep the patient within arm’s reach at all times) to promote a more intensive observation in an attempt to prevent further incidents of abuse.””

“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: 50521 Based on interview and record review, the facility failed to ensure for two (2) of 35 sampled patients (Patients 32 and 33), Patient 32 and 33’s nursing care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) for the use of restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) was developed. This deficient practice had the potential to result in harm to Patients 32 and 33’s safety by not identifying the patients’ needs and risks. Findings: 1. During a review of Patient 32’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/16/2024, the H&P indicated Patient 32 was admitted to the facility for head injury. Patient 32 was combative in the Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care). During a review of Patient 32’s physician order dated 6/9/2024, the order indicated Patient 32 had bilateral upper extremities soft restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely). During a concurrent interview and record review on 7/25/2024 at 11:00 P.M. with Registered Nurse 4 (RN 4), Patient 32’s care plan was reviewed. RN 4 stated Patient 32 had a bilateral upper extremity soft restraint. RN 4 stated Patient 32’s nursing care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) did not include the use of restraints. RN 4 stated it is important to have a care plan related to restraints to indicate the interventions needed. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Care Plan-Interdisciplinary,” reviewed on 12/2022, the P&P indicated, “The Plan of Care shall consist of problems, measurable expected outcomes, and interventions that reflect acceptable standards of care and are consistent with the inter-disciplinary care being provided. Age and other relevant factors will be taken into consideration when developing the plan, which will be initiated by a Registered Nurse (RN) within 24 hours of admission based on an analysis of the admission assessment data ...Within 24 hours of admission, an RN will initiate the care plan, document and review age related and other factors ...The Plan of Care is a permanent part of the Medical Record. Nursing documentation will reflect that the Plan of Care has been reviewed and/or updated daily and upon change in patient’s condition.” 2. During a record review of Patient 33’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/5/2024, the H&P indicated Patient 33 was admitted to the facility after being T-boned (side impact collision or broadside crash, is a car crash where the front of one vehicle hits the side of another creating a “T” shape at the point of impact) by a bus. During a review of Patient 33’s physician’s order dated 7/14/2024, the order indicated Patient 33 had siderail X (times) 4 and bilateral wrists soft restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely). During a concurrent interview and record review on 7/24/2024 at 03:35 P.M., with the Charge Nurse of Behavioral Health Unit (CNBHU), Patient 33’s care plan was reviewed. The CNBHU stated Patient 33’s nursing care plan did not include the use of restraints. The CNBHU stated nursing care plan was important to show the interventions required. During a review of the facility’s policy and procedure (P&P) titled, “Restraints: Non Violent Behavior,” reviewed on 6/2022, the P&P indicated, “The use of restraint is; In accordance with a written modification to the patient’s plan of care; and Implemented in accordance with safe and appropriate restraint techniques and in accordance with state law.” During a review of the facility’s policy and procedure (P&P) titled, “Nursing Care Plan-Interdisciplinary,” reviewed on 12/2022, the P&P indicated, “The Plan of Care shall consist of problems, measurable expected outcomes, and interventions that reflect acceptable standards of care and are consistent with the inter-disciplinary care being provided. Age and other relevant factors will be taken into consideration when developing the plan, which will be initiated by a Registered Nurse (RN) within 24 hours of admission based on an analysis of the admission assessment data ...Within 24 hours of admission, an RN will initiate the care plan, document and review age related and other factors ...The Plan of Care is a permanent part of the Medical Record. Nursing documentation will reflect that the Plan of Care has been reviewed and/or updated daily and upon change in patient’s condition.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 42937 Based on observation, interview and record review, the facility failed to ensure for two of 35 sampled patients (Patients 5 and 28), the use of restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) was ordered by the physician when, all four side-rails of Patients 5 and 28 were raised. This deficient practice resulted in an inappropriate use of restraints and had the potential for Patients 5 and 28 to compromise patient safety with complications such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia [lack of oxygen]), skin tear, etc. Findings: 1. During a concurrent observation and interview, on 7/23/2024 at 10:25 A.M., with Clinical Nurse Supervisor 5 (CNS 5), Patient 5 was observed in bed in the patient’s room. CNS 5 concur that Patient 5’s 4 siderails were all raised. CNS 5 stated that all 4 siderails raised was considered restraints restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) and requires a physician’s order. During a concurrent observation and interview, on 7/23/2024 at 10:30 A.M., with Registered Nurse 16 (RN 16), in Patient 5’s room, RN 16 concurred that Patient 5 was in bed with all 4 siderails raised. RN 16 stated that having all 4 siderails raised with the patient in bed was considered restraint as indicated in the policy and procedure (P&P). RN 16 stated Patient 5 had no orders for restraint and should not have all 4 siderails raised as it can minimize the patient’s ability to move freely. During a review of the facility’s policy and procedure (P&P) titled, “Restraints: Non-Violent Behavior,” reviewed in 6/2022, the P&P indicated the following: -Restraint - Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. -The use of restraint is in accordance with the order of physician or other LIP (licensed Independent Practitioner) who is responsible for the care of the patient. 2. During an observation and interview, on 7/23/2024 at 10:36 A.M., with Performance Improvement Coordinator (PIC) and Registered Nurse 3 (RN 3), Patient 28 was observed in bed, awake and unattended with 4 side rails of the bed raised. RN 3 stated it was Certified Nurse Assistant 1 (CNA 1) who placed Patient 28’s 4 side rails up. During an interview on 7/23/2024 at 4:15 P.M., with CNA 1, CNA 1 stated she raised Patient 28’s 4 side rails when she changed the patient’s (Patient 28) condom catheter (external urinary catheter to collect urine it drains out of bladder send to collection bag strapped to leg). CNA 1 stated she should not have left the patient (Patient 28) with four side rails up, “If they stand, it is dangerous and they can fall.” CNA 1 stated, “four side rails is a restraint.” During a concurrent interview and record review, on 7/25/2024 at 3:57 P.M., with Registered Nurse (RN) 4, RN 4 stated Patient 28 was admitted for inability to care for self. RN 4 stated Patient 28 had no physician’s order for restraints of 4 side rails. RN 4 stated “There is a risk for patient to fall if the 4 side rails are up.” RN stated the “order is needed for 4 siderails up.” During a review of the facility’s policy and procedure (P&P) titled, “Restraints: Non-Violent Behavior,” reviewed in 6/2022, the P&P indicated the following: -Restraint - Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. -The use of restraint is in accordance with the order of physician or other LIP (licensed Independent Practitioner) who is responsible for the care of the patient.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 50521 Based on observation, interview, and record review, the facility failed to ensure for one of 35 sampled patients (Patients 33), Patient 33’s condition was assessed and have the assessment documented in the patient’s record after Patient 33 was put on restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely). This deficient practice had the potential to result in inappropriate, unnecessary, and prolonged use of restraints. Findings: During a review of Patient 33’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/5/2024, the H&P indicated Patient 33 was admitted to the facility after being T-boned (side impact collision or broadside crash, is a car crash where the front of one vehicle hits the side of another creating a “T” shape at the point of impact) by a bus. During a review of Patient 33’s physician’s order dated 7/14/2024, the order indicated Patient 33 had siderail X (times) 4 and bilateral wrists soft restraint. During a review of Patient 33’s “Restraint Monitoring Every 2 Hours” flowsheet dated 7/14/2024, the monitoring flowsheet indicated Patient 33 was monitored for physical and emotional well-being, patient’s rights, dignity, safety, circulation, range of motion/Positioning, Hydration, Nutrition, Toileting at 9:47 P.M. In addition, the monitoring flowsheet indicated Patient 33 was monitored next on 7/15/2024 at 5:47 A.M. (a total of 8 hours since the last restraint monitoring of the patient). The lack of Patient 33’s 2-hour restraint monitoring (safety, circulation, range of motion/Positioning, Hydration, Nutrition, Toileting) from 7/14/2024 at 9:47 P.M., to 7/15/2024 at 5:47 A.M., was verified by the Charge Nurse of Behavioral Health Unit (CNBHU) on 7/24/2024 at 3:35 P.M. During an interview on 7/24/2024 at 3:35 P.M., with the CNBHU, the CNBHU stated Patient 33’s restraint monitoring should be done every 2 hours. The CNBHU stated “we need to monitor patients, to make sure the patient has good circulation.” During a review of the facility’s policy and procedure (P&P) titled, “Restraints: Non Violent Behavior,” reviewed on 6/2022, the P&P indicated, “A patient in restraints is monitored at least every two (2) hours or more often as applicable to the patient...Documentation use the electronic medical record restraint flow sheet, restraint orders, and narrative notes to document all pertinent information in the medical record including but not limited to...Monitoring activities.””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) 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 improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 42937 Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI, a process used to ensure services are meeting quality standards and assuring care reaches a certain level) department provided evidence of measurable data with analysis and tracking of patient - to - patient assault incident in the Behavioral Health Unit (BHU, a hospital unit that provides inpatient care for people with mental health issues). This deficient practice resulted in the facility’s inability to assess and monitor the quality and safe care of the patients in BHU, which may result in patient harm and/or death. Findings: 1. A review of Patient 1’s nursing notes, dated 3/28/2024, at 1:40 P.M., indicated Patient 1 was administered Intramuscular (IM, administered through the muscles) medications, at 1:40 P.M., after an incident of hitting another patient (Patient 2), in the face, without provocation, in the hallway. During an interview on 7/24/2024 at 11:09 P.M., with the Director of Behavioral Health Unit (DBHU), the DBHU stated there was no incident report made regarding Patient 2 being assaulted by Patient 1. The DBHU stated she (DBHU) just found out of the incident on 7/23/2024. The DBHU stated there was no incident report received, no documentation on Patient 2’s record regarding the incident. The DBHU stated they (facility administrators) were not aware if Patient 2 had an injury from the assault since there was no incident report, it was not investigated. 2. A review of Patient 1’s nursing notes, dated 7/9/2024, at 10:57 P.M., indicated Patient 1 was observed pacing the common area and talking to herself (Patient 1), when she (Patient 1) punched her roommate (Patient 3), who was sitting in a wheelchair, in the common area. A review of Patient 3’s nursing notes, dated 7/9/2024, at 11:04 P.M., indicated Patient 3, in a wheelchair, was in the medication window receiving medication when Patient 3’s roommate (Patient 1) approached the patient (Patient 3), without provocation, started yelling and punching Patient 3 in the face. Patient 3 was observed with swelling and bleeding from the nose, complained of pain in the left eye. Patient 3 was taken to ED for head CT scan. A review of Patient 3’s CT scan of the head, dated 7/11/2024, indicated Patient 3 had a fractured (broken bone) left nasal (nose) bone with soft tissue edema (edema), non-displaced fracture of right nasal bone, and mild rightward deviation of the nasal septum (the thin wall that separates the right and left nasal passages). During an interview on 7/23/2024 at 2:05 P.M., with the Clinical Supervisor (CS), the CS stated Patient 1 has been admitted since 2/21/2024. Patient 1 noted to have had two past physical abuse incidents toward other patients since admission with one that resulted in an ED visit (Patient 3). During an interview on 7/24/2024 at 11:09 A.M., with the Director of Behavioral Health Unit (DBHU), the DBHU stated the second incident when Patient 1 assaulted another patient (Patient 3) was on 7/9/2024. The DBHU stated the incident was unprovoked, the physician was notified of the incident and Patient 1 received emergency medication as ordered by the physician. In the same interview on 7/24/2024 at 11:09 A.M., the DBHU stated, the safety intervention in place prior to Patient 1’s attack towards Patients 2 and 3 was the every 15-minute rounding, where the assigned MHW (Mental health Worker) check on the patients every 15 minutes. The DBHU stated there was no new safety plan developed or new intervention implemented that would prevent Patient 1 from physically abusing other patients following the first, then the second incidents of physical abuse to Patients 2 and 3. The DBHU stated on both assaultive incidents, Patient 1 was not placed with a sitter for more intensive observation within arm’s length away at all times, after each incident. During a review of the facility’s policy and procedure (P&P) titled, “One-to-One Observation,” dated 6/14/2021, the P&P indicated, “Patients who are at high risk for self harm or injury to others may require more intensive observation. This observation requires the staff to be within arm’s length at all times.” During a concurrent interview and record review on 7/26/2024 at 1:54 P.M., with the Director of Performance Improvement (DIP), the Quality Council Committee Minutes Q2 2023 - Q1 2024, Patient Safety, Risk Management & Grievance Committee Minutes from July 2023 - June 2024 were reviewed. The DIP stated that the Quality Committee meets quarterly and under quality is the Patient Safety Committee that meets monthly. Department leaders of all unit including BHU attends the Patient Safety Committee and are encouraged to express concern or issues that affect their department, including failure to report patient - to - patient assault incidents. It is the Quality Department’s understanding that the BHU staff failed to complete an incident report that would have notify the BHU department leader of patient - to - patient assault incidents and have a more accurate information of the event. Quality Committee was not made aware of any issues or concern that patient - to - patient assault cases of not being reported and was only aware of Patient 2 assault incident during this survey.”

“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: 50594 Based on interview and record review, the facility failed to ensure for two of 35 sampled patients (Patient 7 and 22), nursing care was provided when: 1. Patient 7’s strict intake and output (I&O - monitoring is a clinical care process that measures and records fluid balance to help caregivers understand a patient’s condition and guide their daily care) was not monitored as ordered by the physician. This deficient practice had the potential to cause adverse health outcomes which could negatively affect Patient 7’s health and safety due to inaccurate intake and output monitoring that that may lead to prolonged hospitalization and/or death of the patient. 2. Patient 22’s call light (device use by patient to call for assistance from facility staff) was not responded timely in accordance with the facility’s protocol regarding call lights. This deficient practice had the potential for Patient 22’s needs to not be met and may result in delayed treatment that could have a negative effect on Patient 22’s provision of care. Findings: 1. During a concurrent interview and record review, on 7/23/24 at 10:52 A.M., with Clinical Nurse Supervisor 4 (CNS 4), Patient’s 7 electronic medical record (EMR, digital version of paper chart), was reviewed. The EMR indicated Patient 7 was diagnosed with pulmonary edema (a condition caused by too much fluid in the lungs, making it difficult to breathe) and congestive heart failure (occurs when the heart muscle doesn’t pump blood as well as it should that causes blood to backs up and fluid can build up in the lungs). CNS 4 stated Patient 7 was placed on fluid restriction and strict monitoring of fluid intake and output (I&O - monitoring is a clinical care process that measures and records fluid balance to help caregivers understand a patient’s condition and guide their daily care) by the physician as indicated in the reviewed EMR. In the same interview and record review, on 7/23/24 at 10:52 A.M., Patient 7’s EMR indicated Patient 7 had two (2) unmeasured urine occurrence on 7/22/24 at 5:00 A.M. CNS 4 stated Patient 7’s nurse failed to accurately measure the patient’s (Patient 7) urine output. CNS 4 stated when a patient was on strict I&O, the nurse must assess and document the patient’s amount of urine output in milliliters. During a concurrent interview and record review on 7/23/2024 at 11 A.M. with Registered Nurse (RN) 15, Patient 7’s medical record for intake and output monitoring, was reviewed. RN 15 stated that when she (RN 15) went observe patient’s (Patient 7) bathroom, RN 15 found that Patient 7 did not have a measuring hat available for her 9Patient 7) to use in her (Patient 7) bathroom. Patient 7 also mentioned to RN 15 that she (Patient 7) was not aware that she (Patient 7) had to measure her (Patient 7) urine output. RN 15 further stated that the order for strict intake and output monitoring was placed by the doctor on 7/21/2024 at 6:00 A.M. RN 15 said that Nursing staff were responsible in educating patients regarding strict intake and output monitoring, and to provide measuring hat for patient use. During a review of the facility ’ s policy and procedure titled, “Standard of nursing Practice: Telemetry,” date revised 6/23/2022, the document indicated the following: Orders are acknowledged by the nurse in the Electronic Medical Record (EMR). Intake and output are maintained and documented in the patient’s electronic record. Patient on fluid restrictions will be monitored closely 2. During an observation on 7/23/2024 at 10:36 A.M., with Performance Improvement Coordinator (PIC) in the hallway of the fourth floor of the Medical Surgical Unit (MSU, a unit that manages patients with a wide range of diagnoses and care needs such as patients who have undergone surgery, wound care, etc.), a green blinking light (call light indicator) on the top of Patient 22’s room door was observed, no audible sound was heard. Patient 22’s family member was at the bedside and there was no staff present inside the patient’s (Patient 22) room. During an observation on 7/23/2024 at 10:43 A.M., with PIC, outside Patient 22’s room, observed the patient’s (Patient 22) call light was still blinking. In addition, it was observed that Patient 22’s hand was bleeding, and the blood was dripping from Patient 22’s hand to the floor and to the patient’s left lower leg ankle area with an ace wrap dressing. Registered Nurse (RN) 5 was notified, and RN 5 went inside Patient 22’s room. During an observation and interview on 7/23/2024 at 11:13 A.M., with PIC and RN 5, Patient 22’s right hand was observed to be covered with gauze and tape. Patient 22’s family member was at the bedside. RN 5 stated the call light (a button or cord placed next to patients’ bed and in the bathroom allowing patients to alert hospital staff remotely of their need for help. When the button is pressed, a signal alerts staff at the nurse’s station and staff can respond to such a call) was not working. Patient 22’s family member stated they have been waiting for a while for someone to come and was not aware the call light was not working. During an interview on 7/25/2024 at 9:36 A.M. with RN 5, RN 5 stated the call light system was connected to the two pods (nursing station) in the unit. RN 5 said when a patient pressed on the call light, it could be answered on both pods. RN 5 stated the unit secretary who was stationed in the pods, should respond to the patient’s call light and should notify the nurse assigned to the patient. RN 5 stated the expectation for the unit secretary to respond to the patient’s call light was less than a minute. During a review of the facility’s document titled, “New Employee Orientation Day 1 Clinical Orientation,” undated, the document indicated “Responsiveness to Call Lights: Everyone is responsible to all bed and chair exit alarms and must respond to the call lights within 5 min (minutes) ...Unresponsive to call lights: Results in dissatisfaction with our patients it can cause unnecessary pain and discomfort, frustration and anxiety, Build a loss of confidence in staff reliability.””

“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: 50521 Based on observation, interview, and record review, the facility failed to ensure for five of 35 sampled patients (Patients 4, 25, 29, 34, and 35) the following: 1. Patient 4’s nursing care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) was developed upon admission for seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain), in accordance with the facility’s policy and protocol regarding care plans. 2. Patient 25’s nursing care plan for care of central line (Hemodialysis Access line, a device inserted to patient bloodstream that can be used for dialysis [a lifesaving procedure to clean the blood] was developed after Patient 25’s insertion of the Hemodialysis Access line, in accordance with the facility’s policy and procedure regarding care plans. 3. Patient 34’s nursing care plan was developed upon admission for skin impairment, in accordance with the facility’s policy and procedure regarding skin integrity. 4. Patients 29 and 35’s nursing care plan was developed upon admission for pain management, in accordance with the facility’s policy and procedure regarding pain management. These deficient practices had the potential to result in the delayed provision of care to the patients (Patients 4, 25, 29, 34, and 35) by not identifying the patients’ needs and risks. Findings: 1. During a concurrent interview and record review on 7/24/24 at 2:00 P.M. with Registered Nurse 17 (RN 17), Patient 4’s electronic medical record (EMR, digital version of the paper chart) indicated Patient 4 was brought in by ambulance for overdose on unknown substance. The record further indicated that the EMS (Emergency Medical Services) reports Patient 4 was found with needles and alcohol bottles lying around on scene and that the patient (Patient 4) had two seizure (a sudden, uncontrolled burst of electrical activity in the brain that cause changes in behavior, movements, etc.) episodes in the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma) hallway. Patient 4 was admitted for seizure disorder. In the same interview on 7/24/24 at 2:00 P.M., RN 17 stated Patient 4’s care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) list did not have documentation that a care plan for seizure disorder was initiated. RN 17 stated it was a nursing standard of practice that a care plan must be developed on admission and that the care plan should be updated daily. RN 17 stated the care plan must address the patient’s current health problem with nursing care and interventions to meet the patient’s needs. During a review of the facility’s policy and procedure (P&P) titled, “Nursing care Plan” with a reviewed date of 12/2022, the P&P indicated the following: a. To ensure that a Plan of Care is developed for each patient that is individualized to meet the patients’ unique needs. The objective is to utilize the nursing process in formulating an organized and individualized plan of care that is effective, communicated and reflects the delivery of quality patient care in order to achieve a mutually agreed upon outcome. b. Problems are identified through analysis of assessment data (subjective and objective). The problem can be actual or potential and should reflect consideration of the patient’s physical, psychosocial, nutritional status, functional status, educational and discharge planning needs. c. The expected outcome is used to evaluate the patient’s progress in relationship to the problem. Specify the expected change in terms of an alteration in a behavior, skill, attitude, physiologic sign or knowledge and identify the criteria that will demonstrate the expected outcome. Based on the evaluation of the plan of care, goals and interventions can be modify as needed. d. Appropriate nursing interventions are selected that reflect the course of action to be taken to facilitate the achievement of the goals and expected outcomes. The interventions should be specific and consistent with established standards of care. The RN will collaborate with the inter-disciplinary team to ensure that interventions are carried out by the appropriate healthcare providers within their scope of practice. e. Interventions and the effectiveness of the inter -disciplinary plan of care must be continuously evaluated as care is rendered and assessment/ reassessment is conducted. f. Documentation under Outcome Status is required daily at the end of each shift, at the time of discharge, and more often as necessary. g. Formulate additional nursing diagnosis, goals, and interventions as a patient’s condition changes h. Every patient who remains hospitalized for greater than 24 hours will have at least one Nursing Plan of Care based on the patient’s primary nursing diagnosis and nursing standards. 2. During a review of Patient 25’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/13/2024, the H&P indicated Patient 25 was admitted to Emergency Department (ED) for blood in the foley catheter (medical device that helps drain urine from the bladder) and pain in the penis. During a review of Patient 25’s “Flowsheet,” dated 7/22/2024 to 7/23/2024, the “Flowsheet,” indicated Patient 25 had a placement of Hemodialysis (a lifesaving procedure to clean the blood) Access to the right jugular (large vein in the neck) on 7/22/2024. During a concurrent interview and record review, on 7/25/2024 at 9:51 A.M., with Registered Nurse (RN) 11. RN 11 stated Patient 25 had a Hemodialysis catheter placement on 7/22/2024. RN 11 said, there was no documented evidence Patient 25’s care plan for central line (including for Hemodialysis Access) was initiated after the hemodialysis catheter was placed. In the same interview on 7/25/2024 at 9:51 A.M., RN 11 stated it was important to have a care plan for Patient 25’s central line (a thin, flexible tubing that is inserted into a large vein) to help in the prevention of central line blood infection. During a record review of the facility’s policy and procedure (P&P) titled, “Nursing care Plan,” with a reviewed date of 12/2022, the P&P indicated the following: a. To ensure that a Plan of Care is developed for each patient that is individualized to meet the patients’ unique needs. The objective is to utilize the nursing process in formulating an organized and individualized plan of care that is effective, communicated and reflects the delivery of quality patient care in order to achieve a mutually agreed upon outcome. b. Problems are identified through analysis of assessment data (subjective and objective). The problem can be actual or potential and should reflect consideration of the patient’s physical, psychosocial, nutritional status, functional status, educational and discharge planning needs. c. The expected outcome is used to evaluate the patient’s progress in relationship to the problem. Specify the expected change in terms of an alteration in a behavior, skill, attitude, physiologic sign or knowledge and identify the criteria that will demonstrate the expected outcome. Based on the evaluation of the plan of care, goals and interventions can be modify as needed. d. Appropriate nursing interventions are selected that reflect the course of action to be taken to facilitate the achievement of the goals and expected outcomes. The interventions should be specific and consistent with established standards of care. The RN will collaborate with the inter-disciplinary team to ensure that interventions are carried out by the appropriate healthcare providers within their scope of practice. e. Interventions and the effectiveness of the inter -disciplinary plan of care must be continuously evaluated as care is rendered and assessment/ reassessment is conducted. f. Documentation under Outcome Status is required daily at the end of each shift, at the time of discharge, and more often as necessary. g. Formulate additional nursing diagnosis, goals, and interventions as a patient’s condition changes h. Every patient who remains hospitalized for greater than 24 hours will have at least one Nursing Plan of Care based on the patient’s primary nursing diagnosis and nursing standards. 3. During a record review of Patient 34’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/20/2024, the H&P indicated Patient 34’s medical history included bilateral below knee amputation (BKA) secondary to unclear etiology (the cause of or manner of causation of a condition). The H&P further indicated for Patient 34’s bilateral BKA to continue with wound care, daily dressing changes, and wound care consultation. During a review of Patient 34’s “Physician Consult (consult written by physicians to direct care and treatment),” note dated 7/22/2024, the note indicated Patient 34 had an “alteration on skin integrity (skin health) and identified patient buttocks and adjacent folds with thin and fragile, skin dry and scaly.” During a concurrent interview and record review on 7/24/2024 at 2:25 P.M., with the Charge Nurse of Behavioral health unit (CNBHU), the CNBHU verified Patient 34 had bilateral (both) lower extremity stump wounds. The CNBHU stated Patient 34 did not have a care plan for impaired skin. CNBHU stated the importance of care plan for skin impairment was to make sure the wound does not get worse. During a review of the facility’s policy and procedure (P&P) titled, “Skin integrity,” revised in 12/2022, the P&P indicated the following: Care Plan: a. The goal of the care plan is to provide a guideline to maintain or improve tissue tolerance to prevent injury and to protect against the adverse effects of mechanical forces. b. Initiate Care Plan for patients with current pressure wounds and/or patients at risk for pressure wounds ... d. Implement interventions identified in Care Plan and monitor patient response to interventions. e. Update Care Plans as necessary. 4.a. During a record review of Patient 29’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/14/2024, the H&P indicated Patient 29’s medical history included leg injury due to motor vehicle accident involving right leg trauma (physical injury). During a review of Patient 29’s “Medication Administration Report (MAR),” dated 7/20/2024, the MAR indicated a physician’s order for Patient 29 to receive “hydrocodone-acetaminophen (otherwise known as Norco - pain medication used to treat moderate to severe pain) 10-325 milligrams (mg, a unit of measurement) 1 tablet every 6 hours as needed for moderate pain (pain score of 4-6).” During a concurrent interview and record review on 7/25/2024 at 5:20 P.M., with Registered Nurse (RN) 4, RN 4 stated Patient 29 did not have a nursing care plan for pain management developed. RN 4 stated “is important to have care plan for pain for this patient (Patient 29) because this patient came in for pain and he has pain medications.” 4.b. During a record review of Patient 35’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 6/19/2024, the H&P indicated Patient 35 had a medical history of psychosis (a mental disorder characterized by a disconnection from reality). During a review of Patient 35’s “Medication Administration Report (MAR),” dated 7/21/2024, the MAR indicated a physician’s order for Patient 35 to receive “acetaminophen (Tylenol - pain medication used to treat mild to moderate pain) 650 milligrams (mg, a unit of measurement) tablet every 6 hours as needed for mild pain (pain score of 1-3).” During a concurrent interview and record review on 7/24/2024 at 1:31 P.M., with the Charge Nurse of Behavioral Health Unit (CNBHU), the CNBHU stated Patient 35 did not have a nursing care plan for pain management developed. CNBHU stated it was important to have a care plan to address Patient 35’s pain because without a care plan, there was no way to know the treatment plan for the patient and the patient’s pain may not get resolved. During a review of the facility’s policy and procedure (P&P) titled, “Nursing care Plan,” with a reviewed date of 12/2022, the P&P indicated the following: a. To ensure that a Plan of Care is developed for each patient that is individualized to meet the patients’ unique needs. The objective is to utilize the nursing process in formulating an organized and individualized plan of care that is effective, communicated and reflects the delivery of quality patient care in order to achieve a mutually agreed upon outcome. b. Problems are identified through analysis of assessment data (subjective and objective). The problem can be actual or potential and should reflect consideration of the patient’s physical, psychosocial, nutritional status, functional status, educational and discharge planning needs. c. The expected outcome is used to evaluate the patient’s progress in relationship to the problem. Specify the expected change in terms of an alteration in a behavior, skill, attitude, physiologic sign or knowledge and identify the criteria that will demonstrate the expected outcome. Based on the evaluation of the plan of care, goals and interventions can be modify as needed. d. Appropriate nursing interventions are selected that reflect the course of action to be taken to facilitate the achievement of the goals and expected outcomes. The interventions should be specific and consistent with established standards of care. The RN will collaborate with the inter-disciplinary team to ensure that interventions are carried out by the appropriate healthcare providers within their scope of practice. e. Interventions and the effectiveness of the inter -disciplinary plan of care must be continuously evaluated as care is rendered and assessment/ reassessment is conducted. f. Documentation under Outcome Status is required daily at the end of each shift, at the time of discharge, and more often as necessary. g. Formulate additional nursing diagnosis, goals, and interventions as a patient’s condition changes h. Every patient who remains hospitalized for greater than 24 hours will have at least one Nursing Plan of Care based on the patient’s primary nursing diagnosis and nursing standards. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” revised on 12/2022, the P&P indicated, “Documentation ...Interdisciplinary Care Plan ...””

“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: 42937 Based on observation, interview and record review, the facility failed to ensure for five of 35 sampled patients (Patients 11, 22, 30, 31, and 34), the facility’s policies and procedures (P&P) were implemented when: 1. Patient 11, who was at risk for skin impairment, was not provided and kept on appropriate support surface, a waffle overlay (a non-powered air support surface that is placed on top of a mattress to help prevent and treat pressure injuries. It’s designed to redistribute pressure on bony areas of the body and has venting holes to allow for air circulation, which can help keep patients cool, dry, and comfortable) that would help ensure maintenance of the patient’s skin integrity, in accordance with the facility’s policy and procedure regarding Skin Integrity. This deficient practice had the potential to cause pressure injuries (PI, localized damage to the skin and underlying tissue caused by prolonged pressure) which could negatively affect Patient 11’s provision of care and that may lead to prolonged hospitalization and/or death of the patient. 2. Patient 22’s Heparin (a medication that stops your blood from forming blood clots) intravenous (IV - in the vein) drip did not have a medication label, in accordance with the facility’s Heparin Therapy Protocol. In addition, two RNs verified Patient 22’s Heparin drip prior to administering the medication without a medication label. This deficient practice had the potential to cause adverse health outcomes which could negatively affect the patient’s health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death. 3. Patients 31 and 34’s wound and PI (Pressure injuries, localized damage to the skin and underlying soft tissue) were not assessed and measured weekly in accordance with the facility’s policy and procedure regarding wound care. This deficient practice had the potential for Patients 31 and 34’s wound and/or PI assessment to be inaccurate and may cause delay in treatment that could result in patient harm such as worsening wound and infection. 4. Registered Nurse 14 (RN) 14, who was assigned to the care of Patient 30, did not perform hand hygiene (washing hands to prevent the spread of germs) after providing patient care to Patient 30, who had a PureWick (a female external catheter is intended for non-invasive urine output management in adults uses with female anatomy for conditions such as urinary incontinence), in accordance with the facility’s policy and procedure regarding Hand Hygiene. This deficient practice had the potential for the introduction of pathogens (a microorganisms such as bacteria or virus that can cause a disease process) from RN 14 not performing hand hygiene and the potential for risk of transmission of microorganism to other patients in the same unit or hospital setting. 5. One of four sampled Emergency Cart (Emergency Cart 1, mobile cart unit stocked with emergency medical equipment, supplies, and drugs use by medical personnel for life threatening emergency), Emergency Cart 1, was not checked daily for all the necessary equipment and supplies that should be readily available during an emergency in accordance with the facility’s policy and procedure regarding Emergency Crash Carts. This deficient practice had the potential to delay patient care and to improve patient outcomes following an emergency medical condition or in a crisis event. Findings: 1. During a concurrent interview and record review on 7/25/2024 at 12:31 P.M., with the Wound Care Nurse (WCN), Patient 11’s electronic medical record (EMR, digital version of paper chart), was reviewed. The EMR indicated Patient 11 was seen in the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma) on 2/8/2024 with a chief complaint of leg discoloration, pain and swelling for a few months. Patient 11’s EMR further indicated the following: - on 2/16/2024, Patient 11 underwent endovascular intervention (a minimally invasive procedure that is performed inside of blood vessels. It is used to treat swelling of an artery, and other problems affecting blood vessels) of her right lower leg. - on 2/21/2024, Patient 11 had a below-knee amputation (BKA, a surgical procedure performed to remove the lower limb below the knee when that limb has been severely damaged or is diseased) of her left leg. - on 3/2/2024, Patient 11 underwent right trans metatarsal amputation (a surgical procedure that removes part of the foot, including the distal portion of the metatarsals, which are the five bones between the ankle and toes) of the right foot. In the same interview on /25/2024 at 12:31 p.m., WCN stated Patient 11 was first seen by the WCN on 2/21/2024, for application of wound vac (Vacuum-assisted closure of a wound is a type of therapy to help wounds heal) to Patient 11’s left BKA surgical site. During a concurrent interview and record review on 7/25/2024 at 2:30 P.M., with the WCN, Patient 11’s EMR indicated the following: - on 2/9/2024 at 10:00 A.M., Patient 11’s Braden score (a tool used to assess the risk of pressure ulcers developing in patients) was 16 (a Braden score of 16 identifies patient at mild Risk for pressure injury), a waffle overlay was initiated for Patient 11 to use. The WCN stated there was no documentation that Patient 11 was kept on a waffle overlay from 2/19/2024 through 3/5/2024. - on 2/21/2024 at 6:01 P.M., Patient 11’s Braden score was 12 (a braden score of 12 identifies patient at high risk for pressure injury). - on 3/4/2024, the Wound Care Team was consulted for patient (Patient 12) sacrum(shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) pressure injury (an injury that breaks down the skin and underlying tissue). - on 3/6/2024, Patient 11 was placed on a Low Air Loss (a mattress designed to prevent and treat pressure wounds). The WCN stated that once a patient was identified at risk for PI and a waffle overlay was used, the nurses should ensure the patient would be kept on the overlay. The WCN stated it was the facility’s practice that a waffle overlay would be used on a patient with a Braden score of 18 and below (The Braden Scale uses a scores from less than or equal to 9 to as high as 23. The lower the number, the higher the risk is for developing an acquired ulcer or injury. 19-23 = no risk. 15-18 = mild risk. 13-14 = moderate risk). The WCN stated all skin interventions including the use of the waffle overlay should be documented in the patient’s EMR. During a review of the facility’s policy and procedure (P&P) titled, “Skin Integrity,” with a revised date of 12/2022; the P&P indicated the following: “Interventions should be initiated according to the documented Braden Scale score and per “Pressure Ulcer Prevention Guidelines, per Braden -Braden Scale Score - High Risk: 10-12 -Initiate the following intervention: 1. Refer to wound care Nurse and Notify Physician 2. Increase frequency of turning schedule 3. Supplements with small shifts in position 4. Pressure Redistribution Support Surface Upon identification of need, place patient on most appropriate support surface available; specialty beds may require a physician order.” 2. During a concurrent observation and interview on 7/23/2024 at 11:20 A.M., with Registered Nurse (RN) 6, Patient 22 was observed connected to an IV (Intravenous, through the vein) infusion. RN 6 stated Patient 22 was receiving Heparin (used to decrease the clotting ability of the blood and prevent harmful clots from forming in blood vessels) IV drip at 5 units/kilogram/hour (u/kg/hr). RN 6 verified Patient 22’s Heparin IV bag had no medication label. During an interview on 7/23/2024 at 11:26 A.M. with RN 6, RN 6 stated, the Heparin IV bag should have come with a medication label from the pharmacy. During an interview on 7/24/2024 at 3:06 P.M. with RN 11. RN 11 stated heparin is a high alert medication and should have a medication label that included: medication concentration, initial dosing order in u/kg/hr, dosage order, patient information, and the patient’s Medical Records Number (MRN). RN 11 stated when a Heparin IV bag did not have a medication label, the medication bag should not be hung and should be returned to pharmacy. In the same interview on 7/24/2024 at 3:06 P.M., RN 11 stated a medication label on the medication was important to know the correct medication order for the patient. During a concurrent interview and record review on 7/26/2024 at 11:34 A.M., with RN 13, Patient 22’s “Medication Administration Report (MAR),”was reviewed. The MAR indicated Patient 22’s Heparin IV drip (new bag) was administered on 7/22/2024 at 3:17 P.M., signed by two RNs. In the same interview on 7/26/2024 at 11:34 A.M., RN 13 stated 2 RNs must verify the Heparin dose order was correct as indicated on the IV bag medication label prior to administering the Heparin IV drip to the patient. RN 13 stated when the Heparin IV bag had no medication label, it should not be administered to the patient. During a review of the facility’s policy and procedure (P&P) titled, “Heparin Therapy Protocol,” revised in 9/2019, the P&P indicated, “Heparin bag changes require two nurses at the bedside to verify patient drug name, concentration and rate, IV pump settings.” During a review of the facility’s policy and procedure (P&P) titled, “Labeling,” revised in 9/2019, the P&P indicated, “Intravenous (IV) Admixture label ...IV Piggyback ...label shall have the following information: patient name, room number, name and strength of drug (s) added, IV solution name and volume, date and time prepared, expiration date, initials of individuals who prepared dose ...” 3.a. During a review of Patient 31’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 6/14/2024, the H&P indicated Patient 30 was admitted to the facility for diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). During a review of Patient 31’s “Inpatient Consult-Plastic Surgery-Wound Care,” dated 7/16/2024, the consult indicated Patient 31 had a sacral (large bone at the base of the spine) deep tissue injury present on admission. During a review of Patient 31’s “Wound Pressure Ulcers,” flowsheet dated 7/17/2024 at 8:00 P.M., the wound pressure ulcers flowsheet indicated Patient 31 had a Stage 2 Pressure injury (partial thickness skin loss with exposed skin) in the sacrum. During a concurrent interview and record review on 7/23/2024 at 2:05 P.M. with Licensed Vocational Nurse (LVN) 7, LVN 7 stated when a patient had a PI, the patient’s PI should be assessed and measured weekly to see wound improvement. LVN 7 stated Patient 31’s record had no documented evidence that Patient 31’s PI on the coccyx (the last bone at the bottom of the spine) was assessed and measured on 7/3/2024, 7/10/2024, and 7/17/2024. During a concurrent interview and record review on 7/26/2024 at 11:38 A.M., with the Wound Care Nurse (WCN), Patient 31’s “Wound Pressure Ulcers,” flowsheet, was reviewed. The WCN verified that the flowsheet did not indicate Patient 31’s Stage 2 PI measurement (length and width) and wound color. The WCN stated it was important to do wound care measurement to see the progress of the wound. During a review of the facility’s policy and procedure (P&P) titled, “Skin Integrity,” revised in 12/2022, the P&P indicated the following: “Detailed assessment should be completed: - Within 24 hours of admission and then weekly thereafter - With a change of condition; upon discovery of a new wound; - Document description of each wound (in centimeters) to include the following: Length-longest head to toe measurement, Width- longest hip to hip measurement, Depth- deepest part of the wound.” 3.b. During a review of Patient 34’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/20/2024, the H&P indicated Patient 34’s medical history included bilateral below knee amputation (BKA) secondary to unclear etiology (the cause of or manner of causation of a condition). The H&P further indicated For Patient 34’s bilateral BKA to continue with wound care, daily dressing changes, and wound care consultation. During an interview on 7/26/2024 at 11:38 A.M. with the Wound Care Nurse (WCN), The WCN stated it was important to do wound care measurement to see the progress of the wound, “the negative effect is it (the wound) can get worse.” The WCN stated it was important to do wound care measurement (length and width) to see the progress of the wound. During a concurrent interview and record review on 7/26/2024 at 12 P.M. with the Wound Care Nurse (WCN), Patient 34’s “Wound Photographs,” dated 7/20/2024, were reviewed. The Wound Photographs showed Patient 34’s bilateral BKA stump covered with foam dressing. The WCN stated the photo did not include wound measurements and wound location. During a review of the facility’s policy and procedure (P&P) titled, “Skin Integrity,” revised in 12/2022, the P&P indicated the following: “Detailed assessment should be completed: - Within 24 hours of admission and then weekly thereafter - With a change of condition; upon discovery of a new wound; - Document description of each wound (in centimeters) to include the following: Length-longest head to toe measurement, Width- longest hip to hip measurement, Depth- deepest part of the wound.” During a review of the facility’s policy and procedure (P&P) titled, “Skin Integrity,” revised on 12/2022, the P&P indicated, “Photographed alterations in skin integrity, open wounds, and pressure ulcers are to be posted on the Wound Photograph Documentation Form in the patient’s medical record or uploaded to the electronic medical record. The photo label should include: Patient’s initials or medical record number, Location of wound/lesion, Date and time of photograph, Nurse’s initials, Measurement device, Body alignment sticker.” 4. During an observation on 7/23/2024 at 11:00 A.M., with Performance Improvement Coordinator (PIC), in the Medical Surgical Unit, Registered Nurse (RN) 14 was observed walking out of Patient 30’s room with the gloves in her hands after providing patient care to Patient 30 who had a Purewick (a female external catheter is intended for non-invasive urine output management in adults uses with female anatomy for conditions such as urinary incontinence). During an interview on 7/23/2024 at 11:07 A.M., with RN 14, RN 14 stated “I am nervous.” RN 14 demonstrated how she (RN 14) would remove her gloves and used hand sanitizer to disinfect her hands. RN 14 stated she was supposed to have the gloves removed and perform hand hygiene after patient care for patient safety. During a review of the facility’s policy and procedure (P&P) titled, “Hand Hygiene Policy,” reviewed in 4/2024, the P&P indicated, “Indications for Hand hygiene between patient care procedures involving different body sites of the same patient (i.e., from urinary to respiratory system). After contact with a patient’s intact skin or with the patient’s environment ...Hand Hygiene with soap and water before and after contact with patient or patient environment, after removing gloves.” 5. During a concurrent observation and interview on 7/23/2024 at 10:18 A.M., with Registered Nurse (RN) 5, two crash carts (emergency cart, contains medications and equipment needed to treat a patient in case of an emergency), were observed on the 4th floor Medical Surgical Unit (MSU). Each of the crash cart had a crash cart log folder, the folder log included a document titled, “Code Cart Checklist (the form included a calendar day for month of June, items needed to be checked in the crash cart, and a corresponding signature for each calendar day),” RN 5 stated crash cart log signatures for each day indicated the cart was “ready for use.” During an observation on 7/23/2024 at 2:53 P.M., with Charge Nurse Supervisor 3 (CNS 3). Emergency Cart 1 located on the 8th floor MSU was observed. Emergency Cart 1 had a crash cart log folder, the folder log included a document titled, “Defibrillator/A Crash Cart Checklist June 2024.” During a concurrent interview and record review on 7/23/2024 at 2:55 P.M., with CNS 3, the “Defibrillator (a device that apply an electrical charge to the heart to restore normal heartbeat)/A Crash Cart Checklist June 2024,” for the 8th floor MSU, was reviewed. CNS 3 stated the log had a missing signature on 6/17/2024. CNS 3 stated the crash cart should be checked and signed daily for completeness to ensure availability of equipment needed in case of an emergency. During a review of the facility’s policy and procedure (P&P) titled, “Emergency Carts (Crash Carts), revised in 9/2019, the P&P indicated, “In each area, a designated Nurse or other licensed staff shall inspect the Emergency Cart daily, at the beginning of each shift or anytime the cart is replaced. The Charge Nurse is responsible for assuring that these inspections occur as required.””

“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: 50594 Based on interview and record review, the facility failed to ensure for two of 35 sampled patient (Patients 22 and 35) the following: 1. Morphine (medication to help relieve moderate to severe pain) was administered to Patient 22 in accordance with the physician’s order. 2. Tylenol (pain medication used to treat mild pain [pain score of 1-3 is mild pain]) was administered to Patient 35 in accordance with the physician’s order. These deficient practices resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect the patients’ health and safety due to unsafe medication administration and may lead to prolonged hospitalization. Findings: 1. During a review of Patient 22’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/16/2024, the H&P indicated, Patient 22 presented to the Emergency Department with a chief of complaint of worsened left foot pain. During a review of Patient 22’s “Medication Administration Report (MAR),” the MAR indicated the following as needed (PRN) medications for management of pain: -Acetaminophen (Tylenol) tablet 650 milligrams (mg, a unit of measurement) every 4 hours PRN (as needed) by mouth for mild pain (pain score of 1-3), with a start date of 7/17/2024; -Morphine 1 milligram intravenous (IV - in the vein) every 4 hours PRN for moderate pain (pain score of 4-6), with a start date of 7/22/2024; and, -Morphine 2 milligrams IV every 4 hours PRN for severe pain (pain score 7-10), with a start date of 7/22/2024. During a concurrent interview and record review on 7/24/2024 at 3:06 P.M. with RN 11, the MAR indicated Patient 22 was given Morphine 2 mg IV on 7/23/2024 at 4:29 P.M. RN 11 verified there was no corresponding pain assessment documented prior to the administration of Morphine 2 mg IV. RN 11 stated it was important to assess the patient’s pain prior to administration of pain medication to know what pain medication would be given based on the patient’s pain score. During an interview on 7/26/2024 at 11:34 A.M. with Registered Nurse (RN) 13, RN 13 stated, pain medication should be given based on the physician’s order. RN 13 stated the MAR should be checked for the correct pain medication based on the patient’s pain level assessment. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” reviewed on 12/2022, the P&P indicated, “Assess for pain using a pain scale (numeric, visual analog, or text based) consistently...Before and after any pain-producing treatment or procedure. With each new report of pain...With routine vital signs and PRN....... Pharmacologic pain management will be provided to patients by physician order...” 2. During a review of Patient 35’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 6/19/2024, the H&P indicated Patient 35 had a medical history of psychosis (a mental disorder characterized by a disconnection from reality). During a review of Patient 35’s “Medication Administration Report (MAR),” dated 7/21/2024, the MAR indicated a physician’s order for Patient 35 to receive the following pain medications: - Acetaminophen (Tylenol) 650 milligrams (mg -a unit of measurement) 1 tablet by mouth every 6 hours as needed (PRN) for mild pain, with a start date of 6/19/2024; and, - Norco (narcotic pain medication) 5-325 mg 1 tablet by mouth every 6 hours PRN for moderate pain (pain score 4-6 is moderate pain) with a start date of 7/2/2024. During a concurrent interview and record review on 7/24/2024 at 1:31 P.M. with the Charge Nurse of Behavioral Health Unit (CNBHU), Patient 35’s MAR, was reviewed. The MAR indicated on 7/22/2024 at 4:36 P.M., Patient 35 was given Tylenol 650 mg 1 tablet by mouth. The corresponding pain assessment indicated Patient 35’s pain score was 4 (moderate pain). CNBHU stated it was important to give the right medication for patient’s pain complaint. CNBHU confirmed Tylenol was for mild pain and Patient 35 complained of moderate pain (pain score of 4-6), which required the ordered medication of Norco to be administered to Patient 35. CNBHU stated the correct medication ordered must be administered for the medication to be effective in addressing the patient’s (patient 35) pain. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” reviewed on 12/2022, the P&P indicated, “Assess for pain using a pain scale (numeric, visual analog, or text based) consistently...Before and after any pain-producing treatment or procedure. With each new report of pain...With routine vital signs and PRN....... Pharmacologic pain management will be provided to patients by physician order...” During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” formulated on 12/2022, the P&P indicated the following: Prior to administration, the 6 R’s (the 6 rights to be checked prior to medication administration, a systematic approach to prevent medication errors) must be verified: a. Right drug -Verify that the medication selected for administration is the correct one based on the medication order and product label by reading the medication label at least 3 times i. When selecting the medication ii. Just prior to administration iii. Just after administration b. Right dose”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36329 Based on observation, interview, and record review the facility restrained (restraint, any physical or mechanical device used to reduce the ability of a patient to move his/her body) without an order from an authorized physician. This deficient practice had the potential for physical and emotional harm to the patient. Findings: During an observation on 4/16/2024 at 1:00 PM, there was a sign, ‘Seizure Precautions’ (measures taken to prevent injury during a seizure) posted along side the door to PT3’s room. All (4) side rails to PT3’s bed were in the up position, confining the patient to his bed. There was no padding on the 4 side rails. PT3 had a foley (urine collection device that has a tube that goes to a collection bag) and the collection bag was resting on the ground under the bed. During an interview on 4/16/2024 at 1:10 PM, RN 4 stated that if a patient is on seizure precautions then there should be padding on all the rails in order to prevent injury during a possible seizure (sudden, uncontrolled burst of electrical activity in the brain that can trigger uncontrolled body movement). During an interview on 4/16/2024 at 1:15 PM, RN 4 clarified that PT4 was not actually on seizure precautions; the signage outside PT3’s door was intended for a patient that was previously in this room. Subsequently RN 4 stated that 4 rails up means a patient is under restraint and that PT3 did not have an order for restraint. A review of PT3’s medical record did not indicate there was an order for restraint. During a review of ‘Restraints: Non Violent Behavior’, (dated 6/15/2022) this policy indicted: All patients have the right to be free from any form of restraint that is imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraints must be implemented through order from a physician or authorized care provider who is responsible for the patient’s care.”

“IC PROFESSIONAL ADHERENCE TO POLICIES CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by hospital personnel. This Standard is not met as evidenced by: 36329 Based on observation, interview, and record review the facility failed to ensure PT3’s foley (urine collection device that has a tube that leads to a reservoir) bag did not come into contact with the floor under his bed. This deficient practice has the potential for infection. Findings: During an observation on 4/16/2024 at 1:00 PM, there was a sign, ‘Seizure Precautions’ (measures taken to prevent injury during a seizure) posted along side the door to PT3’s room. All (4) side rails to PT3’s bed were in the up position, confining the patient to his bed. There was no padding on the 4 side rails. PT3 had a foley catheter (urine collection device that has a tube that goes to a collection bag) and the collection bag was resting on the ground under the bed. During an interview on 4/16/2024 at 1:10 PM, RN 4 stated sometimes the urine collection bag comes to rest on the ground upon lowering the bed so the patient can get out of bed. RN 4 subsequently stated that leaving the bag on the floor can possibly lead to a urinary tract infection (condition in bacteria invades the urinary tract, body system producing and expelling urine). During a review of the ‘Infection Prevention 2023 Program Assessment and 2024 Annual Plan’ indicated part of the facility’s 2024 Surveillance Plan included reducing and eliminating CAUTI (catheter associated urinary tract infection) through the following measures (not all inclusive): Limiting use of indwelling (insertion of catheter through the urinary tract) catheters to acceptable indications; Use of a maintenance bundle (closed drainage system, bag located below the bladder and off the floor, catheter securement, no dependent loops of catheter line leading to collection bag, routine hygiene); Daily review of need for catheter.”

“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: 36329 Based on interview and record review, the facility failed to ensure for one of 30 sampled patients (Patient 5), Patient 5 was provided the documents regarding patient’s rights in Patient 5’s preferred language. This deficient practice resulted in Patient 5 to not be informed of her rights as a patient in the language the patient understands. Findings: During an interview on 2/6/2024 at 2:20 p.m. with Patient 5, Patient 5 stated upon admission, the patient’s (Patient 5) family member signed the documents that explained the patient’s rights. Patient 5 subsequently said that she did not know these forms came in other languages. Patient 5 stated her preferred language was Spanish and the forms given to her were in English. During an interview on 2/6/2024 at 2:21 p.m. with Patient 5’s family member (FM), Patient 5’s FM stated he signed Patient 5’s admission papers because Patient 5 was feverish and was not thinking clearly. Patient 5’s FM stated his preferred language was Spanish and he was given the form to sign in English. A review of the “Patient Rights Acknowledgement” form, indicated Patient 5 was notified of patient rights and responsibilities, patient rights to make decisions about medical care and treatment, current vaccination information, financial assistance, advance directives (legal documents that provide instruction for medical care to the facility in the event the patient is not able to communicate his/her wishes). This document showed it had been signed by Patient 5’s husband on 2/1/2024 and was written in English language. During an interview on 2/9/2024 at 2:30 p.m. the Quality Manager stated patient’s rights and responsibilities are discussed upon admission to the hospital and patient’s rights and responsibilities acknowledgment forms are available in other languages beside English. She confirmed that Spanish forms should have been available at the time of Patient 5’s admission and provided to Patient 5 and Patient 5’s family member. A review of the facility’s “Administrative Policies and Procedures - Patient Rights & Responsibilities,” last revised 6/2022, indicated that patients and their representatives have the right to receive accurate and current information regarding the patient’s health status in terms understandable to patients and representatives, so that they can make informed decisions.”

“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: 36329 Based on observation, interview, and record review, the facility failed to: 1. Ensure the physician’s order for seizure precaution (safety measures provided for the patient during seizure, uncontrolled electrical activity in the brain causing abnormal muscle movement) was followed for one of 30 sampled patients (Patient 2). This deficient practice resulted in Patient 2’s unsafe care and had the potential for Patient 2 to suffer from physical harm during a seizure. 2. Ensure for one of 30 sampled patients (Patient 4) had been turned and repositioned in accordance with the facility’s policy and procedure. This deficient practice had the potential to result in Patient 4’s development, deterioration, and worsening of pressure injury (PI - damage to upper and lower levels of the skin due to pressure of body part on a surface) and had the potential to cause Patient 4 to suffer from pain and wound infection. Findings: 1. During an observation on 2/6/2024 at 2:15 p.m. with Clinical Supervisor (CS) 1, Patient 2’s room door was observed to have a sign which displayed “Seizure Precautions.” At this time, Patient 2 was observed sitting on the side of the bed; Patient 2’s side rails, footboard, and headboard of the bed were not padded. Patient 2 was not wearing a yellow wrist band that indicated she may be at risk of falling. This observation was validated by the CS 1. During a concurrent interview on 2/6/2024 at 2:15 p.m. with CS 1, CS 1 stated Patient 2 was on seizure precaution and that the bed rails should be padded to prevent injury to Patient 2 during a seizure. CS 1 stated all other fall risk precautions should be taken. During a review of the facility’s document titled, “Nursing Skill - Initiating Seizure Precautions for Adults,” the document indicated that nurses should implement safety precautions to prevent seizure-related injuries ranging from bruising to head injury. Some of the precautions mentioned in this procedure include: Removing hazards in the room or relocate to a safe place; Place padding around headboards, footboards, and side rails as appropriate; Place bed into lowest position with side rails raised; Place signage in patient’s room to alert others seizure precautions are in place. 2. During a review of Patient 4’s “Admission/Registration” record, dated 1/20/2024, the record indicated Patient 4 was admitted to the facility on 1/20/2024 at 3:57 p.m. During a review of Patient 4’s “Default Flowsheet Data,” with dates from 1/20/2024 at 12 a.m.-1/25/2024 at 11:59 p.m., the Default Flowsheet Date indicated that on 1/20/2024, Patient 4 had a Stage 3 pressure injury (skin tissue loss where fat may be visible but bone, tendon, or muscle is not exposed) on the right buttock and a Stage 2 pressure injury (one that has progressed to the top layers of the skin but has not affected fatty tissue beneath) on the left buttock. During a review of Patient 4’s “Default Flowsheet Data,” with dates from 1/21/2024 at 12 a.m. - 1/25/2024 at 11:59 p.m., the flowsheet indicated that on the following dates and times, Patient 4 was not regularly turned and repositioned at least every 2 hours: - On 1/22/2024 at 8:00 a.m., Patient 4 was turned and repositioned on the left side. Patient 4 was turned and repositioned next at 8:00 p.m. (12 hours after) on the right side; -On 1/23/24 at 6:00 p.m., Patient 4 was turned and repositioned on the right side. Patient 4 was turned and repositioned next at 8:00 a.m. (12 hours after) on the right side -On 1/24/2024 at 12:00 p.m. Patient 4 was turned and repositioned on the right side. On 1/24/2024 at 2:00 p.m. Patient 4 was still on his right side. During a concurrent interview on 2/6/2024 at 3:10 p.m. with Registered Nurse (RN) 6, RN 6 acknowledged the gaps in documentation of Patient 4’s turning and repositioning from 1/22/2024 through 1/24/2024. RN 6 stated, the patients with pressure injury should be turned and repositioned at least every 2 hours. During a review of the facility’s “Department Policies and Procedures - Skin Integrity,” last revised 12/2022, the document indicated nurses should consider placing patients on a low air loss mattress under the following circumstances: Patients with stage 3, 4 (deep skin injuries that may expose bone, tendons, or muscle), or Deep Tissue Injury (DTI, purplish coloration of intact skin or blood-filled blister from injury to underlying soft tissue caused by pressure), patients with limited number of turning surfaces to which they can be turned. This document stated the nursing team will position patients at risk of pressure injury at least every 2 hours; any limitation to repositioning the patient will 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: 46333 Based on observation, interview, and record review, the facility failed to: 1. Ensure the patient’s acuity level (the measure of nursing intensity or the level of care the patient requires) was included in the nursing patients’ assignment schedule in the Neonatal Intensive Care Unit (NICU, units where intensive care is provided for newborn infants who are premature or have health problems) and the Labor and Delivery Unit (L&D, units that provide care to pregnant individuals during labor, childbirth, and the immediate postpartum period) in accordance with the facility’s staffing policy. This deficient practice had the potential to result in an inappropriate nursing patients’ assignment which may lead to inadequate nursing care for the patients with high acuity level of care. 2. Ensure for one (1) of 30 sampled patients (Patient 16), the facility’s policy on intravenous (IV administered through the vein) therapy guidelines was implemented when, Patient 16’s midline catheter (an 8-12 cm catheter inserted in the upper arm with the tip located just below the armpit) access site was not labeled (date of insertion) and initialed by staff who inserted the IV catheter. This deficient practice had the potential to result in Patient 16’s increased risk for intravascular (within the blood vessel) catheter-related infections. 3. Ensure for six (6) of 30 sampled patients (Patients 17, 18, 19, 20, 21, and 1), the facility’s policy on intravenous therapy guidelines was implemented when Patients 17, 18, 19, 20, 21 and 1’s peripheral (generally placed in the arm or hand) IV (in the vein) access site was not labeled. This deficient practice had the potential to result in the patients’ increased risk for intravascular (within the blood vessel) catheter-related infections. Findings: 1.a. During a concurrent interview and record review on 2/9/2024 at 1:35 p.m. with Registered Nurse (RN) 14, the “Birthing Center (L&D unit) Assignments sheet,” dated 2/9/2024, was reviewed. The Birthing Center (L&D unit) Assignments sheet indicated the RNs’ names assigned to a room number where the L&D patients were located. RN 14 confirmed that there was no assigned acuity level for each of the patients on the assignment sheet. During an interview on 2/9/2024 at 1:35 p.m. with the Director of the L&D Department (DLD), the DLD stated that the L&D department adheres to the same staffing policy and procedure of the facility, titled “Patient Classification and Interrater Reliability Guidelines.” The DLD confirmed that the acuity level of patients and the reason for their admission were not documented on the assignment sheet. During a review of L&D nursing assignment “Birthing Center Assignments,” dated 12/15/2023 through 1/31/2024, for day shift and night shift, the nursing assignments did not include the acuity level assigned to each of the patients. In addition, the nursing assignment did not indicate the licensed credentials of the staff nurses whether they were registered nurses (RN) or licensed vocational nurses (LVN). During a review of the facility’s policy and procedure (P&P) titled, Patient Classification and Interrater Reliability Guidelines,” dated September 2023, the P&P indicated the following: To provide guidelines to categorize patients into classifications which reflect acuity and adherence to regulatory standards. Inter-rater reliability is a method to establish the amount of nursing care needed for each category of patient is validated for each unit and for each shift. The method will address the amount of nursing care needed, by patient category and pattern of care delivery. This method is to determine staff resource allocations based on nursing care requirements for each shift and each unit. This method validates the reliability of the patient classification system for each unit and for each shift. PROCEDURE: - Patient classification will be determined for each patient on each shift and will be updated as the patient’s condition warrants. Acuity will be documented on the staff assignment sheets. 1.b. During a concurrent interview and record review on 2/9/2024 at 3:40 p.m. with the Manager of NICU (MNICU), the NICU assignments titled, “Daily Staffing Sheet,” dated 12/21/2023 through 1/31/2024, was reviewed. The MNICU stated she started entering patient acuity level on the NICU assignment sheet in December 2023 and that prior to December 2023, patients’ acuity was not documented on the Daily Staffing Sheet. The MNICU stated the NICU follows the facility’s staffing policy and procedure titled “Patient Classification and Interrater Reliability Guidelines.” In the same interview and record review, the NICU assignment sheets indicated the following dates did not include the patients’ acuity level: On 12/21/2023, day shift (7 a.m. to 7p.m), the space for acuity was left unfilled. On 12/22/2023, day shift and night shift (7 p.m. to 7a.m) the space for acuity was left unfilled. On 12/23/2023, day shift and night shift, the space for acuity was left unfilled. On 12/24/2023, day shift, the space for acuity was left unfilled. On 12/25/2023, day shift, the space for acuity was left unfilled. On 12/26/2023, day shift and night shift, the space for acuity was left unfilled. On 12/27/2023, night shift, the space for acuity was left unfilled. On 1/1/2024, day shift and night shift, the space for acuity was left unfilled. On 1/2/2024, night shift, the space for acuity was left unfilled. On 1/3/2024, day shift and night shift, the space for acuity was left unfilled. On 1/4/2024, day shift and night shift, the space for acuity was left unfilled. On 1/5/2024, day shift, the space for acuity was left unfilled. On 1/6/2024, day shift, the space for acuity was left unfilled. On 1/7/2024, day shift and night shift, the space for acuity was left unfilled. On 1/9/2024, day shift, the space for acuity was left unfilled. Confirmed with MNICU that the Daily Staffing Sheet as listed above did not include each patient’s acuity level. During a review of the facility’s policy and procedure (P&P) titled, Patient Classification and Interrater Reliability Guidelines,” dated September 2023, the P&P indicated the following: To provide guidelines to categorize patients into classifications which reflect acuity and adherence to regulatory standards. Inter-rater reliability is a method to establish the amount of nursing care needed for each category of patient is validated for each unit and for each shift. The method will address the amount of nursing care needed, by patient category and pattern of care delivery. This method is to determine staff resource allocations based on nursing care requirements for each shift and each unit. This method validates the reliability of the patient classification system for each unit and for each shift. PROCEDURE: - Patient classification will be determined for each patient on each shift and will be updated as the patient’s condition warrants. Acuity will be documented on the staff assignment sheets. During a review of the facility’s policy and procedure (P&P) titled, “Staffing Policy Plan,” dated September 2023, the P&P indicated, “A staffing plan that will be used to determine the personnel recommended for each shift as outlined in the unit’s staffing grid and as necessary to provide the scope of services. The plan shall also establish general guidelines as to the qualifications of staff assigned to provide patient care. Staffing guidelines are to be reviewed annually or more frequently as needed. Staffing guidelines are to be utilized and considered recommendations as acuity will also be utilized as a tool to determine staffing ... Staffing Guidelines: The minimum staffing needed for each skill level (LPN/LVN, RN, CNA, MT, US) is determined by the nurse-patient guidelines and/or patient care acuity needs ...” 2. During a concurrent observation and interview on 2/6/2024 at 2:02 p.m., with Registered Nurse (RN) 1, in Patient 16’s room, Patient 16 was observed with a midline catheter on the right arm. Patient 16’s midline catheter site at the right arm did not have a label with the date the dressing was changed. RN 1 stated, “It is important that the registered nurse assess the IV sites and ensure that there are labels with dates (date the dressing was changed) as the dressing has to be changed every week or when the dressing is soiled to prevent infection.” During a review of Patient 16’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 1/31/2024, the H&P indicated Patient 16 was found with oxygen saturation at 70 percent (a normal oxygen saturation level is between 95 percent and 100 percent). The H&P also indicated Patient 16’s “Problem List,” included atypical pneumonia (inflamed or swollen lung tissue due to infection caused by different bacteria) and the plan was for Patient 16 to be admitted for administration of IV (Intravenous, into the vein) antibiotic (medicines that fight infections caused by bacteria). During a concurrent interview and record review on 2/9/2024 at 2:40 p.m. with the Survey Coordinator and Quality Assurance (SCQA), the SCQA stated an IV guideline was provided for the nursing staff to follow in managing the patient’s IV access. In the same interview and record review, the document provided by the SCQA titled “Inserting a Peripheral IV in Adults,” indicated, “A peripheral IV cannula is inserted using an over-the-needle catheter to deliver fluids, aqueous medications, blood products, and parenteral nutrition directly into a patient’s peripheral vein. It is the fastest way to deliver fluids and medications throughout the body. Monitor for complications of peripheral IV insertion, including extravasation, phlebitis, thrombosis, hematoma, and infiltration, including redness, swelling, pain, and visual or palpable enlargement of the cannulated blood vessel ...Label dressing with date/time of insertion per facility protocol.” (Dynamic Health, EBSCO Information Services, 2024). 3.a. During a concurrent observation and interview on 2/6/2024 at 2:20 p.m. with the Performance Improvement Coordinator (IP coordinator) in Patient 17’s room, Patient 17 was observed with an IV site on the left forearm. Patient 17’s IV site did not have a label with a date (date the IV catheter was inserted) and the IV dressing was observed peeling off around the edges. There was a medication (Zosyn, an antibiotic) infusing through the IV. IP coordinator stated he will inform the primary nurse to change the dressing and label the dressing. During a review of Patient 17’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/3/2024, the H&P indicated that Patient 17 came into the emergency department for a complaint of epigastric (upper middle area of the abdomen) pain that was radiating to the mid-back with associated nausea (feeling the urge to vomit). The H&P further indicated, “Patient 17 had an abdominal ultrasound (imaging test that uses sound waves to make pictures of organs, tissues, and other structures) which revealed cholelithiasis (the formation of gallstones) and signs of acute cholecystitis (inflammation of the gallbladder. Patient with leukocytosis (increase in the number of white cells in the blood during an infection). Patient admitted for further care.” During a review of the facility’s document titled “Inserting a Peripheral IV in Adults,” the document indicated, “A peripheral IV cannula is inserted using an over-the-needle catheter to deliver fluids, aqueous medications, blood products, and parenteral nutrition directly into a patient’s peripheral vein. It is the fastest way to deliver fluids and medications throughout the body. Monitor for complications of peripheral IV insertion, including extravasation, phlebitis, thrombosis, hematoma, and infiltration, including redness, swelling, pain, and visual or palpable enlargement of the cannulated blood vessel ...Label dressing with date/time of insertion per facility protocol.” (Dynamic Health, EBSCO Information Services, 2024). 3.b. During a concurrent observation and interview on 2/6/2024 at 2:40 p.m. with the Clinical Supervisor (CS) 1 and the IP coordinator, in Patient 18’s room, Patient 18 was observed with an IV site on the left forearm. Patient 18’s IV site did not have a label with a date (date the IV catheter was inserted). CS 1 stated, “It is important that the registered nurse assess the IV sites and assure that there are labels with dates as the IV catheter has to be changed every three days to prevent infection.” During a review of Patient 18’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/2/2024, the H&P indicated that Patient 18 was brought in by ambulance for nausea, vomiting, and abdominal pain. The H&P further indicated an ultrasound revealed a thrombus (a blood clot formed in situ within the vascular system of the body and impeding blood flow) in the femoral veins (a large blood vessel in the thigh). The patient (Patient 18) was on antibiotics. During a review of the facility’s document titled “Inserting a Peripheral IV in Adults,” the document indicated, “A peripheral IV cannula is inserted using an over-the-needle catheter to deliver fluids, aqueous medications, blood products, and parenteral nutrition directly into a patient’s peripheral vein. It is the fastest way to deliver fluids and medications throughout the body. Monitor for complications of peripheral IV insertion, including extravasation, phlebitis, thrombosis, hematoma, and infiltration, including redness, swelling, pain, and visual or palpable enlargement of the cannulated blood vessel ...Label dressing with date/time of insertion per facility protocol.” (Dynamic Health, EBSCO Information Services, 2024). 3.c. During a concurrent observation and interview on 2/6/2024 at 2:56 p.m. with CS 1 and the IP coordinator, in Patient 19’s room, Patient 19 was observed with an IV site on the inner left forearm. Patient 19’s IV site did not have a label with a date, and the dressing tape was peeling off with one tape dangling from the IV site. CS 1 stated she will inform the primary nurse to assess the IV site, change the dressing, and label the IV site with a date (date the IV catheter was inserted). During a review of Patient 19’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/4/2024, the H&P indicated Patient 19 presented to the emergency department for symptoms of shortness of breath. The H&P further indicated Patient 19’s chest x-ray (a photographic or digital image of the internal composition) revealed pulmonary vascular congestion [obstruction of the normal flux of blood within the blood vessel network of the lung resulting in engorgement of lungs vessels]). During a review of the facility’s document titled “Inserting a Peripheral IV in Adults,” the document indicated, “A peripheral IV cannula is inserted using an over-the-needle catheter to deliver fluids, aqueous medications, blood products, and parenteral nutrition directly into a patient’s peripheral vein. It is the fastest way to deliver fluids and medications throughout the body. Monitor for complications of peripheral IV insertion, including extravasation, phlebitis, thrombosis, hematoma, and infiltration, including redness, swelling, pain, and visual or palpable enlargement of the cannulated blood vessel ...Label dressing with date/time of insertion per facility protocol.” (Dynamic Health, EBSCO Information Services, 2024). 3.d. During a concurrent observation and interview on 2/6/2024 at 2:56 p.m. with charge nurse (Charge) 3, in Patient 20’s room, Patient 20 was observed with an IV site on the right hand. Patient 20’s IV site did not have a label with a date (date the IV catheter was inserted). Charge 3 stated, “There should always be a label on the IV site with the date ((date the IV catheter was inserted). The facility policy is to assess the IV site every 4 hours to ensure dressing is not soiled and to ensure IV site is changed every 3 days to prevent infection.” During a review of Patient 20’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/4/2024, the H&P indicated Patient 20 presented to the emergency room with a complaint of chills, cough, yellow sputum, intermittent vomiting, and diarrhea (loose, watery stool that occurs more frequently than usual) for one week. H&P further indicated Patient 20 had an elevated white blood count (elevated WBC can be a sign and symptom of an infection), patient was started on antibiotics and admitted for further management.” During a review of the facility’s document titled “Inserting a Peripheral IV in Adults,” the document indicated, “A peripheral IV cannula is inserted using an over-the-needle catheter to deliver fluids, aqueous medications, blood products, and parenteral nutrition directly into a patient’s peripheral vein. It is the fastest way to deliver fluids and medications throughout the body. Monitor for complications of peripheral IV insertion, including extravasation, phlebitis, thrombosis, hematoma, and infiltration, including redness, swelling, pain, and visual or palpable enlargement of the cannulated blood vessel ...Label dressing with date/time of insertion per facility protocol.” (Dynamic Health, EBSCO Information Services, 2024). 3.e. During a concurrent observation and interview on 2/6/2024 at 4:00 p.m. with Charge 3, in Patient 21’s room, Patient 21 was observed with an IV site on the right forearm and the left forearm. In the same observation and interview, Patient 21’s IV site on the right forearm had a smeared writing in black ink that was not legible. Patient 21’s IV site on the left forearm did not have a label with a date (date the IV catheter was inserted). Charge 3 stated, “the IV site label should not be written with a marker over the tape. There is a labeling sticker that comes with the IV kit, or there are IV label stickers.” During a review of Patient 21’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/3/2024, the H&P indicated Patient 21 presented to the emergency department for erratic behavior. The H&P further indicated Patient 21 was positive for leukocytes (an increase in the number of white cells in the blood during an infection), and Patient 21’s chest x-ray indicated a pulmonary edema (a condition caused by too much fluid in the lungs). Patient 21 would be on IV Rocephin (antibiotic medication). During a concurrent interview and record review on 2/9/2024 at 2:40 p.m. with the Survey Coordinator and Quality Assurance (SCQA), the SCQA stated an IV guideline was provided for the nursing staff to follow in managing the patient’s IV access. In the same interview and record review, the document provided by the SCQA titled “Inserting a Peripheral IV in Adults,” indicated, “A peripheral IV cannula is inserted using an over-the-needle catheter to deliver fluids, aqueous medications, blood products, and parenteral nutrition directly into a patient’s peripheral vein. It is the fastest way to deliver fluids and medications throughout the body. Monitor for complications of peripheral IV insertion, including extravasation, phlebitis, thrombosis, hematoma, and infiltration, including redness, swelling, pain, and visual or palpable enlargement of the cannulated blood vessel ...Label dressing with date/time of insertion per facility protocol” (Dynamic Health, EBSCO Information Services, 2024). 3.f. During an observation on 2/6/2024 at 2:10 p.m., with the Quality Manager, Patient 1 was observed to have an IV inserted into the left wrist. Patient 1’s IV site was covered with semi-transparent plastic tape and was not marked with the date the IV was inserted. This observation was validated by the Quality Manager. During an interview on 2/6/2024 at 2:10 p.m. with the Quality Manager, the Quality Manager stated the date of the patient’s (Patient 1) IV insertion was documented in the patient’s electronic record. A review of Patient 1’s electronic medical record on 2/6/2024 at 3:00 p.m. did not indicate any IV insertion documentation. This was confirmed by the Quality Manager during an interview. During a review of the facility’s document titled, “Nursing Skill - Inserting a Peripheral IV In Adults,” the document specified “the IV site should be covered with sterile transparent dressing that maintains a view of the insertion site and its surround area; IV insertion is to be documented in the patient’s plan of care and medical record including date/time.””