Kaiser Foundation Hospital - Downey

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient Rights was met, as evidenced by: 1. The facility failed to ensure that the process for prompt resolution of patient grievances, was followed, for one of 30 sampled patients (Patient 1), in accordance with the facility’s policy regarding grievances (grievances are formal complaints made by a patient about care, services, or treatment), when the facility failed to provide a timely acknowledgement letter (an acknowledgement letter is a written notice sent to confirm that the facility received the grievance) after receiving the grievance; and when a resolution letter (the official, written response provided to the person who filed the grievance) was sent out past 30 days. This deficient practice had the potential to cause unresolved concerns for Patient 1’s family, violated Patient 1’s rights to have a timely and reasonable grievance resolution, and had the potential to damage trust in the healthcare system, and may cause emotional distress to Patient 1’s family. (Refer to A-0122) 2. The facility failed to ensure that the exercise for patient’s rights requirements was met, for one of 30 sampled patients (Patient 21), when: -The Nursing Staff failed to recognize, escalate (recognizing that a patient’s medical condition is worsening and bringing in higher levels of care, or activating a “chain of command” when there are unresolved conflicts, safety concerns, or communication breakdowns ), and appropriately respond to abnormal fetal heart tones (FHT, fetal heart tracings are the continuous recordings of the baby’s heart rate used to assess oxygenation [process to take in oxygen from the air, carry it through the bloodstream] and well-being), including sustained Category III patterns (abnormal non reassuring heart monitor pattern indicating baby may not be getting enough oxygen) from approximately 4:00 a.m. to 4:30 a.m. and 6:11 a.m. to 6:27 a.m. (on 12/23/2025). -The nursing staff did not notify the physician regarding changes in Patient 21’s unborn baby’s condition, at required intervals, in accordance with the facility’s policy and procedure (P&P) titled “Communication and Escalation Policy.” - The attending physician (MD 4) failed to accurately interpret fetal monitoring strips (display the FHT) and did not take immediate action to initiate an urgent cesarean section (a cesarean section is a surgical procedure to deliver a baby through incisions in the abdomen and uterus, performed when a vaginal delivery would be unsafe or too slow); - Oxytocin (referred as Pitocin [medication to induce labor -progressive contractions of the uterus- in pregnant women]) was administered, despite the presence of late decelerations (late decelerations are drops in the baby’s heart rate occurring after a contraction [the involuntary tightening and relaxing of the uterine muscles. These movements prepare the body for birth, help open the cervix, and push the baby down the birth canal], often indicating the baby is not receiving enough oxygen), contrary to facility protocol for Pitocin administration, thus increasing the risk of fetal hypoxia (fetal hypoxia means the baby is not getting enough oxygen, which can cause brain injury or other serious harm). These deficient practices resulted in Patient 21 and Patient 21’s baby, being placed at significant risk for serious harm and had possibly contributed to Patient 21’s baby being born with hypoxic Ischemic encephalopathy (HIE, a type of brain injury caused by lack of oxygen and blood flow around the time of birth), suspected subgaleal hemorrhage (a rare but life-threatening bleeding condition where blood collects between the scalp and skull), and respiratory distress (difficulty breathing, which may include fast breathing, gasping, or signs of not getting enough oxygen). (Refer to A-0129) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 36206 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by: 1. The facility failed to ensure nursing staff documented the meal intake (amount of food taken in) for two of 30 sampled patients (Patients 9 and 10), in accordance with the facility’s policy and procedure (P&P) titled, “Patient Admission Assessment, Reassessment and Plan of Care Standard,” when: 1.a. Patient 9 did not have dinner documented for two days 1.b. Patient 10 did not have several meals documented for 10 days These deficient practices had the potential for Patient 9 and 10’s nutrient consumption and worsening health condition to remain undetected and not promptly addressed with medication and fluid adjustments or supplemental nutrition. (Refer to A-0395) 2. The facility failed to ensure one of 30 sampled patient’s (Patient 21) fetal (unborn baby) heart tone tracing strips (FHT, recorded patterns of the baby’s heart rate. Health care providers track FHT during labor [the process when the unborn baby moves out through the birth canal] to ensure the baby is healthy, tolerating contractions [the involuntary tightening and relaxing of the uterine muscles. These movements prepare the body for birth, help open the cervix, and push the baby down the birth canal] well and getting enough oxygen ), which showed concerning abnormal changes including indications of Category 3 (abnormal non reassuring heart monitor pattern indicating the baby may not be getting enough oxygen) patterns, which indicated a compromised fetal well-being, was correctly assessed, identified, and escalated (recognizing that a patient’s medical condition is worsening and bringing in higher levels of care, or activating a “chain of command” when there are patient safety concerns) promptly to the physician, in accordance with the facility’s policies and procedures regarding fetal assessment and monitoring and “Communication and Escalation Policy.” This deficient practice had the potential to delay the deployment of life-saving treatments and place Patient 21 and Patient 21’s unborn baby at significant risk for harm including fetal demise (death). (Refer to A-0395) 3. The facility failed to ensure one of 30 sampled patient’s (Patient 12) pain level was assessed prior to and 30 minutes after administering a pain medication, fentanyl (a highly potent synthetic opioid), in accordance with the facility’s policy and procedure regarding pain management. Patient 12 was already receiving a continuous dose of fentanyl and received 3 additional doses of fentanyl without a pain assessment. This deficient practice had the potential for administering fentanyl unnecessarily, which could cause lethargy (state of being sluggish, drowsy, or lacking energy) and respiratory depression (breathing is too slow or shallow, causing oxygen levels to drop) for Patient 12. (Refer to A-0395) 4. The facility failed to ensure Oxytocin (referred as Pitocin [medication to induce labor -progressive contractions of the uterus- in pregnant women]), was appropriately administered, based on the facility’s protocol or criteria for Pitocin administration, for one of 30 sampled patients (Patient 21), when Patient 21 was in active labor (means the cervix [the opening to the uterus] is dilating quickly, contractions [tightening of the muscles in the uterus] are strong and regular, and the body is preparing for birth) and was having late decelerations (temporary, gradual drops in a baby’s heart rate that occur after a uterine contraction has peaked. They are the most concerning type of fetal heart rate deceleration because they typically signal uteroplacental insufficiency-meaning the placenta is not providing enough blood or oxygen to the fetus [unborn baby]), in accordance with the facility’s oxytocin protocol titled “Optimizing Induction of Labor Progress for Vaginal Birth.” This deficient practice had the potential for Patient 21 to have a uterine hyperstimulation (excessive contractions of the uterus) thus reducing oxygen flow to Patient 21’s fetus (unborn baby), and potentially resulting in Patient 21’s unborn baby’s fetal distress (a condition during pregnancy or labor in which the fetus shows signs of inadequate oxygenation) including the potential for Patient 21’s uterine rupture (uterus or womb [a hollow, pear-shape organ in the female reproductive system] tears open during labor or pregnancy). (Refer to A-0405) 5. The facility failed to ensure one of 30 sampled patients (Patient 12, a premature infant), received the correct dose of a continuous drip of fentanyl (a highly potent synthetic opioid), when starting a new syringe and during nursing handoff, in accordance with the physician’s order and the facility’s policy and procedure regarding high alert medication (drugs that bear a heightened risk of causing significant patient harm or fatal errors when used incorrectly) administration and medication administration. This deficient practice resulted in Patient 12 receiving ten (10) times the ordered amount of fentanyl for 13.5 hours (hr) and potentially caused Patient 12 to have respiratory distress (difficulty breathing presenting signs and symptoms such as shortness breath, gasping for breath and hyperventilation [rapid breathing]), required bagging (using a handheld device to provide manual, forced respiration for a patient in respiratory distress or failure) and the administration of two rescue medications Narcan (or naloxone, a life-saving medication designed to rapidly reverse an opioid overdose) and vecuronium (a medication used to induce muscle relaxation during surgery or mechanical ventilation). (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 31333 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Pharmaceutical Services was met, as evidenced by: 1. The facility failed to prevent, identify and minimize patient harm as it related to the use and monitoring of a high risk medication (drugs that bear a heightened risk of causing significant patient harm or fatal errors when used incorrectly), fentanyl (opioid pain medication that is 100 times more potent than morphine), for one of 30 sampled patients (Patient 12, who was a premature infant). The hospital failed to implement its policy on high-risk/high-alert medications to incorporate external alerts and internal respective review to identify opioids, including fentanyl, as high-risk/high-alert medications and develop safeguards to reduce the risk of errors. The hospital also did not take appropriate actions to prevent future adverse drug events after pharmacy services dispensed fentanyl refill, too early (the syringe must be replaced every 24 hours, and any leftover medication in the syringe discarded), 10.5 hours after the initial dose was dispensed, without ensuring that the refill was appropriate to dispense to Patient 12. As a result, the pharmacist did not review or question the refill ordered by nursing staff. The Fentanyl was not due based on the syringe containing a volume of 5 ml (5 micrograms [mcg] per ml = 25 mcg/5 ml). The Fentanyl syringe (containing 5 ml) should have lasted for five days. The pharmacist dispensed a dose of Fentanyl too soon (in less than 24 hours), and Patient 12, a 25-week premature infant, who was actually receiving an incorrect dose (10 times the ordered dose) of fentanyl. This deficient practice resulted in Patient 12 receiving the wrong dose of fentanyl for 13.5 hours (hr) and caused Patient 12 to experience respiratory distress (difficulty breathing presenting signs and symptoms such as shortness breath, gasping for breath and hyperventilation [rapid breathing]) and required bagging (using a handheld device to provide manual, forced respiration for a patient in respiratory distress or failure) and the administration of two rescue medications Narcan (or naloxone, a life-saving medication designed to rapidly reverse an opioid overdose) and vecuronium (a medication used to induce muscle relaxation during surgery or mechanical ventilation), to recover. This failure compromised the hospital’s ability to prevent serious patient harm from medication errors involving known high-risk medications. (Refer to A-0491) 2. The facility failed to ensure one (1) of 30 sampled patients (Patient 12), received fentanyl (a potent opioid to treat pain and to keep patient at a desired sedation level while on mechanical ventilation) continuous intravenous (into the veins, IV) infusion (drip) as ordered by the physician. This deficient practice had the potential for life-threatening symptoms such as slow, shallow or completely stopped breathing, that may affect the patient’s health condition and require immediate intervention. (Refer to A-0500) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that the process for prompt resolution of patient grievances, was followed, for one of 30 sampled patients (Patient 1), in accordance with the facility’s policy regarding grievances (grievances are formal complaints made by a patient about care, services, or treatment), when the facility failed to provide a timely acknowledgement letter (an acknowledgement letter is a written notice sent to confirm that the facility received the grievance) after receiving the grievance; and when a resolution letter (the official, written response provided to the person who filed the grievance) was sent out past 30 days. This deficient practice had the potential to cause unresolved concerns for Patient 1’s family, violated Patient 1’s rights to have a timely and reasonable grievance resolution, and had the potential to damage trust in the healthcare system, and may cause emotional distress to Patient 1’s family. Findings: During a review of Patient 1’s History and Physical (H&P, History and Physical examination- a formal and complete assessment of the patient and the problem), dated 12/29/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath and weakness, and had past medical history (PMH, previous or existing medical conditions) of hypertension (high blood pressure), hyperlipidemia (high levels of fats such as cholesterol in the blood), COPD (chronic obstructive pulmonary disease, a long-term lung condition that makes it hard to breathe), asthma, and chronic hypoxemic respiratory failure (a long-term condition in which the body does not get enough oxygen). During an interview on 5/4/2026 at 10:50 a.m. with the Compliance Consultant for Member Operations (CCMO), CCMO said that multiple grievances (formal complaints made by members) were received by the facility after Patient 1’s passing in February 2025. CCMO said, “One of the grievances was received on November 22 [2025], but there was a delay in the acknowledgement letter being sent out to the complainant...” CCMO then verified that the acknowledgement letter (a written notice confirming that the facility received the complaint) should be sent out within 5 calendar days in accordance with the facility’s policy. During the same interview on 5/4/2026 at 10:50 a.m. with the Compliance Consultant for Member Operations (CCMO), CCMO said another grievance was received in January 2026 (1/7/2026), and there was a timely acknowledgement letter sent out to the complainant within 5 calendar days, but the resolution letter was sent out late on April 17, 2026. CCMO said, “April 17 [2026] resolution letter was sent out late. There was a delay in sending the resolution letter to the complainant,” and stated “it was not timely, past the 30-day time frame.” CCMO explained the importance of the 30-day time frame per policy guidelines and regulatory requirements and said the facility should respond on time. CCMO also verified that the resolution letter was mailed past beyond 44 days [even if the extension was applied that allowed 14 days extension to continue the investigation]. CCMO added that the goal was to support member satisfaction and keep up with required time frames. During a review of the facility’s policy and procedure (P&P) titled Hospital Patient Grievance Policy, dated 11/2025, the policy indicated that “Grievance - (An issue, concern, or complaint, whether expressed verbally or in writing, related to any aspect of care, abuse, neglect, or harm arising in connection with a patient’s hospital services utilization.) referred to Member Services will be resolved within the time frames [not listed in the policy ...].” During a review of the facility’s policy and procedure (P&P) titled “Medicare Part C Grievance and Appeals,” dated 7/2018, the policy indicated that “Acknowledgement: All grievances ... will be acknowledged either verbally or in writing... Written acknowledgement will be provided by using the approved acknowledgement letter template within 5 calendar days from the date of contact... Resolution: A resolution letter will be sent on all cases that require written resolution notification... and should be done within 30 calendar days from receipt... or 44 days if an extension is applied... [14-day extension is allowed].””

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 50594 Based on interview and record review, the facility failed to ensure that the exercise for patient’s rights requirements was met, for one of 30 sampled patients (Patient 21), when: -The Nursing Staff failed to recognize, escalate (recognizing that a patient’s medical condition is worsening and bringing in higher levels of care, or activating a “chain of command” when there are unresolved conflicts, safety concerns, or communication breakdowns ), and appropriately respond to abnormal fetal heart tones (FHT, fetal heart tracings are the continuous recordings of the baby’s heart rate used to assess oxygenation [process to take in oxygen from the air, carry it through the bloodstream] and well-being), including sustained Category III patterns (abnormal non reassuring heart monitor pattern indicating baby may not be getting enough oxygen) from approximately 4:00 a.m. to 4:30 a.m. and 6:11 a.m. to 6:27 a.m. (on 12/23/2025). -The nursing staff did not notify the physician regarding changes in Patient 21’s unborn baby’s condition, at required intervals, in accordance with the facility’s policy and procedure (P&P) titled “Communication and Escalation Policy.” - The attending physician (MD 4) failed to accurately interpret fetal monitoring strips (display the FHT) and did not take immediate action to initiate an urgent cesarean section (a cesarean section is a surgical procedure to deliver a baby through incisions in the abdomen and uterus, performed when a vaginal delivery would be unsafe or too slow); - Oxytocin (referred as Pitocin [medication to induce labor -progressive contractions of the uterus- in pregnant women]) was administered, despite the presence of late decelerations (late decelerations are drops in the baby’s heart rate occurring after a contraction [the involuntary tightening and relaxing of the uterine muscles. These movements prepare the body for birth, help open the cervix, and push the baby down the birth canal], often indicating the baby is not receiving enough oxygen), contrary to facility protocol for Pitocin administration, thus increasing the risk of fetal hypoxia (fetal hypoxia means the baby is not getting enough oxygen, which can cause brain injury or other serious harm). These deficient practices resulted in Patient 21 and Patient 21’s baby, being placed at significant risk for serious harm and had possibly contributed to Patient 21’s baby being born with hypoxic Ischemic encephalopathy (HIE, a type of brain injury caused by lack of oxygen and blood flow around the time of birth), suspected subgaleal hemorrhage (a rare but life?threatening bleeding condition where blood collects between the scalp and skull), and respiratory distress (difficulty breathing, which may include fast breathing, gasping, or signs of not getting enough oxygen). Findings: During a review of Patient 21’s obstetric (OB, care related to pregnancy, labor, and childbirth) admission History & Physical (H&P, a medical note that reviews the patient’s health history and current condition to guide care), dated 12/20/2025, the H&P indicated Patient 21 was admitted on 12/20/2025 at 11:58 a.m. to the facility for labor induction (labor induction means starting labor using medications or other methods) due to type 2 Diabetes Mellitus (DM, a long?term condition where the body cannot control blood sugar well). The H&P further indicated that on admission (12/20/2025), the fetal (baby) heart tone monitoring (FHT monitoring means continuously checking the baby’s heart rate and the mother’s contractions [tightening of the muscles in the uterus] to assess the baby’s well-being) indicated the baby was well oxygenated. The H&P also indicated that Patient 21 was not in active labor (the physiological process of childbirth) on admission. During a review of Patient 21’s “Progress Notes,” dated 12/22/2025 at 11:41 p.m., the progress notes indicated Patient 21’s membrane status was grossly ruptured (refers to the amniotic sac [a thin, tough, and transparent pair of membranes that holds a developing fetus and amniotic fluid inside the uterus during pregnancy, meaning whether the “water” is still intact or has ruptured). During a review of Patient 21’s “Flowsheets,” dated 12/22/2025, the progress notes indicated that at 11:57 p.m., Patient 21 was actively pushing (This phase begins when the cervix is fully dilated [10 centimeters] and ends with the delivery of the baby). During a concurrent interview and record review on 4/29/2026 from 10:23 a.m. -12:11 p.m. with the Assistant Clinical Director (ACD 1), the Director of Perinatal Services (DIR 2), and Registered Nurse (RN) 7, Patient 21’s Fetal Heart Tones tracing strips (FHT, recorded patterns of the baby’s heart rate tracked during labor to ensure the baby is healthy, tolerating contractions well and getting enough oxygen) record, dated from 12/22/2025 at 11:00 p.m. to 12/23/2025 at 4:30 a.m., was reviewed. The ACD 1 reviewed the FHT tracings strips from 12/22/2025 starting at 11:00 p.m. and verified that Patient 21 was in active labor (active labor means the cervix is dilating quickly, contractions are strong and regular, and the body is preparing for birth). The ACD 1 further stated: -“Patient (Patient 21) is ready to push (This phase begins when the cervix is fully dilated [10 centimeters] and ends with the delivery of the baby)... fully dilated (the cervix [the opening to the uterus] has opened to 10 centimeters about 4 inches wide), fully effaced (cervix has fully thinned out in preparation for childbirth) - patient (Patient 21) being complete - ready for delivery, can start pushing. Physician does not have to be in the room but should be notified ...nurses document the pushing part in the medical record.” -The ACD 1 then verified that the Obstetrician (OB, a physician who specializes in labor and delivery) physician (MD 7, the provider responsible for Patient 21’s care), was notified on 12/22/2025 at 11:57 p.m. that Patient 21 started pushing and that the baby was doing well (moderate variability means the baby’s heart rate shows healthy changes, which indicates the baby is well?oxygenated and tolerating labor). -ACD 1 and RN 7 continued the interpretation of Patient 21’s FHT tracing strips and the timeline of events on 12/22/2025, and stated the following: -“At 11:57 p.m. (12/22/2025), patient (Patient 21) started pushing. The FHT indicated Category II tracing strips (neither perfectly normal nor definitely abnormal, but requires closer monitoring), late deceleration (are drops in the baby’s heart rate that happen after a contraction and can mean the baby is not getting enough oxygen), baby has reserved variability (refers to small, beat-to-beat fluctuations in a baby’s heart rate) and contractions (the involuntary tightening and relaxing of the uterine muscles. These movements prepare the body for birth, help open the cervix, and push the baby down the birth canal) at 3-4 minutes. -At 12:15 a.m. (on 12/23/2025), FHT Category II, patient (Patient 21) continuing to push, moderate variability (means the baby’s heart rate shows healthy changes, which indicates the baby is well-oxygenated and tolerating labor), deceleration (refers to a temporary drop in baby’s heart rate and below the normal baseline), and no urgency for C-section (cesarean section, is a surgical procedure used to deliver a baby). -At 12:30 a.m. (12/23/2025) -patient (Patient 21) was now in Second stage of labor (when the cervix is fully dilated 10 cm [centimeters, a unit of measure], and ends with the birth of the baby, with active pushing), and with moderate variability (fetus is adequately oxygenated and healthy). -At 12:45 a.m. (12/23/2025), A combination of early (temporary, gradual drops in a baby’s fetal heart rate that happen at the exact same time as a uterine contraction. They mirror the contraction perfectly-starting, reaching their lowest point, and recovering just as the contraction ends) and late deceleration (temporary, gradual drops in a baby’s heart rate that occur after a uterine contraction has peaked. They are the most concerning type of fetal heart rate deceleration because they typically signal uteroplacental insufficiency-meaning the placenta is not providing enough blood or oxygen to the fetus) could be seen, heart rate 150s to 160s., but still early to call for C-section. -At 12:59 a.m. (12/23/2025), At 1 hour mark, patient’s (Patient 21’s) fetal heart rate going down, with variability and contraction are still okay.” During the same concurrent interview and record review on 4/29/2026 from 10:23 a.m-12:11 p.m. with the Assistant Clinical Director (ACD 1), the Director of Perinatal Services (DIR 2), and Registered Nurse (RN) 7, Patient 21’s Fetal Heart Tones tracing strips record, dated from 12/22/2025 at 11:00 p.m. to 12/23/2025 at 4:30 a.m., was reviewed. ACD 1 and RN 7 then continued interpretation of Patient 21’s FHT tracing strips and the timeline of events on 12/23/2025, and stated the following: “-At 1:14 a.m. (12/23/2025), Contractions with moderate variability (indicated that Patient 21’s fetus [unborn baby] was still well oxygenated and doing well) -At 1:52 a.m. (12/23/2025), Registered Nurse (RN 12) started the Pitocin (also called Oxytocin and used to induce labor [to help start childbirth]) at a rate of 2 milliliters (ml, unit of measure) per hour through an intravenous line (IV, into the vein) as ordered by the physician.” -RN 7 stated that right before administering Pitocin (at 1:52 a.m.) to Patient 21 (the mother), Patient 21’s unborn baby showed late decelerations (are drops in the baby’s heart rate that happen after contraction and can mean the baby is not getting enough oxygen). RN 7 then stated that starting Pitocin with late decelerations present, may result in fetal hypoxia (means the baby is not getting enough oxygen, which can be dangerous). -ACD 1 stated, “Two nurses must sign for Pitocin (a high-alert medication, a drug that bears a heightened risk of causing significant patient injury or death when misused or administered incorrectly), because it must be verified by two nurses before use. The patient (Patient 21) did not meet the criteria for Pitocin because there were late decelerations after contractions (late decelerations occur when the baby’s heart rate drops after the contraction, which can show the baby is not getting enough oxygen). According to the criteria, there must be no late decelerations for 30 minutes before Pitocin could be started.” -ACD 1 also stated that the reason Pitocin should not be started (when there is a late deceleration) was because of uterine-placental insufficiency (this means the placenta is not delivering enough oxygen to the baby). During contractions, the baby gets even less oxygen. Adding Pitocin would make the contractions stronger and more frequent, which placed more stress on the baby. The verifier must also check that the patient met all the criteria before Pitocin was started. ACD 1 then added that moving forward, “we will ensure that the laminated algorithm (regarding Pitocin administration) is placed in each room (referring to the L&D patient rooms). As part of the audit, the Pitocin protocol must be followed because we found that the order was not followed.” During a concurrent interview and record review on 4/29/2026 from 10:23 a.m. to 12:11 p.m. with the Assistant Clinical Director (ACD 1), the Director of Perinatal Services (DIR 2), and Registered Nurse (RN) 7, Patient 21’s Fetal Heart Tones tracing strips record, dated from 12/22/2025 at 11:00 p.m. to 12/23/2025 at 4:30 a.m., was reviewed. ACD 1 and RN 7 continued the interpretation of Patient 21’s FHT tracing strips and the timeline of events on 12/23/2026 and stated the following: “On 12/23/2025 at 2:01 a.m. - patient (Patient 21) was in active labor for 2 hours.” -ACD 1 said that if the baby’s heart rate pattern (the strip) showed Category II (meaning the baby’s heart rate was not completely normal but not dangerous and needed close watching), but still had variability (fluctuations in the baby’s heart rate), and the baby seemed to be doing well, the nurse should have called and updated the doctor. ACD 1 then stated that if the baby was not improving or labor was not moving forward, the nurse should have the doctor go to the patient’s bedside right away. ACD 1 also said that there was no documentation indicating that the nurse (RN 12) contacted the physician at the 2-hour mark and updated the MD about the progression of labor for Patient 21. -ACD 1 then reviewed the strip on 12/23/2025 at 3:09 a.m. and said that Patient 21 was now at the 3rd hour mark. ACD 1 stated per nursing notes, physician was notified by the nurse that Patient 21 had been pushing for three hours, and said, “Station still at 2+ (this means the lowest part of Patient 21’s baby’s head has moved 2 centimeters below the mother’s ischial spines, which are bony points in the pelvis used to measure how far the baby has descended during labor). When the station stays the same, the physician will come to the bedside to reassess (the doctor will check the baby’s position, the mother’s progress, and decide what care or actions are needed next).” -ACD 1 then continued, “On 12/23/2025 at 3:12 a.m., Charge Nurse (CN 3) was at the bedside pushing with the patient (Patient 21) ... and at 3:21 a.m. (12/23/2025), the baby (Patient 21’s unborn baby) was still showing good variability (good variability means the baby’s heart rate is making healthy, normal changes, which shows the baby is getting enough oxygen) with deeper variables (are abrupt, jagged drops in the baby’s heart rate) indicating she (Patient 21’s unborn baby) was coming down lower.” - ACD 1 stated that at 3:28 a.m. (12/23/2025), Patient 21’s unborn baby started showing prolonged deceleration (means the baby’s heart rate dropped lower than normal and stayed low for a longer time) and variability was low (low variability means the baby’s heart rate was not making healthy changes, which can show the baby is not getting enough oxygen). ACD 1 said that “prolonged decelerations most likely indicated that the baby (Patient 21’s unborn baby) was no longer tolerating the pushing, had less oxygen, and was beginning to struggle... the baby’s heart rate was still slowly picking up [after each contraction] ...” ACD 1 also said that Patient 21 who had been pushing for 3 ½ hours appeared to also be getting tired. During the same concurrent interview and record review on 4/29/2026 from 10:23 a.m. -12:11 p.m. with the Assistant Clinical Director (ACD 1), the Director of Perinatal Services (DIR 2), and Registered Nurse (RN) 7, Patient 21’s Fetal Heart Tones tracing strips record, dated from 12/22/2025 at 11:00 p.m. to 12/23/2025 at 4:30 a.m., was reviewed. ACD 1 and RN 7 then stated: “-From 3:39-3:41 a.m. (2 minutes of deceleration) on 12/23/2025, the patient’s (Patient 21’s) baby’s heart rate was showing a deceleration. The longer the deceleration, the deeper the drop in the heart rate tracing, and this meant the baby had to work harder and wait longer to get oxygen. The baby was losing reserve (reserve means the baby’s ability to tolerate stress), and the baby was becoming tired. There should be a concern for the baby (Patient 21’s unborn baby) and the physician was called at 3:09 a.m. and should have been at bedside already, but no documentation indicated that the physician was at (Patient 21’s) bedside...” -At 4:00 a.m. (12/23/2025), the baby (Patient 21’s unborn baby) started showing minimal to absent variability (Absent variability in a fetal heart rate means there are no detectable, beat-to-beat fluctuations in the baby’s baseline heart rate. It is an abnormal (Category III) heart rate pattern that can signal fetal distress, often indicating that the fetus is not receiving enough oxygen), which meant Category 3 (is the most serious fetal heart rate pattern, it shows that the baby is not getting enough oxygen, the heart rate is abnormal, and immediate evaluation and delivery are required). ACD 1 said, “At this time, Category 3 means the baby’s oxygenation was compromised. According to the algorithm (regarding administration of Pitocin), the baby had to be delivered sooner rather than later. If not a ‘crash’ C-section (formally known as a Category 1 Cesarean section, is an extremely urgent, life-saving surgery. It is performed when a mother or her baby is in immediate, severe danger and a baby needs to be delivered in minutes rather than hours), then an urgent C-section within 30 minutes ...” During an interview on 4/29/2026 at 11:47 a.m. with the Assistant Clinical Director (ACD 1), ACD 1 verified that despite evidence of a Category III tracing between 4-4:30 a.m. (on 12/23/2025)), and even though the fetal heart rate variability returned, and there was a change in the fetal baseline heart rate (FHT decreased), there was no escalation by the nursing staff or the physician to have the baby (Patient 22) delivered as soon as possible. During further interview and record review on 4/29/2026 at 11:48 a.m. with the Assistant Clinical Director (ACD 1), the Director of Perinatal Services (DIR 2), and Registered Nurse (RN) 7, Patient 21’s Fetal Heart Tones tracing strips records, dated from 12/22/2025 at 11:00 p.m. to 12/23/2025 at 4:30 a.m., were reviewed and verified. The record indicated the following: -On 12/23/2025 at 4:31 a.m., the Obstetrician physician (OB, physician who specializes in labor and delivery) (MD 4), was documented to be at (Patient 21’s) bedside. Per MD 4, Patient 21 should go for a C-section at 6 a.m. (on 12/23/2025). During a review of Patient 21’s Multi-Discipline Progress Notes, dated 12/23/025 at 4:50 a.m., the note indicated that per charge nurse (CN 3), “...Spoke to MD (Medical Doctor, MD 4) to verify if c/s (c-section) was urgent or stat (immediately or as soon as possible). MD (MD 4) stated have her (Patient 21) in the back (referring to the Operating Room) for incision (cut in the abdomen) to be at 0600 (6 a.m.) after Unasyn (medication to kill bacteria) is administered.” During a review of Patient 21’s “MD Progress Note,” dated12/23/2025 at 5:11 a.m., the note indicated that Patient 21 had been pushing for four hours without any change in the baby’s position. The note also indicated that an ultrasound (a noninvasive imaging test that uses high-frequency sound waves to capture real-time pictures or videos of the inside of the body) was done using a transperineal approach (means the probe was placed on the skin between the vagina and the anus; In pregnant women, it is primarily used to monitor the progress of labor and evaluate the pelvic floor muscles). The provider (MD 4) documented that an operative vaginal delivery was not recommended. The note also indicated the following: the baby’s heart rate pattern was Category II (meaning the baby’s heart rate was not completely normal but not dangerous and needed close watching), and the mother appeared extremely tired but the baby was not showing signs of low oxygen or acidosis (occurs when the lungs can’t efficiently remove enough carbon dioxide [an acid] from the body) and because labor was no longer progressing in the second stage (begins when the cervix is completely dilated [10 centimeters] and ends with the birth of the baby), a cesarean section was recommended. During a concurrent interview and record review on 4/29/2026 at 11:50 a.m. with the Assistant Clinical Director (ACD 1) and the Director of Perinatal Services (DIR 2), Patient 21’s baby’s FHT strip, dated 12/23/2025, was reviewed. The record indicated the following: - at 6:11 a.m., the FHT strip indicated Absent Variability (the FHT monitor strip shows a flat line with no detectable fluctuations around the baseline, often indicating fetal distress [a general term used when an unborn baby [fetus] shows signs of trouble, most commonly because they aren’t getting enough oxygen during pregnancy or labor]). -at 6:27 a.m., Patient 21’s FHT strip indicated Category 3- Absent Variability. -at 6:44 a.m., Patient 21’s baby was delivered via C section. -ACD 1 explained that, looking back, the baby’s heart rate strip should have been labeled as Category III, which was the most serious type of fetal heart rate pattern. A Category III strip meant the baby may not be getting adequate oxygen and a crash C-section should have been done right away (A crash C-section means an emergency C-section done immediately to protect the baby because every minute matters). During a review of Patient 21’s baby’s NICU (Neonatal Intensive Care Unit, specialized hospital department for premature, low birth weight, or critically ill newborns) admission note, [undated], the NICU admission note indicated that Patient 21’s baby was born with Hypoxic Ischemic Encephalopathy (HIE2, a moderate type of brain injury that happens when a baby’s brain doesn’t get enough oxygen or blood flow around the time of birth), suspected subgaleal hemorrhage (rare but life?threatening emergency in newborns where blood collects between the scalp and skull) and respiratory distress (difficulty breathing presenting signs and symptoms such as shortness breath, gasping for breath and hyperventilation [rapid breathing]). During a concurrent interview and record review on 4/29/2026 at 11:53 a.m. with the Director of Perinatal Services (DIR 2), the Assistant Clinical Director (ACD 1), and Registered Nurse (RN 7), they confirmed that from 4:00 a.m. to 4:30 a.m. on 12/23/2025, Patient 21’s fetal heart tracing was Category III. ACD 1 stated that the charge nurse (CN 3) and the primary nurse (RN 12) did not identify this fetal heart tracing correctly. DIR 2 stated that during the facility’s internal investigation (an internal review by the hospital to find out what went wrong and why), several failures were found as follows: -One major issue was that the physician (MD 4) was not called at multiple times (when there were abnormalities in Patient 21’s FHT strips) when the physician notification should have been done: not at the 3-hour mark of labor, and not between 4:00 a.m. and 4:30 a.m. when the Category III tracings appeared. -More Category III tracings were again seen from 6:11 a.m. to 6:27 a.m. on 12/23/2025. -ACD 1 said that MD 4 arrived at the bedside at 4:31 a.m., did an ultrasound, but documented the fetal tracing as Category II in the progress note and ordered preparation for a routine (non-urgent) C-section. ACD 1 added that the charge nurse (CN 3) spoke with MD 4 to confirm that a non?urgent C-section was planned. -ACD 1 explained that if the Category III strip had been recognized at the time (4 a.m. on 12/23/2025), the team would have activated an emergency crash C-section and acted immediately. Because Category III was not correctly identified, there was a delay in the C-section. DIR 2 stated that proper recognition would have allowed staff to respond promptly. During an interview on 4/29/2026 at 10:03 a.m. with DIR 2, DIR 2 stated that it was important to notify the physician of any abnormalities so that the physician could evaluate the patient and determine the appropriate course of action. DIR 2 explained that abnormal vital signs must be reported to determine the next steps in treatment, to modify or update treatment plan of care. DIR 2 stated that in the L&D (Labor and Delivery Unit), vital signs check included fetal assessment. DIR 2 stated that the expectation was for the primary nurse to know how to read and interpret the fetal heart tracing (FHT) strip and to notify the charge nurse and the physician. DIR 2 stated that gaps were identified in how FHT tracing strips were interpreted and in the management of patient care for Patient 21. During an interview on 4/29/2026 at 2:11 p.m. with DIR 2, DIR 2 stated that the Assistant Administrator for Patient Safety and Quality (AAPSQ) and the team (the Patient Safety and Quality team), created a CSA (Comprehensive System Analysis) Action Plan, which was a strategic plan designed to meet specific goals. DIR 2 explained that the facility held critical event training once a month for Labor and Delivery staff, which included reviewing fetal heart rate (FHT) strips and participating in mock codes, which were practice drills for medical emergencies. DIR 2 stated that the action plan required staff to have AWHONN (the Association of Women’s Health, Obstetric and Neonatal Nurse provides several advanced training and certification programs for nurses to expand their clinical skills) certification. DIR 2 also stated that L&D staff were required to review the fetal heart rate attestation and algorithm. DIR 2 said the algorithm was now posted in the unit and that information about Pitocin and fetal monitoring was available in each room (referring to the L&D rooms). DIR 2 added that an audit tool was required for 30 patients, regardless of their condition or stage of labor. During an interview on 4/29/2026 at 2:39 p.m. with the Assistant Administrator for Patient Safety and Quality (AAPSQ) and the Educator (ED), AAPSQ stated that the 2026 plan included staff education, fetal monitoring training, and simulation (a controlled activity that imitates real-world emergencies or scenarios to test preparedness) exercises. During an interview on 4/30/2026 12:04 p.m. with the Chief Physician of Obstetrics (MD 1) and the Assistant Administrator for Patient Safety and Quality (AAPSQ), the Chief Physician of Obstetrics (MD 1) stated that the physician (MD 4) was referred to peer review (an internal hospital process where other physicians evaluate a doctor’s clinical decisions and actions to determine whether the care provided met accepted standards, and to identify any needed improvements, education, or corrective actions). During the same interview on 4/30/2026 at 12:04 p.m. with MD 1, MD 1 stated that by the fourth hour of a Category 3 FHT tracing strip, the physician (MD 4) should have been informed of the fetal status, including if fetus had reverted (returned to a normal or safer heart rate pattern after previously having an abnormal or concerning pattern) and should not wait two hours to perform the cesarean section. During an interview on 4/30/2026 at 12:40 p.m. with the Chief Physician of Obstetrics (MD 1), Neonatologist (MD 2), Neonatologist (MD 3), Physician of Risk and Patient Safety (MD 6), and the Assistant Administrator for Patient Safety and Quality (AAPSQ), no comments or details were provided regarding the internal investigation interviews with MD 4 about his (MD 4) interpretation of Patient 22’s (Patient 21’s baby) fetal heart tracing (FHT) strips from 4 a.m. to 4:30 a.m. on 12/23/2025. During the same interview on 4/30/2026 at 12:40 p.m. with the Chief Physician of Obstetrics (MD 1), Neonatologist (MD 2), Neonatologist (MD 3), the Physician of Risk and Patient Safety (MD 6), and the Assistant Administrator for Patient Safety and Quality (AAPSQ), MD 6 stated that, looking back at Patient 21’s case, the patient (Patient 21) should have been taken to the operating room sooner. MD 6 further stated that Patient 21 would have had a better outcome if a crash C-section had been done earlier. MD 1 stated that it had been “a judgment call,” [meaning the decision depended on the physician’s [MD 4] clinical assessment at the time and different doctors might reasonably make different choices based on the same information]. During a review of facility’s policy and procedures (P&P) titled, “Patient Rights and Responsibilities,” revised 9/2024, the P&P indicated, “Purpose: To establish a policy in compliance with Title 22 requirements and all other applicable laws and regulations to ensure patients are aware of their rights ...You have the right to: ...13. Receive care in a safe setting ...” During a review of facility’s policy and procedures (P&P) titled, “Communication and Escalation Policy,” revision date 2/2026, the P&P indicated, “To define the process for Emergency intervention in situations that pose a ‘high likelihood of immediate danger’ to patients ...Escalating healthcare team member concerns regarding patient care ...To Improve and clarify expectations of timely communication between the nursing staff and OB/Certified Nurse Midwife (CNM) ...All physicians and staff are empowered and have the responsibility to immediately intervene to protect the safety of a patient and to prevent a medical accident or adverse outcome. It is the expectation that all participants will immediately stop and respond to a request by reassessing the patient’s safety ...Healthcare team members are responsible for pursuing the channels until they are confident that the patient care needs are being met or a healthcare team administrative team member or physician at a higher level has accepted responsibility for resolution of the problem ...Registered Nurse to call the Attending provider and given an SBAR report of her findings: OB/CNM will evaluate patient and validate Registered Nurse’s findings and plans patient care according to findings ...If Registered Nurse findings were not validated and Registered Nurse remains concerned, the Registered Nurse will communicate her findings to her Charge Registered Nurse who will assess the situation and inform the Assistant Clinical Director (ACD) of the situation ...A review of the findings will be discussed between the Primary Attending OB/CNM, primary Registered Nurse, and Charge Registered Nurse ...” During a review of the facility’s document, “Plan for Provision of Patient Care,” dated 4/2026, the document indicated, “Maternal Child Services ...Requirement for Staff ...The nurse provides comprehensive care to the woman, her fetus/newborn, and her family during the perinatal period ...” During a review of the facility’s policy and procedure (P&P) titled, “Electronic Fetal and Uterine Monitoring,” revised date 4/2026, the P&P indicated, “Purpose to establish a standardized, evidence-based approach for the safe, accurate, and consistent use of electronic fetal monitoring in Labor & delivery, including initiation criteria, interpretation, expectations, required clinical actions, and documentation standards ...Monitoring Standards ...NICHD Categories and Required Actions Category I-Normal Baseline 110-160 bpm (beats per minute), moderate variability, no late/variable decelerations. Action: Continue routine monitoring. Category II -Indeterminate Any pattern not Category I or III. Action: Initiate intrauterine resuscitation, increase surveillance, notify provider appropriately. Category III -Abnormal Absent variability with recurrent late/variable decelerations ...Action: Immediate provider notification and urgent interventions; prepare for possible expedited delivery ...Provider Communication Documentation ...Reason for provider notification ...RN actions taken ...” During a review of the facility’s Oxytocin protocol document titled, “Optimizing Induction of Labor Progress for Vaginal Birth,” effective date 12/10/2025, the protocol indicated, “Communication safety: ...oxytocin decrease/discontinuation or restart delay ...Administration of Oxytocin for Labor Management-Labor Algorithm start oxytocin only if all the following criteria are met: Fetal Assessment: In the 30 mins leading up to oxytocin initiation there must be: ...no late decelerations in the past 30 mins ...No prolonged decelerations ...If criteria not met, notify the physician/midwife and recommendation is to assess patient and determine if reasonable to proceed as ordered ...””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 36206 Based on observation, interview and record review, the facility’s Quality Assurance Performance Improvement (QAPI, a data driven, proactive approach to improving the quality of care and services) program team, failed to ensure that the facility’s Action Plan designed to address medication safety in the NICU (Neonatal Intensive Care Unit, a specialized hospital department for premature, low-birthweight, or critically ill newborns) was thoroughly implemented, to verify that the correct doses of critical intravenous (IV, through the vein) medications were being administered in the NICU, after the facility identified a medication error (on 1/28/2026) involving one of 30 sampled patients (Patient 12), a premature infant, who received ten times the amount of fentanyl (a highly potent synthetic opioid) ordered by the physician, for 13.5 hours from 1/27/2026 through 1/28/2026. The Action Plan included 100 % audits, which were to begin on 1/28/2026 with contingent staff and for the facility’s regular nursing staff when the facility’s staff returned to work from a labor strike and upon caring for an infant on a high alert (drugs that bear a heightened risk of causing significant patient harm or fatal errors when used incorrectly) or critical medication IV infusion, to ensure the patient was receiving the correct dose and rate. This deficient practice resulted in the facility’s QAPI program’s inability to accurately collect and analyze data pertaining to medication safety, which may hinder the facility’s ability to identify gaps in patient care and promote patient safety. This deficient practice also had the potential to negatively impact the implementation of additional safety measures, to ensure the safe administration of critical IV medications. Findings: During an observation on 4/29/2026 at 10 a.m., the Charge Nurse (CN 1) was observed caring for Patient 25 in the Neonatal Intensive Care Unit (NICU, a dedicated hospital department dedicated to providing 24-hour medical care for premature, critically ill, or low-birth-weight newborns). Patient 25 was receiving fentanyl (a highly potent synthetic opioid) via continuous (drip) intravenous infusion (the administration of medications, fluids directly into the bloodstream through a needle or catheter). During an interview on 4/29/2026 at 10:03 a.m., with CN 1, CN 1 explained the process of administering continuous (drip) infusion of fentanyl, including programming the IV pump (a medical device used to deliver precise amounts of fluids-such as medications, nutrients, and blood products-into a patient’s body in a controlled manner) and conducting independent double checks (a safety procedure where two healthcare professionals [usually nurses] verify critical details separately and without communicating their expectations to each other before confirming the action). CN 1 was asked if anyone (NICU staff) conducted audits to ensure the correct dose was being administered to patients on critical IV medications, CN 1 stated no one was assigned to conduct audits. CN 1 has not been audited, and CN 1 has not audited another nurse caring for a patient who was receiving a critical medication via IV infusion. CN 1 further stated that staff were on strike (work stoppage) starting 1/26/2026 and had just returned to work in March 2026. During an interview on 4/28/2026 at 11:07 a.m. with the Assistant Administrator for Patient Safety and Quality (AAPSQ), the AAPSQ stated the following: A medication error occurred during the work stoppage (strike) involving contingent staff (temporary replacement nurses brought in by the hospital), on 1/28/2026 at 8:32 a.m., when nursing staff discovered that Patient 12 was receiving the wrong dose of fentanyl. The facility conducted a debrief of the situation and requested that the two contingency workers (Registered nurses [RN 5 and RN 6]) involved, be removed from their assignments, effectively immediately. In addition, the facility conducted a Corrective System Analysis (CSA, a systemic process for identifying, analyzing, and addressing system failures) on 1/29/2026. One of the gaps identified was that the IV pumps used in the NICU were not connected to the electronic medication administration record (eMAR) and so nurses were required to manually program the pumps correctly (right dose, right rate ...). In addition, nurses failed to conduct an independent double check (when two nurses individually check the order, validate that the IV pump was set up to correctly include, the right dose and rate, and validate the connection to the IV site) accurately. For opioids, such as fentanyl, two nurses were required to conduct the independent double check at the patient’s bedside. That process (independent double check) was not followed. During an interview on 5/4/2026 at 2:48 p.m. with the Director of Children’s Services (DIR 1) and the Nurse Manager (NM1), DIR 1 and NM 1 stated the following: On 1/28/2026, a medication error was identified for Patient 12, who was receiving the wrong dose of fentanyl. It was determined that management would remain onsite, in NICU, 24 hours a day, 7 days a week to spot check or audit patients who were receiving fentanyl drips or another other high alert medication (drugs that bear a heightened risk of causing significant patient harm or fatal errors when used incorrectly) infusion. The purpose of the spots checks/audits was to ensure the IV pumps were set at the correct dose and rate, and to ensure the five (5) rights of medication (right patient, medication, dose, route, and time) administration were performed. High risk patients (someone who has a significantly increased likelihood of experiencing serious medical complications, a decline in health, or mortality) were transferred to an outside hospital while facility staff were on strike. During February and March 2026 [audits], DIR 1 stated that 3 patients were identified to be on a drip and should have been audited. DIR 1 stated she (DIR 1) audited 1 patient (no name) with an audit tool (a standardized checklist used to measure care against established guidelines. This ensures that patient care is safe and adheres to best practices), a second patient (no name) was audited without using a tool, and the 3rd patient was not audited, it was missed. DIR 1 stated the audit documentation for the 3 patients would be provided, however, the audits were not provided by the facility. DIR 1 stated that 100 % of the patients on high alert medication infusion should have been audited. DIR 1 stated the audit tool was developed after 4/23/2026 and DIR 1 verified that the only audits submitted were for Patient 25 and these were the audits conducted on 4/27/2026, 4/28/2026, 4/29/2026, and 4/30/2026. During an interview on 5/4/2026 at 4:55 p.m. with AAPSQ and the Risk and Patient Safety Manager (RPSM), the AAPSQ and RPSM stated the following: A meeting was held with the Director of Children Services (DIR 1) and the Clinical Nurse Specialist (CNS 1). Per DIR 1, audits were not documented. AAPSQ stated audits should have started in February 2026. Additionally, AAPSQ and RPSM met with team (DIR 1), high risk patients were transferred out to outside hospital, therefore, the facility needed to complete 100 % audits for patients on high alert medications to ensure the IV pumps were set up at the correct dose and rate. This needed to be done because the IV pumps in the NICU were different than for adult patients. The IV pumps in the NICU did not have a safety mechanism for a 3rd check, in addition to independent double check conducted at bedside by two nursing staff. The facility learned that staff were not conducting independent double checks. There should have been a 3rd check, with the audits, done by the manager at bedside. There were no documented audits in February and March of 2026. There was no audit tool created until April 2026. AAPSQ only received audits dated at the end of April 2026, no audits were received in February and March 2026. During a review of a facility document titled, “Action Plan: 1/28/2026, NICU Med (medication) Error, Patient 12),” the Action Plan indicated the following: -Action Item: RN (registered nurse) Competency Skillset and Orientation files reviewed (validated files are current and reflect the regional and local training that occurred). -Primary General Contributing Factor: Competency: Lack of following established protocols. - Hierarchy of Effectiveness (Level of Leverage): Moderate. -Areas of Implementation (Process Affected): Medication Administration -Measure of Success: File review completed and information validated -Owners: Director of NICU (DIR 1, Director of Children’s Services) -45-Day Follow up: 4/6/2026 ... -ADHOC (a medical action, team or decision that is improvised, temporary, or put together on the spot to handle a sudden or high specific situation) Comments: 3/11/2026, Audits in February (2026) with contingent workers were not completed as infants were transferred to OON (out of network) hospitals. Audits to begin 2/24 (2026) when staff return to work, and upon caring for an infant on a critical med (medication) IV infusion. 100 % audits will be conducted as population is small ...Results of audits will be presented at QRM in March and April (2026). During a review of the facility’s “Quality Resource Management Committee Minutes,” dated 3/18/2026, the Minutes included the Risk and Patient Safety Report, as follows: “-Situation: An adverse medication error that reached a NICU infant and required emergent intervention. The patient (Patient 12) received the wrong dose of Fentanyl over the duration of 13 hours. Dose inputted into pump was 5 mcg/kg/hr when it should have been 0.5 mcg/kg/hr. The infant (Patient 12) remains in NICU with improved oxygenation following administration of reversal agent; Fentanyl stopped and additional respiratory support provided ... -Background: Infant medical baseline: Infant (Patient 12) has been on life support from day 1 due to extreme prematurity ...Infant has been receiving Fentanyl for pain management and sedation since 1/15/2025. Human error occurred in inputting the dosage into the pump. High alert medication (drugs that bear a heightened risk of causing significant patient harm or fatal errors when used incorrectly) protocol was not followed. Independent double check of the Fentanyl order against the pump did not occur. -Assessment: IV pump involved in this adverse event does not connect with electronic medical record resulting in lack of secondary patient safety check to prevent human error ...Current state: Infant (Patient 12) vitals progressing towards baseline. Current state: no evidence of permanent harm related to the medication error. Medication Administration policies and practices were not followed. Investigation in progress, compliance conducting a User Accession Audit ... Actions: Launching purchase of new pumps ...Immediate risk mitigation: 2 contingent workers are Do Not returns. RN competency skillset and orientation files reviewed. Just in time education huddles ...New process for validating independent double check has been done by manager, MD and/or designee. Facility NICU RN leader or NICU MD will conduct oversite of bedside 2-person check for each high-alert medication infusions ...” During a review of an audit form titled, “DMC NICU HAMP (High Alert Medication Policy) Audit,” 4/27/2026 at 7:45 a.m., the audit form indicated Patient 25 had an order for Fentanyl 0.5 mcg/kg/hr. The audit was conducted at shift change and indicated that the primary and secondary registered nurses (RN) performed the following: Priming and Hanging: 1. Primary RN - primes tubing: programs pump and pauses, connects tubing to baby and clamps it. 2. Primary RN - Rescans baby and med if previously cancelled. 3. Secondary RN - Independently performs 5 rights (right patient, right drug, right dose, right route, and right time) including calculation at the pump - confirms calculation result with primary RN. 4. Secondary RN - Reads contents of syringe to primary RN. 5. Secondary RN - Walks line - Confirms connection with primary RN. 6. Primary RN - Starts infusion & Dual sign-off occurs. During a review of an audit form titled, “DMC NICU HAMP Audit,” 4/28/2026 at 7:45 a.m., the audit form indicated Patient 25’s had an order for Fentanyl 2 mcg/kg/hr. The audit was conducted at shift change and indicated that the primary and secondary registered nurses (RN) performed the following: Priming and Hanging: 1. Primary RN - primes tubing: programs pump and pauses, connects tubing to baby and clamps it. 2. Primary RN - Rescans baby and med if previously cancelled. 3. Secondary RN - Independently performs 5 rights (right patient, right drug, right dose, right route, and right time) including calculation at the pump - confirms calculation result with primary RN. 4. Secondary RN - Reads contents of syringe to primary RN. 5. Secondary RN - Walks line - Confirms connection with primary RN. 6. Primary RN - Starts infusion & Dual sign-off occurs. During a review of an audit form titled, “DMC NICU HAMP Audit,” 4/29/2026, un-timed, the audit form indicated Patient 25 had an order for Fentanyl 2 mcg/kg/hr. The audit was conducted during syringe change (unknown time) and indicated that the primary and secondary registered nurses (RN) performed the following: Preparing Med - Primary RN: 1. Scan baby and med. 2. Performs 5 rights including calculation ... Priming and Hanging Med: 3. Secondary RN - Independently performs 5 rights (right patient, right drug, right dose, right route, and right time) including calculation at the pump - confirms calculation result with primary RN. 4. Secondary RN - Reads contents of syringe to primary RN. 5. Secondary RN - Walks line - Confirms connection with primary RN. 6. Primary RN - Dual sign-off occurs. Shift Change: 1. Primary RN - Primary RN scans baby and med and performs 5 rights including calculation. 2. Secondary RN - Independently performs 5 rights (right patient, right drug, right dose, right route, and right time) including calculation at the pump - confirms calculation result with primary RN. 3. Secondary RN - Primary RN - Reads contents of syringe/bag to secondary RN 4. Secondary RN - If a drip - Secondary RN - Walks line - confirms with primary RN. 5. Dual sign-off occurs. During a review of an audit form titled, “DMC NICU HAMP Audit,” 4/30/2026 at 7:45 a.m., the audit form did not indicate the name of the medication, dose or route that was being audited for Patient 25. The audit was conducted at shift change and indicated that the primary and secondary registered nurses (RN) performed the following: 1. Primary RN - Primary RN scans baby and med and performs 5 rights including calculation. 2. Secondary RN - Independently performs 5 rights (right patient, right drug, right dose, right route, and right time) including calculation at the pump - confirms calculation result with primary RN. 3. Secondary RN - Primary RN - Reads contents of syringe/bag to secondary RN 4. Secondary RN - If a drip - Secondary RN - Walks line - confirms with primary RN. 5. Dual sign-off occurs. During a review of the facility’s “Hospital Quality and Patient Safety Program Description Annual Work Plan and Evaluation,” dated 5/14/2025, the Plan indicated the following: “This Plan informs the improvement processes for patient outcomes, reducing and preventing medical errors, and applying remediation strategies in response to system or process failures ...The foundational elements of all quality and patient safety initiatives and activities provide a framework that also supports quality improvement processes at the Hospital. They are ...Proactive and prioritized performance improvements to prevent failure, mitigate hazards, and improve systems and process reliability ...Assuring compliance with all state and national regulatory, accreditation, and certification standards supporting quality and patient safety ...The Quality and Patient Safety Program structure and oversite ensures that consistent and systematic efforts are maintained to continually measure, assess, and improve processes and outcomes related to services provided ....Leadership is responsible for ...Ensuring uniform delivery of patient care services provided throughout the hospital ...Appointing committee, work groups, performance improvement teams and other forums to ensure multidisciplinary and interdepartmental collaboration on issues of mutual concern; Establishing structures and processes that focus on safety, improving the health care safety of patients, and reducing preventable adverse events; Implementing changes in existing processes to improve the quality of care provided; Establishing quality of care and patient safety metrics, which can be monitored through the hospital’s plan ...The Quality Resource Management Committee serves as the committee to implement, monitor and enhance operational systems to ensure quality improvement, performance improvement and patient safety for the hospital ...The Patient Safety and Risk Management Committees strive to reduce risk, improve patient safety and quality outcomes in the delivery of health services across all settings of care. These two committees (Medical Executive Committee and Quality Resource Management Committee) work in tandem to monitor the effectiveness of the corrective actions taken in response to an adverse event or sentinel event to ensure that the risk reduction strategies achieve expected results.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50516 Based on interview and record review, the facility failed to: 1. Ensure nursing staff documented the meal intake (amount of food taken in) for two of 30 sampled patients (Patients 9 and 10), in accordance with the facility’s policy and procedure (P&P) titled, “Patient Admission Assessment, Reassessment and Plan of Care Standard,” when: 1.a. Patient 9 did not have dinner documented for two days 1.b. Patient 10 did not have several meals documented for 10 days These deficient practices had the potential for Patient 9 and 10’s nutrient consumption and worsening health condition to remain undetected and not promptly addressed with medication and fluid adjustments or supplemental nutrition. 2. Ensure one of 30 sampled patient’s (Patient 21) fetal (unborn baby) heart tone tracing strips (FHT, recorded patterns of the baby’s heart rate. Health care providers track FHT during labor [the process when the unborn baby moves out through the birth canal] to ensure the baby is healthy, tolerating contractions [the involuntary tightening and relaxing of the uterine muscles. These movements prepare the body for birth, help open the cervix, and push the baby down the birth canal] well and getting enough oxygen ), which showed concerning abnormal changes including indications of Category 3 (abnormal non reassuring heart monitor pattern indicating the baby may not be getting enough oxygen) patterns, which indicated a compromised fetal well-being, was correctly assessed, identified, and escalated (recognizing that a patient’s medical condition is worsening and bringing in higher levels of care, or activating a “chain of command” when there are patient safety concerns) promptly to the physician, in accordance with the facility’s policies and procedures regarding fetal assessment and monitoring and “Communication and Escalation Policy.” This deficient practice had the potential to delay the deployment of life-saving treatments and place Patient 21 and Patient 21’s unborn baby at significant risk for harm including fetal demise (death). 3. Ensure one of 30 sampled patient’s (Patient 12) pain level was assessed prior to and 30 minutes after administering a pain medication, fentanyl (a highly potent synthetic opioid), in accordance with the facility’s policy and procedure regarding pain management. Patient 12 was already receiving a continuous dose of fentanyl and received 3 additional doses of fentanyl without a pain assessment. This deficient practice had the potential for administering fentanyl unnecessarily, which could cause lethargy (state of being sluggish, drowsy, or lacking energy) and respiratory depression (breathing is too slow or shallow, causing oxygen levels to drop) for Patient 12. Findings: 1.a. During a review of Patient 9’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/29/2026, the record indicated Patient 9 was admitted to the facility for hypotension (low blood pressure) and weakness. Patient 9’s medical history included hypertension (HTN, high blood pressure), diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic kidney disease (kidneys are not working well to filter blood and waste). During a record review of Patient 9’s “Order,” dated 4/29/2026, the order indicated that Patient 9 had an order for renal diet (specialized diet used for people with kidney issues). During a concurrent interview and record review on 5/4/2026 at 10:33 a.m. with Nurse Manager (NM) 5 and NM 6, Patient 9’s “Flowsheet,” dated 4/29/2026 to 5/3/2026, was reviewed and indicated the following: -On 4/30/2026, Patient 9 did not have dinner documented. -On 5/2/2026, Patient 9 did not have dinner documented. These findings were confirmed by NM 5 and NM 6. During an interview on 5/4/2026 at 11:22 a.m. with NM 5 and NM 6, NM 6 stated it was important to document intake to make sure patients were eating, not losing weight, and helped determine if a nutrition consult (dietician, someone who would evaluate the type and amount of food someone was eating, and weight) was needed. During a review of the facility’s policy and procedure (P&P) titled, “Plan for Provision of Patient Care,” dated 4/2026, the P&P indicated, “Nursing care is accomplished through the execution of the nursing process; patient teaching; administering, supervising, delegating and evaluating nursing care and practice; conducting nursing research and/or supporting medical research in the clinical setting; and implementation of standards of patient care.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Admission Assessment, Reassessment and Plan of Care Standard,” dated 11/2023, the P&P indicated, “The goal of patient assessment is to determine the need for care, the type of care to be provided, and the need for any further assessment. This is accomplished by: 1. Data collected to assess the needs of the patient; 2. Data analyzed to create the information necessary to develop a plan for meeting care or treatment needs.” 1.b. During a review of Patient 10’s “History and Physical (H&P),” dated 4/9/2026, the record indicated Patient 10 was admitted to the facility for dyspnea (difficulty breathing). Patient 10’s medical history included depression (a common mental health condition characterized by persistent sadness, a lack of energy, and a loss of interest in activities once enjoyed), diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN, high blood pressure), hyperthyroidism (metabolism [changes food and drink into energy] increases and can lead to issues such as weight loss). During a record review of Patient 10’s “Order,” dated 4/19/2026 and 4/30/2026, both records indicated Patient 10 had orders for cardiac diet (type of food and specific amount given to people with heart issues). During an interview on 5/1/2026 at 3:38 p.m. with the Assistant Nurse Manager (ANM) 3, ANM 3 stated staff should be charting (documenting) the meals and intakes (amount of food taken) of patients in order to keep up with intake and output (amount of urine, blood and stool), to follow up and make sure the patient was eating and drinking, and to monitor for any changes in the patients’ conditions. During a concurrent interview and record review on 5/4/2026 at 9:54 a.m. with Nurse Manager (NM) 4, Patient 10’s “Flowsheet,” dated 4/21/2026 to 4/30/2026, was reviewed and indicated the following: - On 4/21, Patient 10 did not have the amount of dinner documented - On 4/22/2026, Patient 10 did not have the amount of breakfast, lunch, and dinner documented. -On 4/23/2026, Patient 10 did not have lunch and dinner documented -On 4/25/2026, Patient 10 did not have breakfast, lunch and dinner documented. -On 4/26/2026, Patient 10 did not have dinner documented - On 4/30/2026, Patient 10 did not have breakfast, lunch and dinner documented. During a continued interview and record review on 5/4/2026 at 9:54 a.m. with NM 4, NM 4 stated it was important to document the intake and output of patients to see if there would be any weight changes and assessing whether there might be a need to increase the amount of calories (used to measure nutrients, and tracking these details can help ensure patients receive appropriate nutrition) provided. NM 4 stated that a lack of documentation would result in a gap in information, making it impossible for the physician to determine if the patient was eating or not. During a review of the facility’s policy and procedure (P&P) titled, “Plan for Provision of Patient Care,” dated 4/2026, the P&P indicated, “Nursing care is accomplished through the execution of the nursing process; patient teaching; administering, supervising, delegating and evaluating nursing care and practice; conducting nursing research and/or supporting medical research in the clinical setting; and implementation of standards of patient care.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Admission Assessment, Reassessment and Plan of Care Standard,” dated 11/2023, the P&P indicated, “The goal of patient assessment is to determine the need for care, the type of care to be provided, and the need for any further assessment. This is accomplished by: 1. Data collected to assess the needs of the patient; 2. Data analyzed to create the information necessary to develop a plan for meeting care or treatment needs.” 2. During a review of Patient 21’s obstetric (OB, care related to pregnancy, labor [he process when the unborn baby moves out through the birth canal], and childbirth) admission History & Physical (H&P, a medical note that reviews the patient’s health history and current condition to guide care), dated 12/20/2025, the H&P indicated Patient 21 was admitted on 12/20/2025 at 11:58 a.m. to the facility for labor induction (labor induction means starting labor using medications or other methods) due to type 2 Diabetes Mellitus (DM, a long-term condition where the body cannot control blood sugar well). The H&P further indicated that on admission (12/20/2025), the fetal (Patient 21’s unborn baby) heart tone monitoring (FHT monitoring means continuously checking the baby’s heart rate and the mother’s contractions [tightening of the muscles in the uterus] to assess the baby’s well-being) indicated the baby was healthy and well oxygenated. The H&P also indicated that Patient 21 was not in active labor (the physiological process of childbirth) on admission. During a review of Patient 21’s “Progress Notes,” dated 12/22/2025 at 11:41 p.m., the progress notes indicated Patient 21’s membrane status was grossly ruptured (refers to the amniotic sac [a thin, tough, and transparent pair of membranes that holds a developing fetus and amniotic fluid inside the uterus during pregnancy], meaning whether the “water” is still intact or has ruptured). During a review of Patient 21’s “Flowsheets,” dated 12/22/2025, the progress notes indicated that at 11:57 p.m., Patient 21 was actively pushing (the second stage of labor where the mother bears down to move the baby through the birth canal and ends with the delivery of the baby). During a concurrent interview and record review on 4/29/2026 from 10:23 a.m. to 12:11 p.m. with the Assistant Clinical Director (ACD 1), the Director of Perinatal Services (DIR 2), and Registered Nurse (RN) 7, Patient 21’s Fetal Heart Tones tracing strips (FHT, recorded patterns of the baby’s heart rate. Health care providers track FHT during labor to ensure the baby is healthy, tolerating contractions well and getting enough oxygen) record, dated from 12/22/2025 at 11:00 p.m. to 12/23/2025 at 4:30 a.m., was reviewed. The ACD 1 reviewed the FHT tracings strips from 12/22/2025 starting at 11:00 p.m. and verified that Patient 21 was in active labor (active labor means the cervix is dilating quickly, contractions are strong and regular, and the body is preparing for birth). The ACD 1 further stated: -“Patient (Patient 21) is ready to push (the second stage of labor where the mother bears down to move the baby through the birth canal and ends with the delivery of the baby)... fully dilated (the cervix [the opening to the uterus] has opened to 10 centimeters about 4 inches wide), fully effaced (cervix has fully thinned out in preparation for childbirth) - patient being complete - ready for delivery, can start pushing. Physician does not have to be in the room but should be notified ...nurses document the pushing part in the medical record.” -The ACD 1 then verified that the physician (MD 7, the provider responsible for Patient 21’s care) was notified on 12/22/2025 at 11:57 p.m. that Patient 21 started pushing and that the baby was doing well (moderate variability means the baby’s heart rate shows healthy changes, which indicates the baby is well-oxygenated and tolerating labor). During a concurrent interview and record review on 4/29/2026 from 10:23 a.m. to 12:11 p.m. with the Assistant Clinical Director (ACD 1), the Director of Perinatal Services (DIR 2), and Registered Nurse (RN) 7, ACD 1 and RN 7 continued the interpretation of Patient 21’s FHT tracing strips and the timeline of events on 12/22/2025, and stated the following: “At 11:57 p.m. (12/22/2025), patient (Patient 21) started pushing (the second stage of labor where the mother bears down to move the baby through the birth canal). The FHT indicated Category II tracing strips (FHT is neither perfectly normal nor definitely abnormal, but requires closer monitoring), late deceleration (are drops in the baby’s heart rate that happen after a contraction [the involuntary tightening and relaxing of the uterine muscles. These movements prepare the body for birth, help open the cervix, and push the baby down the birth canal] and can mean the baby is not getting enough oxygen), baby has reserved variability (refers to small, beat-to-beat fluctuations in a baby’s heart rate) and contractions at 3-4 minutes.” “-At 12:15 a.m. (on 12/23/2025), FHT Category II, patient (Patient 21) continuing to push, moderate variability (means the baby’s heart rate shows healthy changes, which indicates the baby is well-oxygenated and tolerating labor), deceleration (refers to a temporary drop in baby’s heart rate and below the normal baseline), and no urgency for C-section (cesarean section, is a surgical procedure used to deliver a baby). -At 12:30 a.m. (12/23/2025), -patient (Patient 21) was now in Second stage of labor (when the cervix is fully dilated 10 cm [centimeters, a unit of measure], and ends with the birth of the baby, with active pushing), and moderate variability (fetus [unborn baby] is adequately oxygenated) and healthy. -At 12:45 a.m. (12/23/2025), - A combination of early (temporary, gradual drops in a baby’s fetal heart rate that happen at the exact same time as a uterine contraction. They mirror the contraction perfectly-starting, reaching their lowest point, and recovering just as the contraction ends) and late deceleration (temporary, gradual drops in a baby’s heart rate that occur after a uterine contraction has peaked. They are the most concerning type of fetal heart rate deceleration because they typically signal uteroplacental insufficiency-meaning the placenta is not providing enough blood or oxygen to the fetus) could be seen, heart rate 150s to 160s., but still early to call for C-section. -At 12:59 a.m. (12/23/2025), At 1 hour mark, patient’s (Patient 21) fetal heart rate going down, with variability and contraction are still okay.” During the same concurrent interview and record review on 4/29/2026 from 10:23 a.m-12:11 p.m. with the Assistant Clinical Director (ACD 1), the Director of Perinatal Services (DIR 2), and Registered Nurse (RN) 7, Patient 21’s Fetal Heart Tones tracing strips record, dated from 12/22/2025 at 11:00 p.m. to 12/23/2025 at 4:30 a.m., was reviewed. ACD 1 and RN 7 then continued the interpretation of Patient 21’s FHT tracing strips and the timeline of events on 12/23/2025, and stated the following: -“At 1:14 a.m. (12/23/2025), Contractions with moderate variability (indicated that Patient 21’s fetus [Patient 21’s unborn baby] was still well oxygenated and doing well...) -At 1:52 a.m. (12/23/2025), Registered Nurse (RN 12) started the Pitocin (also called Oxytocin and used to induce labor [to help start childbirth]) at a rate of 2 milliliters (ml, unit of measure) per hour through an intravenous line (IV, into the vein) as ordered by the physician.” -RN 7 stated that right before administering Pitocin (at 1:52 a.m. on 12/23/2025) to Patient 21, the baby showed late decelerations (are drops in the baby’s heart rate that happen after a contraction and can mean the baby is not getting enough oxygen). RN 7 then stated that starting Pitocin with late decelerations present may result in fetal hypoxia (means the baby is not getting enough oxygen, which can be dangerous). -ACD 1 stated, “Two nurses must sign for Pitocin (a high?alert medication, a drug that bears a heightened risk of causing significant patient injury or death when misused or administered incorrectly), because it must be verified by two nurses before use. The patient (Patient 21) did not meet the criteria for Pitocin because there were late decelerations after contractions (late decelerations occur when the baby’s heart rate drops after the contraction, which can show the baby is not getting enough oxygen). According to the criteria (for Pitocin administration), there must be no late decelerations for 30 minutes before Pitocin could be started.” -ACD 1 also stated the reason Pitocin should not be started (when there is a late deceleration) was because of uterine placental insufficiency (this means the placenta is not delivering enough oxygen to the baby). During contractions, the baby gets even less oxygen. Adding Pitocin would make the contractions stronger and more frequent, which placed more stress on the baby. The verifier must also check that the patient met all the criteria before Pitocin was to be started. ACD 1 then added that moving forward, “we will ensure that the laminated algorithm (regarding Pitocin administration) is placed in each room (patient rooms in the L&D unit). As part of the audit, the Pitocin protocol must be followed because we found that the order was not followed.” During a concurrent interview and record review on 4/29/2026 from 10:23 a.m. to 12:11 p.m. with the Assistant Clinical Director (ACD 1), the Director of Perinatal Services (DIR 2), and Registered Nurse (RN) 7, Patient 21’s Fetal Heart Tones tracing strips record, dated from 12/22/2025 at 11:00 p.m. to 12/23/2025 at 4:30 a.m., was reviewed. ACD 1 and RN 7 then continued interpretation of Patient 21’s FHT tracing strips and the timeline of events on 12/23/2025 and stated the following: “On 12/23/2025 at 2:01 a.m. - patient (Patient 21) was in active labor for 2 hours.” -ACD 1 said that if the baby’s heart rate pattern (the strip) showed Category II (meaning the baby’s heart rate was not completely normal but not dangerous and needed close watching), but still had variability (fluctuations in the baby’s heart rate), and the baby seemed to be doing well, the nurse should still have called and updated the doctor. ACD 1 then stated that if the baby was not improving or labor was not moving forward, the nurse should have the doctor come to the (patient’s) bedside right away. ACD 1 also said that there was no documentation indicating that the nurse (RN 12) contacted the physician at the 2?hour mark and updated the MD about the progression of labor for Patient 21. -ACD 1 then reviewed the strip on 12/23/2025 at 3:09 a.m. and said that Patient 21 was now at the 3rd hour mark. ACD 1 stated per nursing notes, physician was notified by the nurse that Patient 21 had been pushing for three hours, and said, “Station still at 2+ (this means the lowest part of Patient 21’s baby’s head has moved 2 centimeters below the mother’s ischial spines, which are bony points in the pelvis used to measure how far the baby has descended during labor). When the station stays the same, the physician will come to the bedside to reassess (the doctor will check the baby’s position, the mother’s progress, and decide what care or actions are needed next).” -ACD 1 then continued, “On 12/23/2025 at 3:12 a.m., Charge Nurse (CN 3) was at the bedside pushing with the patient (Patient 21) ... and at 3:21 a.m. (12/23/2025), the baby was still showing good variability (good variability means the baby’s heart rate is making healthy, normal changes, which shows the baby is getting enough oxygen) with deeper variables (are abrupt, jagged drops in the baby’s heart rate) indicating she (Patient 21’s unborn baby) was coming down lower.” -ACD 1 stated that at 3:28 a.m. (12/23/2025), the baby (Patient 21’s unborn baby) started showing prolonged deceleration (means the baby’s heart rate dropped lower than normal and stayed low for a longer time) and variability was low (low variability means the baby’s heart rate was not making healthy changes, which can show the baby is not getting enough oxygen). ACD 1 said that “prolonged decelerations most likely indicated that the baby was no longer tolerating the pushing, had less oxygen, and was beginning to struggle... the baby’s heart rate was still slowly picking up [after each contraction] ...” ACD 1 also said that Patient 21 who had been pushing for 3 ½ hours appeared to also be getting tired. During the same concurrent interview and record review on 4/29/2026 from 10:23 a.m. -12:11 p.m. with the Assistant Clinical Director (ACD 1), the Director of Perinatal Services (DIR 2), and Registered Nurse (RN) 7, Patient 21’s Fetal Heart Tones tracing strips record, dated from 12/22/2025 at 11:00 p.m. to 12/23/2025 at 4:30 a.m., was reviewed. ACD 1 and RN 7 then stated: -“From 3:39-3:41 a.m. (2 minutes of deceleration) on 12/23/2025, the patient’s (Patient 21’s) baby’s heart rate was showing a deceleration. The longer the deceleration, the deeper the drop in the heart rate tracing, and this means the baby has to work harder and wait longer to get oxygen. The baby (Patient 21’s unborn baby) was losing reserve (reserve means the baby’s ability to tolerate stress), and the baby was becoming tired. There should be a concern for the baby and the physician was called at 3:09 a.m. and should have been at bedside already, but no documentation indicated that the physician was at bedside... -At 4:00 a.m. (12/23/2025), the baby (Patient 21’s unborn baby) started showing minimal to absent variability (Absent variability in a fetal heart rate means there are no detectable, beat-to-beat fluctuations in the baby’s baseline heart rate. It is an abnormal [Category III] heart rate pattern that can signal fetal distress, often indicating that the fetus is not receiving enough oxygen), which means Category 3 (is the most serious fetal heart rate pattern, it shows that the baby is not getting enough oxygen, the heart rate is abnormal, and immediate evaluation and delivery are required).” ACD 1 said, “At this time, Category 3 means the baby’s oxygenation was compromised. According to the algorithm (regarding administration of Pitocin), the baby had to be delivered sooner rather than later. If not a ‘crash’ C-section (formally known as a Category 1 Cesarean section, is an extremely urgent, life-saving surgery. It is performed when a mother or her baby is in immediate, severe danger and a baby needs to be delivered in minutes rather than hours), then an urgent C-section within 30 minutes ... (RN 12 who took care of Patient 21 on 12/23/2025 was not able to identify and correctly interpret Patient 21’s tracing strip at 4 a.m. which showed category 3).” During an interview on 4/29/2026 at 11:47 a.m. with the Assistant Clinical Director (ACD 1), ACD 1 verified that despite evidence of a Category III tracing between 4-4:30 a.m. (on 12/23/2025), and even though the fetal heart rate variability returned, and there was a change in the fetal baseline heart rate (FHT decreased), there was no escalation by the nursing staff or the physician to have the baby delivered as soon as possible. During further interview and record review on 4/29/2026 at 11:48 a.m. with the Assistant Clinical Director (ACD 1), the Director of Perinatal Services (DIR 2), and Registered Nurse (RN) 7, Patient 21’s Fetal Heart Tones tracing strips records, dated from 12/22/2025 at 11:00 p.m. to 12/23/2025 at 4:30 a.m., were reviewed and verified. The record indicated the following: On 12/23/2025 at 4:31 a.m., the Obstetrician physician (OB, physician who specializes in labor and delivery) (MD 4,) was documented to be at (Patient 21’s) bedside. Per MD 4 Patient 21 “should go for a C-section at 6 a.m. (on 12/23/2025).” During a review of Patient 21’s Multi-Discipline Progress Notes, dated 12/23/025 at 4:50 a.m., the note indicated that per charge nurse [CN 3] “...Spoke to MD (Medical Doctor, MD 4) to verify if c/s (c-section) was urgent or stat [immediately or as soon as possible]. MD (MD 4) stated have her (Patient 21) in the back [referring to the Operating Room] for incision [cut in the abdomen] to be at 0600 [6 a.m.] after Unasyn [medication to kill bacteria] is administered.” During a review of Patient 21’s “MD Progress Note,” dated12/23/2025 at 5:11 a.m., the note indicated that Patient 21 had been pushing for four hours without any change in the baby’s position. The note also indicated that an ultrasound (a noninvasive imaging test that uses high-frequency sound waves to capture real-time pictures or videos of the inside of the body) was done using a transperineal approach (means the probe was placed on the skin between the vagina and the anus. In pregnant women, it is primarily used to monitor the progress of labor and evaluate the pelvic floor muscles). The provider [MD 4] documented that an operative vaginal delivery was not recommended. The note also indicated the following: the baby’s (Patient 21’s unborn baby) heart rate pattern was a Category II (meaning the baby’s heart rate was not completely normal but not dangerous and needed close watching), and the mother (Patient 21) appeared extremely tired but the baby was not showing signs of low oxygen or acidosis (occurs when the lungs can’t efficiently remove enough carbon dioxide [an acid] from the body define) and because labor was no longer progressing in the second stage (begins when the cervix is completely dilated [10 centimeters] and ends with the birth of the baby), a cesarean section was recommended. During a concurrent interview and record review on 4/29/2026 at 11:50 a.m. with the Assistant Clinical Director (ACD 1) and the Director of Perinatal Services (DIR 2), Patient 21’s baby’s FHT strip, dated 12/23/2025, was reviewed. The record indicated the following: - at 6:11 a.m., the FHT strip indicated Absent Variability (the FHT monitor strip shows a flat line with no detectable fluctuations around the baseline, often indicating fetal distress (a general term used when an unborn baby [fetus] shows signs of trouble, most commonly because they aren’t getting enough oxygen during pregnancy or labor]). -at 6:27 a.m. Patient 21’s FHT strip indicated Category 3- Absent Variability. -at 6:44 a.m. Patient 21’s baby was delivered via C- section. -ACD 1 explained that, looking back, the baby’s (Patient 21’s baby) heart rate strip should have been labeled as Category III, which was the most serious type of fetal heart rate pattern. A Category III strip meant the baby may not be getting enough oxygen and a crash C-section should have been done right away (A crash C-section means an emergency C-section done immediately to protect the baby because every minute matters). During a review of Patient 21’s baby’s NICU (Neonatal Intensive Care Unit, specialized hospital department for premature, low?birth weight, or critically ill newborns) admission note, [undated], the NICU admission note indicated that Patient 21’s baby was born with Hypoxic Ischemic Encephalopathy (HIE2, a moderate type of brain injury that happens when a baby’s brain doesn’t get enough oxygen or blood flow around the time of birth), suspected subgaleal hemorrhage (rare but life-threatening emergency in newborns where blood collects between the scalp and skull) and respiratory distress (difficulty breathing presenting signs and symptoms such as shortness breath, gasping for breath and hyperventilation [rapid breathing]). During a concurrent interview and record review on 4/29/2026 at 11:53 a.m. with the Director of Perinatal Services (DIR 2), the Assistant Clinical Director (ACD 1), and Registered Nurse (RN 7), they confirmed that from 4:00 a.m. to 4:30 a.m. on 12/23/2025, Patient 21’s fetal heart tracing was a Category III. ACD 1 stated that the charge nurse (CN 3) and the primary nurse (RN 12) did not identify this fetal heart tracing correctly. DIR 2 stated that during the facility’s internal investigation (an internal review by the hospital to find out what went wrong and why), several failures were found as follows: -One major issue was that the physician [MD 4] was not called by the nursing staff at multiple times (when there were abnormalities in Patient 21’s FHT strips) when they (the physician) should have been: not at the 3-hour mark of labor, and not between 4:00 a.m. and 4:30 a.m. when the Category III tracings appeared. -More Category III tracings were again seen from 6:11 a.m. to 6:27 a.m. on 12/23/2025. -ACD 1 said that MD 4 arrived at the bedside at 4:31 a.m. (on 12/23/2025), did an ultrasound, but documented the fetal tracing as Category II in the progress note and ordered preparation for a routine (non-urgent) C-section. ACD 1 added that the charge nurse (CN 3) spoke with MD 4 to confirm that a non-urgent C-section was planned. -ACD 1 explained that if the Category III strip had been recognized at the time (4 a.m. on 12/23/2025), the team would have activated an emergency crash C-section and acted immediately. Because Category III was not correctly identified, there was a delay in the C-section that should not have happened. DIR 2 stated that proper recognition would have allowed staff to respond promptly. During an interview on 4/29/2026 at 10:03 a.m. with DIR 2, DIR 2 stated that it was important to notify the physician of any abnormalities so that the physician could evaluate the patient and determine the appropriate course of action. DIR 2 explained that abnormal vital signs must be reported to determine the next steps in treatment, to modify or update treatment plan of care. DIR 2 stated that in the L&D (Labor & Delivery Unit), vital signs check included fetal assessment. DIR 2 stated that the expectation was for the primary nurse to know how to read and interpret the fetal heart tracing (FHT) strip and to notify the charge nurse and the physician. DIR 2 stated that gaps were identified in how FHT tracing strips were interpreted and in the management of patient care for Patient 21. During an interview on 4/30/2026 12:04 p.m. with the Chief Physician of Obstetrics (MD 1) and the Assistant Administrator for Patient Safety and Quality (AAPSQ), MD 1 stated that nurses were expected to notify the physician for any Category III fetal heart rate tracings, late decelerations, or deep variable decelerations. MD 1 further stated that when nurses encounter fetal monitoring strips that were concerning and feel uncertain or uncomfortable about their interpretation, they were expected to contact the physician. MD 1 explained that the physician could review the fetal monitoring strip remotely, and if the situation was significant, would go to the patient’s bedside for further evaluation. MD 1 added that the physician’s response may also depend on how the nurse presented the concern. During a review of the facility’s policy and procedure (P&P) titled, “Electronic Fetal and Uterine Monitoring,” revised 4/2026, the P&P indicated, “RN responsibilities: RNs interpret FHR and uterine activity, initiate timely interventions, reassess effectiveness, collaborate with providers, and ensure monitoring equipment is properly applied and functioning ...Category II - Indeterminate; any pattern not Category I or III. Action: Initiate intrauterine resuscitation, increase surveillance, notify provider appropriately ...Category III -Abnormal Absent variability with recurrent late/variable decelerations, or bradycardia; or sinusoidal pattern. Action: Immediate provider notification and urgent interventions; prepare for possible expedited delivery ...” During a review of the facility’s policy and procedure (P&P) titled, “Labor & Delivery Observation Unit/Triage Unit,” Revised 4/2026, the P&P indicated, “It is the policy of [facility name] to ensure patient safety by providing timely, standardized triage, observation, and evaluation of women presenting to Labor and Delivery with labor or pregnancy-related concerns ...” During a review of the facility’s document, “Plan for Provision of Patient Care,” dated 4/2026, the document indicated, “The nurse provides comprehensive care to the woman, her fetus/newborn, and her family during the perinatal period ...Nursing practice and policies and procedures are guided by: American Academy of Pediatrics/American College of Obstetricians and Gynecologist, Guidelines for Perinatal Care ...” During a review of the facility’s policy and procedure (P&P) titled, “Communication and Escalation Policy,” revised date 2/2026, the P&P stated, “Emergency intervention in situation that pose a “high likelihood of immediate danger” to patients ...escalating healthcare team member concerns regarding patient care ...to improve and clarify expectations of timely communication between the nursing staff and OB/Certified Nurse Midwife (CNM) ...Abnormal findings for concerns are reported immediately to the OB/CNM ...” 3. During a review of Patient 12’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/31/2025, the H&P indicated the following: “This (Patient 12) is a 380 grams (13.4 oz), 25-week female infant ...born breech (positioned buttocks or feet first that than head down) by Caesarean Section (surgical delivery of a baby through incisions in the mother’s abdomen and uterus). Cord immediately clamped given infant (Patient 12) with no tone and extremely small size ... Infant (Patient 12) with small attempt at a cry at 1 minute of life. Intubated (tube is inserted into the airway to maintain breathing) ...transferred to the Neonatal Intensive Care Unit (NICU, a specialized hospital department for premature, low-birthweight, or critically ill newborns). Admitting diagnoses included, Premature (or preterm, born before 37 completed weeks of pregnancy) 25 0/7 weeks, and Extremely Low Birth Weight (ELBW, infants born with a birth weight of less than 1,000 gram or 2.2 pounds). Patient (Patient 12) on Jet ventilation (Jet Vent, a specialized technique for delivering high pressure, intermittent burst of oxygen into the airway through small-born catheters). During a review of Patient 12’s Physician’s orders, dated 1/27/2026 at 1700 (5 p.m.), the orders indicated the following: “Fentanyl 25 mcg (micrograms, a unit of measure) in D5W (Dextrose 5% in water, a sterile intravenous [IV- through the vein] fluid containing 5% dextrose [sugar] dissolved in water. It is primarily used in medical settings to treat dehydration or serve as a liquid carrier for other IV medications) 5 ml (5mcg/ml) IV infusion solution syringe. Ordered dose: 0.5 mcg/kg/hr x 0.435 kg, Admin (administration) dose: 0.218 mcg/hr, Route: intravenous (IV, in the vein), Frequency: Continuous, at 0.04 ml/hr. During a review of Patient 12’s Physician’s orders, dated 1/2/2026 at 9:30 a.m., the physician’s orders indicated the following: Fentanyl, ordered dose: 0.2 mcg, intravenous (IV or in the vein), every four (4) hours as needed for moderate pain (4-6 /10, using the NPASS [Neonatal pain, agitation, and sedation scale, is an observational tool used by healthcare providers to assess pain, agitation and sedation levels in premature and full term infants] scale; Scores greater than zero indicate pain or agitation. A score of +1 to +3 indicates mild pain/agitation, while scores +4 or higher typically warrant comfort interventions). During a review of Patient 12’s “Medication Administration Record (MAR),” dated 1/27/2026 through 1/28/2026, the MAR indicated the following: -On 1/27/2026 at 1:02 a.m., Patient 12 received 0.25 mcg of fentanyl. -On 1/28/2026 at 4:08 a.m., Patient 12 received 0.25 mcg of fentanyl. -On 1/28/2026 at 6:56 p.m., Patient 12 received 0.25 mcg of fentanyl. During a review of Patient 12’s “Pain Assessment,” dated 1/27/2026 and 1/28/2026, the pain assessments indicated the following: -On 1/27/2026 at 1:02 a.m., no pain assessment was documented prior to Fentanyl 0.25 mcg (as needed dose) administration. No pain assessment was documented 30 minutes later at 1:32 a.m. (after Fentanyl [as needed dose] administration. -On 1/28/2026 at 4:08 a.m., no pain assessment was documented prior to Fentanyl 0.25 mcg (as needed dose) administration. No pain assessment was documented 30 minutes later at 4:38 a.m. -On 1/28/2026 at 6:56 p.m., no pain assessment was documented prior to Fentanyl 0.25 mcg (as needed dose) administration. No pain assessment was documented 30 minutes later at 7:26 p.m. During a concurrent interview and record review on 4/29/2026 at 2:41 p.m. with the Director of Children Services (DIR 1) and the Clinical Nurse Specialist (CNS 2), DIR 1 and CNS 2 reviewed Patient 12’s medical record and stated the following: Patient 12 was born via C-section on 12/31/2025. Patient 12 was premature and weighed 380 grams (13.4 ounces [0.435 kg]). Patient 12 was intubated, on a ventilator (a breathing machine) and admitted to the NICU. Patient 12 had orders for fentanyl 0.5 mcg/kg/dose, intravenous (IV, in the vein) every four (4) hours for moderate pain (4 - 6). Patient 12 received 0.25 mcg of fentanyl on 1/27/2026 at 1:02 a.m., and on 1/28/2026 at 4:08 a.m., and at 6:56 p.m. During the same concurrent interview and record review on 4/29/2026 at 2:41 p.m. with the Director of Children Services (DIR 1) and the Clinical Nurse Specialist (CNS 2), CNS 2 verified that Patient 12’s pain level should have been assessed prior to administering the fentanyl for baseline, and within 30 minutes after administering fentanyl to ensure the intervention was effective to treat Patient 12’s pain. CNS 2 verified that a pain assessment was not performed before or after the administration of fentanyl on 1/27/2026 at 1:02 a.m., and on 1/28/2026 at 4:08 a.m., and at 6:56 p.m. During the same concurrent interview and record review on 4/29/2026 at 2:41 p.m. with the Director of Children Services (DIR 1) and the Clinical Nurse Specialist (CNS 2), CNS 2 said Patient 12’s pain level should have been assessed using the NPASS (Neonatal pain, agitation, and sedation scale, is an observational tool used by healthcare providers to assess pain, agitation and sedation levels in premature and full term infants) scale and in accordance with the physician’s order, in which Fentanyl was ordered for moderate pain. In addition, CNS 2 and DIR 1 verified that Patient 12 was already receiving continuous fentanyl drip. CNS 2 also verified that Patient 12’s oxygen saturation (the amount of oxygen in the blood) dropped to 83% (normal is between 90% to 95%), on 1/28/2026 at 4:39 a.m., after receiving 0.25 mcg of fentanyl (ordered for “as needed” dose). During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 8/2024, the P&P indicated the following: “Sedation Scales: N-PASS (Neonatal Pain Agitation Sedation Scale) - Five categories are evaluated; Crying, General Behavior, Facial Expression, Extremities tone and Vital Signs. Use of this scale is appropriate for infant populations (Ages 0 - 9 months). Patients are screened, assessed, and re-assessed for pain utilizing a comprehensive pain assessment based on patient condition, age, and abilities ...Pain assessment, planning, intervention, and evaluation will be adapted to patients of all ages and cognitive function ...Documentation ...In conjunction with MAR, licensed personnel shall record pain/comfort assessment, interventions, response to intervention and level of sedation ...Reassess and respond to the patient’s pain, by evaluating the responses to treatment and progress toward pain management goals.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 50594 Based on interview and record review, the facility failed to: 1. Ensure Oxytocin (referred as Pitocin [medication to induce labor -progressive contractions of the uterus- in pregnant women]), was appropriately administered, based on the facility’s protocol or criteria for Pitocin administration, for one of 30 sampled patients (Patient 21), when Patient 21 was in active labor (means the cervix [the opening to the uterus] is dilating quickly, contractions [tightening of the muscles in the uterus] are strong and regular, and the body is preparing for birth) and was having late decelerations (temporary, gradual drops in a baby’s heart rate that occur after a uterine contraction has peaked. They are the most concerning type of fetal heart rate deceleration because they typically signal uteroplacental insufficiency-meaning the placenta is not providing enough blood or oxygen to the fetus [unborn baby]), in accordance with the facility’s oxytocin protocol titled “Optimizing Induction of Labor Progress for Vaginal Birth.” This deficient practice had the potential for Patient 21 to have a uterine hyperstimulation (excessive contractions of the uterus) thus reducing oxygen flow to Patient 21’s fetus (unborn baby), and potentially resulting in Patient 21’s unborn baby’s fetal distress (a condition during pregnancy or labor in which the fetus shows signs of inadequate oxygenation) including the potential for Patient 21’s uterine rupture (uterus or womb [a hollow, pear-shape organ in the female reproductive system] tears open during labor or pregnancy). 2. Ensure one of 30 sampled patients (Patient 12, a premature infant), received the correct dose of a continuous drip of fentanyl (a highly potent synthetic opioid [a powerful, man-made painkiller created in a laboratory, rather than being derived from a plant. It is designed to mimic the pain-relieving and sedative effects of natural drugs]), when starting a new syringe and during nursing handoff, in accordance with the physician’s order and the facility’s policy and procedure regarding high alert medication (drugs that bear a heightened risk of causing significant patient harm or fatal errors when used incorrectly) administration and medication administration. This deficient practice resulted in Patient 12 receiving ten (10) times the ordered amount of fentanyl for 13.5 hours (hr) and potentially caused Patient 12 to have respiratory distress (difficulty breathing presenting signs and symptoms such as shortness breath, gasping for breath and hyperventilation [rapid breathing]), required bagging (using a handheld device to provide manual, forced respiration for a patient in respiratory distress or failure) and the administration of two rescue medications Narcan (or naloxone, a life-saving medication designed to rapidly reverse an opioid overdose) and vecuronium (a medication used to induce muscle relaxation during surgery or mechanical ventilation). Findings: 1. During a review of Patient 21’s obstetric (OB, care related to pregnancy, labor (progressive contractions [tightening of the muscles in the uterus] of the uterus [commonly called the womb]), and childbirth) admission History & Physical (H&P, a medical note that reviews the patient’s health history and current condition to guide care), dated 12/20/2025, the H&P indicated Patient 21 was admitted on 12/20/2025 at 11:58 a.m.to the facility for labor induction (labor induction means starting labor using medications or other methods) due to type 2 Diabetes Mellitus (DM, a long?term condition where the body cannot control blood sugar well). The H&P further indicated that on admission (12/20/2025), the fetal (Patient 21’s unborn baby) heart tone monitoring (FHT monitoring means continuously checking the baby’s heart rate and the mother’s contractions to assess the baby’s well-being) indicated the unborn baby (of Patient 21) was healthy and well oxygenated. The H&P also indicated that Patient 21 was not in active labor (the physiological process of childbirth) on admission. During a review of Patient 21’s “Progress Notes,” dated 12/22/2025 at 11:41 p.m., the progress notes indicated Patient 21’s membrane status was grossly ruptured (refers to the amniotic sac [a thin, tough, and transparent pair of membranes that holds a developing fetus and amniotic fluid inside the uterus during pregnancy], meaning whether the “water” is still intact or has ruptured). During a review of Patient 21’s “Flowsheets,” dated 12/22/2025, the progress notes indicated at 11:57 p.m., Patient 21 was actively pushing (This phase begins when the cervix is fully dilated (10 centimeters) and ends with the delivery of the baby). During a concurrent interview and record review on 4/29/2026 from 10:23 a.m. to 12:11 p.m. with the Assistant Clinical Director (ACD 1), the Director of Perinatal Services (DIR 2), and Registered Nurse (RN) 7, Patient 21’s Fetal Heart Tones tracing strips (FHT, recorded patterns of the baby’s heart rate. Health care providers track FHT during labor to ensure the baby is healthy, tolerating contractions well and getting enough oxygen) record, dated from 12/22/2025 at 11:00 p.m. to 12/23/2025 at 4:30 a.m., was reviewed. The ACD 1 reviewed the FHT tracings strips from 12/22/2025 starting at 11:00 p.m. and verified that Patient 21 was in active labor (active labor means the cervix is dilating quickly, contractions are strong and regular, and the body is preparing for birth). The ACD 1 further stated: “Patient [Patient 21] is ready to push (the second stage of labor where the mother bears down to move the baby through the birth canal)... fully dilated (the cervix [the opening to the uterus] has opened to 10 centimeters about 4 inches wide), fully effaced (cervix has fully thinned out in preparation for childbirth) - patient (Patient 21) being complete - ready for delivery, can start pushing. Physician does not have to be in the room but should be notified ...nurses document the pushing part in the medical record.” -The ACD 1 then verified that the physician (MD 7, the provider responsible for Patient 21’s care), was notified on 12/22/2025 at 11:57 p.m. that Patient 21 started pushing and that the baby was doing well (moderate variability means the baby’s heart rate shows healthy changes, which indicates the baby is well-oxygenated and tolerating labor). -ACD 1 and RN 7 continued the interpretation of Patient 21’s FHT tracing strips and the timeline of events on 12/22/2025, and stated the following: “At 11:57 p.m. (on 12/22/2025), patient (Patient 21) started pushing. The FHT indicated Category II tracing strips (neither perfectly normal nor definitely abnormal, but requires closer monitoring), late deceleration (are drops in the baby’s heart rate that happen after a contraction and can mean the baby is not getting enough oxygen), baby has reserved variability (refers to small, beat-to-beat fluctuations in a baby’s heart rate) and contractions (the involuntary tightening and relaxing of the uterine muscles. These movements prepare the body for birth, help open the cervix, and push the baby down the birth canal) at 3-4 minutes. -At 12:15 a.m. (12/23/2025), FHT Category II, patient (Patient 21) continuing to push, moderate variability (means the baby’s heart rate shows healthy changes, which indicates the baby is well-oxygenated and tolerating labor), deceleration (refers to a temporary drop in baby’s heart rate and below the normal baseline), and no urgency for C-section (cesarean section, is a surgical procedure used to deliver a baby). -At 12:30 a.m. (12/23/2025), - patient (Patient 21) was now in Second stage of labor (when the cervix is fully dilated 10 cm [centimeters, a unit of measure], and ends with the birth of the baby, with active pushing), and moderate variability (fetus is adequately oxygenated and healthy). -At 12:45 a.m. (12/23/2025)- A combination of early (temporary, gradual drops in a baby’s fetal heart rate that happen at the exact same time as a uterine contraction. They mirror the contraction perfectly-starting, reaching their lowest point, and recovering just as the contraction ends) and late deceleration (temporary, gradual drops in a baby’s heart rate that occur after a uterine contraction has peaked. They are the most concerning type of fetal heart rate deceleration because they typically signal uteroplacental insufficiency-meaning the placenta is not providing enough blood or oxygen to the fetus [unborn baby]) could be seen, heart rate 150s to 160s., but still early to call for C-section. -At 12:59 a.m. (12/23/2025), At 1 hour mark, patient’s (Patient 21’s) fetal heart rate going down, with variability and contraction are still okay.” During the same concurrent interview and record review on 4/29/2026 from 10:23 a.m-12:11 p.m. with the Assistant Clinical Director (ACD 1), the Director of Perinatal Services (DIR 2), and Registered Nurse (RN) 7, Patient 21’s Fetal Heart Tones tracing strips record, dated from 12/22/2025 at 11:00 p.m. to 12/23/2025 at 4:30 a.m., was reviewed. ACD 1 and RN 7 then continued interpretation of Patient 21’s FHT tracing strips and the timeline of events on 12/23/2025, and stated the following: “At 1:14 a.m. (12/23/2025), Contractions with moderate variability (indicated that Patient 21’s fetus was still well oxygenated and doing well...) -At 1:52 a.m. (12/23/2025), Registered Nurse (RN 12) started the Pitocin (also called Oxytocin and used to induce labor [to help start childbirth]) at a rate of 2 milliliters (ml, unit of measure) per hour through an intravenous line (IV, into the vein) as ordered by the physician.” -RN 7 stated that right before administering Pitocin [at 1:52 a.m.] to Patient 21, the baby (Patient 21’s unborn baby) showed late decelerations (are drops in the baby’s heart rate that happen after a contraction and can mean the baby is not getting enough oxygen). RN 7 then stated that starting Pitocin with late decelerations present, may result in fetal hypoxia (means the baby is not getting enough oxygen, which can be dangerous). -ACD 1 stated, “Two nurses must sign for Pitocin (a high-alert medication, a drug that bears a heightened risk of causing significant patient injury or death when misused or administered incorrectly), because it must be verified by two nurses before use. The patient (Patient 21) did not meet the criteria for Pitocin because there were late decelerations after contractions (late decelerations occur when the baby’s heart rate drops after the contraction, which can show the baby is not getting enough oxygen). According to the criteria (the protocol for Pitocin administration), there must be no late decelerations for 30 minutes before Pitocin could be started.” -ACD 1 also stated that the reason Pitocin should not be started (when there is a late deceleration) is because of uterine placental insufficiency (this means the placenta is not delivering enough oxygen to the baby). During contractions, the baby gets even less oxygen. Adding Pitocin would make the contractions stronger and more frequent, which placed more stress on the baby. The verifier must also check that the patient met all the criteria (for Pitocin administration) before Pitocin was started. ACD 1 then added that moving forward, “we will ensure that the laminated algorithm (regarding Pitocin administration) is placed in each room. As part of the audit, the Pitocin protocol must be followed because we found that the order was not followed.” During a review of Patient 21’s baby’s NICU (Neonatal Intensive Care Unit, specialized hospital department for premature, low birth weight, or critically ill newborns) admission note, [undated], the NICU admission note indicated that Patient 21’s baby was born with Hypoxic Ischemic Encephalopathy (HIE2, a moderate type of brain injury that happens when a baby’s brain doesn’t get enough oxygen or blood flow around the time of birth), suspected subgaleal hemorrhage (rare but life-threatening emergency in newborns where blood collects between the scalp and skull) and respiratory distress (difficulty breathing presenting signs and symptoms such as shortness breath, gasping for breath and hyperventilation). During a review of Patient 21’s “Medication Detail,” undated, the document indicated Patient 21 had a physician’s order for Oxytocin (referred as Pitocin [medication to induce labor in pregnant women]). During a review of Patient 21’s, “Medication Administration Records (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient),” the MAR indicated that Patient 21 was initially administered Oxytocin (new bag) on 12/21/2025 at 5:00 p.m., and it was stopped on 12/22/2025 at 3:50 p.m. (next day). During a concurrent interview and record review on 4/29/2026 at 3:44 p.m. with Registered Nurse (RN) 7, Patient 21’s, “Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 12/23/2025, was reviewed. RN 7 verified that Oxytocin (new bag) was administered to Patient 21 at 1:52 a.m. (12/23/2025) and was discontinued at 4:30 a.m. (12/23/2025). RN 7 stated that Patient 21 did not meet the criteria for Pitocin administration and that the Pitocin should not have been re-started. RN 7 explained that Oxytocin (Pitocin) was designated as a high alert medication (drugs that bear a heightened risk of causing significant patient harm or fatal errors when used incorrectly), and the primary nurse was responsible for hanging the medication. A second registered nurse, serving as the verifier, must confirm several critical aspects: the medication dosage, the fetal monitoring strip, and the relevant parameters (the specific clinical measurements, conditions, or laboratory results that dictate whether a drug is safe to administer, needs to be withheld, or requires a dosage adjustment. They act as the “checks and balances” to prevent medication errors and adverse reactions). Both nurses were required to cosign, to confirm that the verification process has been completed. During an interview on 4/30/2026 at 12:04 p.m. with the Chief Physician of Obstetrics (MD 1) and the Assistant Administrator for Patient Safety and Quality (AAPSQ), MD 1 stated that a contraindication for Pitocin administration would be the presence of late decelerations or absent fetal heart tones, as Pitocin could further stress the baby. MD 1 further stated that a Category III fetal heart tracing with a prolonged deceleration would necessitate proceeding with a cesarean section, as time was critical. During a review of the facility’s Oxytocin protocol document titled, “Optimizing Induction of Labor Progress for Vaginal Birth,” effective date 12/10/2025, the protocol indicated, “Communication safety: ...oxytocin decrease/discontinuation or restart delay ...Administration of Oxytocin for Labor Management-Labor Algorithm- start oxytocin only if all the following criteria are met: Fetal Assessment: In the 30 mins leading up to oxytocin initiation there must be: ...no late decelerations in the past 30 mins ...No prolonged decelerations ...If criteria not met, notify the physician/midwife and recommendation is to assess patient and determine if reasonable to proceed as ordered ...” During a review of the facility’s policy and procedure (P&P) titled, “Drug Administration -Medication Administration Times,” revised date 3/2024, the P&P indicated, “To ensure accurate and safe administration and documentation ...Medications are administered according to the Five (5) Rights of Medication Administration: ...Right time ...Licensed personnel are responsible for the following related to medication administration: ...Knowledge of the patient’s diagnosis, allergies and contraindications ...Knowledge of medication, including usual dose and route of administration, the desired effects, side effects, special precautions ...” During a review of the facility’s policy and procedure (P&P) titled, “Oxytocin infusion,” revised date 11/2022, the P&P indicated, “Purpose: To specify the safe use of Oxytocin for induction or augmentation of labor ...Definitions: Oxytocin: ...is a synthetic hormone that stimulates uterine contractions by increasing myometrial cell membrane permeability to the sodium, ion, thus increasing the number of contracting myofibrils ...Prolonged decelerations: Visually apparent decrease in the FHR from baseline that is >15bpm, lasting >2minutes, but <10 minutes ...Oxytocin will be immediately discontinued if any of the following occur: ...Prolonged contractions lasting greater than two minutes ...Category III tracing or prolonged deceleration greater than two minutes ...” 2. During a review of Patient 12’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/31/2025, the H&P indicated the following: “This (Patient 12) is a 380 grams (13.4 oz), 25-week female infant ...born breech (positioned buttocks or feet first that than head down) by Caesarean Section (surgical delivery of a baby through incisions in the mother’s abdomen and uterus). Cord immediately clamped given infant (Patient 12) with no tone and extremely small size ... Infant (Patient 12) with small attempt at a cry at 1 minute of life. Intubated (tube is inserted into the airway to maintain breathing) ...transferred to the Neonatal Intensive Care Unit (NICU, a specialized hospital department for premature, low-birthweight, or critically ill newborns). Admitting diagnoses included, Premature (or preterm, born before 37 completed weeks of pregnancy) 25 0/7 weeks, and Extremely Low Birth Weight (ELBW, infants born with a birth weight of less than 1,000 gram or 2.2 pounds). Patient (Patient 12) on Jet ventilation (Jet Vent, a specialized technique for delivering high pressure, intermittent burst of oxygen into the airway through small-born catheters).” During a review of Patient 12’s Neonatology “Progress Note,” dated 1/28/2026 at 6:46 a.m., the progress note indicated “infant (Patient 12) with intermittent desaturations (a drop in blood oxygen levels, usually below 90 %) ...Bagged (using a handheld device to provide manual, forced respiration for a patient in respiratory distress or failure) for a few minutes around 0430 (4:30 a.m.) given persistent desaturation to 60’s (Fentanyl [a highly potent synthetic opioid] PRN [as needed] x 2 [2 doses] given prior). “ During a review of Patient 12’s Neonatology “Progress Note,” dated 1/28/2026 at 9:27 a.m., the progress note indicated the following: “At 0745 (7:45 am), notified by RN (registered nurse) staff that baby (Patient 12) was receiving Fentanyl drip (a method for continuously administering medications directly to a person’s vein) of 5 mcg (micrograms, a unit of measure)/kg (kilogram)/hr (hour), (which was previously ordered at a correct dose of 0.5 mcg/kg/hr), from 1813 (6:13 p.m. on 1/27/2026) to current time (1/28/2026 at 7:45 a.m.). Drip was immediately corrected (upon discovery) to (the ordered) dose of 0.5 mcg/kg/hr.” During a review of Patient 12’s Neonatology “Progress Note,” dated 1/28/2026 at 9:27 a.m., the progress note also indicated the following: “Infant (Patient 12) at the time of exam, calm and good chest wiggle. As infant (Patient 12) had recovered from last bagging (using a handheld device to provide manual, forced respiration for a patient in respiratory distress or failure) episode earlier, the drip (Fentanyl) was weaned (to gradually reduce a medication over a period of time to either reach a new, lower maintenance dosage or to safely discontinue the drug altogether) to correct dose and infant (Patient 12) monitored closely for further events.” During a review of Patient 12’s Neonatology “Progress Note,” dated 1/28/2026 at 9:27 a.m., the progress note also indicated the following: “At approximately a little after 0800 (8 a.m.), infant (Patient 12) with another significant desaturation episode (a drop in blood oxygen levels, usually below 90 %) requiring hand bagging (Oxygen saturation [SpO2] down to 50s). At this time, Fentanyl drip was discontinued and 0.1 mg/kg of Narcan (or naloxone, a life-saving medication designed to rapidly reverse an opioid overdose) given at 0814 (8:14 a.m.) without much change - SpO2 still hovering in 70s - 80s; Vecuronium (a medication used to induce muscle relaxation during surgery or mechanical ventilation) 0.1mg/kg x (one time dose) 1 given at 0834 (8:34 a.m.,) with appropriate response. Infant’s SpO2 gradually improved to mid-90’s ...Parents (of Patient 12) at bedside and notified of medication drip dosing error and remedies taken to reverse the effects of Fentanyl.” During a review of Patient 12’s Physician’s orders, dated 1/27/2026 at 1700 (5 p.m.), the orders indicated the following: “Fentanyl 25 mcg in D5W (Dextrose 5% in water, a sterile intravenous [IV- through the vein] fluid containing 5% dextrose [sugar] dissolved in water. It is primarily used in medical settings to treat dehydration or serve as a liquid carrier for other IV medications) 5 ml (5mcg/ml) IV infusion solution syringe. Ordered dose: 0.5 mcg/kg/hr x 0.435 kg, Admin (administration) dose: 0.218 mcg/hr, Route: intravenous (IV, in the vein), Frequency: Continuous, at 0.04 ml/hr.” During a review of Patient 12’s “Medication Administration Record (MAR),” dated 1/27/2026 through 1/28/2026, the MAR indicated the following: “Fentanyl 25 mcg in D5W 5 ml (5 mcg/ml) IV (in the vein) infusion solution (soln) syringe, Rate 0.04 ml/hr, Dose: 0.5 mcg/kg/hr, Weight Dosing Info (information): 0.435 kg (kilograms), Frequency: CONTINUOUS,. Route: IV. Start 1/27/2026 at 1700 (5 p.m.).” -On 1/27/2026 at 6:13 p.m., New Bag (syringe with Fentanyl), Documented by Registered Nurse (RN) 6 and Dual Signed by RN 8. Dose 0.5 mcg/kg/hr, Rate 0.04 ml/hr. Comment: Verified waste and discarded old syringe of 7.8 ml with RN 8. -On 1/27/2026 at 7:44 p.m., Handoff (Fentanyl), documented by RN 6 and RN 5. -On 1/27/2026 at 9 p.m., Rate Verified (for Fentanyl) by RN 5. Dose 0.5 mcg/kg/hr, Rate 0.04 ml/hr. -On 1/28/2026 at 4:45 a.m., New Bag (or syringe of Fentanyl), documented by RN 5 and RN 9, Dose: 0.5 mcg/kg/hr, Rate: 0.04 ml/hr. -On 1/28/2026 at 7:40 a.m., Already infusing, Dose: 5 mcg/kg/hr, Rate: 0.435 ml/hr. Comment: Received fentanyl drip at 0.435 ml/hr at this time. Escalated to physician. Documented by RN 10 and dual signoff by Clinical Nurse Specialist (CNS) 1. -On 1/28/2026 at 7:44 a.m., Rate Change (Fentanyl). Dose: 0.506 mcg/kg/hr, Rate: 0.044 ml/hr, Comment: Rate changed at bedside during shift report from RN 5. Escalated to CNS 1 and physician. -On 1/28/2026 at 8:10 a.m., Stopped. Comment: Medication (Fentanyl) stopped per physician. -On 1/28/2026 at 8:14 a.m., Naloxone (Narcan) 0.4 mg/injection (inj) - 0.0053 mg given. -On 1/28/2026 at 8:34 a.m., Vecuronium inj 0.05 mg - given. -On 1/28/2026 at 12:15 p.m., Vecuronium inj 0.05 mg - given. During a review of Patient 12’s “Nursing Progress Notes,” dated 1/28/2026 at 10 a.m., the nursing progress notes indicated the following: -0710 (7:24 a.m.): Patient (Patient 12) noted to have fluctuating sats (saturations) in 80s - 89 % during report. -0724 (7:24 a.m.): “Patient (Patient 12) began to experience brady (bradycardia, low heart rate)/desat (oxygen desaturations) events.” Handoff from RN 5 stopped to begin bagging. “RT (respiratory therapist) called to bedside to assist with airway management and bagging at this time and physician notified ...” -0740 (7:40 a.m.): During medication reconciliation (a formal process used by healthcare providers to compare a patient’s current medication list against their new medications or medical orders. The goal is to identify and resolve discrepancies)/line trace (the physical practice where healthcare staff trace all medical lines (like IVs, catheters, and feeding tubes) from their point of origin (e.g., medication bag, IV pump) to the patient’s insertion site. This verifies that all fluids and settings match the patient’s orders), “fentanyl noted to be running at 0.435 ml/hr. Dose and rate corrected at 0744 (7:44 a.m.) to 0.0435 ml/hr ...” -0810 (8:10 a.m.): Physician at bedside. Fentanyl drip stopped. Verbal order from physician to give Narcan. Narcan dose given per code sheet (a structured document used by medical staff to record vital events, timelines, and interventions during a life-threatening medical emergency) at bedside at 0814 (8:14 a.m.). -0834 (8:34 a.m.): “Vecuronium given per order. Sats (oxygen saturations) fluctuated until patient (Patient 12) recovered ...” During a review of Patient 12’s “Nursing Progress Notes,” dated 1/28/2026 at 8:17 p.m., the nursing progress notes indicated the following: “Status: Stable ...At 7:24 a.m., patient (Patient 12) required bagging due to persistent brady (bradycardia)/desat (desaturation) events. After discontinuing fentanyl and Narcan and vecuronium administration, vital signs normalized ...” During a review of a document titled, “History Report,” for the intravenous (IV) syringe pump (#050-13987) used on Patient 12 on 1/27/2026 through 1/28/2026 to administer fentanyl, the history reported indicated the following: -1/27/2026 at 15:50 (3:50 p.m.), Start/Resume normal infusion, infusion rate: 0.0435 ml/hr -1/27/2026 at 20:12 (8:12 p.m.), Infusion stopped -1/27/2026 at 20:12 (8:12 p.m.), Setup, Fentanyl 5 mcg/ml -1/27/2026 at 20:16 (8:16 p.m.) Program, Concentration 5 mcg/ml, Dose 5 mcg/kg/hr, Patient weight 0.435 kg (kilograms), Main Rate: 0.435 ml/hr. -1/27/2026 at 21:11 (9:11 p.m.) Infusion stopped -1/27/2026 at 21:12 (9:12 p.m.) Program, Concentration 5 mcg/ml, Dose 5mcg/kg/hr, Patient weight 0.435 kg (kilograms), Main Rate: 0.435 ml/hr. -1/27/2026 at 21:12 (9:12 p.m.) Start/Resume normal infusion, infusion rate: 0.435 ml/hr ... -1/28/2026 at 06:16 (6:16 a.m.) Infusion stopped -1/28/2026 at 06:17 (6:17 a.m.) Program, Concentration 5 mcg/ml, Dose 5 mcg/kg/hr, Patient weight 0.435 kg (kilograms), Main Rate: 0.435 ml/hr -1/28/2026 at 06:17 (6:17 a.m.) Start/Resume normal infusion, infusion rate: 0.435 ml/hr -1/28/2026 at 09:08 (9:08 a.m.) Infusion stopped During an interview on 4/28/2026 at 11:07 a.m. with the Assistant Administrator for Patient Safety and Quality (AAPSQ), the AAPSQ stated the following: A medication error occurred during the work stoppage (strike) involving contingent staff, on 1/28/2026 at 8:32 a.m., when nursing staff discovered that Patient 12 was receiving the wrong dose of fentanyl. The facility conducted an investigation and identified gaps. One of the gaps was that the IV pump used in the NICU was not connected to the electronic medication administration record and so nurses were required to program the pumps correctly. In addition, the nurses failed to conduct an independent double check (nurses should individually check the order, validate that the IV pump was set up to correct dose and rate, and validate the connection to the IV site) accurately. For opioids, such as fentanyl, two nurses were required to conduct the independent double check at the patient’s bedside. During a concurrent interview and record review on 4/29/2026 at 2:04 p.m. with the Director of Pharmacy (DOP), the DOP stated the following: The DOP stated that Patient 12 received ten (10) times the ordered amount of fentanyl for 13.5 hours from 1/27/2026 at 6:13 p.m., through 1/28/2026 at 7:45 a.m. The DOP stated that the MAR reflected the correct dose was documented, however, the History Report for the IV pump used for Patient 12, indicated the IV Pump was running at the incorrect dose for 13.5 hours until the error was caught at 7:40 a.m., on 1/28/2026. The DOP stated that the biggest concern for fentanyl, or any opioid, was lethargy (state of being sluggish, drowsy, or lacking energy) and respiratory depression (breathing is too slow or shallow, causing oxygen levels to drop). During a concurrent interview and record review on 4/29/2026 at 2:07 p.m., the DOP provided photos of the IV pump used during the administration of fentanyl for Patient 12 on 1/27/2026 and 1/28/2026. The DOP verified that on 1/27/2026 at 8:16 p.m., the IV pump was infusing fentanyl at a dose of 5 mcg/kg/hr instead of 0.5 mcg/kg/hr and the infusion rate was 0.435 ml/hr instead of 0.0435 ml/hr. During a concurrent interview and record review on 4/29/2026 at 2:41 p.m. with the Director of Children Services (DIR 1) and the Clinical Nurse Specialist (CNS 2), DIR 1 and CNS 2 reviewed Patient 12’s medical record and stated the following: Patient 12 was born via C-section on 12/31/2025. Patient 12 was premature and weighed 380 grams (13.4 ounces [0.435 kg]). Patient 12 was intubated, on a ventilator (a breathing machine) and admitted to the NICU. DIR 1 stated that on 1/27/2026 at 6:13 p.m., RN 6 removed a syringe of fentanyl from the IV machine and wasted 7.8 ml, which was signed off by RN 8. RN 6 administered a new syringe of fentanyl via IV at that time (6:13 p.m.). DIR 1 stated that the administration of fentanyl required two nurses to perform an independent double check prior to administration. RN 8 witnessed the wasting of fentanyl but did not perform an independent double check when RN 6 administered a new syringe of fentanyl. At shift change, on 1/27/2026 between 7:15 p.m., and 7:45 p.m., Patient 12 handoff was given from RN 6 to RN 5, the nurses should individually check the order, validate that the IV pump was set up to correct dose and rate, and validate the connection to the IV site, then the nurses sign off, indicating they followed these steps (independent double check). On 1/27/2026 at 9 p.m., RN 6 verified that the fentanyl IV pump was running at a rate of 0.5 mcg/kg/hr. During a concurrent interview and record review on 4/29/2026 at 2:41 p.m. with the Director of Children Services (DIR 1) and the Clinical Nurse Specialist (CNS 2), DIR 1 and CNS 2 reviewed Patient 12’s medical record and stated the following: On 1/28/2026 at 4:45 a.m., RN 6 and RN 9 administered a new syringe of fentanyl, both signed off that dose and rate were verified and correct. On 1/28/2026 at 7:40 a.m., during shift change, RN 10 assumed care for Patient 12 and discovered that the IV pump was running at a rate of 0.435 ml/hr instead of 0.0435 ml/hr and the dose was set as 5 mcg/kg/hr instead of 0.5 mcg/kg/hr. RN 10 and CNS 1 calculated the dosing and performed their independent double check. RN 10 and CNS 1 informed the physician of the medication error. DIR 1 stated she (DIR 1) was not quite sure how the error happened, since the nurses involved were contingent workers (temporary nurses called in from an outside agency to assist with patient care), during the strike, was not allowed to interview the staff. DIR 1 verified that the Medication Administration Record (MAR) indicated that two 2 nurses signed off on the fentanyl and that the doses and rate were documented as being correct, however, DIR 1 verified the wrong dose was given to Patient 12 from 1/27/2026 at 6:13 p.m. to 1/28/2026 at 7:44 a.m., for approximately 13.5 hours. - In addition, DIR 1 verified that on 1/28/2026, Patient 12 had episodes of oxygen desaturations while receiving the incorrect dose of fentanyl and oxygen saturation (O2 sat) should be at a minimum of 92 %. On 1/27/2026 at 10 p.m.- O2 sat was 84.%, at 11 p.m.- O2 sat was 82 %, On 1/28/2026 at 1 a.m.- O2 sat was 82 %, at 2 a.m.- O2 sat was 75 %, at 2:58 a.m.- O2 sat was 88 %, at 3 a.m.- O2 sat was 78 %, at 4:39 a.m.- O2 sat was 83 %, at 5 a.m.- O2 sat was 71 %, at 7:37 a.m.- O2 sat was 62 %. DIR 1stated that despite Patient 12 being on a ventilator, Patient 12 required hand bagging due to the desaturation. DIR 1 stated that the oxygen desaturations may have been caused by the incorrect dose of fentanyl. During a concurrent interview and record review on 5/4/2026 at 2:18 p.m. with the Nurse Manager (NM 1) from the NICU and DIR 1, NM 1 and DIR 1 stated the following: Patient 12 received two rescue medications (Narcan and Vecuronium) after receiving too much fentanyl. A rigid chest could be a complication of fentanyl. Patient 12 received Vecuronium on 1/28/2026. Vecuronium relaxes the chest. Patient 12 also received Narcan for overdose of fentanyl. During a concurrent interview and record review on 5/4/2026 at 2:28 p.m. with the Quality Coordinator Registered Nurse (QCRN), the QCRN reviewed Patient 12’s Medication Administration Record and verified that Patient 12 received Narcan on 1/28/2026 at 8:13 a.m. and Vecuronium on 1/28/2026 at 8 a.m., and at 12:15 p.m. During a review of the facility’s policy and procedure (P&P) titled, “Regional High Alert,” dated 2/2025, the P&P indicated the following: Regional high-alert medications are defined as those drugs which are involved in a higher percentage of medication incidents and/or sentinel events, that carry an increased risk for error and other adverse outcomes ...Purpose: To standardize safe medication practices for high alert medications throughout the medication use process ...Definitions: Independent Double Check: Independent Double Check is defined as a check of the factors listed below. It is performed independently and separately by two qualified health care practitioners (physician/nurse/pharmacist/allied professionals licensed to administer medications), and may occur during preparation, dispensing, hand off and/or administration. The factors to be verified during the independent double check must minimally include: Right patient, Right drug, Right dose, Right route, Right day/time ...Time out: Time Out is defined as the period of time immediately before initiating a high-alert medication/procedure, when two qualified health care practitioners verify the factors listed below, at the patient’s bedside in the location where the medication administration /procedure will be performed. The factors to be verified during the Time Out must include: Availability of any specific equipment for administration of the medication ...if applicable. For patients with I.V. Pumps, verify the setting and rate of infusion. For patients receiving drugs programmed on the intravenous (I.V.) pump using the drug library, verify the correct drug, concentration, and correct entry of patient’s weight (for weight-based drugs) or body surface area, correct dose/rate or duration, and line attachment. The pump setting must be doubled checked against the current medication order. During a review of the facility document titled, “Appendix A ...High Alert Medication List,” dated 11/2025, the documented included a list of drugs classes/medications considered to be high risk medications. Medications included on the list included but not limited to “anticoagulants ...insulins, all opioids. Specific Populations: Pediatric and Neonatal: All adult high alert medications, digoxin ...” During a review of the facility’s policy and procedure (P&P) titled, “Drug Administration - Medication Administration Times,” dated 3/25/2024, the P&P indicated the following: Purpose: To ensure accurate and safe medication administration and documentation and to delineate those staff members who are authorized to administer medications ...Provisions: Medications are administered according to the Five (5) Right of Medication Administration: Right patient, Right medication, Right dose, Right time, Right route ...Licensed personnel are responsible for the following related to medication administration ...Verifying the medication is being administered at the proper time, at the prescribed dose, and by the correct route.”

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 31333 Based on interview and record review, the facility failed to prevent, identify and minimize patient harm as it related to the use and monitoring of a high risk medication (drugs that bear a heightened risk of causing significant patient harm or fatal errors when used incorrectly), fentanyl (opioid pain medication that is 100 times more potent than morphine), for one of 30 sampled patients (Patient 12, who was a premature infant). The hospital failed to implement its policy on high-risk/high-alert medications to incorporate external alerts and internal respective review to identify opioids, including fentanyl, as high-risk/high-alert medications and develop safeguards to reduce the risk of errors. The hospital also did not take appropriate actions to prevent future adverse drug events after pharmacy services dispensed fentanyl refill, too early (the syringe must be replaced every 24 hours, and any leftover medication in the syringe discarded), 10.5 hours after the initial dose was dispensed, without ensuring that the refill was appropriate to dispense to Patient 12. As a result, the pharmacist did not review or question the refill ordered by nursing staff. The Fentanyl was not due based on the syringe containing a volume of 5 ml (5 micrograms [mcg] per ml = 25 mcg/5 ml). The Fentanyl syringe (containing 5 ml) should have lasted for five days. The pharmacist dispensed a dose of Fentanyl too soon (in less than 24 hours), and Patient 12, a 25-week premature infant, who was actually receiving an incorrect dose (10 times the ordered dose) of fentanyl. This deficient practice resulted in Patient 12 receiving the wrong dose of fentanyl for 13.5 hours (hr) and caused Patient 12 to experience respiratory distress (difficulty breathing presenting signs and symptoms such as shortness breath, gasping for breath and hyperventilation [rapid breathing]) and required bagging (using a handheld device to provide manual, forced respiration for a patient in respiratory distress or failure) and the administration of two rescue medications Narcan (or naloxone, a life-saving medication designed to rapidly reverse an opioid overdose) and vecuronium (a medication used to induce muscle relaxation during surgery or mechanical ventilation), to recover. This failure compromised the hospital’s ability to prevent serious patient harm from medication errors involving known high-risk medications. Findings: During a review of Patient 12’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/31/2025, the H&P indicated the following: “This patient (Patient 12) is a 380 grams (13.4 oz), 25-week female infant ...born breech (positioned buttocks or feet first that than head down) by Caesarean Section (surgical delivery of a baby through incisions in the mother’s abdomen and uterus) ... patient (Patient 12) was intubated (tube is inserted into the airway to maintain breathing) ...transferred to the Neonatal Intensive Care Unit (NICU, a specialized hospital department for premature, low-birthweight, or critically ill newborns). Admitting diagnoses included, Premature (or preterm, born before 37 completed weeks of pregnancy) 25 0/7 weeks, and Extremely Low Birth Weight (ELBW, infants born with a birth weight of less than 1,000 gram or 2.2 pounds). Patient (Patient 12) on Jet ventilation (Jet Vent, a specialized technique for delivering high pressure, intermittent burst of oxygen into the airway through small-born catheters).” During a review of Patient 12’s Physician’s orders, dated 1/27/2026 at 5 p.m., the orders indicated: -Fentanyl 25 mcg (micrograms, a unit of measure) in D5W (Dextrose 5% in water, a sterile intravenous [IV- through the vein] fluid containing 5% dextrose [sugar] dissolved in water. It is primarily used in medical settings to treat dehydration or serve as a liquid carrier for other IV medications) 5 ml (5mcg/ml) intravenous (IV, in the vein) infusion solution syringe. -Ordered dose: 0.5 mcg/kg/hr x 0.435 kilogram (kg) (Patient 12’s weight) -Administer dose: 0.218 mcg/hr, -Route: intravenous, Frequency: Continuous, at 0.04 ml/hr. During a review of Patient 12’s “Medication Administration Record (MAR),” dated 1/27/2026 through 1/28/2026, the MAR indicated the following: -Fentanyl 25 mcg in D5W 5 ml (5 mcg/ml) IV infusion solution syringe, Dose: 0.5 mcg/kg/hr, Weight Dosing information: 0.435 kg (kilograms) Rate 0.04 ml/hr, Frequency: Continuous, Route: IV. Start 1/27/2026 at 5 p.m. -On 1/27/2026 at 6:13 p.m., New Bag (Fentanyl), Documented by Registered Nurse (RN) 6 and Dual Signed by RN 8. Dose 0.5 mcg/kg/hr, Rate 0.04 ml/hr ...Comment: Verified waste and discarded old syringe of 7.8 ml with RN 8. -On 1/27/2026 at 7:44 p.m., Handoff (Fentanyl), documented by RN 6 and RN 5. -On 1/27/2026 at 9 p.m., Rate Verified (for Fentanyl) by RN 5. Dose 0.5 mcg/kg/hr, Rate 0.04 ml/hr. -On 1/28/2026 at 4:45 a.m., New Bag (Fentanyl), documented by RN 5 and RN 9, Dose: 0.5 mcg/kg/hr, Rate: 0.04 ml/hr. -On 1/28/2026 at 7:40 a.m., Already infusing, Dose: 5 mcg/kg/hr, Rate: 0.435 ml/hr. Comment: Received fentanyl drip at 0.435 ml/hr at this time. Escalated to physician. Documented by RN 10 and dual signoff by Clinical Nurse Specialist (CNS) 1. -On 1/28/2026 at 7:44 a.m., Rate Change (Fentanyl). Dose: 0.506 mcg/kg/hr, Rate: 0.044 ml/hr, Comment: Rate changed at bedside during shift report from RN 5. Escalated to CNS 1 and physician. -On 1/28/2026 at 8:10 a.m., Stopped. Comment: Medication (Fentanyl) stopped per physician. -On 1/28/2026 at 8:14 a.m., Naloxone (Narcan, a life-saving medication designed to rapidly reverse an opioid overdose) 0.4 mg/injection, 0.0053 mg given. -On 1/28/2026 at 8:34 a.m., vecuronium (a medication used to induce muscle relaxation during surgery or mechanical ventilation) injection 0.05 mg given. -On 1/28/2026 at 12:15 p.m., vecuronium injection 0.05 mg given. During a review of Patient 12’s Neonatology “Progress Notes Addendum,” dated 1/28/2026 at 10:00 a.m., the progress note included the following: -On 1/28/2026 at 7:10 a.m., Patient 12 noted to have fluctuating sats (oxygen saturations, amount of oxygen in the blood) in 80s - 89 % during report. -On 1/28/2026 at 7:24 a.m., Patient 12 began to experience bradycardia (slower than normal heart rate, less than 100 for infant, normal ranging between 120 and 160 - 180 beats per minute [bpm]) and oxygen desaturation (a medical condition where the oxygen levels in the blood fall below the normal, healthy range [typically below 90% to 92%]) events. Handoff from RN 5 stopped to begin bagging ...a Respiratory Therapist (no name) called to bedside to assist with airway management and bagging at the time and MD5 was notified of bradycardia and oxygen desaturation events. -On 1/28/2026 at 7:40 a.m., During medication reconciliation (a formal safety process where healthcare providers compare a patient’s current medication list to any new medications being prescribed)/line trace (physically follow an intravenous [IV] tube from its starting point [the medication bag or fluid source] through infusion pump and directly to the patient’s insertion site), fentanyl noted to be running at 0.435ml/hr. Dose and rate corrected at 7:44 a.m., to 0.0435ml/hr. Medication concern escalated to CNS 1 and MD5 at this time. -On 1/28/2026 at 7:48 a.m., Patient continued to have fluctuating HR (heart rate) and Sats after being placed back on HFJV (High-Frequency Jet Ventilation) post bagging. MD5 notified. -On 1/28/2026 at 8:10 a.m., MD5 at bedside. Fentanyl drip stopped. Verbal order from MD5 to give Narcan. Narcan dose given per code sheet (a structured document used by medical staff to record vital events, timelines, and interventions during a life-threatening medical emergency) at bedside at 8:14 a.m. -On 1/28/2026 at 8:34 a.m., Vecuronium given per order. Sats fluctuated (when blood oxygen levels (SpO2) are unstable, shifting up and down over a period of time) until patient recovered. HR increased to above 200 and was sustained. -On 1/28/2026 at 9:10 a.m., Versed (used primarily as a sedative before medical procedures) given for tachycardia (fast heartbeat, exceeding 160 to 180 bpm for infant) with appropriate response. During an interview on 4/28/2026 at 11:10 a.m. with the Assistant Administrator for Patient Safety and Quality (AAPSQ), the AAPSQ stated an incident occurred when Patient 12 received the wrong dose of fentanyl for 13.5 hours in the Neonatal Intensive Care unit (NICU) on the afternoon of 1/27/2026 until discovered the morning of 1/28/2026. AAPSQ stated the Pharmacy department was involved in the investigation of the incident. During an interview on 4/28/2026 at 12:41 p.m. with the Director of Inpatient Pharmacy (DOP) and the Inpatient Pharmacist Supervisor (Pharm 1), DOP stated that the Neonatal Intensive Care Unit (NICU) intravenous (IV) infusion pump was not connected to the hospital’s HealthConnect (facility’s comprehensive, integrated Electronic Health Record [EHR] system, which integrates clinical decision-support tools directly at the point of care. For example, when nurses administer medication at the bedside, the system uses barcode scanning to ensure the right drug is given to the right patient, at the right dosage, and at the right time) system. DOP stated if the NICU’s IV infusion pump was integrated to the hospital’s HealthConnect system, the physician’s electronic prescription order and the NICU’s IV infusion pump would communicate electronically. DOP stated the NICU’s IV infusion pump has a maximum fentanyl limit set at 10 micrograms (mcg) per kilogram (kg) per hour with a hard stop (blocks the infusion from starting until the dose is reprogrammed within the approved, safe limits) if exceeded and at eight mcg/kg/hr there was a soft stop (alerts the clinician that the dose exceeds standard ranges, but allows them to override the alert and start the infusion). The DOP stated the IV infusion pump for Patient 12’s fentanyl drip required the nurse to input the patient’s weight, required the nurse to calculate the dose and the IV drip rate. DOP stated for an initial or new high-alert medication order, such as fentanyl, the pharmacist would verify the actual ordered dose prior to dispensing. The DOP stated that on 1/28/2026 at 04:45 a.m., a new syringe of fentanyl was provided by pharmacy and administered to Patient 12. DOP stated the pharmacist did not check the refill order for appropriateness of the dose before refilling Patient 12’s fentanyl refill request which was too soon on 1/28/2026. DOP stated that after completing the investigation, the pharmacy department implemented a new process for NICU pharmacy to check order for critical medications, if there were any question pharmacy will contact the primary nurse for clarifications. If a refill was requested by the nurse for a high alert medication, such as a drip, the pharmacist would validate if the dose was appropriate to dispense. Validation would include checking the order and the drip rate and determining whether or not the request was appropriate. DOP stated the action plan after the incident was to reinforce the process of reviewing and assessing refill requests to ensure accuracy and appropriateness of the high alert medication in the NICU. DOP stated the hospital did not have a tracking method or documentation to validate the implementation that pharmacist was reviewing high alert medication refill request prior to dispensing the medication to ADM in the NICU. During an interview on 4/29/2026 at 11:15 a.m. with the DOP, Pharm 1, and the Neonatal Intensive Care Unit Pharmacist (Pharm 6), Pharm 6 stated that Pharm 6 verified new or initial physician orders and did not review refill medication orders for NICU, PICU or Pediatric units. Pharm 6 stated refill requests were sent to the pharmacy by nurses through the electronic medication administration record (eMAR). Pharm 6 stated Pharm 6 was not sure or aware of what was checked for refilling controlled medications, such as fentanyl IV drip. Pharm 6 stated there were no alerts on the NICU IV pump if fentanyl IV syringe dose ended sooner than it should. During an interview on 4/30/2026 at 10:23 a.m. with DOP, Area Pharmacy Director (ADOP), Regional Pharmacy Director (RDOP) Pharm 1, and Pharm 3, Patient 12’s physician order for fentanyl IV drip, administration record, and IV fentanyl infusion pump data, were reviewed. Pharm 3 stated Patient 12’s fentanyl IV syringe was changed from 50 mcg/10 ml to 25 mcg/5 ml syringe on 1/27/2026 at 1813 (6:13 p.m.). Pharm 3 stated based on an ordered dose of 0.5 mcg/kg/hr and Patient 12’s weight of 0.435 kg, the calculated dose based on weight should have been 0.218 mcg per hour with an infusion rate of 0.04 ml/hour. DOP stated a 5 ml (5mcg/ml = 25 mcg/5ml) fentanyl syringe would last five (5) days. DOP stated within 24 hours, based on ordered dose, Patient 12 should have received 0.96 ml (4.8 mcg of fentanyl) and expected to waste 4.04 ml (20.2 mcg of fentanyl). During a concurrent interview and record review on 4/30/2026 at 12 p.m. with DOP, ADOP, RDOP, Pharm 1, and Pharm 3, Pharm 1 stated Patient 12’s IV fentanyl syringe started on 1/27/2026 at 1813 (6:13 p.m.), was documented in the eMAR as being infused at the correct rate of 0.04 ml/hr, with the volume of fentanyl used over 10.5 hours and no documented waste. Pharm 1 stated a refill syringe of IV fentanyl was started on 1/28/2026 at 4:45 a.m., documented in the eMAR as being infused at the correct rate of 0.04 ml/hr, and ran for over three hours. Pharm 1 stated Patient 12’s IV infusion pump was actually infusing at a rate of 0.435 ml/hr (10 times the prescribed rate) until 1/28/2026 at 7:44 a.m. Pharm 1 stated Patient 12 was administered about 6.32 ml (about 31.6 mcg) fentanyl over 13.5 hours instead of the prescribed 0.96 ml (4.8 mcg) of fentanyl over 24 hours. During an interview on 4/30/2026 at 3:11 p.m. with the DOP, the DOP stated refill for high alert medications, such as fentanyl did not require a pharmacist reverification of the order unless there was a change in the dose or frequency which would make it a new order. DOP stated for Patient 12, there was no pharmacist reverification required on 1/28/2026 at 3:54 a.m., when the refill request for fentanyl was sent as there was no change in the order. DOP stated for refill medications pharmacist review the physician order and MAR last dispensed dose if the request was too soon based on the last dispensed, with the pharmacist doing their own calculations and how long the fentanyl IV should last and if determined to be too soon to refill, the pharmacist would contact the nurse to determine the reason for requesting the medication earlier than necessary. DOP stated there was no documentation that the nurse was called to inquire why the fentanyl IV drip was requested for an early refill. DOP stated, for Patient 12 the IV fentanyl syringe was dispensed earlier than required without knowing what was happening with the IV pump error. DOP stated the pharmacy did not catch the fentanyl error for Patient 12 in which the dose for fentanyl was calculated wrong at the IV pump, that incorporated system errors that included pharmacy release of the fentanyl syringe too soon for administration to Patient 12. DOP stated the plan was to enforce the pharmacists to review refill request of high alert medications for appropriateness. DON stated there was no documentation to verify that high alert medication refills were being reviewed by the pharmacist. During a review of the facility’s policy and procedure (P&P) titled, “Regional High Alert Medication,” dated 7/2024, the P&P indicated, “Regional high-alert medications are defined as those drugs which are involved in a higher percentage of medication incidents and/or sentinel events, or that carry an increased risk for error or other adverse outcomes ... Purpose: To standardize safe medication practices for high alert medications throughout the medication use process. To increase awareness of high alert medications and the safeguards necessary to maximize the safe use of these medications ... Scope/Coverage: This policy applies to all employees who are employed ...This policy applies to all registry/travelers who are required to complete the high alert medication training prior to start of assignment ... Pharmacy Pause: Pharmacy Pause is defined as checks performed independently by two pharmacists or a pharmacist and a pharmacy technician, before a specified high-alert medication is dispensed from the pharmacy. The factors to be verified during the Pharmacy Pause must include: Right patient identification using two identifiers (e.g. patient name, medical record number). Right Drug (e.g. verified against original physician order). Provisions/Procedures: The following operational standards apply to high alert medications: The High-Alert Medication safety practices are special safeguards that may be applicable to any step in the medication administration process. Refer to the appendix for the list of high alert medication and safety strategies utilized to mitigate risk for error or other adverse outcomes. These steps include but are not limited to ...Compounding/ Preparation, Dispensing, Distribution, Monitoring ... Orders for High-Alert Medication will include, at a minimum: Date and time the order is written or placed in ...HealthConnect Drug name (generic), dose, route, frequency, and date of administration for each drug Rate and/or duration of administration, if applicable ... The following will be available on the patient’s medical record: All elements used to calculate the dose (e.g. height, weight used for medication dosing during that encounter, and/or BSA, if applicable) ... Smart pump technology and devices will be used for all high alert medication infusions to assure the safe delivery of these infusions. The device’s drug library must be utilized for all infusion therapy listed in the drug library. For patients receiving drugs programmed on the intravenous (I.V.) pump using the drug library, verify the correct drug, concentration, correct entry of patient weight (for weight-based drugs) or body surface area (for body surface area dosed drugs), correct dose/ rate or duration, and line attachment. The pump settings must be double checked against the current medication order.” During a review of the facility document titled, “Appendix A ...High Alert Medication List,” dated 11/2025, the document included a list of drug classes/medications considered to be high risk medications. Medications included on the list included but not limited to anticoagulants ...insulins, all opioids. Specific Populations: Pediatric and Neonatal: All adult high alert medications, digoxin ... During a review of the facility’s policy and procedure (P&P) titled, “Drug Administration - Medication Administration Times,” dated 3/25/2024, the P&P indicated the following: Purpose: “To ensure accurate and safe medication administration and documentation and to delineate those staff members who are authorized to administer medications ...Provisions: Medications are administered according to the Five (5) Right of Medication Administration: Right patient, Right medication, Right dose, Right time, Right route ...Licensed personnel are responsible for the following related to medication administration ...Verifying the medication is being administered at the proper time, at the prescribed dose, and by the correct route.” During a review of the facility’s policy and procedure (P&P) titled, “Controlled Substances,” dated 12/2023, the P&P indicated, “Purpose: To establish policies and procedures that govern the oversight of the distribution, documentation, procurement, and wastage for all controlled substances distributed throughout the medical center ...Scope: This policy applies to all employees ...Controlled Substance Monitoring and Oversight: The Inpatient Pharmacy has a process in place to monitor adherence to provisions set forth in this policy for controlled substance storage conditions, removal, administration, wastage, return, and inventory discrepancies in the care delivery areas ...Distribution: Controlled substances are distributed by authorized pharmacy staff under the oversight of a licensed pharmacist. Pharmacy has a process in place to ensure all controlled substances distributed from pharmacy inventory are accurately stocked in the ADM and non-ADM departments ...” During a review of the facility’s policy and procedure (P&P) titled, “Drug Dispensing - Automated Dispensing Machine (Pyxis) Override Medications,” dated 9/2023, the P&P indicated, “The Inpatient Pharmacy will be responsible for determining override access for nurses and units working with nursing to establish the medication list, and reviewing all override removal transactions to validate its appropriateness.” During a review of the facility’s policies and procedures (P&P) titled, “Drug Administration - Medication Administration Times,” dated 3/2024, indicated, “Adverse Drug Event (ADE): any injury (i.e., patient harm) resulting from the use of medication (or lack of an intended use of a medication), regardless of preventability, is considered an ADE. Purpose: to ensure accurate and safe medication administration and documentation and to delineate those staff members who are authorized to administer medications ... Medication administration schedules have been established as guidelines for scheduled prescribed medications, recognizing that professional judgment by the nurse or pharmacist will be utilized to tailor the administration of the medication for the patient, taking into account when the patient received the last dose before admission to the hospital, time of previous administration ...Due to the unique needs and feedings of neonatal patients, the NICU, pediatric, and PICU areas may utilize customized medication administration times. Provisions: 1. Medications are administered according to the Five (5) Rights of Medication Administration: a. Right patient b. Right medication c. Right dose d. Right time e. Right route”

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 31333 Based on interview and record review, the hospital failed to ensure one (1) of 30 sampled patients (Patient 12), received fentanyl (a potent opioid to treat pain and to keep patient at a desired sedation level while on mechanical ventilation) continuous intravenous (into the veins, IV) infusion (drip) as ordered by the physician. This deficient practice had the potential for life-threatening symptoms such as slow, shallow or completely stopped breathing, that may affect the patient’s health condition and require immediate intervention. Findings: During a review of Patient 12’s electronic medical record, the record indicated Patient 12 had an admission date of 12/31/2025 at 1335 (1:35 p.m.). Patient 12’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/31/2025, indicated “patient’s (Patient 12’s) initial weight was 380 grams (13.4 oz), 25-week female infant ...born breech (positioned buttocks or feet first that than head down) by Caesarean Section (surgical delivery of a baby through incisions in the mother’s abdomen and uterus) ... Patient (Patient 12) was intubated (tube is inserted into the airway to maintain breathing) ...transferred to the Neonatal Intensive Care Unit (NICU, a specialized hospital department for premature, low-birthweight, or critically ill newborns). Admitting diagnoses included, Premature (or preterm, born before 37 completed weeks of pregnancy) 25 0/7 weeks, and Extremely Low Birth Weight (ELBW, infants born with a birth weight of less than 1,000 gram or 2.2 pounds). Patient (Patient 12) on Jet ventilation (Jet Vent, a specialized technique for delivering high pressure, intermittent burst of oxygen into the airway through small-born catheters).” During a review of Patient 12’s Physician’s orders, dated 1/27/2026 at 5 p.m., the order indicated: Fentanyl 25 mcg in D5W (Dextrose 5% in water, a sterile intravenous [IV- through the vein] fluid containing 5% dextrose [sugar] dissolved in water. It is primarily used in medical settings to treat dehydration or serve as a liquid carrier for other IV medications) 5 ml (5mcg [microgram- a unit of measure]/ml) intravenous (IV, in the vein) infusion solution syringe. Ordered dose: 0.5 mcg/kg/hr x 0.435 kilogram (kg) (Patient 12’s weight) Administer dose: 0.218 mcg/hr, Route: intravenous, Frequency: Continuous, at 0.04 ml/hr. During a review of Patient 12’s “Medication Administration Record (MAR),” dated 1/27/2026 through 1/28/2026, the MAR indicated the following: -Fentanyl (a potent opioid to treat pain and to keep patient at a desired sedation level while on mechanical ventilation) 25 mcg in D5W 5 ml (5 mcg/ml) IV infusion solution syringe, Dose: 0.5 mcg/kg/hr, Weight Dosing information: 0.435 kg (kilograms) Rate 0.04 ml/hr, Frequency: Continuous, Route: IV. Start 1/27/2026 at 5 p.m. -On 1/27/2026 at 6:13 p.m., New Bag (Fentanyl), Documented by Registered Nurse (RN) 6 and Dual Signed by RN 8. Dose 0.5 mcg/kg/hr, Rate 0.04 ml/hr ...Comment: Verified waste and discarded old syringe of 7.8 ml with RN 8. -On 1/27/2026 at 7:44 p.m., Handoff (Fentanyl), documented by RN 6 and RN 5. -On 1/27/2026 at 9 p.m., Rate Verified (for Fentanyl) by RN 5. Dose 0.5 mcg/kg/hr, Rate 0.04 ml/hr. -On 1/28/2026 at 4:45 a.m., New Bag (Fentanyl), documented by RN 5 and RN 9, Dose: 0.5 mcg/kg/hr, Rate: 0.04 ml/hr. -On 1/28/2026 at 7:40 a.m., Already infusing, Dose: 5 mcg/kg/hr, Rate: 0.435 ml/hr. Comment: Received fentanyl drip at 0.435 ml/hr at this time. Escalated to physician. Documented by RN 10 and dual signoff by Clinical Nurse Specialist (CNS) 1. -On 1/28/2026 at 7:44 a.m., Rate Change (Fentanyl). Dose: 0.506 mcg/kg/hr, Rate: 0.044 ml/hr, Comment: Rate changed at bedside during shift report from RN 5. Escalated to CNS 1 and physician. -On 1/28/2026 at 8:10 a.m., Stopped. Comment: Medication (Fentanyl) stopped per physician. -On 1/28/2026 at 8:14 a.m., Naloxone (Narcan, a life-saving medication designed to rapidly reverse an opioid overdose) 0.4 mg/injection, 0.0053 mg given. -On 1/28/2026 at 8:34 a.m., vecuronium (a medication used to induce muscle relaxation during surgery or mechanical ventilation) injection 0.05 mg given. -On 1/28/2026 at 12:15 p.m., vecuronium injection 0.05 mg given. During an interview on 4/28/2026 at 11:10 a.m. with the Assistant Administrator for Patient Safety and Quality (AAPSQ), the AAPSQ stated an incident occurred when Patient 12 received the wrong dose of fentanyl for 13.5 hours in the Neonatal Intensive Care unit (NICU) on the afternoon of 1/27/2026 until discovered the morning of 1/28/2026. AAPSQ stated the Pharmacy department was involved in the investigation of the incident. During an interview on 4/28/2026 at 12:41 p.m. with the Director of Inpatient Pharmacy (DOP) and the Inpatient Pharmacist Supervisor (Pharm 1), DOP stated that the Neonatal Intensive Care Unit (NICU) intravenous (IV) infusion pump was not connected to the hospital’s HealthConnect (facility’s comprehensive, integrated Electronic Health Record [EHR] system, which integrated clinical decision-support tools directly at the point of care. For example, when nurses administer medication at the bedside, the system used barcode scanning to ensure the right drug was given to the right patient, at the right dosage, and at the right time) system. DOP stated if the NICU’s IV infusion pump was integrated to the hospital’s HealthConnect system, the physician’s electronic prescription order and the NICU’s IV infusion pump would communicate electronically. DOP stated for an initial or new high-alert medication order, such as fentanyl, the pharmacist would verify the actual ordered dose prior to dispensing. The DOP stated that on 1/28/2026 at 4:45 a.m., a new syringe of fentanyl was provided by pharmacy and administered to Patient 12. DOP stated the pharmacist did not check the refill order for appropriateness of the dose before refilling Patient 12’s fentanyl refill request which was too soon on 1/28/2026. During an interview on 4/29/2026 at 11:15 a.m. with the DOP, Pharm 1, and Neonatal Intensive Care Unit Pharmacist (Pharm 6), Pharm 6 stated that Pharm 6 verified new or initial physician orders and did not review refill medication orders for NICU, PICU or Pediatric units. Pharm 6 stated refill requests were sent to the pharmacy by nurses through the electronic medication administration record (eMAR). Pharm 6 stated Pharm 6 was not sure or aware of what was checked for refilling controlled medications, such as fentanyl IV drip. Pharm 6 stated there were no alerts on the NICU IV pump if fentanyl IV syringe dose ends sooner that it should. During a concurrent interview and record review on 4/30/2026 at 12 p.m. with DOP, ADOP, RDOP, Pharm 1, and Pharm 3, Pharm 1 stated Patient 12’s IV fentanyl syringe started on 1/27/2026 at 1813 (6:13 p.m.), was documented in the eMAR as being infused at the correct rate of 0.04 ml/hr, with the volume of fentanyl used over 10.5 hours and no documented waste. Pharm 1 stated a refill syringe of IV fentanyl was started on 1/28/2026 at 4:45 a.m., documented in the eMAR as being infused at the correct rate of 0.04 ml/hr, and ran for over three hours. Pharm 1 stated Patient 12’s IV infusion pump was actually infusing at a rate of 0.435 ml/hr (10 times the prescribed rate) until 1/28/2026 at 7:44 a.m. Pharm 1 stated Patient 12 was administered about 6.32 ml (about 31.6 mcg) fentanyl over 13.5 hours instead of the prescribed 0.96 ml (4.8 mcg) of fentanyl over 24 hours. During an interview on 4/30/2026 at 3:11 p.m. with the DOP, the DOP stated refill for high alert medications, such as fentanyl did not require a pharmacist reverification of the order unless there was a change in the dose or frequency which would make it a new order. DOP stated for Patient 12 there was no pharmacist reverification required on 1/28/2026 at 3:54 a.m., when the refill request for fentanyl was sent as there was no change in the order. DOP stated for refill medications, pharmacist reviewed the physician order and the MAR last dispensed dose to determine if the request was too soon based on the last dispensed, with the pharmacist doing their own calculations and how long the fentanyl IV should last and if determined to be too soon to refill, the pharmacist would contact the nurse to determine the reason for requesting the medication earlier than necessary. DOP stated there was no documentation that the nurse was called to inquire why the fentanyl IV drip was requested for an early refill. DOP stated for Patient 12, the IV fentanyl syringe was dispensed earlier than required without knowing what was happening with the IV pump error. DOP stated the pharmacy did not catch the fentanyl error for Patient 12 in which the dose for fentanyl was calculated wrong at the IV pump, that incorporated system errors that included pharmacy release of the fentanyl syringe too soon for administration to Patient 12. DOP stated the plan was to enforce the pharmacists to review refill request of high alert medications for appropriateness. DON stated there was no documentation to verify that high alert medication refills were being reviewed by the pharmacist. During a review of the facility’s policy and procedure (P&P) titled, “Regional High Alert Medication,” dated 7/2024, the P&P indicated, “Regional high-alert medications are defined as those drugs which are involved in a higher percentage of medication incidents and/or sentinel events, or that carry an increased risk for error or other adverse outcomes ... To standardize safe medication practices for high alert medications throughout the medication use process. To increase awareness of high alert medications and the safeguards necessary to maximize the safe use of these medications ...This policy applies to all employees who are employed ...This policy applies to all registry/travelers who are required to complete the high alert medication training prior to start of assignment ... The following operational standards apply to high alert medications ...The High-Alert Medication safety practices are special safeguards that may be applicable to any step in the medication administration process. Refer to the appendix for the list of high alert medication and safety strategies utilized to mitigate risk for error or other adverse outcomes. These steps include but are not limited to ...Compounding/ Preparation, Dispensing, Distribution, Monitoring, Orders for High-Alert Medication will include, at a minimum: Date and time the order is written or placed in ...HealthConnect Drug name (generic), dose, route, frequency, and date of administration for each drug Rate and/or duration of administration, if applicable ... The following will be available on the patient’s medical record: All elements used to calculate the dose (e.g. height, weight used for medication dosing during that encounter, and/or BSA, if applicable) ... Smart pump technology and devices will be used for all high alert medication infusions to assure the safe delivery of these infusions. The device’s drug library must be utilized for all infusion therapy listed in the drug library. For patients receiving drugs programmed on the intravenous (I.V.) pump using the drug library, verify the correct drug, concentration, correct entry of patient weight (for weight-based drugs) or body surface area (for body surface area dosed drugs), correct dose/ rate or duration, and line attachment. The pump settings must be double checked against the current medication order.” During a review of the facility document titled, “Appendix A ...High Alert Medication List,” dated 11/2025, the document included a list of drugs classes/medications considered to be high risk medications. Medications included on the list included but not limited to “anticoagulants ...insulins, all opioids. Specific Populations: Pediatric and Neonatal: All adult high alert medications, digoxin ...” During a review of the facility’s policy and procedure (P&P) titled, “Drug Administration - Medication Administration Times,” dated 3/25/2024, the P&P indicated the following: “To ensure accurate and safe medication administration and documentation and to delineate those staff members who are authorized to administer medications ...Medications are administered according to the Five (5) Right of Medication Administration: Right patient, Right medication, Right dose, Right time, Right route ...Licensed personnel are responsible for the following related to medication administration ...Verifying the medication is being administered at the proper time, at the prescribed dose, and by the correct route.” During a review of the facility’s policy and procedure (P&P) titled, “Controlled Substances,” dated 12/2023, the P&P indicated, “To establish policies and procedures that govern the oversight of the distribution, documentation, procurement, and wastage for all controlled substances distributed throughout the medical center ... This policy applies to all employees ... Controlled Substance Monitoring and Oversight: The Inpatient Pharmacy has a process in place to monitor adherence to provisions set forth in this policy for controlled substance storage conditions, removal, administration, wastage, return, and inventory discrepancies in the care delivery areas ...””

“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: 46333 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by: 1. The facility failed to monitor, assess and reassess for complete vital signs (essential, measurable indicators of the body’s most basic functions, used by healthcare providers to assess physical health, detect illnesses, or monitor treatment. The vital signs are body temperature, pulse rate [heart rate], respiration rate [breathing], and blood pressure, oxygen saturation, and pain level), every two hours, for three of 32 sampled patients (Patient 23, 25, and 27) while in the Emergency Department (ED, a hospital facility providing 24 hours, seven days a week, unscheduled, urgent medical care for severe injuries and acute illnesses), in accordance with the facility’s policy and procedures regarding vital signs assessment, reassessment and documentation. This deficient practice had the potential for worsening changes in the patients’ condition to go unidentified and placed the patients at risk of not receiving appropriate care if needed. (Refer to A-0395) 2. The facility failed to perform a complete pain assessment for one of 32 sampled patients (Patient 26) when Patient 26 presented to the Emergency Department complaining of back pain, in accordance with the facility’s triage (a medical process of rapidly assessing and sorting patients to prioritize care based on the severity of their condition) policy and pain assessment and management. This deficient practice had the potential for Patient 26’s pain not being addressed and potentially suffering from unrelieved pain, unnecessary physical suffering, and emotional distress. (Refer to A-0395) 3. The facility failed to ensure a pain assessment was completed for one of 32 sampled patients (Patient 21), when Patient 21 arrived at the ED complaining of Dysuria (painful urination), in accordance with the facility’s policy regarding pain assessment and management. This deficient practice led to Patient 21’s pain to not be addressed and could have caused distress and suffering from more pain. (Refer to A-0395) 4. The facility failed to ensure the nursing staff developed and kept current a nursing care plan (a written document that describes nursing care and goals for each patient) that reflected the patient’s needs for infection control precautions (steps to prevent the spread of germs) and education for one (1) of 32 sampled patients (Patient 2) placed on droplet isolation (a type of infection control where the patient is separated to prevent germs spread by droplets from coughs or sneezes) for Mycoplasma pneumoniae (a bacteria that causes lung infection), in accordance with the facility’s policy regarding plan of care. There was no documented evidence that a care plan was initiated to address patient or family education (teaching provided to the patient and family) regarding droplet isolation status, including the reason for isolation, required personal protective equipment (PPE, items like masks, gloves, and gowns used to protect people from infection), and hand hygiene (proper hand washing or use of sanitizer to prevent germs). This deficient practice has the potential to result in the patient and family not receiving required information about isolation precautions, PPE use, and hand hygiene, which increased the risk of spreading infection within the facility. (Refer to A-0396) 5. The facility failed to ensure three (3) of 32 sampled patients’ (Patients 17, 18 and 22) pain level was addressed and promptly communicated with the physician, in accordance with the facility’s policy regarding pain management. There was also a lack of documentation explaining why pain medication was not provided or delay in pain medication administration when: 5.a. Patient 17’s pain level was 5/10 (indicates moderate pain on a pain scale of 0-10; 0 [no pain], 1-3 [mild pain], 4-6 [moderate pain], 7-10 [severe pain]) and 7/10 (indicates severe pain) for four hours and did not receive an intervention for pain. 5.b. Patient 18 had pain level of 8/10 (severe pain) and 10/10 (severe pain) for two hours before receiving pain medication. 5.c. Patient 22 had pain level of 5/10 (moderate pain) to 8/10 (severe pain) for two hours with no intervention for pain. These deficient practices had the potential to delay interventions for managing pain resulting in worsening of pain, which can cause significant physical and emotional distress for Patients 17, 18 and 22. (Refer to A-0398) 6. The facility failed to administer, in a timely manner, a medication (Oseltamivir [an antiviral drug used to treat and prevent the flu] 30 milligrams [mg, a unit of measure]) ordered to be given two times a day, for one of 32 sampled patients (Patient 24), in accordance with the physician’s order and the facility’s policy and procedure regarding Drug Administration, Medication Administration Times. This deficient practice resulted in a delay of administering medication and had the potential for decreased effectiveness of the medication. (Refer to A-0405) 7. The facility failed to assess one of 32 sampled patient’s (Patient 27) pain level before administering a pain medication (Oxycodone [a potent opioid analgesic used for managing acute or chronic moderate to severe pain]), in accordance with the facility’s policy regarding pain management. The facility also failed to ensure that the correct medication was administered based on Patient 27’s pain score of 10/10 (indicates severe pain on a pain scale of 0-10; 0 [no pain], 1-3 [mild pain], 4-6 [moderate pain], 7-10 [severe pain]), in accordance with the physician’s order. Patient 27 received Acetaminophen (Tylenol, an over-the-counter medicine used to relieve pain and reduce fever) ordered for mild pain instead of Oxycodone for severe pain. This deficient practice had the potential for ineffective pain relief for Patient 27, which may cause prolonged suffering including physical and emotional distress and delayed recovery. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Physical Environment was met, as evidenced by: 1. The facility failed to ensure that one (1) of four (4) fire doors sampled (Fire door 1, doors designed to prevent the spread of fire and smoke) in the Intensive Care Unit (ICU, a hospital area for critically ill patients) were not obstructed (blocked), as required for life safety from fire. This deficient practice created the potential for harm to patients, staff, and visitors by delaying or preventing the proper closure of fire doors in an emergency, increasing the risk of injury or death from fire or smoke. (Refer to A-0709) 2. The facility failed ensure for one of two docking area sampled (Dock 1) that there were posted signage indicating “CAUTION - Biohazardous Waste Storage Area - Unauthorized Persons Keep Out” (a required warning to keep people away from dangerous medical waste) in English and Spanish, and to keep the area locked (secured with a lock to prevent entry), as indicated by the facility’s Medical Waste Management Plan (the facility’s official written plan for handling medical waste) for the management of the dock station (the area where waste is received and stored) where biohazard waste (waste that contains infectious materials or potentially infectious substances such as blood) is stored. This deficient practice created the potential for unauthorized individuals to access biohazardous waste (infectious or dangerous medical waste), which could result in harm to patients, staff, or visitors through exposure to hazardous materials, accidental injury, or environmental contamination. (Refer to A-0713) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Infection Prevention and Control, and Antibiotic Stewardship Program was met, as evidenced by: 1. The facility failed to implement a physician’s order for droplet isolation (precautions to prevent transmission of infectious agents through respiratory droplets), in a timely manner, for one (1) of 32 sampled patients (Patient 2). The isolation order was implemented approximately two and a half hours after the physician’s order. This deficient practice resulted in the potential for exposure and transmission of infectious agents to staff, patients, and visitors due to delayed implementation of droplet isolation precautions. (A-0749) 2. The facility failed to provide a hand-washing station (sink with soap and water) in one (1) of two (2) sampled docking stations (Dock 1, the area where Environmental Services staff sort and package biohazard waste), where there is a risk of exposure to infectious materials and potential for spills. The infection prevention and control program failed to maintain a clean and sanitary environment to avoid sources and transmission of infection. This deficient practice resulted in the potential for staff to be unable to perform proper hand hygiene after exposure to biohazard waste, increasing the risk of infection transmission to staff, patients, and visitors. (Refer to A-0750) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 52001 Based on interviews and record reviews, the facility failed to ensure timely physician notification to obtain an order for management of pain, in accordance with the facility’s policy regarding pain management, for one of 32 sampled patients (Patient 9), when Patient 9 presented to the Emergency Department (ED, a specialized, 24/7 hospital department designed to provide immediate, unscheduled care for acute, life-threatening, or severe medical conditions) with severe upper back pain rated 10/10 on the numerical pain scale (represents the worst pain imaginable, often described as unbearable, excruciating, or “unspeakable”). Patient 9 waited more than 2 hours for pain medication despite ongoing complaints of severe pain associated with cervical spine fracture (a serious injury to one or more of the seven vertebrae in the neck) as indicated in Patient 9’s CT scan (Computerized Tomography, a non-invasive medical imaging procedure) result obtained on 8/28/2024. This deficient practice resulted in unnecessary pain, delay in diagnosis, and increased risk of patient harm for Patient 9. Findings: During a review of Patient 9’s “Patient Care Timeline,” titled Rapid (a medical process of rapidly assessing and sorting patients to prioritize care based on the severity of their condition) Triage Intake, dated 8/28/2024 at 8:49 a.m., the triage note indicated the following: - Patient 9’s pain score, based on a Numeric Pain Scale 0-10, was 10/10 (represents the worst pain imaginable, often described as unbearable, excruciating, or “unspeakable”). - Patient 9’s pain location: Back - Patient 9’s pain character: Sharp - Patient 9’s pain Duration: Continuous - Patient 9’s Pain Intervention: Rest/Sleep - Patient 9’s blood pressure was152/60 (normal, healthy blood pressure reads 120/80 mmHg [millimeters of Mercury, a unit of measure]; severe pain can cause the blood pressure to increase) During a review of Patient 9’s “Patient Care Timeline,” titled Chief Complaint Updated, dated 8/28/ 2024 at 8:49 a.m., the note indicated “BACK PAIN (BIBA (Brought in by Ambulance) BLS (Basic Life Support, the immediate, life-saving care provided to someone experiencing a medical emergency) from home for upper pain after getting massage yesterday and unable to get up this morning).” During a review of Patient 9’s “Patient Care Timeline,” titled ED (Emergency Department, a hospital unit providing 24/7, unscheduled medical care for acute, severe, or life-threatening conditions) Assess (Assessment, dated 8/28/2026 at 10:00 a.m., the note indicated the following: - Patient 9’s pain score, based on a Numeric Pain Scale 0-10, was 8/10. - Patient 9’s pain location: Back - Patient 9’s pain character: Sharp - Patient 9’s pain Duration: Continuous - Patient 9’s Alleviating Factors: Medication - Patient 9’s Pain Intervention: Rest/Sleep During a review of Patient 9’s “Patient Care Timeline,” titled ED Assess (Assessment), dated 8/28/2026 at 10:36 a.m., the note indicated the following: - Patient 9’s pain score, based on a Numeric Pain Scale 0-10, was 10/10. - Patient 9’s pain location: Right; Shoulder - Patient 9’s Acceptable Pain Level: 0 - Patient 9’s pain character: Sharp - Patient 9’s pain Duration: Continuous - Patient 9’s Pain Intervention: positioning - Patient 9’s blood pressure reading was 169/87 During a review of Patient 9’s “Patient Care Timeline,” titled ED Assess (Assessment), dated 8/28/2026 at 11:00 a.m., the note indicated that Patient 9’s blood pressure reading was 161/91. There was no documented pain assessment (patient’s pain location, pain character, duration, intervention) at this time (11:00 a.m.) During a review of Patient 9’s “initial ED Provider Note,” dated 8/28/2024 at 12:09 p.m., the provider’s note indicated “History: ...male h/o (history of) hypertension (HTN-high blood pressure), HLD (Hyperlipidemia, a condition characterized by high levels of lipids [cholesterol and triglycerides] in the blood, which can increase the risk of heart disease and stroke), gout (a common, treatable form of inflammatory arthritis characterized by sudden, severe attacks of pain, redness, and tenderness in joints), GERD (Gatroesophageal Reflux Disease, a chronic digestive disorder occurring when stomach acid or bile frequently flows back [refluxes] into the esophagus), spinal stenosis of C-Spine with myelopathy (a serious condition involving the narrowing of the spinal canal in the neck, causing compression and dysfunction of the spinal cord), presents with BACK PAIN History obtained from: patient (Patient 9) Location: right neck pain radiating to right scapular area and down right arm Timing: constant Duration: since yesterday (8/27/2024) Severity: moderate Quality: spasm (a sudden, involuntary, and often painful contraction or tightening of a muscle or muscle group that cannot relax) Moderating Factor: worsened with moving neck Associated symptoms: tingling and pain radiates down right arm Context: Pt (Patient) stated he (Patient 9) had massage yesterday (8/27/2024) due to neck spasm. No neck manipulation. After massage, pain worsened this morning upon awakening ... Clinical Impression: 1. Right Trapezius Strain, Int (overstretched or torn muscles in the upper back, neck, and shoulder, causing pain, stiffness, limited range of motion, and spasms) 2. Neck Muscle Strain, Int 3. Cervical Radiculopathy (a condition where a nerve root in the neck [cervical spine] becomes compressed or irritated, causing pain, numbness, tingling, or weakness that radiates from the neck into the shoulder, arm, and hand) ...” During a review of Patient 9’s “Patient Care Timeline” titled “Orders Placed,” dated 8/28/2024, the following was noted: - At 12:10 p.m., Acetaminophen IV (Intravenous, through the vein) Soln (solution) 1,000 mg (milligrams, a unit of measure) and morphine Inj. (Injection) Soln (solution) 4 mg were ordered for pain - At 12:34 p.m., Acetaminophen IV Soln (solution) 1,000 mg was administered intravenously. - At 12:34 p.m. morphine Inj. Soln (solution) 4 mg was administered intravenously. During a review of Patient 9’s “ED Provider Notes,” dated 8/28/2024 at 9:11 p.m., the noted indicated ... “Notified by nurse that patient is complaining of pain in R (Right) elbow and R shoulder pain that is not relieved by Norco 10-325 (a combination medication that contains hydrocodone [an opioid] and acetaminophen [an analgesic]). Nurse also reports the following history from daughter ‘daughter stated he (Patient 9) had a fall last night and they found him on the floor this morning because he was unable to get up due to pain’ ...” During a review of Patient 9’s diagnostic imaging (non-invasive technologies used to create detailed, internal images of the human body, allowing doctors to diagnose, monitor, and treat medical conditions) report, titled “Teleradiology Report,” dated 8/28/2024 at 11:54 p.m., the report indicated ... “CT (Computerized Tomography, a non-invasive medical imaging procedure) C Spine (Cervical Spine, the neck): Fixation of C3-C5 (a surgical procedure performed to treat degenerative conditions, trauma, infections, tumors, or instability in the mid-cervical spine). There is anterolisthesis (a spinal condition where an upper vertebra slips forward over the one below it, causing misalignment, potential nerve compression, and pain) of C5 on C6 (backbone of the neck). Fracture of right facet (joints in the neck) of C6 ...” During a concurrent interview and record review on 1/21/2026 at 9:42 a.m. with the ED Nurse Manager (MN1), the following was noted: -MN 1 verified through record review that Patient 9 did not receive pain medication for longer than 2 hours. During an interview on 1/22/2026 at 11:28 a.m. with the ED Nurse Manager (MN 2), MN 2 stated the following: -MN 2 stated that the expectation in the ED was for the nurse to notify the provider that the patient was in pain. -MN 2 stated that the expectation and common practice in the ED was for the nurse to document that the patient had unrelieved pain and that the provider was notified. -MN 2 stated that if the nurse had notified the provider about Patient 9’s severe pain sooner, there would have been imaging done sooner to rule out the source of Patient 9’s pain. -MN 2 stated that based on Patient 9’s medical records, there was no documentation notifying the provider that Patient 9’s pain was not managed. During a review of the facility’s policy and procedure (P&P) titled, Patient Right and Responsibilities, dated 9/2024, the P&P indicated ... “PATIENT RIGHTS ... you have the right to: ... Appropriate assessment and management of your pain ...” During a review of the facility’s policy and procedure (P&P) titled, Pain Management, dated 8/2024, the P&P indicated ... “5.0 Policy: Nursing will collaborate inter-professionally with the patient, physician and other treatment team members to devise an effective patient specific pain management plan. Patients are screened, assessed, and re-assessed for pain utilizing a comprehensive pain assessment based on patient condition, age, and abilities. Patients have the right to: -Be believed when they say they have pain ... -Know what alternative plan treatments may be available ... -Be treated for pain and receive treatment in a timely manner. 6.2 Notify the physician if the patient has reported pain upon admission for pain management orders, if not already present on admitting orders ... 6.6.8 Reassess and respond to the patient’s pain, by evaluating the response to the treatment and progress towards pain management goals ...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to: 1. Monitor, assess and reassess for complete vital signs (essential, measurable indicators of the body’s most basic functions, used by healthcare providers to assess physical health, detect illnesses, or monitor treatment. The vital signs are body temperature, pulse rate [heart rate], respiration rate [breathing], and blood pressure, oxygen saturation, and pain level) every two hours for three of 32 sampled patients (Patient 23, 25, and 27) while in the Emergency Department (ED, a hospital facility providing 24 hours, seven days a week, unscheduled, urgent medical care for severe injuries and acute illnesses), in accordance with the facility’s policy and procedures regarding vital signs assessment, reassessment and documentation. This deficient practice had the potential for worsening changes in the patients’ condition to go unidentified and placed the patients at risk of not receiving appropriate care if needed. 2. Perform a complete pain assessment for one of 32 sampled patients (Patient 26) when Patient 26 presented to the Emergency Department complaining of back pain, in accordance with the facility’s triage (a medical process of rapidly assessing and sorting patients to prioritize care based on the severity of their condition) policy and pain assessment and management. This deficient practice had the potential for Patient 26’s pain not being addressed and potentially suffering from unrelieved pain, unnecessary physical suffering, and emotional distress. 3. Ensure a pain assessment was completed for one of 32 sampled patients (Patient 21), when Patient 21 arrived at the ED complaining of Dysuria (painful urination), in accordance with the facility’s policy regarding pain assessment and management. This deficient practice led to Patient 21’s pain unaddressed, potentially causing distress and additional suffering. Findings: 1.a. During a concurrent interview and record review on 1/21/2026 at 6:56 a.m. with Nurse Manager (MN 2), MN 2 stated the following: Patient 23 arrived at the Emergency Department on 10/1/2021 at 9:48 p.m. with shortness of breath (feeling of being unable to get enough air). ESI (Emergency Severity Index, a five-level system for prioritizing patients in the ED from most to least urgent) level was 1 (most urgent), which was a life-or-death situation. Patient 23 was having an asthma attack (a sudden worsening of symptom caused by inflammation, mucus plugging, and tightening of muscles around the airway) and Patient 23’s oxygen saturation (measures the percentage of oxygen-carrying hemoglobin in the blood) on room air was 88% (low, normal is equal to or greater than 92 %) upon arrival. MN 2 stated that Patient 23 was placed in a room at 9:59 p.m. and placed on 2 Liters of oxygen via nasal cannula (a lightweight, disposable device used to deliver supplemental oxygen to patients with breathing difficulties). During the same concurrent interview and record review on 1/21/2026 at 6:56 a.m., with Nurse Manager (MN 2), MN 2 stated that complete vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygenation levels and pain) should be monitored every two (2) hours while patients were in the treatment area or roomed. On 10/1/2021 at 9:49 p.m., Patient 23’s vital signs were, Temperature was 102.5 degrees Fahrenheit (F, high, normal is 98.6 degrees F), heart rate was 111 (HR, high, normal is 60 to 100), respiratory rate was 20 (normal), blood pressure was 118/76 (normal is below 120/80), and 87 % oxygen saturation on room air. MN 2 verified that Patient 23’s complete set of vital signs were not monitored every two hours, according to the facility’s policy. A complete Vital signs check was necessary to determine if the patient was stable or if the patient’s condition was worsening. During a review of Patient 23’s “ED Provider Note,” dated 10/2/2021 at 1:32 a.m., the ED Provider Note indicated the following: Patient (Patient 23) presented with shortness of breath, asthma attack “all day.” Room air SpO2 (oxygen saturation in the blood) 88 % ...presents today secondary to cough and shortness of breath all day. On arrival patient (Patient 23) does have a 102 fever (indicating infection) ...” During a review of Patient 23’s flowsheet titled “Vital Signs,” dated 10/1/2021 to 10/2/2021, the flowsheets indicated the following vital signs: -On 10/1/2021 at 9:49 p.m., Temperature (Temp) 102.5, Blood pressure (BP) 118/76, Pulse (or heart rate) 111, Respiratory Rate (Resp) 20, oxygen saturation (O2sat) 87 %. No pain assessment recorded. -On 10/1/2021 at 10:03 p.m., Pulse 108, Resp 19, O2 Sat 94 %. No BP, temperature check, pain assessment. -On 10/1/2021 at 10:07 p.m., BP 127/57, Pulse 109, Resp 19, O2 Sat 96 %. No temperature check. -On 10/1/2021 at 10:18 p.m., Pulse 110, Resp 19, O2 Sat 94 %. No temperature check. -On 10/1/2021 at 10:33 p.m., Pulse 111, O2 Sat 91 % -On 10/1/2021 at 10:48 p.m., Pulse 107, O2 Sat 93 % -On 10/1/2021 at 11:18 p.m., Pulse 99, O2 Sat 94 % -On 10/1/2021 at 11:33 p.m., Pulse 107, O2 Sat 94 %. No temperature check. -On 10/2/2021 at 12:03 a.m., O2 sat 88%. No temperature check. -On 10/2/2021 at 12:18 a.m., O2 sat 92 % -On 10/2/2021 at 12:33 a.m., O2 sat 94 % -On 10/2/2021 at 12:48 a.m., O2 sat 94 % -On 10/2/2021 at 1 a.m., Temperature 98.8 degrees F -On 10/2/2021 at 2:31 a.m., Pulse 96, Resp 16, BP 99/61, O2 sat 95 % -On 10/2/2021 at 3 a.m., BP 105/84, O2 sat 89 % -On 10/2/2021 at 3:01 a.m., Pulse 91, Resp 16, BP 105/84, O2 Sat 95 % -On 10/2/2021 at 4 a.m., BP 120/80, O2 Sat 92 % During a review of the facility’s policy and procedure (P&P) titled “Documentation in the Emergency Department Triage and Nursing Flowsheets,” revision date 12/2022, the P&P indicated the following: Frequency of reassessments: A documented focused reassessment shall occur every two (2) hours with vital signs or more frequently when clinically indicated based on the patient’s status. 1.b. During a concurrent interview and record review on 1/21/2026 at 1:25 p.m. with Nurse Manager (MN 2), MN 2 stated that complete vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygenation levels and pain) should be monitored every two (2) hours while patients were in the treatment area or roomed. Vital signs were necessary to check if the patient was stable or if the patient’s condition was worsening. MN 2 verified that Patient 25’s temperature was not monitored every two (2) hours, according to the facility’s policy and procedure. During a review of Patient 25’s “ED Provider Note,” dated 1/19/2026 at 11:06 a.m., the ED Provider Note indicated the following: “Patient (Patient 25) was brought in by BLS (basic life support) ambulance presents with neck pain status post (after) fall over the weekend. Pain and difficulty moving. Pain only with movement ...Patient (Patient 25) with history of hypertension (high blood pressure) ...chronic back pain ...comes complaining of neck pain after his legs gave out and he fell down two days ago.” During a review of Patient 25’s “Patient Care Timeline,” dated 1/19/2026, the Patient Care Timeline indicated the following: -At 9:48 a.m., Vital Signs: Temp: 98 degrees F, BP: 153/63 (high, normal is less than 120/80), Resp: 16, Pulse: 64, SpO2: 97 % on Room Air (RA), Pain: 4/10. -At 10:25 a.m., Vital Signs: Pulse: 72, BP: 141/65 (high), Resp: 15, SpO2: 97 % RA. -At 12:00 p.m., Vital Signs: Pulse: 66, BP: 166/75 (high), Resp: 15, SpO2: 98 % RA, Pain: 4 -At 2:00 p.m., Vital Signs: Pulse: 66, BP: 145/58 (high), Resp: 16, SpO2: 98 % RA, Pain: 0 -At 3:45 p.m., Vital Signs: Pulse: 65, Resp: 18, SpO2: 98 % RA, Pain: 0 -At 4 p.m., Vital Signs: Pulse: 64, BP: 116/52, Resp: 18 SpO2: 98 % RA -At 5 p.m., Vital Signs: Pulse: 67, BP:126/56, Resp:18, SpO2: 98 % RA, Pain: 0 -At 6 p.m., Vital Signs: Pulse: 68, BP:135/58, Resp:18, SpO2: 96 % RA, Pain: 3 -At 7:30 p.m., Vital Signs: Temp: 98.2, Pulse: 82, BP:141/61 (high), Resp:16, SpO2: 98 % RA, Pain:0 -At 9 p.m., Vital Signs: Pulse: 68, BP:127/66, Resp:16, SpO2: 98 % RA, Pain: 0 -At 11 p.m., Vital Signs: Pulse: 68, BP:142/61 (high), Resp:16, SpO2: 97 % RA, Pain: 0 During a review of the facility’s policy and procedure (P&P) titled “Documentation in the Emergency Department Triage and Nursing Flowsheets,” revision date 12/2022, the P&P indicated the following: Frequency of reassessments: A documented focused reassessment shall occur every two (2) hours with vital signs or more frequently when clinically indicated based on the patient’s status. 1.c. During a concurrent interview and record review on 1/21/2026 at 1:25 p.m. with Nurse Manager (MN 2), MN 2 stated that complete vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygenation levels and pain) should be monitored every two (2) hours while patients were in the treatment area or roomed. Vital signs check was necessary to determine if the patient was stable or if the patient’s condition was worsening. MN 2 verified that Patient 27’s temperature was not monitored every two (2) hours, according to the facility’s policy and procedure. During a review of Patient 27’s “ED Provider Note,” dated 1/20/2026 at 1:26 a.m., the ED Provider Note indicated the following: Patient 27 presented from a skilled nursing facility (SNF) with acute (sudden) on chronic (something that continues over an extended period of time) back pain. Patient 27 lived at home, then was admitted to the hospital last week for an infected knee joint. “Was discharged yesterday to a SNF for rehabilitation ...” During a review of Patient 27’s “Patient Care Timeline,” dated 1/19/2026 through 1/20/2026, the Patient Care Timeline indicated the following: -On 1/19/2026 at 11:04 p.m., Patient 27 arrived at the Emergency Department (ED). -At 11:07 p.m., Vital Signs: Temp: 98.1 degrees F, BP: 135/76, Resp: 20 Pulse: 95, SpO2: 98 % on RA, Pain: 10 (worst pain, on scale of 1 - 10). -At 11:22 p.m., Vital Signs: BP: 166/84 (high), Resp: 20 Pulse: 89, SpO2: 95 % on 3 L via NC, Pain: 8 -On 1/20/2026 at 1:34 a.m., Vital Signs: BP 131/74, Pulse: 73. Resp: 20, SpO2: 96 %, Pain: 9 -At 5:20 a.m., Vital Signs: Temp: 98.56 degrees F, Pulse 78, BP: 121/76, Resp: 19, SpO2: 95 % on 3 L oxygen via NC. Pain: 10 During a review of the facility’s policy and procedure (P&P) titled “Documentation in the Emergency Department Triage and Nursing Flowsheets,” revision date 12/2022, the P&P indicated the following: Frequency of reassessments: A documented focused reassessment shall occur every two (2) hours with vital signs or more frequently when clinically indicated based on the patient’s status. 2. During a concurrent interview and record review on 1/21/2026 at 1:51 p.m. with Nurse Manager (MN 2), MN 2 stated the following: Patient 26 arrived at the Emergency Department with complaints of abdominal pain, nausea (urge to vomit) and vomiting. Patient 26 was placed in a room at 8 a.m. on 1/20/2026. MN 2 reviewed Patient 26’s “Patient Care Timeline,” and verified that a complete pain assessment was not performed for Patient 26 initially upon presenting to the ED or at any time during Patient 26’s stay in the ED. MN 2 did not know Patient 26’s pain level because it was not documented. MN 2 further said that Pain should be assessed to determine Patient 26’s baseline pain level, to notify the physician if pain was present, and to implement interventions to address Patient 26’s pain. Pain assessment should also include the patient’s acceptable pain level, location, intensity, character, and what makes pain better or worse. MN 2 verified that no pain assessments were documented for Patient 26 and that no interventions were implemented to address Patient 26’s pain. During a review of Patient 26’s “Patient Care Timeline,” dated 1/20/2026, the Patient Care Timeline indicated the following: -At 6:54 a.m., Patient 26 “arrived at the Emergency Department (ED), from home, complaining of abdominal pain, with positive (+) N/V (nausea/vomiting), per family. Patient (Patient 26) drinks alcohol every day, last drink was 2 a.m., this morning.” -At 6:56 a.m., Vital Signs: Temp: 98.4 degrees F, BP: 188/101 (high), Resp: 16, SpO2: 100 -At 8:09 a.m., Vital Signs: Pulse: 70, BP: 175/79, Resp: 18, SpO2: 98 % RA -At 10 a.m., Vital Signs: Pulse: 81, BP: 173/93 (high), Resp: 17, SpO2: 99 % RA -At 12 p.m., Vital Signs: Pulse: Temp: 98 degrees F, Pulse: 78, BP: 154/106 (high), Resp: 18, SpO2: 98 % RA -MN 2 verified that there was no documentation of Patient 26’s pain assessment from 6:54 a.m. (upon ED arrival) to 12 p.m. During a review of the facility’s policy and procedures (P&P) titled, “Emergency Department Triage Policy,” dated 12/04/2025, the P&P indicated that the Triage Team records patient arrival information, including vital signs and pain assessment, into the Hospital’s Health Connect system. During a review of the facility’s policy and procedures (P&P) titled, “Documentation in the Emergency Department Triage and Nursing Flowsheets,” dated 12/2022, the P&P indicated the following: “Members of the nursing and medical staff shall enter the following information in the patient’s Emergency Department medical record ...A pertinent history of the illness or injury, physical findings including known allergies, patient’s vital signs, and stated pain level.” During a review of the facility’s policy and procedures (P&P) titled, “Pain Management,” revised date 8/2024, the P&P indicated the following: Patients are screened, assessed and re-assessed for pain utilizing a comprehensive pain assessment based on patient condition, age, and abilities. Patients have the right to: - Be believed when they say they have pain. - Be asked to “rate” their pain according to established pain scales - Be treated for pain and receive treatment in a timely manner Procedure: Pain assessment, planning, intervention, and evaluation will be adapted to patients of all ages and cognitive function ...Pain intensity ratings will be recorded as part of the initial admission patient assessment. For patients reporting pain at the time of admission obtain the following information, which may include but is not limited to: - Patient and family understanding and knowledge of pain and its management. - Intensity using one of the standardized pain rating scales - Location - Quality - Onset and duration - Precipitation and alleviating factors - Present pain management regime ... - Baseline, acceptable pain level (the functional pain goal) Notify the physician if the patient has reported pain upon admission for pain management orders ... Ongoing Pain Management: Assess and reassess all patients with pain for pain intensity, location, precipitation factors, and responses to interventions throughout their hospitalization. Pain will be assessed at a minimum of: with routine shift assessments, operative or other procedures and prior to discharge. 3. During a review of Patient 21’s “ED Provider Notes,” dated 1/20/2026, the record indicated Patient 21 was in the ED for urinary frequency and dysuria (painful urination) and had a history of urinary tract infections (UTI). During a review of Patient 21’s “Patient Care Timeline,” dated 1/20/2026, the record indicated Patient 21 arrived at the ED at 7:17 a.m. Patient 21’s vital signs (set of blood pressure [BP], temperature, respiration [Resp], heart rate and oxygen level) indicated the following: -At 7:23 a.m., temperature 98.3, BP 140/83, Resp 18, pulse 90, oxygen level 100% on room air. No pain level was documented. -At 9:00 a.m., BP 130/88, Resp 18, pulse 81, oxygen level 99% on room air. No pain level was documented. -At 10:00 a.m., pulse 84, BP 136/98, Resp 17, oxygen level 98% on room air. No pain level was documented. -At 11:00 a.m., temperature 98, pulse 79, BP 137/77, Resp 18 and oxygen level 100% on room air. No pain level was documented. -At 12:00 p.m., pulse 80, BP 140/87, Resp 17, oxygen level 99% on room air. No pain level was documented. -At 2:00 p.m., Patient 21 was discharged from the facility. -At 7:23 a.m., 9:00 a.m., 10:00 a.m., 11:00 a.m. and 12:00 p.m. Patient 17’s pain level was not documented along with the vital signs. During an interview on 1/23/2026 at 9:30 a.m. with Nurse Manager (MN) 2, MN 2 emphasized the importance of documentation for tracking treatment and care. MN 2 stated that refusals should be documented to understand why something was not done, affirming that patients have the right to refuse any aspect of their care. MN 2 further stated that assessing pain was crucial to understand the baseline and to address pain if present. MN 2 also stated nurses were expected to communicate with the provider or indicate patient concerns regarding their pain. MN 2 stated pain assessment should be included with the vital signs check, and the assessment should be done every two hours per policy. During a concurrent interview and record review on 1/23/2026 at 9:40 a.m. with MN 2 and Director of ED (DIR 5), Patient 21’s “Flowsheets,” dated 1/20/2026, was reviewed. MN 2 confirmed Patient 21 did not have nursing documentation on pain while Patient 21 was in a bed or in triage. MN 2 and DIR 5 confirmed pain was expected to be assessed. MN 2 stated that without pain assessment, there would be no baseline to determine if pain improved. During a review of the facility’s policy and procedures (P&P) titled, “Documentation in the Emergency Department Triage and Nursing Flowsheets,” dated 12/2022, the P&P indicated, “Members of the nursing and medical staff shall enter the following information in the patient’s Emergency Department medical record ...A pertinent history of the illness or injury, physical findings including known allergies, patient’s vital signs, and stated pain level.” During a review of the facility’s policy and procedures (P&P) titled, “Pain Management,” dated 8/2024, the P&P indicated, “Patients are screened, assessed and re-assessed for pain utilizing a comprehensive pain assessment based on patient condition, age, and abilities. Patients have the right to: - Be believed when they say they have pain. - Be asked to “rate” their pain according to established pain scales ... - Be treated for pain and receive treatment in a timely manner ... Procedure: Pain assessment, planning, intervention, and evaluation will be adapted to patients of all ages and cognitive function ...Pain intensity ratings will be recorded as part of the initial admission patient assessment. For patients reporting pain at the time of admission obtain the following information, which may include but is not limited to: - Patient and family understanding and knowledge of pain and its management. - Intensity using one of the standardized pain rating scales - Location - Quality - Onset and duration - Precipitation and alleviating factors - Present pain management regime ... - Baseline, acceptable pain level (the functional pain goal) Notify the physician if the patient has reported pain upon admission for pain management orders ... Ongoing Pain Management: Assess and reassess all patients with pain for pain intensity, location, precipitation factors, and responses to interventions throughout their hospitalization. Pain will be assessed at a minimum of: with routine shift assessments, operative or other procedures and prior to discharge.””

“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: 46333 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan (a written document that describes nursing care and goals for each patient) that reflected the patient’s needs for infection control precautions (steps to prevent the spread of germs) and education for one (1) of 32 sampled patients (Patient 2) placed on droplet isolation (a type of infection control where the patient is separated to prevent germs spread by droplets from coughs or sneezes) for Mycoplasma pneumoniae (a bacteria that causes lung infection), in accordance with the facility’s policy regarding plan of care. There was no documented evidence that a care plan was initiated to address patient or family education (teaching provided to the patient and family) regarding droplet isolation status, including the reason for isolation, required personal protective equipment (PPE, items like masks, gloves, and gowns used to protect people from infection), and hand hygiene (proper hand washing or use of sanitizer to prevent germs). This deficient practice has the potential to result in the patient and family not receiving required information about isolation precautions, PPE use, and hand hygiene, which increased the risk of spreading infection within the facility. Findings: During a review of Patient 2’s “History and Physical (H&P-a document summarizing the patient’s medical condition and examination),” dated 1/20/2026, the record indicated the patient (Patient 2) presented with one week of fever, cough, and pleuritic chest pain (sharp chest pain that worsens with breathing). The patient (Patient 2) reported worsening symptoms, including productive cough with green sputum (mucus), recurrent fevers, and shortness of breath with activity. During a concurrent interview and record review on 1/21/2026 at 10:30 a.m. with the ICU/DOU Nurse Manager (MN 4, the nurse in charge of the Intensive Care Unit and Direct Observation Unit, areas for very sick patients or those needing close monitoring), Patient 2’s electronic medical record (EMR, a digital version of the patient’s chart) under “Patient Infection Status,” was reviewed. The EMR indicated that Patient 2 was placed on droplet isolation (a type of infection control where the patient is separated to prevent germs spread by droplets from coughs or sneezes) at 7:30 p.m. on 1/20/2026 following a physician order for isolation due to pneumonia (lung infection) caused by Mycoplasma pneumoniae (a bacteria that spreads through droplets when an infected person coughs or sneezes). MN 4 stated the EMR alerted the nurse when an isolation order was entered, and the nurse must immediately place the patient in isolation and document that the patient and/or family were educated about isolation status, PPE (personal protective equipment- items like masks, gloves, and gowns used to protect people from infection), and hand hygiene. During the same interview on 1/21/2026 at 10:30 a.m. with the ICU/DOU Nurse Manager (MN 4), Patient 2’s “Manage Plan & Document Progress,” was reviewed. The care plan included sections titled “Pneumonia (infection in the lungs) Education,” dated 1/20/2026. The care plan indicated: - Causes: May include bacteria, viruses, or aspiration (breathing in food, fluids, or vomit). Risk factors: Include smoking, chronic lung disease such as COPD (chronic obstructive pulmonary disease-a long-term lung condition), stroke (occurs when blood flow to the brain is interrupted), comorbidities (other health problems) such as diabetes (a chronic disease where the body has high blood sugar [glucose] because it doesn’t produce enough insulin [helps in the breakdown of sugar in the body] or can’t effectively use the insulin it produces) or heart disease, recent surgery, recent trauma, and diseases affecting the immune system such as cancer or HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome-a condition where the virus attacks and weakens the body’s immune system, making it harder to fight infections). Status: Not started. -Activity: Follow provider recommendations for activity. It will take time to get better. Start doing things again slowly. Balance activity with rest. Rest helps healing; activity helps return to regular routine and prevents other health problems. Status: Not started. - Infection Prevention: Review importance of handwashing. Visitors should wash hands before and after touching the patient. The patient should wash hands frequently and cough or sneeze into the inside of their elbow. Status: Not started. -MN 4 confirmed that the patient (Patient 2) had been admitted for over 8 hours. MN 4 stated there was no documented evidence that the nurse provided education on droplet isolation precautions. MN 4 stated the nurse must initiate the pneumonia care plan and provide education to the patient (Patient 2), followed by documentation in the EMR that the education was provided. During a review of the facility’s policy and procedure titled “Patient Admission Assessment, Re-assessment and Plan of Care Standard,” dated November 2023, the policy indicated an appropriate Patient Plan of Care is to be developed collaboratively (by the care team) and documented within 8 hours of admission for inpatients (patients staying overnight in the hospital), and documentation of patient education is to be maintained in the patient’s education section of the Plan of Care. During a review of facility protocol titled, “Droplet Precautions” (signage posted on patient doors), not dated, the protocol indicated: -Admit the patient to a private room (a room occupied by only one patient). -Educate visitors on proper hand hygiene (washing hands with soap and water or using alcohol-based sanitizer). -Visitors should wear an isolation mask (a medical mask to prevent inhalation of droplets). -Provide education on PPE use for visitors with close contact (e.g., feeding, holding) and document in the medical record. -Patients with respiratory symptoms (such as coughing or sneezing) should remain masked as much as possible.”

“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: 50516 Based on interview and record review, the facility failed to ensure three (3) of 32 sampled patients’ (Patients 17, 18 and 22) pain level was addressed and promptly communicated with the physician, in accordance with the facility’s policy regarding pain management. There was also a lack of documentation explaining why pain medication was not provided or delay in pain medication administration when: 1. Patient 17’s pain level was 5/10 (indicates moderate pain on a pain scale of 0-10; 0 [no pain], 1-3 [mild pain], 4-6 [moderate pain], 7-10 [severe pain]) and 7/10 (indicates severe pain) for four hours and did not receive an intervention for pain. 2. Patient 18 had pain level of 8/10 (severe pain) and 10/10 (severe pain) for two hours before receiving pain medication. 3. Patient 22 had pain level of 5/10 (moderate pain) to 8/10 (severe pain) for two hours with no intervention for pain. These deficient practices had the potential to delay interventions for managing pain resulting in worsening of pain, which can cause significant physical and emotional distress for Patients 17, 18 and 22. Findings: 1. During a review of Patient 17’s “ED Provider Notes,” dated 9/25/2025, the record indicated Patient 17 went to the Emergency Department (ED) at 11:03 a.m. with chief complaint of abdominal pain, suprapubic (lower abdominal) pain and dysuria (painful urination). Patient 17 had a medical history of urinary tract infection (UTI). During an interview on 1/23/2026 at 9:30 a.m. with Nurse Manager (MN) 2, MN 2 emphasized the importance of documentation for tracking treatment and care. MN 2 stated that refusals should be documented to understand why something was not done, affirming that patients have the right to refuse any aspect of their care. MN 2 further stated that assessing pain was crucial to understand the baseline and to address pain if present. MN 2 also stated nurses were expected to communicate with the provider or indicate patient concerns regarding their pain. During a concurrent interview and record on 1/23/2026 at 10:00 a.m. with MN 2 and the Director of Emergency Department (DIR 5), Patient 17’s “Flowsheet,” dated 9/25/2025, was reviewed. The record indicated the following pain assessments: -At 11:04 a.m., the pain level was 7/10 (indicates severe pain on the pain scale of 0-10; 0 [no pain], 1-3 [mild pain], 4-6 [moderate pain], 7-10 [severe pain]) at the abdomen/pelvic area with an acceptable pain level of 4, and pain intervention of “anticipatory pain medication.” -At 12:24 p.m., the pain level was 7/10 at the pelvic/abdomen area with an acceptable pain level of 0, and pain intervention of “anticipatory pain medication.” -At 1:00 p.m., the pain level was 7/10 at the pelvic area with an acceptable pain level of 0, and pain intervention of “anticipatory pain medication.” -At 2:00 p.m., the pain level was 5/10 (indicates moderate pain) in the pelvic area with an acceptable pain level of 0, and pain intervention of “anticipatory pain medication.” -At 4:00 p.m. and 5:00 p.m., the pain level was 0/10 During the same concurrent interview and record review on 1/23/2026 at 10:00 a.m. with MN 2 and DIR 5, Patient 17’s “Medication Administration Record (MAR),” dated 9/25/2025, was reviewed. The record indicated Patient 17 did not receive pain medication. MN 2 confirmed that there was no documentation indicating that Patient 17 did not want pain medication nor was there any indication or presence of a physician order for pain medication. MN 2 it was important to communicate with the provider at the earliest time regarding pain management. During a review of the facility’s policy and procedure (P&P) titled, “Documentation in the Emergency Department Triage and Nursing Flowsheets,” dated 12/2022, the P&P indicated, “Discharge Assessment Summary should include: 3. All patients who have documented pain on the Emergency Medical record shall have an acceptable level of pain documented on discharge. If the patient’s level of pain exceeds the acceptable level reported then a reassessment by a medical provider shall take place. Efforts to ensure pain is under control from the patient’s perspective shall be attempted before discharge. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 8/2024, the P&P indicated, “Nursing will collaborate inter-professionally with the patient, physicians and other treatment team members to devise an effective patient specific pain management plan. Patients are screened, assessed and re-assessed for pain utilizing a comprehensive pain assessment based on patient condition, age, and abilities. Patients have the right to: - Be believed when they say they have pain. - Be asked to “rate” their pain according to established pain scales. - Know what alternative pain treatments may be available. - Ask for changes in treatment if pain persists ... - Be treated for pain and receive treatment in a timely manner ... 6.2 Notify the physician if the patient has reported pain upon admission for pain management orders, if not already present on admitting orders ... 6.6.8 Reassess and respond to the patient’s pain, by evaluating the response to the treatment and progress toward pain management goals.” 2. During a review of Patient 18’s “Patient Care Timeline,” dated 1/20/2026, the record indicated Patient 18 arrived at the Emergency Department (ED) at 4:17 a.m. for nausea (urge to vomit), vomiting and abdominal pain and had a history of acid reflux (stomach acid goes back up the throat). During an interview on 1/23/2026 at 9:30 a.m. with Nurse Manager (MN) 2, MN 2 emphasized the importance of documentation for tracking treatment and care. MN 2 stated that refusals should be documented to understand why something was not done, affirming that patients have the right to refuse any aspect of their care. MN 2 further stated that assessing pain was crucial to understand the baseline and to address pain if present. MN 2 also stated nurses were expected to communicate with the provider or indicate patient concerns regarding their pain. During a concurrent interview and record review on 1/23/2026 at 9:53 a.m. with MN 2 and the Director of Emergency Department (DIR 5), Patient 18’s “Flowsheet-Pain Assessment,” dated 1/20/2026, was reviewed. The record indicated the following pain assessments: -At 4:20 a.m., the pain level was 10/10 (indicates severe pain) to the abdomen and was unable to self report an acceptable pain level; -At 6:02 a.m., the pain level was 8/10 (indicates severe pain) to the abdomen, was unable to self report an acceptable pain level, and pain intervention included positioning, anticipatory pain medication, rest/sleep; -At 7:00 a.m., the pain level was 8/10 to the abdomen, was unable to self report an acceptable pain level, and pain interventions included positioning, anticipatory pain medication, rest/sleep. During the same concurrent interview and record review on 1/23/2926 at 9:53 a.m. with MN 2, Patient 18’s “Medication Administration Record (MAR),” dated 1/20/2026, was reviewed. The record indicated at 7:21 a.m., Patient 18 received Morphine (strong pain medication) 4 milligrams (mg, a unit of measure) one time intravenously (IV, through the vein). MN 2 stated there was no need to wait for the physician if there was a need to escalate anything (the nurse could have requested an order for pain medication for Patient 18 when Patient 18 verbalized pain level of 10/10 and 8/10 at 4:20 a.m. and 6:02 a.m., respectively). MN 2 also stated she would have felt uncomfortable if she was the patient (Patient 18 did not receive pain medication for almost 3 hours while suffering from severe pain). During a review of the facility’s policy and procedure (P&P) titled, “Documentation in the Emergency Department Triage and Nursing Flowsheets,” dated 12/2022, the P&P indicated, “Discharge Assessment Summary should include: 3.All patients who have documented pain on the Emergency Medical record shall have an acceptable level of pain documented on discharge. If the patient’s level of pain exceeds the acceptable level reported then a reassessment by a medical provider shall take place. Efforts to ensure pain is under control from the patient’s perspective shall be attempted before discharge. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 8/2024, the P&P indicated, “Nursing will collaborate interprofessionally with the patient, physicians and other treatment team members to devise an effective patient specific pain management plan. Patients are screened, assessed and re-assessed for pain utilizing a comprehensive pain assessment based on patient condition, age, and abilities. Patients have the right to: - Be believed when they say they have pain. - Be asked to “rate” their pain according to established pain scales. - Know what alternative pain treatments may be available. - Ask for changes in treatment if pain persists ... - Be treated for pain and receive treatment in a timely manner ... 6.2 Notify the physician if the patient has reported pain upon admission for pain management orders, if not already present on admitting orders ... 6.6.8 Reassess and respond to the patient’s pain, by evaluating the response to the treatment and progress toward pain management goals.” 3. During a review of Patient 22’s “Patient Care Timeline,” dated 1/20/2026, the record indicated Patient 22 arrived at the ED at 3:43 a.m. for complaints of dizziness, fever, body aches, cough, shortness of breath (feeling of not getting enough air), dysuria (painful urination), sore throat and abdominal pain. At 7:20 a.m., Patient 22 was discharged from the ED. During an interview on 1/23/2026 at 9:30 a.m. with Nurse Manager (MN) 2, MN 2 emphasized the importance of documentation for tracking treatment and care. MN 2 stated that refusals should be documented to understand why something was not done, affirming that patients have the right to refuse any aspect of their care. MN 2 further stated that assessing pain was crucial to understand the baseline and to address pain if present. MN 2 also stated nurses were expected to communicate with the provider or indicate patient concerns regarding their pain. During a concurrent interview and record review on 1/23/2026 at 9:45 a.m. with MN 2 and the Director of Emergency Department (DIR 5), Patient 22’s “Flowsheet-Pain Assessment,” dated 1/20/2026, was reviewed. The record indicated the following pain assessments: -At 3:45 a.m., the pain level was 7/10 (indicates severe pain) to the abdomen and was unable to self report an acceptable pain level; -At 5:25 a.m., the pain level was 8/10 (indicates severe pain) to the abdomen and was unable to self report an acceptable pain level; -At 7:00 a.m., the pain level was 5/10 (indicates moderate pain) for a headache and there was no documented acceptable pain level. -MN 2 confirmed Patient 22 did not receive any pain medication. MN 2 confirmed there was no documentation Patient 22 did not want any pain medication, and there was no medication ordered during Patient 22’s ED stay. MN 2 stated there should be an indication of why Patient 22 did or did not receive pain medication. During a review of the facility’s policy and procedure (P&P) titled, “Documentation in the Emergency Department Triage and Nursing Flowsheets,” dated 12/2022, the P&P indicated, “Discharge Assessment Summary should include: 3. All patients who have documented pain on the Emergency Medical record shall have an acceptable level of pain documented on discharge. If the patient’s level of pain exceeds the acceptable level reported then a reassessment by a medical provider shall take place. Efforts to ensure pain is under control from the patient’s perspective shall be attempted before discharge. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 8/2024, the P&P indicated, “Nursing will collaborate inter-professionally with the patient, physicians and other treatment team members to devise an effective patient specific pain management plan. Patients are screened, assessed and re-assessed for pain utilizing a comprehensive pain assessment based on patient condition, age, and abilities. Patients have the right to: - Be believed when they say they have pain. - Be asked to “rate” their pain according to established pain scales. - Know what alternative pain treatments may be available. - Ask for changes in treatment if pain persists ... - Be treated for pain and receive treatment in a timely manner ... 6.2 Notify the physician if the patient has reported pain upon admission for pain management orders, if not already present on admitting orders ... 6.6.8 Reassess and respond to the patient’s pain, by evaluating the response to the treatment and progress toward pain management goals.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 36206 Based on observation, interview and record review, the facility failed to: 1. Administer, in a timely manner, a medication (Oseltamivir [an antiviral drug used to treat and prevent the flu] 30 milligrams [mg, a unit of measure]) ordered to be given two times a day, for one of 32 sampled patients (Patient 24), in accordance with the physician’s order and the facility’s policy and procedure regarding Drug Administration, Medication Administration Times. This deficient practice resulted in a delay of administering medication and had the potential for decreased effectiveness of the medication. 2. Assess one of 32 sampled patient’s (Patient 27) pain level before administering a pain medication (Oxycodone [a potent opioid analgesic used for managing acute or chronic moderate to severe pain]), in accordance with the facility’s policy regarding pain management. The facility also failed to ensure that the correct medication was administered based on Patient 27’s pain score of 10/10 (indicates severe pain on a pain scale of 0-10; 0 [no pain], 1-3 [mild pain], 4-6 [moderate pain], 7-10 [severe pain]), in accordance with the physician’s order. Patient 27 received Acetaminophen (Tylenol, an over-the-counter medicine used to relieve pain and reduce fever) ordered for mild pain instead of Oxycodone for severe pain. This deficient practice had the potential for ineffective pain relief for Patient 27, which may cause prolonged suffering including physical and emotional distress and delayed recovery. Findings: 1. During an observation in the Emergency Department, on 1/20/2026 at 11:17 a.m., Patient 24 was awake and receiving 1 Liter of oxygen via nasal cannula (a lightweight, disposable device used to deliver supplemental oxygen to patients with breathing difficulties). Patient 24’s oxygen saturation (measures the amount of oxygen in the blood) was 96% (normal range is equal or greater than 92 %). During a review of Patient 24’s “ED Provider Note,” dated 1/19/2026 at 4:39 p.m., the ED Provider Note indicated “patient (Patient 24) with a history of diabetes (high blood sugar), hypertension (high blood pressure) ...interstitial lung disease (a large group of over 200 disorders causing inflammation and scarring in the lung tissue surrounding air sacs) presents to the emergency department for cough, congestion, difficulty breathing, low oxygen at home. Oxygen in the 80’s at home ...Diagnosis: Influenza (flu, a contagious respiratory infection) and Hypoxia (tissues and cells do not receive enough oxygen).” During a review of Patient 24’s Medication Administration Record (MAR), dated 1/19/2026 through 1/20/2026, Patient 24’s MAR indicated the following: On 1/19/2026 at 6 p.m., Oseltamivir (an antiviral drug used to treat and prevent the flu) 30 milligrams (mg, a unit of measure) was ordered to be administered orally (by mouth) two (2) times a day. -On 1/19/2026 at 6:26 p.m., Patient 24 received 30 mg of Oseltamivir by mouth. -On 1/20/2026 at 1:03 p.m., Patient 24 received 30 mg of Oseltamivir by mouth. During a concurrent interview and record review on 1/21/2026 at 11:17 a.m. with Nurse Manager (MN 2), MN 2 stated the following: Patient 24 arrived at the emergency department on 1/19/2026 at 2:27 p.m., for cough and low oxygen saturation. Oseltamivir was ordered on 1/19/2026 at 6 p.m., to be given two times a day. Patient 24 received Oseltamivir on 1/19/2026 at 6:26 p.m., and on 1/20/2026 at 1:03 p.m. Oseltamivir was ordered to be given twice a day and should have been given 12 hours after the first dose (should have been given at 6 a.m., on 1/20/2026) rather than at 1:03 p.m., (8 hours later), to maintain appropriate levels of the medication to ensure effectiveness in the medication. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration and Documentation,” revised date 11/2023, the P&P indicated the following: Medications will be administered according to the Five (5) Rights of Medication Administration: Right Patient, Right Medication, Right Dose, Right Time, Right Route ...Medications will be scheduled according to the facility standard administration times ...In order to be considered timely, medications are administered up to sixty (60) minutes before or after the scheduled due time ...Licensed personnel are responsible for the following related to medication administration ...Verifying the medication(s) is being administered at the proper time, at the prescribed dose, and by the correct route.” During a review of the facility’s policy and procedure (P&P) titled, “Drug Administration - Medication Administration Times,” revised on 3/2024, the P&P indicated the following: Medications are to be administered according to the Five (5) Rights of Medication Administration: a. Right patient b. Right medication c. Right dose d. Right time e. Right route ...Medications are scheduled according to the facility standard administration times ...In order to be considered timely, medications are administered up to sixty (60) minutes before or after the scheduled due time ...Attachment A: Frequency: 2 Times a day, Display name: BID, 24 Hour Time: 10 a.m. and 8 p.m. 2. During a review of Patient 27’s “ED Provider Note,” dated 1/20/2026 at 1:26 a.m., the ED Provider Note indicated the following: “Patient (Patient 27) presented from a skilled nursing facility (SNF, a licensed healthcare institution providing 24-hour, short-term, or long-term rehabilitation and medical care for patients recovering from illness, injury, or surgery) with acute (sudden and intense) on chronic (pain that lasts for an extended period) back pain. Patient (Patient 27) lived at home, then was admitted to the hospital last week for an infected knee joint. Was discharged yesterday to a SNF for rehabilitation ... Musculoskeletal (the integrated body system of muscles, bones, and joints that provides structure, stability, and movement): Positive for back pain, knee pain.” During a review of Patient 27’s “Patient Care Timeline,” dated 1/19/2026 through 1/20/2026, the Patient Care Timeline indicated the following: -On 1/19/2026 at 11:04 p.m., Patient 27 arrived at the Emergency Department (ED). -At 11:07 p.m., Pain Assessment: Pain Score: 10 (worst pain, on numeric scale of 0 - 10). Acceptable pain level: 0, Location: Back, Character: Sharp, Duration: Continuous, Alleviating Factors: Rest, Aggravating Factors: Activity, Pain Intervention: Care. -At 11:22 p.m., Pain Assessment: Pain score: 8, Acceptable pain level: 0, Location: Back, Character: Sharp, Duration: Continuous. -On 1/20/2026 at 1:34 a.m., Pain Score: 9. -On 1/20/2026 at 2:30 a.m., Pain Score: 9. -On 1/20/2026 at 5:20 a.m., Pain Score: 9, Acceptable pain level: 3 ...Location: Back and left knee, Character: Sharp, Duration: Continuous, Aggravating Factors: Activity, Alleviating Factors: Medication, Rest, Pain Intervention: Positioning, Rest/sleep, Medication. -On 1/20/2026 at 6 a.m., Pain Score: 10, Acceptable pain level: 3 ...Location: Back and left knee, Character: Sharp, Duration: Continuous, Aggravating Factors: Activity, Alleviating Factors: Medication, Rest, Pain Intervention: Positioning, Rest/sleep, Medication, cold application. -On 1/20/2026 at 7 a.m., Pain Score: Sleeping. -On 1/20/2026 at 7:30 a.m., Pain Score: 10. -On 1/20/2026 at 8 a.m., Pain Score: 6. -On 1/20/2026 at 10 a.m., Pain Score: 9. -On 1/20/2026 at 12 p.m., Pain Score: Sleeping. During a review of Patient 27’s Medication Administration Record (MAR), dated 1/18/2026 through 1/20/2026, the MAR indicated the following Medication Orders and Administration times: -Oxycodone (a potent opioid analgesic used for managing acute or chronic moderate to severe pain) IR (immediate release) Tab (tablet) 10 milligrams (mg), Frequency: every 4 hours as need (PRN), Route: Oral, PRN Reason: Severe pain (7 - 10), Start 1/20/2026 at 3:05 a.m. -Oxycodone IR Tab 5 mg, Frequency: every 4 hours as need (PRN), Route: Oral, PRN Reason: moderate pain (4 - 6), Start 1/20/2026 at 3:05 a.m. -Oxycodone IR 5 mg was administered on 1/20/2026 at 4:56 a.m., at 12:32 p.m., and at 5:22 p.m. -Acetaminophen (Tylenol, an over-the-counter medicine used to relieve pain and reduce fever) Tablet 500 mg, Frequency: Every four (4) hours as needed, Route: Oral, PRN Reason: mild pain (1-3). -Acetaminophen 500 mg was administered on 1/20/2026 at 5:43 a.m. During a concurrent interview and record review on 1/21/2026 at 2:07 p.m. with Nurse Manager (MN 2), MN 2 reviewed Patient 27’s pain assessments and Medication Administration Record and stated that pain levels should be assessed prior to administering pain medication to check for baseline and to assess the effectiveness of the medication. Pain medications should be administered according to the physician’s orders. MN 2 verified that on 1/20/2026 at 4:56 a.m., Oxycodone 5 mg was administered to Patient 27, without a documented pain assessment prior to administering the medication. Oxycodone 5 mg was ordered for moderate pain level (4 - 6). In addition, on 1/20/2026 at 5:20 a.m., Patient 27’s pain level was 10 and Patient 27 received Acetaminophen 500 mg on 1/20/2026 at 5:43 a.m. MN 2 stated that Acetaminophen 500 mg was ordered for mild pain (1 - 3), and it was not given in accordance with the physician’s order. Patient 27 should have received Oxycodone 10 mg for severe pain (7 - 10). MN 2 verified that Patient 27’s pain on 1/20/2026 at 6 a.m., was 10/10 and stated that it seemed that the medication (Acetaminophen) did not work. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration and Documentation,” revised date 11/2023, the P&P indicated the following: “Medications will be administered according to the Five (5) Rights of Medication Administration: Right Patient, Right Medication, Right Dose, Right Time, Right Route ...Licensed personnel are responsible for the following related to medication administration ...Verifying the medication(s) is being administered at the proper time, at the prescribed dose, and by the correct route.” During a review of the facility’s policy and procedure (P&P) titled, “Drug Administration - Medication Administration Times,” revised on 3/2024, the P&P indicated the following: “Medications are to be administered according to the Five (5) Rights of Medication Administration: Right patient, Right medication, Right dose, Right time, Right route ...” During a review of the facility’s policy and procedures (P&P) titled, “Pain Management,” revised date 8/2024, the P&P indicated the following: Patients are screened, assessed and re-assessed for pain utilizing a comprehensive pain assessment based on patient condition, age, and abilities. Patients have the right to: - Be believed when they say they have pain. - Be asked to “rate” their pain according to established pain scales ... - Be treated for pain and receive treatment in a timely manner ... Procedure: Pain assessment, planning, intervention, and evaluation will be adapted to patients of all ages and cognitive function ...Pain intensity ratings will be recorded as part of the initial admission patient assessment. Ongoing Pain Management: Assess and reassess all patients with pain for pain intensity, location, precipitation factors, and responses to interventions throughout their hospitalization. Pain will be assessed at a minimum of: with routine shift assessments, operative or other procedures and prior to discharge”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 50516 Based on interview and record review, the facility failed to ensure that one of 32 sampled patient’s (Patient 17) medical record contained a signed “Against Medical Advice (AMA, leaving before a physician formally discharges someone from their care)” form, when Patient 17’s record indicated Patient 17 had a signed AMA form and the form could not be located, in accordance with the facility’s policy and procedure (P&P) titled, “Hospital Medical Record Definition.” This deficient practice had the potential to compromise Patient 17’s right to be informed of the risks of leaving AMA when not deemed stable for discharge from the hospital. Additionally, the lack of documentation might also compromise Patient 17’s safety. Findings: During a review of Patient 17’s “ED Provider Notes,” dated 9/25/2025, the record indicated Patient 17 went to the ED for abdominal pain, suprapubic (lower abdominal) pain and dysuria (painful urination). Patient 17 had a medical history of urinary tract infection (UTI). During a review of Patient 17’s “Patient Care Timeline,” dated 9/25/2025, the record indicated Patient 17 arrived at the ED at 11:03 a.m. and a note indicated at 5:10 p.m., “Pt (Patient 17) left against medical advice/AMA. Dr (name of physician) made aware. Pt (Patient 17) pulled her own IV (intravenous, plastic tube inserted into the vein to deliver medications) and was so upset about the waiting time for the CT (Computed Tomography, detailed x-ray) scan. (Name of charge registered nurse) made aware.” During a concurrent interview and record review on 1/22/2026 at 2:44 p.m. with Nurse Manager (MN) 2, Patient 17’s “ED Notes,” dated 9/25/2025, was reviewed. The record indicated, “Met with pt (Patient 17) in main radiology after signing ama. Pt (Patient 17) verbalized frustration about waiting for CT. Pt (Patient 17) escorted to ED CT for scan. After scan pt (Patient 17) verbalized needing to pick up son. Pt (Patient 17) ambulated (walked) out of ed (ED) with steady gait. 4-5-6. Pink/warm/dry.” MN 2 stated “4-5-6” was the Glascow Coma Scale (GCS, scale of 1-15, with 4 indicating spontaneous [done without thinking] eye opening, 5 indicating awareness of time, person and place, and 6 indicating able to follow commands, giving a total score of 15 which indicates someone is fully alert) and Patient 17’s mentation was documented and had a steady gait. During a continued interview and record review on 1/22/2026 at 2:44 p.m. with MN 2, Patient 17’s “ED Assess (Assessment Form),” dated 9/25/2025, was reviewed. The record indicated, “pt (Patient 17) left against medical advice/AMA.” MN 2 stated both notes (ED Notes and ED Assessment forms) indicated Patient 17 left AMA. MN 2 also confirmed there was no AMA Form. During a concurrent interview and record review on 1/23/2026 at 10:00 a.m. with MN 2, MN 2 stated the AMA form was important because it allowed the patient to exercise their right of leaving if they chose to and explained the risks of leaving AMA. During an interview on 1/23/2026 at 10:43 a.m. with Medical Records Manager (MN 13), MN 13 stated it was important for the medical record to be complete to ensure they were meeting all the requirements, and MN 2 also acknowledged that if a form was not included in the medical record, it was not complete. During a review of the facility’s policy and procedure (P&P) titled, “Hospital Medical Record Definition,” dated 6/29/2023, the P&P indicated, “The Hospital Medical Record is the repository for the clinical documentation relevant to the care and treatment of one patient. It is created and maintained for every episode of hospital inpatient care, hospital outpatient care, hospital outpatient visit, and Emergency Department visit. The information contained in the Hospital Medical Record must be complete, accurate, legible, timely, accessible, properly filed and retained and protected from unauthorized access, release, and use ...Standards of Care. The patient’s Hospital Medical Record provides documentation that the services provided are within community standards of care, state and federal laws and regulations, and the requirements of accrediting agencies.””

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 46333 Based on observation (direct visual inspection), interview (discussion with staff), and record review (examination of facility documents), the facility failed to ensure that one (1) of four (4) fire doors sampled (Fire door 1, doors designed to prevent the spread of fire and smoke) in the Intensive Care Unit (ICU, a hospital area for critically ill patients) were not obstructed (blocked), as required for life safety from fire. This deficient practice created the potential for harm to patients, staff, and visitors by delaying or preventing the proper closure of fire doors in an emergency, increasing the risk of injury or death from fire or smoke. Findings: During a concurrent observation and interview on 1/20/2026 at 4:07 p.m. with the ICU Manager (MN 7) in the hallway of the ICU, four hospital beds (patient beds) were observed in the hallway. One bed was blocking the fire door to the ICU. The blocked bed had a sign posted stating, “Out of Order, Emailed sent 12/22/2025, Stryker bed, Bed not detecting the mattress.” Other beds in the hallway had signs indicating various mechanical issues, such as broken brakes or non-inflating mattresses. MN 7 stated that four beds were broken and awaiting repair and acknowledged that the bed should not block the fire door. MN 7 was unsure who placed the bed there and stated it would be moved. During an interview on 1/21/2026 at 2:20 p.m. with the Director of Environmental Services (EVS, the department responsible for cleaning and waste) (DIR 6), DIR 6 stated that EVS picked up broken beds, but did not transfer rental or bariatric beds (extra-large beds for heavier patients). Beds in the ICU were not picked up by EVS and remained in the ICU for repair by the vendor engineering (outside repair company). During an interview on 1/21/2026 at 2:30 p.m. with the Director of Engineering (DIR 7), DIR 7 stated that broken beds in the ICU were serviced by the vendor, who came to the ICU to repair the beds in the unit. When storage areas were full, beds may be pushed into the corridor (hallway). Because these were special ICU beds, they were not moved out of the ICU. During an interview on 1/21/2026 at 11:30 a.m. with the ICU Nurse Manager (MN 4), MN 4 stated that if too many broken gurneys (wheeled stretchers for transporting patients) were in the hallway and blocking the fire door, the issue must be escalated (reported to a higher authority) to the leader of EVS. The manager should be called, and someone will be sent immediately. For safety purposes, fire doors must be kept clear of any obstruction (blockage). During an interview on 1/23/2026 at 10:55 a.m. with RN 1 (Registered Nurse, Charge Nurse in ICU), RN 1 stated that when a bed was broken, staff tagged the bed (attach a label describing the problem) and called the vendor for repair. If too many broken beds were in the hallway and blocked fire doors, staff must call EVS to help move them, and this was documented in a log (written record) kept at the nurse station. During an interview on 1/23/2026 at 12:45 p.m. with the Director of Environmental Health and Safety (DIR 8), DIR 8 stated that the double doors in the ICU were fire doors, rated to protect patients and staff for a specific time (typically two hours) during a fire. DIR 8 emphasized that fire doors must not be obstructed, so they can be closed quickly in an emergency to protect patients and staff. During a review of the facility’s policy and procedure titled, “Environmental of Care Committee,” dated November 2023, the P&P indicated, “The Environment of Care Committee is a multi-disciplinary improvement team whose primary function is to support management and performance improvement processes designed to ensure a safe, functional and effective environment of care for patients, staff and visitors at the medical center and medical offices. This is accomplished through the identification and analysis of environmental ... (a) The ECC meets as frequently as necessary to ensure that risks, hazards, failures and incidents are addressed in a timely manner, but no less than every other month. As part of its standing agenda, the Committee receives and examines reports and summaries of action taken relative to: ... Fire Prevention.” During a review of the facility’s policy and procedure (P&P, official written rules) titled, “Medical Center Fire Plan - Code Red Response,” dated November 2021, the P&P indicated, “The facility’s basic fire response plan shall be followed should a fire occur. The primary objectives are to ensure life safety and control the risks associated with fires and the byproducts of combustion (smoke and gases produced by burning materials) ... Basic Staff and Licensed Independent Practitioners (LIPs, healthcare providers allowed to practice independently) Response- In the event a fire is discovered, individual(s) at the fire’s point of origin shall ensure the following steps are immediately taken (NOTE: the acronym “RACE” is used to help remember the steps): 1. RESCUE anyone from immediate danger. Relocation includes moving patients out of the immediate vicinity of the fire to the closest area of refuge. ALARM and Notification - Activate systems of notification and early warning ... CONFINE/CONTAIN the fire - Close all doors and windows to help forestall the fire and restrict the movement of smoke.” The policy references NFPA 101 (National Fire Protection Association, a nonprofit organization that develops and publishes codes and standards intended to minimize the risk and effects of fire by establishing criteria for building, processing, design, service, and installation in the United States and worldwide). During a review of NFPA 101: Life Safety Code, Section 7.1.10.1 (2021 Edition): “Means of egress (exit routes) shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.””

“DISPOSAL OF TRASH CFR(s): 482.41(b)(6) (4) The hospital must have procedures for the proper routine storage and prompt disposal of trash. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed ensure for one of two docking area sampled (Dock 1) that there were posted signage indicating “CAUTION - Biohazardous Waste Storage Area - Unauthorized Persons Keep Out” (a required warning to keep people away from dangerous medical waste) in English and Spanish, and to keep the area locked (secured with a lock to prevent entry), as indicated by the facility’s Medical Waste Management Plan (the facility’s official written plan for handling medical waste) for the management of the dock station (the area where waste is received and stored) where biohazard waste (waste that contains infectious materials or potentially infectious substances such as blood) is stored. This deficient practice created the potential for unauthorized individuals to access biohazardous waste (infectious or dangerous medical waste), which could result in harm to patients, staff, or visitors through exposure to hazardous materials, accidental injury, or environmental contamination. Findings: During an observation on 1/20/2026 at 12:00 p.m. at the facility dock station (waste storage area), the driveway to the dock station was open and accessible to the public (not restricted or blocked), with no gates or locks present. Two individuals without uniforms or badges (not identified as staff) were observed pushing a body bag with a zipper (a large, sealed bag used to transport deceased individuals), appearing to contain a body, down the ramp of the dock station and into an unmarked van (a vehicle with no company or facility identification). There was no signage (warning sign) indicating “Authorized Personnel Only” (only staff allowed) or any biohazard warning (notice of dangerous infectious waste) in English or Spanish. During an interview on 1/20/2026 at 12:15 p.m. with the Transportation Manager (MN 6), MN 6 stated, “Mortuary (a company that handles the transport of deceased individuals) people pick up body. No, we do not escort them. After they sign-out at admitting (the admissions office), admitting will direct them to go this way, through the docking station and down the ramp where they parked. Those people were from a private mortuary company thus they have no logo or uniform.” During an interview on 1/20/2026 at 12:05 p.m. with Director of Environmental Services (DIR 6, the manager responsible for cleaning and waste), DIR 6 stated that sharps (objects like needles or scalpels that can cut or puncture skin) and needles were placed in a locked area at the end of the docking station, requiring batching in (grouping items together for disposal). DIR 6 described the process for handling medical and biohazard waste (waste that can cause infection), including storage in red bins (special containers for hazardous waste) and a biohazard trailer (a large container for holding infectious waste), but acknowledged that the trailer remained open until full and was never locked (not secured). DIR 6 also confirmed that there was no assigned staff for monitoring or surveillance (no one is watching or checking the area) of the dock area. During an interview on 1/23/2026 at 11:02 a.m. with Environmental Services staff (EVS 2, a worker responsible for cleaning and waste), EVS 2 described the process of transporting biohazard waste from the nursing unit (patient care area) to the dock station, confirming that the trailer remained open until full and was never locked. During an interview on 1/23/2026 at 11:12 a.m. with Environmental Services staff (EVS 3), EVS 3 stated that the biohazard vendor picked up the trailer in about two to three days when it was full, but the trailer remained unlocked until the vendor picked it up. During an interview on 1/23/2026 at 12:45 p.m. with the Director of Environment Health and Safety (DIR 8, the manager responsible for safety and environmental health), DIR 8 stated, “That area should be secure (locked and restricted), we need to secure so we don’t have diversion (theft or removal) of needles or contaminated material (items that could spread infection) where others cannot get to potential hazard material (dangerous waste). We need to put signage (warning signs) to warn the people to stay out.” During a record review on 1/23/2026 at 11:21 a.m. with the Director of Environmental Services (DIR 6), the facility’s policy and procedure (P&P) titled, “Medical Waste Management Plan,” dated August 2025, was reviewed. The P&P indicated: Biohazardous waste” includes all of the following: Regulated medical waste (also called clinical or biomedical waste) includes any waste or reusable material generated from the medical treatment, diagnosis, or immunization of humans or animals (when the animal is suspected of having a disease that can infect humans), as well as waste from biomedical research and the production or testing of biological products. Waste suspected of containing highly communicable diseases is also considered biohazardous. Laboratory waste includes cultures from humans or animals infected with pathogens that can also infect humans, cultures and stocks of infectious agents, waste from producing bacteria or viruses, discarded vaccines, and items used to handle cultures (such as dishes and transfer devices). Certain laboratory wastes are also classified as hazardous under federal regulations. Blood and blood products: Waste that contains visible fluid human blood or blood products, or containers and equipment with fluid blood, as well as blood from animals suspected of being infected with diseases that can spread to humans. Isolation waste: Materials contaminated with excretions, secretions, or discharges from humans or animals who are isolated to prevent the spread of highly communicable diseases. “The central biohazardous waste holding area (main storage area for infectious waste) shall be kept locked (secured with a lock), and a conspicuous sign (easily seen warning sign) shall be posted in English that indicates the following: ‘CAUTION - Biohazardous Waste Storage Area - Unauthorized Persons Keep Out;’ and in Spanish: ‘CUIDADO - Zona de Residuos Biologicos Peligrosos - Prohibida la Entrada a Personas No Autorizadas.’ The sign shall be readily legible (easy to read) during daylight hours from a distance of 25 feet.””

“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 interview and record review, the facility failed to implement a physician’s order for droplet isolation (precautions to prevent transmission of infectious agents through respiratory droplets), in a timely manner, for one (1) of 32 sampled patients (Patient 2). The isolation order was implemented approximately two and a half hours after the physician’s order. This deficient practice resulted in the potential for exposure and transmission of infectious agents to staff, patients, and visitors due to delayed implementation of droplet isolation precautions. Findings: During a review of Patient 2’s “History and Physical (H&P, a document summarizing the patient’s medical condition and examination),” dated 1/20/2026, the H&P indicated the patient (Patient 2) presented with one week of fever, cough, and pleuritic chest pain (sharp chest pain that worsens with breathing). The patient reported worsening symptoms, including productive cough with green sputum (mucus), recurrent fevers, and shortness of breath with activity. During a concurrent interview and record review on 1/21/2026 at 10:30 a.m. with the ICU/DOU Nurse Manager (MN 4), Patient 2’s electronic medical record (EMR, the digital patient chart), was reviewed. Under “Patient Infectious Status,” dated 1/20/2026 at 4:58 p.m., the EMR indicated the patient (Patient 2) had pneumonia caused by Mycoplasma pneumoniae (a bacterial infection of the lungs that spreads through respiratory droplets when an infected person coughs, sneezes, or talks), and the physician had ordered droplet isolation precautions (precautions to prevent transmission of infectious agents through respiratory droplets). MN 4 stated that when an isolation order was entered, the EMR alerted the nurse, and the nurse must place the patient in isolation immediately. During the same concurrent interview and record review on 1/21/2026 at 10:30 a.m. with the ICU/DOU (ICU/DOU refers to the Intensive Care Unit and Direct Observation Unit, hospital areas where critically ill patients and those requiring close monitoring are cared for) Nurse Manager (MN 4), Patient 2’s electronic medical record (EMR, the digital patient chart) document titled, “Safety Intervention,” was reviewed. The record indicated Patient 2 was placed on droplet isolation (a type of infection control precaution used to prevent the spread of contagious pathogens through respiratory droplets when a patient coughs, sneezes, or talks) at 7:30 p.m., approximately two and a half hours after the order was entered. The order was acknowledged by Registered Nurse (RN 8, a licensed nurse responsible for direct patient care) at 6:20 p.m. MN 4 stated the nurse must immediately place the patient in isolation or request assistance from the charge nurse (a nurse who supervises the unit during shift) to move the patient to a droplet precaution room. MN 4 also stated the nurse must document that the patient and/or family were educated on isolation status, personal protective equipment (PPE, items such as masks, gloves, and gowns worn by healthcare workers to protect themselves and prevent the spread of infection), and hand hygiene. During an interview on 1/21/2026 at 2:40 p.m. with the Director of Infection Prevention (DIR 4, the manager responsible for infection control programs), DIR 4 stated that as soon as a test was ordered that may result in a positive finding for a droplet-transmissible disease (an illness spread through respiratory droplets), the patient should be placed in isolation immediately. DIR 4 stated staff were empowered to initiate isolation based on symptoms to prevent transmission while awaiting test results. During a review of facility’s protocol titled “Droplet Precautions” (signage posted on patient doors), not dated, the protocol indicated: -Admit the patient to a private room (a room occupied by only one patient). -Educate visitors on proper hand hygiene (washing hands with soap and water or using alcohol-based sanitizer). -Visitors should wear an isolation mask (a medical mask to prevent inhalation of droplets). -Provide education on PPE use for visitors with close contact (e.g., feeding, holding) and document in the medical record. -Patients with respiratory symptoms (such as coughing or sneezing) should remain masked as much as possible. -If aerosol-generating procedures (medical procedures that produce airborne particles, such as intubation or suctioning) are performed, healthcare workers must wear an N95 respirator (a tight-fitting mask that filters airborne particles) or powered air-purifying respirator (PAPR, a device that uses a battery-powered blower to provide filtered air). During a review of the facility’s policy and procedure (P&P) titled “Infection Prevention and Control Strategic Workplan 2025,” the P&P indicated: Strategies to ensure timely identification of communicable diseases (illnesses that can spread from person to person) and implementation of prevention measures, including adherence to standard precautions (basic infection control practices applied to all patients) and transmission-based precautions (additional measures used for patients known or suspected to be infected with contagious pathogens, which are microorganisms such as bacteria or viruses that can spread and cause disease).”

“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: 46333 Based on observation, interview, and record review, the facility failed to provide a hand washing station (sink with soap and water) in one (1) of two (2) sampled docking stations (Dock 1, the area where Environmental Services staff sort and package biohazard waste), where there is a risk of exposure to infectious materials and potential for spills. The infection prevention and control program failed to maintain a clean and sanitary environment to avoid sources and transmission of infection. This deficient practice resulted in the potential for staff to be unable to perform proper hand hygiene after exposure to biohazard waste, increasing the risk of infection transmission to staff, patients, and visitors. Findings: During a concurrent observation and interview on 1/20/2026 at 12:05 p.m. with the Director of Environmental Services (DIR 6, the manager responsible for cleaning and waste), the dock station was observed to have three stations: one for soiled linen and cleaning cloths, one for packing biohazard waste into bins and trailers, and one for medical waste. The stations for medical waste and soiled linen did not have hand sanitizers (alcohol-based hand cleaning dispensers); only the biohazard waste station had two hand sanitizers, but one was out of order (not working). There were no hand-washing stations (no sink with soap and water), no paper towels, and no soap available for staff to wash their hands if they became soiled (visibly dirty or contaminated). DIR 6 stated that staff would have to go inside the building using their badge and walk down the hallway to enter a code on the restroom door to access a sink for hand washing. During an interview on 1/21/2026 at 2:05 p.m. with DIR 6, DIR 6 stated that the biohazard red bag had the potential for spills when staff handled the trash bag. DIR 6 stated that thicker bags were used to prevent ripping, and that when hands were soiled, they should be washed. During an interview on 1/21/2026 at 2:40 p.m. with the Director of Infection Prevention Program (DIR 4), DIR 4 stated that staff who soil their hands would use hand sanitizer first, then go inside the building to wash their hands. DIR 4 confirmed that staff must enter a code to access a restroom with a hand-washing sink, and that touching other surfaces may transfer contaminants (germs or infectious material). The DIR 4 also confirmed that when hands were visibly soiled, hand sanitizer was not sufficient, and staff should not walk to another station to find hand sanitizer. During an interview on 1/23/2026 at 11:02 a.m. with the Environmental Services staff (EVS 4), EVS 4 stated that after handling biohazard bags, if hands were soiled, staff used hand sanitizer and then went to the locker room to wash their hands. There were no paper towels or towels in the docking station. There was no hand-washing sink in the dock. During an interview on 1/23/2026 at 11:12 a.m. with Environmental Services staff (EVS 5), EVS 5 stated that if a biohazard bag ripped and debris got on hands, staff went to the restroom in the locker room to wash up. Staff must open a door, turn right, and enter a code to access the sink. There was no paper towel in the docking station. PPE available included goggles and gloves. During a review of the facility’s policy and procedure (P&P, official written rules) titled “Medical Waste Management Plan,” the P&P indicated: “Wear gloves (gown should be worn if soiling likely). Place torn/contaminated bag into a new RED biohazard bag. Remove gloves and other protective attire, wash hands and place red bag in biohazardous waste container.” During a review of the facility’s 2026 safety training titled, “Hand Hygiene & Artificial Nails,” the training material indicated, “Hand hygiene removes dirt, organic material, and transient microorganisms from the hands to decrease the risk of cross contamination. Hand hygiene is the primary measure for reducing the risk of transmitting infections among patients and health care personnel. Routine Handwashing: To remove soil and transient microorganisms. Wash hands with soap and water for at least 20 seconds. Hand rub/sanitizing: To destroy transient and resident microorganisms on unsoiled hands. Rub alcohol-based hand sanitizer into hands vigorously until dry ... Easy access to alcohol foam/gel dispensers throughout the hospital and clinics ...” During a review of the facility’s policy and procedure titled, “Infection Prevention and Control Strategic Workplan 2025,” the P&P indicated: “The scope of service for the Infection Prevention and Control program includes environmental rounds ... Promote adherence to the WHO 5 Moments for Hand Hygiene. Infection Prevention: Intervene directly to prevent HAI (healthcare-associated infection), prevent transmission of communicable diseases, and prevent workplace injuries in healthcare workers providing guidance, education, and benchmark data to set targets.””

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Pharmaceutical Services was met, as evidenced by: 1. The facility failed to ensure medications were kept securely, and/or locked, inside two (2) of two sampled medication carts (Medication Cart 1 and 20), in two (2) of two sampled rooms, in the operating room 2 (OR 2, a specialized area in a hospital where surgical procedures are performed) and in the Endoscopic Ultrasound (a procedure that combines endoscopy [a medical procedure where a thin, flexible tube with a camera and light (an endoscope) is inserted into the body to visualize internal organs and structures] and ultrasound [a medical imaging technique that uses high-frequency sound waves] to create images of the digestive tract [where food and liquids travel through as they are ingested, digested, absorbed, and eventually eliminated as waste] and nearby organs and tissues) room (EUS), in accordance with the facility’s policy regarding “Operations - Operating Room/Pre-Op/Post Anesthesia Care Unit - Drug Administration.” This deficient practice had the potential for unauthorized access to dangerous medications that may or may not affect the safety of the hospital’s patients, staff, and visitors. (Refer to A-0502) 2. Ensure unauthorized personnel would not have access to medications stored in the Endoscopic Ultrasound (a procedure that combines endoscopy [a medical procedure where a thin, flexible tube with a camera and light (an endoscope) is inserted into the body to visualize internal organs and structures] and ultrasound [a medical imaging technique that uses high-frequency sound waves] to create images of the digestive tract [where food and liquids travel through as they are ingested, digested, absorbed, and eventually eliminated as waste] and nearby organs and tissues) room (EUS) and in three (3) of three (3) medication refrigerators (a medical refrigerator, designed to maintain a consistent temperature range for the storage of medication and other temperature-sensitive medical supplies), located in the Operating Room department (OR or surgical department, a hospital ward where patients are cared and treated before, during and after surgery) corridor coves (Core 1 and 2, Outpatient Core), in accordance with the facility’s policy regarding medication storage. This deficient practice had the potential for unsafe storage and inappropriate access of drugs that may affect patients’, staff, and visitors’ safety. (Refer to A-0504) 3. Ensure nine (9) of nine sampled injectable medication syringes drawn up for a procedure, were properly labeled, and unused and/or outdated portions of one (1) of one sampled multidose vial (a container of liquid medication, intended for injection or infusion, that holds more than one dose), would be discarded after a procedure, in three (3) of three sampled areas, the Operating Room 2 (OR 2), the OR anesthesia work room, and in the Endoscopic Ultrasound (a procedure that combines endoscopy and ultrasound to create images of the digestive tract and nearby organs and tissues) unit (EUS), as per facility’s policy regarding safe medication practices. The facility also failed to ensure used multiple dose vials (a small container, typically cylindrical and made of glass, used especially for holding liquid medicines) and four (4) of five (5) medications with overwrap that were removed, had proper dating to prevent using beyond manufacturer’s guidance, in accordance with the facility’s policy regarding medication storage. This deficient practice had the potential for outdated or contaminated medications being available for use in the patient care areas, which may result in problems such as infection and reduced drug effectiveness. (Refer to A-0505) 4. Inspect and maintain stock drug (medication) supplies in one of two (2) sampled pediatric (branch of medicine dealing with the health and medica care of infants, children and adolescents from birth up to age of 18) anesthesia (a medical technique that involves using medications to temporarily block pain and sensation, making procedure like surgery possible without discomfort) carts (Cart 1, a supply cart stocked with medications and other supplies to be used by an anesthesiologist), on a monthly basis, in accordance with the facility’s policy and procedure regarding drug administration. This deficient practice resulted in two expired (outdated) medications observed in Cart 1 and had the potential to result in using medications with reduced drug effectiveness, thus compromising patient care. (Refer to A-0505) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment”

“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: 28851 Based on interview and record review, the facility failed to ensure that nurses notified the physician, in accordance with the facility’s policy and procedure regarding Patient Controlled Analgesia (PCA- a type of pain management where patients administer their own pain medication through a pump by pressing a button), when one of 40 sampled patient’s (Patient 10’s) respiratory rate (number of breaths taken per minute) was measured at less than twelve (12) breaths per (/) minute (Normal respiratory rate is 14-22 breaths/minute for children), for nine (9) times, on 5/6/2025 between 3:15 p.m. to 7 p.m., as per order. The facility also failed to ensure the facility’s policy and procedure did not have a different limit of respiratory rates for nurses to notify physicians. This deficient practice had the potential for adverse events such as respiratory depression (where breathing becomes too slow or shallow, preventing proper gas exchange between the lungs and blood), due to a delay in notifying physicians of abnormal vital sign (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient’s essential body functions) measurements. Findings: During a review of Patient 10’s admission record, the admission record indicated Patient 10 was an 11 years old patient admitted to the hospital on 5/6/2025 at 5:30 a.m. with diagnoses of congenital scoliosis (a condition present at birth where the spine [a series of interconnected bones that runs from the base of the skull to the tip of the tailbone] curves sideways due to abnormal vertebral [back bones] development) and a post-operative admission from posterior (back of the body) spinal fusion (a surgical procedure that joins two or more vertebrae in the spine). During a concurrent interview and record review on 5/8/2025 at 2:41 p.m. in the presence of the Inpatient Pharmacy Supervisor (IPS 3) and the interim Director of Pediatrics Services (iDPS), Patient 10’s medication orders, were reviewed. Patient 10’s orders indicated the patient (Patient 10) had an order for hydromorphone (Dilaudid, a powerful opioid analgesic for the treatment of moderate to severe pain) PCA (or patient controlled analgesic device, which is a type of pain management where patients administer their own pain medication through a pump by pressing a button), dated 5/6/2025 at 12:50 p.m. and discontinued on 5/8/2025 at 9:52 a.m. IPS 3 stated the PCA order referred to a pediatric (the branch of medicine dealing with the health and medical care of infants, children, and adolescents from birth up to the age of 18) order set (a predefined, electronic collection of instructions and service requests grouped together for a specific clinical scenario or condition) for monitoring vital signs and parameters (a measurable characteristic or a fixed limit that influences or defines how something is done). During a review of Patient 10’s hydromorphone order, the order indicated, “order part of order set: PCA PEDS IP SCAL NATL (refers to Patient-Controlled Analgesia [PCA] in pediatric [PEDS] patients, within an inpatient [IP] setting, potentially involving pain scales [SCAL] and possibly referencing national guidelines or standards [NATL]). Further review of the PCA PEDS IP SCAL NATL indicated a checked box for “Measure vital signs and sedation (A state of calmness, relaxation, or sleepiness caused by certain drugs) scale” and “ ... notify physician if: respiratory rate less than 12/min ...” During a review of Patient 10’s vital signs monitoring flowsheet dated 5/6/2025, the flowsheet indicated the following respiratory rates: Respiratory rate = 10 at 3:15 p.m. Respiratory rate = 10 at 3:30 p.m. Respiratory rate = 11 at 4 p.m. Respiratory rate = 10 at 4:15 p.m. Respiratory rate = 11 at 4:30 p.m. Respiratory rate = 8 at 5 p.m. Respiratory rate = 10 at 5:15 p.m. Respiratory rate = 11 at 5:30 p.m. Respiratory rate = 9 at 7 p.m. During a concurrent interview and record review on 5/8/2025 at 2:45 p.m. with the interim Director of Pediatrics Services (iDPS), Patient 10’s nursing progress notes, were reviewed. iDPS stated there was no record indicating nurses had notified the physician of Patient 10’s respiratory rates on 5/6/2025. IDPS stated nurses should have notified physicians. During a review of the facility’s policy and procedures (P&P) titled, Patient Controlled Analgesia (PCA), last reviewed in 3/2023, the P&P indicated “ ... For Pediatric patients, the provider will order the following: ... Notify the provider if respiratory rate less than 12/minute ... RN responsibilities: ... RN will notify provider if ... Respiratory Rate is less than 8/minute ...””

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 28851 Based on observation, interview, and record review, the hospital failed to ensure medications were kept securely, and/or locked, inside two (2) of two sampled medication carts (Medication Cart 1 and 20), in two (2) of two sampled rooms, in the operating room 2 (OR 2, a specialized area in a hospital where surgical procedures are performed) and in the Endoscopic Ultrasound (a procedure that combines endoscopy [a medical procedure where a thin, flexible tube with a camera and light (an endoscope) is inserted into the body to visualize internal organs and structures] and ultrasound [a medical imaging technique that uses high-frequency sound waves] to create images of the digestive tract [where food and liquids travel through as they are ingested, digested, absorbed, and eventually eliminated as waste] and nearby organs and tissues) room (EUS), in accordance with the facility’s policy regarding “Operations - Operating Room/Pre-Op/Post Anesthesia Care Unit - Drug Administration.” This deficient practice had the potential for unauthorized access to dangerous medications that may or may not affect the safety of the hospital’s patients, staff, and visitors. Findings: During a concurrent observation and interview on 5/7/2025 at 2:51 p.m. in the Operating Room (OR, a specialized area in a hospital where surgical procedures are performed) 2 (OR 2) with the Director of Pharmacy (DOP), the director of Perioperative Services (DIR 1), and the director of anesthesiology (DIR 2), there was a medication cart, labeled as “eye medication cart #20,” wide opened and fully stocked with the medications for eye procedures. DIR 1 stated the medication cart #20 did not have locking mechanism. DIR 1 stated EVS (Environmental services, team responsible for maintaining a clean, safe, and sanitary environment for patients, staff, and visitors) and surg tech (Surgical technician, a healthcare professional who assists surgeons and other medical staff during surgical procedures) have access to the room (OR 2), where medication cart #20 was observed. During a concurrent observation and interview on 5/8/2025 at 7:18 p.m. with the Director of Pharmacy (DOP), inside the Endoscopic Ultrasound (a procedure that combines endoscopy [a medical procedure where a thin, flexible tube with a camera and light (an endoscope) is inserted into the body to visualize internal organs and structures] and ultrasound [a medical imaging technique that uses high-frequency sound waves] to create images of the digestive tract [where food and liquids travel through as they are ingested, digested, absorbed, and eventually eliminated as waste] and nearby organs and tissues) room (EUS), located on the first floor, there was a medication cart (Medication Cart #1) that had the first drawer left open. On top of the medication cart, there was a vial (a small container, typically cylindrical and made of glass, used especially for holding liquid medicines). During a concurrent interview on 5/8/2025 at 7:18 p.m. with the Director of Pharmacy (DOP), the DOP stated the vial was Bridion (brand name sugammadex, a medication used to reverse the effects of certain muscle relaxants used during surgery) 200 milligrams (mg, unit to measure mass) per 2 milliliters (ml, unit to measure volume). The DOP stated the medication cart (medication cart #1) was an anesthesia (brings on a sleep-like state with the use of a combination of medicines) medication cart and should be locked. A concurrent inspection of the anesthesia medication cart indicated it contained high alert meds (those that pose a heightened risk of causing significant patient harm if used incorrectly) such as propofol (generic for Diprivan, a sedative, hypnotic agent used primarily in general anesthesia) and other medications used in medical procedures. During an interview on 5/8/2025 at 7:38 p.m. with the Director of Pharmacy (DOP), the DOP stated the anesthesia medication cart should be locked and medication should not be left on top of the cart. During a review of the facility’s policy and procedures (P&P) titled, Operations - Operating Room/Pre-Op/Post Anesthesia Care Unit - Drug Administration (PR 2370.00, dated 5/2022), the P&P indicated “ ... All medications are secured in a locked cabinet or pyxis machines with accessibility by authorized personnel only ...””

“ACCESS TO LOCKED AREAS CFR(s): 482.25(b)(2)(iii) Only authorized personnel may have access to locked areas. This Standard is not met as evidenced by: 28851 Based on observation, interview, and record review, the facility failed to ensure unauthorized personnel would not have access to medications stored in the Endoscopic Ultrasound (a procedure that combines endoscopy [a medical procedure where a thin, flexible tube with a camera and light (an endoscope) is inserted into the body to visualize internal organs and structures] and ultrasound [a medical imaging technique that uses high-frequency sound waves] to create images of the digestive tract [where food and liquids travel through as they are ingested, digested, absorbed, and eventually eliminated as waste] and nearby organs and tissues) room (EUS) and in three (3) of three (3) medication refrigerators (a medical refrigerator, designed to maintain a consistent temperature range for the storage of medication and other temperature-sensitive medical supplies), located in the Operating Room department (OR or surgical department, a hospital ward where patients are cared and treated before, during and after surgery) corridor coves (Core 1 and 2, Outpatient Core), in accordance with the facility’s policy regarding medication storage. This deficient practice had the potential for unsafe storage and inappropriate access of drugs that may affect patients’, staff, & visitors’ safety. Findings: During a concurrent observation and interview on 5/7/2025 at 2:52 p.m. at the facility’s operating room (OR) department corridor cove (core 2) with the charge nurse (RN 2), it was observed core 2 had access to three (3) OR suites (OR 1, 2, and 3). RN 2 stated non-clinical staff, such as central supplies and the environmental services (team responsible for maintaining a clean, safe, and sanitary environment for patients, staff, and visitors), had access to the area to restock supplies and to clean the area (core 2). During a concurrent observation and interview on 5/7/2025 at 4:11 p.m. at OR corridor cove (core 2) with Registered Nurse (RN) 2, there was a medication fridge left unlocked. The medication fridge contained injectable medications including diltiazem (medication to treat high blood pressure), vasopressin (medication to help in blood pressure regulation), carboprost (medication to stop bleeding), and methylergonovine (medication to manage postpartum [afterbirth] bleeding). RN 2 stated he (RN 2) unlocked it (the medication fridge) in the morning so OR nurses could retrieve the medications inside throughout the day as needed. During a concurrent observation and interview on 5/8/2025 at 9:04 a.m. with the Nurse Manager (NM) 2, in the Outpatient OR Core area, there was an unlocked medication fridge. The Outpatient Core area also housed surgical supply carts. NM 2 stated the charge nurse unlocks the fridge in the morning prior to the start of any outpatient procedures and then locks it at night; in addition to the OR clinical staff, housekeeping could access this corridor (Outpatient OR Core area where an unlocked medication fridge was observed). During an observation on 5/8/2025 at 7:10 p.m., the director of pharmacy (DOP) and the inpatient pharmacy supervisor (IPS 3) led the surveyors on a tour to the EUS (Endoscopy Ultrasound room) on the first floor. The EUS was located inside a room labeled “Control room,” in a corridor connected to the emergency department and other imaging service rooms. There was a patient sitting in a wheelchair at the end of the corridor. Upon entering through the unlocked door of the Control room, the area was empty, no staff were present. Next, the door to the EUS treatment room was open, unlocked, and there was a medication cart that had the first drawer left open. DOP stated the medication cart was an anesthesia (brings on a sleep-like state with the use of a combination of medicines) medication cart that contained high alert meds (those that pose a heightened risk of causing significant patient harm if used incorrectly) such as sedatives (drugs that slow down brain activity and reduce anxiety or tension) and hynotics (drugs that promote sleep). During an observation on 5/9/2025 at 9:48 a.m. in the OR corridor cove (Core 2), there was a medication (med) refrigerator (fridge) located near a staff elevator. The med fridge was unlocked. During an interview on 5/9/2025 at 9:55 a.m. with the Director of Pharmacy (DOP), the OR charge nurse, and the assistant nurse director the DOP stated medication fridges located in the corridor (such as OR Core 2) should be locked. The OR charge nurse stated he (OR charge nurse) was the only person with the key to open the medication refrigerators (in OR Core 2) and he (OR charge nurse) left them unlocked so that other nurses can access the med fridge. A concurrent interview with the assistant nurse director confirmed that other personnel, such as environmental services staff and sterile processing staff, had access to the area (OR Core 2). During a concurrent observation and interview on 5/9/2025 at 10:15 a.m. with the Supervisor of Operating Room (SOR) 1 in Core 1, the medication fridge was found unlocked. The medication fridge contained injectable medications including Carboprost (medication used to treat sever bleeding after childbirth, Vasopressin (medication used to raise blood pressure in adults with life-threatening low blood pressure when other treatments have not worked), and Methylergonovine (Methergine, a medication that treats excessive bleeding after childbirth). SOR 1 stated that the locking mechanism was not functioning and stated that the fridge should remain locked at all times. SOR 1 also stated that efforts were underway to repair the lock. During a review of the facility’s policy and procedures (P&P) titled, Medication Storage, the P&P indicated “ ... Only authorized personnel have access to medications ... All non-controlled medications ... are secured when the patient care area is not staffed. Anesthesia carts ... may remain unlocked ... as long as there are authorized OR/procedural unit personnel present ...” During a review of the facility’s policy and procedures (P&P) titled, Operations - Operating Room/Pre-Op/Post Anesthesia Care Unit - Drug Administration (PR 2370.00, dated 5/2022), the P&P indicated “ ... All medications are secured in a locked cabinet or pyxis machines with accessibility by authorized personnel only ...””

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 28851 Based on observation, interview, and record review, the facility failed to: 1. Ensure nine (9) of nine sampled injectable medication syringes drawn up for a procedure, were properly labeled, unused and/or outdated portions of one (1) of one sampled multidose vial (a container of liquid medication, intended for injection or infusion, that holds more than one dose), would be discarded after a procedure, in three (3) of three sampled areas, the Operating Room 2 (OR 2), the OR anesthesia work room, and in the Endoscopic Ultrasound (a procedure that combines endoscopy and ultrasound to create images of the digestive tract and nearby organs and tissues) unit (EUS), as per facility’s policy regarding safe medication practices. The facility also failed to ensure used multiple dose vials (a small container, typically cylindrical and made of glass, used especially for holding liquid medicines) and four (4) of five (5) medications with overwrap that were removed, had proper dating to prevent using beyond manufacturer’s guidance, in accordance with the facility’s policy regarding medication storage. This deficient practice had the potential for outdated or contaminated medications being available for use in the patient care areas, which may result in problems such as infection and reduced drug effectiveness. 2. Inspect and maintain stock drug (medication) supplies in one of two (2) sampled pediatric (branch of medicine dealing with the health and medica care of infants, children and adolescents from birth up to age of 18) anesthesia (a medical technique that involves using medications to temporarily block pain and sensation, making procedure like surgery possible without discomfort) carts (Cart 1, a supply cart stocked with medications and other supplies to be used by an anesthesiologist), on a monthly basis, in accordance with the facility’s policy and procedure regarding drug administration. This deficient practice resulted in two expired (outdated) medications observed in Cart 1 and had the potential to result in using medications with reduced drug effectiveness, thus compromising patient care. Findings: 1. During a concurrent observation and interview on 5/7/2025 at 2:11 p.m. with the Director of Pharmacy (DOP), the director of Perioperative Services (DIR 1), and the director of anesthesiology (DIR 2), there was an anesthesia cart observed in the Operating Room (OR) 2. The DOP confirmed that there were nine (9) syringes in the first drawer of the anesthesia cart, as follows: -One 20 milliliters (ml, unit to measure volume) syringe filled to 20 ml. The label indicated 5/7/2025 at 6:30 a.m., propofol (generic for Diprivan, a sedative, hypnotic agent used primarily in general anesthesia) 10 milligrams (mg, unit to measure mass) per ml, no quantity, and initial: CC. -One 10 ml syringe filled to 10 ml. The label indicated it was filled with propofol 10 mg/ml on 5/7/2025 at 7 a.m., no quantity, and initial CC. -One 5 ml syringe filled to approximately at 2.2 ml. The label indicated it was filled with glycopyrrolate (medication used to treat a variety of conditions by reducing bodily secretions and relaxing smooth muscles) 0.2 mg on 5/7/2025, no quantity, no time, and the initial were not legible -Two 5 ml syringes filled to 5 ml each. The label indicated the content was lidocaine 1%, datedon 5/7/2025, time was not legible time, no quantity, and the initial was CC. -One empty syringe with a label which indicated Precedex (dexmedetomidine, a medication used for sedation during surgical or diagnostic procedure), no date/time, no strength, no quantity, and no initial. -Two empty syringes without label. -One 10 ml syringe filled to 10 ml. The label indicated it was filled with propofol 10 mg/ml on 5/7/2025 at 1 p.m., no quantity, and the initial was AM. During an interview on 5/7/2025 at 2:35 p.m. with the certified registered nurse anesthetist (CRNA, advanced practice registered nurse who specializes in administering anesthesia and related care to patients undergoing surgery or medical procedures), CRNA stated nurses or the anesthesiologist would draw up syringes with anesthetic medications before a case and those syringes should be discarded after the case ended. CRNA stated the aforementioned syringes with the initial “CC” were drawn by a nurse student that she (CRNA) was precepting for a case in the morning and did not know she (nurse student) needed to initial as well. At 2:40 p.m., CRNA stated the syringe dated on 5/7/2025 at 1 p.m. was drawn by her (CRNA) in preparation for an upcoming surgery. During an interview on 5/9/2025 at 12:50 p.m. with the Director of Pharmacy (DOP), the DOP stated that syringes drawn up in the OR before/during a case should be labeled with med (medication) names, strength, quantity , date & time drawn to determine the BUD (Beyond Use Date, the date after which a compounded [custom-made drugs created by pharmacists or physicians, tailoring drug formulations to a patient’s specific needs] medication (sterile [any medication that is free from microorganisms and prepared in a sterile environment] or non-sterile) should not be used. It is determined from the date and time the medication is compounded and is different from the manufacturer’s expiration date), and initials. The DOP stated syringes drawn in the OR settings had a BUD of four (4) hours. During an observation on 5/7/2025 3:22 p.m. in the OR anesthesia work room with the DOP and a certified anesthesia Technologist or Technician (CATT), there was a procedure cart (cart #9) in the room. On top of the cart, there was a multidose vial of lidocaine (commonly used to as local anesthesia or a nerve block to numb the pain during a medical procedure) 1 percent (%) in a half-full 20 ml vial. On the vial was a blank label which indicated “Discard after 28 days. EXP. [expiration] Date (blank).” The DOP confirmed the vial had been used and should have an open date or expiration date on the label. During an observation on 5/8/2025 at 7:18 p.m. inside the Endoscopy Ultrasound room (EUS) on the first floor, with the Director of Pharmacy (DOP), there was a medication cart that had the first drawer left open. The DOP stated it was an anesthesia cart. Upon inspection of the anesthesia cart, there were 5 syringes of succinylcholine PFS (a skeletal muscle relaxant used during surgery or medical procedures); 1 of 5 syringes had a clear over wrap (a method where a flexible material, like film or paper, is wrapped around a product or another package to create a secure seal) while the other 4 syringes did not have the over wrap. During an interview on 5/9/2025 at 12:48 p.m. with the Director of Pharmacy (DOP), the DOP stated the medication with plastic over wrap should be kept in the overwrap until use. During a review of the facility’s policy and procedures (P&P) titled, Safe Medication Practices: Medication Labeling in the Perioperative and Procedural Settings (reviewed on 3/2023), the P&P indicated “ ... Label all medications, medication containers (for examples, syringes ...) ... on and off the sterile field that are not immediately administered ... Labeling occurs when any medication or solution is transferred from the original packaging to another container ... labels include ... medication name, strength, quantity ... Remove all labeled containers on the sterile field and discard their contents at the conclusion of the procedure ... Two qualified person verification of the label’s accuracy is required if two or more people participate in the preparation, labeling ...” This policy did not have the updated information regarding the BUD of 4 hours for syringes drawn up in the OR settings. During a review of the facility’s policy and procedures (P&P) titled, Safe Medication Practices: Medication Labeling in the Perioperative and Procedural Settings (reviewed on 3/2023), the P&P indicated “ ... Write date on vial/bottle label when first entering or opening a multiple dose vial ...” During a review of the facility’s policy and procedures (P&P) titled, Medication Storage, the P&P indicated “ ... Storage of parenteral medications outside of the overwrap ... once removed from the overwrap, products are labeled with a beyond-use date per manufacturer’s recommendations ...” 2. During a concurrent observation and interview on 5/8/2025 at 3:41 p.m. with the Manager (MA) of Anesthesia (a medical technique that involves using medications to temporarily block pain and sensation, making procedure like surgery possible without discomfort), at the anesthesia workroom (storage room), there was a pediatric (branch of medicine dealing with the health and medica care of infants, children and adolescents from birth up to age of 18) anesthesia cart (Cart 1, a supply cart stocked with medications and other supplies to be used by an anesthesiologist) stocked with one (1) Phenylephrine (medication to treat nasal congestion or stuffiness) injection 1,000 micrograms (mcg, unit of measure) per 10 milliliters (ml, unit of measure) with expiration date of 4/29/2025 and one (1) Epinephrine (medication to treat severe allergic reaction, cardiac arrest [when the heart stops beating], asthma and other conditions) injection 100 mcg/10ml with expiration date of 4/22/2025. MA stated the expired medications (phenylephrine and epinephrine) should be discarded. MA further stated the anesthesiologist technician was responsible for checking the anesthesia cart regularly and discarding any expired (outdated) medication. During an interview on 5/8/2025 at 11:34 a.m. with the Director of Pharmacy (DOP), the DOP stated the following: there was a facility approved list titled, “anesthesia department - ancillary (services that support or supplement the primary care) anesthesia cart” provided to the anesthesia department to prepare stock medications in any anesthesia cart. The pharmacy department did not keep track of how many anesthesia carts were made by the anesthesia department and what medications were stocked in the anesthesia cart. The expectation was for the anesthesia department staff to check the anesthesia carts regularly. Any expired medications should be removed from the anesthesia cart. During an interview on 5/8/2025 at 1:58 p.m. with the Director of Anesthesiology (Dir 2), Dir 2 stated the following: there was no check list for anesthesia department staff to complete when checking the anesthesia carts. The expectation was for the anesthesia tech (technician) to check the anesthesia cart on a daily basis. It was their (anesthesia tech’s) responsibility to maintain supplies and check for expiration (of medications). The potency and effectiveness would be changed in expired medications. Any expired medications found in the anesthesia cart should be removed. During a review of the facility’s policy and procedure (P&P) titled, “Drug Administration,” dated 5/2022, the P&P indicated, “All drug supplies in the Operating rooms/Pre-Op/PACU are inspected monthly by the pharmacist. The pharmacy personnel check stock drug supplies, including emergency drugs, for expiration dates.” During a review of the facility’s job description for certified anesthesia tech, dated 9/30/2013, the job description indicated, “Essential responsibilities ... keep sufficient stock of supplies and non scheduled drugs in anesthesia workroom, machines and carts. Reviews for outdated medications. Coordinates with Pharmacy for out of stock drugs.””

“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: 42937 Based on observation, interview, and record review, the facility failed to: 1. Ensure surveillance and maintenance of a clean and sanitary environment in one of two sampled operating room (surgical room 2), in accordance with the facility’s policy regarding infection prevention, when tape residue was found on a surgical stretcher’s headrest attachment inside surgical room 2, This deficient practice had the potential for cross- contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another, potentially leading to infections) and risks of infection among surgical patients. 2. Maintain a sanitary and controlled surgical environment (in which surgery is conducted while maintaining a sterile area around the incision site, and only sterile items are permitted to come in contact with this area), when an entry alarm system was not properly functioning, intended to prevent unauthorized or unmonitored access to one of two sampled sterile (free from germs) operating room (OR, a designated space within a hospital or medical facility where surgical procedures are performed, in a controlled environment to minimize infection risk) suite, when no alarm was triggered when entry to the sterile zone without a badge used in accordance with the facility’s protocol regarding infection prevention. This deficient practice created a potential breach in infection prevention practices by allowing entry into a designated sterile area without staff awareness or contamination safeguards. Findings: 1. During a concurrent observation and interview on 05/07/2025 at 2:08 p.m. with the Director of Peri-op (Peri-operative, encompasses the medical care provided to a patient before, during, and after a surgical procedure) Services (Dir 1), it was observed that a surgical stretcher’s headrest attachment inside surgical room 2 had multiple tape residue. Dir 1 stated that surgical room 2 had been cleaned and was ready for patient use. Dir 1 added that the environmental services (EVS, also known as housekeeping, are responsible for cleaning, disinfecting in hospitals) staff and the clinical staff were responsible in ensuring cleanliness of the operating rooms and its equipment. During the same interview on 5/07/2025 at 2:08 p.m. with the Director of Peri-op (Dir 1), Dir 1 said that the staff [EVS and the Clinical Staff] should have made sure that there was no tape residue on the head rest prior to making it (referring to the surgical stretcher) available for patient use. DIR 1 stated sticky tape residue could harbor bacteria and other microorganisms, increasing the risk of surgical site infections (SSI) and cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another, potentially leading to infections) between patients. During an interview on 5/9/2025 at 10:59 p.m. with the Director of Infection Prevention (Dir 3). Dir 3 stated that tape residue should be removed from all patient equipment in the OR. DIR 3 said adhesive substances could harbor bacteria, blood and pathogen, and could potentially cause surgical site infections (SSI) and cross contamination. DIR 3 stated it was the surgery department leadership’s and clinical staff’s responsibility to monitor, identify infection risk and implement preventive measures to minimize the risk of infection to surgical patients. They (the surgery department leadership and clinical staff) were also responsible for ensuring compliance with surgical guidelines and standards. During a review of the facility’s policy & procedure (P&P) titled, “The Infection Prevention Program,” last reviewed 12/2024, the P&P indicated, “ The infection prevention and control program is a plan of action designed to identify infections that occur in patients and staff that have the potential for disease transmission, identify opportunities for reduction of risk for disease transmission, recommend risk reduction practices by integrating principles of infection control into all direct and indirect standards of practice.” During a review of the facility’s policy & procedure (P&P) titled, “Surgical Site Infection Prevention,” last reviewed 12/2024, the P&P indicated, in cleaning and disinfection of environmental surfaces, the Environmental Services (EVS) will perform between case and end of day terminal cleaning (a comprehensive process of thoroughly cleaning and disinfecting a room after a patient has been discharged or transferred) using a hospital EPA (Environmental Protection Agency) approved disinfectant. This will ensure that all surgical patients will have a clean/disinfected environment. 2. During a concurrent observation and interview on 5/9/2025 at 9:15 a.m. with the Assistant Nursing Director of the Operating Room (ADOR), the door located in the 2 North hallway that leads directly into the OR suite, was observed. A red line (a demarcation, often a colored band on the floor, that separates the semi-restricted area from the restricted, sterile [free from germs] area. This line signals that proper surgical attire, including surgical scrubs, a cap, and mask, must be worn when crossing into the restricted area) was visibly marked on the floor to indicate the beginning of the sterile environment. When the door was pushed open without using a badge entry (a method of controlling access to an area or facility using a credential, typically an ID badge, that is presented to an access control system), the alarm did not go off. ADOR stated that the door had a delayed egress function (a security feature on a door that introduces a brief delay before the door unlocks) and was designed to alarm if the handle was pressed down for 15 seconds without badge use- alerting staff to a potential unauthorized entry into a sterile zone. However, when the door was accessed without a badge, no alarm was triggered. ADOR further stated that while the door was intended to be used in emergencies for rapid patient transport, any non-emergency access must alarm, to notify staff and maintain the integrity of the sterile field. ADOR confirmed that the alarm was critical to ensure no unmonitored or non-sterile entry occurred. During an interview on 5/9/2025 at 9:20 a.m. with the Engineering Manager (EM), EM confirmed the door alarm was a required infection control safeguard and that it was not functioning properly at the time. The EM confirmed that the failure of this alarm could potentially allow an unauthorized person into a sterile area without alarming staff to intervene. During an interview on 5/9/2025 at 10:30 a.m. with the Director of Infection Prevention (Dir) 3, Dir 3 stated the redline was to prevent entry without proper attire, as there was a risk for cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another, potentially leading to infections). During a review of the facility’s policy and procedure (P&P) titled, “Infection Prevention and Control Strategic Workplan 2025,” dated 2025, the P&P indicated, “The Infection Preventionists support the (name of the facility) mission of promoting the health of our members and the communities we serve. We are committed to collaborative practice and management of Infection Prevention and Control through the application of epidemiology across the continuum of care to prevent adverse outcomes, to improve patient care and safety and to minimize infectious occupational hazards associated with health care delivery ... Intervening Directly to Prevent Transmission of Infectious Diseases ...” During a review of the facility’s policy and procedure (P&P) titled, “Surgical Attire Practices,” dated March 2025, the P&P indicated, “To provide guidelines for all individuals entering the semi-restricted and restricted areas including but not limited to Perioperative, Labor & Delivery, Sterile Processing, and Procedural Center (providers, staff, physicians, others) for clean surgical scrub attire, including jewelry, clothing, shoes, head coverings, masks, jackets, and other accessories worn within the semi-restricted and restricted areas of the surgical or invasive environment ... All Personnel (providers, staff, physicians, others) will dress in the prescribed manner prior to entering the semi restricted and restricted areas of the perioperative departments. All providers, staff, physicians and others must wear freshly laundered blue surgical attire intended for use within the surgical suite. Surgical attire should be made of low-linting material, contain shed skin squames, provide comfort, and promote a professional appearance ...””

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 43236 Based on observation, interview, and record review, the facility failed to follow policy & procedure for supplies in the operating room (OR) department, when two (2) of two (2) plasma rollers (a surgical instrument used to stop bleeding when incisions are made during surgeries involving the prostate), were identified as expired. This deficient practice had the potential to result in the use of expired or compromised supplies during surgical procedures, placing patients at risk for ineffective treatment and excessive bleeding during prostate surgeries. Findings: During a concurrent observation and interview on 5/7/2025, at 2:02 p.m. with Nurse Manager (NM) 1 and Registered Nurse (RN) 2, the OR area in the facility’s “2 North” area, a separate OR department from the main OR department, was observed. RN 2 stated 2 North has three operating rooms which usually handled urology (surgeries involving the bladder, kidneys, urethra, and prostate) and gynecology (surgeries involving the female reproductive system) cases, and cases such as laparoscopic appendectomies (a minimally invasive surgical procedure to remove the appendix through small incisions, rather than one large one) and laparoscopic cholecystectomies (a minimally invasive surgical procedure where the gallbladder is removed through small incisions, rather than one large one). During a concurrent observation and interview on 5/7/2025 at 2:51 p.m. with NM 1 and RN 2, the sterile core corridor behind the ORs in 2 North, was observed. There were multiple surgical supply shelves inside the sterile core corridor. Two plasma rollers were present in one of the supply shelves in sealed and unopened packaging. Both rollers’ packaging indicated an expiration date of 10/14/2024. NM 1 confirmed that those supplies were expired and should not be present in the sterile corridor. NM 1 further stated that the plasma rollers were used during TURP surgery (transurethral resection of the prostate - a surgical procedure used to treat urinary problems caused by an enlarged prostate) to stop bleeding, and that it was the OR staff’s responsibility to ensure that expired supplies were not left to be used. During a review of the facility’s policy & procedure (P&P) titled, “Equipment and Supplies - Perioperative Service,” last reviewed 12/2024, the P&P indicated, “Routine disposable supplies will be replenished daily by Materials Management ... Sterile supplies are rotated from left to right and bottom to top.””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to provide necessary stabilizing treatment for an emergent medical condition (EMC- a health condition or situation that needs immediate medical attention. Example: chest pain, stroke [Blood clot in the brain], heavy bleeding, and severe head injury) for one of 21 sampled patients (Patient 1), in accordance with the facility’s policy regarding “Emergency Medical Screening Examination Treatment and Transfer,” and “Emergency Management of Code Stroke Alert and Code Stroke in the Emergency Department.” Patient 1 presented to the Emergency Department (ED) with chest pain, shortness of breath (difficulty breathing), headache, left arm and left leg numbness, left shoulder pain, and facial numbness. This deficient practice resulted in the facility failing to promptly treat and stabilize Patient 1’s emergent medical condition of acute stroke (a blood clot or bleeding in the brain preventing blood from reaching the brain). This deficient practice had the potential for Patient harm. (Refer to A-2407) Findings: During a concurrent interview and record review on 4/3/2025 at 10 a.m. with the Assistant Director of Emergency Department (ADED), Patient 1’s Emergency Department Patient Care Timeline, dated 3/3/2025, was reviewed. The Emergency Department Patient Care Timeline indicated Patient 1 arrived in the Emergency Department (ED) at 6:07 p.m., with a chief complaint of “chest pain, shortness of breath, headache, left arm and left leg numbness, left shoulder pain, and facial numbness” and “LKWT (Last known well time) 11 p.m. on 3/2/2025.” Patient 1 was triaged (Acuity Level) on 3/3/2025 at 6:07 p.m., as Emergency Severity Index (ESI) level-3 (Urgent- Requires 2 or more resources to provide relief and make a diagnosis). Vital Signs were as follows: Temperature: 97.8F (normal 97F to 99F); Pulse 99 (normal 60 to 100); Respiration rate (RR): 18 breaths per minute (normal RR 12 to 20); Blood Pressure169/99 (normal BP 120/80); Pulse oximetry 98% on room air (RA) and with 10/10 Pain assessment. During a review of Patient 1’s Physician Orders dated 3/3/2025 at 6:17 p.m., the Physician’s Orders indicated the following: Electrocardiogram (a simple, painless test that records the electrical activity of the heart, helping doctors assess heart health and identify potential problems like irregular heartbeats or heart attacks); complete blood count (a blood test that measures the components of blood, including red blood cells, white blood cells, and platelets); basic metabolic panel (a common blood test that assesses your body’s metabolism, fluid balance [the body’s ability to maintain a stable internal environment by regulating the amount and distribution of fluids, ensuring proper hydration and electrolyte levels, and supporting vital functions like cellular metabolism and temperature regulation], and kidney function, measuring levels of glucose [sugar], electrolytes [essential minerals vital to many key functions of the body], and kidney waste products); troponin level ( found in heart muscle and usually elevated when heart muscle is damaged; Chest Xray; CT (Computed Tomography, a medical imaging technique that uses X-rays to create detailed, three-dimensional images of internal organs and structures within the body)0 of Head and MRI (Magnetic Resonance Imaging, an imaging technique that uses a strong magnetic field and radio waves to create detailed images of the inside of the body) of Brain. Patient 1 was roomed at 7:54 p.m. and Patient 1’s MSE (Medical Screening Exam) was at 7:59 p.m. During a review of Patient 1’s ED physician Notes, dated 3/3/2025, the ED Physician’s Notes indicated Patient 1’s diagnosis was acute stroke (a blood clot or bleeding in the brain preventing blood from reaching the brain). Patient 1’s MRI of the brain ordered on 3/3/2025 indicated findings of “Acute CVA (cerebrovascular accident, a bleed in the brain).” During a concurrent interview and record review on 4/3/2025 at 10:30 a.m. with the ADED, Patient 1’s Emergency Department Patient Care Timeline, dated 3/3/2025, was reviewed. The ADED confirmed there was no documentation of a Registered Nurse (RN) in Triage (a preliminary nursing assessment to determine urgency of need for treatment), nor was there Physician assessment. The ADED confirmed lab (laboratory) and imaging orders for Patient 1. The ADED confirmed there was no documentation of “Stroke Alert (a medical notification that indicates a patient may be experiencing a stroke),” called by Triage RN and no “Code Stroke (a hospital protocol, an emergency alert, initiated when a patient is suspected of having a stroke),” called by the physician. During a review of the facility’s policy and procedure (P&P) titled, “Emergency Medical Screening Examination Treatment and Transfer,” dated 2/16/2024, the P&P indicated “the facility will provide an appropriate Medical Screening Exam (MSE) to any individual who comes to the Emergency Department (ED) to determine if an Emergency Medical Condition (EMC) exists. A MSE will be provided within the capabilities and capacity of the emergency department.” “If after the MSE it is determined that the individual has an EMC the hospital must within its capability and capacity to provide further medical examination and treatment required to stabilize the EMC.” During a review of the facility’s policy and procedure (P&P) titled, “Emergency Management of Code Stroke Alert and Code Stroke in the Emergency Department,” dated 11/2024, the P&P indicated “overall goal of Stroke Treatment in the Emergency Department are rapid safe and appropriate assessment and treatment of patients exhibiting signs and symptoms concerning for acute stroke” and “Stroke Alert is level 1 activation by nursing after rapid assessment of patient identified to have signs and symptoms potential for stroke with a last known well time of 24 hours prior” and “Code Stroke is level two activation decided by the physician after Stroke Alert and prompt quick medical assessment of the patient.””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 31993 Based on interview and record review, the facility failed to provide necessary stabilizing treatment for an emergent medical condition (EMC- a health condition or situation that needs immediate medical attention. Example: chest pain, stroke [Blood clot in the brain], heavy bleeding, and severe head injury) for one of 21 sampled patients (Patient 1). Patient 1 presented to the Emergency Department (ED) with chest pain, shortness of breath (difficulty breathing), headache, left arm and left leg numbness, left shoulder pain, and facial numbness. This deficient practice resulted in the facility failing to promptly treat and stabilize Patient 1’s emergent medical condition of acute stroke (a blood clot or bleeding in the brain preventing blood from reaching the brain). This deficient practice had the potential for Patient harm. Findings: During a concurrent interview and record review on 4/3/2025 at 10 a.m. with the Assistant Director of Emergency Department (ADED), Patient 1’s Emergency Department Patient Care Timeline, dated 3/3/2025, was reviewed. The Emergency Department Patient Care Timeline indicated Patient 1 arrived in the Emergency Department (ED) at 6:07 p.m., with a chief complaint of “chest pain, shortness of breath, headache, left arm and left leg numbness, left shoulder pain, and facial numbness” and “LKWT (Last known well time) 11 p.m. on 3/2/2025.” Patient 1 was triaged (Acuity Level) on 3/3/2025 at 6:07 p.m., as Emergency Severity Index (ESI) level-3 (Urgent- Requires 2 or more resources to provide relief and make a diagnosis). Vital Signs were as follows: Temperature: 97.8F (normal 97F to 99F); Pulse 99 (normal 60 to 100); Respiration rate (RR): 18 breaths per minute (normal RR 12 to 20); Blood Pressure169/99 (normal BP 120/80); Pulse oximetry 98% on room air (RA) and with 10/10 Pain assessment. During a review of Patient 1’s Physician Orders dated 3/3/2025 at 6:17 p.m., the Physician’s Orders indicated the following: Electrocardiogram (a simple, painless test that records the electrical activity of the heart, helping doctors assess heart health and identify potential problems like irregular heartbeats or heart attacks); complete blood count (a blood test that measures the components of blood, including red blood cells, white blood cells, and platelets); basic metabolic panel (a common blood test that assesses your body’s metabolism, fluid balance [the body’s ability to maintain a stable internal environment by regulating the amount and distribution of fluids, ensuring proper hydration and electrolyte levels, and supporting vital functions like cellular metabolism and temperature regulation], and kidney function, measuring levels of glucose [sugar], electrolytes [essential minerals vital to many key functions of the body], and kidney waste products); troponin level ( found in heart muscle and usually elevated when heart muscle is damaged; Chest Xray; CT (Computed Tomography, a medical imaging technique that uses X-rays to create detailed, three-dimensional images of internal organs and structures within the body) of Head and MRI (Magnetic Resonance Imaging, an imaging technique that uses a strong magnetic field and radio waves to create detailed images of the inside of the body) of Brain. Patient 1 was roomed at 7:54 p.m. and Patient 1’s MSE (Medical Screening Exam) was at 7:59 p.m. During a review of Patient 1’s ED physician Notes, dated 3/3/2025, the ED Physician’s Notes indicated Patient 1’s diagnosis was acute stroke (a blood clot or bleeding in the brain preventing blood from reaching the brain). Patient 1’s MRI of the brain ordered on 3/3/2025 indicated findings of “Acute CVA (cerebrovascular accident, a bleed in the brain).” During a concurrent interview and record review on 4/3/2025 with ADED, Patient 1’s Emergency Department Patient Care Timeline, dated 3/3/2025, was reviewed. The ADED confirmed there was no documentation of a Registered Nurse (RN) in Triage (a preliminary nursing assessment to determine urgency of need for treatment), nor was there Physician assessment. The ADED confirmed lab (laboratory) and imaging orders for Patient 1. The ADED confirmed there was no documentation of “Stroke Alert (a medical notification that indicates a patient may be experiencing a stroke),” called by Triage RN and no “Code Stroke (a hospital protocol, an emergency alert, initiated when a patient is suspected of having a stroke),” called by the physician. During a review of the facility’s policy and procedure (P&P) titled, “Emergency Medical Screening Examination Treatment and Transfer,” dated 2/16/2024, the P&P indicated “the facility will provide an appropriate Medical Screening Exam (MSE) to any individual who comes to the Emergency Department (ED) to determine if an Emergency Medical Condition (EMC) exists. A MSE will be provided within the capabilities and capacity of the emergency department.” “If after the MSE it is determined that the individual has an EMC the hospital must within its capability and capacity to provide further medical examination and treatment required to stabilize the EMC.” During a review of the facility’s policy and procedure (P&P) titled, “Emergency Management of Code Stroke Alert and Code Stroke in the Emergency Department,” dated 11/2024, the P&P indicated “overall goal of Stroke Treatment in the Emergency Department are rapid safe and appropriate assessment and treatment of patients exhibiting signs and symptoms concerning for acute stroke” and “Stroke Alert is level 1 activation by nursing after rapid assessment of patient identified to have signs and symptoms potential for stroke with a last known well time of 24 hours prior” and “Code Stroke is level two activation decided by the physician after Stroke Alert and prompt quick medical assessment of the patient.””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 36206 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to ensure one of five sampled nursing staff (Registered Nurse 6 [RN 6]) had a complete departmental annual competency evaluation (assessment of a clinician’s skills, abilities and knowledge to ensure provision of safe and effective care to patients) done in accordance with the facility’s policy and procedure on competency evaluation. This deficient practice had the potential to result in patients receiving inadequate care and treatment from staff whose competencies were not completed annually. (Refer to A-0394) 2. The facility failed to obtain a pain assessment (process where a nurse gathers, sorts and analyzes a patient’s health information) and reassessment for three of 30 sampled patients (Patient 1, 11, and 22) in accordance with the facility’s policy and procedure regarding assessment and re-assessment when: 2.a. Patient 1, who was in the Obstetrics Triage Unit (Unit 1, OB triage, provides immediate, specialized assessment for women at all stages of pregnancy), did not have a documented baseline pain assessment on admission or any reassessment during episodes of contractions (tightening of the uterus that provides the force to expel the fetus [unborn baby] through the birth canal). This deficient practice had the potential for Patient 1 to have unrelieved pain. Thus, negatively affecting the physical, emotional, and psychosocial (social factors of a person’s thoughts and behaviors) well-being of the patient (Patient 1). (Refer to A-0395) 2.b. Patient 11’s pain was not assessed prior to receiving pain medication (Tylenol, administered for mild pain). This deficient practice had the potential for Patient 11 to receive pain medications unnecessarily. (Refer to A-0395) 2.c. Patient 22’s pain was not addressed for more than two hours after Patient 22 reported a pain level of 10 out of 10 (a score of 0 means no pain, and 10 means the worst pain ever felt). This deficient practice resulted in the delay of appropriate pain management for Patient 22 and had the potential to cause adverse health outcomes such as worsening of pain that takes longer to relieve. (Refer to A-0395) 3. The facility failed to assess fetal (baby in the womb) heart rate and uterine contractions (the tightening and shortening of the uterine muscles) for one of 30 sampled patients (Patient 9) in accordance with the facility’s policy and procedure regarding assessment of fetal heart rate and contractions. This deficient practice had the potential for abnormalities in the baby’s heart rhythm and Patient 9’s contractions to become unidentified by staff and puts Patient 9 at risk for harm due to lack of assessment which might delay the implementation of necessary interventions needed. (Refer to A-0398) 4. The facility failed to ensure notification of a physician and ensure documentation of physician notification regarding one of 30 sampled patient’s (Patient 24) critical serum sodium (NA, the concentration of sodium [salt] in the blood) laboratory result in accordance with the facility’s policy and procedure regarding critical results (laboratory test results that exceed established limits either high or low). This deficient practice had the potential for Patient 24’s condition to be left unaddressed leading to consequences of hypernatremia (high sodium in the body) which can lead to seizures (a sudden, uncontrolled burst of electrical activity in the brain), coma (a state of prolonged loss of consciousness), and death. (Refer to A-0398) 5. The facility failed to ensure that a seizure precaution padding (device to prevent the patient from injuring themselves against the hard frame or side rails of the hospital bed) was applied to the lower side rails (safety devices used to prevent patients from falling out of their beds) for one of 30 sampled patients (Patient 25), in accordance with the facility’s policy and procedure regarding seizure (a sudden, uncontrolled burst of electrical activity in the brain leading to changes in movements and levels of consciousness) management. This deficient practice had the potential for Patient 25 to suffer injuries such as bruising, lacerations (cuts), or broken bones when without padded side rails for protection while having a seizure episode. (Refer to A-0398) 6. The facility failed to ensure that one of 30 sampled patient’s (Patient 25) sequential compression device (SCD, helps to prevent blood clots from forming in the lower limbs) was turned on while applied to Patient 25’s bilateral lower extremities in accordance with a physician order for SCD and with the facility’s established protocol regarding the use of SCDs. This deficient practice had the potential for Patient 25 to develop blood clots in her (Patient 25) lower limbs causing life threatening complications such as pulmonary embolism (a sudden blockage in a lung). (Refer to A-0398) 7. The facility failed to ensure one of 30 sampled patient’s (Patient 25) bed alarm (devices that contains sensors that trigger an alarm when the patient tries to get out of bed) was turned on and working and a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) mat (a safety pad placed on the floor beside the bed to prevent injuries resulting from falls) was placed on the floor beside the patient’s (Patient 25) bed to prevent injuries resulting from falls in accordance with the facility’s protocol regarding fall prevention. These deficient practices had the potential for Patient 25 to suffer injuries such as bruising, lacerations, and broken bones resulting from a fall. (Refer to A-0398) 8. The facility failed to ensure one of 30 sampled patient’s (Patient 24) antibiotic medication (Unasyn, an intravenous [administered through the vein] antibiotic used to treat an infection) was administered in a timely manner (one hour before or one hour after scheduled time) in accordance with the facility’s policy and procedure regarding medication administration. This deficient practice resulted in the delay of treatment for Patient 24 and had the potential to cause adverse health outcomes such as recurring infection (infections that become severe and long lasting, etc. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“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: 47126 Based on observation, interview, and record review, the facility failed to ensure informed consent (a process in which patients are given important information, including possible risks and benefits) was obtained for the facility’s condition of admission (COA, a document that include provisions under which the patient provides informed consent for treatment and may also require the patient’s confirmation of understanding on various arrangements related to the treatment the patient will receive in the facility) for one of 30 sampled patients (Patient 25), when the patient’s (Patient 25) signature did not match the patient’s (Patient 25) previous consent form. This deficient practice resulted in Patient 25 to not be informed of her (Patient 25) rights as a patient which may lead to Patient 25’s inability to effectively make decisions regarding her care or treatment. Findings: During a concurrent observation and interview on 4/17/2024 at 11:20 a.m. with Registered Nurse (RN) 4, Patient 25 was observed in bed with her (Patient 25) eyes closed. RN 4 stated Patient 25 was admitted with a diagnosis of breast cancer that metastasized (the spread of cancer cells from the place where they first formed to another part of the body) to the brain. During a review of Patient 25’s “Internal Medicine History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 3/29/2024, the H&P indicated, “...Patient (Patient 25) was extubated (removal of the endotracheal tube [a tube to help provide oxygen to the lungs]) but still with altered mental status (a change in mental function that stems from illness, disorders, and injuries affecting the brain), non-verbal (inability to speak) ...” During a concurrent interview and record review on 4/17/2024 at 3:39 p.m. with the Nursing Manager (NM) 1, Patient 25’s “Hospital Conditions of Admission [Inpatient/Outpatient Services]” (COA, a document that include provisions under which the patient provides informed consent for treatment and may also require the patient’s confirmation of understanding on various arrangements related to the treatment the patient will receive in the facility), dated 3/31/2024, was reviewed. The COA indicated the document was, “Signed by: [Patient 25’s name], Relationship: Self.” NM 1 said the signature did not look like Patient 25’s name. During a subsequent review of Patient 25’s COA dated 3/19/2024, the COA indicated “Signed by: [Patient 25’s name], Relationship: Self”. NM 1 verified the signature obtained on 3/19/2024, was the Patient 25’s name and the signatures on both COAs did not match. During a concurrent interview and record review on 4/17/2024 at 4:16 p.m. with the Financial Counselor (FC), Patient 25’s COA dated 3/31/2024, was reviewed. The FC stated the signature on the COA did not match the patient’s name and was not a valid consent. The FC further stated the facility’s practice is to have an admitting office representative obtain the signature. If the patient is unable to sign the consent themselves, a family representative would sign the document and the family representative’s name and relationship to the patient would be documented on the COA. However, this was not done for Patient 25. During a review of the facility’s policy and procedure (P&P) titled, “Consent Procedures [Including Illiterate or Non-English],” revised on November 2023, the P&P indicated, “ ...The Admission Department is responsible for obtaining appropriate consent on the Conditions of Admission for Hospital Services ... There will be a Conditions of Admissions signed for all hospital admissions/registrations for hospital services ...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36206 Based on observation, interview, and record review, the facility failed to obtain a physician’s order for the use of restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) for one of 30 sampled patients (Patient 10) in accordance with the restraint’s manufacturer’s instructions and with the facility’s policies and procedures regarding restraints use. This deficient practice resulted in Patient 10 being restrained without a physician’s order and had the potential to compromise patient safety with complications such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia [lack of oxygen]), skin tear, etc. Findings: During an observation on 4/17/2024 at 2:20 p.m., in the Medical Surgical (serves general population such as illness and surgery) and Telemetry (area in hospital where patient undergoes continuous heart monitoring) Unit, the following was observed: Patient 10 sat on a chair in his (Patient 10) room. Patient 10 had a wide belt wrapped around the torso and the back of the chair. The belt was secured or fastened on Patient 10’s left side of the body between the abdomen and the back. Certified nurse assistant (CNA) 1 was sitting just outside Patient 10’s room, observing Patient 10. Concurrently, during an interview, on 4/17/2024 at 2:20 p.m., Patient 10 stated he (Patient 10) was unable to get off the chair because the staff “Tied me in.” During an interview on 4/17/2024 at 2:20 p.m., CNA 1 stated Patient 10 was confused. CNA 1 was observing Patient 10 because Patient 10 was at risk for falls (an unintentional event that results in the person coming to rest on the ground or another lower level). CNA 1 said she (CNA 1) was helping Patient 10 with any needs he (Patient 10) may have such as toileting, etc. During a concurrent interview and record review on 4/17/2024 at 2:25 p.m. with Assistant Nurse Manager (ANM) 1, ANM 1 stated the following: Patient 10 was wearing a support belt (torso belt). ANM 1 reviewed the manufacturer’s instructions for the Torso Belt, and verified the instructions indicated the belt was a restraint and required a physician’s order. Patient 10 did not have an order for use of the belt. ANM 1 said when patients are placed on restraints, the nurses should monitor patients every two (2) hours for mental status (behavioral and cognitive functioning [thinking, reasoning, remembering]), circulation (blood flow through the body), nutritional needs (food and nutrients), hydration needs (fluid intake such as water, juice, etc.), elimination needs (toileting), and range of motion (movement of limbs). ANM 1 verified Patient 10 was not monitored every two hours by a registered nurse. ANM 1 stated that CNA 1 was monitoring Patient 1’s mental status only, every two hours. During an interview on 4/17/2024 at 2:57 p.m. with Physical Therapist (PT) 1, PT 1 reviewed the Torso Belt’s manufacturer’s instructions and stated the following: The Torso Belt was used on patients for support and stability. PT 1 was not aware that the Torso belt required a physician’s order or that the belt was considered a restraint by the manufacturer. During a review of Patient 10’s History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/13/2024, the H&P indicated the following: Patient 10 was admitted to the facility for weakness and disorientation (a state of mental confusion). Patient more confused/combative than normal and was attempting to get out of bed at home. Patient 10’s diagnoses included a history of dementia (a condition characterized by progressive loss of intellectual functioning), paroxysmal atrial fibrillation (irregular, often rapid heart rate, that commonly causes poor circulation). Patient 10 is alert, awake, and oriented to self ...poor strength and tone (amount of tension or resistance to movement in muscles) in all four extremities. During a review of Patient 1’s “Physical Therapy Initial Assessment,” dated 4/13/2024 at 10:02 p.m., the Physical Therapy Initial Assessment indicated the following: “Medical diagnosis: weakness. Treating impairments/dysfunction: Impaired mobility (a disability that affects movement such as walking) ...Fall Risk (the likelihood that a person would fall due to risk factors such as impaired mobility) ...Patient 10 is able to sit at the edge of the bed ...Patient 10 is unable to maintain sitting balance without assistance ...” During a review of the manufacturer’s instructions for use titled, “Torso Belt Application Instruction,” dated 10/2023, the manufacturer’s instructions indicated the following: RX (prescription) Only ...Intended Use: Torso Belts are to be used for patients at risk of leaning and falling from chairs ...Do not use on a patient who is unwilling or unable to follow instructions, and is at risk of a fall or re-injury from self-release. Warning: Caution: Patient should be checked per facility’s policy. To guard against the formation of a decubitus ulcers, patient’s position should be changed, and patient should be re-evaluated per facility’s policy. Incorrect use of this product could result in suffocation or serious injury. Do not cut off circulation - check circulation often ...Monitor according to facility policy ...Patient Restraints: General Precautions & Warning. RX only ... Always follow your facility’s policies and procedures and regulations when restraining a patient. Important Information: Please read all instructions, precautions, and warning prior to use. Know your facility’s policies and procedures before using any product or device. Follow manufacturer’s instructions provided with the product or device. During a review of the facility’s policy and procedure (P&P) titled, “Restraint Use,” dated 9/1/2022, the P&P indicated the following: All patients have the right to be free from restraint or seclusion (involuntary confinement of a patient in a room alone from which the patient is physically prevented from leaving), or any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff ...A restraint is 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. Restraint Orders: Orders for restraint can only be obtained from physicians/licensed practitioners with privileges ...The order shall include the type of restraint to be applied and shall be based on specific behaviors that indicate the need for restraint ...Assessment, monitoring, and documentation of all restraint types: Registered nurses (RN) are responsible for assessment, monitoring and provision of care for patients in restraints ...Patients in non-behavioral restraints are monitored and assessed at least every two (2) hours or sooner ...Assessment at every two (2) hours include: Behavior/mental status; Circulation; Nutritional needs (food/meal); Hydration needs; Elimination needs; Range of Motion (ROM); restraints released and reapplied ...”

“LICENSURE OF NURSING STAFF CFR(s): 482.23(b)(2) The nursing service must have a procedure in place to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure. This Standard is not met as evidenced by: 48186 Based on interview and record review, the facility failed to ensure one of five sampled nursing staff (Registered Nurse 6 [RN 6]) had a complete departmental annual competency evaluation (assessment of a clinician’s skills, abilities and knowledge to ensure provision of safe and effective care to patients) done in accordance with the facility’s policy and procedure on competency evaluation. This deficient practice had the potential to result in patients receiving inadequate care and treatment from staff whose competencies were not completed annually. Findings: During a concurrent interview and record review on 4/18/2024 at 2:22 p.m. with Assistant Nurse Manager 2 (ANM 2), the Human Resources Consultant (HRC) and the Director of Professional Development and Education (DPDE), Registered Nurse 6’s (RN 6) personnel file was reviewed. HRC and DPDE stated the following: RN 6 was hired on 11/26/2018. RN 6’s last departmental annual competency evaluation was 8/31/2021. ANM 2 stated the following: The departmental annual competency should be completed once per year by December 31st. RN 6 was on a leave of absence from 6/28/2022 through 9/2/2022, 9/28/2022 through 11/26/2023, and 12/4/2023 through 1/6/2024. RN 6 returned to work on 1/6/2024. As of 4/18/2024, RN 6 is still catching up to complete the departmental annual skills competency and this is not completed. RN 6’s annual skills competency evaluation should have been scheduled and completed immediately when she (RN 6) returned to work from her (RN 6) leave of absence on 1/06/2024. The departmental annual evaluation is important to make sure the employee is competent with the skills they are performing. During a review of the facility’s policy and procedure (P&P) titled, “Education/Competency,” dated 11/2023, the P&P indicated the following: “Purpose: To ensure all staff are competent to fulfill their assigned job duties ... Policy: ...each employee in the Medical Center will have his/her individual performance reviewed on an annual basis utilizing all related medical center-wide competencies, in addition, each employee will have his/her performance reviewed on department-specific competencies chosen for the year ...””

“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: 48186 Based on observation, interview and record review, the facility failed to obtain a pain assessment (process where a nurse gathers, sorts and analyzes a patient’s health information) and reassessment for three of 30 sampled patients (Patient 1, 11, and 22) in accordance with the facility’s policy and procedure regarding assessment and re-assessment when: 1. Patient 1, who was in the Obstetrics Triage Unit (Unit 1, OB triage, provides immediate, specialized assessment for women at all stages of pregnancy), did not have a documented baseline pain assessment on admission or any reassessment during episodes of contractions (tightening of the uterus that provides the force to expel the fetus [unborn baby] through the birth canal). This deficient practice had the potential for Patient 1 to have unrelieved pain. Thus, negatively affecting the physical, emotional, and psychosocial (social factors of a person’s thoughts and behaviors) well-being of the patient (Patient 1). 2. Patient 11’s pain was not assessed prior to receiving pain medication (Tylenol, administered for mild pain). This deficient practice had the potential for Patient 11 to receive pain medications unnecessarily. 3. Patient 22’s pain was not addressed for more than two hours after Patient 22 reported a pain level of 10 out of 10 (a score of 0 means no pain, and 10 means the worst pain ever felt). This deficient practice resulted in the delay of appropriate pain management for Patient 22 and had the potential to cause adverse health outcomes such as worsening of pain that takes longer to relieve. Findings: 1. During an observation on 4/15/2024 at 2:27 p.m., in the Obstetrics Triage Unit (Unit 1, OB triage, provides immediate, specialized assessment [process where a nurse gathers, sorts and analyzes a patient’s health information] for women at all stages of pregnancy), nine triage bays were observed in Unit 1. There were two patients in the unit. During a concurrent interview and closed record review on 4/16/2024 at 9:48 a.m. with Labor & Delivery Manager (L&DM) and Registered Nurse (RN) 2, Patient 1’s medical record (a record of a patient’s medical information) was reviewed. RN 2 verified the following information in the medical record: Patient 1 was admitted to Unit 1 on 3/6/2024 at 9:01 p.m. with a diagnosis of pre-term labor (labor [uterine contractions] occurring between after 20 and before 37 weeks during pregnancy) with uterine contractions (the tightening and shortening of the uterine muscles). The uterine contraction intensity was every 7 minutes and moderate. RN 2 stated that moderate uterine contractions were assessed by feeling the stomach. During a concurrent interview and closed record review on 4/16/2024 at 2:17 p.m. with Registered Nurse 2 (RN 2), Clinical Informatics Specialist (CIS), and the Regional Director of Maternal Child Health (RDMCH), Patient 1’s medical record was reviewed. CIS, RN 2 and RDMCH verified the following information: Patient 1 did not have a documented pain assessment or reassessment, when admitted to Unit 1. There was only one pain assessment documented on discharge from the facility, dated 3/6/2024 at 1:34 a.m., which indicated 3/10 pain (mild pain). RDMCH stated that on admission, Patient 1 should have had an admission pain assessment to determine a baseline (a minimum or starting point used for comparisons) for pain and to provide interventions for the patient to address pain. RN 2 stated the following: Pain should have been reassessed to establish if interventions were effective. Contractions could have caused pain and discomfort, so Patient 1 should have been assessed for pain when Patient 1 had complaints of contractions. Pain reassessments were supposed to be done within one hour from the time a patient complains of pain or were medicated for pain. During an interview on 4/17/2024 at 8:53 a.m. with Registered Nurse 3 (RN 3), RN 3 stated the following: Pain is included in the Registered Nurses admission assessment, per policy. Pain is assessed with vital signs (includes temperature, heart rate, respiratory rate, blood pressure, and pain level) or when the patient states they are having pain, per unit protocol. Pain is assessed at least once unless there are abnormal vital signs. Patient 1 should have had at least one pain assessment indicating how strong uterine contractions were, to establish a baseline. The pain assessment is given numerically by the patient using a pain scale 0-10 (zero is no pain, 10 is severe pain). The pain assessment should be documented in the medical record. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 3/2023, the P&P indicated the following: “Policy Statement: The physicians and staff are committed to providing appropriate pain management that is evidence-based practice and proven to be safe and effective ... Policy: Nursing will collaborate interprofessional with the patient, physicians and other treatment team members to devise an effective patient specific pain management plan. Patients are screened, assessed and re-assessed for pain utilizing a comprehensive pain assessment based on patient condition, age, and abilities ... Procedure: Pain intensity ratings will be recorded as part of the initial admission patient assessment ... Ongoing Pain Management: Assess and re-assess all patients with pain for pain intensity, quality, location precipitating factors, and responses to interventions throughout their hospitalization. Pain will be assessed at a minimum with routine shift assessments, operative or other procedures and prior to discharge ... Adult Pain Scale: 0-10 ...” During a review of the facility’s policy and procedure (P&P) titled, “Evaluation of Obstetrical Outpatients by Registered Nurses in Triage/Labor and Delivery,” dated 11/2023, the P&P indicated the following: “Procedure: 1. Assess the following: ... g. Maternal vital signs including temperature, pulse, respiratory rate, blood pressure, pain level, and DTR’s Deep tendon reflex’s (involuntary response of muscles in response to a stimulus) (if indicated) ... Procedure- Pre-procedure: 1. Conduct initial patient assessment. 2. Reassess the patient within 1 hour if the initial assessment not definitive of labor or other indication for hospital admission. Reassessment to include the following, Fetal Heart Rate, uterine activity, vital signs, pain level. 3. Document findings on the triage assessment form ...” 2. During a review of Patient 11’s History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/15/2024, the H&P indicated the following: Patient 11 was admitted to the facility for altered level of consciousness (a change in the patient’s state of awareness [ability to relate to self and the environment] and alertness) after he (Patient 11) was found down in a parking lot. Diagnoses included stroke (a blockage of blood supply to the brain). Patient 11’s past medical history included hypertension (high blood pressure) and diabetes (high blood sugar). During a concurrent interview and record review on 4/18/2024 at 1:08 p.m. with Assistant Nurse Manager (ANM) 1, ANM 1 stated the following: ANM 1 said Patient 11 had an order to be given Tylenol for mild pain. On 4/18/2024 at 10:09 a.m., Patient 11 received Tylenol 650 milligrams (mg, a unit of measurement) by mouth. The pain intensity, location, character, or duration of the pain was not assessed prior to administering the Tylenol. This was verified by ANM 1. ANM 1 stated she (ANM 1) did not know the reason Tylenol had been given and that it (reason) should have been documented in the medical record. During a review of Patient 11’s “Medication Administration Record (MAR),” dated 4/18/2024 at 10:06 a.m., the MAR indicated Patient 11 was given Tylenol 650 mg by mouth. During a review of Patient 11’s pain assessments, dated 4/18/2024, the pain assessments indicated the following: At 4:11 a.m., pain score was 0 (no pain). At 10:45 a.m., pain score was documented as “sleeping.” During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 3/2023, the P&P indicated the following: Patients are screened, assessed and re-assessed for pain utilizing a comprehensive pain assessment based on patient condition, age, and abilities ... Assess and re-assess all patients with pain for pain intensity, quality, location, precipitating factors, and responses to interventions throughout their hospitalization.” 3. During a review of Patient 22’s medical record (MR) titled, “Emergency Department (ED, responsible for the provision of medical care to patients arriving to the hospital in need of immediate care) Service Note,” dated 4/16/2024, the MR indicated, Patient 22 presented to the ED complaining of right lower back pain and had past medical history (information about the patient’s medical, personal and family history that might be relevant to the presenting illness) of diabetes (high blood sugar), hypertension (high blood pressure), and lumbar spondylosis (a condition in which there is abnormal wear on the cartilage [connective tissue protecting the bones and joints] and bones of the back and is a common cause of chronic back pain). During a review of Patient 22’s medical record (MR) titled, “Patient Care Timeline,” dated 4/17/2024, the MR indicated, Patient 22 arrived at the Emergency Department (ED) on 4/16/2024, at 5:30 a.m., complaining of severe back pain, reporting a pain level 10/10 (a score of 0 means no pain, and 10 means the worst pain ever felt). During further review of Patient 22’s MR titled, “Patient Care Timeline,” dated 4/16/2024, the MR indicated, Patient 22 was taken to a room at 6:22 a.m. on 4/16/2024. During a review of Patient 22’s MR, titled, “Vital Signs,” dated 4/16/2024, at 7:00 a.m., Patient 22’s MR indicated, Patient 22’s pain level was recorded 10/10 on 4/16/2024, at 7:00 a.m. During a review of Patient 22’s MR titled, “Vital Signs,” dated 4/16/2024, the MR indicated, on 4/16/2024, at 8:01 a.m., Patient 22 reported pain level 10/10 again. During a review of Patient 22’s MR titled, “Patient Care Timeline,” dated 4/16/2024, the MR indicated, Patient 22 received pain managing medication, Ofirmev (acetaminophen injection used to treat mild to moderate pain) 1,000 milligrams (mg, a unit of measurement) on 4/16/2024, at 8:16 a.m. During a concurrent interview and record review on 4/18/2024, at 9:35 a.m., with Clinical Director of Emergency Department (CDED), Patient 22’s medical record titled, “Patient Care Timeline,” dated 4/16/2024, was reviewed. The MR indicated, on 4/16/2024, Patient 22 reported a pain level of 10/10 at 5:30 a.m., at 7:00 a.m., and at 8:00 a.m., but was not treated for pain until 8:16 a.m. CDED stated, per facility’s policy, nursing shall address pain in a timely manner and patients should not be waiting for pain management for a long time. CDED further said, Patient 22 reported severe pain (10/10), and nursing could escalate to obtain medication orders from the physician to initiate pain management treatment, but did not do it. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 3/2023, the P&P indicated, “Pain is subjective, and exists when the patient states he/she has pain. patient self-report of pain is the best indicator for the existence of pain and is all that is needed to initiate treatment. Nursing will collaborate with the patient and physicians to devise an effective patient specific pain management plan. Patients have the right to be treated for pain and receive treatment in a timely manner and should notify the physician if the patient has reported pain upon admission for pain management orders, if not already present on admitting orders.””

“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: 47126 Based on observation, interview and record review, the facility failed to: 1. Assess fetal (baby in the womb) heart rate and uterine contractions (the tightening and shortening of the uterine muscles) for one of 30 sampled patients (Patient 9) in accordance with the facility’s policy and procedure regarding assessment of fetal heart rate and contractions. This deficient practice had the potential for abnormalities in the baby’s heart rhythm and Patient 9’s contractions to become unidentified by staff and puts Patient 9 at risk for harm due to lack of assessment which might delay the implementation of necessary interventions needed. 2. Ensure notification of a physician and ensure documentation of physician notification regarding one of 30 sampled patient’s (Patient 24) critical serum sodium (NA, the concentration of sodium [salt] in the blood) laboratory result in accordance with the facility’s policy and procedure regarding critical results (laboratory test results that exceed established limits either high or low). This deficient practice had the potential for Patient 24’s condition to be left unaddressed leading to consequences of hypernatremia (high sodium in the body) which can lead to seizures (a sudden, uncontrolled burst of electrical activity in the brain), coma (a state of prolonged loss of consciousness), and death. 3. Ensure that a seizure precaution padding (device to prevent the patient from injuring themselves against the hard frame or side rails of the hospital bed) was applied to the lower side rails (safety devices used to prevent patients from falling out of their beds) for one of 30 sampled patients (Patient 25), in accordance with the facility’s policy and procedure regarding seizure (a sudden, uncontrolled burst of electrical activity in the brain leading to changes in movements and levels of consciousness) management. This deficient practice had the potential for Patient 25 to suffer injuries such as bruising, lacerations (cuts), or broken bones when without padded side rails for protection while having a seizure episode. 4. Ensure that one of 30 sampled patient’s (Patient 25) sequential compression device (SCD, helps to prevent blood clots from forming in the lower limbs) was turned on while applied to Patient 25’s bilateral lower extremities in accordance with a physician order for SCD and with the facility’s established protocol regarding the use of SCDs. This deficient practice had the potential for Patient 25 to develop blood clots in her (Patient 25) lower limbs causing life threatening complications such as pulmonary embolism (a sudden blockage in a lung). 5. Ensure one of 30 sampled patient’s (Patient 25) bed alarm (devices that contains sensors that trigger an alarm when the patient tries to get out of bed) was turned on and working and a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) mat (a safety pad placed on the floor beside the bed to prevent injuries resulting from falls) was placed on the floor beside the patient’s (Patient 25) bed to prevent injuries resulting from falls in accordance with the facility’s protocol regarding fall prevention. These deficient practices had the potential for Patient 25 to suffer injuries such as bruising, lacerations, and broken bones resulting from a fall. Findings: 1. During a concurrent interview and record review on 4/17/2024 at 10:12 a.m., with Regional Director for Maternal Child Health (RDMCH), the RDMCH stated the following: Patient 9 arrived at the OB (Obstetrics) triage (provides immediate, specialized assessment for women at all stages of pregnancy) on 3/26/2024 at 11:51 a.m. because Patient 9 fainted, felt dizzy, and complained of a headache. When Patient 9 arrived at the OB triage, the patients are placed on a fetal heart monitor to check the baby’s heart rate and the mother’s uterine contractions for a least 20 minutes in order to interpret the results and make an assessment of the baby’s and the mother’s condition. The assessment should be documented in the medical record. A normal interpretation of the fetal heart rate and the mother’s contractions should be documented prior to patients being discharged. The RDMHC stated that Patient 9 was placed on a fetal heart monitor on 3/26/2024 from 12:15 p.m. to 12:49 p.m. There was no evidence of an interpretation or assessment of the fetal (baby) heart rate or of the mother’s uterine contractions by a registered nurse. Patient 9 was discharged home on 3/26/2024 at 12:50 p.m. During a review of Patient 9’s History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 3/26/2024 at 12:32 p.m., the H&P indicated the following: Patient 9 felt faint feeling in bed at 9 a.m. Patient 9 with an intrauterine pregnancy (when a fertilized egg is implanted in the uterus [where an unborn baby develops and grows] and starts to develop within it) at 33 weeks and 3/7 (days). During a review of Patient 9’s “Fetal Monitoring Note,” dated 3/26/2024 from 12:15 p.m., through 12:32 p.m., the note indicated there was no assessment of the baby’s heart rate or the Patient 1’s uterine contractions. During a review of the facility’s policy and procedure (P&P) titled, “Evaluation of Obstetrical Outpatients by Registered Nurses in Triage/Labor and Delivery,” dated 3/2023, the P&P indicated the following: Assess the following: Contraction pattern including frequency, duration, and intensity of contractions; Fetal heart rate/pattern. 2. During a concurrent observation and interview on 4/17/2024, at 11:39 a.m., with the Registered Nurse (RN) 5, Patient 24 was observed in bed with his eyes closed. RN 5 stated the patient (Patient 24) was admitted for hypernatremia (high sodium [salt] in the body) and failure to thrive (when an older adult has loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). During a review of Patient 24’s “Internal Medicine History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/15/2024, the H&P indicated, Patient 24 was admitted on 4/15/2024, and “ ...presents to the hospital with 2 week history of progressively worsening generalized weakness and 2 day history of poor oral intake and increasing confusion. His wife present at bedside reports that he barely ate or drank anything yesterday ... His lab work was notable for ...serum sodium 160 ...” During a concurrent interview and record review on 4/17/2024, at 3:07 p.m., with the Nursing Manager (NM) 1, Patient 24’s laboratory results dated were reviewed: 1. April 16, 2024, at 2:54 a.m., Sodium (salt) 160 (normal is 135 to 145 milliequivalents per liter (mEq/L, concentration of a substance in a liter of fluid) 2. April 16, 2024, at 9:23 a.m., Sodium 159 During an interview with NM 1 on 4/17/2024 at 3:07 p.m., NM 1 was unable to provide documentation of the physician being notified of the critical laboratory values indicated in Patient 24’s electronic medical record. NM 1 further stated the facility’s practice is for the physician to be notified of critical laboratory results within 15 minutes of receiving the results and to document the notification to the physician in the patient’s medical record. NM 1 stated that critical laboratory results are reported to the physician by the RN to ensure interventions are ordered for the patient. During a review of the facility’s policy and procedure (P&P) titled, “Critical Results,” revised on October 2021, the P&P indicated, “ ...Responsibilities of the person receiving the critical result: ... the staff can use [Name of flowsheet] to document the receipt of such information, which includes ...Name of the Provider Notification ...Time of Provider Notification ...” Further review of the P&P indicated “ ...Definitions: 1) Critical Results: Critical laboratory values and diagnostic test results that require an immediate and/or emergent response by a physician or if the lack of intervention is likely to cause significant morbidity/mortality within 24 hours. Critical laboratory values are levels which exceed a pre-determined upper or lower limit beyond which the patient’s health is or could be significantly at risk ...” The P&P indicated critical results for sodium were less than 120 milliequivalents per liter (mEq/L- concentration of a substance in a liter of fluid) and greater than 158 mEq/L. 3. During an observation on 4/17/2024 at 11:15 a.m., in Patient 25’s room, Patient 25 was observed lying in bed with her eyes closed. All four side rails were raised with the two upper side rails padded and the lower two side rails unpadded. During a concurrent observation and interview on 4/17/2024 at 11:20 a.m. with the Registered Nurse (RN) 4, in Patient 25’s room, RN 4 verified all four side rails were raised and the two upper side rails were padded for seizure (a sudden, uncontrolled burst of electrical activity in the brain leading to changes in movements and levels of consciousness) precautions. RN 4 stated Patient 25 was admitted for breast cancer that metastasized (the spread of cancer cells from the place where they first formed to another part of the body) to the brain and seizures. RN 4 further stated the two upper side rails were padded to protect Patient 25’s head from injury during a seizure. During a concurrent interview and record review on 4/17/2024 at 3:50 p.m., with the Nursing Manager (NM) 1, Patient 25’s electronic health record flowsheet (flowsheet, a tool to help clinicians document patient data in a grid-like format) titled “Safety Interventions: Seizure Precautions,” dated 4/17/2024, was reviewed. The flowsheet indicated, on 4/17/2024 at 8:00 a.m., all four side rails were padded for safety. NM 1 stated according to facility policy, all four side rails are raised and padded for seizure precaution patients due to the patient possibly suffering injury to the upper and lower body during a seizure. During an interview on 4/18/2024 at 3:21 p.m. with the Quality Assurance Registered Nurse (QARN), the QARN stated the facility does not have a policy and procedure (P&P) for seizure precautions, but the facility follows the [Name of Publishing Company] guidelines for seizure precautions. During a review of [Name of Publishing Company] guidelines titled “Seizure Management,” revised on 12/11/2023, the guidelines indicated “ ...Patients at risk for seizures need precautionary measures to help prevent injury if a seizure occurs. Equipment ...Padding for side rails ...” During a review of Patient 25’s nursing care plan (care plan - contains relevant information about a patient’s diagnosis, the goals of treatment, and interventions to meet the goal) titled “Plan of Care Problem: Seizure, Active Management” dated 4/18/2024, the care plan indicated “ ...Goal: Absence of Seizures/Seizure Related Injury, Intervention: Prevent Seizure-Related Injury ...enclosure bed used ...” During a review of the facility’s policy and procedure (P&P) titled, “Restraint Use,” revised date on 9/1/2022, the P&P indicated, “ ...Side rails: A restraint does not include methods that protect the patient from falling out of bed. Examples include raising the side rails when a patient is ... experiencing involuntary movement ... to prevent the patient from falling out of the bed ... Patient is placed on seizure precautions and all side rails raised and padded ...” 4. During a concurrent observation and interview on 4/17/2024 at 11:20 a.m., with the Registered Nurse (RN) 4, in Patient 25’s room, the sequential compression device (SCD, helps to prevent blood clots from forming in the lower limbs) sleeves were observed applied to Patient 25’s lower limbs. However, the SCD device was unplugged from a power source. RN 4 validated the SCD was not plugged into a power source and thus was not in proper use. RN 4 stated the SCD should be turned on according to facility protocol. During a review of Patient 25’s “Internal Medicine Progress Note” (progress note) dated 3/30/2024, the progress note indicated to apply prophylaxis (intervention to prevent a future problem such as blood clots forming in lower extremities) SCDs. During a review of Patient 25’s physician’s orders dated 3/30/2024, the order indicated “ ...Apply knee length sequential compression device ...” During an interview on 4/18/2024 at 3:21 p.m. with the Quality Assurance Registered Nurse (QARN), the QARN stated the facility does not have a policy and procedure (P&P) for VTE prevention but follows the [Name of Publishing Company] guidelines for VTE prevention. During a review of [Name of Publishing Company] guidelines titled “Sequential compression therapy,” revised on 5/22/2023, the guidelines indicated “ ...This safe, effective, noninvasive therapy massages the legs in a wavelike, milking motion that promotes blood flow in the lower extremities to decrease risk of thrombosis (developing blood clots) ...Operating the system ...Plug the compression controller into the proper wall outlet. Turn on the power ...” 5.a. During a concurrent observation and interview on 4/17/2024 at 11:25 a.m., with the Registered Nurse (RN) 4 and the Charge Nurse (CN) 5, in Patient 25’s room, Patient 25 was observed lying in bed, with her eyes closed, and the hospital bed alarm (devices that contains sensors that trigger an alarm when the patient tries to get out of bed) was not engaged (turned on and working). RN 4 and CN 5 validated the bed alarm was not engaged. RN 4 stated the facility practice for fall (an unintentional event that results in the person coming to rest on the ground or another lower level) risks patients include bed alarm being engaged. During a concurrent interview and record review on 4/17/2024 at 3:50 p.m., with the Nursing Manager (NM) 1, Patient 25’s fall risk assessment (FRA, a tool a health care provider uses to check to see how likely a patient will fall) titled “Hester Davis Fall Risk Assessment,” dated 4/17/2024 at 8:30 a.m., the FRA indicated a total score of 28 (a score of 15 or greater means patient is a high risk for fall). NM 1 stated facility fall precautions include the bed alarms being engaged so the nurse will be notified that the patient is trying to get out of bed, and the nurse can intervene before the patient hurts him or herself. During a review of Patient 25’s nursing care plan (care plan, contains relevant information about a patient’s diagnosis, the goals of treatment, and interventions to meet the goal) titled, “Adult Inpatient Plan of Care,” dated 4/18/2024, the care plan indicated “ ...Problem: HD (Hester Davis) Fall Risk Goal: Patient will remain as independent as possible. Patient will have lower fall risk, lower injury risk, and remain safe from falls and injury ...Intervention: High Fall Risk Interventions ... (Scores 15 or greater) ... bed alarm/mat while in bed ...” During a review of the facility’s policy and procedure (P&P) titled “Adult Falls Prevention Policy” dated 12/19/23, the P&P indicated “ ...In-Patient Adult Units ... Scores greater than or equal to 15 High Risk: Implement ...bed/chair alarms ...” 5.b. During a concurrent observation and interview on 4/17/2024 at 11:27 a.m., with Registered Nurse (RN) 4 and Nursing Manager (NM) 2, in Patient 25’s room, two fall mats (a safety pad placed on the floor beside the bed to prevent injuries resulting from falls [an unintentional event that results in the person coming to rest on the ground or another lower level]) were leaning against the wall near the doorway. NM 2 stated facility protocol is for fall mats to be placed on the floor on one or both sides of the patient’s bed. During a concurrent interview and record review on 4/17/2024 at 3:50 p.m., with NM 1, Patient 25’s fall risk assessment (FRA - a tool a health care provider uses to check to see how likely a patient will fall) titled “[Trademarked Name] Fall Risk Assessment,” dated 4/17/2024 at 8:30 a.m., the FRA indicated a total score of 28 (A score of 15 or greater means patient is a high risk for fall). NM 1 stated facility fall precautions include placing fall mats on one or both sides of the patient’s bed to prevent further injury if the patient falls out of bed. During a review of Patient 25’s nursing care plan (care plan, contains relevant information about a patient’s diagnosis, the goals of treatment, and interventions to meet the goal) titled “Adult Inpatient Plan of Care” dated 4/18/2024, the care plan indicated “ ...Problem: [Trademarked name] Fall Risk Goal: Patient will remain as independent as possible. Patient will have lower fall risk, lower injury risk, and remain safe from falls and injury ...Intervention: High Fall Risk Interventions ... (Scores 15 or greater) ... bed alarm/mat while in bed ...place fall mats on one or both sides of the bed ...” During a review of the facility’s policy and procedure (P&P) titled, “Adult Falls Prevention Policy” dated 12/19/2023, the P&P indicated “ ...In-Patient Adult Units ... Scores greater than or equal to 15 High Risk: Implement ...placement of floor mat ...””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 47126 Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled patient’s (Patient 24) antibiotic medication (Unasyn, an intravenous [administered through the vein] antibiotic used to treat an infection) was administered in a timely manner (one hour before or one hour after scheduled time) in accordance with the facility’s policy and procedure regarding medication administration. This deficient practice resulted in the delay of treatment for Patient 24 and had the potential to cause adverse health outcomes such as recurrent infection (infections that become severe and long lasting), etc. Findings: During a concurrent observation and interview on 4/17/2024, at 11:39 a.m., with the Registered Nurse (RN) 5, Patient 24 was observed in bed with his (Patient 24) eyes closed. RN 5 stated the patient (Patient 24) was admitted for hypernatremia (high sodium in the body) and failure to thrive (when an older adult has loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). During a review of Patient 24’s “Internal Medicine History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/15/2024, the H&P indicated Patient 24 was admitted on 4/15/2024, and “ ...presents to the hospital with 2 week history of progressively worsening generalized weakness and 2 day history of poor oral intake (food and/or beverage intake that is less than established referenced standards or recommendations based on physiological needs) and increasing confusion. His (Patient 24) wife present at bedside reports that he (Patient 24) barely ate or drank anything yesterday ... His lab (Laboratory) work was notable for ... white count 18.6 (white blood cell count - values greater than 11 indicate a possible infection) ... Aspiration Pneumonia, suspected (an inflammation and infection of the lungs or large airways. Occurs when food or liquid is breathed into the airways or lungs instead of being swallowed) ... continue IV Unasyn (ampicillin-sulbactam - an antibiotic used to treat an infection) ...” During a concurrent interview and record review on 4/17/2024 at 2:35 p.m., with the Nursing Manager (NM) 1, Patient 24’s Medication Administration Report (MAR) was reviewed. The MAR indicated a physician’s order of Unasyn three grams (gm- unit of measurement) to be given intravenously (into the vein), every six hours. The MAR further indicated: 1. On 4/16/2024 at 3:07 p.m., indicated Patient 24 was administered Unasyn, three hours after the scheduled dose at 12:00 p.m. 2. On 4/17/2024 at 2:17 p.m., indicated Patient 24 was administered Unasyn, two hours after the scheduled dose at 12:00 p.m. During an interview on 4/17/2024 at 2:35 p.m. with NM 1, NM 1 stated the facility protocol was to administer medications within a one-hour window before or after the scheduled due time. NM 1 further stated medications should be administered at the scheduled time to maintain a therapeutic level in the patient’s body for the infection to not worsen. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration and Documentation,” revised on November 2023, the P&P indicated “ ...In order to be considered timely, medications are administered up to sixty (60) minutes before or after the scheduled due time ...””

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that a patient’s complete and accurate information necessary to monitor patient’s condition was documented in the patient’s medical record for one of 30 sampled patients (Patient 1). The facility failed to document the following, as appropriate: Patient 1’s gestational age (term used during pregnancy to describe how far along the pregnancy is), accurate and complete prenatal care history (medical care received during pregnancy), pain assessment upon admission to the facility, current medication updated record (medications the patient is presently taking including all prescriptions, over-the-counters, herbals and vitamin/mineral/dietary [nutritional] supplements, with each medication’s name, dosage, frequency and administered route), and discharge diagnosis (the main reason of illness or condition due to which a patient was seen) is provided in Patient 1’s “After Visit Summary” (AVS, is given to patients after medical evaluation to summarize their health and guide future care), and the record confirming all new prescriptions were transmitted to the pharmacy of choice. This deficient practice had the potential to result in poor quality of care delivered to Patient 1 due to inadequate documentation of important information necessary to guide Patient 1’s treatment plan and also had the potential to negatively affect Patient 1’s outcomes after discharge from the facility. Findings: During a review of Patient 1’s medical record (MR) titled “L&D Triage Evaluation,” dated 3/6/2024, the MR indicated, Patient 1 arrived to Labor & Delivery Triage (L&D Triage is a specialized area that involves assessing pregnant women of 20 and above weeks of gestation [pregnancy], labor condition and fetal [unborn baby] well-being and preparing tests and interventions for obstetric [relating to childbirth] problems), complaining of regular uterine contractions (tightening and shortening of the uterine muscles). The MR further indicated, primary nurse documented, “Unknown” gestational age (term used during pregnancy to describe how far along the pregnancy is) of Patient 1’s pregnancy. The MR also indicated, primary nurse documented Patient 1 does prenatal care (medical care received during pregnancy and record of, if any, complications associated with the pregnancy, medical provider’s information and address) outside of the facility, no records available, and has history of diabetes (high blood sugar) controlled with diet and Metformin (medication used to control high blood sugar). During a review of Patient 1’s medical record titled, “Medication History List,” dated 3/6/2024, the MR indicated, on 3/6/2024, the primary nurse marked as “reviewed” Patient 1’s medication record (Medications the patient is presently taking including all prescriptions, over-the-counters, herbals and vitamin/mineral/dietary [nutritional] supplements with each medication’s name, dosage, frequency and administered route), but did not document Metformin in Patient 1’s current medication list and did not indicate which medications Patient 1 was currently taking or not taking. During further review of Patient 1’s medical record (MR), no information of Patient 1’s prenatal care history (medical care received during pregnancy and record of, if any, complications associated with the pregnancy, medical provider’s information and address) was recorded in Patient 1’s medical chart. During an interview on 4/16/2024 at 9:22 a.m., with L&D manager (L&DM) and registered nurse (RN) 2, L&DM stated, if a patient is not the facility’s organization member, primary nurse should attempt to obtain medical records to establish patient’s prenatal history. Likewise, RN 2 said, primary nurse shall obtain a detailed medical history, conduct patient’s initial assessment, and document the findings in patient’s medical chart. During a concurrent interview and record review, on 4/16/2024 at 9:22 a.m., with L&DM, Patient 1’s “Prior-to-Admission (PTA) Medications” list and nursing initial assessment, dated 3/6/2024, was reviewed. The record indicated, primary nurse did not document Metformin (medication to help lower blood sugar) in Patient 1’s PTA Medication record and Patient 1’s gestational age was documented as “unknown.” L&DM stated, all current medications taken by the patient should be reviewed by the primary nurse during the initial assessment and documented in a medical record as “taking” or “not taking.” L&DM further stated, Patient 1’s gestational age should also be documented by the primary nurse, but the primary nurse did not. During a record review of Patient 1’s medical record (MR) titled, “Nursing Flowsheet (integrated tool developed to help clinicians document patient data in a grid-like format),” dated 3/6/2024, the MR indicated, primary nurse did not record Patient 1’s initial pain assessment. During an interview on 4/16/2024, at 3:40 p.m., with RN 2, RN 2 stated, initial pain assessment should be done upon admission, especially if a patient presents with contractions. In the case of Patient 1, RN 2 verified that there was no documentation of Patient 1’s initial pain assessment upon arrival to the facility. During an interview on 4/16/2024, at 3:40 p.m., with the Regional Director, Maternal/Child Health (RDMCH), RDMCH stated, primary nurse should obtain a baseline (an initial measurement of a condition that is taken at an early point and used for comparison over time to look for changes) pain assessment on admission and carry out interventions (action taken to improve the situation) based on initial findings (results). During a concurrent interview and record review on 4/17/2024, at 8:55 a.m., with Patient 1’s primary nurse, (RN 3), Patient 1’s MR titled, “Nursing Flowsheet,” dated 3/6/2024, was reviewed. RN 3 stated, Patient 1’s initial pain assessment was not documented on 3/6/2024 and RN 3 said the standard practice was to document pain assessment, but RN 3 was unsure as to why the assessment for Patient 1 was not documented and stated, that, maybe, there was no time to document. RN 3 also stated, typically, primary nurses don’t document patient’s gestational age, but primary nurses shall document patient’s medical history, prenatal care, and chart current medications and mark the medication list as “reviewed.” In the case of Patient 1, RN 3 confirmed that these information (prenatal care, current medication, marking medication list as “reviewed”) were not documented in Patient 1’s medical chart. During a review of Patient 1’s MR titled, “L&D Triage Evaluation,” dated 3/6/2024, the MR indicated, Patient 1 presented to the facility complaining of regular uterine contraction. The MR further indicated, physician documented Patient 1 was 24 weeks and 4 days pregnant with twins, as per patient report, had preterm uterine contractions (preterm uterine contractions can cause premature labor) with no evidence of preterm labor (occurs when regular contractions results in the opening of cervix [narrow end of the womb] after week 20 and before week 37 of pregnancy), and was diagnosed with bacterial vaginosis (a condition as a result of imbalance of “good” and “harmful” bacteria in a vagina, and if left untreated is associated with an increased risk of preterm labor). During further review of the MR, dated 3/6/2024, the MR indicated, physician documented the plan for Patient 1 was to be discharged home with a new prescription for an antibiotic, Flagyl (used to treat an infection) 500 milligrams (mg, measuring unit) to be taken orally, twice a day for 7 days and a follow up with primary obstetrician (a physician specializing in caring for mothers and babies during pregnancy) on 3/8/2024. The MR contained no record of how and when the new prescription for Flagyl 500 mg was sent to Patient 1’s pharmacy of choice. During a review of Patient’s 1 MR titled, “After Visit Summary,” (AVS) dated 3/6/2024-3/7/2024, the MR indicated, Patient 1’s medication list was not reviewed, no diagnosis of bacterial vaginosis was recorded, no documentation of new prescription provided to Patient 1 was documented, no instructions for a follow up with primary obstetrician in two days were documented in the AVS record or provided to Patient 1 prior to leaving the facility. During an interview on 4/16/2024 at 3:40 p.m. with the Director of Perinatal Services (DPNS), DPNS stated, all prescribed medications shall be included as provided in AVS record space for a patient’s education. During an interview on 4/17/2024 at 8:53 a.m. with Patient 1’s primary nurse (RN 3), RN 3 stated, on 3/7/2024, RN 3 provided Patient 1 with a printed copy of AVS. RN 3 stated, there was no documentation of Patient 1’s diagnosis of bacterial vaginosis in the AVS copy provided to Patient 1 but should have been documented. RN 3 said, Flagyl 500 mg (medication prescribed to Patient 1 for bacterial vaginosis) education was verbally provided to Patient 1 prior to departure, but RN 3 did not document in Patient 1’s AVS record that Patient 1 was prescribed Flagyl 500 mg for bacterial vaginosis. RN 3 further stated, per facility’s policy, physicians don’t give out physical prescriptions to patients anymore, and the physician was responsible for calling in the prescription to Patient 1’s pharmacy of choice. RN 3 also stated, RN 3 did not know if the prescription for Flagyl 500 mg was called in and to what pharmacy. During an interview on 4/17/2024 at 2:54 p.m., with the Clinical Director of Emergency Department (CDED), CDED stated, the facility’s discharge process includes providing patients with After Visit Summary (AVS) which shall indicate the reason for being seen and a diagnosis specific to patient’s condition. CDED further stated, the AVS record shall include current medications which should be reviewed prior to departure, and all new prescriptions, if ordered by physician. CDED also stated, follow up care instructions shall be recorded in the AVS and a hard copy of AVS is provided to the patient before departure. During an interview on 4/19/2024 at 8:31 a.m. with Risk and Safety Medical Director (MD2), MD 2 stated, per facility’s policy, physicians do not give physical prescriptions to patients prior to discharge. MD 2 further stated, if a patient is the facility’s organization member, all prescriptions can be routed to the facility’s pharmacy that is open 24 hours a day, but if a patient is not the facility’s organization member, new prescriptions must be called in to the pharmacy of patient’s preference. MD 2 also stated, per facility’s protocol, the expectation for all physicians, prescribing a new medication, is to document the information into the patient’s medical record, such as when and where the prescription was called to. During a concurrent interview and record review on 4/19/2024 at 8:31 a.m. with MD 2, Patient 1’s AVS record, dated 3/7/2024 was reviewed. Patient 1’s AVS record contained no information where and when was Flagyl 500 mg prescription for Patient 1 was called to. MD 2 stated, there was no documentation of Flagyl 500 mg being called in to a pharmacy and stated, the physicians are expected to document this information in patient’s medical record, but the physician who discharged Patient 1 did not. During a review of the facility’s policy and procedure (P&P) titled, “Registration/assessment/Admission for Labor and Delivery,” dated 04/2022, the P&P indicated, triage RN will be accountable to obtain patient information. The RN will record patient’s vital signs and pain level and document in electronic patient care record and will enter all information and review patient information in electronic medical record-OB Nursing Navigator: Observation. During a review of the facility’s policy and procedure (P&P) titled, “Evaluation of Obstetrical Outpatients by Registered Nurses (RNs) in Triage/Labor and Delivery,” dated 11/2023, the P&P indicated, “Evaluation of obstetrical patients by RN in the Triage/labor and Delivery units in order to facilitate appropriate disposition includes performing and documenting the following assessments: reviewing chart, including history and gestational age by assessing chief complaint including onset, duration, precipitation factors, current medications, and relevant signs and symptoms. Obstetrical history including complications of pregnancy, gravida, parity, and previous labor experience, gestational age, including last menstrual period and expected date of confinement (childbirth), maternal vital signs, including temperature, respiratory rate, blood pressure, and pain level. During a review of the facility’s policy and procedure (P&P) titled, “ Medication Reconciliation across the Continuum of Care,” dated 5/2023, the P&P indicated, “ All patients presenting for emergency care, for inpatient admission or for performance of a procedure must have a complete list of medications created as a part of the initial assessment with input from the patient/significant other. The patient’s past medical records and admission orders shall be reviewed to screen for omissions, discrepancies, and adverse drug interactions. The medication list must include the patient’s current medications, including vitamins, over-the-counter medications. Medication reconciliation must occur as soon as possible to meet patient safety standards per Medical Center policy. During a review of the facility’s policy and procedure (P&P) titled, “Medication Reconciliation across the Continuum of Care,” dated 5/2023, the P&P indicated, “Medication reconciliation must occur at the time of discharge or exit from the organization. A) A complete list of medication that the patient is to be taking following discharge shall be developed and reconciled. B) the discharge list shall include not only the medications that are prescribed at the time of discharge, but any other medications the patient will be taking, including over the counter medications, vitamins, etc. C) A copy of discharge medication list, along with the discharge instructions, must be given to the patient at the time of discharge with patient-friendly instructions. E) IF a patient is to be treated by a health care provider outside of the organization, the discharging provider/designee will print the appropriate report and if the identity of the provider is unknown, the list of medications shall be given to the patient so he/she can present it to the provider at their follow-up appointment. During a review of the facility’s policy and procedure (P&P) titled, “Medication Reconciliation across the Continuum of Care,” dated 5/2023, the P&P indicated, “ At the time of discharge, RN is responsible to ensure to confirm the correct pharmacy with the patient/family and that patient/family has all needed prescriptions and transmitted order to the pharmacy. For patients receiving care in the outpatient or emergency department setting, based within the hospital, an After Visit Summary (AVS) will be provided instead of discharge instructions. During a review of the facility’s policy and procedure (P&P) titled, “Medication Reconciliation across the Continuum of Care,” dated 5/2023, the P&P indicated, “The physician must review and sign all orders. For patients who will be using non-facility’s pharmacy to fill prescriptions, print a hard copy of the prescriptions and authorize them with signature. If the patient is being discharged home, copy Discharge Medication list from discharge summary to discharge instructions. The discharge medication list shall include not only the medications that are prescribed, but any other medications the patient will be taking, including over-the counter medications, vitamins, etc.””