Dameron Hospital

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 42291 The hospital failed to have an effective discharge planning process to arrange for necessary post-hospital care and patient preferences according to hospital policy and procedures when: 1. Eleven of 16 sampled patients (Patients 1, 2, 3, 4, 5, 7, 8, 9, 10 and 13) were not screened timely and the discharging planning evaluation process was not completed within 24 hours of their admission to the hospital (refer to A- 0800); and 2. One of 16 sampled patients (Patient 7) was discharged to a Skilled Nursing Facility (SNF) different than the SNF he resided prior to his hospitalization without communicating and honoring Patient 7’s preferences (refer to A- 0808). These failures placed patients at risk for potential readmission, and delayed discharges, and had the potential to not honor patient preferences and right to decision making for post hospital care. The cumulative effect of these systemic problems resulted in the inability of the hospital to comply with the statutory mandated Condition of Participation for Discharge Planning.”

“Standard-level Tag for Pharmaceutical Service CFR(s): 482.25 Standard-level Tag for §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients... This Standard is not met as evidenced by: 45882 Based on observations, interviews and record reviews, the hospital failed to ensure timely delivery of medications ordered from its vendor due to credit hold restrictions (restriction placed by a company or creditor on a hospital’s ability to make new purchases on credit). This failure could potentially result in patients not receiving medications in a timely manner leading to negative health outcomes. Findings: During a concurrent interview and record review on 4/6/26 at 11:22 a.m., with Pharmacy Buyer (PB) and Director of Pharmacy (DPH), a routine audit of the hospital’s controlled substances purchase records for March 2026 showed that deliveries for orders placed on 3/18/26 and 3/11/26 arrived one and two days later than expected respectively. Further review of February 2026 medication purchase orders revealed a consistent delay as orders placed on 2/5/26 and 2/8/26 were not received by pharmacy until 2/10/26. During the concurrent interview, the PB stated that, in recent months, the pharmacy’s main vendor had periodically placed purchases on credit hold. During a concurrent interview and review of the email correspondence on 4/6/26 at 2:43 p.m., with the PB and DPH, an email dated 3/18/26 from the pharmacy vendor indicated “Please provide update regarding upcoming payment, as the credit limit is already exhausted. Since there is no credit left, the following order is being held and cannot be released until payment is received to bring the account under the limit.” During the concurrent interview with the DPH, he explained that credit holds typically occurred when outstanding balances were not paid within the vendor’s required timeframe. As a result, the pharmacy experienced occasional delays in receiving ordered medications which could impact inventory management and patient care. During an interview conducted on 4/7/26 at 1:49 p.m., with a staff pharmacist (Pharm1), Pharm1 acknowledged that he was aware of occasional delays in medication deliveries from their primary pharmacy vendor these past few months. Pharm1 stated to address patient needs during these times, he noted that the pharmacy would redistribute medications from other departments as needed, and when necessary, borrowed from other neighboring hospitals. During a review of the hospital’s policy and procedures (P&P) titled, “Drug Procurement/Inventory Control” dated 7/20/23, the P&P indicated, “1. Medication will be ordered on a routine basis as inventory levels and usage dictates. Amounts ordered will vary according to numerous factors, of which patient load and usage is of the primary concern. 2. [Name] Hospital pharmacy utilizes the concept of prime vendor. Our primary wholesaler will be our prime source of medications. We will have next-day delivery six days per week, except in cases of manufacturer or wholesaler back orders.””

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 45882 Based on observation, interview, and record review the facility failed to ensure 11 of 16 sampled patients (Patients 1, 2, 3, 4, 5, 7, 8, 9, 10, 13, and 16) were screened timely and that the discharging planning evaluation was completed within 24 hours of their admission to the hospital per the facility’s policy and procedure (P&P). These failures had the potential for Patients 1, 2, 3, 4, 5, 7, 8, 9, 10, 13, and 16 to have increased risks for delayed discharges and possible readmissions to hospital. Findings: During a review of the facility’s P&P titled “Care Management-Discharge Planning,” last revised 4/2/25, the P&P indicated, “Discharge planning policy, procedures, and processes are established to ensure adherence to the hospital mandate set by the Centers for Medicare & Medicaid Services (CMS) Section 482.43, ...Discharge Planning ... The CMS CoPs [Conditions for Participation] requires hospitals to complete discharge planning evaluation for all patients for post-hospital care within 24 hours of admission or registration, and must be completed before discharge ...The written communication involves documentation of the completed assessment in the patient’s chart ... within 24 hours ...In the event that documentation is not done in 24 hours, a late entry is permitted.” During a review of Patient 1’s “History and Physical (H&P),” dated 4/4/26, the H&P indicated Patient 1 had a history of peptic ulcers (stomach sores), prior gunshot wound and was admitted for a liver capsule abscess (a collection of pus). During a concurrent interview and record review on 4/6/26 at 2 p.m. with the Chief Nursing Officer (CNO), Patient 1’s medical record was reviewed. The CNO confirmed there was no documented evidence of discharge planning within 24 hours of admission. CNO stated she would have expected case management to have written a note and agreed there was no discharge plan evaluation in Patient 1’s electronic medical record (EMR). During a review of Patient 2’s H&P, dated 3/31/26, the H&P indicated Patient 2 had a history of diabetes, and bilateral nephrostomy tubes (flexible tubes inserted into kidneys to drain urine into collection bags outside the body). Patient 2’s diagnoses included urinary tract infection and sepsis (inflammatory responses throughout the body that can damage vital organs). During a concurrent interview and record review on 4/6/26 at 2 p.m. with the CNO, Patient 2’s medical record was reviewed. The CNO confirmed there was no documented evidence of discharge planning evaluation within 24 hours of admission. During a review of Patient 3’s H&P, dated 3/18/26, the H&P indicated Patient 3 was a 76 year old with a history of high blood pressure, diabetes, chronic heart failure (heart muscle too weak to pump blood), and chronic obstructive pulmonary disease (a long term lung disease that makes it hard to breathe). Patient 3 had a history of multiple admissions and current admission diagnoses included abdominal pain, melena (blood in the stool), acute upper gastrointestinal bleed and used supplemental oxygen at home. During a concurrent interview and record review on 4/6/26 at 2 p.m. with CNO, Patient 3’s medical record was reviewed. The CNO confirmed there was no documented evidence of discharge planning within 24 hours of admission. CNO indicated that Patient 3’s discharge evaluation should have been completed within 24 hours of admission. During a review of Patient 4’s H&P, dated 3/31/26, the H&P indicated Patient 4 was an 84 year old with a history of high blood pressure, diabetes, and stroke. Patient 4’s current diagnoses included urinary tract infection, acute encephalopathy (inflammation of the brain causing temporary confusion), and a right collarbone fracture. During a concurrent interview and record review on 4/7/26 at 2:17 p.m. with Assistant Manager (AM), Patient 4’s discharge plan documentation for dates 3/27/26 to 4/6/26 were reviewed. Patient 4’s initial discharge plan documentation was done on 4/2/26, 6 days post admission. AM confirmed discharge planning notes were documented 6 days post admission. During a review of Patient 5’s H&P, dated 4/5/26, the H&P indicated Patient 5 was an 86 year old brought to hospital via ambulance following a ground -level fall at home. Patient 5 history included high blood pressure, seizures, and a heart pacemaker. During a concurrent interview and record review on 4/7/26 at 2:17 p.m. with AM, Patient 5’s discharge plan documentation for dates 4/5/26 to 4/7/26 were reviewed. Patient 5’s initial discharge plan documentation was dated 4/7/26, two days post admission. During a review of Patient 7’s H&P, dated 3/30/26, the H&P indicated Patient 7 was a 68 year old brought to hospital via ambulance from a SNF for severe abdominal pain and shortness of breath. Patient 7 had a history of a stroke, right sided weakness and a G-tube (gastrostomy tube, flexible tube placed directly into the stomach through a small hole in the belly used to provide nutrition). During a concurrent interview and record review on 4/8/26 at 9:30 a.m. with CNO, Patient 7’s discharge plan documentation for dates 3/30/26 to 4/6/26 were reviewed. Patient 7’s initial discharge discussion with Patient 7’s sister was documented on 4/3/26, 4 days post admission. CNO stated that the expectation was for patients to be seen the following day, post admission, by the case manager. During an interview on 4/8/29 at 2:02 p.m. with Case Management Director (CMD), CMD stated that the expectation was for the discharge planning evaluation to be done within 24 hours of admission and stated, “Because of lack of staff, it wasn’t done.” During a review of Patient 8’s H&P, dated 3/30/26, the H&P indicated Patient 8 was admitted to the facility on 3/30/26 with diagnosese of acute osteomyelitis of right great toe (a serious, rapid-onset infection of the bone), diabetes, and cellulitis of right lower limb (a potentially serious bacterial infection affecting the deeper layers of the skin, usually but not always, on the lower legs). During a concurrent interview and record review on 4/8/26, at 11:15 a.m., with the CNO, Patient 8’s medical record was reviewed. The CNO confirmed there was no documented evidence of discharge planning within 24 hours of admission. The CNO confirmed the initial discharge was not completed within 24 hours of the patient 8’s admission. During a review of Patient 9’s H&P, dated 4/4/26, the H&P indicated Patient 9 was admitted to the facility on 4/4/26 with diagnoses of chronic obstructive pulmonary exacerbation (an event characterized by shortness of breath and or cough and sputum that worsens over 2 weeks, which may be accompanied by rapid breathing and/or rapid heart rate and is often associated with inflammation caused by infection, pollution or other insult to the airways), congestive heart failure exacerbation (a sudden or rapid worsening of heart failure symptoms such as extreme shortness of breath, rapid weight gain and sever swelling, requires urgent medical attention), hyperglycemia (blood sugar above a person’s target range, if left untreated can cause severe complications), and acute hypoxemic respiratory failure (a sudden, life-threatening inability of the lungs to get enough oxygen into the bloodstream). During a concurrent interview and record review on 4/8/26, at 11:36 a.m., with the CNO, Patient 9’s medical record was reviewed. The CNO confirmed there was no documented evidence of discharge planning within 24 hours of admission. The CNO confirmed the initial discharge assessment was not completed within 24 hours of the patient 9’s admission. During a review of Patient 10’s H&P, dated 4/4/26, the H&P indicated Patient 10 was admitted to the facility on 4/4/26 with diagnoses of hypocalcemia (low calcium level), and hypothyroidism (occurs when the thyroid gland fails to produce sufficient hormones, slowing the body’s metabolism). During a concurrent interview and record review on 4/8/26, at 11:50 a.m., with the CNO, Patient 10’s medical record was reviewed. The CNO confirmed there was no documented evidence of discharge planning within 24 hours of admission. The CNO confirmed the initial discharge assessment was not completed within 24 hours of the patient 10’s admission. During a review of Patient 13’s H&P, dated 4/4/26, the H&P indicated Patient 13 was admitted to the facility on 4/4/26 with diagnoses of hepatic abscess (a pocket of pus in the liver caused by bacterial, parasitic, or fungal infection), high blood pressure, and hyperlipidemia (a condition characterized by high levels of fat in the blood). During a concurrent interview and record review on 4/8/26, at 1:30 p.m., with the CNO, Patient 13’s medical record was reviewed. The CNO confirmed there was no documented evidence of discharge planning within 24 hours of admission. The CNO confirmed the initial discharge was not completed within 24 hours of patient admission. During a review of Patient 16’s H&P, dated 4/2/26, the H&P indicated Patient 16 was admitted to the facility on 4/2/26 with diagnoses of pneumonia (serious lung infection), shortness of breath, cough, and chest pain. During a concurrent interview and record review on 4/8/26, at 1:50 p.m., with the CNO, Patient 16’s medical record was reviewed. The CNO confirmed there was no documented evidence of discharge planning within 24 hours of admission. The CNO confirmed the initial discharge was not completed within 24 hours of patient admission.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 44260 Based on interview, and record review, the facility failed to discuss with the patient the results of their discharge evaluation for 1 of 16 patients reviewed for discharge planning (Patient 7) when Patient 7 was discharged to a skilled nursing facility (SNF) different than the SNF he resided prior to his hospitalization. This failure had the potential to be an inappropriate discharge plan for Patient 7 and the risk of not following the patient’s wishes with the selection of the discharge location. Findings: During a review of Patient 7’s “History and Physical [H&P],” dated 3/30/26, the H&P indicated Patient 7 was a 68 year old with a history of a cerebrovascular accident (CVA, also known as a stroke, which occurs when blood flow to part of the brain is interrupted or reduced. The lack of oxygen causes brain cells to die, typically leading to symptoms like weakness, numbness, or difficulty speaking). Further review of the H&P indicated that Patient 7 was brought in by ambulance from a SNF for severe abdominal pain, shortness of breath and was admitted for pneumonia (a lung infection). During a concurrent interview and record review on 4/8/26, at 9:40 a.m., with the facility’s Chief Nursing Officer (CNO), Patient 7’s electronic medical record (EMR) was reviewed. The CNO stated Patient 7 was a resident at (SNF A) prior to his hospitalization and per family request was discharged to (SNF B) on 4/6/26. The CNO confirmed Patient 7 was his own responsible party (RP - individual making medical, legal, financial decisions). The CNO further confirmed there was no documentation in Patient 7’s EMR if Patient 7 was agreeable in being discharged to a different SNF. The CNO acknowledged that staff should have discussed with Patient 7 to see if he agreed with the discharge since he was his own RP and was alert and oriented to person, place and time. A review of the facility’s policy and procedure titled, “Care Management - Discharge Planning Process,” last revised on 4/2/25, indicated, “An effective discharge planning process: 1. Determines the safe/appropriate post-hospital discharge destination...f. Results of the discharge planning evaluation must be discussed with the patient or their patient representative [RP]; offering a range of realistic options to consider for after-acute care hospital/post-acute care facility care depending upon...5. Patient’s preferences and goals, as applicable...Document the following in the patient’s medical record ...B. Discussion of the results of the discharge planning evaluation with the patient and family...””

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 50925 Based on observation, interview, and document review, the facility failed to ensure the needs and resources of the surgical services department were met when Medical Doctor (MD) 1’s sterile surgical supply (SSS - medical tools that have been completely cleaned to prevent infection) par levels (PL - the minimum amount of supplies needed to avoid running out before the next surgical procedure) were not adjusted to meet the needs of the surgical procedures. This failure had the potential to cause surgical procedure delays, cancellations or reschedules that could further compromise the health and safety of patients needing urological surgery (surgical procedures for the urinary tract). Findings: During a concurrent observation and interview on 4/6/26, at 9:54 a.m., with Operating Room Registered Nurse (ORRN) 1, in the operating room (OR) sterile supply room (SSR), the ORRN 1 stated the facility had only one urologist (medical doctor/surgeon that specializes in the urinary tract) on staff, MD 1, and he only did his surgical procedures as add-ons (cases done outside of regular working hours in the evening and on the weekends). ORRN 1 further stated when MD 1 would schedule his surgical procedures, all other staff had gone home for the day, and it was the responsibility of the OR RN and the operating room technician (ORT) to acquire all SSS needed for the surgical procedures. ORRN 1 stated oftentimes SSS frequently used by MD 1 were not on the shelves in the SSR and after checking with central supply (large room that contains additional supplies) if the items could not be found they would have to call other facilities to borrow them for the surgical procedures. ORRN 1 further stated it had been difficult to track down all the sterile surgical supplies needed for MD 1’s surgical procedures and she would like to have seen more supplies available for MD 1 in the SSR rather than calling other facilities not knowing if they could acquire the supplies needed. During a concurrent observation and interview on 4/6/26, at 10:24 a.m., with ORT 1, in the OR’s SSR, ORT 1 stated MD 1 had worked at the facility for approximately two years and had consistently performed two to five surgical procedures weekly. ORT 1 further stated the facility should have by now adjusted MD 1’s sterile surgical supplies PL to meet the needs of the surgical procedures he had been performing on a regular basis. ORT 1 stated if MD 1 had a surgical procedure added on and if there were not enough supplies the case would sometimes get cancelled. During an interview on 4/6/26, at 1:30 p.m., with the Materials Manager (MM) and the Operations Manager (OM), the MM stated the ordering schedule for SSS were based on surgical procedures done and she was unsure who set the PL for MD1’s surgical supplies. The OM stated the facility should have adjusted the PL for MD 1’s sterile surgical supplies considering he had been consistently performing urological surgical procedures over the last two years and by now the facility has an idea of what surgical supplies MD 1 had been using on a regular basis. During a concurrent observation and interview on 4/7/26, at 2:22 p.m., with Operating Room Materials Coordinator (ORMC), in the SSR, the following urological surgical supplies were confirmed by the ORMC as the most frequently used for MD 1: a. Single use ureteroscope (SU - a single use, flexible digital camera stick device to diagnose and treat kidney stones) with a par level of three with one box on the shelf, and; b. Power device (PD - a small device that connects to the handle of the LithoVue ureteroscope) with a par level of two with two boxes on the shelf. The ORMC stated the SU and the PD had to be used together and there was one SU missing on the shelf. The ORMC stated the par levels were not enough for both items and would like them to have been higher as they seem to be constantly ordering them and sometimes they do not have any on the shelves. The ORMC stated it was his responsibility to stock these items and have them available at all times for MD 1’s cases, but due to the low PL that did not always happen. During a phone interview on 4/9/26, at 12:30 p.m., with MD 1, MD 1 stated he was the only urological provider at the facility for the last couple of years and a majority of his surgical procedures were kidney stone cases that required the use of the SU and the PD. MD 1 further stated he preferred this specific brand name SU and PD for this kidney stone cases and did not want to use an alternative. During a review of the facility’s policy and procedure (P&P) titled, “Central Services - Par Management and Delivery Process”, dated 11/4/24, the P&P indicated, “Purpose: To ensure each unit’s par location is properly stocked with the materials it needs to operate”. During a review of the facility’s P&P titled, “Scope of Service/Structure Standards - Surgical Services Department,” dated 3/7/25, the P&P indicated, “The Surgical Services Department provides a safe and comfortable environment for both patients and personnel in order to provide optimum assistance to the surgeons in meeting the emergency, preventive and restorative health needs of the patients ...The Director of Surgery ...shall be responsible for the following: Maintaining adequate operating room supplies and equipment”.”

“INFORMED CONSENT CFR(s): 482.51(b)(2) A properly executed informed consent form for the operation must be in the patient’s chart before surgery, except in emergencies. This Standard is not met as evidenced by: 51078 Based on interviews and record reviews the facility failed to ensure two out of seven (Patient 18, and Patient 20) sampled surgical patients’ medical records (MR) did not contain properly executed informed consents (IC - legal document granting permission by a patient to a doctor for treatment or surgical procedure with full knowledge of consequences, and possible risks and benefits) when Patient 18’s IC did not contain the name of the surgeon performing the surgical procedure, and Patients 20’s IC contained dates that had been altered. These failures placed Patient 18 and Patient 20 at risk for not being adequately informed regarding the surgical procedures performed and prevented the health care team from having accurate information related to those surgical procedures. Findings: During a concurrent interview and MR review on 4/8/26 at 3:05 p.m. with the Operating Room Charge Nurse (ORCN) 2, Patient 18’s IC titled, “AUTHORIZATION TO SURGERY OR SPECIAL PROCEDURE”, dated 1/21/26, was reviewed. The ORCN 2 confirmed the section of the IC that indicated the name of the physician who performed the surgical procedure was blank. The ORCN 2 stated this area should have contained the name of the surgeon that performed the surgical procedure and it was the operating room nursing staff’s responsibility to be sure the IC is completed in its entirety before the surgical procedure began. During a concurrent interview and MR review on 4/9/26 at 11:20 a.m. with the ORCN 1 and the Quality and Risk Specialist (QRS), Patient 20’s IC titled, “AUTHORIZATION TO SURGERY OR SPECIAL PROCEDURE”, dated 2/6/26, was reviewed. The ORCN 1 confirmed the IC indicated the date 2/6/26 in three areas to include the patient signature/date line, the patient signature/date line regarding consent to blood transfusion, and the physician signature/date line regarding consent for blood transfusion. The ORCN 1 further confirmed that all three dates had been altered, and the day portion of each entry had been changed from a five to a six. The ORCN 1 stated the staff member who had changed the dates on the IC for Patient 20 did not follow facility policy and procedure (P&P) regarding proper correction of handwritten errors and that the numbers had clearly been altered. The QRS also confirmed the three dates had been altered on the IC for Patient 20. During a review of the facility’s P&P titled, “Consent And Informed Consent - California”, dated 7/1/24, the P&P indicated, “Consent to Surgery [IC] ...The consent should include ...Name or names of practitioners who will perform important parts of the procedure ...nursing staff shall be responsible for verifying that the documentation has been included in the chart PRIOR to surgery”. During a review of the facility’s P&P titled, “Documentation of Patient Care”, dated 4/11/25, the P&P indicated, “All information related to patient care will be documented appropriately in the patient’s medical record ...document charting errors accurately ...Do not delete, cross out words beyond recognition, alter ...any part of the patients health record ...Entry Charted in Error ...wrong information ...For handwritten entries: use one line to cross through the entry. Initial, date, and time correction is made ...document correct information”.”