Pih Health Hospital-Whittier

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 45774 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by: 1.The facility failed to develop an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for two of 32 sampled patients (Patient 7 admitted for acute pain and Patient 8 was admitted for altered mental status) for appropriate care. This deficient practice had the potential result in Patient 7 and Patient 8 not receiving the right level of care and not meeting the needs for the identified patient’s concerns. (Refer to A-0396). 2. The facility ’ s failure to: A. Ensure two of 32 sampled patients (Patients 3 and Patient 5) intravenous (IV) (administering fluids, medication and nutrients directly into the veins) dressing site was labeled with a date, time and initial written by the nurse on the patients ’ dressing per the facility policy and procedure. This deficient practice had the potential to result in Patient 3 and Patient 5 at risk for infection due to a dirty or compromised (unsafe) dressing. (Refer to A-0398). B. Document two of 32 sampled patients (Patient 6 and Patient 7) actual time for pain reassessment in medical record. This deficient practice had the potential result in Patient 6 and Patient 7 ’ s pain level was not reassessed and without time recorded when pain reassessment was done in the medical record per hospital policy. (Refer to A-0398). 3. The facility nursing staff failed to ensure correct IV (intravenous into the vein) fluid was administered not the discontinued Magnesium Sulfate (medication used for treating high blood pressure caused by pregnancy and involuntary muscle movements from temporary abnormal brain activities caused by high blood pressure) for one of 32 sampled patients (Patient 1). This deficient practice had cause Patient 1’s to receive the discontinued Magnesium Sulfate (medication for managing preeclampsia) IV instead of the new order medication Dextrose 5% Lactate Ringers (D5LR- sterile, nonpyrogenic solution used for intravenous fluid and electrolyte replenishment and caloric supply) IV and Patient 1 may potentially be at risk to experience side effect from Magnesia Sulfate including low blood pressure, muscle weakness, and drowsiness/lethargy, 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: 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: 45774 Based on observation, interview, and record review, the facility failed to follow and implement the facility’s falls prevention policy for one of 32 sampled patients (Patient 3). This deficient practice placed patients at risk for falls and injury. Findings: During a review of Patient 3 ’ s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/3/2025 at 9:29 p.m., indicated, the H&P indicated Patient 3 ’ s was admitted on 7/3/2025 due to Sepsis (a body ’ s overwhelming and life-threatening response to infection), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and diabetic foot infection (a serious complication of diabetes, often stemming from poorly managed or undetected foot ulcers). During a concurrent observation and interview on 7/8/2025 at 10:30 a.m. with Accreditation and Licensing Coordinator (AL) and Clinical Director (CD3). Patient 3 was observed with both feet were wrapped with dressing. Patient 3 did not have a fall risk wristband on neither left nor right wrist. CD3 stated that if Patient 3 is identified as a fall risk, he should have a yellow color fall risk wristband. CD3 agreed Patient 3 did not have a fall risk wristband on. CD3 further stated she needed to check on the patient ’ s record if patient is identified with fall risk. During an interview and record review on 7/8/2025 at 10:40 a.m., with AL and CD3. CD3 reviewed Patient 3 ’ s medical record at nursing station and stated that Patient 3 ’ s fall risk is identified as moderate. CD3 stated that the facility is using John Hopkins fall assessment tool (a tool used to assess a patient’s risk of falling in a healthcare setting, 0-5 is universal risk, 6-13 is moderate fall risk, and 13 and above is high fall risk). CD3 stated that this patient should have a yellow fall risk wristband and a falling star magnet post on Patient 3 ’ s door for staff to identify Patient 3 is a risk for fall. During a review of Patient 3’s “Adult Assessment Intervention” flowsheet (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 7/8/2025, at 8:15 a.m., the flowsheet indicated Patient 3 scored a 8 on the John Hopkins fall assessment tool indicated that Patient 3 is identified as moderate fall risk. During a review of the facility’s policy and procedure (P&P), titled “Falls Prevention and Management in Adult,” policy number E.87200.609, last revised date 7/1/25, indicated “Patient will be scored at one of three levels using John Hopkins Fall Assessment: universal, moderate and high ....any patient assess/reassessed to be at risk of fall shall have a basic set of interventions deployed to prevent a fall ...intervention for moderate and high risk included applied fall magnet and apply yellow fall risk wristband.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 45774 Based on interview, and record review, the facility failed to develop an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for two of 32 sampled patients (Patient 7 and Patient 8) for Patient 7 diagnosis of acute pain and Patient 8 diagnosis of altered mental status. This deficient practice had the potential result in Patient 7 and Patient 8 not receiving the right level of care and not meeting the needs for the identified patient’s concerns. Findings: During a record review of Patient 7’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/9/2025, indicated Patient 7 was admitted on 7/9/2025 with diagnosis of abdominal pain (pain at abdominal area),Choledocholithiasis (presence of gallstones within the common bile duct), and morbid obesity (a severe and dangerous level of being overweight that significantly and negatively impacts health and shortens the lifespan). During a concurrent interview and record review on 7/10/2025 at 10:10 a.m., with Clinical Director 1 (CD1). CD 1 stated there was no initial plan of care developed for Patient 7. CD1 further stated that the nurse should have developed an initial plan of care for Patient 7 for acute pain within four to five hours of admission. The primary nurse must develop a plan of care for all actual or potential patient’s needs to plan patient care and interventions toward meeting those needs. The primary nurse did not develop a plan of care, and this might potentially cause the patient to not get the appropriate care he needed. During a record review of Patient 8’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/9/2025 , indicated Patient 8 was admitted on 7/9/2025 with diagnosis of altered mental status (AMS - disruption in how the brain works that causes a change in behavior), febrile (someone is sick and running a temperature), and Tachycardia (a condition where the heart beats faster than normal, typically over 100 beats per minute). During a concurrent interview and records review on 7/10/2025 at 11:25 a.m., with CD1. CD1 stated the initial plan of care for altered mental status was not develop for Patient 8. CD1 further stated this patient was admitted last night on 7/9/25 before midnight, the primary nurse should have develop an initial plan of care for Patient 8 within four to five hours or at least within her shift. The nurse must develop a plan of care for all actual or potential patient’s needs to plan the patient care and interventions toward meeting those needs. The primary nurse did not develop one and this might potentially cause the patient to not get the appropriate care he needs. During a review of the facility’s policy and procedure (P&P) titled, Patient Plan Of Care, policy number E.87200.613, last revised date 1/24/25, indicated, “Each patient will have an individualized plan of care based on needs identified by patient ’ s assessment, reassessment, and results of diagnostic testing ....Plan of care is based on patient ’ s goals and time frames, settings, and services required to meet those goals ....Upon admission, disciplines will complete an assessment/evaluation of their patient within their scope of practice and initiate or contribute to patient ’ s individual plan of care.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 45774 Based on observation, interview and record review, the facility failed to Ensure two of 32 sampled patients (Patients 3 and Patient 5) intravenous (IV) (administering fluids, medication and nutrients directly into the veins) dressing site was labeled with a date, time and initials written by the nurse on the patients ’ dressing per the facility policy and procedure. This deficient practice had the potential to result in Patient 3 and Patient 5 at risk for infection due to a dirty or compromised (unsafe) dressing. Document two of 32 sampled patients (Patient 6 and Patient 7) actual time for pain reassessment in medical record. This deficient practice had the potential result in Patient 6 and Patient 7 ’ s pain level was not reassessed and without time recorded when pain reassessment was done in the medical record per hospital policy. Finding: 1. A. During a review of Patient 3 ’ s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/3/2025 at 9:29 p.m., indicated Patient 3was admitted on 7/3/2025 with diagnosis of sepsis (a body ’ s overwhelming and life-threatening response to infection), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and diabetic foot infection (a serious complication of diabetes, often stemming from poorly managed or undetected foot ulcers). During a concurrent observation and interview on 7/8/2025 at 10:30 a.m. with Accreditation and Licensing Coordinator (ALC) and Clinical Director (CD3), Patient 3 was observed with a peripheral intravenous (PIV) saline lock (access in a vein use to administer medication or withdraw blood) in patient ’ s left middle forearm and the PIV dressing site was observed to be blank with no date, time and nurse ’ s initials written on it. CD3 stated all nurses are expected to label the date, time and nurse ’ s initials after intravenous (IV- administering fluids, medication and nutrients directly into the veins) inserted or dressing changed. The CD3 stated without labeling the date and time, it could compromise the IV site for risk of infection. During a review of the facility’s policy and procedure (P&P) titled, Intravenous (IV) Therapy for Adult and Pediatrics-Peripheral and Central, policy number E.87200.307, last revised date 7/3/2024, indicated all IV sites will be change only as clinically warranted(required)based on integrity (strength) and patency(being open) of the site and labeled with initiation (start) date and time. B. During a review of Patient 5 ’ s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/7/2025 at 11:41 a.m., indicated Patient 5 ’ s was admitted on 7/7/2025 with diagnosis of Pneumonia (lung infection), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and end stage renal disease (ESRD, a stage where the kidneys can no longer support the body’s needs for waste removal and fluid balance). During a concurrent observation and interview on 7/8/2025 at 10:45 a.m. with Accreditation and Licensing Coordinator (ALC) and Clinical Director 1 (CD1), Patient 5 was observed with a peripheral intravenous (PIV- a thin, flexible tube inserted into a peripheral vein (like those in the hand, arm, or foot) to deliver fluids, medications, or blood products) saline lock (access in a vein use to administer medication or withdraw blood) in patient ’ s right wrist and the PIV dressing site was observed to be blank with no date, time, and nurse ’ s initials written on it. CD1 stated all nurses are expected to label with the date, time and nurse ’ s initial after IV inserted or dressing changed. The CD1 stated without labeling the date and time, it could compromise the IV site for risk of infection. During a review of the facility’s policy and procedure (P&P) titled, Intravenous (IV) Therapy for Adult and Pediatrics-Peripheral and Central, policy number E.87200.307, last revised date 7/3/2024, indicated all IV sites will be change only as clinically warranted(required)based on integrity (strength) and patency(being open) of the site and labeled with initiation (start) date and time. 2. A. During a record review of Patient 6’s “Office visit” (a physician or other qualified provider, where a patient seeks evaluation, diagnosis, treatment, or management of a specific health concern or condition),” dated 5/30/2025, indicated Patient 6 planned to schedule left robotic assisted total knee arthroplasty (a surgical procedure that uses robotic technology to enhance the precision and accuracy of knee replacement surgery). During a record review of Patient 6’s “Facesheet Report (summary of a patient ’ s information), indicated Patient 6 was admitted on 7/9/2025 at 5:27 a.m., with diagnosis of left Robotic-assisted total knee arthroplasty for surgery of degrative arthritis of left knee (a condition where the cartilage in the knee joint gradually wears away, leading to pain, stiffness, and decreased mobility). During a review of Patient 6’s “ Flowsheet” (a form in an electronic medical record that collects all the necessary data and displays it for easier review), indicated Patient 6 ’ s pain level (scale use to rate pain intensity (strength) from 0 to 10 , where 0 is no pain and 10 is worst pain) as follows: On 7/9/2025, at 11:39 p.m., Patient 6 ’ s pain level is 9 at left knee; nursing staff indicated single medication modality (method of treatment). On 7/10/2025, at 4:54 a.m., Patient 6 ’ s pain level is 7 at left knee; nursing staff indicated single medication modality. During a review of Patient 6’s medication administration record (MAR-record that document all medication given to a patient) indicated: On 7/9/2025, at 11:39 p.m., Norco 10/325 (hydrocodone and acetaminophen 10/325 milligram (mg-unit of weight), 1 tablet by mouth every 4 hours as needed (PRN) for pain were administered. On 7/10/2025, at 4:54 a.m., Norco 10/325 (hydrocodone and acetaminophen 10/325 milligram (mg), 1 tablet by mouth every 4 hours as needed (PRN) for pain were administered. During a concurrent record review and interview of the MAR on 7/10/2025 at 9:40 a.m., with Clinical Director (CD1), CD1 stated there was no pain reassessment documented within one hour after Norco 10/325 was administered on 7/9/25, at 11:39 p.m. and on 7/10/2025 at 4:54 a.m., indicated on Patient 6 ’ s medical records. CD1 further stated that the nurse did not reassess Patient 6 ’ s pain after administering pain medication within one hour after administration. During a review of the facility’s policy and procedure (P&P) titled, pain management, policy number E.87200.624, last revised date 3/28/24, indicated “reassessment after intervention for pain - If an intervention for pain is provided, response to that intervention should be assessed. Reassessment is recommended to occur within an hour following medications for treatment of pain. Documentation of this reassessment must occur at least at next routine pain assessment or prior to end of shift. Reassessment at a minimum will include intensity of pain or patient’s response to intervention. If pain was not relieved to the patient’s satisfaction, continue to treat and / or notify physician. B. During a record review of Patient 7’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/9/2025 at 3:31 a.m., indicated Patient 7 was admitted on 7/9/2025 at 3:15 a.m., with diagnosis of abdominal pain (pain at abdominal area), Choledocholithiasis (presence of gallstones within the common bile duct), and morbid obesity (a severe and dangerous level of being overweight that significantly and negatively impacts health and shortens the lifespan). During a review of Patient 7’s “ Flowsheet” (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 7/9/2025, at 8:16 a.m., indicated Patient 7 ’ s pain level was nine (9) on the abdomen; nursing staff indicated single medication modality. (method of treatment) During a review of Patient 7’s Medication Administration Record (MAR) indicated on 7/9/2025, at 8:31 a.m., Dilaudid 1 milligram (mg – unit of measurement) intravenous (IV - through the vein) was administered for pain. During a concurrent record review and interview of the MAR on 7/10/2025 at 10:10 a.m., with Clinical Director (CD1), CD1 stated there was no indication a pain reassessment was documented within 1 hour after Dilaudid 1 mg was administered on 7/9/25, at 8:31 a.m., on Patient 7 ’ s medical records. CD1 further stated the nurse only documented pain reassessment done four (4) hours after administration of pain medication on 7/9/25, at 12:31 p.m. During a review of the facility’s policy and procedure (P&P) titled, pain management, policy number E.87200.624, last revised date 3/28/24, indicated “reassessment after intervention for pain - If an intervention for pain is provided, response to that intervention should be assessed. Reassessment is recommended to occur within an hour following medications for treatment of pain. Documentation of this reassessment must occur at least at next routine pain assessment or prior to end of shift. Reassessment at a minimum will include intensity of pain or patient’s response to intervention. If pain was not relieved to the patient’s satisfaction, continue to treat and / or notify physician.”

“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: 45774 Based on interview and record review, the facility nursing staff failed to ensure correct IV (intravenous into the vein) fluid was administered not the discontinued Magnesium Sulfate (medication used for treating high blood pressure caused by pregnancy and involuntary muscle movements from temporary abnormal brain activities caused by high blood pressure) for one of 32 sampled patients (Patient 1). This deficient practice had cause Patient 1’s to receive the discontinued Magnesium Sulfate (medication for managing preeclampsia) IV instead of the new order medication Dextrose 5% Lactate Ringers (D5LR- sterile, nonpyrogenic solution used for intravenous fluid and electrolyte replenishment and caloric supply) IV and Patient 1 may potentially be at risk to experience side effect from Magnesia Sulfate including low blood pressure, muscle weakness, and drowsiness/lethargy, etc. This deficient practice had the potential to cause Patient 1 to not receive the right medication on time and potentially lead to other complications. Finding: During a record review of Patient 1’s “History & Physical” (H&P, a formal and complete assessment of the patient and the problem), dated 7/14/2024 , indicated Patient 1 was admitted on 7/14/2024 with diagnosis of labor induction (the process of artificially starting labor using medical methods, either to initiate contractions or to make them stronger) and advanced maternal age in multigravida (pregnancies in women aged 35 or older who have had at least one previous pregnancy). During a record review of Patient 1’s Intrapartum Progress note (clinical documentation used during labor and delivery to record a woman’s progress and the status of both the mother and fetus), dated 7/15/2024 at 8:04 a.m., indicated Patient 1 ’ s had severe pre-eclampsia (a pregnancy complication characterized by new-onset high blood pressure ) and Patient 1 ’ s blood pressure (BP) 142/77 was recorded on 7/14/24 at 6:58 p.m., and provider (Medical Doctor) ordered Magnesium Sulfate (is a key medication for managing preeclampsia)(high blood pressure during pregnancy) intravenous (IV) loading dose 4 grams and 1 gram per hour. During a record review of Patient 1’s Vaginal Delivery Procedure note (clinical documentation used during labor and delivery to record giving birth to a baby through the birth canal), dated 7/15/2024 at 1:20 p.m., indicated Patient 1 had delivered a baby girl with vacuum assisted during a prolonged second stage of labor, (Vacuum cup is attached to the baby ’ s head to assist with delivery) estimated blood loss 400 milliliter (ml-measurement of unit of volume) with complications of preeclampsia. During a record review of Patient 1’s Maternal Assessment/Intervention Note (clinical documentation for nursing assessment and intervention), dated 7/16/2024 at 12:42 p.m., indicated Registered Nurse (RN7) stopped Magnesium Sulfate Intravenous (IV) administration. During a record review of Patient 1’s Medication Administration Record (MAR-record that document all medication given to a patient), indicated Dextrose 5% Lactate Ringers (D5LR- sterile, nonpyrogenic solution used for intravenous fluid and electrolyte replenishment and caloric supply) IV bolus (rapid intravenous administration of a single, concentrated dose of medication or fluid directly into a vein)was started on 7/16/24 at 2:54 p.m. and ended 3:04 p.m. During a record review of Patient 1 ’ s Adult Rapid Response Team Record (a hospital- based team that provide immediate critical care to patients ’ condition is worsening), indicated on 7/16/2024 at 3:38p.m. Patient 1 complain of shortness of breath and the Rapid Response Team was called. The assessment section indicated Patient 1 was little anxious (worried), tachypneic (abnormal, rapid shallow breathing and the Magnesium infusion completed around 1:00p.m. During a concurrent record review and interview on 7/9/2025 at 11:10 a.m., with Clinical Director 4 (CD4). CD 4 stated that Patient 1 was a postpartum (period after childbirth up to six weeks) patient with severe preeclampsia and the Magnesium Sulfate usually will be continue for 24 hours after delivery. On 7/16/25, physician verbally ordered at bedside to discontinue the Magnesium Sulfate and started D5LR IV bolus. Registered Nurse (RN7) stopped Magnesium Sulfate on 7/16/24 at 12:42 p.m., however RN7 did not discarded the discontinue Magnesium Sulfate bag or the IV tubing and left the Magnesium Sulfate on the IV pump. RN7 supposed to start the D5LR on 7/16/24 at 2:54p.m., but she connected the wrong IV tubing with the Magnesium Sulfate instead of the D5LR IV bolus. The infusing Magnesium Sulfate was stopped at 3:04 p.m, 10 minutes after it was started. At 3:38p.m. on 7/16/2024, Patient 1 walked to the restroom and started to feel short of breath. CD4 stated RN7 should have discarded all discontinued medication and should not leave it in the room. CD4 stated discussed with RN7 regarding the Magnesium Sulfate bag or IV tubing left on the IV pump and connecting the wrong tubing with the Magnesium Sulfate instead of the D5LR IV bolus. During a review of the facility’s policy and procedure (P&P) titled, Medication Administration in Audits and Pediatrics”, policy number E.87200.611, last revised date 9/27/23, indicated “Prior to administration of medication, invasive lines and tubes will be traced to ensure that medication is administered via proper route.”

“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: 45774 Based on interview and record review, the facility failed ensure for one of 32 sampled patients (Patient 17), had a medical record that was accurately written regarding Patient 17 ’ s status of permacath (a thin, flexible tube inserted into a large vein, such as in the neck, guided into a central vein near the heart; also called a central line) presence. This deficient practice had the potential to result in a lack of accurate information to be utilized detailing Patient 17 ’ s care and Permacath status and presence. Findings: During a review of Patient 17 ’ s “History and Physical (H&P),” dated 3/19/2025, the H&P indicated, Patient 17 was admitted to the facility on 3/18/2025 for hyperkalemia (high potassium levels) with a past medical history of end stage renal disease (ESRD – kidney failure) on hemodialysis (a medical procedure that cleans the blood of a person whose kidneys are not functioning properly). During a concurrent interview and record review on 7/8/2025 at 3:45 PM with the Clinical Nurse Specialist (CNS 1), Patient 17 ’ s infectious disease consultation note on 3/29/2025 was reviewed. The record indicated “The patient developed purulent (containing pus; a thick yellowish or greenish opaque (cloudy) liquid produced in infected tissue) drainage (liquid waste) from his right internal (inside) jugular (of the neck and throat area) Perm-A-Cath (permacath) site on 03/21/2025. The catheter (a thin, flexible tube) has been subsequently (later) removed on 3/21/2025.” The CNS 1 stated this record indicated the Infectious Disease Medical Doctor (ID) confirmed the removal of Patient 17 ’ s infected permacath to have occurred on 3/21/2025. During a concurrent interview and record review on 7/9/2025 at 10:40 AM with the Vice President of Regulatory Affairs (VP), Patient 17 ’ s “Discharge Summary,” dated 3/30/2025 was reviewed. The record indicated on 3/22/2025, Patient 17 had “pus (a thick yellowish or greenish opaque liquid produced in infected tissue) expressing out of prior permacath site, this was removed this Thursday”. The VP stated she could not locate a note indicating who had removed Patient 17 ’ s infected permacath on the stated date to corroborate (confirm) the information from the “Discharge Summary.” The VP also stated all physicians should document any removal of any central line, such as a permacath. During a concurrent interview and record review on 7/9/2025 at 11:00 AM with the VP, Patient 17 ’ s chest x-ray, dated 3/18/2025 was reviewed. The record did not indicate or mention any permacath being present within the findings nor impression. The VP stated this record indicated that Patient 17 was not admitted to the facility with the permacath in place. During an interview on 7/9/2025 at 11:00 AM with the VP, the VP stated she understood there was a discrepancy (difference) of documentation between Patient 17 ’ s chest x-ray result from 3/18/2025, with no mention of the presence of a permacath being in place, and the infectious disease consultation note on 3/29/2025, indicating an infected permacath was removed on 3/21/2025. During a review of the facility ’ s policy and procedure (P&P) titled, “Medical Record Documentation – E.87000.708,” dated 4/4/2025, the (P&P) indicated, “Entries in the medical record will be made by health care practitioners and physicians involved in the care and treatment of the patient . . . Entries are to be factual and objective.””

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 42937 Based on interview and record review, the facility failed to arrange referral of 1 of 30 sampled patient (Patient 1) for outpatient admission to General Acute Care Hospital (GACH 2) for higher level of care, prior to discharge as per physician’s order. This deficient practice resulted to the delay of referral and care of Patient 1 to an appropriate outpatient service provider at the time of discharge. Findings: During a record review of Patient 1’s electronic medical record (EMR) and interview with the Care Management Director (CMD) on 7/9/2024 at 2:45 p.m., the DCM stated that patient 1 had a discharge order with a condition that she will be referred for outpatient admission to General Acute Care Hospital (GACH 2) prior to discharge. The case manager on-call was not made aware of the order therefore the referral was not arranged at time of discharge. Patient 1 was discharged home on 7/9/2024 at 9:05 p.m. The discharge order was written afterhours and case manager on-call rely on nursing or provider communication of any case management need. During a record review of Patient 1’s electronic medical record (EMR) and interview with the Vice President of Regulatory Affairs (VPRA) on 7/9/2024 at 3:00 p.m., the VPRA stated that the nurse should have clarified Patient 1’s discharge order with the provider. During a record review of Patient 1’s electronic medical record (EMR) and interview with the Vice President of Nursing operation (VPNO) on 7/9/2024 at 3:23 p.m., the VPNO stated that part of the discharge order was for case management to arrange outpatient admission to GACH 2. Expectation from the discharge nurse is to reach out to case management for any patient referral needs. The discharge order was written after hours, and the facility do have after hours case manager on call. For order clarification, nurse should reach out to the provider who wrote the order. There was a point of clarification to the written order, but the discharge nurse thought that the arrangement for outpatient admission to GACH 2 was already completed by case management. The patient was discharged home on 3/21/2024 at 9:05 p.m. During a record review of Patient 1’s electronic medical record (EMR) and interview with the Care Management Director (CMD) on 7/9/2024 at 4:00 p.m., the CMD stated that the discharge order indicated “Discharge pending arrangement for outpatient admission to [GACH 2] GI (Gastro-Intestinal) higher level of care.” This part of the discharge order was for case management to make every effort to arrange Patient 1’s referral to outpatient admission to GACH 2. If case management was unable to meet such orders, case management must follow up with the provider. During a record review of Patient 1’s electronic medical record (EMR) and interview with the Care Manager (CM) on 7/10/2024 at 10:38 a.m., the CM stated that her initial conversation with the provider on 3/21/2024 at 4:15 p.m. was to discharge patient home with plan for outpatient follow up. It was not a confirmed plan, there was no official discharge order at that time. Official discharge order was written on 3/21/2024 at 6:23 p.m., the order indicated discharge pending arrangement for outpatient admission to GACH 2. This was a conditional order that meant prior to discharging Patient 1, case management needs to arrange outpatient admission to GACH 2. This order was something case management will be able to do or at least make effort to initiate the referral to GACH 2. During a review of the facility’s policy and procedure (P&P) titled, “Discharge Planning” last revised March 2021, the P&P indicated the following: 1. Hospital discharge planning is a process that involves determining the appropriate post-hospital discharge destination for a patient; identifying what the patient requires for a smooth and safe transition from the hospital to his/her discharge destination; and beginning the process of meeting the patient’s identified post-discharge needs. 2. [Name of Facility] have established a policy and procedure to address the discharge planning process of patients who it determines would be at risk for adverse health consequences post-discharge without adequate discharge planning through assessment by nursing and physician. 3. The discharge planning process will include notification to the patient, family, and/or caregiver of the patient’s continuing health care needs posthospitalization and provide the patient, family and/or caregiver the opportunity to participate and ask questions during the discharge planning process.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38310 Based on observation, interview, and record review the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by: 1. The facility failed to ensure a safe environment for one of 30 sampled patients (Patient 1), in the radiology magnetic resonance imaging (MRI - noninvasive medical imaging test that produces detailed images of almost every internal structure in the human body, including the organs, bones, muscles, and blood vessels) department, outpatient building, when a MRI Technician (MRI Tech 1) wheeled a non-MRI-safe wheelchair into the MRI procedure/scanning room where metal objects were not allowed due to the magnetic field, in accordance with the facility’s policy and procedure regarding MRI Safety and Screening Policy. MRI Tech 1 lost control of the non-MRI-safe wheelchair which got drawn into the gantry (contains the main magnet and several other electromagnetic devices essential to producing images) of the MRI machine. This deficient practice resulted in injury to facility staff, who sustained bleeding in his (MRI Tech 1) neck requiring a medical screening examination in the Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care), after getting injured from the wheelchair that got sucked by the magnetic field and Patient 1, who complained of pain in her (Patient 1) head after being abruptly moved from the MRI table to the floor. The deficient practice also had the potential for serious harm including death to the patient (Patient 1) and/or staff (MRI Tech 1). (Refer to A-0144) The effect of this deficient practice resulted in the facility’s inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatment.”

“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: 38310 Based on observation, interview and record review, the facility failed to ensure a safe environment for one of 30 sampled patients (Patient 1), in the radiology magnetic resonance imaging (MRI - noninvasive medical imaging test that produces detailed images of almost every internal structure in the human body, including the organs, bones, muscles, and blood vessels) department, outpatient building, when a MRI Technician (MRI Tech 1) wheeled a non-MRI-safe wheelchair into the MRI procedure/scanning room where metal objects were not allowed due to the magnetic field, in accordance with the facility’s policy and procedure regarding MRI Safety and Screening Policy. MRI Tech 1 lost control of the non-MRI safe wheelchair which got drawn into the gantry (contains the main magnet and several other electromagnetic devices essential to producing images) of the MRI machine. This deficient practice resulted in injury to facility staff, who sustained bleeding in his (MRI Tech 1) neck requiring a medical screening examination in the Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care), after getting injured from the wheelchair that got sucked by the magnetic field and Patient 1, who complained of pain in her (Patient 1) head after being abruptly moved from the MRI table to the floor. The deficient practice also had the potential for serious harm including death to the patient (Patient 1) and/or staff (MRI Tech 1) resulting from the non-MRI-safe wheelchair sucked by the MRI magnet. On 2/8/2024, at 3:37 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the facility’s Vice President of Regulatory Affairs (VP). The facility failed to provide a safe environment for one of 30 sampled patients (Patient 1), in the radiology magnetic resonance imaging (MRI - noninvasive medical imaging test that produces detailed images of almost every internal structure in the human body, including the organs, bones, muscles, and blood vessels) department, outpatient building. On 2/6/2024, at 1:58 p.m., the Vice President of Quality Management, the Vice President of Operations, and the Radiology Manager stated an accident happened on 1/10/2024 at approximately 5 p.m., in the outpatient building, when an MRI Technician 1 (MRI Tech 1) had Patient 1 on the MRI table. The Hospital Assistant 1 (HA 1) wheeled Patient 1 (a minor) to Zone 2 (waiting and screening area) using a non-MRI safe wheelchair for the MRI procedure. The non-MRI safe wheelchair was left in Zone 2 where there were other MRI safe wheelchairs available. The HA 1 assisted the patient (Patient 1) to Zone 4 (procedure/scanning room) using the MRI safe walker and placed Patient 1 on the MRI table. To accommodate the patient’s (Patient 1) father to be present during the procedure, MRI Tech 1 brought in a non-MRI-safe wheelchair by the MRI scanning room past Zone III (Metal Detector walk area). The MRI Tech 1 then lost control of the wheelchair in his (MRI Tech 1) hands. HA1 saw the MRI Tech 1 wheeling the non-MRI safe wheelchair for Patient 1’s father and shouted “not that wheelchair” as HA 1 saw that the wheelchair was colored blue (the common metal wheelchair used by the hospital). The MRI safe wheelchairs were colored maroon. The HA 1 immediately removed Patient 1 from the table and placed Patient 1 on the floor for safety. The non-MRI safe blue colored wheelchair started to lift off the ground and got drawn into the gantry of the MRI machine. On 2/6/2024, at 1:58 p.m., the Radiology Manager stated the MRI Tech 1 brought in an unsafe equipment past the facility’s metal detector alarms in Zone III and entered the MRI scanning room (designated as Zone IV), where metal objects were not allowed to enter, with a vulnerable pediatric patient (Patient 1) positioned on the MRI table. On 2/7/2024, at 2:27 p.m., MRI Tech 1 stated he (MRI Tech 1) worked on 1/10/2024. MRI Tech 1 stated after he (MRI Tech 1) received hand-off (communication that occurs whenever the treatment team for a patient changes in which there is a transfer of patient information) from MRI Tech 2, regarding Patient 1, who was a minor and was positioned on the MRI table for a procedure with assistance from HA 1, MRI Tech 1 spoke with Patient 1, who wanted her (Patient 1) parent with her (Patient 1) during MRI scanning. Afterwards, MRI Tech 1 left the MRI scanning room and went to the waiting area (designated Zone II), where Patient 1’s parent was and proceeded to do MRI safety scan for Patient 1’s parent, in order to enter the MRI scanning room to be beside his (Patient 1’s parent) child. After MRI Tech 1 did MRI screening for Patient 1’s parent, MRI Tech 1 stated he (MRI Tech 1) entered zones III and IV with Patient 1’s parent, with a non-MRI-safe wheelchair, for the father to sit on, during MRI scanning. MRI Tech 1 stated he (MRI Tech 1) did not remember hearing the metal detector alarms go off upon entering Zone III and into Zone IV with the non-MRI safe wheelchair. Likewise, there was no documentation of Patient 1’s father’s MRI Outpatient Screening was completed. On 2/8/2024, at 11:40 a.m., the Radiology Manager stated there were environmental safeguards in place in Zone III (where metal detectors were located), prior to entrance to Zone IV (procedure/scanning room) where MRI machine was located, which had an audible alarm to warn staff of metal detection. On 2/9/2024, at 6:55 PM, IJ was removed in the presence of the Vice President of Regulatory Affairs after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record reviews. The IJ Removal Plan indicated the following: 1. Re-education of the MRI staff, revision of the MRI Screening Tool, quality control for environmental safety devices, and removal of non-MRI safe equipment in the MRI suite. 2. Verbal and written one-to-one education of MRI staff. 3. Definition of MRI zones, revised MRI Safety and Screening policy for patient and/or their support person, including documentation of MRI screening for patient and/or patient’s support person in patient’s medical record, emergency procedure during MRI scanning, and environmental checks for safety devices and for ensuring MRI safe equipment in the MRI suite. Findings: During an initial tour of the facility on 2/6/2024, at 12:40 p.m., with the Vice President of Regulatory Affairs (VPRA), the Director of Operations (Dir Ops), the Vice President of Quality Management (VPQM), and the Manager of Radiology (MRD), the MRD stated the facility’s Magnetic Resonance Imaging (MRI- noninvasive medical imaging test that produces detailed images of almost every internal structure in the human body, including the organs, bones, muscles, and blood vessels) department follows the nationally recognized guidelines of the American College of Radiology (ACR - a professional medical society representing diagnostic radiologists [involves undertaking a range of imaging procedures to obtain images of the inside of the body], radiation oncologists [specializing in cancer treatments], interventional radiologists [diagnose and treat diseases using imaging techniques], nuclear medicine physicians [uses imaging technology for better visualization of the body’s internal organs], etc.). During an interview on 2/6/2024, at 1:58 p.m., with the Manager of Radiology (MRD), in the facility’s board conference room, MRD stated an accident happened on 1/10/2024, at approximately 5 p.m., in the MRI department, outpatient building, when MRI Technologist (MRI Tech) 1 had Patient 1 on the MRI table for a scanning procedure. The hospital assistant (HA) 1 wheeled Patient 1 from the lobby into Zone 2 (waiting and screening area of the MRI suite), using a non-MRI-safe wheelchair, for the scheduled outpatient MRI procedure. The non-MRI-safe wheelchair was left in Zone 2, where there was other MRI-safe equipment available, including MRI-safe wheelchair. During the same interview on 2/6/2024, at 1:58 p.m., with the Manager of Radiology (MRD), MRD said, the HA 1 assisted Patient 1 into Zone 4 (procedure/scanning room) using the MRI-safe walker and placed Patient 1 on the MRI table. To accommodate Patient 1’s father to be present during the procedure with Patient 1, MRI Tech 1 brought in a non-MRI-safe wheelchair, for Patient 1’s father to sit on, passed Zone 3 (metal detector walk area) into Zone 4, where MRI Tech 1 then lost control of the non-MRI-safe wheelchair in his hands due to the magnetic field in the area. MRD further stated, as MRI Tech 1 was bringing in the non-MRI-safe wheelchair into Zone 4, HA 1 observed the incident and noticed the blue-colored wheelchair (common metal wheelchair used by the facility). The MRI-safe wheelchairs are maroon-colored. The HA 1 immediately removed Patient 1 off the table and abruptly placed Patient 1 on the floor. The blue-colored wheelchair (non-MRI safe) started to lift off the ground and got drawn into the gantry (contains the main magnet and several other electromagnetic devices essential to producing images) of the MRI machine. Concurrently, MRD stated, MRI Tech 1 brought in an unsafe equipment (a non-MRI-safe wheelchair) past the facility’s metal detector’s alarms, in Zone 3, and entered the MRI scanning room (Zone 4), where metal objects were not allowed to enter, with a vulnerable pediatric patient (Patient 1) positioned on the MRI table. During an interview on 2/7/2024, at 2:27 p.m., with MRI Tech 1, MRI Tech 1 stated the following: 1. He (MRI Tech 1) worked on 1/10/2024, in the MRI department, at the outpatient building. 2. He received hand-off report (communication that occurs whenever the treatment team for a patient, changes in which there is a transfer of patient information) from MRI Tech 2, regarding Patient 1, who was a child and was positioned on the MRI table for a procedure with the assistance of HA1. 3. He interviewed Patient 1, who stated she (Patient 1) wanted her father with her (Patient 1) during the MRI scanning. 4. He left the MRI scan room (Zone 4) and went into the waiting area (Zone 2) where Patient 1’s father was waiting and proceeded to do the MRI screening for Patient 1’s father, in order to allow Patient 1’s father to enter the MRI scan room (Zone 4) to be beside his (Patient 1) child. 5. He took Patient 1’s father past Zone 3 (metal detector walk area) and then to Zone 4, using a blue wheelchair (non-MRI-safe wheelchair) from the waiting area, for Patient 1’s father to sit on, during the MRI scanning procedure of Patient 1. 6. MRI scanning takes 30 minutes, and he (MRI Tech 1) did not want Patient 1’s father to have to stand the entire time. 7. He (MRI Tech 1) did not remember hearing the metal detector alarms go off upon entering Zone 3 and into Zone 4, while pushing the blue wheelchair (non-MRI-safe wheelchair). 8. After entering the MRI scan area (Zone 4) with the blue wheelchair (non-MRI-safe wheelchair), he (MRI Tech 1) felt the MRI scanner pulling on the blue wheelchair and getting stronger. 9. Blue wheelchair then lifted off the ground, left his (MRI Tech 1) hands, and flew into the gantry (contains the main magnet and several other electromagnetic devices essential to producing images) of the MRI scanner. 10. HA 1 noticed the situation, when he (MRI Tech 1) entered MRI scan room (Zone 4) and abruptly grabbed Patient 1 off the MRI table and onto the floor, like a person diving in to save the child, as the blue wheelchair lifted off the ground and was pulled off MRI Tech 1’s hands towards the gantry. 11. After the incident, he (MRI Tech 1) checked on Patient 1 and observed Patient 1 was breathing okay and had no signs of injury. 12. Patient 1 complained that her (Patient 1) head hurt. 13. He (MRI Tech 1) left the MRI scan room into the control room to call the emergency number #12999, for assistance, and returned to the scan room. 14. The emergency response team started to arrive in the MRI suite to assist and check on Patient 1. 15. He (MRI Tech 1) couldn’t remember who showed up for help. 16. Emergency response team called 9-1-1 to take Patient 1 to another facility for further evaluation and care. 17. Someone from the emergency response team instructed him (MRI Tech 1) to go to the emergency department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) to get evaluated because there was blood observed on his (MRI Tech 1) neck. Concurrently, during a review of Patient 1’s outpatient records, dated 1/10/2024, MRI Tech 1 stated there was no documentation of Patient 1’s father’s MRI Outpatient Screening being completed. During an interview on 2/7/2024, at 4:10 p.m., with Hospital Assistant (HA) 1, HA 1 stated he worked on 1/10/2024, at the MRI department outpatient building. HA 1 said he (HA 1) remembered the MRI incident. HA 1 stated the following: 1. Picked up Patient 1 from the lobby with her (Patient 1) father and observed the patient (Patient 1) dragged her leg while walking with her (Patient 1) walker. 2. Grabbed a blue wheelchair (non-MRI-safe wheelchair used throughout the facility) from the lobby and transported Patient 1 into the MRI suite. 3. Left the blue wheelchair in the waiting area (Zone 2). 4. Took patient (Patient 1) to get dressed in gown and accompanied Patient 1 into the MRI scan room (Zone 4) using a MRI-safe walker, after getting screened by MRI Tech 2 5. MRI Tech 1 arrived after meal break and received hand-off from MRI Tech 2. 6. MRI Tech 1 entered the MRI scan room and asked Patient 1, who was a minor, if she (Patient 1) wanted her father with her and Patient 1 stated she wanted her father with her (Patient 1). 7. MRI Tech 1 screened Patient 1’s father and brought the father in using a blue wheelchair (non-MRI-safe wheelchair). The purpose for bringing in the wheelchair was to have something for Patient 1’s father to sit on while waiting for Patient 1 inside the MRI scanning room since patient 1 requested for her father to be present during the procedure 8. Everyone in the MRI department knows that the blue wheelchair is not MRI-safe. 9. When he (HA 1) saw MRI Tech 1 brought in the blue wheelchair to the MRI scan room (Zone 4), while Patient 1 was on the MRI table and was getting her ear plugs and getting ready for the procedure, he (HA 1) shouted to MRI Tech 1, “NO!” but it was too late. 10. He (HA 1) saw the blue wheelchair (non-MRI-safe wheelchair) lift off the ground and take off. 11. At the same time, he (HA 1) abruptly picked up the patient (Patient 1) from the MRI table fast and put her (Patient 1) on the floor. 12. He (HA 1) felt the blue wheelchair fly into the air and into the MRI scanner where Patient 1 was moments prior to the incident. 13. Afterwards, Patient 1 complained that her (Patient 1) head was hurting after being abruptly taken off the MRI table and on to the floor while the non-MRI-safe wheelchair was being pulled by the magnetic field into the MRI scanner. 14. Emergency team was called and arrived to assist with Patient 1. During an interview on 2/8/2024, at 11:40 a.m., with the Manager of Radiology (MRD), MRD stated there were environmental safeguards in place in Zone 3 (metal detector walk area), prior to entrance of Zone 4 (procedure/scanning room), where the MRI machine was located, which had an audible alarm to warn others of metal detection. During a concurrent interview and record review on 2/8/2024, at 11:40 a.m., with the Manager of Radiology (MRD), the facility’s MRI System Quality Assurance (a systematic continuous process, used to determine if MRI equipment meets quality standards) policy, dated 3/31/2023, was reviewed. MRD stated there was no documentation for quality control (QC - how a company measures product quality) by MRI Technologists prior to each use of the MRI machine. During a review of Patient 1’s face sheet (a document that gives a patient’s information at a quick glance), dated 1/10/2024, the face sheet indicated the following: 1. Dependent minor (Patient 1) 2. Patient’s (Patient 1) reason for visit was low back pain. During a review of Patient 1’s history and physical (H&P - the most formal and complete assessment of the patient and the problem), dated 1/8/2024, the H&P indicated the following: 1. History - 11-year-old who had severe pain in the lower back and radiating down the left leg 2. Patient (Patient 1) reported constant and sharp pain that worsened with prolonged walking and standing, bending, stooping, lifting, and twisting. 3. Plan for MRI and for patient (Patient 1) to walk with the use of a walker and to limit physical activities. During a review of Patient 1’s physician notes - Code Blue (used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention), dated 1/10/2024, the physician notes indicated the following: 1. Responded to Code Blue in MRI department at the outpatient building. 2. Patient (Patient 1) was on the ground, awake and alert. 3. There was no cardiopulmonary arrest (sudden unexpected loss of heart function, breathing, and consciousness). 4. Was informed that a wheelchair (non-MRI-safe wheelchair) was magnetically attracted to the MRI machine and was drawn into the gantry. 5. Patient (Patient 1) fell to the ground from the MRI table. 6. Patient (Patient 1) had no gross visible (visible to the naked eye) traumatic head injuries and recommended c-spine (cervical spine- neck region of the spinal column or backbone) immobilization (used to prevent further injury to the spinal column). 7. Patient (Patient 1) appeared hemodynamically stable (blood pressure and heart rate are stable) and grossly neurologically intact (no problem with brain function that can be found on a physical exam). 8. Paramedics were called and were on the way to have patient (Patient 1) transported for further evaluation. During a review of the facility’s policy and procedure (P&P) titled, Patient Rights and Responsibilities, dated 8/19/2019, the P&P indicated the following: 1...the right to receive care in a safe setting... During a review of the facility’s document titled, Metal Detector’s manufacturer’s instructions for use, dated 2023, the document indicated the following: 1. Metal detector is a ferromagnetic (materials that are noticeably attracted to a magnet) detection system designed to be placed immediately outside the MRI entryway door (Zone IV entrance). 2. Metal detector device that warns trained staff whether potentially dangerous ferromagnetic objects, that could become projectiles and cause physical harm, are approaching the MRI room. 3. Metal detector device is used to augment MRI facilities of existing safety practices. 4. Final objective safety check immediately prior to the MRI room. 5. Device is not a replacement for any aspect of existing safety protocols and methods. 6. The audible alarm is triggered when a ferrous object is being detected. 7. The primary alert is using a visual early warning to alert users to the presence of potentially dangerous ferromagnetic material, in advance of the sensor units. The safe response to observing the visual indication, while approaching the MRI door is to stop, think and check before proceeding into the MRI room. 8. The secondary alert method is audible with an audible alarm triggered only if the primary alert is ignored and the object passes between the two sensor units. 9. The combination of visual and audible alerts is designed to allow staff and healthcare workers to undertake their duties without disruption. 10. The safe response to hearing an audible indication as one passes through the metal detector system, is to stop, retreat away from the door, think and check before proceeding into the MRI room. During a review of facility’s policy and procedure (P&P) titled, MRI Safety Zone Definitions and Access policy, dated 8/13/22, the P&P indicated the following: 1. Zone I (1) - public areas including hallway adjacent to MRI suite. 2. Zone II (2) - holding area upon entry to MRI suite, where exam preparation occurs, including MRI safety screening, medical history, and patient gowning. 3. Zone III (3) - designated space inside holding area immediately outside the threshold to Zone IV of screened MRI patients and hospital personnel with Level 2 MRI staff and technologist control room. 4. Zone IV (4) - MRI scanner room with persons after screened must remain supervised by Level 2 MRI staff with posted signage warning of potential dangers and indicating, “The Magnet is On.” During a review of facility’s policy and procedure (P&P) titled, MRI System Quality Assurance policy, dated 3/31/2023, the P&P indicated the following: 1. MR system and/or other applicable medical equipment is to be maintained by authorized personnel. 2. Facility will adhere to all manufacturer’s specifications and government regulations. 3. Quality Control (QC) shall be performed by MRI technologist, prior to each use. 4. QC testing involving use of imaging phantom will occur weekly with records maintained by staff. 5. Preventative maintenance of equipment (PM - the regular and routine maintenance of equipment and assets to keep them running and prevent any costly unplanned downtown from unexpected equipment failure) will be performed, as outlined by manufacturer, and will be done by contracted service provider. 6. Physiological monitors and gating equipment will undergo PM annually with Biomedical department responsible for maintaining inventory list and schedule of maintenance intervals. During a review of the facility’s policy and procedure (P&P) titled, MRI Safety and Screening policy, dated 9/28/2023, the P&P indicated the following: 1. Purpose is to ensure safety and to establish procedures for screening patients, medical personnel, and anyone entering MRI examination room and/or exposed to magnetic field. 2. All patients, medical staff, and other individuals must be screened by authorized MRI personnel before entering Zones III and IV of the MRI suites. 3. MRI technologist must screen all equipment or materials before placing them inside Zone IV. 4. Inpatients will have MRI Screening completed by a Registered Nurse (RN) along with the patient and/or family member, prior to being transferred to MRI department. Afterwards, the MRI technologist will check the patient’s medical records for completion of the screening tool. Then the radiology transporter will transport the patient off the unit into the MRI department. Upon arrival to the MRI suite in Zone II, MR technologist will review screening tool. After initial safety screening is completed, patient will be screened by the MR technologist using a metal detection device, prior to patient entering Zone IV, or transferred to an MR conditional gurney or wheelchair for a 2-person visual screening, prior to entering Zone IV. 5. Outpatients will be given an Outpatient MRI Screening tool upon arrival to reception area. Outpatient will be taken to MRI suite, by Hospital Assistant (HA) or Radiology Transporter, to Zone II. In Zone II, MR technologist will review outpatient’s screening tool. Afterwards, outpatient will be screened by MR technologist using a metal detection device, prior to patient proceeding into Zone IV, or will be transported to MR safe gurney or wheelchair for a 2-person visual screening, prior to patient proceeding into Zone IV. 6. All persons who enter Zones III or IV will be informed of the potential risk when placed in proximity and/or inside the static magnetic field. 7. All MR staff shall be instructed on importance of carefully screening all persons, equipment, and materials place inside examination room.”

“PERIODIC EQUIPMENT MAINTENANCE CFR(s): 482.26(b)(2) Periodic inspection of equipment must be made and hazards identified must be promptly corrected. This Standard is not met as evidenced by: 42937 Based on observation, interview and record review, the facility failed to ensure there was preventive maintenance or quality control performed to ensure safe equipment use for one of one sampled medical equipment (non-MRI-safe wheelchair) in the MRI equipment room of the radiology magnetic resonance imaging (MRI - noninvasive medical imaging test that produces detailed images of almost every internal structure in the human body, including the organs, bones, muscles, and blood vessels) department, outpatient building in accordance with the facility’s policy regarding equipment inspection and maintenance in the MRI department. This deficient practice had the potential to result in patient or staff injury when a broken wheelchair or a non-MRI-safe wheelchair was used in the MRI department. Findings: During a concurrent observation and interview on 2/6/2024, at 12:53 p.m., with the Manager of Radiology (MRD), it was observed that (1) broken non-MRI-safe wheelchair was left inside the MRI equipment room in the radiology MRI department. MRD stated MRI staff was responsible in identifying and tagging broken equipment in the MRI department. MRD said the staff should also put in a work order request to have the facilities department people remove the broken equipment. MRD concurred that there was no tag indicating a broken equipment and MRD was not sure if a work order was placed to have the broken non-MRI-safe wheelchair removed from the MRI equipment room. MRD further said that the non-MRI-safe wheelchair had been in the equipment room since 1/10/2024, when it was damaged when MRI Tech 1 brought the non-MRI-safe wheelchair inside the procedure/scanning room (Zone 4), which had the magnetic field. Thus, the non-MRI-safe wheelchair was drawn into the gantry (contains the main magnet and several other electromagnetic devices essential to producing images) of the MRI machine. During a concurrent interview and record review on 2/8/2024, at 11:10 a.m., with the Manager of Radiology, the facility’s MRI System Quality Assurance (a systematic continuous process, used to determine if MRI equipment meets quality standards) policy, dated 3/31/2023, was reviewed. MRD stated that the facility had a Medical Safety Officer overseeing the facility’s operation safety but had no dedicated MRI Safety officer, the facility was working on creating a MRI Safety Committee to improve MRI related safety practices. MRD further said the Radiology leadership team had oversight on MRI safety practices. Likewise, MRD stated there was no documentation for quality control (QC - how a company measures product quality) by MRI Technologists prior to each use of the MRI machine. During a review of the facility’s policy and procedure (P&P) titled, MRI System Quality Assurance policy, dated 3/31/2023, the P&P indicated the following: 1. MRI system and/or other applicable medical equipment is to be maintained by authorized personnel. 2. Facility will adhere to all manufacturer’s specifications and government regulations. 3. Quality Control (QC) shall be performed by MRI technologist, prior to each use. 4. Preventative maintenance of equipment (PM - the regular and routine maintenance of equipment and assets to keep them running and prevent any costly unplanned downtown from unexpected equipment failure) will be performed, as outlined by manufacturer, and will be done by contracted service provider.”