Community Hospital of the Monterey Peninsula

“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: 36623 Based on observation, interview, and record review, the hospital failed to comply with the Condition of Participation: Nursing Services as evidenced by: 1. Failure to remove an empty medication bag from an infusion pump for Patient 2 (refer to A398); 2. Failure to perform vital signs hourly for Patient 4 (refer to A398); 3. Failure to reaassess pain upon discharge for Patient 5 (refer to A398); 4. Failure to ensure medication was administered in accordance with the orders of the practitioner and accepted standards of practice when Patient 1 received Levophed (a concentrated, potent drug that is administered via a continuous intravenous [IV] infusion, used to raise blood pressure in patients with severe, acute hypotension [short-term low blood pressure]) at a rate of 999 milliliters (ml, unit of measurement) per hour. This failure resulted in a medication error (refer to A405). The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment.”

“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: 36623 Based on interview and record review, the hospital failed to ensure their policy and procedures were followed for three of 30 patients (Patients 2, 4, and 5) when: 1. An empty bag of medication was left connected to an intravenous (IV, fluid or medications delivered into a vein) infusion pump for Patient 2; 2. Patient 4’s vital signs were not taken hourly; 3. Patient 5’s pain was not reassessed upon discharge. These failures had the potential to negatively impact the quality of care and services rendered to the patients. Findings: 1. During a tour of the Intensive Care Unit with the ICU Assistant Director (IAD) on 11/21/25 at 10:49 a.m., the IAD verified there was an empty bag of Vancomycin (an antibiotic) connected to an IV infusion pump that was not running for Patient 2. During a concurrent interview and record review on 11/21/25 at 10:53 a.m. with Registered Nurse (RN) A, RN A verified she was in charge of Patient 2 and Patient 2’s Physician Order for Vancomycin IV was every 12 hours. RN A also verified Vancomycin was last given on 11/20/25 at 10:35 p.m. and was stopped at 12:08 a.m. on 11/21/25. Review of the hospital’s policy and procedure, “Intravenous Infusion via the Alaris System Infusion Pump,” effective 2023 indicated, “Medications which are not in use are disconnected from the infusion pump. Medications must be discarded after 4 hours if not in use.” 2. Review of Patient 3’s Emergency Physician Note, dated 8/26/25 indicated she presented to the ED on 8/26/25 at 9:46 a.m. with chest, back, and hip pain. It indicated Patient 4 was discharged on 8/26/25 at 1:57 p.m. During an interview and concurrent record review on 11/19/25 at 1:15 p.m., the EDD verified Patient 4’s vital signs were taken on 8/26/25 at 9:47 a.m. and 1:12 p.m. The EDD stated Patient 3’s vital signs should have been done hourly. 3. Review of Patient 5’s Emergency Physician Note, dated 9/19/23 indicated she presented to the Emergency Department (ED) on 9/19/23 at 10:56 p.m. with ankle pain and leg pain. It indicated Patient 5 was discharged on 9/19/23 at 11:28 p.m. During an interview and concurrent record review on 11/19/25 at 1:15 p.m. with the ED Director (EDD), the EDD verified Patient 5’s pain was assessed on 9/19/23 at 9 p.m. and the patient’s pain rating was 7. The EDD stated there was no pain medication ordered for Patient 5. She also stated there was no documentation that Patient 5’s pain was reassessed. The EDD stated along with vital signs, pain should be reassessed on discharge, “which we did not do.” Review of the hospital’s policy, “Pain Management (General Patient Care Policy),” effective 2025 indicated for patients experiencing pain, it is managed according to the prescribed treatment plan, utilizing multi-modal pain management (different drug classes of pain medication) and non-pharmacological interventions (e.g. therapeutic music, pet therapy, relaxation). Review of the hospital’s policy, “Documentation Standards (Emergency Department),” indicated in the ED, routine vital signs for adults are every hour unless otherwise ordered.”

“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: 36623 Based on interview and record review, the facility failed to ensure medication was administered in accordance with the orders of the practitioner and accepted standards of practice for one out of 30 sampled patients (Patient 1) when Patient 1 received Levophed (a concentrated, potent drug that is administered via a continuous intravenous [IV] infusion, used to raise blood pressure in patients with severe, acute hypotension [short-term low blood pressure]) at a “significantly high dose” of 999 milliliters (ml, unit of measurement) per hour (hr) while the ordered dose was 3.75 to 18.75 ml/hr.” This failure resulted in a medication error, causing Patient 1to experience significantly elevated blood pressure and an increase in size of her cerebellar hemorrhage (bleeding in the brain) from a bleeding aneurysm (a bulging blood vessel in the brain). As a result, Patient 1 had more signs of increased pressure inside her brain on imaging studies, needed an extra-ventricular drain (a device which drains fluid to relieve pressure on the brain), and needed a larger amount of blood and necrotic (dead) tissue removed after she was transferred to a higher level of care for treatment of the aneurysm. Findings: Levophed (norepinephrine) is identified as one of the high-alert medications by the Institute for Safe Medication Practices (ISMP a nonprofit patient safety organization with recognized national expertise in medication error prevention). According to 2024 ISMP List of High-Alert Medications in Acute Care Settings, “High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients.” A review of Patient 1’s medical record indicated the patient was admitted to the hospital on 9/16/23. Patient 1 was brought to the ED (Emergency Department) by ambulance due to severe neck pain followed by headache, nausea, and vomiting and was admitted to the Intensive Care Unit (ICU, area in a hospital where specialized care is provided for critically ill patients with life-threatening conditions) on 9/16/23. A review of the radiologist’s report of a computed tomography (CT) head (a detailed, 3D X-ray that takes pictures of the brain, skull, and blood vessels from different angles) without intravenous (IV, administering fluids, nutrition, or medications into a vein) contrast (acts like a dye that temporarily highlights internal structures, helping doctors see abnormalities such as tumors or blood clots more easily) performed 9/16/23 at 1:25 p.m. indicated, “No aneurysms are identified ... Addendum There is hemorrhage seen in the right cerebellar hemisphere. Blood is present in the fourth ventricle [a specific fluid filled space inside the brain].” Review of the radiologist’s report of a CT head without IV contrast performed 9/16/23 at 7:56 p.m. indicated, “Again seen is hemorrhage in the right cerebellar hemisphere and fourth ventricle ... No change compared to earlier today. Right cerebellar fourth intraventricular hemorrhage [bleeding in the right side of the cerebellum that has extended into the fourth ventricle]. Hydrocephalus [the buildup of excess cerebrospinal fluid (CSF) in the brain’s ventricles, which increases pressure on the brain].” Review of the radiologist’s report of a CT head without IV contrast performed 9/17/23 at 5:11 a.m indicated, “When compared with previous examination, no significant change has occurred.” Review of the radiologist’s report of a MRI [magnetic resonance imaging] without IV contrast performed 9/17/23 at 10:26 a.m. indicated, “No areas of restricted diffusion are seen suggesting acute infarction ... Redemonstration of right cerebellar and 4th ventricular hemorrhage with hydrocephalus. No new acute hemorrhage identified.” Review of the radiologist’s report of a CT head without IV contrast performed 9/17/23 at 9:40 p.m. indicated, “1. Stable right cerebellar hemorrhage with developing localized mass effect [displacement of brain tissue by blood]. 2. Stable hemorrhage in the 4th ventricle.” Review of the radiologist’s report of a CT head without IV contrast performed 9/18/23 at 3:58 a.m. indicated, “1. Right cerebellar and fourth intraventicular hemorrhage. Stable. 2. Hydrocephallus. Stable.” A review of Patient 1’s physician orders indicated Norepinephrine bitartrate- NaCl [sodium chloride solution] (Levophed) 4 mg (milligram, a unit of measurement)/250 ml (milliliter, a unit of measurement) or 16 mcg (microgram, a unit of measurement)/ml infusion, dated 9/17/23. The ordered dose was from 1 to 5 mcg/min (an adjustable flow rate in amount of Levophed in mcg over a minute), which equaled an infusion rate of 3.75 to 18.75 ml/hr. The order also indicated a goal mean arterial pressure (MAP, the average blood pressure in your arteries over a full heartbeat cycle, and it tells doctors if the organs are getting enough blood flow to function properly, MAP between the range of 70 and 100 mmHg is considered normal) of greater than 65 mmHg (millimeters of mercury, a unit for measuring pressure). A review of Patient 1’s Medication Administration Record (MAR, record of medications given) on 9/17/23 indicated Patient 1’s Levophed infusion was stopped at 9/18/23 at 6:48 a.m. A review of Patient 1’s Discharge Summary, dated 9/19/25, indicated the following: “9/17: Slightly hypotensive overnight despite IV fluid bolus. Was started on low-dose Levophed, currently on 1 mcg/min ... 9/18 ... Of note, patient’s BP had been low entire admission. No evidence of hypertension ... Per ED MD 1832 9/18 [9/18/23 at 6:32 p.m.]: I was called urgently to the ICU for a CODE BLUE. I appeared ... to see [Patient 1] unresponsive with agonal breathing [abnormal breathing pattern characterized by gasping or labored breathing], diaphoretic [excessive sweating], and posturing with arms extended and wrists hyperextended ... The patient was initially hypertensive, it was realized that she was on levophed and this was adjusted to keep her permissively hypertensive but not overly hypertensive ... Per ICU MD 9/18: ‘At 6:10 PM I received a phone call notifying me that this is 57-year-old patient with hemorrhagic stroke developed a severe excruciating headache. At that time stat head CT was requested. 3 minutes later at 6:13 pm I received a second phone call notifying me that she had developed bradycardia [slow heart rate], diaphoresis, unresponsiveness; started posturing and had a “CODE BLUE” ... Patient was quickly intubated [a procedure involving inserting a tube through the mouth or nose into the airway to help with breathing] ... Following intubation she stabilized somewhat and was rushed to the scanner ...’ “ A review of Patient 1’s Code Blue Record, dated 9/18/23, indicated the patient was non-responsive at 6:10 p.m. and intubated at 6:20 p.m. It also indicated at 6:25 p.m., “XRAY being done will go to CT scan [and] continue care in ICU.” During a concurrent interview and record review of Patient 1’s medical record on 11/19/25 at 10:08 a.m. with the Interim ICU Nurse Director (IIND), the IIND explained how Levophed was inadvertently administered to Patient 1. He stated Levophed was always run via an IV infusion pump (a machine that accurately delivers a set amount of fluids, medicine, or nutrients into a person’s body through an IV line over a specific time). The IIND verified Patient 1 had an order for Levophed with an ordered dose 1 to 5 mcg/min and the ordered infusion rate of 3.75 to 18.75 ml/hr. The IIND also verified Levophed was stopped at 6:48 a.m. on 9/18/23. He stated the bag of Levophed was not disconnected from the patient. The IIND stated the Code (Emergency Response) Team was called on 9/18/23 at 6:10 p.m. (almost 12 hours after Levophed was stopped) due to Patient 1 becoming non-responsive. He stated, “The Levophed was restarted in error during the code. It was supposed to be a bolus [the administration of a single, relatively large dose of a substance] of an isotonic solution [has the same concentration of salt and other dissolved substances as the fluid inside your body’s cells].” The IIND verified there was no documented physician order for a bolus during the code for Patient 1 on 9/18/23. The IIND verified there was an order for Normal Saline infusion at 100 ml/hr through IV started on 9/18/23 at 5 p.m. The IIND also verified there was no documentation that Levophed was restarted. He stated Patient 1’s nurse probably did not trace the tubing (a safety step where a healthcare provider follows the tubing or line from the patient’s body to its origin to confirm it is connected to the right patient and the right medication). The IIND stated, “Nurses should be more cautious and must slow down and think through what they are doing.” During a concurrent interview and record review of Patient 1’s medical record on 11/21/25 at 11:13 a.m. with the ICU Assistant Director (IAD), the IAD verified Patient 1’s Physician Order for Levophed with an ordered dose 1 to 5 mcg/min and the ordered infusion rate of 3.75 to 18.75 ml/hr. The order also indicated a goal MAP of greater than 65 mmHg. The IAD stated the nurse must continue Levophed if Patient 1’s MAP was not within the goal. The IAD verified Levophed was stopped on 9/18/23 at 6:48 a.m. The IAD verified Patient 1’s MAP (MAP between the range of 70 and 100 mmHg is considered normal) trend on 9/18/23 were as follows: 6:00 a.m.: 53 mmHg 6:15 a.m.: 61 mmHg 6:30 a.m.: 59 mmHg 6:45 a.m.: 70 mmHg (Levophed was stopped at 6:48 a.m.) 7:00 a.m.: 64 mmHg 9:00 a.m.: 56 mmHg 12:00 p.m.: 63 mmHg 12:32 p.m.: 62 mmHg 2:00 p.m.: 46 mmHg 2:02 p.m.: 56 mmHg 3:00 p.m.: 49 mmHg 3:30 p.m.: 56 mmHg 4:00 p.m.: 62 mmHg 6:00 p.m.: 59 mmHg 6:10 p.m.: 123 mmHg 6:12 p.m.: 176 mmHg 6:13 p.m.: 148 mmHg 6:14 p.m. 131 mmHg The IAD verified Patient 1’s blood pressure (BP, a normal blood pressure reading is below 120/80 mmHg and greater than 90/60 mmHg) trend on 9/18/23 were as follows: 3:00 p.m.: 80/36 3:30 p.m.: 91/39 4:00 p.m.: 95/46 5:00 p.m.: 102/49 6:00 p.m.: 96/40 6:09 p.m.: 187/70 6:10 p.m.: 168/98 6:12 p.m.: 211/158 6:13 p.m.: 196/126 6:14 p.m.: 173/109 6:15 p.m.:153/100 6:17 p.m.: 144/89 6:18 p.m.: 124/85 6:19 p.m.: 162/100 6:20 p.m.: 158/105 6:21 p.m.: 159/101 6:22 p.m.: 158/103 6:24 p.m.: 154/99 6:25 p.m.: 135/94 The IAD verified Patient 1’s blood pressure and MAP started to rise from 6:09 p.m. onwards. The IAD stated Levophed should have been removed from the IV Infusion Pump after it was stopped at 6:48 a.m. on 9/18/23. The IAD verified Patient 1’s Code Notes for 9/18/23 did not indicate a physician order for a fluid bolus. During an interview on 11/21/25 at 1:30 p.m. with the Chief Compliance Officer (CCO), the CCO verified Patient 1 was transferred to a hospital with a higher level of care (receiving hospital) on 9/19/23. During a concurrent interview and record review of Patient 1’s medical record on 11/21/25 at 1:58 p.m. with the Pharmacist (PH), the PH verified Patient 1’s Physician Order for Levophed dated 9/17/23. The PH stated if Levophed was ran at 100 ml/hr it was “a significantly high dose” and probably twice the maximum dose for Levophed. According to the Prescribing Information for Levophed, revised 10/2020 indicated, “LEVOPHED is indicated to raise blood pressure in adult patients with severe, acute hypotension ... Typical maintenance intravenous dosage is 2 to 4 mcg per minute [or 7.5 to 15 ml/hour] ... Overdosage with LEVOPHED may result in headache, severe hypertension, reflex bradycardia ...” During a phone interview with Registered Nurse B (RN B) on 11/25/25 at 10:53 a.m., RN B described how she identified Levophed was inadvertently administered to Patient 1 at a high rate. RN B stated after Patient 1 had a code for unresponsiveness in the ICU on 9/18/23, she accompanied Patient 1 during patient transport to get a CT scan. RN B stated she noticed Patient 1’s Levophed connected to an IV infusion pump, which was running at a rate of 999 ml/hr (a free flow rate or unprogrammed rate). RN B also stated that was the maximum infusion rate of an infusion pump. RN B stated she stopped the infusion immediately and told Patient 1’s nurse. RN B also stated she did not inform a physician about the Levophed running at a high rate. Patient 1’s nurse was not available for interview. A review of the radiologist’s report of Patient 1’s CT Scan Head wo IV Contrast (Non-Contrast Head CT, NCHCT) performed 9/18/23 at 6:34 p.m. indicated, “There has been interval increase in size of the right cerebellar hemorrhage which now measures 4 x 3.5 x 3 cm ... Impression: 1. Interval increase in size of right cerebellar hemorrhage. 2. Interval increase in mass effect on the brainstem with effacement of the fourth ventricle and obliteration of basilar cisterns (fluid-filled spaces in the brain are flattened). 3. Increasing hydrocephalus ...” During an interview on 11/25/25 at 11:34 a.m. with Medical Doctor (MD) C, MD C stated if Levophed was ran at a high rate, it could cause worsening of an already existing intracranial hemorrhage. Review of the UpToDate (an online medical reference) article “Spontaneous intracerebral hemorrhage: Acute treatment and prognosis” (updated 6/17/25) indicated, “Uncontrolled elevations in blood pressure and blood pressure variability are risk factors for hemorrhagic expansion and poor outcome ... Severely elevated blood pressure can worsen ICH [intracerebral hemorrhage] by inciting continued or recurrent bleeding and by causing hemorrhage expansion and potentially worse outcomes ... Patients with space-occupying lesions such as acute ICH are at risk for progressive neurologic impairment from brain compression due to increased intracranial pressure (ICP). Acute ICH may lead to elevated ICP due to several mechanisms. These include: - Mass effect of the initial hematoma - Expansion or rebleeding of the ICH - Cerebral edema surrounding the hemorrhage - Hydrocephalus from ventricular outflow obstruction ... Some patients with ICH may present with clinical evidence of, or imaging features concerning for, rapidly progressive neurological impairment due to elevated ICP. For these selected patients, emergent surgical consultation is indicated to assess whether surgery may be lifesaving. Such ICH features may include: - Cerebellar hemorrhage that is either greater than 3 cm in diameter or associated with acute neurological deterioration, brainstem compression, or hydrocephalus due to ventricular obstruction. - Intraventricular hemorrhage with ventricular enlargement associated with acute neurologic deterioration ... The indications for evacuation of a cerebellar hematoma depend on the ICH size and location, the time since onset, and the clinical status of the patient. As examples, patients presenting acutely with a cerebellar hemorrhage greater than 3 cm in diameter ... and brainstem compression will typically require urgent surgical decompression of the cerebellum with craniectomy and hematoma evacuation. Some patients with smaller acute cerebellar hematomas may also warrant surgical decompression if they are deteriorating neurologically or have brainstem compression and/or hydrocephalus due to ventricular obstruction. Other patients with small, subacute cerebellar hematomas that do not exert mass effect on the brainstem may be managed medically with close monitoring. These recommendations are in broad agreement with published guidelines.” A review of a report sent by the hospital to the California Department of Public Health, dated 9/21/23 indicated, “On 9/18/23 the patient complained of severe head pain and, approximately three minutes later, the patient became unresponsive, diaphoretic, and developed agonal breathing. A Code Blue was called and the patient was intubated. No chest compressions were necessary. A repeat CT scan was performed which revealed an interval increase in size of right cerebellar hemorrhage, interval increase in mass effect on the brainstem with effacement of the fourth ventricle and obliteration of the basilar cisterns, and increasing hydrocephalus per the radiologist’s reading. It was noted after the code that the norepinephrine used to keep the patient permissively hypertensive was infusing at a higher than ordered rate.” Review of Patient 1’s “Operative Note” dated 9/19/23 at 10:25 a.m. indicated Patient 1 received a ventriculostomy (creating a hole in a cerebral ventricle for placement of an extra-ventricular drain) due to “normotensive [normal blood pressure, sic] recurrent right cerebellar hemorrhage with obstructive hydrocephalus”. A review of Patient 1’s Critical Care History and Physical (H&P) Note from the receiving hospital, dated 9/19/25, indicated the patient had NCHCT with enlarging right cerebellar Intraparenchymal Hemorrhage (IPH, bleeding directly into the tissue of the cerebellum) with hydrocephalus, which “worsened after inadvertent norepi [Levophed]” administration. Review of the radiologist report of Patient 1’s neurointerventional radiology angiogram at the receiving hospital dated 9/25/23 at 6:21 p.m. indicated, “Impression: 1. Fusiform [spindle-shaped] dissecting [tear in the artery wall] distal right AICA [anterior inferior cerebellar artery, one of the blood vessels supplying the cerebellum] aneurysm, compatible with source of patient’s right cerebellar hematoma. 2. Coil embolization of the AICA at the internal auditory canal resulting in decreased flow to the aneurysm. Slow residual supply from right SCA [superior cerebellar artery]-AICA collaterals [a secondary network of small blood vessels] with trace/trickle delayed flow to the aneurysm by case end.” A review of Patient’s 1 Discharge (DC) Summary from the receiving hospital, dated 10/9/25 indicated Patient 1 was admitted on 9/19/23 and was discharged on 10/9/23. The DC Summary also indicated: “Brief Hospital Course by Problem Patient was taken to the operating room on 9/24/23 for stated procedure: -far lateral suboccipital craniectomy [a surgical procedure where a neurosurgeon removes a section of the skull at the base of the head (craniectomy) to access the brainstem and nerves from a very specific, “far lateral” angle], partial condylectomy [a surgery where a surgeon removes only a portion of the mandibular condyle, which is the part of the jawbone that connects to the skull to form the temporomandibular joint (TMJ)], microdissection with microscope [using a microscope to cut out and collect tiny, specific parts of a specimen, such as single cells or small tissue samples], trapping of dissecting AICA [blocking the blood vessel to isolate the weakened, torn section of the anterior inferior cerebellar artery (AICA, a key blood vessel near the brainstem and cerebellum)] and clipping of ruptured AICA aneurysm [an emergency brain surgery to repair a burst balloon-like bulge (aneurysm) on the AICA], hematoma evacuation with AICA strokectomy [a surgical procedure to remove a blood clot and dead tissue from the brain, specifically in an area affected by a stroke in the AICA], ICG angiography [an eye test that uses a harmless, green fluorescent dye injected into your bloodstream to take pictures of the blood vessels in the back of your eye, specifically the layer called the choroid]... “ A review of the hospital’s policy and procedure (P&P), “Intravenous Infusion via The Alaris System Infusion Pump” effective 2023 indicated, “Medications which are not in use are disconnected from the infusion pump. Medications must be discarded after 4 hours if not in use ...” A review of the hospital’s P&P, “ICU [Intensive Care Unit] Standards of Care and Documentation Standards,” effective 2021 indicated, “The nursing staff will use barcode scanning of the patient and the medication when administering medications to patients ... Medication administration documentation should be completed as close to real time as possible.” A review of the hospital’s P&P, “The Practice of Professional Nursing (General Patient Care),” effective 2022 indicated the registered nurse accepts responsibility for implementing care as ordered by the physician. A review of the hospital’s P&P, “Medication Policy: Administration of Medication” effective 11/2020 indicated the following: “A. Medications will be administered utilizing the 5 Rights and 3 Checks process. The third check of the 5 rights is completed using the barcoding process for all inpatients ... b. 5 Rights: Healthcare practitioners are accountable for giving the right patient, the right drug, the right dose, at the right time, via the right route. c. 3 Checks: i. First Check: Validate the 5 Rights with the medication order. ii. Second Check: Validate the 5 Rights at the point of medication removal. iii. Third Check: Validate the 5 Rights at the point of administration ...” According to the Infusion Nurses Society’s (INS, an international nonprofit organization representing the specialty practice of infusion therapy) “Infusion Therapy Standards of Practice, 9th Edition” dated January/February 2024, it indicated, “Medications and infusion solutions are identified, compared against the medication order and infusion control device (if applicable), and verified by reviewing the label for the name (brand and generic), dosage and concentration, total volume, beyond-use/expiration date, route of administration, frequency, rate of administration ... Perform a cognitive review of all components of the medication assessment, including an d beyhond the medication rights (eg, appropriateness of drug, dose, route ... correct infusion is activated ...””

“CONTENT OF RECORD: CONSULTATIVE RECORDS CFR(s): 482.24(c)(4)(iii) [All records must document the following, as appropriate:] Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. This Standard is not met as evidenced by: 36623 Based on interview and record review, the facility failed to document the results of consultations (when a care provider asks a secondary care provider or specialist for advice or their opinion regarding a patient’s specific condition) by staff involved in the care of two of 30 patients (Patients 6 and 25). This failure resulted in information regarding justification of treatment or reasons to support or revise the patient’s plan of care not being available in the patients’ records. Findings: 1. Review of Patient 25’s Emergency Department (ED) Provider Notes, dated 7/20/25 indicated she presented to the emergency department on 7/20/25 with shortness of breath. The notes also indicated the plan was to admit Patient 25 to the Intensive Care Unit (ICU) and Doctor of Medicine D (MD D) has taken over her care. The notes further indicated, “I am concerned that the acuity of their condition warrants close inpatient monitoring. This may include further diagnostic tests more readily available in the inpatient setting, specialty consultation, and/or more immediate interventions that will prevent further deterioration should their condition worsen ... The patient will potentially need urgent procedural intervention by interventional radiology on-call.” Review of Patient 25’s ICU Admission H&P Note, dated 7/20/25 indicated, “I [MD D] discussed with [MD E] and [MD E] to consider thrombectomy [a medical procedure, which involves removing a blood clot (thrombus) from a blood vessel] ... However thrombectomy was felt to be challenging and [MD D] planned to do CDT [Catheter-Directed Thrombolysis, a medical procedure which involves delivering a clot-dissolving medication (thrombolytic) directly to a blood clot using a catheter (a small flexible tube) to restore blood flow] ...” There was no documentation from MD E and MD F that indicated their recommendations related to the care of the patient, decision-making for proposed treatment or justification for not performing possible interventions. Review of the hospital’s On-Call Hours, printed 7/21/25 indicated on 7/20/25, the On-Call Radiologist “Day Call” was MD E and the On-Call Radiologist “Night Call” was MD F. 2. Review of Patient 6’s ED Provider Notes, dated 9/6/24 indicated the patient presented to the ED on 9/ for left eye brow/eyelid weakness/droopiness. The notes indicated, “I [Doctor of Medicine G (MD G)] will discuss her case with [MD H] ... after discussion with neurology, we did go on to do an MRI which is otherwise unremarkable for stroke ...” During concurrent interview and record review on 11/19/25 at 1:15 p.m., the ED Director (EDD) reviewed Patient 6’s ED records. When asked who was MD H, the ED Director stated MD H was the neurologist on call. She stated MD H would be the person the ED providers would consult if there was a concern for stroke. There was no documentation from MD H that indicated their recommendations related to the care of the patient, decision-making for proposed treatment, or justification for not performing possible interventions. Review of the hospital’s policy, “Use of Specialty Back-Up Coverage,” effective 2021 indicated, “The Medical Staff, in establishing on-call specialty panels, seeks to provide medical suppport services and/or transfer arrangements that are consistent with the capablities of the Hospital and the well-being of our patients.” The policy also indicated some of the specialties on call include Critical Care/Pulmonary, Nuerosurgery/Neurology, and Radiology. Review of the hospital’s Medical Staff Rules and Regulations 2025 indicated, “A written or dictated opinion signed by the consultant must be included in the patient’s medical record within twienty-four (24) hours or less after the consultation has been performed.” It also indicated the written or dictated consultant reports must contain recommendations for treatment.”

“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: 48590 Based on interview and record review, the hospital failed to obtain an order for the use and discontinuation of the use of restraints (any manual method or device that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) for three of six patients when: 1. Patient 2 was placed in bilateral (both sides) wrist restraints without a physician order, 2. Patient 16 was kept and continued to be in an enclosure bed restraint (a hospital bed with a tent-like structure creating an enclosed space) with a 1:1 sitter (constant, one-to-one supervision by staff), and 3. Patient 18’s ankle restraints was not discontinued when no longer needed. These failures had the potential to result in an inappropriate/unnecessary and prolonged use of restraints. Findings: 1. Review of Patient 2’s medical record indicated she was admitted to the hospital on 10/31/25 for pneumonia (an infection in one or both lungs). Review of Patient 2’s restraint flowsheet, dated 11/2/25 at 12:00 a.m., indicated wrist restraints was initiated. Review of Patient 2’s physician order indicated the wrist restraint verbal order (instruction or command spoken aloud in person or by telephone by a provider) was placed on 11/2/25 at 4:11 a.m. During a concurrent interview and record review with the Intensive Care Unit Director (ICUD), on 11/12/25 at 10:42 a.m., the ICUD stated the verbal order should have been placed in the medical record prior to administration of restraint. The ICUD confirmed that the time and date of the actual application of the restraints was not accurate. 2. Review of Patient 16’s medical record indicated he was admitted to the hospital on 10/23/25 for dementia (a decline in mental abilities, severe enough to interfere with daily life). Review of Patient 16’s medical record indicated an enclosure bed restraint was ordered on 11/3/25 at 9:48 a.m. and discontinued at 11:59 p.m. on 11/4/25. A 1:1 sitter order was placed on 11/4/25 at 1:57 p.m. and discontinued on 11/8/25 at 4:10 p.m. During a concurrent interview and record review with the Assistant Director of Terrace West (ADTW), on 11/13/25 at 11:58 a.m., the restraint flowsheet from 11/4/25 at 4 p.m. until 11/5/25, indicated the enclosure bed restraint was open with 1:1 sitter. The ADTW stated that the restraint should have been discontinued if the enclosure bed restraint was open. The ADTW also stated the restraint was not in place if the enclosure bed was open and it should be discontinued. The ADTW further stated it was not documented that the restraint was discontinued. 3. Review of Patient 18’s medical record indicated he was admitted to the hospital on 10/7/25 for altered mental status (unusual changes in a person’s emotional response, thinking or behavior). During a concurrent interview and record review with the Clinical Analyst (CA) on 11/14/25 at 9:13 a.m., ankle restraints was used on Patient 18 from 10/17/25 at 8 a.m. until 10/18/25 at 4 p.m. without a physician order. The CA confirmed there was no physician order for the ankle restraints. During an interview with the Telemetry Services Director (TSD) on 11/14/25 at 9:37 a.m., the TSD stated she did not see the order for the ankle restraints. Review of the hospital’s policy and procedures (P&P), titled “Patient Restraint”, dated 2025, indicated “Restraints are applied according to an individualized, time-limited order, initiated by licensed practitioner ...Restraints are implemented in a manner that is least restrictive to the patient and are removed as soon as discontinuation criteria is met ...Verbal orders are allowed in certain situation, and the RN must enter the order promptly.” Review of the hospital’s P&P, titled “Using an Enclosure Bed”, dated 2025, indicated “Documentation ...date/time enclosure bed was initiated/discontinued ...””

“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: 48590 Based on interview and record review, the hospital failed to ensure the registered nurse evaluated the nursing care for seven of 30 patients when pain assessment and/or reassessment were not done for Patients 12, 11, 10, 17, 13, 21 and 15. This failure had the potential for patients to have continued pain and discomfort. Findings: Patient 12 was admitted to the hospital on 11/5/25 for hip fracture (a break in the thigh bone near the hip joint). During a concurrent interview and record review with the Director of Med-Surge Nursing (DMSN) on 11/13/25 at 9:55 a.m., Patient 12’s pain was assessed on 11/7/25 at 6:25 a.m., 11/9/25 at 9:42 p.m., and 11/11/25 at 10:43 p.m. prior to administration of Oxycodone (a narcotic used to treat moderate to severe pain). The DMSN confirmed there was no pain reassessment done within one hour after administration of pain medication. Patient 12’s pain was not assessed on 11/8/25 at 2:02 p.m. prior to administration of Oxycodone. The DMSN confirmed there was no pain assessment done prior to administration of pain medication. Patient 11 was admitted to the hospital on 11/6/25 for decompressive laminectomy (removal of a portion of the lower spine). During a concurrent interview and record review with the DMSN on 11/13/25 at 10:07 a.m., Patient 11’s pain was assessed on 11/8/25 at 1:21 p.m. and on 11/9/25 at 9:43 p.m. prior to administration of Hydrocodone-Acetaminophen (Norco, a controlled medication to treat moderate to severe pain). The DMSN confirmed there was no pain reassessment done within one hour after administration of pain medication to determine its effectiveness. Patient 11’s pain was not assessed on 11/10/25 at 1:58 p.m. prior to administration of Norco. The DMSN confirmed there was no pain assessment done prior to the administration of pain medication. Patient 10 was admitted to the hospital on 11/4/25 for lower extremity weakness (loss of muscle strength in the leg). During a concurrent interview and record review with the DMSN on 11/13/25 at 10:14 a.m., Patient 10’s pain was assessed on 11/4/25 at 8:55 p.m., 11/6/25 at 7:53 a.m., and on 11/6/25 at 3:25 p.m. prior to administration of Tramadol (Ultram, a narcotic used to treat moderate to severe pain). The DMSN confirmed there was no pain reassessment done within one hour after administration of pain medication. Patient 17 was admitted to the hospital on 9/29/25 for hip fracture (a break in the thigh bone near the hip joint). During a concurrent interview and record review on 11/13/25 at 2:22 p.m., with the Clinical Analyst (CA), Patient 17’s pain was not assessed on 10/7/25 at 12:31 a.m. prior to administration of Oxycodone. The CA confirmed there was no pain assessment done. Patient 13 was admitted to the hospital on 10/29/25 for pleural effusion (buildup of fluid between the lungs and chest). During a concurrent interview and record review with the DMSN on 11/13/25 at 2:31 p.m., Patient 13’s pain was assessed on 10/31/25 at 9:52 p.m. and 11/4/25 at 4:23 p.m. prior to administration of Acetaminophen (Tylenol, used to relieve mild to moderate pain). The DMSN confirmed there was no pain reassessment done within one hour after administration of pain medication. Patient 21 was admitted to the hospital on 11/8/25 for intractable pain (severe and often constant pain that is difficult to manage or relieve). During a concurrent interview and record review on 11/14/25 at 9:56 a.m., with the CA, Patient 21’s pain was assessed on 11/8/25 at 9:02 p.m. prior to administration of Hydromorphone (Dilaudid, used to treat moderate to severe pain). The CA confirmed there was no pain reassessment within one hour after administration of pain medication. Patient 21’s pain was not assessed on 11/8/25 at 10:29 p.m. and on 11/8/25 at 11:43 p.m. prior to administration of pain medication. The CA confirmed there was no pain assessment done. Patient 21’s pain was assessed on 11/11/25 at 5:05 a.m. prior to administration of Morphine (used to treat moderate to severe pain). The CA confirmed there was no pain reassessment done within one hour after administration of pain medication. Patient 15 was admitted to the hospital on 11/4/25 for small bowel obstruction (blockage in the small intestine that prevents food, fluids and gas from passing through). During a concurrent interview and record review with the DMSN on 11/13/25 at 3:24 p.m., Patient 15’s pain was assessed on 11/5/25 at 8:43 a.m. prior to administration of Acetaminophen. The DMSN confirmed there was no pain reassessment done within one hour after administration of pain medication. Patient 15’s pain was not assessed on 11/5/25 at 9:59 p.m., 11/6/25 at 10:32 a.m., 11/6/25 at 8:26 p.m., 11/7/25 at 9:12 a.m., 11/8/25 at 8:19 p.m., 11/9/25 at 10:01 a.m., and 11/9/25 at 8:58 p.m. prior to the administration of Acetaminophen. The DMSN confirmed there was no pain assessment done prior to administration of pain medication. Patient 15’s pain was not assessed prior to administration of Acetaminophen on 11/9/25 at 8:58 p.m., and no pain reassessment was conducted within one hour after administration of pain medication. The DMSN confirmed there was no pain assessment and reassessment done. During an interview on 11/14/25 at 1:31 p.m., with the Interim Accreditation Consultant (IAC), the IAC stated pain assessment prior to pain medication administration and reassessment for the effectiveness of the pain medication administered should be documented in the pain assessment flowsheet and not in the purposeful rounding flowsheet. Review of the hospital’s Policy and Procedure (P&P), titled “Pain Management”, dated 2025, indicated “A. Documentation Requirements: 1. Flowsheet - Pain Assessment (all patients) ...B. Pain Screening, Assessment, Treatment and Reassessment ...2. If pain is reported, an assessment is performed ...4. Pharmacologic interventions are reassessed to determine if the intervention was effective ...b. Pain assessment occurs 60 minutes for needed medications.””

“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: 48590 Based on interview and record review, the hospital failed to provide nursing services according to their policy and procedures for three of seven patients (Patient 2, 14 and 29) when temperature was not checked one hour post blood transfusion and no stop date/time when transfusion was completed. This failure had the potential to affect the patients’ health and safety. Findings: Review of Patient 2’s medical record indicated she was admitted to the hospital on 10/31/25 for pneumonia (an infection in one or both lungs). Review of the vital signs for transfusion order, dated 11/5/25, indicated “check the patient’s vital signs ...1-hour post-transfusion.” During a concurrent interview and record review with the Intensive Care Unit Director (ICUD), on 11/12/25 at 10:29 a.m., the ICUD confirmed the temperature in the vital signs was missing one hour after blood transfusion. The ICUD further stated it should have been done. Review of Patient 14’s medical record indicated she was admitted to the hospital on 11/8/25 for acute blood loss anemia (body does not have enough healthy red blood cells because of excessive bleeding). Review of Patient 14’s flowsheet indicated blood transfusion was started on 11/9/25 at 8:59 a.m. and at 12:16 p.m. During a concurrent interview and record review with the Director of Med-Surge Nursing (DMSN), on 11/13/25 at 2:41 p.m., the DMSN confirmed there was no stop time documented in the flowsheet. The DMSN stated there should be a stop time documented when the blood transfusion was completed. Review of Patient 29’s medical record indicated she was admitted on 10/11/25 for abdominal pain (discomfort between the chest and groin area). During a concurrent interview and record review with the Telemetry Services Director (TSD), on 11/14/25 at 1:53 p.m., blood transfusion was started on 10/12/25 at 8:43 a.m. and stopped at 3:30 p.m. on 10/12/25. The TSD stated the nurse forgot to chart. The TSD further stated there was a delay in the documentation. Review of the hospital’s policy and procedure (P&P), titled “Blood Product Administration”, dated 2023, indicated “D. Clinical Record 1. Document in blood flowsheet: d. Vital signs.””

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 32398 Based on observation, interview, and record review, the facility failed to follow it’s chosen professional organization of choice’s (i.e. the Joint Commission, a medical services accreditation organization) recommendations for surgical counts for two of four sampled patients (Patients 11and 16), when: 1. A foreign object was left in Patient 16 and, 2. Surgical staff who participated in a surgical procedure did not account for vaginal packing that was to be intentionally retained in the vaginal vault of Patient 11. These failures resulted in a second surgery to remove the retained foreign object for Patient 16 and, for in Patient 11, in retaining vaginal packing for longer than necessary, thereby putting her at risk for developing toxic shock syndrome (a condition, the likelihood of which is increased, by prolonged retention of a foreign object in the vagina) (refer to A-0951).”

“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: 32398 Based on observation, interview, and record review, the facility failed to follow it’s chosen professional organization of choice’s (i.e. the Joint Commission, a medical services accreditation organization) recommendations for surgical counts for two of four sampled patients (Patients 11and 16), when: 1. A foreign object was left in Patient 16 and, 2. Surgical staff who participated in a surgical procedure did not account for vaginal packing that was to be intentionally retained in the vaginal vault of Patient 11. These failures resulted in a second surgery to remove the retained foreign object for Patient 16 and, for in Patient 11, in retaining vaginal packing for longer than necessary, thereby putting her at risk for developing toxic shock syndrome (a condition, the likelihood of which is increased, by prolonged retention of a foreign object in the vagina). Findings: 1. Patient 16 was admitted to the general acute care hospital (GACH) with a chief complaint of neck pain. The GACH sent an email to the Department which indicated that Patient 16 presented to the operating room for an anterior cervical spine (C5-7) (refers to the front (anterior) aspect of the cervical spine, which is the neck region of the vertebral column) decompression discectomy (a surgical procedure that aims to relieve pressure on spinal nerves, often caused by a herniated disc or spinal stenosis) with fusion (fusing the adjacent vertebrae together (fusion) to stabilize the spine and relieve nerve compression) and possible posterior (the back aspect) discectomy and fusion with O arm navigation (a surgical imaging and navigation system that provides real-time, 3D images of a patient’s anatomy during surgery, particularly in spinal procedures). During an interview with the director of surgical services (DSS) on 6/2/25 at 12:35 p.m., she stated that during surgery, they used fluoroscopy, an O-arm. It is portable and surrounds patient and spins like a CT scan. During an interview with DOR (operating room director) on 6/3/25 at 10:08 a.m., she stated the distractor pins are used to hold a retractor device during anterior cervical procedures and should be removed at the end of the procedure. Generally, the pin would be sticking out, so the surgeon cannot close the operative site; however, it was possible to close Patient 16’s operative site with one pin still there. At the time during Patient 16’s procedure, the pins were not items that were counted, though sponges and needles were counted. During an interview with registered nurse A (RN A) on 6/3/25 at 10:33 a.m., she stated distractor pins are used to anchor a double retraction device, to a vertebra, to retract the tissue to allow the surgeon to visualize the vertebra. When the retraction device is removed, each pin is removed individually. The patient was larger than typical, so possibly, one of the pins was hidden by her tissue, and not removed. During an observation and interview with DSS on 6/6/25 at 10:33 a.m., she stated the part of the pin sticking out of Patient 16’s vertebra was about 2 inches to 1 ½ inches, and showed a sample of the type pin that was used from a package. During an interview with the director of risk management and compliance on 6/6/25 at 10:45 a.m., she stated, “At the time [of Patient 16’s procedure], we used the Universal Protocol through Joint Commission, for surgical counts. During a review of the Surgeon D’s (SMD) CT Cervical Spine w/o IV contrast note, it indicated the CT was ordered on 6/26/25, for follow up. The results indicated findings: metallic rod projecting from the anterior C4 vertebral body. The rod courses between the internal jugular vein and the trachea. During a review of Patient 16’s electronic record, an informed consent form, dated 6/26/25 and signed at 3:42 p.m., indicated it was for removal of surgical vertebral pin. During a review of SMD’s notes, an operative note, dated 6/26/25 at 4:19 p.m., indicated the procedure was for removal of a surgical vertebral pin. The operative note indicated anterior cervical exploration was conducted for removal of a Kaspar vertebral body distraction pin. The indication for the surgery was listed as 1 day status post complex reconstruction for severe ossification of the posterior longitudinal ligament with morbid obesity with a retained C4-5 vertebral body distraction pin. The procedure in detail indicated Patient 1 was brought to the operating room and placed under general anesthesia. The anterior neck was prepped and draped. The patient’s previous anterior cervical incision was opened and a soft tissue dissection was taken down to the spine. An easily exposed C4 vertebral body Caspar distraction pin was removed. During a review of the facility’s policy and procedure (P&P) titled, “Surgical Count and Retained Foreign Object Prevention and management (General Patient Care Policy),” effective date 2023, it indicated, “C. An instrument/surgical soft good count is indicated when ... 2. There is a possibility that an instrument/surgical soft good could be retained ... G. Inspect the integrity of all objects prior to use and immediately upon removal from the patient ... H. Every effort is made to remove all surgical/procedural items and/or device fragments.” During a review of the Association of periOperative Registered Nurses (AORN) guidelines, titled Retained Surgical Items from their website www.aornguidelines.org, it indicated ...Standard Procedure ...During the initial count and when adding items to the sterile field, count packaged items according to the number in which the item is packaged ... Instruments and Device Fragments ... account for individual pieces of assembled instruments and record these on the count sheet. Inspect instruments for all removable parts, breakage, or fragmentation immediately on the instrument’s removal from the surgical site. During a review of the Joint Commission’s publication titled, “The Joint Commission Sentinel Event Alert, Issue 51, dated October 17, 2013, it indicated, “A counting procedure should ... Include soft goods (including therapeutic packing), needles/sharps, instruments, and small miscellaneous item, and document unretrieved device fragments ... Be applicable in all settings where invasive procedures are performed ... Wound opening and closing procedures should include ... Methodical wound exploration, including visual and, whenever possible, manual examination. This can and should be done for laparoscopic procedures as well.” 2. Review of the document titled “OB Vaginal Delivery Note”, dated 1/17/25, indicated Patient 1 delivered a viable male infant. Review of the document also indicated Patient 1 sustained a vaginal laceration, which was repaired with sutures (stitches meant to close surgical wounds or incisions). Review of the document also indicated there was nothing documented about the presence of packing in the vaginal vault. During an interview with the Family birthing Center Assistant Director (FBC-AD) on 6/3/25 at 1:02 PM, the FBC-AD stated, “intentional vaginal packing would come with a note, either in the AVS or a provider note.” The FBC-AD also stated that vaginal packing is not something the providers want patients to remove on their own, and that providers would have instructions to not remove the packing until they are seen by their provider. Review of facility policy titled “Surgical Count and Retained Foreign Object Prevention and Management (General Patient Care Policy) ,” unknown revision date, indicated, “An instrument/surgical soft good count is indicated when ... The surgical wound encompasses a body cavity, such as abdomen, pelvis or chest ... There is a possibility of progressing to an open procedure or of extending an incision to allow for an instrument to be left behind ... Any retained foreign objects are recorded in the patient record, including but not limited to location of item and rationale for leaving the item in patient.” Review of “Appendix F-Family Birthing Center Vaginal Deliver Table Counts” in the above policy “Surgical Count and Retained Foreign Object Prevention and Management (General Patient Care Policy),” also indicated, “Vaginal delivery counts include but are not limited to all surgical soft goods and sharps that might be used during a vaginal delivery ... An initial count of surgical soft goods and sharps is performed during table set up ... The count is written on the designated area of the Family Birth Center (FBC) communication board in each patient room, and is documented in the FBC Delivery Record.””

“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: 46939 Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, “Pain Management (General Patient Care Policy)”, for one of 30 sampled patients (Patient 14), when staff administered a PRN (as needed) pain medication without charting a pain assessment following the indication (valid reason for using a medication) for use according to pain medication order. This failure resulted in Patient 14 to receive an unnecessary medication. Findings: During a review of Patient 14’s medical orders, dated 2/23/25, order indicated, “Oxycodone (Roxicodone) [controlled pain medication] immediate release tablet 5 mg Nasogastric [tube entering nose down the throat to the stomach-used for nutrition feeding and medications in sedated patients] Every 4 hours PRN, CPOT >2 [Critical Care Pain Observation Tool (CPOT) rates critically ill patients’ pain based on clinical observation. The possible total score ranges from 0 (no pain) to 8 (maximum pain)]”. During a review of Patient 14’s Medication Administration Record (MAR), dated 2/24/25, MAR indicated, at 1739 (5:23 pm) Patient 14 was administered “oxycodone (Roxicodone) immediate release tablet 5 mg [milligrams]”. During a concurrent interview and record review on 2/25/25, at 11:48 a.m., with Assistant Director of Float Pool (ADF), Patient 14’s “Flowsheet” dated 2/25/25 was reviewed. Patient 14’s Flowsheet indicated, a CPOT assessment was completed at 1600 (4P.M.) with a score of 0. Flowsheet indicated, no CPOT assessment was charted at time of pain medication administration (1739). Flowsheet indicated a CPOT assessment was charted at 1800 with a score of 0. ADF stated, there is no CPOT assessment at time of pain medication administration. During an interview on 2/25/25, at 2:30 p.m., with Assistant Director of Intensive Care Unit (ADI), ADI stated, their policy is, before a nurse can give a PRN pain medication, they need to complete a pain assessment. During a review of the facility P&P titled, “Pain Management (General Patient Care Policy)”, dated 2025, the P&P indicated, “1. Pain is assessed using an approved tool (Appendix A) . . . 2. If the patient has pain, the assessment tool is completed in its entirety by an RN. . . Appendix A: Scale Critical Care Pain Observation Tool CPOT”.”

“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: 46939 Based on interview and record review, the hospital failed to assess patient’s response to interventions for five of 30 sampled patients (Patient 2, Patient 3, Patient 4, Patient 8, and Patient 11) when: pain reassessments were not completed timely after administration of PRN (as needed) pain medication. This failure resulted in nursing staff being unaware of pain medication effectiveness and had the potential for Patient 2, Patient 3, Patient 4, Patient 8, and Patient 11, to have continued pain. Findings: During a review of Patient 2’s Medication Administration Record (MAR) dated, 9/12-9/14/24 MAR indicated, an order for “Acetaminophen (TYLENOL) tablet 650 mg” for mild pain, Frequency: every 4 hours PRN. MAR indicated, Tylenol was given on 9/13/24 at 0916, 09/13/24 at 1349, 9/13/24 at 2003, 9/14/24 at 0330, 9/14/24 at 0845, 9/14/24 at 1519, and 9/14/24 at 2325. During a concurrent interview and record review on 10/29/24 at 1 p.m.., with Risk Management Clinical Analyst (RMCA), Patient 2’s “Flowsheet History” (document of health record where nurses chart patients pain assessment) dated 9/12/24-9/15/24, was reviewed. Flowsheet indicated, on 9/13/24 Patient 2 was reassessed for pain score (rating of 1-10 based on severity of pain, 10 being highest pain possible) after administration at 0916, not until 1105 (1 hour and 49 minutes after). Flowsheet indicated, Patient 2 was reassessed after administration on 9/13/24 at 1349, not until 1527 ( 1 hour and 38 minutes after). ). Flowsheet indicated, Patient 2 was reassessed after administration on 9/13/24 at 2003, not until 2255 (2 hours and 52 minutes after). ). Flowsheet indicated, Patient 2 was reassessed after administration on 9/14/24 at 0330 not until 0732 (4 hours and 2 minutes after). ). Flowsheet indicated, Patient 2 was reassessed after administration on 9/14/24 at 0845 not until 1104 (2 hours and 19 minutes after). ). Flowsheet indicated, Patient 2 was reassessed after administration on 9/14/24 at 1519 not until 1843 (3 hours and 24 minutes). ). Flowsheet indicated, Patient 2 was reassessed after administration on 9/14/24 at 2325 not until 9/15/24 at 0806 (7 hours and 41 minutes after). RMCA stated, the above findings were documented as stated, in Patient 2’s health record. During a review of Patient 3’s MAR dated 10/30/24, MAR indicated an order for Dilaudid (Narcotic medication. It can treat moderate to severe pain.) 0.5 mg, every 4 hours PRN for breakthrough pain. MAR indicated, Dilaudid was given at 0532 per Patient 3’s request for 8/10 pain. During a concurrent interview and record review on 10/30/24 at 10 a.m., with RMCA, Patient 3’s “Flowsheet History” dated 10/30/24 was reviewed. Flowsheet indicated, Patient 3 received Dilaudid at 0532, and was not reassessed for pain until 0841 (3 hours and 9 minutes after). RMCA stated, there is no pain reassessment charted after 0532 administration of Dilaudid until 0841. During a review of Patient 4’s MAR dated 10/30/24, MAR indicated an order for Roxicodone (narcotic medication) 10 mg, every 4 hours PRN for pain. MAR indicated, Patient 3 was given Roxicodone on 10/30/24 at 0430. During a concurrent interview and record review on 10/30/24 at 11 a.m., with RMCA, Patient 4’s “Flowsheet History” dated 10/30/24 was reviewed. Flowsheet indicated, Patient 3 was given Roxicodone at 0430 with a pain score of 7/10. Flowsheet indicated, Patient 3 was not reassessed for the pain score until 0752 (3 hours and 22 minutes after). RMCA stated, Patient 4 was not reassessed after pain medication given at 0430 until 0752. During a review of Patient 8’s MAR dated 10/30/24, MAR indicated an order for Roxicodone 10 mg, every 4 hours PRN for pain. MAR indicated, Patient 8 was given Roxicodone on 10/30/24 at 0409. During a concurrent interview and record review on 10/30/24 at 11:24 a.m., with RMCA, Patient 8’s “Flowsheet History” dated 10/30/24 was reviewed. Flowsheet indicated, Patient 8 was given Roxicodone at 0409 and was not reassessed for pain until 0809 (4 hours later). During a review of Patient 11’s MAR dated 10/30/24, MAR indicated an order for Roxicodone 5 mg, give every 4 hours PRN for pain. MAR indicated, Patient 11 was given Roxicodone at 0421. During a concurrent interview and record review on 10/30/24 at 11:50 a.m., with RMCA, Patient 11’s “Flowsheet History” dated 10/30/24 was reviewed. Flowsheet indicated, Patient 11 was given Roxicodone at 0421 and not reassessed for pain until 0713 (2 hours and 52 minutes later). RMCA stated, Patient 11 was reassessed after the 0421 administration of pain medication at 0713. During a review of the hospitals Policy & Procedure (P&P) titled, “Pain Management”, dated 2022, the P&P indicated, “Reassessment. . .If the pain relief strategy included pharmacological agents [medications], reassessment of effect will occur within 60 minutes of medication administration”.”