Southern California Hospital at Hollywood

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45774 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Patient Rights as evidenced by: 1. Registered Nurse 1 (RN 1) inappropriately respond by physically assaulting Patient 14 after getting provoked by the patient. And security personnel failed to separate the altercation between Registered Nurse 1 (RN 1) for one of 44 sampled patients (Patient 14). This deficient practice resulted in Patient 14 eloping after the altercation and extent of the injuries of Patient 14 were not established. (Refer to A-0145) 2. The Conditions of Admission (COA, a document that includes provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risk and benefits]) and the Important Message from Medicare (IMM – a notice given to the patient with Medicare benefits indicating the patient ’ s rights to a hospital discharge appeal) for five of 44 sampled patients (Patient 1, Patient 2, Patient 20, Patient 32, and Patient 33), was not provided. These deficient practices can result in Patient 1, Patient 2, Patient 20, Patient 32, and Patient 33 to not be informed of their rights as a patient, which may result in the inability to effectively make decisions regarding their care or treatment. (Refer to A-0117). 3. The patient ’ s personal cellular phone for one of three sampled patients (Patient 38) was not returned upon discharge per facility ’ s policy and procedure. This deficient practice resulted in Patient 38 being discharged from the facility without Patient 38 ’ s personal cellular phone. (Refer to A-0118). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 45774 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Quality Assessment & Performance Improvement as evidenced by: 1. The facility ’ s Quality Assurance Performance Improvement (QAPI, a healthcare system to maintain and improve the quality of care, safety, and quality of life for patients on an ongoing basis) Committee failed to prioritize preventative measures to manage assaultive behavior in the emergency department (ED, a medical facility that provides immediate medical care to persons with urgent or life-threatening conditions). This deficient practice resulted in a repeated adverse event of physical violence, inflicted by a facility staff member, to one of 44 sampled patients (Patient 14) and caused Patient 14 to elope (to run away) with unknown injuries. (Refer to A-283). 2. The facility failed to report a sentinel/adverse event (a serious, unexpected occurrence involving death or serious injury, or the risk of it, that signals the need for immediate investigation) to a required regulatory organization (CDPH, California Department of Public Health) for one of 44 sampled patients (Patient 14), when a physical altercation, inflicted by a staff member Registered Nurse 1, (RN 1), occurred in the emergency department (ED) between RN 1 and Patient 14. This deficient practice resulted in a missed opportunity to conduct a thorough investigation to ensure the facility implemented corrective actions and identified trends to prevent the likelihood of future harm, while contributing to a safer environment through quality improvement initiatives. (Refer to A-286). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 45774 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by: 1. The facility failed to develop a nursing care plan (a written action plan that documents a patient ’ s needs, risks, and goals to ensure consistent, quality care) addressing bleeding (loss of blood), glucose (a simple sugar that serves as the source of energy for the body), cardiac (relating to the heart), dehydration (fluid loss) and malnutrition (a lack of proper nutrition, a condition that occurs when a person does not receive or absorb enough nutrients from their diet to meet their body ’ s needs) needs for six of 44 sampled patients (Patient 20, Patient 24, Patient 27, Patient 29, Patient 31, and Patient 32). This deficient practice had the potential to result in Patient 20 Patient 24, Patient 27, Patient 29, Patient 31, and Patient 32 not receiving the right level of care and not meeting the needs for their specific identified patient health concerns. (Refer to A-396). 2. The facility failed to provide complete annual skills competency (the level of performance that a nurse is expected to achieve, which combines their knowledge, skills, abilities, and judgment) and education for one of seven registered nurses (Registered Nurse [RN] 31) in accordance with the facility ’ s policy and procedure for “Competency Assessment.” This deficient practice had the potential for RN 31 to carry out nursing duties in which RN 31 may not be competent of performing, which could potentially compromise patient safety. (Refer to A-397). 3. A. The facility failed to document one of 30 sampled patients (Patient 8) for pain reassessment in medical record. This deficient practice had the potential result in Patient 8 ’ s pain level was not reassessed and evaluate of effectiveness of administration of pain medication in the medical record per hospital policy. (Refer to A-398). B. The facility failed to ensure for one of 44 sampled patients (Patients 22) that pain assessment (pain assessment includes a pain scale uses numbers from 0 to 10, with 0 representing no pain and 10 representing the worst pain possible, location of pain, character of pain, and duration of pain) was not completed prior to pain medication administration according to the facility ’ s policies and procedures on pain management. This deficient practice had the potential to result in a delay in providing necessary treatment to address Patient 22 ’ s pain. (Refer to A-398) The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 45774 Based on interview and record review the facility failed to ensure for five of 44 sampled patients (Patient 1, Patient 2, Patient 20, Patient 32, and Patient 33), the Conditions of Admission (COA, a document that includes provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risk and benefits]) and the Important Message from Medicare (IMM – a notice given to the patient with Medicare benefits indicating the patient ’ s rights to a hospital discharge appeal) was provided. These deficient practices can result in Patient 1, Patient 2, Patient 20, Patient 32, and Patient 33 to not be informed of their rights as a patient, which may result in the inability to effectively make decisions regarding their care or treatment. Findings: A. During a review of Patient 1 ’ s Face Sheet (front page of the chart that contains a summary of basic information about the resident), dated 6/25/2025, indicated Patient 1 was admitted on 6/27/2025, the emergency contact person is Patient 1 ’ s brother. During a review of Patient 1 ’ s “History and Physical (H&P),” dated 6/27/2025, indicated Patient 1 was admitted for bradycardia (a slower than expected heart rate, generally beating fewer than 60 beats per minute) with a history of congestive heart failure (CHF – a heart disorder which causes the heart to not pump the blood efficiently), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), ESRD (End Stage Renal Disease – irreversible kidney failure), and hypertension (HTN – high blood pressure). During a concurrent interview and record review on 10/02/2025 at 3:37 p.m. with the Director of Patient Access (DPA), the DPA review Patient 1 ’ s Conditions of Admission (COA, a document that includes provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risk and benefits]) ,indicated the letters ’ UTS ’ (the facility ’ s initials for Unable to Sign) and ’ Vented ’ (the use of a machine to take over the breathing function for a patient). The DPA stated in this situation the Patient Access Staff (admitting department staff who are responsible for obtaining COA signatures, providing Patient Rights literature, and obtaining IMM signature) won ’ t try to obtain a signature the following day since a vented patient is usually not able to sign a COA the next day either. The DPA stated documentation for follow-up was not entered in the facility ’ s signature system for follow-up. The DPA stated Patient Staff did not attempt to contact the Skilled Nursing Facility (SNF) to determine who Patient 1 ’ s responsible party was for signatures on the COA and Important Message from Medicare (IMM – a notice given to the patient with Medicare benefits indicating the patient ’ s rights to a hospital discharge appeal) forms. During a review of the facility ’ s policy and procedure (P&P) titled, “Consent Form Requirements,” dated 4/2022, the P&P indicated, “Notification of the Legal Representative: Patient Access will make a reasonable effort to contact a family member, legal guardian, dual power of attorney, conservator, domestic partner, or public guardian in the event a patient lacks the capacity to make healthcare decisions, upon admission ...Basic Consent Form Packet: These forms are provided to all patients. (a) Conditions of Admission (COA): Lists the terms and conditions to being admitted to the hospital ... and (d) Patient Rights: Lists all patient rights (handout only) ...Signature Follow-Up Process: In the event the consent forms could not be signed at the time of admission, Patient Access will properly document the reason on the COA in the provided space, make a note the registration system, and then fill out the Signature Follow Up log. Over the following two days (usually completed by the Patient Access morning staff) Patient Access will make one additional attempt each day to obtain the signatures from the patient or legal representative...” B. During a review of Patient 2 ’ s Face Sheet, dated 7/17/2025, the Face Sheet indicted Patient 2 was admitted on 7/17/2025, does not have an emergency contact. During a review of Patient 2 ’ s “History and Physical (H&P),” dated 7/18/2025, indicated Patient 2 was readmitted from a skilled nursing facility (SNF – a facility that provides 24 hour nursing care and rehabilitative services for patients recovering from illness, injury, or surgery) for psychiatric (related to mental illness or its treatment) evaluation and treatment for verbal aggression (any behavior, often using harsh or insulting language, intended to harm another person) toward staff. During a concurrent interview and record review on 10/02/2025 at 3:47 p.m. with the Director of Patient Access (DPA), Patient 2 ’ s Conditions of Admission (COA, a document that includes provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risk and benefits]) indicated the letters ’ UTS ’ (the facility ’ s initials for Unable to Sign) and the word ’ Behavior ’ on the designated patient signature line. The DPA stated the follow-up task to obtain Patient 2 ’ s signature for the COA was handed off by Patient Access staff to psychiatric technicians (staff members trained in the treatment of psychiatric patients) in the Behavioral Health Unit (a specialized facility that provides treatment and support for individuals experiencing mental health conditions) where Patient 2 was admitted. DPA stated the facility ’ s consent policy does not direct Patient Access staff to assign to another person the responsibility to obtain a COA signature. The DPA stated the incorrect assumption that Patient 2 was under a conservatorship (a court order where a judge appoints a person to manage the financial, medical, or personal affairs of another adult who is unable to care for themselves) upon admission was corrected to reflect patient was not under conservatorship, but in follow-up Patient Access staff did not attempt to obtain Patient 2 ’ s COA signature. During the same interview on 10/02/2025 at 4:30 p.m. the DPA indicated, “We dropped the ball on getting follow-up for the COAs and giving patients the Patient Rights and Important Message from Medicare (IMM – a notice given to the patient with Medicare benefits indicating the patient ’ s rights to a hospital discharge appeal) information. If a patient doesn ’ t have a COA signed properly, we can ’ t guarantee the right decisions are being made by the patient or their designated person.” During a review on the facility ’ s policy and procedure (P&P) titled, “Consent Form Requirements,” last reviewed 4/2022, indicated: “Patient Access will make a reasonable effort to contact a family member, legal guardian, dual power of attorney, conservator, domestic partner, or public guardian in the event a patient lacks the capacity to make healthcare decisions, upon admission.” “Basic Consent Form Packet: These forms are provided to all patients. (a) Conditions of Admission (COA): Lists the terms and conditions to being admitted to the hospital ... and (d) Patient Rights: Lists all patient rights (handout only).” “Situational Medicare Forms: These Medicare forms are provided to Medicare patients as appropriate. (a) Important Message from Medicare (IMM): The IMM is given to all Medicare patients at the time or (sic) registration, regardless of medical service.” Signature Follow-Up Process: In the event the consent forms could not be signed at the time of admission, Patient Access will properly document the reason on the COA in the provided space, make a note the registration system, and then fill out the Signature Follow Up log. Over the following two days (usually completed by the Patient Access morning staff) Patient Access will make one additional attempt each day to obtain the signatures from the patient or legal representative.” C. During a review of Patient 20 ’ s Face Sheet (front page of the chart that contains a summary of basic information about the resident), dated 8/16/2025, indicated Patient 20 was admitted on 8/16/2025, the emergency contact person is listed as Patient 20 ’ s son. The face sheet indicated Patient 20 was admitted to the facility for coffee ground emesis (forceful ejection of stomach contents through the mouth). During an interview on 10/02/2025 at 4:30 p.m. with the Director of Patient Access (DPA), the DPA indicated, “We dropped the ball on getting follow-up for the Conditions of Admission (COA, a document that includes provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risk and benefits]) and giving patients the Patient Rights and Important Message from Medicare (IMM – a notice given to the patient with Medicare benefits indicating the patient ’ s rights to a hospital discharge appeal) information. If a patient doesn ’ t have a COA signed properly, we cannot guarantee the right decisions are being made by the patient or their designated person.” During a concurrent interview and record review on 10/02/2025 at 5:15 p.m. with the Director of Patient Access (DPA), the DPA verified Patient 20 ’ s COA indicated the letters ’ UTS ’ (the facility ’ s initials for Unable to Sign) and Patient (Patient 20) unable to sign because patient is non-verbal. The DPA indicated in this situation that the Patient Staff (admitting department staff who are responsible for obtaining COA signatures, providing Patient Rights literature) won ’ t try to obtain a signature the following day since a non-verbal patient is usually not able to sign a COA the next day either, so the must follow-up with next of kin. The DPA stated documentation for follow-up was not entered into the facility ’ s signature system for follow-up. The DPA stated Patient Staff did not attempt to contact Patient 20 ’ s son to obtain a telephone authorization for the COA form. During a review of the facility ’ s policy and procedure (P&P) titled, “Consent Form Requirements,” dated 4/2022, the P&P indicated, “Notification of the Legal Representative: Patient Access will make a reasonable effort to contact a family member, legal guardian, dual power of attorney, conservator, domestic partner, or public guardian in the event a patient lacks the capacity to make healthcare decisions, upon admission ...Basic Consent Form Packet: These forms are provided to all patients. (a) Conditions of Admission (COA): Lists the terms and conditions to being admitted to the hospital ... and (d) Patient Rights: Lists all patient rights (handout only) ...Signature Follow-Up Process: In the event the consent forms could not be signed at the time of admission, Patient Access will properly document the reason on the COA in the provided space, make a note the registration system, and then fill out the Signature Follow Up log. Over the following two days (usually completed by the Patient Access morning staff) Patient Access will make one additional attempt each day to obtain the signatures from the patient or legal representative...” D. During a review of Patient 32 ’ s Face Sheet (front page of the chart that contains a summary of basic information about the resident), dated 7/24/2025, indicated Patient 32 was admitted on 7/24/2025, does not have an emergency contact. During a review of Patient 32 ’ s “History and Physical (H&P),” dated 7/24/2025, indicated Patient 32 was admitted for decreased oral intake. During a concurrent interview and record review on 10/2/2025 at 9:43 a.m. with Registered Nurse 2 (RN 2), Patient 32 ’ s Conditions of Admission (COA, a document that includes provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risk and benefits]) indicated the letters ’ UTS ’ (unable to sign) on the designated patient signature line. RN 2 stated that Patient Access staff were responsible to have COA consent form signed. RN 2 added that she was not sure what “UTS” means, but in the event when patient lack capacity or was unable to sign consent forms due to medical condition, Patient Access staff (admitting department staff who are responsible for obtaining COA signatures, providing Patient Rights literature, and obtaining IMM signature) should make attempt to reach out to patients ’ legal representative or next of kin. There was no documentation in patients 32 records that attempt was made by Patient Access staff to reach out to patients ’ legal representative or next of kin. During a review of the facility ’ s policy and procedure (P&P) titled, “Consent Form Requirements,” dated 4/2022, the P&P indicated, “Notification of the Legal Representative: Patient Access will make a reasonable effort to contact a family member, legal guardian, dual power of attorney, conservator, domestic partner, or public guardian in the event a patient lacks the capacity to make healthcare decisions, upon admission ...Basic Consent Form Packet: These forms are provided to all patients. (a) Conditions of Admission (COA): Lists the terms and conditions to being admitted to the hospital ... and (d) Patient Rights: Lists all patient rights (handout only) ...Signature Follow-Up Process: In the event the consent forms could not be signed at the time of admission, Patient Access will properly document the reason on the COA in the provided space, make a note the registration system, and then fill out the Signature Follow Up log. Over the following two days (usually completed by the Patient Access morning staff) Patient Access will make one additional attempt each day to obtain the signatures from the patient or legal representative...” E. During a review of Patient 33 ’ s Face Sheet, dated 7/23/2025, the Face Sheet indicated Patient 33 was admitted on 7/23/2025, Patient sister as emergency contact. During a review of Patient 33 ’ s “History and Physical (H&P),” dated 7/24/2025, indicated Patient 33 presented to the emergency department for noncompliant and aggressive behavior. Patient was being admitted for psychiatric evaluation. During a concurrent interview and record review on 10/2/2025 at 2:02 p.m. with Registered Nurse 2 (RN 2), Patient 33 ’ s Conditions of Admission (COA, a document that includes provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risk and benefits] indicated the letters ’ UTS ’ (unable to sign) on the designated patient signature line. RN 2 stated there was no documentation in Patients 33 records that attempt was made by Patient Access staff to reach out to patients ’ legal representative (person authorized to act on behalf of that person) or next of kin. A review of the Policy and Procedure titled “Consent Form Requirements”, with last review date of 06/2025, the document indicates the following: Procedure/ Purpose: It is the responsibility of Patient Access to complete the required consent forms with the patient, or the patient’s legal representative. Patient Access must explain each fo1m in a capacity in which the patient understands. The patient must then sign and date the consent forms. Patient Access will act as a witness to the signatures and document this in legible writing in the provided spaces. Copies of all appropriate consent forms will be provided to the patient and/or representative. Notification of the Legal Representative: Patient Access will make a reasonable effort to contact a family member, legal guardian, dual power of attorney, conservator, domestic partner, or public guardian in the event a patient lacks the capacity to make healthcare decisions, upon admission. Signature Follow-Up Process: In the event the consent forms could not be signed at the time of admission, Patient Access will properly document the reason on the COA in the provided space, make a note the registration system, and then fill out the Signature Follow Up log. Over the following two days (usually completed by the Patient Access morning staff) Patient Access will make one additional attempt each day to obtain the signatures from the patient or legal representative.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 45774 Based on interviews and record review, the facility failed to return patient ’ s personal cellular phone to one of three sampled patients (Patient 38) as per facility ’ s policy and procedure. This deficient practice resulted in Patient 38 being discharged from the facility without Patient 38 ’ s personal cellular phone. Findings: During an interview with Family Member 1 (FM1) on 9/29/2025 at 8:56 a.m., FM1 stated Patient 38 ’ s phone has not been found. The phone was “pinged”(a way to locate a phone) and its location indicated it was at the General Acute Care Hospital (GACH 1). During a review of Patient 38 ’ s, “History and Physical” (H&P-documentation of patient ’ s medical history)”, dated 10/23/2025 at 4:39 p.m., indicated, Patient admitted for evaluation for abnormal labs and increased confusion (mental state of not thinking clearly). During a review of Patient 38 ’ s “Belongings List “dated 10/23/ 2025 at 3:54 a.m., indicated Registered Nurse (RN21 ’ s) documented that, “Patient 38 is in possession of belongings including Patient 38 ’ s Cellular Phone.” During a review of Patient 38 ’ s “Nursing Narrative Note”, dated 10/23/2025 at 9:08 a.m. indicated, Registered Nurse 22 (RN22) documented, “checked patient ’ s belonging twice. Patient stated that he had a phone with him and the belonging list by Emergency Room Registered Nurse (EDRN) indicated patient had a phone, but NO PHONE was found in patient ’ s belonging after patient got to the floor (specific area of the hospital where patients receive care). A follow up with Emergency Room Registered Nurse (EDRN) and no phone was found in the ER (Emergency Room) after patient left. During a review of Patient 38 ’ s “Nursing Narrative Note” dated10/23/2025 at 9:29a.m. indicated, Registered Nurse 24 (RN24) documented “Spoke with Emergency Room charge nurse, patients phone missing when transferred to another room. No phone is found with security.” During an interview with Senior Director of Quality and Risk (SDQR) on 10/2/2025 at 11:30 a.m. stated, “We did not find this patient ’ s cell phone after following up with all parts of the facility including the documented departments within the medical record. Including security department, emergency department, and the telemetry unit.” During a review of the facility ’ s policy and procedure (P&P) titled “Care of Patient Belongings and Valuables”, dated 6/2022, indicated, D. Transfer Process i. Nurse Responsibility a. Re-inventory patient belongings to update the original Patient Property List to reflect the patient ’ s current belongings. E. Discharge and Expired Patient Process i. Nurse Responsibility a. At time of discharge or death, review the Patient Property List to ensure all listed belongings are present to be returned to the patient or patient next of kin.””

“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: 45774 Based on observation, interview, and record review, the facility failed to ensure its nursing staff protected one of 44 sampled patients (Patient 14) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury) when nursing staff failed to provide an appropriate response to a patient (Patient 14) that provoked staff in accordance with the facility ’ s policy and procedure regarding patient rights (a set of legal and ethical principles that protect and empower patients in healthcare settings and ensure that patients receive safe, quality care while respecting their autonomy and dignity). This failure resulted in Patient 14 eloping (escaping) from the facility and had the potential for Patient 14 to sustain possible injuries with unknown severities due to physical violence inflicted by facility staff members. On 10/1/2025 at 3:28 PM, the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Executive Officer (CEO), the Director of Quality (DQ), an administrator (Admin), the Manager of Quality (MQ), the Risk Management Specialist (RMS), the Associate Chief Nursing officer (ACNO), and the Associate Administrator (AA). The facility failed to ensure Patient 14 was free from physical abuse while at the facility. This deficient practice resulted in Patient 14 being involved in a physical altercation with a facility staff member that resulted in a violation of Patient 14 ’ s rights, which may have resulted in injuries of unknown severity. Patient 14 arrived in stable condition at the facility ’ s Emergency Department (ED) on 2/11/2025 with a chief complaint of left ankle (the part or joint connecting the foot with the leg) pain related to an ankle sprain (injury that occurs when tissue supporting ankle is stretched or torn) from a recent mechanical fall to the ground three days prior. Inside the ED ’ s triage room, RN 1 and Patient 14 were together. Patient 14 then left the triage room visibly frustrated. Patient 14 then walked towards the outside of the main entrance of the ED, where he was met by RN 1 and started a physical altercation with RN 1. Patient 14 first pushed RN 1, RN 1 then kicked at Patient 1 in return. RN 1 then pushed Patient 14 and kicked at Patient 1 again. Instead of walking away, RN 1 continued to engage with Patient 14 and threw multiple punches. Patient 14 eloped from facility after the physical altercation with RN 1 had ended. During a concurrent observation and interview on 9/30/2025 at 2:36 PM, with the Risk Management Specialist (RMS), video footage of the outside emergency department (ED) front doors is being observed. On 2/11/2025 at 9:35:10 PM, Patient 14, is seen exiting the waiting room walking towards ED front doors. At 9:35:25 PM, RN 1 is then seen exiting the ED front doors and meeting Patient 14, and Patient 14 pushed RN 1. At 9:36:26 PM, RN kicked at Patient 14. At 9:35:27 PM, RN 1 then proceeded to push Patient 14 back. RN 1 and Patient 14 begin to throw succeeding punches at each other until RN 1 is held back by other facility staff at 9:35:41 PM. Security Guard 1 was observed to be attempting to break up fight initially at the beginning of the altercation between RN 1 and Patient 14, but did not intervene during the altercation. The RMS stated that the video footage time stamp was “a little off” from actual time of event. On 10/2/2025 at 3:38 PM, the IJ was removed in the presence of ACNO, the Admin, the QM, the CEO, the DQ, and the RMS. The elements of the IJ Removal (interventions to correct the deficient practice) were verified and confirmed by the survey team while onsite through observation, interview and record review. The IJ Removal Plan indicated: Immediate Corrective Action: On January 24, 2025, the Nursing Supervisor rounding log was updated to include the time of rounds and the names of both the Emergency Department Charge Nurse and the Security Officer present. The ACNO provided written instructions to all Nursing Supervisors that, while making rounds in the ED, they are required to directly connect with both the Charge Nurse and Security Officer. Nursing Supervisor rounding logs are reviewed monthly for compliance and reported to the Quality Council. On February 19, 2025, the Chief Nursing Officer sent communication to all department leaders in the form of an email informing them of the requirement that all hospital employees are required to obtain and maintain an annual Management of Assaultive Behavior (MAB) Certification as a condition of employment. To assist employees with meeting this requirement, the facility offered three options to obtain their certification. Company-Paid on-Site Training – Employees can take the course at SCH-Culver City. Company-Paid Off-Site Training – Employees may also take the course off-site through our education vendor FlexEd. Non-Company-Paid /Instructor of Choice. Employees will have until August 31, 2025, to meet the certification requirement, or they will be placed on an unpaid leave of absence for up to 30 days and will be subject to disciplinary actions. On October 1, 2025, the Hospital Administrator, Associate Chief Nursing Officer and Director of Quality & Risk Management reviewed the policy SMP.020 titled “Use of Force.” The policy was revised to include: The policy applies to all departments and not just high-risk locations. All hospital staff are expected to follow the following preventative measures Passive/Verbal Resistance - In the event an individual is verbally stating their intention of non-compliance, is argumentative, or being deliberately non-compliant with facility staff to ensure their safety and well-being, employees should: Allow the individual to de-escalate and calm down on their own. If not emergent, resume conversation at a later time; Provide space, backing away or place safe barriers between themselves and the individual; Attempt to de-escalate the individual, or Engage Security to de-escalate the individual and/or situation. Active Resistance – in the event an individual is using verbal threats or vulgarity, pulling away, or fleeing without an attempt to injure another: If the individual is free-to-leave the facility voluntarily, attempt de-escalation techniques. Provide clear verbal commands to the individual indicating the action they should follow. Attempts to apprehend the individual will be avoided. If the individual continues to be combative, Security may escort the individual off of the property. If an individual is not free to leave the facility, empty hand/pressure point escort, and/or clinical medication/behavioral restraints may be used. Active Physical Aggression – in the event an individual is actively exhibiting physical violence to others: Follow protocol for Code Gray response and contact Security immediately Attempt to retreat and/or back away from the physical attack for safety and continue using de-escalation techniques. Security will follow protocol to neutralize the situation If unable to defuse the situation, Security will follow proper escalation protocol, including contacting law enforcement to manage the situation further. Any patient involved in a use of force event must be assessed and treated for potential injury or condition sustained, regardless of their presenting complaint. After any use of force (e.g., restraint, hold, patient-to-patient or patient-to-staff altercation), the patient must undergo a focused assessment to identify possible injury. Document the assessment, treatment, and education in the medical record. Notify the provider for evaluation and orders as appropriate. Patients must not be discharged or transferred until any incidental conditions are addressed. Notify the immediate supervisor (e.g., manager or director) Complete an incident report on the incident reporting system. On October 1, 2025, the Director of Emergency Services initiated education to emergency department staff on the revised Use of Force Policy. The education was initiated on the day shift, continued on the oncoming shift and will be ongoing on every shift until 100% education is completed for all active staff. On October 1, 2025, the Security Manager initiated education to security personnel on the revised Use of Force Policy. The education was initiated on the mid shift and continued on the oncoming night shift and will be ongoing until 100% of active security staff are trained. On October 1, 2025, the Associate Chief Nursing Officer initiated education to nursing supervisors on the day shift and continued on the incoming night shift. The training will be ongoing until 100% of Nursing Supervisors are educated on the revised Use of Force Policy. Subsequent Corrective Actions: On September 9, 2025, the Hospital Administrator sent an email to the leadership team regarding extension of the MAB completion deadline to October 31, 2025. Current compliance for ED staff and Security staff is 100%. All other hospital staff in non-risk departments is 91.8%. On October 1, 2025, the ACNO, Hospital Administrator and Director of Quality &Risk Management created an educational tool that addresses: Proper use of de-escalation techniques and verbal interventions Immediate activation of Security and Code Gray procedures when needed Required assessment of patients following any use-of-force event or altercation Documentation of assessment, treatment, and patient education in the medical record Notification of provider and supervisor for evaluation and follow-up Completion of an incident report in the reporting system Education was initiated on October 1, 2025, and will continue until all ED, security & house supervisors staff members have obtained the education. Staff members that are on a leave of absence will be required to complete the training within the first two shifts upon returning to work. On October 2, 2025, the Hospital Administrator, Associate Chief Nursing Officer, and Director of Quality & Risk Management reviewed Policy SMP.019, “Workplace Violence Prevention Plan.” The policy was revised to strengthen post-incident response procedures to ensure timely assessment and care of any individual who sustains an injury. Integration of abuse/harassment prevention and proper incident reporting into the hospital ’ s annual skills fair for the emergency room. On October 2, 2025, a post test was created to use at annual skills day for emergency room staff & security. Date of Completion: October 31, 2025 Monitoring for Compliance: The ACNO will audit the Nursing Supervisor Rounding Log on a weekly basis to ensure compliance. The data from this audit will be provided to the Quality Council, Medical Executive Committee (MEC) and Governing Board Monthly. Audits will be reported until 100% compliance is demonstrated for 3 consecutive months. The Security Manager will monitor the security roster and ensure that every security guard has received education on the October 1, 2025, Revised Use of Force policy. The Emergency Room Director will monitor the emergency department staff roster and ensure that every employee has received education on the October 1, 2025, Revised Use of Force policy. The ACNO or designee and the Security Manager will audit education compliance of the Emergency Department & Security staff, and a monthly report will be submitted to the Quality Council, MEC and Governing Board until 100% compliance has been achieved (excluding staff on LOA). The hospital administrator is scheduled to report MAB compliance percentages to the Medicine Executive Committee on October 21.2025 and the Governing Board to follow. On October 1, 2025, the Director of Quality & Risk Management established a process for all use-of-force event incidents to be reviewed at the monthly Patient Safety Committee. Each event will be discussed to identify system improvements, reinforce policy compliance, and determine if additional staff education or corrective actions are needed. Person Responsible: Chief Nursing Officer Findings: During a review of Patient 14 ’ s note titled, “EDMD General, Adult,” dated 2/11/2025, the note indicated, Patient 14 was seen in the emergency department (ED) on 2/11/2025 for left ankle (the part or joint connecting the foot with the leg) pain related to an ankle sprain (injury that occurs when tissue supporting ankle is stretched or torn) from a recent mechanical fall to the ground three days prior. Patient 14 had a past medical history of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar affective disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and asthma (long term lung condition that makes it difficult to breathe). The note also indicated, Patient 14 heard voices, struck a triage (the process of quickly evaluating and categorizing patients in an ED to determine the priority of their treatment) registered nurse (RN), then eloped from the facility. During an interview on 9/26/2025 at 8:33 AM with RN 1, RN 1 stated, on 2/11/2025, he was in the triage room with Patient 14 while trying to discharge him. RN 1 stated, Patient 14 told him he (Patient 14) wanted to be held with a 5150 hold (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves]) because he (Patient 14) was hearing voices. RN 1 stated Patient 14 became violent when his (Patient 14 ’ s) request was not carried out. RN 1 stated he exited triage room while looking for the nearest security guard. RN 1 stated the closest security guard was located by the metal detector. RN 1 stated the other security guard was not in the ED since he was moved to a separate fast track (a dedicated area where patients with less urgent medical conditions receive prompt evaluation and treatment) location. RN 1 stated Patient 14 had punched him (RN 1) outside the emergency room front doors. RN 1 stated he (RN 1) pushed Patient 14 back in response. RN 1 then stated a series of punches were thrown between him and Patient 14. During a concurrent observation and interview on 9/30/2025 at 2:36 PM with the Risk Management Specialist (RMS), surveillance footage from 2/11/2025 of the outside emergency department (ED) front doors was observed. At 9:35:10 PM, Patient 14, was seen exiting the waiting room and walking towards ED front doors. At 9:35:25 PM, RN 1 was then seen exiting the ED front doors and meeting Patient 14, and Patient 14 pushed RN 1. At 9:36:26 PM, RN 1 kicked at Patient 14. At 9:35:27 PM, RN 1 then proceeded to push Patient 14 back. RN 1 and Patient 14 begin to throw succeeding punches at each other until RN 1 was held back by other facility staff at 9:35:41 PM. Security Guard 1 was observed to be attempting to break up fight initially at the beginning of the altercation between RN 1 and Patient 14, but did not intervene during the altercation. The RMS stated that the video footage time stamp was “a little off” from actual time of event. During a review of the facility ’ s document titled, “Safety/Security Event,” dated 2/11/2025, the document indicated, an anonymous user had submitted on 2/11/2025, an incident report describing the physical altercation between Patient 14 and RN 1. The document indicated, the incident described occurred on 2/11/2025 at 8:40 PM. The document indicated, Patient 14 was discharged from the ED then punched a waiting room window and walked out. RN 1 exited the ED to tell the author that Patient 14 was not allowed back in the ED. Patient 14 became upset and “tried to swing at him [RN 1] with his fist. Patient 14 continued to pursue RN 1 and punched RN 1 in the face first. The author stated he had called a code grey (typically signals a security risk from a combative or threatening person who is unarmed but poses a danger to others). The author described how he pulled Patient 14 off of RN 1 and other staff members pulled RN 1 back. The author also indicated other staff members “ran the guy of the parking lot and took him of[f] the property[,] he tried to come back twice.” During a review the facility ’ s document titled, “Safety/Security Event,” dated 2/12/2025, indicated, RN 1 had submitted on 2/12/2025, an incident report describing the physical altercation between Patient 14 and RN 1. The document indicated, the incident described occurred on that occurred on 2/11/2025 at 9:30 PM. The document indicated , Patient 14 had asked for a 5150 hold, but RN 1 had explained he could not do 5150 hold, Patient 14 became agitated and took off his jacket and ripped his paperwork and opened the door [of triage room]. The document indicated, Patient 14 had elbowed RN 1 ’ s abdomen, so RN 1 attempted to close the [triage] door. The document indicated, RN 1 left the triage room to notify the security guard about the situation. The document indicated, RN 1 was followed outside by Patient 14 and assaulted by Patient 14. The document indicated, RN 1 was assaulted on the forehead, back of his head and behind his left ear. During a review of the facility ’ s event log, dated 2/11/2025, the event log indicated on 2/11/2025, one code grey was called at 8:34 PM. During an interview on 10/1/2025, at 2:40 PM, with Security Guard 1 (SG 1), SG 1 stated, he recalled the incident that occurred on 2/11/2025. SG 1 stated, he was working the front metal detector post at the time when he heard a loud bang and Patient 14 yelling. SG 1 stated he was walking Patient 14 out when RN 1 walked out of the ED front doors and yelled that he did not want Patient 14 allowed back into the ED. SG 1 stated, Patient 14 tried to swing at RN 1, so he called for assistance on his walkie talkie. SG 1 stated, “they started going at it.” SG 1 stated, he had unsuccessfully attempted to come between Patient 14 and RN 1 to break up the fight. SG 1 stated other staff members helped to break up the physical altercation between RN 1 and Patient 14. SG 1 could not confirm the accuracy of the time stamp on the video footage. SG 1 confirmed he had submitted his incident report immediately after the event occurred as Anonymous at 8:40 PM that same day on 2/11/2025. Regarding the time stamp present on surveillance footage, SG 1 stated he was not aware of the time being incorrect, but stated it could be due to daylight ’ s savings, but could not confirm. SG 1 stated that during the altercation, there was another security guard present but not located inside the ED since he was moved to the separate fast track area to keep watch of the patients there. During a record review of RN 1 ’ s suspension letter, the letter indicated, on 2/12/2025, RN 1 was suspended “pending completion of an investigation into concerns around possible misconduct.” During a concurrent interview and record review, on 10/1/2025, at 2:36 PM, with the Risk Management Specialist (RMS), RN 1 ’ s termination letter titled “Separation of Employment,” dated 3/13/2025 was reviewed. The letter indicated, RN 1 ’ s employment with the facility was terminated due to “failure to adhere to company policies and procedures, specifically the appropriate de-escalation of a situation involving a patient and the use of excessive force against that patient.” The RMS stated, RN 1 should have walked away and not continued to engage in physical violence with Patient 14. During a review of the facility ’ s policy and procedure (P&P) titled, “Workplace Violence Prevention Plan 2025,” dated 5/2025, the P&P indicated, the purpose of the Workplace Violence and Prevention Plan is “To protect the safety and health of our employees, medical staff, business partners, patients and visitors from aggressive and violent behaviors.” During a review of the facility ’ s document titled, “Workplace Guidelines,” undated, the document indicated, “Employees refrain from behavior that is considered rude or offensive to others. . . Behavior that puts the safety of our patients/members, customers, employees, or visitors in danger is not allowed. . . examples of unacceptable conduct and performance. . . Fighting or provoking a fight on Company time or property.” During a review of the facility ’ s P&P titled, “Patient Rights and Responsibilities”, dated 3/2023, the P&P indicated, the patient has the right to be free from all forms of abuse and harassment.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 45774 Based on interviews and record review, the facility ’ s Quality Assurance Performance Improvement (QAPI, a healthcare system to maintain and improve the quality of care, safety, and quality of life for patients on an ongoing basis) Committee failed to take actions on preventative measures for performance improvement to manage assaultive behavior in the emergency department (ED, a medical facility that provides immediate medical care to persons with urgent or life-threatening conditions) for one of 44 sampled patients (Patient 14) when another incident of facility staff assaulting a patient occurred after it was already identified in the past. This deficient practice resulted in a repeated physical violence inflicted by a facility staff member Patient 14 and caused Patient 14 to elope (to run away) with unknown injuries. Findings: During a review of Patient 14 ’ s “Physician Progress Note,” dated 2/11/2025, Patient 14 ’ s progress note indicated, Patient 14 was seen in the Emergency Department ( ED) on 2/11/2025 for left ankle (the body part connecting the foot with the leg) sprain (an injury to the ligaments around a joint) from a recent fall three days prior. Patient 14 had a past medical history of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar affective disorder (a mental health condition that causes extreme mood swings). The progress note further indicated that Patient 14 heard voices, struck a triage nurse (a nurse that assesses patients to determine the severity and urgency of their medical condition), then eloped. During an interview on 9/26/2025 at 8:33 a.m. with Registered Nurse 1 (RN 1), RN 1 stated, during an attempt to discharge Patient 14, Patient 14 requested to be held on a 5150 hold (a law that allows an adult who is experiencing a mental health crisis to be involuntarily detained for 72 hours when evaluated to be a danger to others, themselves, or gravely disabled) due to hearing voices. RN 1 stated that Patient 14 became violent when Patient 14 ’ s request was not carried out. RN 1 reported exiting the triage room while looking for the nearest security guard (SG). RN 1 stated the closest Security Guard (SG) was located near the metal detector. RN 1 reported being punched by Patient 14. RN 1 acknowledged pushing Patient 14 in response. RN 1 then stated a series of punches were exchanged with Patient 14. During a concurrent observation on 9/30/2025 at 2:36 p.m., with the Risk Management Specialist (RMS), the facility ’ s surveillance footage of the ED on 2/11/2025 was observed. At 9:35:10 p.m., Patient 14, was seen exiting the waiting room and walking towards the ED ’ s front doors. At 9:35:25 p.m., RN 1 was then seen exiting the ED ’ s front doors simultaneously encountering Patient 14. Patient 14 pushed RN 1. At 9:36:26 PM, RN 1 responded by kicking at Patient 14. At 9:35:27 p.m., RN 1 proceeded to push Patient 14 back. RN 1 and Patient 14 then began throwing succeeding punches at each other until RN 1 was held back by other facility staff at 9:35:41 p.m. SG 1 was observed attempting to break up the fight but stepped back to avoid being hit as the fight escalated. During a review of the facility ’ s adverse event reporting document titled, “Safety/Security Event,” dated 2/11/2025, the anonymous adverse event report described the physical altercation between Patient 14 and RN 1. The report indicated that the physical altercation occurred on 2/11/2025 at 8:40 p.m. The report further indicated that following discharge, Patient 14 punched a waiting room window and walked out. RN 1 then exited the ED to notify the SG of Patient 14 ’ s behavior and to not allow Patient 14 to return back inside the ED. Patient 14 became upset and “tried to swing” at RN 1 with a fist. Patient 14 continued to pursue RN 1 and punched RN 1 in the face. A code grey (an alerting system that signals a security risk from a combative or threatening person who is unarmed but poses a danger to others) was called. The report described Patient 14 being pulled off RN 1 while other staff members pulled RN 1 away. The report further indicated that staff members “ran” (chased) Patient 14 out of the parking lot and away from the property. Patient 14 attempted to return twice. During a review the facility ’ s adverse event reporting document titled, “Safety/Security Event,” dated 2/12/2025, the event report indicated there was physical altercation between Patient 14 and RN 1. The report indicated that the physical altercation occurred on 2/11/2025 at 9:30 p.m. The report stated that Patient 14 asked to be placed on a 5150 hold, but RN 1 explained to Patient 14 that the facility ’ s behavioral unit was voluntary (done by choice) and does not have behavioral holds; as holds (5150) require an involuntary (not done willingly) status which was not offered at the facility. Patient 14 was noted to be agitated and observed ripping the facility provided documents. Per the report, Patient 14 elbowed RN 1 in the abdomen, resulting in RN 1 attempting to close the triage door. The report further indicated that RN 1 left the triage room to notify the SG about Patient 14 ’ s disruptive behavior. RN 1 was then followed outside by Patient 14 and assaulted. The report indicated that RN 1 was assaulted on the forehead, back of the head and behind the left ear. During a review of the facility ’ s “Adverse Event Log”, dated 2/11/2025, the event log indicated that on 2/11/2025, a code grey was initiated at 8:34 p.m. During an interview on 10/1/2025 at 2:40 PM, with SG 1, SG 1 reported working the front metal detector post, when a loud bang and yelling was heard. SG 1 reported assessing the cause of the noise and encountered Patient 14 visibly upset. Shortly after, RN 1 walked out of the ED and yelled that Patient 14 was not allowed back into the ED. SG 1 then stated that Patient 14 tried to swing (hit) at RN 1. SG 1 stated that assistance was called via the facility ’ s walkie talkie (a handheld, portable radio that allows people to talk and listen to each other over short distances). SG 1 stated that, “they (Patient 14 and RN 1) started going at it.” SG 1 reported attempting to come between Patient 14 and RN 1 to break up the fight as other staff members assisted. SG 1 reported filing an incident report immediately following the event, anonymously at 8:40 p.m. on 2/11/2025. During a review of RN 1 ’ s “Suspension Letter”, the letter served as RN 1 ’ s notification of suspension, “pending completion of an investigation into concerns around possible misconduct.” During a concurrent interview and record review, on 10/1/2025, at 2:36 PM, with the Risk Management Specialist (RMS), the RMS stated that RN 1 ’ s employment with the facility was terminated (the end of something) due to “failure to adhere to company policies and procedures, specifically the appropriate de-escalation of a situation involving a patient and the use of excessive force against that patient”, as indicated in the “Termination Letter”, dated 3/13/2025 that was given to RN 1. The RMS stated that RN 1 should have walked away and not continue to engage in physical violence with Patient 14. During an interview on 10/2/2025 at 4:24 p.m., with the Director of Quality (DQ), the DQ stated that the QAPI Committee met monthly, on the fourth Tuesday of each month, except for August and December (“dark months”, no meetings). DQ stated the committee consisted of all department leaders and the chief executive officer (CEO), the chief nursing officer (CNO), the assistant chief nursing officer (ACNO), and the administrators (clinical and non-clinical, i.e. human resource, biomedical, purchasing, etc.). DQ reported currently working on sepsis (a life-threatening condition that occurs when the body ’ s immune system overreacts to an infection) recognition, screening, and indicators. DQ reported also working on falls and radiology (a medical specialty that uses images [i.e. x-ray, ultrasound, etc.] to diagnose and monitor diseases and injuries) turnaround times for performing diagnostic test (a medical procedure used to identify or confirm an illness, condition, or injury), dictating (the process of transcribing spoken text) results and misreads (to read, understand, or misinterpret something incorrectly). DQ stated that QAPI data gathered for discussion and/or improvement was based on incident reports, grievances (a formal complaint), survey (an unannounced inspection) findings, patient/staff feedback, core measures (a set of national standards for quality care based on scientific evidence that aim to improve patient outcomes for common conditions), and national benchmarks (a standard point used to measure and compare performance, quality, or outcomes). DQ further stated that every deficiency (insufficiency in performance, quality, or care of something that is needed or expected) was reported to the facility ’ s governing body (GB, a group of people who formulate the policy and direct the affairs of an institution) monthly. DQ stated the altercation between Patient 14 and RN 1 was reported to GB as the facility recently received a deficiency for a separate altercation, similar in nature. Per DQ, the facility received an “immediate jeopardy (IJ, a finding by health inspectors that a healthcare facility ’ s failures have caused, or are highly likely to cause, serious injury, harm, impairment, or death to a patient)” physical assualt deficiency between staff and patient before this incident with RN 1 and Patient 14 and had to develop a plan of correction (POC, a formal, written document where an organization outlines steps it will take to fix problems or deficiencies found during an inspection or survey) to remove the IJ. DQ stated the facility staff continued to work on the required “Management of Assaultive Behavior (MAB)” training outlined in the POC. DQ reported that the current altercation was a repeat offense for the facility but not one of the top three topics discussed in the facility ’ s monthly QAPI meetings. DQ further elaborated that “everything” was reported to GB. Per DQ, a summary of problematic issues as well as met goals were presented to GB. DQ was not able to state any topics related to the current and previous physical altercation that were discussed in the QAPI meetings except for the required training completion percentage. There was no mention of preventative measures (an action or step taken to stop an undesirable event or problem from happening). The DQ stated the physical altercations which occurred in the facility ’ s ED was of high importance and concern. DQ further stated the initial altercation should not have occurred the first time, but most definitely should not have been repeated. DQ stated that the facility implemented corrective actions, but based on the incident occurring again, it was understandable that it may had appeared that the corrective actions were not effective and perhaps adjustments and/or follow-up analysis outside of training should have been implemented or discussed; however, there were no changes to the plan of correction (POC) following the occurrence between RN 1 and Patient 14. During a review of the facility ’ s “Quality Assessment & Performance Improvement (QAPI) Minutes”, dated 1/28/25 through 9/23/25, there was no documentation of preventative, corrective, update (follow-up), or specific complaint/survey finding (associated with the current or previous physical altercation that occurred in the facility ’ s Emergency Department) topics, except for the required MAB training compliance that began 3/25/25. During a review of the facility ’ s policy and procedures (P&P), titled “Performance Improvement Plan (Version #2)”, dated 12/2024, indicated that the purpose of the plan was to provide a culture where care is delivered in a safe environment and quality car is measured, monitored, and continuously improved. The P&P indicated that the organization ’ s scope (space or opportunity for action or thought) should be measured, assessed, and improved as prioritized by the leaders of the hospital, the GB, and the Quality (QAPI) Council. The P&P further indicated that prioritization of performance improvement initiatives would be initiated by the Quality Council for approval at the GB based on the following criteria: Patient safety Low/high volume of occurrence(s) High risk Problem prone occurrence(s) Regulatory or accreditation implications Competency of staff and training needs The P&P further indicated that the organization requires an intense analysis of undesirable patterns or trends in performance when the following is identified which includes but was not limited to: When a sentinel event (a serious, unexpected occurrence in healthcare that results in death, permanent harm, or severe temporary harm to a patient) or serious safety event occurs, a root cause analysis (RCA, a problem-solving method for identifying the fundamental reasons a problem or even occurred) is completed. The RCA is overseen by Risk Management (a group that identify, analyze, and control potential issues [risks] that could negatively impact an organization ’ s objectives). The corrective action may be shared with the Quality Council as appropriate for follow-up. The P&P indicated that all meetings would have minutes that are reflective of the issue, discussion, and action ad follow-up if required. The P&P indicated that the responsibility of the Quality Council was to assure that the principles of performance improvement are utilized throughout the organization. A summary of activities are reported at least four times a year to the GB. The Quality Council: 1. Establishes the performance improvement methodology and prioritized performance activities. 2. Provides information and ongoing communication to the GB and hospital leaders. 3. Reviews, analyzes, and acts upon all regulatory agencies mandated required measures. 4. Oversee and approve information received from other committees, and ensure this information is communicated to GB.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 45774 Based on interviews and record review, the facility failed to report a sentinel/adverse event (a serious, unexpected occurrence involving death or serious injury, or the risk of it, that signals the need for immediate investigation) to a required regulatory organization (CDPH, California Department of Public Health) for one of 44 sampled patients (Patient 14), when a physical altercation, inflicted by a staff member (Registered Nurse 1, RN 1), occurred in the emergency department (ED) between RN 1 and Patient 14. This deficient practice resulted in a missed opportunity to conduct a thorough investigation to ensure the facility implemented corrective actions and identified trends to prevent the likelihood of future harm, while contributing to a safer environment through quality improvement initiatives. Findings: During a review of Patient 14 ’ s “Physician Progress Note,” dated 2/11/2025, Patient 14 ’ s progress note indicated, Patient 14 was seen in the Emergency Department (ED) on 2/11/2025 for left ankle (the body part connecting the foot with the leg) sprain (an injury to the ligaments around a joint) from a recent fall three days prior. Patient 14 had a past medical history of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar affective disorder (a mental health condition that causes extreme mood swings). The progress note further indicated that Patient 14 heard voices, struck a triage nurse (a nurse that assesses patients to determine the severity and urgency of their medical condition), then eloped. During an interview on 9/26/2025 at 8:33 a.m. with Registered Nurse 1 (RN 1), RN 1 stated, during an attempt to discharge Patient 14, Patient 14 requested to be held on a 5150 hold (a law that allows an adult who is experiencing a mental health crisis to be involuntarily detained for 72 hours when evaluated to be a danger to others, themselves, or gravely disabled) due to hearing voices. RN 1 stated that Patient 14 became violent when this request was not carried out. RN 1 reported exiting the triage room while looking for the nearest security guard (SG). RN 1 stated the closest SG was located near the metal detector. RN 1 reported being punched by Patient 14. RN 1 acknowledged pushing Patient 14 in response. RN 1 then stated a series of punches were exchanged with Patient 14. During a concurrent observation on 9/30/2025 at 2:36 p.m., with the Risk Management Specialist (RMS), the facility ’ s surveillance footage of the ED on 2/11/2025 was observed. At 9:35:10 p.m., Patient 14, was seen exiting the waiting room and walking towards the ED ’ s front doors. At 9:35:25 p.m., RN 1 was then seen exiting the ED ’ s front doors simultaneously encountering Patient 14. Patient 14 pushed RN 1. At 9:36:26 PM, RN 1 responded by kicking at Patient 14. At 9:35:27 p.m., RN 1 proceeded to push Patient 14 back. RN 1 and Patient 14 then began throwing succeeding punches at each other until RN 1 was held back by other facility staff at 9:35:41 p.m. SG 1 was observed attempting to break up the fight but stepped back to avoid being hit as the fight escalated. During a review of the facility ’ s adverse event reporting document (incident report), titled “Safety/Security Event”, dated 2/11/2025, the anonymous incident report described the physical altercation between Patient 14 and RN 1. The report indicated that the physical altercation occurred on 2/11/2025 at 8:40 p.m. The report further indicated that following discharge, Patient 14 punched a waiting room window and walked out. RN 1 then exited the ED to notify the SG of Patient 14 ’ s behavior and to not allow Patient 14 to return back inside the ED. Patient 14 became upset and “tried to swing” at RN 1 with a fist. Patient 14 continued to pursue RN 1 and punched RN 1 in the face. A code grey (an alerting system that signals a security risk from a combative or threatening person who is unarmed but poses a danger to others) was called. The report described Patient 14 being pulled off RN 1 while other staff members pulled RN 1 away. The report further indicated that staff members “ran” (chased) Patient 14 out of the parking lot and away from the property. Patient 14 attempted to return twice. During a review the facility ’ s adverse event reporting document (incident report), titled “Safety/Security Event,” dated 2/12/2025, the incident report indicated there was physical altercation between Patient 14 and RN 1. The report indicated that the physical altercation occurred on 2/11/2025 at 9:30 p.m. The report stated that Patient 14 asked to be placed on a 5150 hold, but RN 1 explained to Patient 14 that the facility ’ s behavioral unit was voluntary (done by choice) and does not have behavioral holds; as holds (5150) require an involuntary (not done willingly) status which was not offered at the facility. Patient 14 was noted to be agitated and observed ripping the facility provided documents. Per the report, Patient 14 elbowed RN 1 in the abdomen, resulting in RN 1 attempting to close the triage door. The report further indicated that RN 1 left the triage room to notify the SG about Patient 14 ’ s disruptive behavior. RN 1 was then followed outside by Patient 14 and assaulted. The report indicated that RN 1 was assaulted on the forehead, back of the head and behind the left ear. During a review of the facility ’ s “Adverse Event Log”, dated 2/11/2025, the event log indicated that on 2/11/2025, a code grey was initiated at 8:34 p.m. During an interview on 10/1/2025 at 2:40 PM, with SG 1, SG 1 reported working the front metal detector post, when a loud bang and yelling was heard. SG 1 reported assessing the cause of the noise and encountered Patient 14 visibly upset. Shortly after, RN 1 walked out of the ED and yelled that Patient 14 was not allowed back into the ED. SG 1 then stated that Patient 14 tried to swing (hit) at RN 1. SG 1 stated that assistance was called via the facility ’ s walkie talkie (a handheld, portable radio that allows people to talk and listen to each other over short distances). SG 1 stated that, “they (Patient 14 and RN 1) started going at it.” SG 1 reported attempting to come between Patient 14 and RN 1 to break up the fight as other staff members assisted. SG 1 reported filing an incident report immediately following the event, anonymously at 8:40 p.m. on 2/11/2025. During a review of RN 1 ’ s “Suspension Letter”, the letter served as RN 1 ’ s notification of suspension, “pending completion of an investigation into concerns around possible misconduct.” During a concurrent interview and record review, on 10/1/2025, at 2:36 PM, with the Risk Management Specialist (RMS), the RMS stated that RN 1 ’ s employment with the facility was terminated (the end of something) due to “failure to adhere to company policies and procedures, specifically the appropriate de-escalation of a situation involving a patient and the use of excessive force against that patient”, as indicated in RN 1 ’ s “Termination Letter”, dated 3/13/2025. The RMS stated that RN 1 should have walked away and not continue to engage in physical violence with Patient 14. During an interview on 10/2/25 at 5:23 p.m., with the Director of Quality (DQ), the DQ stated that the physical altercation between RN 1 and Patient 14 was reported to California Department of Public Health(CDPH-an agency that oversees public health) per the facility ’ s P&P. DQ was not able to provide documentation of the reported event, but requested to reference intake (the initial information received about a complaint or facility reported event) numbers CA00946889 and CA00949766, which were previously investigated by CDPH as a state investigation. The referenced intake numbers were verified by CDPH management to be complaints reported by a non-facility staff person and not a facility reported incident (FRI, an official document filed after an adverse event occurs within a facility) as indicated by the DQ. During an interview on 10/2/25 at 5:50 p.m., with the Director of Quality (DQ), DQ was informed that the referenced intake numbers (CA00946889 and CA00949766) reported to be Facility Reported Incidents (FRIs), were confirmed to be outside complaints regarding the physical altercation that occurred on 2/11/25. CDPH records indicate that the incident was never reported by the facility. DQ stated that the occurrence should have been reported to CPDPH per the facility ’ s adverse event policy. DQ further stated that the risk of not reporting the incident to CDPH resulted in the inability to have CDPH present to assist the facility with a thorough investigation and ensure appropriate steps were put in place to prevent the incident from happening again. During a review of the facility ’ s policy & procedures (P&P, a written rule that guides an organization ’ s decisions with specific instruction on how to implement that rule), titled “Sentinel/Adverse Event Policy”, dated 2/2022, the P&P indicated that the purpose of the policy was in case that there is a serious incident which appears to be a sentinel/adverse event, the organization would act immediately to protect the patient(s), family member(s), visitor, volunteers, employees, or physicians from further injury. Per the P&P, all employees, volunteers, and physicians received information in their hospital orientation that enables them to identify when a sentinel/adverse event occurs. Upon notification of the event, the Risk Management (RM, the proactive process of identifying, analyzing, and controlling potential issues [risk] that could negatively impact an organization) Department would identify any outside regulatory agencies or formal bodies that may require notification of the event (i.e. the state agency, regulatory constituents, OSHA, etc.). The facility would comply with the reporting requirements and deadlines as set forth in Senate Bill 1301 (different laws in different legislative sessions or jurisdictions) as it relates to Sentinel/Adverse events. The Senate Bill requires hospitals to report sentinel/adverse events to CDPH five days after a hospital detects the event or if the event was an ongoing urgent or emergent threat to the welfare, health or safety of patients, personnel, or visitors, not later than 24 hours after detection. The law defines a sentinel/adverse event as: 1. Criminal events a. The death or significant injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds of a facility.”

“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: 45774 Based on interview and record review, the facility failed to develop a nursing care plan (a written action plan that documents a patient ’ s needs, risks, and goals to ensure consistent, quality care) addressing bleeding (loss of blood), glucose (a simple sugar that serves as the source of energy for the body), cardiac (relating to the heart) ,dehydration (fluid loss) and malnutrition (a lack of proper nutrition, a condition that occurs when a person does not receive or absorb enough nutrients from their diet to meet their body ’ s needs) needs for six of 44 sampled patients (Patient 20, Patient 24, Patient 27, Patient 29, Patient 31, and Patient 32). This deficient practice had the potential to result in Patient 20, Patient 24, Patient 27, Patient 29, Patient 31, and Patient 32 not receiving the right level of care and not meeting the needs for their specific identified patient health concerns. Findings: A. During a review of Patient 20 ’ s “History & (and) Physical (H&P),” dated 8/17/2025, the H&P indicated Patient 20 was admitted to the facility for coffee ground emesis (forceful ejection of stomach contents through the mouth). The H &P further indicated, Patient 20 ’ s active hospital problem list included Dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake). During a concurrent interview and record review, on 9/30/2025 at 3:05 p.m., with Registered Nurse 30 (RN 30), RN 30 verified Patient 20 ’ s Nutrition Evaluation consult, dated 8/17/2025, indicated “Reason for assessment/diagnoses: Admitting Dx: Dehydration: Acute Kidney injury [occurs when kidneys suddenly lose their ability to filter waste from the blood, developing within hours or days]).” During a concurrent interview and record review on 10/2/2025 at 10:18 a.m., with Infection Control Clinical Coordinator (ICCC), ICCC stated Patient 20 ’ s nursing care plan list was missing a plan of care for dehydration. ICCC stated the applicable dehydration care plan is titled, “Nutrition imbalance- less than body requirement” and this care plan was not listed for Patient 20. ICCC stated Patient 20 ’ s dehydration nursing care plan should have been initiated on admission because it contributed to the main reason the patient was admitted to the facility. ICCC stated that when a dehydration nursing care plan was initiated, the nurses could properly monitor Patient 20 ’ s progress, and the nurses would be able to follow a personalized care plan for the Patient 20. During a review of the facility ’ s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care,” revised on 2/2024, indicated, “C. An individualized Plan of Care is developed for each patient; each patient ’ s care plan identifies goals that: i. Reflect the patient ’ s unique needs. ii. Are realistic and measurable iii. Include a time frame for achievement, when appropriate D. Nursing referrals for interdisciplinary intervention and the nursing care plan shall be generated by the data collected during the nursing assessment (s) and clinical status. E. Each discipline shall initiate and revise the Interdisciplinary Plan of Care ...” B. During a review of Patient 24 ’ s “History & (and) Physical (H&P),” dated 9/26/2025, the H&P indicated Patient 24 was admitted to the facility for Abdominal Pain and Melena (black, tarry stools that contain blood). During a review of Patient 24 ’ s “Admission Note Nursing,” dated 9/25/2025, the record indicated Patient 24 ’ s reason for Admission included Severe Protein-Calorie Malnutrition (a condition characterized by a severe deficiency in both protein and calories). During a concurrent interview and record review, on 9/29/2025 at 4:23 p.m., with Registered Nurse 29 (RN 29), RN 29 verified Patient 24 ’ s Nutrition Evaluation consult, dated 9/26/2025, indicated “reason for assessment Severe Protein- Calorie malnutrition (less than 60% of standard weight: Hypernatremia [too much sodium and not enough water in the blood]).” During a concurrent interview and record review on 9/29/2025 at 4:23 p.m., with RN 29, RN 29 stated Patient 24 ’ s nursing care plan list was missing a plan of care for Malnutrition. RN 29 stated the applicable Malnutrition care plan is titled, “Nutrition imbalance less than body requirement” and this care plan was not listed for Patient 24. RN 29 stated Patient 24 ’ s Malnutrition nursing care plan should have been initiated on admission because it contributed to the main reason the patient was admitted to the facility. RN 29 stated when a Malnutrition nursing care plan is initiated, the nurses could monitor Patient 24 ’ s progress, and the nurses would communicate the care for the patient. During a review of the facility ’ s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care,” revised on 2/2024, indicated, “C. An individualized Plan of Care is developed for each patient; each patient ’ s care plan identifies goals that: i. Reflect the patient ’ s unique needs. ii. Are realistic and measurable iii. Include a time frame for achievement, when appropriate D. Nursing referrals for interdisciplinary intervention and the nursing care plan shall be generated by the data collected during the nursing assessment (s) and clinical status. E. Each discipline shall initiated and revise the Interdisciplinary Plan of Care ...” C. During a review of Patient 27 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem)”, dated 9/26/25 at 2:59 p.m., with the Bariatric Manager (BM), Patient 27 ’ s H&P indicated that an emergency department (ED) workup revealed atrial fibrillation (Afib, a condition where the upper chambers of the heart [atria] beat irregularly and rapidly) with rapid ventricular response (a condition where the heart ’ s lower chambers [ventricles] beat rapidly), which was converted to a normal rhythm with medication. Patient 27 was noted to have severe debilitation (serious weakening and loss of energy) and malnutrition (lack of proper nutrition). A cardiologist was consulted, and Patient 27 was placed on anticoagulants (medications that prevent the formation of blood clots) for the heart condition. During a review of Patient 27 ’ s “Medication Administration Record (MAR, a document that provides a list of all medications given to a patient by a healthcare professional)”, with Bariatric Manager ( BM), Patient 27 ’ s MAR indicated that Patient 27 received Albumin Human 25% (a protein solution that comes from human plasma that is used to increase the volume of blood in the body) via intravenous piggyback (IVPB, a method of administering medication through an IV), amiodarone (a medication used to treat and prevent serious arrhythmias [irregular heart rhythms]), digoxin (a medication used to treat heart failure and irregular heart rhythms), diltiazem (a medication used to treat high blood pressure, chest pain, and certain heart rhythm disorders), metoprolol (a medication used to treat several heart and circulatory conditions), phenylephrine infusion (a continuous drip of medication used to raise blood pressure, when a person ’ s blood pressure is dangerously low), and heparin (a medication that prevents blood from clotting). During a review of Patient 27 ’ s “Physician Orders”, with BM, Patient 27 ’ s physician orders indicated that Patient 27 was to be placed on continuous cardiac monitoring (telemetry, a procedure that continuously records the electrical activity of the heart to detect and monitor any abnormalities) During a concurrent interview and record review on 9/30/25 at 3:25 p.m., with BM, BM stated there was no care plan addressing Patient 27 ’ s risk for bleeding . BM stated that a care plan was important to identify Patient 27 ’ s personal needs and plan of care. BM stated without a care plan, Patient 27 ’ s goals, treatments, care barriers, and needs may potentially be unidentified, resulting in inadequate care and/or delay of care. This could lead to serious adverse events, worsening symptoms, and/or death. BM further stated that it was important to identify Patient 27 ’ s bleeding risk due to being on medication that may have caused the risk, and for safety precautions. D. During a review of Patient 29 ’ s “H&P”, dated 9/9/25 at 2:01 p.m., with Bariatric Manager ( BM), Patient 29 ’ s H&P indicated that Patient 29 had a past medical history of type II diabetes mellitus (DM2, a condition in which the body does not use insulin [a hormone that helps regulate blood sugar levels] effectively or does not produce enough insulin), hypertension (HTN, high blood pressure), and cellulitis (a common bacterial skin infection that causes inflammation). Patient 29 was admitted to the intensive care unit (ICU, a hospital unit for critically ill patients who require constant monitoring) for acute septic shock (a life-threatening condition that happens when a person ’ s blood pressure drops to a dangerously low level after an infection) secondary to multiple medical conditions with orders to monitor Patient 29 ’ s glucose (amount of sugar in a person bloodstream). During a review of Patient 29 ’ s “Medication Administration Record (MAR-document of medication taken by individual)”, with Bariatric Manager (BM), Patient 29 ’ s MAR indicated that Patient 29 received glucose monitoring with regular human insulin (a short-acting, man-made insulin that lowers blood sugar levels) sliding scale coverage (insulin dosage based on a patient ’ s blood sugar reading) every six hours and intravenous (IV, medications or fluids given directly into a vein) medications in a dextrose (a simple sugar, identical to glucose) solution. During a concurrent interview and record review on 10/2/25 at 10:07 a.m., with BM, BM stated there was no care plan addressing Patient 29 ’ s DM2 or glucose needs. BM stated a care plan should have been initiated to address Patient 29 ’ s DM2 as complications of DM2 may lead to other serious medical conditions (i.e. kidney failure, HTN, coma, etc.). BM further stated a plan of care is important to address Patient 29 ’ s diet needs, glucose control, barriers, knowledge of the condition, and to address Patient 29 ’ s individual DM2 associated complications. E. During a review of Patient 31 ’ s “H&P”, dated 9/28/25 at 9:07 p.m., with Bariatric Manager ( BM), Patient 31 ’ s H&P indicated that Patient 31 had a past medical history of hypertension (HTN, high blood pressure) and bilateral inguinal hernias (a bulging of contents of the abdomen through a weak area in the abdominal wall on both sides, right and left). Patient 31 denied a history of DM but had an elevated glucose workup. Patient 31 was noted to have an abnormal electrocardiogram (EKG, a test that records the electrical activity of the heart). Patient 31 was admitted for close cardiac monitoring. During a review of Patient 31 ’ s “Medication Administration Record (MAR)”, with BM, Patient 31 ’ s MAR indicated that Patient 31 received blood glucose monitoring four times daily, before meals and at bedtime. Patient 31 also received regular insulin sliding scale coverage before meals and at bedtime as needed. Patient 31 ’ s MAR further indicated that Patient 31 received metoprolol (a medication used to treat several heart and circulatory conditions) daily and clonidine (a medication used to treat high blood pressure) as needed for elevated blood pressure (BP). During a concurrent interview and record review on 10/2/25 at 12:29 p.m., with BM, BM indicated there was no care plan for Patient 31 identifying Patient 31 ’ s BP/cardiac needs or glucose. BM stated addressing Patient 31 ’ s glucose needs was important due to the lack of Patient 31 having a medical diagnosis that would indicate cause for an elevated blood sugar. BM further stated having a plan of care would assist to appropriately identify the cause of Patient 31 having an elevated blood sugar and/or identifying a new onset of a medical condition. BM went on to state that the initiation of a care plan addressing Patient 31 ’ s BP/cardiac needs was important for reasons previously mentioned, to identify Patient 31 ’ s goals, effectiveness of treatment(s), barriers, and potential complications, which may result in inadequate care and/or delay of care without a plan. F. During a review of Patient 32 ’ s “History and Physical (H&P),” dated 7/24/2025, indicated Patient 32 was sent to the emergency department for decreased oral intake. Upon work-up and evaluation, the patient was found to be very dehydrated (Dehydration, occurs when the body uses or loses more fluid than it takes in) and in renal failure (also known as kidney failure, it occurs when the kidneys lose their ability to properly filter waste products and excess fluid from the blood) and was tachycardic (heart rate of more than 100 beats per minute at rest). The Patient was aggressively hydrated with intravenous fluid (solutions administered directly into a vein to replenish fluids, electrolytes, and nutrients). During a concurrent interview and record review on 10/2/2025 at 9:50 a.m. with Registered Nurse 2 (RN 2), Patient 32 ’ s Plan of Care from 7/24/2025 – 10/2/2025, the record did not include any care plan that will address Patient 32 ’ s dehydration. RN 2 stated that the admitting nurse failed to initiate a care plan that will help address patients ’ dehydration. The correct care plan tile for dehydration is “Fluid and Electrolyte Imbalance.” Care Plan would be important because it would address the root of the problem and would also be a communication tool among the care teams of what care interventions are in place for the patient and its progress. During a review of the facility ’ s policies and procedures (P&P, guidelines dictating an organization ’ s directions on a topic and step-by-step instructions how to carry out tasks), titled “Interdisciplinary Plan of Care”, dated 3/2024, the P&P indicated: I. Purpose/Objective B. The Interdisciplinary Plan of Care shall be based upon the assessment performed by all disciplines, which describes the intentions, rationale, and interventions associated with identified issues. C. This provides for the continuum of care in meeting the needs of the patient throughout their stay. The admission data collection shall be completed within 24 hours of admission. III. Policy/Procedure C. An individualized Plan of Care is developed for each patient; each patient ’ s care plan identifies goals that: i. Reflect the patient ’ s unique needs ii. Are realistic and measurable iii. Include a time frame for achievement, when appropriate “Attachment A” of the P&P, page three of six, indicated a sub-section of the cardiovascular section of a care plan should address fluid volume deficit, ineffective tissue perfusion (inadequate blood flow to the tissues), decreased cardiac output (the heart pumps less blood than the body ’ s needs), and fluid volume excess (too much fluid in the body). The sub-section of safety identifies bleeding risk, and the sub-section of the nutrition identifies nutrition imbalanced, more or less than body requirements. Too much or too little nutrition increases the risk of developing illnesses like cardiovascular disease (a group of conditions that affect the heart and blood vessels) or DM, from a combination of factors such as consuming foods that are high in sugar and fats or reduced physical activity levels.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 45774 Based on interview and record review, the facility failed to provide complete annual skills competency (the level of performance that a nurse is expected to achieve, which combines their knowledge, skills, abilities, and judgment) and education for one of seven registered nurses (Registered Nurse [RN] 31) in accordance with the facility ’ s policy and procedure for “Competency Assessment.” This deficient practice had the potential for RN 31 to carry out nursing duties in which RN 31 may not be competent of performing, which could potentially compromise patient safety. Findings: During a concurrent interview and personnel file review on 10/2/2025 at 3:52 p.m. with the Human Resources Manager (HRM) and Director of Clinical Education (DCE), the HRM and DCE reviewed RN 31 ’ s file and stated the following: RN 31 worked in the Intensive Care Unit (provides critical care and life support to patients who are very ill) from 11/13/2023 to present. The HRM stated RN 31’s abuse (intentional maltreatment of an individual that may cause physical or psychological injury) annual competencies and restraint (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) annual competencies was not completed for the year 2024. The HRM stated the unit managers are responsible for making sure their staff has annual competencies for abuse and restraint training and education. The HRM stated the annual abuse and restraint competencies are necessary to ensure RN 31 ’ s skills are meeting the requirements and to ensure safety patient services. During a concurrent interview and review of RN 31’s personnel file with HRM and DCE, the personnel file indicated the following: RN 31 was hired on 11/13/2023. RN 31’s restraint annual competency titled, “Restraint Test,” dated 11/19/2023, the HRM stated there were no other records of further competencies. The HRM stated RN 31 was missing restraint annual training for 11/2024. During a concurrent interview and review of RN 31’s personnel file with HRM and DCE, the personnel file indicated the following: RN 31’s Abuse annual competency titled, “Abuse Reporting,” dated 11/19/2023, the HRM stated there were no other records of further competencies. The HRM stated RN 31 was missing abuse annual training for 11/2024. During a review of the facility’s policies and procedure (P&P) titled, “Competency Assessment,” dated 3/2023, the P&P indicated the following: “To assure that all patient care providers are competent to perform responsibilities in their specific areas of clinical practice ... The employee will demonstrate competence in the role-specific job description and responsibilities. Competency is part of the performance appraisal system and is assessed upon hire; transfer to a new role, prior to assignment to a new unit, when there is a change in either job performance or job requirements and thereafter on an annual basis ...””

“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: 45774 Based on observation, interview and record review, the facility failed to: 1.Document one of 30 sampled patients (Patient 8) for pain reassessment in medical record. This deficient practice had the potential result in Patient 8 ’ s pain level was not reassessed and evaluate of effectiveness of administration of pain medication in the medical record per hospital policy. 2. Ensure for one of 44 sampled patients (Patients 22)that pain assessment (pain assessment includes a pain scale uses numbers from 0 to 10, with 0 representing no pain and 10 representing the worst pain possible, location of pain, character of pain, and duration of pain) was not completed prior to pain medication administration according to the facility ’ s policies and procedures on pain management. This deficient practice had the potential to result in a delay in providing necessary treatment to address Patient 22 ’ s pain. Finding: 1. During a review of Patient 8’s “Emergency Department Medical Doctor (EDMD) note, dated 9/30/2025, the EDMD note indicated Patient 8 ’ s came to Emergency Department (ED) on 9/30/2025 due to left hand pain after piece of luggage fell on her hand while traveling. Patient 8 indicated her pain is 7 out of 10 (pain scale is a numerical scale used to assess pain intensity, where 0 indicates no pain and 10 represents the worst pain imaginable). The EDMD also indicated Patient ’ s 8 left hand swollen tender decreased range of motion. During a review of Patient 8’s physician order (the instructions a doctor gives for a patient’s treatment, care, or a specific course of action), dated 9/30/2025 at 0:10 a.m., Ibuprofen [nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, reduce fever, and decrease inflammation] 800 milligram (mg) was ordered one time as needed by mouth for moderate pain (subjective experience that doctors often rate on a pain scale of 1 to 10, with 4-6 considered moderate). During a review of Patient 8’s Medical Administration Record (MAR, legal document used by nurses and other healthcare professionals to track all medications administered to a patient) dated 9/30/2025 at 0:10 a.m., indicated Ibuprofen (pain medication)800 mg was administered to Patient 8 once time by mouth. MARS also indicated one hour post medication administered reassessment was not done. During a concurrent interview and record review on 9/30/2025 at 3:40 p.m., with Risk Management Specialist (RMS), Patient 8’s medication administration record (MAR) was reviewed and indicated pain medication Ibuprofen 800 mg was administered to Patient 8 once time by mouth was given at 9/30/2025 at 0:10 a.m.; concurrently, no pain reassessment was documented in the MAR. RMS concurred that the nurse should reassess and document the pain reassessment within 1 hour after pain medication administered. During a review of the facility’s policy and procedure (P&P) titled, pain management, last approved date 5/2025, indicated “ A reassessment of pain shall be performed on admission, every shift and on all pre/post medication administration ... the care provider renders a conclusion from the patient interaction about pain and document the conclusion. 2. During a review of Patient 22 ’ s “History & (and) Physical (H&P),” dated 9/24/2025, the H&P indicated Patient 22 was admitted to the facility with a diagnosis of Acute on Chronic Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and Intractable low back pain (severe pain in the lower back that does not respond to conventional treatments, such as rest and physical therapy). During a review of Patient 22 ’ s “Medication Administration Report (MAR)” dated 9/25/2025, the MAR indicated a physician ’ s order for Patient 22 to receive the following: - Acetaminophen (pain medication) 650 mg (mg-a unit of measurement) tablet oral (by mouth) every 6 hour as needed (PRN) for severe pain (pain score of 7-10 is severe pain) with a start day of 9/24/25. During a concurrent interview and record review, on 9/29/2025 at 4:04 p.m., with Registered Nurse (RN) 29, RN 29 verified Patient 22 ’ s corresponding pain assessment in the medical record (MR) titled, “Flowsheets -Pain Assessment,” was not completed. RN 29 verified Patient 22 ’ s MAR indicated the following medication administration: -On 9/25/2025 at 9:00 p.m. Patient 22 was administered Acetaminophen 650 mg tablet; the pain assessment was not completed. The corresponding pain assessment did not indicate the pain score, location of pain, pain descriptors, and duration of pain. During a concurrent interview and record review on 9/29/2025 at 04:04 p.m., with RN 29, RN 29 stated a complete pain assessment includes the pain score, location of pain, pain descriptors, and duration of pain. RN 29 stated a complete pain assessment was not performed by nursing care and the expectation was to document the full pain assessment prior to medication administration for Patient 22. During a review of the facility ’ s policy and procedure (P&P) titled, “Pain Management,” dated 5/2025, the P&P indicated, “All patients admitted as inpatients and presenting to the Emergency Department shall be questioned as whether or not they are experiencing pain ...C. The comprehensive assessment shall include, to the extent relevant, intensity (based on the patient ’ s statement of pain, which may range from a simple statement of pain level to a formal scale), site (s), quality (e.g. dull, sharp, throbbing, stabbing), radiation, onset (e.g. initial pain assessment may vary depending on the clinical presentation and the nature of the interaction...””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 45774 Based on observation, interview, and record review, the facility failed to adhere to their infection prevention and control program when one of seven sampled employees (Mental Health Technician 1) was observed wearing non-surgical gloves on the 4th floor Behavioral Health Unit (BHU, where patients with mental health emergencies are stabilized) overflow hallway without an indicated need for gloves to be used. This failure had the potential for Mental Health Technician 1 (MHT 1) to spread infection to patients, staff and visitors, which also increased the risk for cross-contamination of infectious materials and increased the possibility of hospital-acquired infections (HAIs) to cause harm and prolonged hospitalizations for the patients on the unit. Findings: During an observation on 9/30/2025 at 3:17 PM on the 4th floor BHU overflow, a tour of the unit was conducted with the Chief of Nursing (CNO), the Infectious Disease Director (DID), and the Behavioral Health Unit Director (BHUD). During a concurrent observation and interview on 9/30/2025 at 3:25 PM with MHT 1 on the 4th floor BHU overflow, MHT 1 was observed wearing a pair of non-sterile gloves while occupying the unit hallway. MHT 1 stated, he wore the gloves all the time because he was a “germaphobe (refers to a person with an extreme fear of germs and an obsession with cleanliness)” MHT 1 stated, he had also just finished cleaning spilled water from the floor. MHT 1 was also observed to be touching his face while still wearing the same pair of gloves. During an interview on 10/2/2025 at 10:15 AM with the Infection Control Clinical Coordinator (ICCC), the following was noted: The ICCC stated, per the facility ’ s policy, no gloves should be worn in the hallway and gloves that were worn should be disposed of after leaving a patient ’ s room. The ICCC stated wearing gloves can spread infection from one patient to another patient, and it was not appropriate to wear gloves in the hallway, even if a person was a germaphobe. The ICCC stated, the expectation was that staff did not wear gloves when they were not performing patient care. During an interview on 10/2/2025 at 10:40 AM with the DID, the DID stated that it was unacceptable for staff to wear gloves while in the hallways of the BHU, and that MHT 1 was made aware that it was an infection control risk to wear gloves in the hallway. During an interview on 10/2/2025 at 12:15 PM with the BHUD, the BHUD stated, per the facility ’ s policy and procedure, gloves should only be worn during patient contact. The BHUD stated that MHT 1 wore the gloves to clean a water spill from the floor but should have taken the gloves off right away after cleaning the water spill. During a review of the facility ’ s policy and procedure (P&P) titled, “2025 Infection Prevention and Control Plan,” dated 2/2025, the P&P indicated, “ ...V1. Priorities and Goals ... A. Priority objective ... i. Identifying and preventing healthcare-associated infections by using sound infection prevention practices such as: Hand hygiene Standard and transmission-based precautions Proper use of personal protective equipment...” During a review of the facility ’ s P&P titled, “Standard Precautions,” dated 2/2022, the P&P indicated, “ ...III. Policy/Procedure ... Personal protective equipment (PPE) ... Gloves ... For touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes and non-intact skin...””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 45774 Based on observation and interview, the facility failed to ensure for one of three sampled campuses (Campus 1) cafeteria, was kept clean and free of flies, in accordance with the facility ’ s policy regarding infection control and prevention. This deficient practice had the potential to cause disease transmission through contaminated areas and objects, which could negatively impact the patient ’ s, visitor ’ s, and staff ’ s overall health. Findings: During a concurrent observation and interview on 9/30/2025 at 11:36 a.m. with Patient Services Manager (PSM), in the cafeteria, PSM stated he (PSM) saw more than 13 flies in one of the three black trash cans located closed by the food serving counter, flies flying around the blue and green recycling containers and around the walls of the black trash can area. PSM stated the area around the black trash can looked dirty and with white and brown stains underneath. PSM stated the flies are a safety concern because they can easily spread food borne illness. During a concurrent observation and interview on 9/30/2025 at 2:06 p.m. with Cafeteria Cashier (CC), in the cafeteria, CC stated she (CC) saw a few flies in one of the three black trash cans located in the cafeteria. CC stated she (CC) was responsible for cleaning the cafeteria area, including sweeping, cleaning tables, cleaning coffee station, and the Dish Washer (DW) was responsible for cleaning the trash cans and the area around the trash cans. CC stated the flies in the cafeteria are a health concern, “because they can cause infestation, spread sickness, and flies transmit diseases.” During a concurrent interview and record review on 9/30/2025 at 2:46 p.m. with PSM, PSM stated the facility ’ s pest control (the process of managing or eliminating unwanted organisms, known as pests, to prevent harm to human health and environment) report indicated, “last serviced was on 9/11/2025 and the pest activity found: Location: Cafeteria-interior Finding: Small flies noted during service small flies noted near trash cans in cafeteria Action needed/taken: this area was inspected and serviced.” During a concurrent interview on 9/30/2025 at 3:11 p.m. with Environmental Services (EVS, department responsible for maintaining a clean working environment) Director (EVSD), EVSD stated she is aware of the flies in the cafeteria and stated the facility ’ s pest control company has a follow up visit on 10/1/2025. EVSD stated some of the responsibilities of the EVS department included removing the trash bags for the three black trash cans in the cafeteria, but it was the cafeteria staff ’ s responsibility to keep the black trash cans washed and the area around the trash cans cleaned. During a concurrent observation and interview on 9/30/2025 at 3:45 p.m. with Infectious Disease Director (DID), in the cafeteria, DID stated she (DID) saw a few flies in one of the three black trash cans and a couple of flies around the walls of the dirty trash can area. DID stated the flies are an infection control issue since flies can spread infections. DID stated the three doors of the kitchen area were open and that is an opportunity for flies to enter the food area since doors in the kitchen are open and flies can enter the area of food preparation that is a risk of pest in the food. DID stated the three doors of the kitchen area should be kept always closed. DID stated she will need to reeducate staff regarding the importance of keeping the cafeteria clean for a sanitary environment and the three doors of the kitchen closed to prevent transmission of flies in the kitchen area. During a review of the facility ’ s policy and procedure (P&P) titled, “2025 Infection Prevention and Control Plan,” dated 2/2025, the P&P indicated, “The Infection Prevention and Control Plan established by [Name of the Facility] provides a multidisciplinary and systematic approach to promoting quality patient care with emphasis on risk reduction of disease transmission in the healthcare environment. The program goal is to identify infections and reduce or eliminate the risks of acquiring and transmitting infections and communicable diseases between patients, healthcare workers, visitors, contract workers, volunteers, and students in all service locations of the facility ...10. The Infection Prevention and Control Committee (IPCC) reviews pest control reports. In addition, the Director of IPC, or qualified designee, in collaboration with facilities and dietary services personnel, will carry out bimonthly kitchen audits. Reports from audit activity will be reviewed by the IPC and EOC committees. In addition, Pest Control Committee meetings will be held as necessary. All reports from the Pest Control Committee will be presented to the IPCC ...” During a review of the facility ’ s policy and procedure (P&P) titled, “Pest Control,” dated 5/2022, the P&P indicated, “To describe the processes and procedures for Pest Control. The hospital is serviced routinely with the provision for more frequent treatments as needed. To ensure the protection of patients, visitors, and staff from all pests when evidence or suspicions arise and/or when pests are present ...3. Departments will use the pest identification matrix as reference (see Appendix A) ... Appendix A Flies Prevention- Sanitation and Proper housekeeping. Trash cans and dumpsters should have lids and cleaned frequently. Area around compactor and dumpster should be hosed daily ...” During a review of the facility ’ s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 3/2023, the P&P indicated, “To assure that regulatory guidelines are followed and patient safety maintained ...b. The patient has the right to receive care in a safe setting ...””

“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 meet the Condition of Participation for Patient Rights as evidenced by: The facility failed to ensure two of 30 sampled patients (Patients 1 and Patient 2), were free from abuse (the improper treatment of a person), when Patient 1 and Patient 2 were physically assaulted (when someone physically attacks another person causing bodily harm) by facility staff. This deficient practice resulted in EMT 1 and Security Guard 1 (SG 1) inappropriately responding by physically assaulting Patient 1 and 2 respectively after getting provoked by the patients. Also, not reporting the incident to their chain -in- command (supervisors) had the potential harm to all ED patients, visitors, and staff. (Refer to A-0145) The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 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 follow manufacturer ’ s recommendation of labeling the open and discard date of one of two sampled open glucose control solution (a liquid used to test the accuracy of blood glucose meters). This deficient practice has the potential to result in inaccurate blood glucose meter (a portable machine that’s used to measure glucose in the blood) readings. (Refer to A-395) 2. The facility failed to ensure two of seven sampled employees completed their annual mandatory abuse and restraint training and maintained current certification of management of assaultive behavior (MAB – de-escalation training). These deficient practices had the potential for the following: A. patients getting physically abused, B. patients on restraints, not monitored and/or provided less restrictive measures, C. Patients with aggressive behavior harming others. D. (Refer to A-397) 3. The facility failed to ensure one of 30 sampled patients (Patients 14) intravenous (IV) (means administering fluids, medication and nutrients directly into the veins) dressing site was documented with a date, time and initial of nurse written on dressing as per facility policy and procedure. This deficient practice had the potential to compromise Patient 14’s health and risk of infection due to dirty or compromised dressing. (Refer to A-398). 4. The facility failed to ensure fall precautions were executed for one of 30 sampled patients (Patient18). This deficient practice had the potential for Patient 18 to fall and fracture (break) bones, cause traumatic brain injury (damage caused by a blow to the head), and result in long term disabilities. (Refer to A-398). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. 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 Emergency Services was met as evidenced by: 1. The facility failed to ensure Emergency equipment, including radiant warmers (equipment used to provide immediate access and warmth to newborn infants) and born-out-of-asepsis (BOA – unplanned out of-hospital birth) kits, to stabilize newborns delivered in the ED, and were readily available. (Refer to A-1103) 2. The facility failed to ensure Diagnostic tests ordered STAT (right now), in the ED, were performed timely for one of thirty sampled patients (Patient 4). (Refer to A-1103) 3. The facility failed to ensure two of three crash carts had back boards (use as a surface to perform cardiopulmonary resuscitation (CPR) (emergency treatment done when someone breathing or heart stop) on patients in an emergency situation). (Refer to A-1103) 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 failed to ensure: 1. Emergency department (ED) staff to de-escalate and manage violent patients in accordance with facility policy and procedure of “Prevention and Management of Violence by a Patient or Visitor, Zero Tolerance” for two of 30 sampled patients (Patient 1 and 2). This deficient practice resulted in EMT 1, and Security Guard 1 responded by physically assaulting Patient 1 and 2 respectively after getting provoked by the patients in October and November 2024 in consecutive month. 2.Staff to report abuse incidents between staff and patients for two of 30 patients (Patients 1 and 2) after patient 1 and patient 2 were physically assaulted in accordance with facility policy and procedure of “Reporting of Events Via Occurrence Reporting System.” This deficient practice has the potential to put patients to further injury from the physical assault. 3.The contracted security service department abide with facility policy to assure Security Guard ’ s (SG) competency of de-escalate and managing a violent patient. And SG1 and SG2 did not report to supervisor immediately after two of 30 sampled patients (Patients 1 and 2) were physically abused by EMT 1 and SG2 respectively. This deficient practice has the potential to inflict further injury to the patients from a physical assault. Findings: 1. The Security Manager (SM) stated on 1/22/24 at 11:36 PM, that Patient 1, a 27 y/o female who presented to the Emergency Room on 10/09/24 with right shoulder pain was assaulted by Emergency Medical Technician (EMT 1). The assault happened on 10/9/24 at around 4:00 AM. Patient 1 was in the ED (Emergency Department) lobby and was verbally aggressive to staff. Security Guard 1 (SG1), Security Guard 2 (SG2), and EMT 1 was with Patient 1 to deescalate (to decrease or reduce) the situation. The Security Manager (SM) stated, Patient 1 spat at EMT1, and EMT 1 reacted by pushing security guard to the side and lunging towards Patient 1 and started punching Patient 1 ’ s head area. SG1 and SG2 pulled EMT1 off Patient 1 to stop the attack. Patient 1 left the ED and the Police was called. Police came and arrested Patient 1 outside ED. Patient 1 was arrested because she made threats to harm the facility staff. SM added that a security report was not created. It was expected that the security staff complete a written security report after any unusual occurrence. EMT1 should not have assaulted Patient 1. Staff should never put hands on a patient. The expectation from security staff was to deescalate the situation. The Director of Quality and Risk (DQR) stated on 1/23/25 at 11:00 AM that Emergency Department Manager (EDM) was onsite and aware of the incident of EMT1 physically assaulting Patient 1, and Patient 1 making threats to come back and harming staff. EDM did not notify the rest of leadership. There was a lack in notification and failing to follow chain of command. That situation should have been escalated (increase rapidly) to the House Supervisor and the Administrator on call. That way, a proper safety measure can be put in place in response to Patient 1 ’ s threats to the facility. During review of EMT1 ’ s personnel file and interview with Human Resource Manager (HRM) on 1/23/25 at 1:27 PM, Record indicated that EMT1 has not completed Management of Assaultive Behavior (MAB) training. HRM stated that MAB is required for all ED EMT and nursing personnel. 2. During an interview with Security Manager (SM) on 1/22/25 at 11:36 a.m., SM stated on 11/4/24 around 7am, at the end of night shift, he received a text message from security guard (SG1) stating that SG1 defended himself and punched Patient 2. SM stated SG1 completed his shift and did not report to any supervisor regarding the incident until he sent a text message to SM. SG1 was suspended only after finishing his shift. During the interview with SM, he stated that SG1 should never hit a patient even when he was provoked by the patient. Also, they need to report to a supervisor immediately and the supervisor can inform SM to start investigating ASAP (as, soon, as, possible) During an interview with SG2 on 1/23/25 at 9:51 am, SG 2 stated Patient 2 came into ED after midnight and patient had blood on his face and mouth. Patient 2 was lying on the floor in the waiting area. SG2 and SG1 were trying to assist patient 2 to sit back on the chair. In a short while, SG1 accompanied Patient 2 outside the ED. SG2 stated after couple minutes, he heard some noise outside, he went outside the ED entrance and saw SG1 and Patient 2 were located at the junction of ED driveway and the City Street. Patient 2 was sitting on the ground and SG1 was standing next to Patient 2. When Patient 2 tried to stand up, SG1 punched Patient 2 on his shoulder. SG2 stated he did not report what he observed to the supervisor since he was not involved in the incident. During an interview with Director of Quality and Risk (DQR) on 1/27/25 at 3:15 p.m., DQR stated the facility did conduct training to the ED staffs including ED and EMT after the 1st abuse incident that EMT 1 hit Patient 1; however, the security guards were not included in the training. Concurrently, DQR admitted that there was no reporting to chain of command immediately per facility policy regarding both abuse incidents that happened involving staffs physically assaulting the patients. A record review, titled “incident report” dated 11/6/24, indicated that an assault incident occurred at 11/4/24 at 2:10 am by SG1. Indicated that SG1 arrived in front of the ED at 2:10 am to give lunch breaks to the other staff and he saw SG2 trying to ask Patient 2 to get off the floor. SG1 saw Patient 2 face with blood and asked what happened. Patient 2 stated “someone hit me”. SG1 accompanied Patient 2 outside the ED, and Patient 2 suddenly wrapped his arm around SG1 ’ s neck; SG1 pushed Patient 2 away, then Patient 2 squared up and hit SG1 ’ s chin. SG1 fought back against Patient 2. A review of the facility ’ s policy titled, “Prevention and Management of Violence by a Patient or Visitor, Zero Tolerance ’ dated approved 11/2022 (old version), indicated that Hospital procedure if patient or visitor becomes behaviorally escalated engage in de-escalation and limit setting as is appropriate to the patient or visitor ’ s stage of escalation. If at any time a patient or visitor becomes physical threatening, staff should immediately disengage and leave the room if appropriate and notify management of the situation. In an emergency, staff should call security and call a code Gray. A review of the facility ’ s policy titled, “workplace violence prevention plan”, dated 3/2024; indicated that Southern California Hospitals encourages all workforce members to report workplace violence to the hospital in accordance with established hospital policies and to see assistance and intervention from local emergency services or law enforcement when a violent incident occurs. A review of the facility ’ s policy titled, “Medical staff chain of command” dated 6/2022, indicated that Southern California Hospital is committed to providing safe quality patient care. Any healthcare professional who identifies a potential problem with respect to patient safety and /or quality, and unable to resolve it independently, is empowered to invoke the following procedures e.g. clinical chain of command until a satisfactory resolution is achieved. A review of the facility ’ s policy titled, “Reporting of Events Via Occurrence Reporting System” dated 12/24 indicated the purpose if to improve the quality of patient care and enhance patient, visitor and staff safety and reduce the facility’s exposure to risk of financial loss ...an occurrence/event report is to be submitted through current Incident Reporting system on every occurrence/event involving a patient, visitor, physician, employee (staff or contract), or volunteer in any area or department of Southern California Hospital ... The responsibility for completing an Occurrence/Event/Risk report submission through the Occurrence Reporting System rests with any staff member (including physicians and agency/contract personnel who witnesses, discovers, or has the best knowledge of an occurrence as previously defined. 3. A record review, titled “incident report” dated 11/6/24, indicated that an assault incident occurred at 11/4/24 at 2:10 am by SG1. Indicated that SG1 arrived in front of the ED at 2:10 am to give lunch breaks to the other staff and he saw SG2 trying to ask Patient 2 to get off the floor. SG1 saw Patient 2 face with blood and asked what happened. Patient 2 stated “someone hit me”. SG1 accompanied Patient 2 outside the ED, and Patient 2 suddenly wrapped his arm around SG1 ’ s neck; SG1 pushed Patient 2 away, then Patient 2 squared up and hit SG1 ’ s chin. SG1 fought back against Patient 2. During an interview with SG2 on 1/23/25 at 9:51 am, SG 2 stated he observed SG 1 Patient 2 on his shoulder. SG2 stated he did not report what he observed to the supervisor since he was not involved in the incident. During an interview with Security Manager (SM) on 1/22/25 at 11:36 a.m., SM stated on 11/4/24, he received a text message from security guard (SG1) stating that SG1 defended himself and punched Patient 2. SM stated SG1 completed his shift and did not report to any supervisor regarding the incident until he sent a text message to SM. During the interview with SM, he stated that SG1 should never hit a patient even when he was provoked by the patient. Also, they need to report to a supervisor immediately and the supervisor can inform SM to start investigating ASAP (as, soon, as, possible) A review of the facility ’ s policy titled, “ Prevention and Management of Violence by a Patient or Visitor, Zero Tolerance” dated 11/2024, indicated any act of intimidation, aggressive or violence behavior, or threat of violence will not be tolerated and should be reported immediately to employee ’ s direct manager who will notify the House Supervisor, Security, and Administrator-On-Call as needed. And if any time a patient or visitor become physically threatening, staff should immediately disengage and leave the room.”

“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 two of 30 sampled patients (Patients 1 and Patient 2), were free from abuse (the improper treatment of a person), when Patient 1 and Patient 2 was physically assaulted (when someone physically attacks another person causing bodily harm) by facility staff. This deficient practice resulted in EMT 1 and Security Guard 1 (SG 1) inappropriately responding by physically assaulting Patient 1 and 2 respectively after getting provoked by the patients. Also, not reporting the incident to their chain -in- command (supervisors) had the potential harm to all ED patients, visitors, and staff. On 1/23/2025, at 5:36 PM, the survey team called an Immediate Jeopardy (IJ, a situation in which the facility ’ s noncompliance with one or more requirements have, caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Director of Quality and Risk (DQR), Chief Nursing Officer (CNO), Chief Executive Officer (CEO), Administrator (Admin), and Associate Chief Nursing Officer (ACNO). The facility failed to ensure two of thirty sampled patients (Patient 1 and Patient 2) were free from all forms of abuse. The facility failed to follow their policy and procedure resulted in EMT 1 and Security Guard 1 inappropriately responding by physically assaulting Patient 1 and 2 respectively after getting provoked by the patients. The facility did not follow their policy and procedure in dealing with the physical assault which happened. The above-mentioned facility administrators were informed of the immediate jeopardy situation regarding the failure to ensure two of thirty sampled patients (Patient 1 and Patient 2) were free from abuse. On 1/24/2025 at 6:02 p.m., while onsite, the IJ was removed after verifying and confirming the facility’s implementation of the IJ Removal Plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, in the presence of the following facility members: Chief Nursing Officer (CNO), Director of Quality and Risk (DQR), Chief Executive Officer (CEO), Administrator (Admin), and Associate Chief Nursing Officer (ACNO). The IJ Removal Plan included the following: 1. On beginning 11/1/2024, the plan of action included that the ACNO provided written instructions to all house supervisors making rounds in the emergency department (ED), was increased to every three (3) hours with a rounding log created. 2. On 10/16/2024, the plan of action included all nursing staff are required to obtain mandatory management of assaultive behavior certification (MAB - de-escalation training), with training scheduled for February 2025. 3. On 12/11/2024, the plan of action included a re-education of all security guards on the facility ’ s policy, Use of Force, with signed attestations that training was received. 4. On 12/11/2024, DQR completed a contract service evaluation for security services and required security company to correct deficiencies identified, including use of excessive force towards patients, failure to perform appropriate de-escalation techniques, and inappropriate/unprofessional behavior, by 1/3/2025. 5. On 1/16/2025, DRQ met with security manager reviewed security services corrective action plan and made recommendations for security services. 6. On 1/24/2025, the house supervisor rounding log was revised to include the times of the rounds, the name of the ED charge nurse and the name of the security officer, and communication with both the charge nurse and security officer. 7. On 1/23/2025, the ACNO provided the list of expired licensure report to all house supervisors and nursing staff office, to ensure that facility staff with expired licenses or required certifications were not called to cover staffing needs. The report was provided to the nursing managers and directors weekly. 8. On 1/23/25, the hospital administrator and DQR reviewed the 2025 Security Post Orders and made revisions to the 2025 Post Orders, which included attestations from all the security officers indicating training was received, read and understood. 9. On 1/23/2025, facility administration created and initiated an educational tool regarding MAB training, Code Gray procedures, immediate reporting of unusual occurrences, and incident reporting system for all ED staff and security officers to complete within the first two hours of their shift, upon returning to duty. 10. On 1/24/2025, risk management specialist conducted one-to-one training with each security officer on incident reporting, including a completed a post-test. Findings: 1. The Security Manager (SM) stated on 1/22/24 at 11:36 PM, that Patient1 who presented to the Emergency Room on 10/09/24 with right shoulder pain was physically assaulted by Emergency Medical Technician (EMT 1). The assault happened on 10/9/24 at around 4:00 AM. Patient 1 was in the ED (Emergency Department) lobby and was verbally aggressive to staff. Security Guard 1 (SG1), Security Guard 2 (SG2), and EMT 1 was with Patient 1 to deescalate (to decrease or reduce) the situation. Security Manager (SM) stated, Patient 1 spat at EMT1, and EMT 1 reacted by pushing security guard to the side and lunging towards Patient 1 and started punching Patient 1 ’ s head area. SG1 and SG2 pulled EMT1 off Patient 1 to stop the attack. Patient 1 left the ED and the Police was called. Police came and arrested Patient 1 outside ED. Patient 1 was arrested because she made threats to harm the facility staff. SM added that a security report was not created. It was expected that the security staff complete a written security report after any unusual occurrence. EMT 1 was sent home and terminated a month after this incident. EMT1 should not have assaulted Patient 1. Staff should never put hands on a patient. The expectation from security staff was to deescalate the situation. The Director of Quality and Risk (DQR) stated on 1/23/25 at 11:00 AM that Emergency Department Manager (EDM) was onsite and aware of the incident of EMT1 physically assaulting Patient 1, and Patient 1 making threats to come back and harming staff. EDM did not notify the rest of leadership. There was a lack in notification and failing to follow chain of command. That situation should have been escalated (increase rapidly) to the House Supervisor and the Administrator on call. That way, a proper safety measure can be put in place in response to Patient 1 ’ s threats to the facility. During a concurrent review of EMT1 ’ s personnel file and interview with Human Resource Manager (HRM) on 1/23/25 at 1:27 PM, Record indicated that EMT1 has not completed Management of Assaultive Behavior (MAB) training. HRM stated that MAB is required for all ED EMT and nursing personnel. A review of the facility ’ s policy titled, “Prevention and Management of Violence by a Patient or Visitor, Zero Tolerance ’ dated approved 11/2022 (old version), indicated that Hospital procedure if patient or visitor becomes behaviorally escalated engage in de-escalation and limit setting as is appropriate to the patient or visitor ’ s stage of escalation. If at any time a patient or visitor becomes physical threatening, staff should immediately disengage and leave the room if appropriate and notify management of the situation. In an emergency, staff should call security and call a code Gray. A review of the facility ’ s policy titled, “workplace violence prevention plan”, dated 3/2024; indicated that Southern California Hospitals encourages all workforce members to report workplace violence to the hospital in accordance with established hospital policies and to see assistance and intervention from local emergency services or law enforcement when a violent incident occurs. A review of the facility ’ s policy titled, “Medical staff chain of command” dated 6/2022, indicated that Southern California Hospital is committed to providing safe quality patient care. Any healthcare professional who identifies a potential problem with respect to patient safety and /or quality, and unable to resolve it independently, is empowered to invoke the following procedures e.g. clinical chain of command until a satisfactory resolution is achieved. A review of the facility ’ s policy titled, “Reporting of Events Via Occurrence Reporting System” dated 12/24 indicated the purpose if to improve the quality of patient care and enhance patient, visitor and staff safety and reduce the facility’s exposure to risk of financial loss ...an occurrence/event report is to be submitted through current Incident Reporting system on every occurrence/event involving a patient, visitor, physician, employee (staff or contract), or volunteer in any area or department of Southern California Hospital ... The responsibility for completing an Occurrence/Event/Risk report submission through the Occurrence Reporting System rests with any staff member (including physicians and agency/contract personnel who witnesses, discovers, or has the best knowledge of an occurrence as previously defined. 2. During an interview with Security Manager (SM) on 1/22/25 at 11:36 a.m., SM stated on 11/4/24 around 7am, at the end of night shift, he received a text message from security guard (SG1) stating that SG1 defended himself and punched Patient 2. SM stated SG1 completed his shift and did not report to any supervisor regarding the incident until he sent a text message to SM. SG1 was suspended only after finishing his shift. During the interview with SM, he stated that SG1 should never hit a patient even when he was provoked by the patient. Also, they need to report to a supervisor immediately and the supervisor can inform SM to start investigating ASAP (as, soon, as, possible) During an interview with SG2 on 1/23/25 at 9:51 am, SG 2 stated Patient 2 came into ED after midnight and patient had blood on his face and mouth. Patient 2 was lying on the floor in the waiting area. SG2 and SG1 were trying to assist patient 2 to sit back on the chair. In a short while, SG1 accompanied Patient 2 outside the ED. SG2 stated after couple minutes, he heard some noise outside, he went outside the ED entrance and saw SG1 and Patient 2 were located at the junction of ED driveway and the City Street. Patient 2 was sitting on the ground and SG1 was standing next to Patient 2. When Patient 2 tried to stand up, SG1 punched Patient 2 on his shoulder. SG2 stated he did not report what he observed to the supervisor since he was not involved in the incident. During an interview with Director of Quality and Risk (DQR) on 1/27/25 at 3:15 p.m., DQR stated the facility did conduct training to the ED staffs including ED and EMT after the 1st abuse incident that EMT 1 hit Patient 1; however, the security guards were not included in the training. Concurrently, DQR admitted that there was no reporting to chain of command immediately per facility policy regarding both abuse incidents that happened involving staffs physically assaulting the patients. A record review, titled “incident report” dated 11/6/24, indicated that an assault incident occurred at 11/4/24 at 2:10 am by SG1. Indicated that SG1 arrived in front of the ED at 2:10 am to give lunch breaks to the other staff and he saw SG2 trying to ask Patient 2 to get off the floor. SG1 saw Patient 2 face with blood and asked what happened. Patient 2 stated “someone hit me.” SG1 accompanied Patient 2 outside the ED, and Patient 2 suddenly wrapped his arm around SG1 ’ s neck; SG1 pushed Patient 2 away, then Patient 2 squared up and hit SG1 ’ s chin. SG1 fought back against Patient 2. A review of the facility ’ s policy titled, “Patient Rights and Responsibilities”, dated 3/2023, indicated that patient has the right to be free from all forms of abuse or harassment. A review of the facility ’ s policy titled, “Prevention and Management of Violence by a Patient or Visitor, Zero Tolerance ’ dated approved 11/2022 (old version), indicated that Hospital procedure if patient or visitor becomes behaviorally escalated engage in de-escalation and limit setting as is appropriate to the patient or visitor ’ s stage of escalation. If at any time a patient or visitor becomes physical threatening, staff should immediately disengage and leave the room if appropriate and notify management of the situation. In an emergency, staff should call security and call a code Gray. A review of the facility ’ s policy titled, “workplace violence prevention plan”, dated 3/2024; indicated that Southern California Hospitals encourages all workforce members to report workplace violence to the hospital in accordance with established hospital policies and to see assistance and intervention from local emergency services or law enforcement when a violent incident occurs. A review of the facility ’ s policy titled, “Medical staff chain of command” dated 6/2022, indicated that Southern California Hospital is committed to providing safe quality patient care. Any healthcare professional who identifies a potential problem with respect to patient safety and /or quality, and unable to resolve it independently, is empowered to invoke the following procedures e.g. clinical chain of command until a satisfactory resolution is achieved. A review of the facility ’ s policy titled, “Reporting of Events Via Occurrence Reporting System” dated 12/24 indicated the purpose if to improve the quality of patient care and enhance patient, visitor and staff safety and reduce the facility’s exposure to risk of financial loss ...an occurrence/event report is to be submitted through current Incident Reporting system on every occurrence/event involving a patient, visitor, physician, employee (staff or contract), or volunteer in any area or department of Southern California Hospital ... The responsibility for completing an Occurrence/Event/Risk report submission through the Occurrence Reporting System rests with any staff member (including physicians and agency/contract personnel who witnesses, discovers, or has the best knowledge of an occurrence as previously defined.”

“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: 38310 Based on observation, interview and record review, the facility failed to ensure its nursing staff to perform assessment and document restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) monitoring every 2 hours in accordance to facility ’ s policy and procedure of restraints on one of 30 sampled patients (Patient 17) for 12 hours (from 7 p.m. to 7 a.m.) on 1/16/2025, 1/17/2025 and 1/18/2025, consecutively for 3 nights. This deficient practice had the potential to put Patient 17 at risk for skin break down and other injury due to lack of assessment and monitoring. Findings: During a review of Patient 17 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/26/2024, the H&P indicated, Patient 17 was admitted to the facility with diagnoses including failure to thrive (condition that adults involves, weight loss, fatigue and other physical decline), but not limited to Non-ST-elevation myocardial infarction (NSTEMI, a type of heart attack that occurs when a coronary artery is partially blocked, reducing blood flow to the heart), and sepsis (a body ’ s overwhelming and life-threatening response to infection). During a concurrent observation and interview on 1/22/2025 at 10:07 a.m. with Assistant Chief Nursing Officer (ACNO) at Patient 17 ’ s room, Patient 17 was in bed with bilateral (both) soft wrists restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) on. ACNO stated Patient 17 was on bilateral soft wrist restraints due to pulling lines. During a review of Patient 17 ’ s “physician order (orders written by physicians to direct care and treatment),” dated 1/16/2025, 1/17/2025, and 1/18/2025 the physician order indicated, there was need for bilateral wrists restraints due to pulling tube/lines and interfering with dressing, wounds, or devices. During a concurrent interview and record review on 1/22/2025 at 10:35 a.m. with ACNO, Patient 17 ’ s “Non-Behavioral restraints flowsheet (documentation of restraints use and assessment),” dated 1/16/2025, 1/17/2025, and 1/18/2025 was reviewed. The restraint flowsheet indicated Patient 17 ’ s was on bilateral soft wrists restraints and there is no entry of assessment starting from at 8 p.m. on 1/16/2025 to 7 a.m. on 1/17/25, and 1/17/2025, and 1/18/2025 respectively. There was no assessment done from 7 p.m. to 7 a.m. (12 hours) consecutively for 3 days. ACNO stated that the assigned registered nurse should document and assess Patient 17 every two hours to check for skin for any injury, circulation, range of motion (ROM, the full movement potential of a joint, usually its range of flexion and extension), discoloration, and swelling while Patient 17 was on restraints. Patient 17 could be at risk for skin breakdown and injury due to lack of proper monitoring. During a review of the facility ’ s policy and procedure (P&P) titled, “Restraint”, dated 3/2024, the P&P indicated, assessment by a trained and competent Registered Nurses (RN) in restraint application and management, as defined by the training requirements of this document, are done and documented at least every 2 hours for non-violent behavior restraint. Assessment by a responsible Licensed Independent Practitioner (LIP) shall occur as often as indicated by patient ’ s condition, behavior, environmental considerations, and this policy.”

“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: 38310 Based on observation interview and record review, the facility failed to follow manufacturer ’ s recommendation of labeling the open and discard date of one of two sampled open glucose control solution (a liquid used to test the accuracy of blood glucose meters). This deficient practice has the potential to result in inaccurate blood glucose meter (a portable machine that’s used to measure glucose in the blood) readings. Findings: During a concurrent observation and interview, on 01/21/2025, at 3:18 p.m., It was observed that one of two open glucose control solution bottles in the acute rehab unit nurse station has no written open and discard dates. The registered nurse (RN3) confirmed that one of two open glucose control solution bottle has no written open and discard dates. RN3 stated that the facility follows manufacturer ’ s guideline of labeling each of the glucose control solution bottle of its open and discard date once the bottle is open. It is the responsibility of the staff nurse to write the open and discard dates on the bottle. The solution expires 90 days after opening, and it needs to be tracked by nursing staff to ensure accurate results when testing a blood glucose meter. A review of the glucose control solution manufacturer ’ s recommendation titled “Nova Stat Strip Glucose Control Solution”, REF 41743, indicated the following: · Precautions: Use only for 3 months after first opening. When you open a new vial of control solution, count forward 3 months and write that date on the label of the control solution vial. Discard any remaining solution after the date you have written on the vial. · Expiration: The expiration date is printed on the control vials. Once opened, solution stored as indicated will be stable for up to 3 months or until the expiration date, whichever comes first.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure two of seven sampled employees (Emergency Medical Technician – EMT 1 and Registered Nurse – RN 9) completed their annual mandatory abuse and restraint training and maintained current certification of management of assaultive behavior (MAB – de-escalation training). These deficient practices had the potential for employees to perform uncorrected practice for the following: A. Patients getting physically abused, B. Patients on restraints, not monitored and/or provided less restrictive measures, C. Patients with aggressive behavior harming others. Findings: 1. On 1/23/2025, at 1:27 PM, during concurrent interview with human resources manager (HRM) and director of education (Dir Ed), HRM stated upon hire, new Emergency Department (ED) employees attend hospital orientation, which included training in abuse, restraints, and de-escalation of aggressive behavior (MAB). HRM stated abuse, restraint and MAB training must be done annually. Concurrently, during record review of personnel files for emergency medical technician (EMT)1 and registered nurse 9, HRM stated the following: 1. EMT1 ’ s training for abuse, restraints, and MAB were not current: last abuse training on 7/2021, restraint training on 4/4/2023, and expired MAB training certificate on 9/2021. 2. Registered Nurse 9 training for abuse, restraints, and MAB were not current: abuse training on 11/2022, restraint training on 11/2022, and expired MAB training certificate on 10/2023. A review of facility ’ s job description for emergency medical technician (EMT), undated, indicated the following: 1. Primary duties included ensuring the safety of the patient. 2. Required qualifications included MAB training certificate, upon hire and recertification. A review of facility ’ s job description for Registered Nurse (RN) in the emergency department, undated, indicated the following: 1. Specialty training to provide prompt response and treatment for any patient presenting with any life-threatening, emergent, or urgent medical needs. 2. Required qualifications included MAB training certificate upon hire, and recertification. A review of facility ’ s Workplace Violence Prevention Plan, dated 3/2024, indicated the following: 1. This policy applies to all staff employed by the facility. 2. Purpose is to protect the safety and health of employees, medical staff, patients, and visitors from aggressive and violent behaviors. 3. High-risk areas for aggressive and violent behaviors included the emergency department. 4. The hospital leadership will provide effective training to employees who are reasonably anticipated to encounter aggressive and violent behaviors in the job, upon hire and annually. 5. Incidents of the use of physical force against an employee by a patient or a person accompanying a patient must be reported.”

“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: 38310 Based on observation, interview and record review, the facility failed to ensure: 1. One of 30 sampled patients (Patients 14) intravenous (IV) (means administering fluids, medication and nutrients directly into the veins) dressing site was documented with a date, time and initial of nurse written on dressing as per facility policy and procedure.This deficient practice had the potential to compromise Patient 14’s health and risk of infection due to dirty or compromised dressing. 2. Fall precautions were executed for one of 30 sampled patients (Patient18). This deficient practice had the potential for Patient 18 to fall and fracture (break) bones, cause traumatic brain injury (damage caused by a blow to the head), and result in long term disabilities. Finding: 1. During a review of Patient 14 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/19/2025, the H&P indicated, Patient 14 was admitted to the facility with diagnoses including sepsis (a body ’ s overwhelming and life-threatening response to infection), pneumonia (a lung infection that cause the air sacs in the lungs filling with fluid or pus that caused by bacteria, viruses, or fungi), and hypertension (chronic condition that blood pressure in the blood vessels is high). During a concurrent observation and interview on 1/21/2025 at 2:50 p.m. with Interim Director Telemetry and Emergency Department (IDTED) in Patient 14 ’ s room, Patient 14 was observed in bed, with an intravenous (IV) saline lock in her left hand. The IV dressing was observed to be blank with no date and no nurse ’ s initial written on it. Concurrently, IDTED stated all nurses are expected to label the date and their initial on the IV dressing after changed. The IDTED also said, without labeling the date it could compromised the IV site for risk of infection. During a review of the facility ’ s policy and procedure (P&P) titled, “Intravenous Therapy - Initiation and Management of Peripheral Intravenous Line”, dated 6/2023, the P&P indicated the dressing should be changed aseptically (a way that prevent infections) after 72 hours ... label the site with the date and initial. 2. During an observation on 1/22/2025 at 10:30 AM, Patient 18 walked out of a room with a blanket that smelled of urine wrapped around her shoulders. At that time Patient 18 was screaming for someone to help her while walking to the nurses station, unassisted by staff. The nursing station was approximately 20 feet from Patient 18 ’ s room. It was observed staff member took approximately 1 minute to notice Patient 18 had walked to the nurses station. LVN 1 then guided Patient 18 back to her room. Patient 18 had one yellow sock on her right foot and a pink band around her right wrist as she walked through the doorway to her room. There was no audible alarm blaring at this time. During an interview on 1/22/2025 at 10:32 AM, LVN 1 stated Patient 18 had a pink bank around her wrist indicating Patient 18 has a conservator (a person appointed by a court-ordered arrangement to make decisions for another person). LVN 1 stated that a yellow band should be around her wrist indicating Patient 18 is at risk of falling; LVN 1 also said Patient 18 should have been wearing two slip resistant socks to reduce the risk of falling. A record review of the document titled ’ History and Physical ’ (medical exam that includes a patient interview, physical exam, and documentation of findings of the exam) dated 1/13/2025 indicated Patient 18 had been admitted on 1/13/2025, for right lower extremity cellulitis (skin infection causing redness and swelling) and UTI (urinary tract infection, an infection of the bladder/urinary tract). The History and Physical indicated Patient 18 also had a history of bipolar (disorder sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), seizures (sudden uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and schizoaffective (mental illness disorder that can affect thoughts, mood, and behavior). A record review of the document ’ Flowsheets ’ dated 1/21/2025, the Flowsheets indicated Patient 18 ’ s Morse Fall scale (tool use to assess a patient ’ s risk of falling) score was 50. The tool uses the 6 following factors relative to the patient that determine the risk for future falls: History of falling, secondary diagnosis (identification of possible illness), Ambulatory aid used such as a cane, Intravenous therapy (fluid given directly into the blood stream), Gait (manner of walking), Mental status (measure of a person ’ s mental capacity such as mood and behavior). A record review of the document titled ’ Falls Prevention Policy ’ number PAT.042 effective 9/24/2019, the Falls Prevention Policy indicated a fall is a sudden, unintentional descent, with or without injury to the patient resulting in the patient coming to rest on the floor, on or against some other surface, on another person, or on an object. It is only considered a fall when a patient attempts to stand or sit and falls into a bed, chair, or commode if the patient is injured. The Fall Prevention Policy indicated a nurse shall assess every patient for risk of falling every shift and as needed; Nurses should implement standard interventions (e.g. socks, band, signage) as well as individualized interventions such as help with toileting and ambulation to prevent falls according to the assessed level of the patient ’ s fall risk using the Morse Fall scale as a reference. The Falls Prevention Policy indicated a score of greater than 45 represents a high fall risk; minimum fall prevention strategies should include patient wearing non-skid socks, signage, and patient ID band indicating the patient is at risk for falling. The Falls Prevention Policy indicted other measures to prevent falls according to the Morse Risk score: placing the patient close to the nurse station, place 3 side rails up, and a personal alarm if one is available.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 38310 Based on observation, interview and record review, the facility ’ s Emergency Department (ED) failed to ensure the following: A. Emergency equipment, including one of one radiant warmer (equipment used to provide immediate access and warmth to newborn infants) and one of one born-out-of-asepsis (BOA – unplanned out of-hospital birth) kits, to stabilize newborns delivered in the ED, and were readily available. B. Diagnostic tests ordered STAT (right now), in the ED, were performed timely for one of thirty sampled patients (Patient 4). C. Two of three crash carts had back boards (use as a surface to perform cardiopulmonary resuscitation (CPR) (emergency treatment done when someone breathing or heart stop) available for use on patients in an emergency situation). These deficient practices had the potential for delays in emergency care and services to ED patients. Findings: A. On 1/21/2025, at 1:21 PM, during initial tour of the Emergency Department (ED) with Administrator (Adm 2) and Director of Quality and Risk (DQR), registered nurse (RN) 1 stated walk-in patients in active labor are normally placed in room , where there is a crash cart for pediatric patients and other equipment for stabilizing the laboring woman and newborn. RN 1 stated the ED staff would call the on-call obstetrician (OB – physician who provides care during pregnancy, birth and after-birth period), and prepare the room with pediatric crash cart and warm blankets from the blanket warmer for the baby. Concurrently, Pediatric crash cart was observed without a back board. RN 1 stated she did not know why there was no back board in the pediatric crash cart. On 1/22/2025, at 2:10 PM, during interview with director of education (Dir Ed) and nurse educator (NEd)2, NEd2 stated crash carts should have a backboard included. NEd2 stated the nurses, in every unit, should be checking the crash carts daily to make sure that emergency equipment, including back boards are included in the crash carts. Concurrently, during record review of the Crash Cart Inventory, NEd2 stated she did not know why the back board was not indicated on the crash cart inventory. On 1/23/2025, at 1:12 PM, during telephone interview with DQR and facility ’ s emergency on-call OB, OB stated emergency equipment needed in the ED for a laboring woman getting ready to deliver an infant included a radiant warmer to keep the baby warm after childbirth and a born-out-of-asepsis (BOA – unplanned out of-hospital birth) kit, which contains supplies for emergency deliveries, including bulb syringe, sterile gloves, sterile towels, umbilical cord clamps, and a scalpel. Concurrently, DRQ stated the facility ’ s radiant warmer was not in the hospital, because it was out for service. DRQ stated she found a BOA kit, in central supply, which should have been stocked in the ED. A review of facility ’ s Crash Cart/AED – Inspection, Maintenance, Exchange policy, dated 3/2024, indicated the following: 1. The emergency crash carts will be immediately available in each patient care areas. 2. The crash carts shall be checked daily, in each unit, by licensed personnel, and documented on a checklist log (Ambu bag, O2 cylinder, Defib, Suction, Backboard, pharmacy) to verify the integrity of the crash cart and to ensure that all equipment is available and functioning. 3. Central supply will verify the existing components on the crash cart and replacement items will be pulled. 4. The crash cart will be inspected for completeness, cleanliness and functionality by central supply. B. On 1/24/25, at 3:21 PM, during concurrent interview with nursing educator (NEd)2 and record review of Patient 4 ’ s medical record review, NEd2 stated the following: 1. Face sheet (a document that summarizes a patient ’ s key information in their medical record) was admitted to the facility on 11/14/2024, with a diagnosis, which included ventilator (breathing machine) dependent. 2. Nursing Triage note, dated 11/14/2024, indicated patient ’ s chief complaint was to replace patient ’ s gastrostomy tube (G-tube – a small tube surgically inserted into the stomach through the abdomen) replacement. 3. ED physician note, dated 11/14/2024, indicated patient came from a nursing home with a clogged g-tube and ordered computed tomography (CT scan – a noninvasive medical procedure that uses X-rays to create a detailed cross-sectional images of the body) and chest X-ray to find the g-tube ’ s position and check for infection. Concurrently, during record review of Patient 4 ’ s physician orders, dated 11/14/2024, NEd2 stated, at 10:55 AM, ED physician ordered a STAT chest x-ray and CT of patient ’ s abdomen and pelvis, but the STAT chest x-ray and CT of the abdomen and pelvis was not done until 1410 – not done STAT (within one hour). During review of the facility ’ s STAT Turnaround Time policy, dated 1/24/2025, indicated the following: 1. All stats print automatically in the emergency department. 2. Delays in meeting the stat turnaround time of one hour can cause delays in patient care. C.During a concurrent observation and interview on 01/21/2025 at 1:45 p.m. of the emergency department (ED) with the Director of Quality and Risk (DQR), it was observed that two of three (crash cart 15 and pediatric crash cart) did not have a back board. DQR stated that crash cart should have back board. During an interview on 01/21/2025 at 2:09 p.m. with the register nurse (RN1), RN1 stated that each crash carts should have a back board. Back board is used as back support to patient receiving chest compression during code blue. During an interview on 1/22/2025 at 2:10 p.m. with the nurse educator (NED2), NED2 stated that each crash cart should have a back board. Backboard is not part of the facility ’ s crash cart checklist (a tool used by staff that ensures all necessary emergency medications, equipment, and supplies are readily available on a crash cart), but it should be. A review of the facility ’ s policy titled , “Crash Cart and AED Inspection, Maintenance, Exchange, dated 3/2024 indicated the crash carts shall be checked daily, in each unit, by licensed personnel, and documented on a checklist log (Ambu bag, O2 cylinder, Defib, Suction, Backboard, pharmacy) to verify the integrity of the crash cart and to ensure that all equipment is available and functioning.”

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to maintain room temperature between 70 and 75 degrees Fahrenheit (a unit of measurement for four of nine care areas sampled, which included the emergency room (ED), step-down units (SDUs), the fifth floor medical and telemetry units (a floor in a hospital where patients undergo continuous heart monitoring and/or are recovering from surgery), and the Detox Unit (a hospital unit that allows substance users to start the recovery process safely), in accordance with facility policy and procedure regarding temperature monitoring and control. This deficient practice had the potential to create an environment that increases the growth of microorganisms (small living things that may cause disease), which increases the risk of healthcare-associated infections and compromises the integrity of medical supplies, medications, and vaccines, leading to contamination and putting patient safety at risk. Findings: During a concurrent observation and interview on 9/17/2024 at 2:30 p.m. with the facility Operations manager (MO) in the emergency room, cooling device was observed installed in ED room 1, 2, 3 and in area of room 1 through 12. The MO stated engineers come every hour to check temperature after the temperature had been out of range. MO stated prior to the temperature being out of range during the heat wave, from 10/8/2024 through 10/12/2024, the temperature in the emergency department was not monitored. The MO confirmed that the temperature in the ED and general acute care areas should be maintained between 70-75 degrees Fahrenheit in accordance with the facility policy and procedure. During an interview on 9/19/2024 at 10:50 a.m. with the infection preventionist (IP), the IP stated high temperatures can compromise the sterility of the operation room (RO, a room in a hospital where operations are done), medical supplies, and medication efficacy, as well as medication like stool softener, as it can melt. During a review of the facility’s “Daily Temperature Reading in Patient Care Areas,” log dated from 9/4/2024 through 9/17/2024, the log indicated as follows: On 9/8/2024, the third floor; step-down units, the temperature reading in room 308 was 78.2 degrees Fahrenheit. On 9/8/2024, the fifth floor; telemetry and medical surgical unit, the temperature reading in room 517 was at 78.4 degrees Fahrenheit. On 9/8/2024, the sixth floor; Detox units, the temperature reading in room 680 was 77.2 degrees Fahrenheit. On 9/9/2024, the third floor; step-down units, the temperature reading in room 311 was 80.4 degrees Fahrenheit. On 9/9/2024, the fifth floor; telemetry and medical surgical unit, the temperature reading in room 529 was 81.1 degrees Fahrenheit. On 9/9/2024, the sixth floor; Detox units, the temperature reading in room 683 was 82.7 degrees Fahrenheit. On 9/10/2024, the fifth floor; telemetry and medical surgical unit, the temperature reading in room 527 was at 81.1 degrees Fahrenheit. On 9/10/2024, the sixth floor; Detox units, the temperature reading in room 679 was 83.6 degrees Fahrenheit. On 9/11/2024, the fifth floor; telemetry and medical surgical unit, the temperature reading in room 517 was at 80.8 degrees Fahrenheit. On 9/11/2024, the sixth floor, Detox units, the temperature reading in room 678 was 82.5 degrees Fahrenheit. On 9/12/2024, the fifth floor, telemetry and medical surgical unit, the temperature reading in room 503 was at 77.9 degrees Fahrenheit. On 9/12/2024, the sixth floor; Detox units, the temperature reading in room 680 was 76.3 degrees Fahrenheit. During a review of the facility’s policy and procedure (P&P) titled, “Temperature, Humidity and Air Exchange Monitoring and Control,” dated September 2024, the P&P indicated, “Temperature, humidity, and air exchanges are maintained and monitored at (name of the facility) to provide an environment that promotes patient safety, comfort and favorable outcomes. The tables that follow are based on the minimum standards outlined in portions of the 2010 California Mechanical Code (Title 24) that pertain to hospitals and licensed outpatient clinics and other information available from the American Society of Heating, Refrigerating, and Air-Conditioning (ASHRAE) and the American Society for Healthcare Engineering of the American Hospital Association (ASHE). General Acute Care (inpatient care, including the following basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services): temperature range (70-75). Emergency Department: treatment area (70-75) and Triage area (70-75).””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to adhere to intravenous (IV- administered through the vein) therapy guidelines for one of the 30 sampled patients (Patient 3). Patient 3’s IV catheter (small tubing placed in the arm or hand) access site was not labeled (date and initial by staff who inserted the IV catheter), in accordance with the facility’s IV Therapy policy and procedure. This deficient practice had the potential to result in negative consequences for the patients increasing their chances for intravascular (within the blood vessel) catheter related infections. Findings: During a review of Patient 3’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/17/2024, the “H&P” indicated that Patient 3’s medical history included hypertension (when the pressure in the blood vessels is too high [140/90 mmHg or higher]) and diabetes (a disease in which the blood sugar is too high). The H&P further indicated, “Pt (Patient 3) states she was started on oral abx (an antibiotic, a medicine that inhibits the growth of or destroys microorganisms) with no improvement in her legs. She also feels sob (shortness of breath), having some chest discomfort intermittently.” The H&P indicated one of the assessments and plans is to start Patient 3 on antibiotics. During a concurrent observation and interview on 9/17/2024 at 3:45 p.m. with the Administrator (ADM 1), in Patient 3’s room, Patient 3’s IV (intravenous- into the vein) catheter to the right forearm did not have a label. The ADM 1 stated, “The IV site should have a label to indicate when it (the IV catheter) was inserted.” During an interview on 9/17/2024 at 3:55 p.m. with Registered Nurse (RN) 12, outside of Patient 3’s room, RN 12 stated, “The catheter site should be labeled to show when it (the IV catheter) was inserted because the catheters must be reassessed to be changed in 4 to 5 days or if necessary to prevent infection.” RN 12 stated she forgot to label the catheter site after another RN helped to insert the IV catheter. During a review of the facility’s policy and procedure (P&P) titled, “Intravenous therapy-Initiation and Management of Peripheral Intravenous Lines,” dated June 2023, the P&P indicated, “To provide standards for the management of peripheral intravenous therapy with consideration of patient’s safety and comfort and the goals of intravenous therapy ... Apply the transparent dressing from the IV Start Kit. The area of insertion into skin should not be covered or obscured from view by tape. Apply transparent dressing over site. Label the site with the date and initials.””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 36329 Based on observation, interview, and record review the facility failed to: 1. Ensure one of one observed toilet seat was clean and sanitary before patient use. This deficient practice had the potential for infectious organisms to be transmitted to patients. 2. Ensure one of one Portable fan in one patient room was free of dust in case of patient use. This deficient practice had the potential for dust particles to be inhaled by patients which may result in respiratory issues. 3. Ensure Shower stalls were not covered in black stains that may pass harmful pathogens to patients by inhalation or touch. This deficient practice had the potential to cause patient harm such as infection, respiratory problems such as coughing, etc. 4. Ensure four of six sampled faucets (Faucet 1, 2, 3, and 4) in the operating room (OR) department did not have brown, yellow, and green deposits in the inner spout of the faucets. This deficient practice had the potential to spread pathogens (organisms that cause disease); when the faucet is used, water flow can dislodge these deposits, releasing the deposits onto surfaces and onto personnel’s hands. Findings: 1. During an observation on 9/18/2024 at 11:43 a.m., in room 676 of the Detoxification Unit (dedicated space where short term medical and psychological care is given to patients experiencing withdrawal symptoms from dependent use of alcohol or drugs), there were 2 beds appearing to just have been made and the floor was clean. The bathroom could be seen on the left as this observer entered the room; there was a smear of brown substance on the toilet seat. The toilet seat cover was in the up position but there was no band across the toilet indicating the toilet had been cleaned. During an interview on 9/18/2024 at 11:43 a.m., in room 676, with the Chief Nursing Officer (CNO) 1, CNO 1 stated that a patient from another room on this floor (Detoxification Unit) must have used the bathroom after it had been cleaned but she (CNO) would have a housekeeper clean the seat immediately. CNO 1 subsequently stated this unsanitary practice could pass infection to anyone who may have contact with the toilet seat. During a review of the facility’s policy and procedure titled, “Discharge Room Cleaning Procedure,” issue date 10/1/2023, the “Discharge Room Cleaning Procedure” policy indicated, the procedure for cleaning restrooms: “Using the bowl mop and germicide, clean under the rim of the toilet and all around the inside of the toilet in a circular motion. Dip the cloth and disinfect the top and bottom of the toilet seat, then the outside of the toilet. Flush toilet. Leave toilet seat in up position and apply a toilet band if applicable.” 2. During an observation on 9/18/2024 at 11:57 a.m., in room 677, of the Detoxification Unit, there were two beds appearing to just have been made and the floor was clean. At the foot of the beds was a portable fan with a metal grill; the metal grill of the portable fan was filled with white dust. No patients were in the room at this time. During an interview on 9/18/2024 at 11:57 a.m., in room 677, with the Chief Nursing Officer (CNO) 1, CNO 1 stated the room had just been cleaned but EVS (Environmental Services, department in the facility that ensures the physical environment is cleaned and disinfected) had overlooked cleaning the fan. CNO 1 subsequently said dust from the fan could blow on patients and cause respiratory (referring to the organs responsible for breathing including lungs, nose, and throat) infection. During a review of the facility’s policy and procedure titled, “Discharge Room Cleaning Procedure,” issue date 10/1/2023, the “Discharge Room Cleaning Procedure” policy did not indicate a specific procedure for cleaning free standing fans but indicated the following for “high dusting: High dust, beginning at the entranceway (to a room) and working around the room in a circle.” 3. During an observation on 9/18/2024 at 2:06 p.m., in shower room #4, in the BHU (Behavioral Health Unit, space dedicated to patient mental health care), there were black and green spots observed on the external part of the shower base where the base meets the back wall of the shower. There were the same black and green spots on the grout lines (substance placed between tiles in the shower to seal the wall from moisture) of the shower room. Lastly, there were black and green spots on the ceiling of the shower room (#4). During an observation on 9/18/2024 at 2:08 p.m., in shower room #5, in the BHU, there was a rust-colored circular device on the ceiling of the shower stall. During an interview on 9/18/2024 at 2:08 p.m., outside of Shower room #5, with the Facility Manager of Operation (MO), MO verified that the object in the ceiling of the shower stall in Shower Room #5 was a rusty sprinkler head (device that releases water to extinguish a fire when one is detected). During an interview on 9/18/2024 at 2:10 p.m., outside of Shower Room #5, Registered Nurse (RN) 10 stated any particles drifting from the rusty sprinkler could cause respiratory illness if inhaled. During an interview on 9/20/2024 at 10:55 a.m. with the Environmental Services (EVS) Director (EVS 1), EVS 1 stated he did not recall the appearance of the shower stall in Shower Room #4 but said that he (EVS 1) was responsible for cleaning that shower stall on 9/18/2024. EVS 1 subsequently said that the procedure for cleaning mold in showers consists of scrubbing the stain with a clean cloth soaked with bleach. EVS 1 stated that these types of stains are not easily removed. During an interview on 9/20/2024 at 11:05 a.m., the EVS Director said the current practice for cleaning stains from shower includes using a bleach solution, but the facility had recently added a new mold stain remover to the facility’s list of approved EVS supplies. During an interview on 9/18/2024 at 3:44 p.m. with the Infection Preventionist (IP), the IP stated showers should be cleaned in the morning and after each use. The IP then stated the responsibility of cleaning mold from showers lies with the Environmental Services department. The IP subsequently verified that inhaling mold and rust particles may cause respiratory complications. 4. During a concurrent observation and interview on 9/17/2024 at 2:30 p.m. with the Facility Manager of Operation (MO) and the Director of OR (DOR), in the OR’s hallway by OR 1, Faucet 1 and Faucet 2 had brown, yellow, and green deposits. MO confirmed that there should be no deposits inside the spout of the OR faucets. MO stated, “We will have it cleaned immediately.” During a concurrent observation and interview on 9/17/2024 at 2:35 p.m. with the Facility Manager of Operation (MO) and the Director of OR (DOR), in the OR’s hallway by OR 1, Faucet 3 and Faucet 4 had brown, yellow, and green deposits. MO stated, “The OR’s sinks are cleaned daily. Part of the cleaning process should include checking and cleaning the faucet.” During a review of the facility’s policy and procedure (P&P) titled, “Surgical Areas Cleaning,” dated 10/1/2023 the P&P indicated, “The Surgical and Operating Room (O.R.) are the most critical areas of the hospital. Extreme care must be taken to ensure the following schedule is carried out rigorously and in accordance with departmental procedures and AORN standards to include OR areas, Cath Labs, Interventional Radiology, and Same Day Surgery areas ... Daily Terminal Cleaning (AORN Env Cleaning Recommendation): When daily OR schedule is completed, OR rooms should be re-cleaned ...Damp wipe and disinfect scrub sink areas related to the OR suite and replenish all supplies.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42937 Based on observation, interview and record review, the facility failed to ensure that the Condition of Participation for Patient’s Rights was met as evidenced by: 1. Failure to ensure a patient was provide an informed consent for a non-emergency procedure and for anesthesia (a state of controlled, temporary loss of sensation or awareness that is induced for medical purposes), prior to the procedures according to facility policy and procedure for one (1) of thirty (30) sampled patients (Patient 29). Patient 29 had an esophago-gastro-duodenoscopy (EGD - a diagnostic endoscopic procedure used to visualize the oropharynx [the middle part of the throat/behind the mouth], esophagus [the hollow muscular tube that passes food and liquid from the throat to the stomach], and proximal duodenum [first part of the small bowel/intestine]) and for colonoscopy (a procedure that checks the inside of the entire colon [intestine]). This deficient practice resulted in Patient 29 not being provided information regarding the risks and benefits of the procedure and anesthesia being administered, prior to the procedure. (Refer to A - 0131). 2. Failure to maintain a safe environment in the Behavioral Health Unit (BHU, where patients with mental health emergencies are stabilized) Unit, during a code blue (any patient with an unexpected cardiac [heart] or respiratory [lung] arrest [stop] requiring resuscitation [revive from unconsciousness or apparent death] and activation of a hospital-wide alert) for one (1) of thirty (30) sampled patients (Patient 1), when: a. A rapid response (a system designed to identify and respond to patients with early signs of clinical deterioration with the goal of preventing respiratory or cardiac arrest [heart stops]) was not immediately initiated. This deficient practice resulted in delay for Patient 1 in receiving Cardiopulmonary Resuscitation (CPR, chest compressions and breathing for a patient that is not breathing and does not have a pulse). (Refer to A - 0144). b. No functioning suction machine (device used to remove fluids from the airways) was available during a code blue (any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital-wide alert) which had compromised the success of intubation (the insertion of a tube either through the mouth or nose and into the airway to aid with breathing). This deficient practice resulted to the physician assistance (PA)’s inability to clear Patient 1’s airway was not able to intubate (a process where a healthcare provider inserts a tube through a person’s mouth or nose, then down into their trachea (airway/windpipe) to provide air to assist with breathing. (Refer to A - 0144). c. Emergency treatment according to the American Heart Association Advance Cardiac Life Support (ACLS) Guidelines 2023 (Guidelines all certified personnel use in response to heart problems) during a “Code Blue” (used to summon personnel and equipment to the scene of a cardiopulmonary arrest or a life-threatening medical emergency) was not provided to Patient 1. This deficient practice resulted to Patient 1 receiving a shock of 200 Joules (electrical shock administered by electrode pads (chest pads) for ventricular fibrillation [type of irregular heart rhythm]) that was not indicated for Patient 1, who as asystole (flat line, no electrical activity). (Refer to A - 0144). The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 42937 Based on interview and record review, the facility failed to ensure that the Condition of Participation for Nursing Services was met as evidenced by: 1. Failure to develop and implement a baseline care plan addressing the primary diagnosis for one (1) of thirty (30) sampled patients (Patient 7), who was admitted to the facility with a diagnosis of seizure (an uncontrolled, abnormal electrical activity of the brain that causes uncontrolled muscle twitching or jerking). This deficient practice had the potential for delayed provision of necessary care and services related to seizures for Patient 7 and other patients. (Refer to A - 0396). 2. Failure to ensure four (4) of five (5) personnel nurse files reviewed had abuse training on file according to facility policy and procedure for Abuse, Neglect and Abandonment. This deficient practice had the potential for patients at the facility not being provide with appropriate care for abuse. (Refer to A - 0397). 3. Failure to ensure one (1) of five (5) sampled employees Registered Nurse 2 (RN 2) had current training for restraints (devices used to limit a patient’s movement). This deficient practice had the potential for the unsafe environment for patients on restraints. (Refer to A - 0397). 4. Failure to ensure one (1) of five (5) sampled employees RN 1 was competent to provide treatment for an emergency treatment according to the American Heart Association Advance Cardiac Life Support (ACLS) Guidelines 2023 (Guidelines all certified personnel use in response to heart problems) during a “Code Blue” (used to summon personnel and equipment to the scene of a cardiopulmonary arrest or a life-threatening medical emergency) was not provided to Patient 1. This deficient practice resulted to Patient 1 receiving a shock of 200 Joules (electrical shock administered by electrode pads (chest pads) for ventricular fibrillation [ type of irregular heart rhythm]) that was not indicated for Patient 1, who as asystole (flat line, no electrical activity). Refer to A - 0397). 5. Failure to update and accurately document on the medical record information regarding assessment and care provided for three (3) of the thirty (30) sampled patients’ (Patient 11, Patient 12, and Patient 16) in accordance with the facility’s policy and procedure (P&P). a. Patient 11’s fall risk assessment was not updated to reflect that Patient 11 had recently fallen according to facility P&P for fall. b. Patient 12’s fall history assessment was not updated to reflect that Patient 12 had recently fallen according to facility P&P for fall. c. Patient 16’s Code Blue Record (recording of the event during which any patient had an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital-wide alert) was incomplete and contained inappropriate scratching out of writing according to facility P&P for code blue. This deficient practice resulted Patient 11, Patient 12, and Patient 16’s medical record information not accurate and complete. The deficient practice had the potential for the care and safety of patients not appropriately implemented after a fall or an emergency. (Refer to A - 0398). 6. Failure to immediately initiate a rapid response (a system designed to identify and respond to patients with early signs of clinical deterioration with the goal of preventing respiratory or cardiac arrest [heart stops]) according to facility’s P&P for rapid response (a system designed to identify and respond to patients with early signs of clinical deterioration with the goal of preventing respiratory [lung] or cardiac [heart] arrest) for one (1) of 30 sampled patient (Patient 1), who was found unresponsive. This deficient practice resulted in delay for Patient 1 in receiving Cardiopulmonary Resuscitation (CPR, chest compressions and breathing for a patient that is not breathing and does not have a pulse). Patient 1 eventually died. (Refer to A - 0398). The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care by the nursing staff.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure a patient was provide an informed consent for a non-emergency procedure and for anesthesia (a state of controlled, temporary loss of sensation or awareness that is induced for medical purposes), prior to the procedures according to facility policy and procedure for one (1) of thirty (30) sampled patients (Patient 29). Patient 29 had an esophago-gastro-duodenoscopy (EGD - a diagnostic endoscopic procedure used to visualize the oropharynx (the middle part of the throat/behind the mouth), esophagus (the hollow muscular tube that passes food and liquid from the throat to the stomach)stomach, and proximal duodenum) and for colonoscopy (a procedure that checks the inside of the entire colon, including the large intestine). This deficient practice resulted in Patient 29 not being provided information regarding the risks and benefits of the procedure and anesthesia being administered, prior to the procedure. Findings: On 1/12/2024, at 11:27 AM, during concurrent interview with Quality Improvement Advisor (QIA) and record review of Patient 29’s entire medical records, dated 12/15/2023, QIA stated there was no informed consent for Patient 29’s non-emergency procedure, performed on 12/15/2023, for EGD and for colonoscopy. QIA stated patient should have had a signed informed consent for EGD and colonoscopy to discuss the risks and benefits of the procedures, because the procedures were not emergency procedures for Patient 29. On 1/12/2024, at 11:27 AM, during an interview, QAA stated there was no informed consent for the anesthesia delivered to Patient 29, on 12/15/2023, during the EGD and colonoscopy, performed on 12/15/2023. QAA stated Patient 29 should have had a signed informed consent for anesthesia provided during EGD and colonoscopy procedures to discuss the risks and benefits of anesthesia. On 1/12/2024, at 11:27 AM, during a concurrent interview and record review of Patient 29’s post-anesthesia care assessment/implementation record, dated 12/15/2023, QAA stated patient was administered monitored anesthesia care (MAC - type of anesthesia service in which an anesthesia clinician continually monitors and supports the patient’s vital functions, treats problems that occur, administers sedative or analgesic medications as needed) during a non-emergent procedure (EGD and colonoscopy). On 1/12/2024, at 11:27 AM, during a concurrent interview and record during review of Patient 29’s Physician Note, dated 12/13/2023, QAA stated Patient 29 had severe anemia (a condition when the blood had a lower-than-normal amount of healthy red blood cells) but had no signs of active gastro (stomach) -intestinal bleeding. A review of facility’s Informed Consents policy, dated 12/2022, indicated the following: 1. The patient must be given the opportunity to give an informed consent prior to the performance of procedures that place the patient at risk. 2. The patient’s physician provides patient with information regarding the high-risk procedures or treatments planned, including anesthesia or sedation, so that an informed decision by the patient is made. 3. The patient’s consent was to validate the process of informing the patient and must be on the patient’s chart prior to the initiation of the procedure. 4. Informed consent information includes a discussion with the patient about the risks, drawbacks, anticipated convalescence, complications, and expected benefits of the procedure and associated anesthesia. 5. Consent must be obtained at the time when the patient was fully capable of understand the procedure so that an informed decision can be made.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 42937 Based on observation, interview, and record review, the facility failed to maintain a safe environment in the Behavioral Health Unit (BHU, where patients with mental health emergencies are stabilized) Unit, during a code blue (any patient with an unexpected cardiac [heart] or respiratory [lung] arrest [stop] requiring resuscitation [revive from unconsciousness or apparent death] and activation of a hospital-wide alert) for one (1) of thirty (30) sampled patients (Patient 1). Patient 1 had a code blue and the facility failed to provide safe care by: 1. Failure to immediately initiate a rapid response (a system designed to identify and respond to patients with early signs of clinical deterioration with the goal of preventing respiratory or cardiac arrest [heart stops]) when Patient 1 was found unresponsive. 2. Not having a functioning suction machine (device used to remove fluids from the airways) available during a code blue (any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital-wide alert) which had compromised the success of intubation (the insertion of a tube either through the mouth or nose and into the airway to aid with breathing). 3. An emergency treatment according to the American Heart Association Advance Cardiac Life Support (ACLS) Guidelines 2023 (Guidelines all certified personnel use in response to heart problems) during a “Code Blue” (used to summon personnel and equipment to the scene of a cardiopulmonary arrest or a life-threatening medical emergency) was not provided to Patient 1. This deficient practice resulted in delay for Patient 1 to receive Cardiopulmonary Resuscitation (CPR, chest compressions and breathing for a patient that is not breathing and does not have a pulse), the physician assistance (PA)’s was unable to clear Patient 1’s airway was not able to intubate (a process where a healthcare provider inserts a tube through a person’s mouth or nose, then down into their trachea (airway/windpipe) to provide open airway to facilitate breathing, and Patient 1 received a shock of 200 Joules (electrical shock administered by electrode pads (chest pads) for ventricular fibrillation [ type of irregular heart rhythm]) that was not indicated for Patient 1. Patient 1 was asystole (flat line, no electrical activity) when 200 Joules shock was delivered. Patient 1 died 24 minutes after being found unresponsive after code blue was called on 9/18/20 at 4:55 p.m. On 1/11/2024 at 2:43 p.m., the survey team called an immediate jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Director of Risk Management. The facility failed to ensure Patient 1 received safe care after becoming unresponsive and a code blue was called to resuscitate Patient 1. On 12/29/2023, facility submitted IJ removal plan. IJ removal plan accepted, and onsite survey team validated implementation of the IJ removal plan at 6:30 p.m. IJ removed at 7:17 p.m. in the presence of the facility’s Chief Nursing Officer and Chief Executive Officer. The IJ Removal Plan indicated the following actions: A. The hospital’s sitter form was revised to require RNs to sign off when 1:1 sitters’ handoff during breaks and change of shift to ensure that information related to reason for the 1:1 and recent observation are communicated. B. Re-education for all Behavioral Health Unit (BHU) staff on RN sign off for 1:1 sitter handoff requirement. C. An additional crash cart was placed in the BHU unit. D. Code response requirements for Respiratory Therapy were enhanced to require RTs to bring Glide scopes (a device that is used for difficult airway management) to all code blue codes. E. Code blue mock drill was included on the skills day agenda for BHU November 2023. F. Mock code blue drills scheduled to be conducted quarterly in BHU and other areas where code blues rarely occur. G. A purchase order for battery operated suction machines was requested for approval. H. Communication devices will be purchased/distributed to enhance communication on the Behavioral Health Unit. I. If a medical emergency occurs and the Emergency Department (ED) or Urgent Care physician is unable to intubate the patient, the on-call panel will be utilized. Findings: A review of Patient 1’s “History of Present Illness,” dated 9/9/2023 indicated, Patient 1 was admitted to the Behavioral Health Unit (BHU, unit dedicated to increasing health related to different behavioral diagnosis) with a diagnosis of “Paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves with feelings of distrustful or suspicious of other people) with acute exacerbation. Patient 1 was at the psychiatric unit (BHU) over the previous 4 weeks. Patient 1 was transferred from BHU to the emergency room because of declining kidney function, aggressive behavior, and noncompliance with care. Patient 1 was restrained prior to transfer because he was physically threatening staff during medical care. Patient 1 was evaluated in the emergency room and magnesium (a mineral need in the body, normal range 1.82 milligram [mg, unit of measurement]/deciliter [dL, unit of measurement] to 2.1 mg/dL)was slightly low and phosphorus (a mineral need in the body to build strong bones and teeth, normal level 2.5 to 4.5 mg/dL) was slightly low and he was treated and medically cleared. Patient 1 was transferred back to the BHU to continue his psychiatric and medical management. 1. During an interview, with the Director of Behavioral Unit (DBHU) on 1/9/2024, at 3:43 p.m., DBHU stated, on 09/18/23, Patient 1 was in the seclusion room with Mental Health Technician 1 (MHT 1). MHT 1 observed Patient 1 lowering himself to the floor, then Patient laid down to the floor. MHT 1 check Patient 1 about 45 seconds to a minute later after Patient 1 laid down on the floor. MHT 1 found Patient 1 to be unresponsive and did not initiate and call rapid response. MHT 1 left Patient 1 and then MHT 1 went to the nurse station to asked for help from Licensed Vocational Nurse 2 (LVN 2). MHT did not indicate the situation was an emergency to LVN 2. LVN 2 went to checked on Patient 1. LVN 2 found Patient 1, Patient 1 was unresponsive, and not breathing. LVN 2 initiated the rapid response. DBHU stated MHT1 was the first responder and should have called a rapid response upon identifying the patient (Patient 1) to be unresponsive. A review of the Patient’s 1 “Nursing Narrative Note”, by LVN 2, dated 9/18/2023 5:45 p.m., indicated on 09/18/2023 at 4:52 p.m., MHT 1 came and stated Patient 1 fell to the floor, LVN 2 ran into the room and observed Patient 1 on the floor. Patient 1’sface was blue, and chest was not raising and falling. LVN 2 informed Charge Nurse to call a rapid response. A review of the facility’s policy and procedure (P&P), titled, “Rapid Response Team”, revised date 07/2022, indicated the purpose was (1) To quickly recognize the patient’s clinical deterioration, (2) To respond quickly and appropriately to adverse changes in the patient’s condition, and (3) To avert inpatient Code Blue situations through timely intervention. The policy also indicates that Rapid Response can be called by any hospital personnel, outside clinical contractor, clinical student, patient, or their family member. 2. A review of Patient 1’s “Physician Code Blue,” dated 9/18/2023, indicated, reason for code blue was Patient 1 was in full arrest (loss of all heart activity), respiratory arrest (breathing stops), and unresponsive. The note indicated, “Patient is lying on gurney and is unresponsive in full cardiac arrest. No heart sounds heard. CPR (Cardiopulmonary Resuscitation, chest compressions and breathing for a patient that is not breathing and does not have a pulse) in progress ...” During an interview, on 1/10/2023 at 1:10 p.m. with the Director of Behavior Health Unit (DBHU), DBHU stated during the code blue in Patient 1’s room, “The suction machine was not working because there was no extension cord long enough to plug the suction machine to the nearest electrical outlet.” During an observation, on 1/10/2024 at 2:00 PM, in Patient 1’s room on the Behavioral Health Unit (BHU), Patient 1’s room was an isolation room (single patient room). Patient 1’s room was the location of the Code Blue. A bed was in the center of the room. The walls do not have electrical outlets. There are two doors in this room with locking abilities. Door 1 had a small window with the ability to view the hallway when looking from inside the room to the exterior. Door 2 was for a private bathroom. During a concurrent observation and interview on 1/10/2023 at 2:03 p.m. with DBHU and the Charge Nurse 2 (CN 2) of BHU in the room where Patient 1 was found during code blue, there was no electrical outlet on all walls of the room. The DBHU confirmed that there was no outlet in the room during the code blue, which prevented the suction machine from being plugged in. A review of Patient 1’s “Code Blue Record (record kept during resuscitation of time for each intervention and Patient 1’s’s response to intervention),” dated 9/18/2023, the record indicated that the code blue first time of entry started at 4:55 p.m. The record indicated under “Intubated by” was the name of the physician assistance (PA), but the PA name had a line drawn through, and under “Time,” indicated a time of 5:12 p.m., but also had a line drawn through (Patient 1 was not intubated). During an interview on 1/10/2023 at 4:40 p.m., the House Supervisor (HS), HS stated he arrived in the Patient 1’s room with the PA when the code blue was called. HS stated the patient (Patient 1) was never intubated. HS further stated, “(name of the PA) first attempt was not successful, but the second time (name of the PA) scream out that she got it but is not able to confirm placement (tube is in correct place). The PA was not able to intubate at the end.” HS confirmed this was the reason that the Code Blue Record had a line drawn through the entries. During a phone interview, on 1/11/2024 at 9:33 a.m. with the PA, the PA stated, “During intubation, it (intubation) was difficult because there was no suction. There was no plug. There was nowhere to plug in the suction machine.” PA further stated, “After bagging (using an ambu bag, a medical device used to manually assist with breathing that forces air into the lungs) the patient for a long time, we will need to intubate (placement of a tube into the trachea (windpipe) to provide artificial respiration to the lungs). Now that the RT (Respiratory Therapist) is there and the two ER (emergency room) nurses are there, I tried very hard to visualize and walk through it (the intubation process).”PA stated that she only tried to intubate once. The PA stated, “I saw how difficult the lack of suction was and how dark it was. It (intubation) was not worth trying again, as it interrupted CPR. The MD (ED physician) called the time of death at 17:19 (5:19 p.m.).” During a review of the facility’s policy and procedure (P&P) titled, “Code Blue,” dated, 9/2022 the P&P indicated, the purpose and objective were “To outline the duties and responsibilities of all personnel in maintaining vital functions during the cardiopulmonary arrest of any patient aged 14 and over. The Emergency Department (ED) maintains equipment and supplies needed for the resuscitation of the pediatric patient ... Responsibilities: The 1st responder stays with the patient and initiates CPR (cardiopulmonary resuscitation, an emergency lifesaving procedure performed when the heart stops beating). Assists in obtaining equipment and supplies as designated by the Code Blue Team Leader or M.D. after relieved of CPR ... Third responder: Sets up suction equipment and suctions airways as necessary ...” 3. During an observation of the nursing station at the BHU, on 1/10/2024 at 2:00 PM with Director of BHU, a crash cart (a cart on wheels with Advance Cardiac Life Support [ACLS] supplies) was observed equipped with a cardiac (heart) monitor with defibrillator (a device that apply an electric charge or current to the heart to restore a normal heartbeat). During a telephone interview on 1/11/2024 at 8:41 AM, with Registered Nurse 1 (RN 1) about Patient 1’s code blue incident stated, “The crash cart was there (in Patient 1’s isolation room) when I entered the room. I charged the monitor and selected 200 joules. I interpreted the rhythm (heart rhythm, or heartbeat) and cleared the patient (from other people touching the patient). And shocked the patient at 200 joules with a rhythm of asystole (no heartbeat). A patient does not receive a shock at asystole rhythm.” During a telephone interview, on 1/11/2024 at 8:48 AM, with RN 1, RN 1 stated his ACLS certificate (certificate of competence to provide ACLS care) was expired. RN 1 stated his ACLS was expired due to ACLS was not required in the BHU. During a telephone interview on 1/11/2024 at 9:27 AM, with the Emergency Department Physician Assistant (PA 1), PA 1 stated “Entering the room (Patient 1’s room), RN 1 was delivering the shock.” PA 1 stated “RN 1 was the only one leading prior to my arrival as the higher medical authority. PA 1 stated RN 1 said, “Everyone step away I am giving a shock.” PA 1 stated, asking RN 1, “Why did you give a shock that was asystole?” During an interview on 1/12/2024 at 10:50 AM with the Director of BHU, Director of BHU stated, “We adhere to American Heart Guidelines for BLS (Basic Life Support) and ACLS ... ACLS certified personnel has the ability (is trained) to interpret EKG (electrocardiogram, a line seen on paper or monitor showing electrical activity through the heart) rhythms ... The expectation is to start CPR (Cardiopulmonary Resuscitation, chest compressions and breathing for a patient that is not breathing and does not have a pulse) immediately. The expectation is to set up the BLS procedures (Basic Life Support, including apply electrode pads) and wait for qualified personnel to interpret the EKG rhythm.” A review of Patient 1’s “Intake Information/Initial Assessment” (Code Blue Document) dated 9/18/2023 at 1651 (4:51 PM), indicated, at “1656 (4:56 PM), Rhythm asystole (no electrical activity to create the heart to mechanically pump), 1 shock delivered,” at “1719 (5:19 PM), Code Stopped (stopped treatment per ACLS guidelines), Disposition (status of Patient 1) Following Code Expired (Dead)”. A review of the facility’s policy and procedure (P&P) titled, “Code Blue” (Cardiopulmonary Resuscitation) dated 9/2022, the P&P indicated, “The term Code Blue will be used to summon personnel and equipment to the scene of a cardiopulmonary arrest or a life-threatening medical emergency ... American Heart Association guidelines will be followed.” A review of American Heart Association Advance Cardiac Life Support Services guidelines (AHA ACLS guidelines) titled, “Adult Cardiac Arrest Algorithm, Asystole/PEA (pulseless electrical activity, heart is not mechanically pumping)” dated 2020 (with 2023 updates), under 9. Asystole/PEA (Pulseless Electrical Activity) treatment intervention was to administer Epinephrine (medication used during emergency to stimulate the heart) response to ASAP (As Soon As Possible) 10. CPR (Cardiopulmonary Resuscitation) 2 minutes (provide CPR for 2 minutes prior to the next step [step 11]).” No shock was indicated asystole. The guideline indicated shock was indicated for ventricular fibrillation (VF, a type of irregular heart rhythm)or ventricular tachycardia (VT, a type of abnormal heart rhythm).”

“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: 48342 Based on interview and record review, the facility failed to develop and implement a baseline care plan addressing the primary diagnosis for one (1) of thirty (30) sampled patients (Patient 7), who was admitted to the facility with a diagnosis of seizure (an uncontrolled, abnormal electrical activity of the brain that causes uncontrolled muscle twitching or jerking). This deficient practice had the potential for delayed provision of necessary care and services related to seizures for Patient 7 and other patients. Findings: A review of Patient 7’s “Admission Record” (undated), indicated Patient 7 was admitted on 9/19/2023, with a primary diagnosis of seizure. Other active diagnosis includes auditory hallucination (hearing voices or noises that don’t exist in reality), aggressive behavior (behavior intending to cause physical or mental harm), and cholecystitis (inflammation of the gallbladder [a small organ on the right side of the belly]). A review of Patient 7’s “History and Physical Reports” (H&P), dated 9/18/2023 at 4:20 PM, indicated Patient 7 has history of repeated falls. A review of Patient 7’s “Care Plan” initiated on 9/20/2023, Patient 7’s Care Plan addressed safety-fall risk, knowledge deficit, gait instability, limited mobility, and pain management. There was no care plan addressing the admitting diagnosis of seizures. A review of Patient 7’s “Medication Administration Record (MAR)”, dated 9/19/2023 to 9/19/2023, Patient 7s MAR indicated administration of Keppra (medication that help treat and prevent seizures) 500 milligrams (mg, unit of measurement) given in the emergency room (page one of two). A review of Patient 7’s “Physician Progress Note”, dated 9/24/2023 at 11:51 PM, indicated a recent onset seizure disorder presents after a witnessed episode on the psychiatric floor (page two of two). The Physician Progress Note indicated the patient is doing well on Keppra (page two of two) and seizure precautions (page two of two). A review of Patient 7’s “Nursing Narrative Note”, dated 9/19/2023 at 9:58 AM, indicated Patient 7 was brought in by the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with mental health emergency) for complaints of a seizure episode at 2:00 AM. A review of Patient 7’s “Nursing Narrative Note”, dated 9/19/2023 at 2:57 AM, indicated Patient 7 reports having a seizure at 12:10 AM. Patient 7’s doctor was called and informed about the patient’s seizure episode. A review of Patient 7’s “Discharge Instructions”, dated 10/11/2023 at 12:09 PM, indicated Patient 7 was to be discharged with medication Keppra (levetiracetam) 500 mg two times per day. This medication was continued for the treatment and prevention of seizures. During a concurrent interview with Staff Nurse 2 (SN 2) and record review of Patient 7’s Admission Orders and Care Plan, on 1/11/2024 at 5:30 PM, with SN 2, SN 2 stated Patient 7 had no care plan addressing seizures. SN 2 stated Patient 7 should have a care plan addressing seizures to identify the risk associated with seizures like falls, hurting themselves, and the risk of a compromised airway. SN 2 stated it (a care plan) was important to have a care plan addressing seizures for the patient’s safety. During a concurrent interview with the Director of Risk Management (DRM) and record review of Patient 7’s Admission Orders and Care Plan, on 1/12/2024 at 4:57 PM, with the DRM, DRM stated Patient 7 was admitted to the emergency room for seizures. DRM stated Patient 7 had no care plan addressing seizures. DRM stated if Patient 7 was being treated for seizures and had reports of having seizures a care plan should have been initiated. DRM stated the care plan was important to identify appropriate interventions (actions taken to improve a situation) and to identify appropriate safety precautions. A review of facility policy and procedure (P&P), titled, “Interdisciplinary Plan of Care,” dated 11/2022, indicated, “The Interdisciplinary Plan of Care shall be based upon the assessments performed by all disciplines, which describes the intentions, rationale, and interventions associated with identified issues.” The P&P indicated the following: 1. The plan of care provides for the continuum of care in meeting the needs of the patient throughout their stay. 2. An individualized Plan of Care was to be developed for each patient that reflect the patient’s unique needs. 3. Each discipline shall initiate and revise the Interdisciplinary Plan of Care based upon ongoing assessment of the patient’s needs. 4. All disciplines review and the patient’s plan of care each shift and update goals when there are changes in patient condition.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure licensed nurses had current competence to provide necessary care for patient as evidence by: 1. Failure to ensure four (4) of five (5) nurse (Registered Nurses [RN 1, RN 8, RN 9, and RN 10] files reviewed had abuse training on file according to facility policy and procedure for Abuse, Neglect and Abandonment. This deficient practice had the potential for patients at the facility not being provide with appropriate care for abuse. 2. Failure to ensure one (1) of five (5) sampled employees (RN 2) had current training for restraints (devices used to limit a patient’s movement). This deficient practice had the potential for the unsafe environment for patients on restraints. 3. Failure to ensure one (1) of five (5) sampled employees RN 1 was competent to provide treatment for an emergency treatment according to the American Heart Association Advance Cardiac Life Support (ACLS) Guidelines 2023 (Guidelines all certified personnel use in response to heart problems) during a “Code Blue” (used to summon personnel and equipment to the scene of a cardiopulmonary arrest or a life-threatening medical emergency) was not provided to Patient 1. This deficient practice resulted to Patient 1 receiving a shock of 200 Joules (electrical shock administered by electrode pads (chest pads) for ventricular fibrillation [ type of irregular heart rhythm]) that was not indicated for Patient 1, who as asystole (flat line, no electrical activity). Findings: 1. On 1/12/2024, at 3:27 PM, during interview with Human Resources Operation Manager (HR Mgr.) and Director of Human Resources (HR Dir.), HR director stated the following: a. All employees were screened prior to being hired with background checks for criminal history. b. Abuse training was required for all employees, was provided upon hire during orientation, and was done annually, through on-line training. On 1/12/2024, at 6:30 PM, during concurrent interview with HR Dir. and HR Mgr., and record review of personnel files, HR Dir. stated four of five sampled employees (RN 1, RN 8, RN 9, & RN 10) did not have current abuse training. A review of facility’s Abuse, Neglect and Abandonment policy, dated 8/2022, indicated the following: a. All employees will comply with abuse reporting requirements under state and local laws, as mandated reporters, to report witnessed or suspected abuse of a patient. b. Mandated reporter was anyone in their professional capacity or within their scope of employment, who has observed or has knowledge of an incident that reasonably appears to be abuse of neglect must complete a form for each report of known or suspected instance of abuse involving an elder or dependent adult and report to their adult protective services (APS - agency to help elder adults and dependent adults when these adults are unable to meet their own needs, or are victims of abuse, neglect, or exploitation) or local law enforcement. A review of facility’s Competency Assessment policy, dated 3/2023, indicated included the following: a. Competency was part of the performance appraisal system and is assessed upon hire, transfer to a new role, prior to assignment to a new unit, when there is a change in job performance or job requirements and thereafter, on an annual basis. b. Skills selected for competency assessment are determined from organization-wide and department specific, job descriptions, performance evaluations, policies and procedures, additional standards of practice for specialty areas. c. Competency requirements are updated as needed and reviewed annually by the managers, directors or designee, and the education department to reflect changes in performance improvement activities, developments in science and technology, and changing patient care needs. d. Competency verification includes satisfactory annual performance appraisal, observation of required competency skills, verbal interviews demonstrating proficiency in specific knowledge/skills, continuing education and in-services, role and department specific competency/skills demonstration, medical record documentation review. 2. On 1/12/2024, at 4:06 PM, during a concurrent interview with HR Dir. and HR Mgr., and record review of RN 2’s personnel file, HR Dir stated RN 2’s last documentation for restraint training was done on 2/13/2021. On 1/12/2024, at 4:06 PM, during an interview, HR Dir. stated training for restraints was done upon hire, during hospital orientation, and annually, through on-line training. A review of facility’s Competency Assessment policy, dated 3/2023, indicated the following: a. Initial competency assessment begins when the Human Resources Department establishes the educational background, licensure, certification, and previous experiences and references to the job candidate. b. Activities included: orientation, in-service education, equipment in-service, continuing education courses, competency assessment/skills validation, preceptor activities, 90-day, and annual performance review, and participation in performance/quality improvement teams. c. Skills selected for competency assessment are determined from organization-wide and department specific, job descriptions, performance evaluations, policies and procedures, additional standards of practice for specialty areas. d. Competency requirements are updated as needed and reviewed annually by the managers, directors or designee, and the education department to reflect changes in performance improvement activities, developments in science and technology, and changing patient care needs. e. Competency verification includes satisfactory annual performance appraisal, observation of required competency skills, verbal interviews demonstrating proficiency in specific knowledge/skills, continuing education and in-services, role and department specific competency/skills demonstration, medical record documentation review. f. All ongoing competencies must be 100% completed by the end of the designated year. 3. A review of Patient 1’s “Physician Code Blue,” dated 9/18/2023, indicated, reason for code blue was Patient 1 was in full arrest (loss of all heart activity), respiratory arrest (breathing stops), and unresponsive. The note indicated, “Patient is lying on gurney and is unresponsive in full cardiac arrest. No heart sounds heard. CPR (Cardiopulmonary Resuscitation, chest compressions and breathing for a patient that is not breathing and does not have a pulse) in progress ...” During an observation of the nursing station at the BHU, on 1/10/2024 at 2:00 PM with Director of BHU, a crash cart (a cart on wheels with Advance Cardiac Life Support [ACLS] supplies) was observed equipped with a cardiac (heart) monitor with defibrillator (a device that apply an electric charge or current to the heart to restore a normal heartbeat). During a telephone interview, on 1/11/2024 at 8:41 AM, with a Registered Nurse 1 (RN 1) about Patient 1’s code blue incident stated, “The crash cart was there (in Patient 1’s isolation room) when I entered the room. I charged the monitor and selected 200 joules. I interpreted the rhythm (heart rhythm, or heartbeat) and cleared the patient (from other people touching the patient). And shocked the patient at 200 joules with a rhythm of asystole. A patient does not receive a shock at asystole rhythm.” During a telephone interview, on 1/11/2024 at 8:48 a.m., with RN 1, RN 1 stated his ACLS certificate (certificate of competence to provide ACLS care was expired. RN stated his ACLS was expire due to ACLS was not required in the BHU. During a telephone interview, on 1/11/2024 at 9:27 AM, with the Emergency Department Physician Assistant (PA 1), PA 1 stated “Entering the room (Patient 1’s room), RN 1 was delivering the shock.” PA 1 stated “RN 1 was the only one leading prior to my arrival as the higher medical authority. PA 1 stated RN 1 said, “Everyone step away I am giving a shock.” PA 1 stated, asking RN 1, “Why did you give a shock that was asystole?” During an interview, on 1/12/2024 at 10:50 AM with the Director of BHU, Director of BHU stated, “We adhere to American Heart Guidelines for BLS (Basic Life Support) and ACLS ... ACLS certified personnel has the ability (is trained) to interpret EKG (electrocardiogram, a line seen on paper or monitor showing electrical activity through the heart) rhythms ... The expectation is to start CPR (Cardiopulmonary Resuscitation, chest compressions and breathing for a patient that is not breathing and does not have a pulse) immediately. The expectation is to set up the BLS procedures (Basic Life Support, including apply electrode pads) and wait for qualified personnel to interpret the EKG rhythm.” A review of Patient 1’s “Intake Information/Initial Assessment” (Code Blue Document), dated 9/18/2023 at 1651 (4:51 PM), indicated, at “1656 (4:56 PM), Rhythm asystole (no electrical activity to create the heart to mechanically pump), 1 shock delivered,” at “1719 (5:19 PM), Code Stopped (stopped treatment per ACLS guidelines), Disposition (status of Patient 1) Following Code Expired (Dead)”. A review of the facility’s policy and procedure (P&P) titled, “Code Blue” (Cardiopulmonary Resuscitation) dated 9/2022, the P&P indicated, “The term Code Blue will be used to summon personnel and equipment to the scene of a cardiopulmonary arrest or a life-threatening medical emergency ... American Heart Association guidelines will be followed.” A review of American Heart Association Advance Cardiac Life Support Services guidelines (AHA ACLS guidelines) titled, “Adult Cardiac Arrest Algorithm, Asystole/PEA (pulseless electrical activity, heart is not mechanically pumping)” dated 2020 (with 2023 updates), under 9. Asystole/PEA (Pulseless Electrical Activity) treatment intervention was to administer Epinephrine (medication used during emergency to stimulate the heart) response to ASAP (As Soon As Possible) 10. CPR (Cardiopulmonary Resuscitation) 2 minutes (provide CPR for 2 minutes prior to the next step [step 11]).” No shock was indicated asystole. The guideline indicated shock was indicated for ventricular fibrillation (VF, a type of irregular heart rhythm)or ventricular tachycardia (VT, a type of abnormal heart rhythm). A review of facility’s Competency Assessment policy, dated 3/2023, indicated the following: a. Skills selected for competency assessment are determined from organization-wide and department specific, job descriptions, performance evaluations, policies and procedures, additional standards of practice for specialty areas. b. Competency requirements are updated as needed and reviewed annually by the managers, directors or designee, and the education department to reflect changes in performance improvement activities, developments in science and technology, and changing patient care needs. c. Competency verification includes satisfactory annual performance appraisal, observation of required competency skills, verbal interviews demonstrating proficiency in specific knowledge/skills, continuing education and in-services, role and department specific competency/skills demonstration, medical record documentation review. d. All ongoing competencies must be 100% completed by the end of the designated year.”

“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 staff failed provide adequate care according to facility policy and procedure as evidence by: 1. Failure to update and accurately document the medical record information regarding assessment and care provided for three (3) of the thirty (30) sampled patients’ (Patient 11, Patient 12, and Patient 16) in accordance with the facility’s policy and procedure (P&P). a. Patient 11’s fall risk assessment was not updated to reflect that Patient 11 had recently fallen according to facility P&P for fall. b. Patient 12’s fall history assessment was not updated to reflect that Patient 12 had recently fallen according to facility P&P for fall. c. Patient 16’s Code Blue Record (recording of the event during which any patient had an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital-wide alert) was incomplete and contained inappropriate scratching out of writing according to facility P&P for code blue, This deficient practice resulted Patient 11, Patient 12, and Patient 16’s medical record information not accurate and complete. The deficient practice had the potential for the care and safety of patients not appropriately implemented after a fall or an emergency. 2. Failure to immediately initiate a rapid response (a system designed to identify and respond to patients with early signs of clinical deterioration with the goal of preventing respiratory or cardiac arrest [heart stops]) according to facility’s P&P for rapid response (a system designed to identify and respond to patients with early signs of clinical deterioration with the goal of preventing respiratory [lung] or cardiac [heart] arrest) for one (1) of 30 sampled patient (Patient 1), who was found unresponsive. This deficient practice resulted in delay for Patient 1 in receiving Cardiopulmonary Resuscitation (CPR, chest compressions and breathing for a patient that is not breathing and does not have a pulse). Patient 1 eventually died. Findings: 1 a. During a review of Patient 11’s “History and Physical (H&P, a physician’s examination of a patient),” dated 11/10/2023, indicated, Patient 11 was admitted to the facility for psychiatric (mental) evaluation. Patient 11’s medical history included diabetes mellitus (the body is unable regulate blood sugar causing blood sugar levels to be abnormally high), chronic (persisting for a long time) back pain, and urgency of urination (a sudden and strong need to urinate). During a concurrent observation and interview, on 1/9/2024 at 1:49 p.m., with the Administrator (ADM) and the Assistance Chief Nursing Officer (ACNO) in Patient 11’s room, Patient 11 was sitting on the bed. Patient 11 stated, “I fell in the patio while standing up. There were staff nearby and assisted me back onto the seat.” A review of Patient 11’s “Nursing Narrative Note” dated 11/15/2023 at 6:59 a.m., the note indicated, “Patient (Patient 11) was in the Patio for a smoke break. MHW (mental health worker) witnessed the patient (Patient 11) fell on his right shoulder. Assisted patient (Patient 11) to his room and assessed patient for any pain, redness, or injury. No pain, redness or injury noted.” During a concurrent interview and record review of Patient 1’s Morse Fall Scale (a rapid and simple method of assessing a patient’s likelihood of falling), on 1/9/2024 at 3:00 p.m. with the ACNO. Patient 11’s “Morse Fall Scale,” dated 11/15/2023 was reviewed. The ACNO stated the Morse Fall Scale for the morning shift, on 11/15/2023, had a missing entry. ACNO stated, “There should be an update to the patient’s (Patient 11) Morse Fall Risk assessment to indicate that the patient (Patient 11) has fallen.” ACNO stated it (documentation) was important to update Patient 11’s Morse Fall Risk to communicate that the patient (Patient 11) had an increased risk of falling and to increase monitoring to prevent the patient (Patient 11) from falling again. ACNO stated, “A yellow wrist band will be place on the patient’s wrist.” 1. b. A review of Patient 12’s “History and Physical (H&P),” dated 12/14/2023, indicated, Patient 12 was admitted to psychiatric unit (a unit of a general hospital that provides inpatient services for individuals with serious mental illness or serious emotional disturbance) for suicidal ideation (having thoughts about the possibility of ending one’s own life). The H&P indicated Patient 12 has existing edema (a condition characterized by an excess of watery fluid collecting in the tissue) to both lower extremities (the part of the body that includes the hip, thigh, knee, leg, ankle, and foot). During a concurrent observation and interview on 1/9/2024 at 1:40 p.m. with the Administrator (ADM) and the Assistance Chief Nurse Officer (ACNO) in Patient 12’s room, Patient 12 was observed exiting the restroom in a slow motion but was not limping. Patient 12 stated, “I fell in the restroom.” Patient 12 stated he could not recall how he fell. During a concurrent interview and record review on 1/9/2024 at 4:00 p.m. with the ACNO, Patient 12’s “Nursing Narrative Note,” dated 12/16/2023, was reviewed. The note indicated, on 12/15/2023 at 12:23 a.m. Patient 12 fell in the bathroom and hit his head and scrape his elbow. During a concurrent interview and record review of Patient 12’s Morse Fall Scale, on 1/9/2024 at 4:02 p.m. with the ACNO, Patient 12’s “Morse Fall,” ,dated 11/15/2023 was reviewed. The Morse Fall Scale indicated Patient 12 has “No” history of falls. The ACNO stated the Morse Fall Scale should have been updated to indicate “Yes” under “History of Fall,” to indicate that Patient 12 had fallen. The ACNO stated, “It is important to identify that the patient had fallen to communicate to other staff and to individualized interventions to reduce risk and prevent future fall.” During a review of the facility’s P&P titled, “Documentation.” dated September 2022, indicated, “Admission Documentation: the minimum data set required but not limited to those identified below should be assessed and documented/updated in the admission/visit assessment. All entries made by assistive personnel must be validated by a Registered Nurse. The medical record system serves all members of the interdisciplinary team as a source of primary information about the patient, which was changed by further physical and psychosocial assessments and evaluations throughout the patient stay. All Initial assessments completed within 2 hours of admission (full systems [head to toe] including skin, suicide and fall risk), skin integrity, pain, venous thromboembolism (VTE, blot clot in the vein), suicide, potential violence to others, methicillin-resistant Staphylococcus aureus (MRSA, a type of bacteria), acuity, functional status, nutrition and hydration status and learning and communication needs.” A review of the facility’s P&P titled, “Fall Prevention Policy,” dated September 2019, indicated, the facility, “Believes all falls can be prevented by assessing the risk of patients and with the provision of individualized care. When a fall occurs, we are dedicated to reviewing the event and implementing corrective actions to prevent future falls from occurring. The purpose: To establish guidelines for assessing fall risk, implementing standard and individualized interventions to reduce risk, and guide staff on post-fall assessments, interventions, huddles, and follow-up care ...Responsibilities of Staff (Inpatient areas): A nurse assesses every patient for fall risk at every point of entry, every shift, and as needed when the patient’s condition warrants ... Fall Risk Assessment shall be performed as follows: Patients are reassessed for fall risk every shift, with a change in status, upon transfer to another unit by the receiving unit nurse, post-fall, or as the patient’s condition warrants ...Reassessment is performed and documented on the “Shift Assessment” at least once a shift and when patient’s status or condition changes.” 1. c. A review of Patient 16’s “History and Physical (H&P),” dated 10/4/23, indicated Patient 16 was admitted due to a fever and abnormal labs. Patient 16 presented with difficulty breathing and cloudy urine (urine has a hazy or milky color that is not normal, clear, or light yellow and may indicate a urinary infection). A review of Patient16’s “Nursing Narrative Note,” dated 10/6/2023 at 10:53 a.m. the note indicated, “At 1322 (1:22 p.m.), Patient (Patient16) noted with asystole (when the heart’s electrical system fails entirely, which causes the heart to stop pumping) on the monitor. Code [blue was] called and CPR (Cardiopulmonary Resuscitation, an emergency lifesaving procedure) started. Code team (emergency response team) in the room ACLS (Advanced Cardiovascular Life support, a group of procedures and techniques that treat immediately life-threatening conditions) protocol guided by (name of the physician [MD3]) ...” During a concurrent interview and record review of Patient 16’s Code Blue Record, on 1/12/2024 at 4:45 p.m. with the House Supervisor (HS), Patient 16’s Code Blue Record, undated, was reviewed. Patient 16’s Code Blue Record was incompletely filled out. HS read the Code Blue Record and stated, “There is no date; looking at this document (Patient 16’s Code Blue Record), we do not know when this (Patient 16’s Code Blue) occurred; we can’t tell which source of ventilation (the supply of air to the lungs, by means of a machine or device used to support or replace the breathing) the patient (Patient 16) has or has received. The patient (Patient 16) was shocked at 1337 (1:37 p.m.), but we cannot tell what rhythm (heart rhythm or heartbeat) the patient (Patient 16) was in when the shock was delivered. We don’t know how much energy was delivered to the patient (Patient 16), and there is no documentation of the patient’s (Patient 16) condition or response.” HS also stated the document contained scratched-out entries. HS stated, “An incorrect entry should have a line drawn across the incorrect entry with the word “Error” written directly on top.” A review of the facility’s P&P titled, “Code Blue,” dated September 2022, the P&P indicated, “Purpose/ Objective: A patient’s right to accept or refuse medical treatment is fundamental, particularly when faced with a terminal illness; the aim of this policy is to provide a guideline for cardiopulmonary resuscitation while promoting the patient’s right to make decisions regarding his/her healthcare by requesting no resuscitation. To outline the duties and responsibilities of all personnel in maintaining vital functions during the cardiopulmonary arrest of any patient aged 14 and over ... Unit Nurse Manager/Director/Nursing Supervisor ... Receives and reviews the copy of Cardiopulmonary Resuscitation Report and Code Blue Evaluation Form following the code ... Documentation is done on the Cardiopulmonary Resuscitation Report by the designated recorder at the code. This report becomes a permanent part of the chart ...” A review of the facility’s policy and procedure (P&P) titled, “Documentation.” dated September 2022, the P&P indicated, “Document Correction: When an error is made in a handwritten medical record entry, the information may NOT be obliterated or otherwise altered by blacking out the entry with a marker, using white out, writing over the entry, etc. If the error is made when making an entry, draw a single line through the error only, leaving the remainder of the entry documented and write the word error.” 2. A review of Patient 1’s “History of Present Illness,” dated 9/9/2023 indicated, Patient 1 was admitted to the Behavioral Health Unit (BHU, unit dedicated to increasing health related to different behavioral diagnosis) with a diagnosis of “Paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves with feelings of distrustful or suspicious of other people) with acute exacerbation. Patient 1 was at the psychiatric unit (BHU) over the previous 4 weeks. Patient 1 was transferred from BHU to the emergency room because of declining kidney function, aggressive behavior, and noncompliance with care. Patient 1 was restrained prior to transfer because he was physically threatening staff during medical care. Patient 1 was evaluated in the emergency room and magnesium (a mineral need in the body, normal range 1.82 milligram [mg, unit of measurement]/deciliter [dL, unit of measurement] to 2.1 mg/dL)was slightly low and phosphorus (a mineral need in the body to build strong bones and teeth, normal level 2.5 to 4.5 mg/dL) was slightly low and he was treated and medically cleared. Patient 1 was transferred back to the BHU to continue his psychiatric and medical management. During an interview, with the Director of Behavioral Unit (DBHU) on 1/9/2024, at 3:43 p.m., DBHU stated, on 09/18/23, Patient 1 was in the seclusion room with Mental Health Technician 1 (MHT 1). MHT 1 observed Patient 1 lowering himself to the floor, then Patient laid down to the floor. MHT 1 check Patient 1 about 45 seconds to a minute later after Patient 1 laid down on the floor. MHT 1 found Patient 1 to be unresponsive and did not initiate and call rapid response. DBHU stated MHT1 was the first responder and should have called a rapid response upon identifying the patient (Patient 1) to be unresponsive. MHT 1 left Patient 1 and then MHT 1 went to the nurse station to asked for help from Licensed Vocational Nurse 2 (LVN 2). MHT did not indicate the situation was an emergency to LVN 2. LVN 2 went to checked on Patient 1. LVN 2 found Patient 1, Patient 1 was unresponsive, and not breathing. LVN 2 initiated the rapid response. DBHU stated MHT1 was the first responder and should have called a rapid response upon identifying the patient (Patient 1) to be unresponsive. A review of the Patient 1’s, “Nursing Narrative Note,” by LVN 2, dated 9/18/2023 5:45 p.m., indicated on 09/18/2023 at 4:52 p.m., MHT 1 came and stated Patient 1 fell to the floor, LVN 2 ran into the room and observed Patient 1 on the floor. Patient 1’s face was blue, and chest was not raising and falling. LVN 2 informed Charge Nurse to call a rapid response. A review of the facility’s policy and procedure (P&P), titled, “Rapid Response Team,” revised date 07/2022, indicated the purpose was (1) To quickly recognize the patient’s clinical deterioration, (2) To respond quickly and appropriately to adverse changes in the patient’s condition, and (3) To avert inpatient Code Blue situations through timely intervention. The policy also indicates that Rapid Response can be called by any hospital personnel, outside clinical contractor, clinical student, patient, or their family member.”