Emanuel Medical Center

“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: 45977 Based on interview and record review, the hospital failed to ensure nursing staff developed and maintained individualized care plans reflecting the needs of the patients and care to be provided for the patients when three of 32 patients (Patient (Pt) 1, Pt 2, and Pt 15), care plans did not address the specific problems, interventions, and goals for which the patient was admitted. These failures had the potential for inconsistent care delivery for Pt 1, Pt 2, and Pt 15 and had the potential for not receiving nursing care to reflect their individual needs and goals which could negatively affect patient well-being. Findings: 1. During a concurrent interview and record review on 2/5/26 at 1:51 p.m. with Nurse Manager Critical Care Unit/Progressive Care Unit (CCU/PCU) (NM 1), Pt 1’s “Electronic Medical Record (EMR),” dated 3/28/25 was reviewed. The History and Physical (H&P) indicated at 1:35 a.m., Pt 1, a 44 year-old female, was admitted on 3/28/25 at 1:17 a.m. with a diagnosis of pyelonephritis (a type of kidney infection that happens when bacteria (tiny germs) travel up from the bladder into the kidneys and cause an infection), was positive for Methamphetamines (drugs that speed up the messages between your brain and body. They are called stimulants because they make you feel more awake and alert), and Pt 1 stated that she thought she might be going into alcohol withdrawal. The Plan of Care (POC) was reviewed, and NM 1 could not find a care plan related to substance abuse or withdrawal. NM 1 stated there should have been a care plan to address these issues. NM 1 stated that having a care plan provided guidance to the staff and helped to ensure staff were consistently doing appropriate interventions to minimize withdrawal symptoms such as hallucinations, seizures, severe confusion, and even death. 2. During a concurrent interview and record review on 2/5/26 at 2:15 p.m. with NM 1, Pt 2’s “Electronic Medical Record (EMR),” dated 6/18/25 was reviewed. The History and Physical (H&P) indicated, at 11:40 p.m. Pt 2, a 54 year-old female, was admitted on 6/18/25 at 11:30 p.m. with a diagnosis of acute sepsis (a serious illness that happens when your body has a big reaction to an infection. Instead of just fighting the germs, your body’s defense system goes into overdrive and starts hurting your own organs). The H&P indicated, Pt 2 was found down in an abandoned warehouse in critical condition and upon arrival to the Emergency Department (ED), Pt 2 was positive for Methamphetamines. The H&P indicated, a Blood Sugar level of 29 (a normal blood sugar is usually 70-100 (mg/dL (milligram/deciliter). 29 mg/dL is way below normal - this is called severe hypoglycemia), Lactic Acid of 12 (a chemical your body makes when your muscles work hard or when your body doesn’t get enough oxygen. A level of 12 is a medical emergency. It means something is very wrong, and doctors need to treat the cause right away). NM 1 stated that Pt 2 was very critical when she arrived to the ED. The POC was reviewed and NM 1 stated she could not find a care plan related to substance abuse/withdrawal. NM 1 stated there should have been a care plan to address these issues. NM 1 stated having a care plan provided guidance to the staff and helped to ensure staff were consistently doing appropriate interventions to minimize withdrawal symptoms such as hallucinations, seizures, severe confusion and even death. 3. During a concurrent interview and record review on 2/4/26 at 4:05 p.m. with NM 1, Pt 15’s “H&P,” dated 2/1/26 at 5:19 a.m., Pt 15’s “Face sheet (provides demographics of the patient, name, date of birth, admission date, chief complaint),” and Pt 15’s “electronic health records (EHR),” dated 2/1/26 were reviewed. The “H&P” indicated Pt 15 was a 92 year old with a past medical history of congestive heart failure (when the heart backs up with fluid), atrial fibrillation (a common irregular heart rhythm), diabetes (a metabolic disorder where the blood sugar has high levels due to inadequate production of insulin), dementia (a syndrome characterized by a decline in memory, reasoning, language and judgement that interferes with daily life), and wound of the coccyx (tailbone) and was admitted to the intensive care unit for sepsis. NM 1 stated the nursing care plan had the problem foci for infection, falls, prevention of blood clots, prevention of falls, and discharge education. NM 1 stated the primary problem of the wound on the coccyx was not addressed in the care plan and it was expected that staff developed the care plan to be individualized to the patient’s medical problems. During a review of the facility’s policy and procedure (P&P) titled, “Assessment/Reassessment of the Patient,” dated 7/22/24, the P&P indicated “ ... the interdisciplinary plan of care will be initiated upon admission, within 24 hours ...the plan is individualized and based upon actual or potential problems, anticipated length of stay, assessed needs, policies, patient care standards, cultural issues, available resources and will be consistent with other therapies and/or disciplines ...” During an interview on 02/06/2026 at 10:01 a.m. with Chief Nursing Officer (CNO), the CNO stated her expectation would be that care plans would be started and documented per protocol. The CNO stated having appropriate and timely care plans was what drove the care for the patients. During a review of professional article titled, “Why are care plans important in healthcare?” located at https://biologyinsights.com/why-are-care-plans-important-in-healthcare, dated January 13, 2026, the article indicated “ ... care plans are a cornerstone of effective healthcare delivery. They provide a structured approach to patient care by outlining individualized goals, interventions, and evaluation criteria ... Initiating care plans early is essential for delivering consistent, high-quality, and patient-focused care across all healthcare environments ... Standardized documentation of the patient’s status prevents critical information from being overlooked during these vulnerable handoffs. By clearly outlining the agreed-upon approach, the care plan prevents conflicting interventions or unnecessary delays in treatment. Maintaining this high level of consistency in routine care is important for process efficiency and safeguarding the patient’s stability across various care environments ...””

“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: 45977 Based on interview and record review the licensed nursed failed to follow their policies and procedures when: 1. Licensed nurses did not document in accordance with hospital policies and procedures (P&P) titled, “Assessment/Reassessment of the Patient Plan of Care” and “RN Job Summary” the use of sequential compression devices (SCD) for two of four sampled patients (Patient (Pt) 5 and Pt 19). SCD’s are used for the prevention of venous thromboembolism (VTE -- blood clots) forming in the legs 2. Licensed nurses did not follow the provider order for adjusting a heparin medication (a blood thinning drug that prevents or treat blood clots) in accordance with hospital P&P titled, “Heparin Infusion Guidelines” and “RN Job Summary” for on one of four sample patients (Pt 3). These failures had the potential for inconsistent care delivery and the potential for not receiving nursing care to reflect their individual needs and goals which could negatively affect patient well-being. Findings: 1. During a review of Pt 5’s “History & Physical (H&P),” dated 2/3/26, the “H&P” indicated, Pt 5 was admitted on 2/3/26 and had a previous medical history of chronic lymphocytic leukemia (CLL -a slow growing cancer of the blood and bone marrow), diabetes (a metabolic disorder where the blood sugar has high levels due to inadequate production of insulin), and bloody stools. Pt 5 had been complaining of chest pain and shortness of breath and was admitted to the intensive care unit. During a concurrent interview and record review on 2/4/26 at 11:07 a.m. with Nurse Manager of Critical Care Unit/Progressive Care Unit (NM 1), Pt 5’s “H&P,” dated 2/3/26 at 5:29 a.m., Pt 5’s “Face sheet (provides demographics of the patient, name, date of birth, admission date, chief complaint),” and Pt 5’s “electronic health records (EHR),” dated 2/3/26 were reviewed.. NM 1 stated the nursing care plan had the problem foci for pain, prevention of blood clots, prevention of falls and bleeding. NM 1 stated SCDs were ordered for the patient but there was no documentation that the patient had them applied. NM 1 stated there was no documentation the provider had been notified about not applying the SCDs. NM 1 stated the nurses should follow the orders of the provider, document their actions and/or clarify the order about the SCDs. NM 1 stated the patient was at risk for developing a clot which could be important to his health. During a review of Pt 19’s “H&P,” dated 2/3/26, the “H&P” indicated, Pt 19 was admitted on 2/3/26 and had a previous medical history of congestive heart failure (when the heart fails to pump efficiently and fluids backs up in the circulatory system), end stage renal disease (the final irreversible stage where kidneys can no longer filter waste, toxins and excess fluids from the blood), diabetes, hypertension (high blood pression), and pleural effusions (pockets of fluids around the lungs). Pt 19 had been complaining of shortness of breath and fluid overload and was admitted to the intensive care unit. During a concurrent interview and record review on 2/5/26 at 10:15 a.m. with NM 1, Pt 19’s “H&P,” dated 2/3/26 at 3:57 a.m., Pt 19’s “Face sheet,” and Pt 19’s “EHR,” dated 2/3/26 were reviewed. NM 1 stated the nursing care plan had the problem foci for kidney disease, infection, heart failure, fluid overload, respiratory distress, mobility, diabetes, wound care, prevention of blood clots, and bleeding. NM 1 stated SCDs were ordered for the patient but there was no documentation that the patient had them applied. NM 1 stated Pt 19 was at high risk for developing clots and SCDs should be applied and documented. NM 1 stated the nurses should follow the orders of the provider. NM 1 stated the patient was at risk of developing a clot that could potentially result in the patient dying. During an interview on 02/06/2026 at 10:01 a.m. with the Chief Nursing Officer (CNO), the CNO stated she expected the nurses to follow the orders written by the providers and document the actions that have been taken. During a review of the facility’s document titled, “RN Job Summary,” dated 12/4/24, the document indicated, “ ... The RN is responsible for the provision and coordination of patient centered care. ... Promotes patient safety by maintaining the policies and procedures of the hospital ... Implementation - ... Demonstrates skills needed to implement the identified plan of care. Demonstrated ability to prioritize and adjust priorities based on patient/unit needs. Performs total patient care ...” During a review of the facility’s P&P titled, “Assessment/Reassessment of the Patient,” dated 7/22/24, the P&P indicated, “ ... The RN in partnership with the patient initiates the interdisciplinary plan of care (which includes discharge planning issues) upon admission. ... All individuals in the interdisciplinary team involved in the care of the patient are responsible for contributing to the Interdisciplinary Plan of Care throughout the continuum of care (admission through discharge) and documenting those contributions. ... The plan of care should reflect the following (as applicable): This list is not all inclusive: ... VTE ... “ 2. During a review of Pt 3’s “H&P,” dated 2/3/26, the “H&P” indicated Pt 3 was admitted on 2/2/26 and had a previous medical history of coronary artery disease (a heart condition where buildup narrows the blood vessels supply the heart muscle), colon cancer and breast cancer. Pt 3 had been complaining of shortness of breath and palpitations (a sensation of a rapid fluttering, pounding or irregular heartbeat). Pt 3 was diagnosed with pulmonary emboli (clots in the lungs) and started on a continuous heparin intravenously (IV-- through the vein) drip. Pt 3 was admitted to the intensive care unit. During a concurrent interview and record review on 2/4/26 at 10:40 a.m. with NM 1, Pt 3’s “H&P”, dated 2/2/26 at 6:41 p.m., Pt 3’s “Face sheet,” and Pt 3’s “EHR,” dated 2/2/26 were reviewed. NM 1 stated Pt 3 had been started on continuous heparin IV drip and the orders were per a protocol (a standardized, hospital-approved, and nurse-driven set of instructions for administering and monitoring heparin, a high-alert anticoagulant (“blood thinner”) medication. The order is designed to ensure safe, precise, and effective dosing to prevent, treat, or manage blood clots.). NM 1 stated Pt 3 had lab draws every six hours to measure the partial thromboplastin time (PTT - a medical blood test that measures how long it takes blood to clot, used to monitor blood-thinning medications). NM 3 stated nurses were to adjust the Heparin IV dose based on the ordered protocol. NM 3 stated on 2/2/26 at 6:37 a.m., the heparin IV drip was running at 18 units/kilogram/hour (units/kilogram/hr) and the PTT result was high at 132 seconds (normal range is 25 to 35 seconds). NM 3 stated per the protocol, the heparin IV drip should be turned off for 1 hour and adjusted to 15 units/kg/hr and the provider should be notified. NM 3 stated the drip was restarted at 9:27 a.m., 2 hours and 50 minutes after being turned off. NM 3 stated the nurses did not chart why it had been turned off longer than 1 hour and they did not follow the order and protocol. NM 3 stated nothing was charted about notifying the provider. NM 3 stated she expected the nurses to follow the medication orders as patients could be injured as a result. During a review of Pt 3’s orders, “heparin IV additive,” dated 2/2/26, the order indicated, “ ... PTT[less than] 35 Give 80 units/kg IV bolus (maximum dose: 10,000 units) then increase drip rate by 4 units/kg/hr. Recheck PTT in 6 hours. ... PTT 35-44 Give 40 units/kg IV bolus (maximum dose 10,000 units) then increase drip rate by 2 units/kg/hr. Recheck PTT in 6 hours. ... PTT 45-75 Therapeutic range-no change, If no dose change required following 2 consecutive in range PTT, then change PTT order to every 12 hours, After 2 consecutive PTT’s on every 12 hours in range then change PTT to every morning, ... PTT 76-89 Decrease drip by 2 units/kg/hr, Recheck PTT in 6 hours, PTT [great than]90 Hold infusion for 1 hour then decrease drip rate by l units/kg/hr, Notify provider. Recheck PTT in 6 hours. ... “ During an interview on 02/06/2026 at 10:01 a.m. with Chief Nursing Officer (CNO), the CNO stated she expected the nurses to follow the orders written by the providers and document the actions that have been taken. During a review of the facility’s document titled, “RN Job Summary,” dated 12/4/24, indicated “ ... The RN is responsible for the provision and coordination of patient centered care. ... Promotes patient safety by maintaining the policies and procedures of the hospital ... Implementation - ... Demonstrates skills needed to implement the identified plan of care. Demonstrated ability to prioritize and adjust priorities based on patient/unit needs. Performs total patient care ...” During a review of the facility’s P&P titled, “Heparin Infusion Guidelines,” dated 5/7/24, the P&P indicated “ ... C. Nurse will: ... 2. Check heparin dosage with second licensed nurse and document co-signature in EHR before administering a bolus dose, and upon initiation of therapy, at shift change, and with every change in infusion rate. ... 3. Administer heparin via IV pump. ... 4. Order and monitor PTTs and adjust drip rate as per order set. ... Purpose: ... A. To provide a standard heparin infusion with appropriate guidelines for ordering and safe administration. ... B. To facilitate the calculation of heparin infusion rates and reduce medication errors. ...” During a review of a professional reference titled, “Lippincott Manual of Nursing Practice (11th ed.),” dated 2018, the reference indicated, “Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record, administer medications as ordered, and follow physician’s orders that should have been questioned or not followed, such as orders containing medication dosage errors.””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 45977 Based on observation, interview, and record review, the hospital’s infection prevention and control program (IPCP) failed to ensure a clean and sanitary environment in accordance with hospital policies and procedures and national standards of practice for infection control to prevent and control infections among patients, personnel, and visitors for one of 10 patients (Patient, Pt 3) when Pt 3’s intravenous tubing (a flexible, medical-grade, sterile plastic tube that connects an fluid container (bag/bottle) to a needle or catheter inserted into a patient’s vein) and intravenous site (a tube inserted into the vein to give medications) was not labeled and dated in accordance with hospital policy and procedure (P&P) titled, “IV [Intravenous] Therapy Policy and Procedures.” As a result of these failures Pt 3 was at risk for transmission of infections (an infectious agent is transferred from a reservoir to a susceptible host) and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and increased the potential for hospital acquired infections and illnesses. Findings: During a concurrent observation and interview on 2/3/26 at 11:50 a.m. with Pt 3, Nurse Manager of Intensive Care Unit (ICU ) (NM 1), and the Director of Critical Care (DCC) in Pt 3’s hospital room, a bag of IV liquid was observed hanging from the IV pole, with tubing connected to Pt 3. The tubing did not have a label. Pt 3 had three IVs, two on each upper arm and one located on the right forearm. The right forearm was missing a label indicating the date it was inserted. Pt 1 stated she thought the IV on the right forearm had been inserted the previous day. NM 1 stated the IV tubing and IV site on the right forearm should be labeled. NM 1 stated the nurse should have labeled the IV site and the IV tubing as per the policy. The DCC stated, the nurses should follow the policies and label the IV insertion site with the date the IV was inserted and initials of the nurse and the tubing should be labeled with the date it was hung. The DCC stated this was important as it prevented infections from occurring to the patient. During an interview on 2/6/26 at 10:00 a.m. with the Chief Nursing Officer (CNO), the CNO stated IV insertion site, and the tubing should be labeled according to policy. The CNO stated labeling IV tubing and IV sites was done to prevent infection. During a review of the hospital’s P&P titled, “IV Therapy Policy and Procedures,” dated 3/20/23, the P&P indicated, “ ... Purpose ... A. To clearly delineate the roles and responsibilities of hospital personnel in regard to intravenous therapy. B. To describe procedures that, emphasize patient safety for the initiation and management of intravenous therapy. ... G. Dressings ... Label IV site with date, time, size of IV catheter and initials of person starting IV ... Label IV tubing with start date, discard date and nurse initials. ... If obliged to leave the IV site for greater than 96 hours, change the IV tubing down to the hub ... “”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 45977 Based on interview and record review the hospital failed to follow their policy “Patient Complaints/Grievances” when one of two sampled patients (Pt 19), grievance acknowledgment letter was not sent out in 7 days, an extension letter was not sent out after the initial 7 days, and the response to the grievance was sent out 36 days after receipt of the grievance. This failure resulted in Pt 19 not receiving a timely response to their grievance. Findings: During a concurrent interview and document review on 12/4/25 at 11:06 a.m. with the Administrative Services Manager (ASM), Director of Clinical Quality Improvement (QD), and the Patient Safety Officer (PSO), the hospital’s “Grievance & Complaint Log,” undated and grievance process was reviewed. The QD stated patients could file grievances in a couple of different ways from calling a phone number that is available all the time, they can email them, mail, fax, the Press Ganey Survey (a standardized patient experience questionnaire used by thousands of United States healthcare organizations to measure satisfaction with care). The QD stated they also do leadership rounding where we could get the grievances from staff and patients directly. The ASM stated, “When we receive a grievance, we review it and determine which department Director and Manager they should send it to. The ASM stated the expectation is for them to start their investigation while we send out a letter to the patient or patients’ representative to let them know we received their grievance and will be looking into the issues.” The ASM stated this letter was usually sent out within the first 7 days of receipt of the grievance and if the investigation took longer than 7 days then we would send out another letter explaining more time was needed. The ASM stated the goal was to have the grievances resolved within 30 days of receipt of the grievance. The ASM stated she/he was surprised when the Grievance & Complaint log was reviewed and grievance number 14 for Pt 19 was received on 9/9/25 and the resolution letter was sent on 10/15/25 (36 days after receipt of the grievance). The QD stated grievance 14 was emailed to both her and the ASM and they were not sure why it took so long for them to send over the grievance to the Director and Manager of the Emergency Department (ED). The QD stated on 10/2/25, grievance 14 was sent to the Director and Manager of the ED. The ASM stated it should not have taken 36 days for the resolution letter to go out for Pt 19. During an interview on 12/5/25 at 10:36 a.m. with the Chief Nursing Officer (CNO), the CNO stated she met weekly with the grievance committee to review the status of current grievances. The CNO stated her expectation was staff should follow the Grievance policy. During a review of the hospitals policy and procedure (P&P) titled, “Patient Complaints/Grievances,” dated 8/28/25, the P&P indicated, “ ... II. PURPOSE: The Hospital places a high value on delivering excellent service that is responsive to individual needs. This policy provides a mechanism for initiation, review, and when possible, prompt resolution of patient complaints concerning the quality of care of service(s) received. III ... B. “Grievance” an oral or written Complaint that is not immediately resolved at the time of the Complaint by staff present. A Grievance may be made by the patient’s representative regarding, but not limited to the patient’s care, abuse or neglect ... A written Complaint is always considered a Grievance and may be submitted by fax or email. Whenever the patient or patient’s representative requests that the Complaint be handled as a formal Complaint or Grievance, or when the patient requests a response from the hospital, then the Complaint is a Grievance ... IV ... The patient shall have the ability to file a Complaint or Grievance as part of the patient rights process and in compliance with the Medicare CoP ... V. ... C. Patient Grievance 1. Whether a patient/family Grievance is received by hospital staff in person, by telephone or in writing, a Patient and Family Complaint/Grievance report shall be originated by staff receiving the grievance. The staff shall forward the Patient and Family Complaint/Grievance report to the manager/director of the affected department for investigation and resolution ... 3. The seriousness of the grievance should drive the response time. Grievances should be resolved and the patient notified of the response in 7 days ... If the resolution of the grievance is determined to take longer than 7 days, the Grievance Committee or designee will send a response to the patient informing him/her that the Hospital is still working to resolve the grievance and that the Hospital will follow-up with a written response within a stated number of days (a “Deferral Letter”). No more than seven days shall elapse before a response is sent to the patient. If a grievance is made by a patient’s attorney, hospital operations counsel or litigation claims person before any written response to the grievance, including a deferral letter or final letter is given ... 4. Each grievance will be followed up with a written notice of decision in a manner and language that the patient and patient’s legal representative understands within 30 days. The hospital may use additional tools to resolve the grievance such as a meeting with the patient or family ... E. Responsible Person The DCQI (Director of Clinical Quality Improvement) or the Patient Safety Officer is responsible for ensuring that all individuals adhere to the requirements of this policy that these procedures are implemented and followed at the Hospital and that instances of non-compliance with this policy are reported to the Chief Nursing Officer (CNO) ...””

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 45977 Based on interview and record review the hospital failed to follow their policy “Patient Complaints/Grievances” when two of two sampled patients (Pt 17 and Pt 19), grievance letters were not sent to either of the patients because the grievances were submitted by their insurance companies. This failure resulted in both Pt 17 and Pt 19 not receiving answers to their grievances. Findings: During a review of the hospital’s “Grievance & Complaint Log last 6 months,” undated, the log indicated, “ ... 13 Date Received 9/5/25 Tracking # (number sign) 3020 [patients] Name/Complainant Name [insurance company name] on behalf of [Pt 17’s name] ... Grievance Description ... member [Pt 17] states she was admitted on 8/18/25 and left after the ER physician was yelling at her for asking a couple of questions. Member states the nurses and member’s friend tried standing up for her, but the physician would not change his attitude, so she left. Method of Receipt Written ... Department Involved ED ... Date Final Resolution Letter Sent 9/12/2025 ... 14 Date Received 9/9/2025 Tracking # 3021 Pt’s Name/Complainant Name [name of insurance company] on behalf of [Pt 19] ... Grievance Description DOS (date of service): 8/29/25. Per father [for Pt 19], pt needed an MRI (Magnetic Resonance Imaging- uses strong magnets, radio waves, and a computer to create detailed images of soft tissues like the brain, spinal cord, muscles, ligaments, and organs) for a loose knee. [Doctor] was rude and didn’t help pt, did not do any physical tests, x-ray (imaging test using electromagnetic radiation to create pictures of the inside of the body) done but did not answer questions and didn’t diagnose pt. Was pt advised to see his PCP or a specialist? Method of Receipt Written ... Department Involved ED ... Date Final Resolution Letter Sent 10/15/2025 ... # of days from Grievance Receipt to Resolution Letter 36 ...” During an interview on 12/3/25 at 5:09 p.m. with Pt 17, Pt 17 stated she filed a complaint with her insurance company for her visit on 8/18/25 to this hospital. Pt 17 stated the hospital never reached out to her and she had not received any letter from the hospital related to her complaint. During a concurrent interview and document review on 12/4/25 at 11:06 a.m. with the Administrative Services Manager (ASM), the Director of Clinical Quality Improvement (QD), and the Patient Safety Officer (PSO), the hospitals “Grievance & Complaint Log last 6 months,” undated was reviewed. The QD stated Pt 17 and Pt 19’s grievances came from their insurance companies and neither of the patients were contacted about these grievances and the resolution letters went to the insurance companies and not the patients. The QD stated Joint Commission (accreditation is the objective evaluation process that can help health care organizations measure, assess, and improve performance in order to help healthcare organizations fulfill their mission to provide safe, high-quality care) was just here doing a survey and recommended we send resolution letters to the patients involved in the grievances, but they had not. During an interview on 12/5/25 at 10:36 a.m. with the Chief Nursing Officer (CNO), the CNO stated she met weekly with the grievance committee to review the status of current grievances. The CNO stated her expectation was staff should follow the Grievance policy. The CNO stated, “Unless an insurance company asked us not to send a letter to the patient, the hospital should send the resolution letter to the patient, so the patients knew the hospital addressed the issues the patients reported. During a review of the hospitals policy titled, “Patient Complaints/Grievances,” dated 8/28/25, the policy indicated, “ ... II. PURPOSE: The Hospital places a high value on delivering excellent service that is responsive to individual needs. This policy provides a mechanism for initiation, review, and when possible, prompt resolution of patient complaints concerning the quality of care of service(s) received. III ... B. “Grievance” an oral or written Complaint that is not immediately resolved at the time of the Complaint by staff present. A Grievance may be made by the patient’s representative regarding, but not limited to the patient’s care, abuse or neglect ... A written Complaint is always considered a Grievance and may be submitted by fax or email. Whenever the patient or patient’s representative requests that the Complaint be handled as a formal Complaint or Grievance, or when the patient requests a response from the hospital, then the Complaint is a Grievance ... IV ... The patient shall have the ability to file a Complaint or Grievance as part of the patient rights process and in compliance with the Medicare CoP ... V. ... C. Patient Grievance 1. Whether a patient/family Grievance is received by hospital staff in person, by telephone or in writing, a Patient and Family Complaint/Grievance report shall be originated by staff receiving the grievance. The staff shall forward the Patient and Family Complaint/Grievance report to the manager/director of the affected department for investigation and resolution ... 3. The seriousness of the grievance should drive the response time. Grievances should be resolved and the patient notified of the response in 7 days ... If the resolution of the grievance is determined to take longer than 7 days, the Grievance Committee or designee will send a response to the patient informing him/her that the Hospital is still working to resolve the grievance and that the Hospital will follow-up with a written response within a stated number of days (a “Deferral Letter”). No more than seven days shall elapse before a response is sent to the patient. If a grievance is made by a patient’s attorney, hospital operations counsel or litigation claims person before any written response to the grievance, including a deferral letter or final letter is given ... 4. Each grievance will be followed up with a written notice of decision in a manner and language that the patient and patient’s legal representative understands within 30 days. The hospital may use additional tools to resolve the grievance such as a meeting with the patient or family ... E. Responsible Person The DCQI (Director of Clinical Quality Improvement) or the Patient Safety Officer is responsible for ensuring that all individuals adhere to the requirements of this policy that these procedures are implemented and followed at the Hospital and that instances of non-compliance with this policy are reported to the Chief Nursing Officer (CNO) ...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45977 Based on observation interview and record review the facility failed to protect and promote each patient’s rights when: 1. Three of four patients (Pt 3, Pt 18 and Pt 22) preferred language was other than English and did not receive communication or information in a language of their preference, in accordance with hospital policy and procedure (P&P). Informed consents (A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) were not in the patient’s preferred language and an interpreter was not utilized to translate the informed consent (Pt 22). There was minimal to no documentation an interpreter was used during Pt 3 and Pt 18’s hospitalization in accordance with hospital policy (Refer to A117). 2. Pt 1’s family submitted a grievance and the hospital did not track and monitor the complaint/grievance process for each patient in order to achieve prompt response in accordance with the hospital’s policy and procedure. The hospital did not develop and implement a log or other process to track the progress for prompt resolution of each patient complaint/grievance (Refer to A118). 3. Licensed Nurse (LN)s did not implement every two hour monitoring for one of three patients (Pt 25) to determine if the restraints (a device that restricts movement) could be released in accordance with hospital policy and procedure (P&P) (Refer to A154 finding #1). 4. LNs failed to obtain a physician order (PO) for renewal of non violent physical restraints (preventing movement of body and limbs) for one of three patients (Pt 24) while patient remained in non-violent physical restraints , in accordance with hospital P&P (Refer to A154 finding #2). The cumulative effect of these systemic problems resulted in failure to ensure patients were cared for in a safe manner, and their rights were protected and promoted at all times.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 45977 Based on observation, interview and record review, the hospital failed to consider the right of patients to receive communication in preferred language for three of four sampled patients (Pt 3, Pt 18 and Pt 22) whose preferred language was not English, patient care and services were not communicated in the preferred language, interpreter service was not used, informed consents (A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) were not in the patient’s preferred language in accordance with hospital policy and procedure. These failures had the potential for ineffective communication, misunderstandings, and possible patient harm . Findings: 1. During a concurrent interview and record review on 10/24/24 at 10:50 a.m. with Manager (Mgr) 6, Pt 22’s “History & Physical [H&P an assessment from physician including medical history and exam],” dated 9/17/24 and the “Face Sheet [FS a document that contains a summary of a patients’ personal information],” dated 9/17/24, were reviewed. “The “H&P” indicated, Pt 22 had a past medical history (PMH) of left sided craniotomy (a surgical procedure that involves removing a section of the skull to access the brain), behavioral issues secondary to traumatic brain injury (TBI a brain injury caused by an external force, such as a blow to the head. TBIs can range from mild to severe, and can affect how a person thinks, feels, acts, and moves), seizure disorder (a chronic brain condition that causes recurring seizures [a temporary episode of abnormal electrical activity in the brain that causes sudden change of behavior, movement, or consciousness]) due to TBI, and high blood pressure. Pt 22’s “H&P” indicated, “ ... presented to the ER [Emergency Room] on 9/5/24 for a 5150 hold [California law that allows for the involuntary psychiatric detention of a person for up to 72 hours] ... Patient has been in the ER close to 2 weeks, been trying to get placement ...”. Mgr 6 stated the “Face Sheet (FS )” indicated Pt 22’s preferred language was Portuguese. Pt 22 was transferred to the inpatient Medical Surgical (MS- a hospital unit where patients are treated for a variety of conditions) Unit on 9/17/24 at 6:55 p.m. During a concurrent interview and record review on 10/24/24 at 11 a.m. with Mgr 6, Pt 22’s “Interpreter Services Form [ISF]” dated 10/19/24 at 8:34 a.m. was reviewed. The “ISF” indicated the Licensed Nurse (LN) utilized a video interpreter for medication pass (the process through which medication is administered to patients) and physical assessment. The “ISF” indicated the LN documented Interpreter Name, Interpreter identification number and Interpreter Agency Name . Mgr 6 stated LNs should complete the “ISF” when an interpreter was used to communicate with Pt 22. Mgr 6 stated no other “ISF” forms were in Pt 22’s medical record. Mgr 6 stated LNs should have used interpreter services to communicate with Pt 22 and should have documented the interpreters name and identification number on the “ISF” form. During a concurrent interview and record review on 10/24/24 at 11:15 a.m. with Mgr 6, Pt 22’s “Electronic Medical Record [EMR a digital version of a patient’s medical history, including diagnoses, medications, tests, allergies, immunizations, and treatment plans]” was reviewed. The “Nursing Narrative [a type of nursing documentation used to provide clear, detailed information about a patient]” document from 10/19/24 at 6:19 p.m. indicated “ ... Pt a/o [alert and oriented] x 1(to self only knows name), bedbound [confined to bed], but ROM (Range of Motion amount of movement a joint or body part can make around a fixed point or joint) on L [left side] performed ... Swallowed pills whole and very cooperative w/[with] RN using translator. Pt able to converse w/ translator ... although responses were confused when RN tried to [assess] orientation ...” Mgr 6 stated no other “Nursing Narratives” were in Pt 22’s “EMR” indicating LNs used interpreter services to communicate with Pt 22. Mgr 6 stated no other documentation was in Pt 22’s “EMR” indicating LNs communicated with Pt 22 in English only and not in the preferred language of Portuguese . Mgr 6 stated LNs should have used interpreter services so Pt 22 knew his plan of care. Mgr 6 stated Pt 22’s “EMR” indicated he was often confused due to his brain injury and utilizing interpreting services to speak with him in his preferred language could help with confusion and could potentially decrease agitation (disruptive movement or vocal outbursts). During an interview on 10/24/24 at 2:59 p.m. with Registered Nurse (RN)13, RN 13 stated she was Pt 22’s Primary Nurse for the day . RN 13 stated Pt 22 understood commands in English and Spanish as well as his preferred language of Portuguese. RN 13 stated she did not know if there was any documentation in Pt 22’s “EMR” indicating Pt 22 understood any other languages besides Portuguese. RN 13 stated she did not utilize interpreter services to communicate with Pt 22. RN 13 stated she should document in Pt 22’s “EMR” when communicating with him in languages not documented as his preferred language. Pt 22’s “EMR” did not indicate any LN documentation of other languages being used to communicate with Pt 22 other than English. During a concurrent observation and interview on 10/24/24 at 3:05 p.m. with Pt 22 in his hospital room, Pt 22 was observed lying in his hospital bed on his back with his eyes open staring at the wall. Pt 22 had his side rails (horizontal bars attached to the side of a bed that can help people get in and out of bed, turn, or pull themselves up) padded and his call light was next to him on the bed. The Director of Medical Surgical (DMS), and a Medical Surgical Charge Nurse entered the room for observation of patient interview. Pt 22 was asked in English if he spoke English and if he was in any pain. Pt 22 did not respond to questions but made eye contact with interviewer. Pt 22 was then asked in Spanish if he was thirsty or if he was in pain. Pt 22 continued to make eye contact and responded no to both questions. Pt 22 did not respond when asked if he spoke English in either Spanish or English. During an interview on 10/25/24 at 1:10 p.m. with Family Member (FM) 2, FM 2 were contacted regarding his language preferences. FM 2 stated her father did not speak English but could understand some Spanish as it was very similar to Portuguese. FM 2 stated she interpreted for her father when she was at the hospital, but she was not there all the time. FM 2 stated she believed LNs should communicate with her father in his preferred language of Portuguese. FM 2 stated LNs had called her on the telephone in the past to have her talk to her father and try to calm him when he was agitated. FM 2 stated communicating with him in his preferred language may help to prevent his confusion and agitation. During an interview on 10/25/24 at 2:54 p.m. with the DMS , she stated she was not aware Pt 22 did not speak English. The DMS stated LNs reported to her Pt 22 spoke English. The DMS stated Pt 22 had not spoken to her in English. The DMS stated her expectation was for LNs to utilize interpreting services for patients in their preferred language. The DMS stated speaking to patients in their preferred language allows patients to feel more comfortable in their surroundings. During an interview on 10/28/24 at 1:17 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she assisted with care for Pt 22 on multiple occasions. CNA 1 stated Pt 22 responds to “simple commands” in English, such as questions about needing to be changed or if he was hungry. CNA 1 stated for more complex communication she would utilize Pt 22’s daughter on the telephone or utilize family if at bedside. CNA 1 stated she did not document the interpreting assistance by family in Pt 22’s “EMR”. During an interview on 10/28/24 at 3:12 p.m. with RN 14, RN 14 stated she was Pt 22’s primary nurse on 10/19/24 and used interpreter services to communicate with him. RN 14 stated she received in report from the off going nurse Pt 22 did not speak English, and he was cognitively impaired (problems with ability to think, learn, remember, use judgement, and make decisions). RN 14 stated the off going LN reported Pt 22 only spoke Portuguese, and the family was not at bedside to interpret. RN 14 stated hospital policy was to use the medical interpreter service for assessments, new medications, education, or any procedures. RN 14 stated without using the interpreter service during her assessment she would be unable to determine how cognitively impaired Pt 22 was. RN 14 stated when she used the interpreter, Pt 22 was disoriented, but spoke in complete full sentences. RN 14 stated when she asked Pt 22 if he knew where he was, he knew he was in a hospital, but he thought he was in a “Mental Hospital in Portugal”. RN 14 stated Pt 22 had a history of aggression with staff members. RN 14 stated it was possible Pt 22 became more agitated not only due to his TBI, but possibly due to frustrations of not understanding the languages being spoken. RN 14 stated the whole day of her shift Pt 22 was very pleasant and had no behavior issues. RN 14 stated LNs should communicate with patients in their preferred language. RN 14 stated LNs should document in the “EMR” when using a family member to interpret. RN 14 stated “if you don’t chart it, it wasn’t done”. During an interview on 10/28/24 at 2:57 p.m. with the Director of Patient Access (DPA), the DPA stated, the Patient Access staff completed the preferred language form in a patient’s “EMR”. The DPA stated a language preference was determined at time of arrival to the hospital. The DPA stated LNs could contact Patient Access staff to change the preferred language if incorrect in the “EMR”. During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated, LNs should be communicating with patients in their preferred language. The CNO stated LNs should be using the hospital resources available, including the video interpreting services or telephone interpreting services. The CNO stated her expectation was for LNs to follow hospital P&P for interpreting services. . During a review of the hospital’s policy and procedure (P&P) titled, “Interpreters”, dated 2/19/19, indicated, “ ... [name of hospital] staff will arrange to use the on demand video remote interpretation (VRI) service or language interpretation line at no cost to facilitate effective communication with a patient ... who is not fluent in English and/or when patient or patient representative has communicated his or her primary language is not English (the documented primary language is considered the patient’s preferred language for receiving information) ... [name of hospital] prohibits the use of outside interpreters other than the VRI or the contracted language line ... If the patient’s documented primary language is considered the patient’s preferred language for receiving information but the patient is fluent in more than one language and that language is English then the patient may elect to receive the information in English. The nurse shall document this in the medical record ... A patient may, after being informed of the availability of the interpreter service, choose to have an adult family member as an interpreter ...the patient must provide written permission to have access to the patient’s personal health information ... When the interpretation is of a medical nature, The VRI ... or language line is utilized ... when the interpretation is of a general nature (basic care no medical decision) any available employee, visitor, or volunteer may be utilized ... If the patient is unable to provide written consent, verbal consent is acceptable ... Staff will document in the patient’s medical record when interpreter service are made available to the patient and when an interpreter service [names of services] is utilized. Whenever an interpreter service is used the name of the outside service must be indicated in the medical record along with the interpreter Identification (ID ) ... If the patient elects to have a family member interpret, the [hospital] Staff must document the name of the person who acted as the interpreter and that person’s relationship to the patient ... Translation of documents ... Documents requiring patient’s signature whenever possible will be in the language the patient speaks. If the document is not available in their primary language the interpreter service should be used and the information recorded in the document ... Consents are available in English and Spanish, other languages require the use of the interpreter service ... The name of the interpreter or the interpreter ID number must be documented on the consent ... Discharge instructions will be provide in the patient’s primary language ...” During a review of professional reference titled, “Clinicians’ Obligations to Use Qualified Medical Interpreters When Caring for Patients with Limited English Proficiency,” dated 3/2017, (retrieved from https://journalofethics.ama assn.org/article/clinicians obligations use qualified medical interpreters when caring patients limited english/2017 03) indicated, “ ... Access to language services is a required and foundational component of care for patients with limited English proficiency (LEP) ... In the United States, patients with LEP have a legal right to access health care in their preferred language ...” 2. During a concurrent interview and record review on 10/25/24 at 11:03 a.m. with Manager (Mgr) 4, Pt 18’s “Face Sheet (FS),” dated 10/11/24 was reviewed. Mgr 4 stated the FS indicated Pt 18’s preferred language was Spanish. During a review of Pt 18’s “Consent for Treatment and Conditions for Admission (COA)”, dated 10/10/24, the COA indicated the COA was written in English. During an interview on 10/28/24 at 2:56 p.m. with the Director of Patient Access (DPA), the DPA stated the COA should have been written in the patient’s preferred language when the patient stated his preferred language was not English. During a review of the hospital’s policy and procedure (P&P) titled, “Interpreters”, dated 2/19/19, indicated, “ ... [name of hospital] staff will arrange to use the on demand video remote interpretation (VRI) service or language interpretation line at no cost to facilitate effective communication with a patient ... who is not fluent in English and/or when patient or patient representative has communicated his or her primary language is not English (the documented primary language is considered the patient’s preferred language for receiving information) ... [name of hospital] prohibits the use of outside interpreters other than the VRI or the contracted language line ... If the patient’s documented primary language is considered the patient’s preferred language for receiving information but the patient is fluent in more than one language and that language is English then the patient may elect to receive the information in English. The nurse shall document this in the medical record ... A patient may, after being informed of the availability of the interpreter service, choose to have an adult family member as an interpreter ...the patient must provide written permission to have access to the patient’s personal health information ... When the interpretation is of a medical nature, The VRI ... or language line is utilized ... when the interpretation is of a general nature (basic care no medical decision) any available employee, visitor, or volunteer may be utilized ... If the patient is unable to provide written consent, verbal consent is acceptable ... Staff will document in the patient’s medical record when interpreter service are made available to the patient and when an interpreter service [names of services] is utilized. Whenever an interpreter service is used the name of the outside service must be indicated in the medical record along with the interpreter ID ... If the patient elects to have a family member interpret, the [hospital] Staff must document the name of the person who acted as the interpreter and that person’s relationship to the patient ... Translation of documents ... Documents requiring patient’s signature whenever possible will be in the language the patient speaks. If the document is not available in their primary language the interpreter service should be used and the information recorded in the document ... Consents are available in English and Spanish, other languages require the use of the interpreter service ... The name of the interpreter or the interpreter ID number must be documented on the consent ... Discharge instructions will be provide in the patient’s primary language ...” During a review of professional reference titled, “Clinicians’ Obligations to Use Qualified Medical Interpreters When Caring for Patients with Limited English Proficiency,” dated 3/2017, (retrieved from https://journalofethics.ama assn.org/article/clinicians obligations use qualified medical interpreters when caring patients limited english/2017 03) indicated, “ ... Access to language services is a required and foundational component of care for patients with limited English proficiency (LEP) ... In the United States, patients with LEP have a legal right to access health care in their preferred language ...”. 3. During a concurrent interview and record review on 10/23/24 at 2:00 p.m. with Manager (Mgr) 6, Pt 3’s “FS,” dated 10/23/24 and “EMR”” were reviewed. Mgr 6 stated the FS indicated Pt 3’s preferred language was Spanish. Mgr 6 stated she was unable to find any record while in the emergency room that nurses or providers spoke to the patient in her preferred language or used interpreter’s services. Mgr 6 stated it should be documented how staff communicated to Pt 3. During a review of Pt 3’s “Consent for Treatment and Conditions for Admission (COA)”, dated 10/10/24, the COA indicated the COA was written in English. During an interview on 10/28/24 at 2:56 p.m. with the Director of Patient Access (DPA), the DPA stated the COA should have been written in the patient’s preferred language when the patient stated his preferred language was not English. During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated, LNs should be communicating with patients in their preferred language. The CNO stated LNs should be using the hospital resources available, including the video interpreting services or telephone interpreting services. The CNO stated her expectation was for LNs to follow hospital P&P for interpreting services. During a review of the hospital’s policy and procedure (P&P) titled, “Interpreters”, dated 2/19/19, indicated, “ ... [name of hospital] staff will arrange to use the on demand video remote interpretation (VRI) service or language interpretation line at no cost to facilitate effective communication with a patient ... who is not fluent in English and/or when patient or patient representative has communicated his or her primary language is not English (the documented primary language is considered the patient’s preferred language for receiving information) ... [name of hospital] prohibits the use of outside interpreters other than the VRI or the contracted language line ... If the patient’s documented primary language is considered the patient’s preferred language for receiving information but the patient is fluent in more than one language and that language is English then the patient may elect to receive the information in English. The nurse shall document this in the medical record ... A patient may, after being informed of the availability of the interpreter service, choose to have an adult family member as an interpreter ...the patient must provide written permission to have access to the patient’s personal health information ... When the interpretation is of a medical nature, The VRI ... or language line is utilized ... when the interpretation is of a general nature (basic care no medical decision) any available employee, visitor, or volunteer may be utilized ... If the patient is unable to provide written consent, verbal consent is acceptable ... Staff will document in the patient’s medical record when interpreter service are made available to the patient and when an interpreter service [names of services] is utilized. Whenever an interpreter service is used the name of the outside service must be indicated in the medical record along with the interpreter ID ... If the patient elects to have a family member interpret, the [hospital] Staff must document the name of the person who acted as the interpreter and that person’s relationship to the patient ... Translation of documents ... Documents requiring patient’s signature whenever possible will be in the language the patient speaks. If the document is not available in their primary language the interpreter service should be used and the information recorded in the document ... Consents are available in English and Spanish, other languages require the use of the interpreter service ... The name of the interpreter or the interpreter ID number must be documented on the consent ... Discharge instructions will be provide in the patient’s primary language ...” During a review of professional reference titled, “Clinicians’ Obligations to Use Qualified Medical Interpreters When Caring for Patients with Limited English Proficiency,” dated 3/2017, (retrieved from https://journalofethics.ama assn.org/article/clinicians obligations use qualified medical interpreters when caring patients limited english/2017 03) indicated, “ ... Access to language services is a required and foundational component of care for patients with limited English proficiency (LEP) ... In the United States, patients with LEP have a legal right to access health care in their preferred language ...””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 45977 Based on observation, interview and record review, the hospital failed to consider the right of patients to receive communication in preferred language for three of four sampled patients (Pt 3, Pt 18 and Pt 22) whose preferred language was not English, patient care and services were not communicated in the preferred language, interpreter service was not used, informed consents (A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) were not in the patient’s preferred language in accordance with hospital policy and procedure. These failures had the potential for ineffective communication, misunderstandings, and possible patient harm . Findings: 1. During a concurrent interview and record review on 10/24/24 at 10:50 a.m. with Manager (Mgr) 6, Pt 22’s “History & Physical [H&P an assessment from physician including medical history and exam],” dated 9/17/24 and the “Face Sheet [FS a document that contains a summary of a patients’ personal information],” dated 9/17/24, were reviewed. “The “H&P” indicated, Pt 22 had a past medical history (PMH) of left sided craniotomy (a surgical procedure that involves removing a section of the skull to access the brain), behavioral issues secondary to traumatic brain injury (TBI a brain injury caused by an external force, such as a blow to the head. TBIs can range from mild to severe, and can affect how a person thinks, feels, acts, and moves), seizure disorder (a chronic brain condition that causes recurring seizures [a temporary episode of abnormal electrical activity in the brain that causes sudden change of behavior, movement, or consciousness]) due to TBI, and high blood pressure. Pt 22’s “H&P” indicated, “ ... presented to the ER [Emergency Room] on 9/5/24 for a 5150 hold [California law that allows for the involuntary psychiatric detention of a person for up to 72 hours] ... Patient has been in the ER close to 2 weeks, been trying to get placement ...”. Mgr 6 stated the “Face Sheet (FS )” indicated Pt 22’s preferred language was Portuguese. Pt 22 was transferred to the inpatient Medical Surgical (MS- a hospital unit where patients are treated for a variety of conditions) Unit on 9/17/24 at 6:55 p.m. During a concurrent interview and record review on 10/24/24 at 11 a.m. with Mgr 6, Pt 22’s “Interpreter Services Form [ISF]” dated 10/19/24 at 8:34 a.m. was reviewed. The “ISF” indicated the Licensed Nurse (LN) utilized a video interpreter for medication pass (the process through which medication is administered to patients) and physical assessment. The “ISF” indicated the LN documented Interpreter Name, Interpreter identification number and Interpreter Agency Name . Mgr 6 stated LNs should complete the “ISF” when an interpreter was used to communicate with Pt 22. Mgr 6 stated no other “ISF” forms were in Pt 22’s medical record. Mgr 6 stated LNs should have used interpreter services to communicate with Pt 22 and should have documented the interpreters name and identification number on the “ISF” form. During a concurrent interview and record review on 10/24/24 at 11:15 a.m. with Mgr 6, Pt 22’s “Electronic Medical Record [EMR a digital version of a patient’s medical history, including diagnoses, medications, tests, allergies, immunizations, and treatment plans]” was reviewed. The “Nursing Narrative [a type of nursing documentation used to provide clear, detailed information about a patient]” document from 10/19/24 at 6:19 p.m. indicated “ ... Pt a/o [alert and oriented] x 1(to self only knows name), bedbound [confined to bed], but ROM (Range of Motion amount of movement a joint or body part can make around a fixed point or joint) on L [left side] performed ... Swallowed pills whole and very cooperative w/[with] RN using translator. Pt able to converse w/ translator ... although responses were confused when RN tried to [assess] orientation ...” Mgr 6 stated no other “Nursing Narratives” were in Pt 22’s “EMR” indicating LNs used interpreter services to communicate with Pt 22. Mgr 6 stated no other documentation was in Pt 22’s “EMR” indicating LNs communicated with Pt 22 in English only and not in the preferred language of Portuguese . Mgr 6 stated LNs should have used interpreter services so Pt 22 knew his plan of care. Mgr 6 stated Pt 22’s “EMR” indicated he was often confused due to his brain injury and utilizing interpreting services to speak with him in his preferred language could help with confusion and could potentially decrease agitation (disruptive movement or vocal outbursts). During an interview on 10/24/24 at 2:59 p.m. with Registered Nurse (RN)13, RN 13 stated she was Pt 22’s Primary Nurse for the day . RN 13 stated Pt 22 understood commands in English and Spanish as well as his preferred language of Portuguese. RN 13 stated she did not know if there was any documentation in Pt 22’s “EMR” indicating Pt 22 understood any other languages besides Portuguese. RN 13 stated she did not utilize interpreter services to communicate with Pt 22. RN 13 stated she should document in Pt 22’s “EMR” when communicating with him in languages not documented as his preferred language. Pt 22’s “EMR” did not indicate any LN documentation of other languages being used to communicate with Pt 22 other than English. During a concurrent observation and interview on 10/24/24 at 3:05 p.m. with Pt 22 in his hospital room, Pt 22 was observed lying in his hospital bed on his back with his eyes open staring at the wall. Pt 22 had his side rails (horizontal bars attached to the side of a bed that can help people get in and out of bed, turn, or pull themselves up) padded and his call light was next to him on the bed. The Director of Medical Surgical (DMS), and a Medical Surgical Charge Nurse entered the room for observation of patient interview. Pt 22 was asked in English if he spoke English and if he was in any pain. Pt 22 did not respond to questions but made eye contact with interviewer. Pt 22 was then asked in Spanish if he was thirsty or if he was in pain. Pt 22 continued to make eye contact and responded no to both questions. Pt 22 did not respond when asked if he spoke English in either Spanish or English. During an interview on 10/25/24 at 1:10 p.m. with Family Member (FM) 2, FM 2 were contacted regarding his language preferences. FM 2 stated her father did not speak English but could understand some Spanish as it was very similar to Portuguese. FM 2 stated she interpreted for her father when she was at the hospital, but she was not there all the time. FM 2 stated she believed LNs should communicate with her father in his preferred language of Portuguese. FM 2 stated LNs had called her on the telephone in the past to have her talk to her father and try to calm him when he was agitated. FM 2 stated communicating with him in his preferred language may help to prevent his confusion and agitation. During an interview on 10/25/24 at 2:54 p.m. with the DMS , she stated she was not aware Pt 22 did not speak English. The DMS stated LNs reported to her Pt 22 spoke English. The DMS stated Pt 22 had not spoken to her in English. The DMS stated her expectation was for LNs to utilize interpreting services for patients in their preferred language. The DMS stated speaking to patients in their preferred language allows patients to feel more comfortable in their surroundings. During an interview on 10/28/24 at 1:17 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she assisted with care for Pt 22 on multiple occasions. CNA 1 stated Pt 22 responds to “simple commands” in English, such as questions about needing to be changed or if he was hungry. CNA 1 stated for more complex communication she would utilize Pt 22’s daughter on the telephone or utilize family if at bedside. CNA 1 stated she did not document the interpreting assistance by family in Pt 22’s “EMR”. During an interview on 10/28/24 at 3:12 p.m. with RN 14, RN 14 stated she was Pt 22’s primary nurse on 10/19/24 and used interpreter services to communicate with him. RN 14 stated she received in report from the off going nurse Pt 22 did not speak English, and he was cognitively impaired (problems with ability to think, learn, remember, use judgement, and make decisions). RN 14 stated the off going LN reported Pt 22 only spoke Portuguese, and the family was not at bedside to interpret. RN 14 stated hospital policy was to use the medical interpreter service for assessments, new medications, education, or any procedures. RN 14 stated without using the interpreter service during her assessment she would be unable to determine how cognitively impaired Pt 22 was. RN 14 stated when she used the interpreter, Pt 22 was disoriented, but spoke in complete full sentences. RN 14 stated when she asked Pt 22 if he knew where he was, he knew he was in a hospital, but he thought he was in a “Mental Hospital in Portugal”. RN 14 stated Pt 22 had a history of aggression with staff members. RN 14 stated it was possible Pt 22 became more agitated not only due to his TBI, but possibly due to frustrations of not understanding the languages being spoken. RN 14 stated the whole day of her shift Pt 22 was very pleasant and had no behavior issues. RN 14 stated LNs should communicate with patients in their preferred language. RN 14 stated LNs should document in the “EMR” when using a family member to interpret. RN 14 stated “if you don’t chart it, it wasn’t done”. During an interview on 10/28/24 at 2:57 p.m. with the Director of Patient Access (DPA), the DPA stated, the Patient Access staff completed the preferred language form in a patient’s “EMR”. The DPA stated a language preference was determined at time of arrival to the hospital. The DPA stated LNs could contact Patient Access staff to change the preferred language if incorrect in the “EMR”. During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated, LNs should be communicating with patients in their preferred language. The CNO stated LNs should be using the hospital resources available, including the video interpreting services or telephone interpreting services. The CNO stated her expectation was for LNs to follow hospital P&P for interpreting services. . During a review of the hospital’s policy and procedure (P&P) titled, “Interpreters”, dated 2/19/19, indicated, “ ... [name of hospital] staff will arrange to use the on demand video remote interpretation (VRI) service or language interpretation line at no cost to facilitate effective communication with a patient ... who is not fluent in English and/or when patient or patient representative has communicated his or her primary language is not English (the documented primary language is considered the patient’s preferred language for receiving information) ... [name of hospital] prohibits the use of outside interpreters other than the VRI or the contracted language line ... If the patient’s documented primary language is considered the patient’s preferred language for receiving information but the patient is fluent in more than one language and that language is English then the patient may elect to receive the information in English. The nurse shall document this in the medical record ... A patient may, after being informed of the availability of the interpreter service, choose to have an adult family member as an interpreter ...the patient must provide written permission to have access to the patient’s personal health information ... When the interpretation is of a medical nature, The VRI ... or language line is utilized ... when the interpretation is of a general nature (basic care no medical decision) any available employee, visitor, or volunteer may be utilized ... If the patient is unable to provide written consent, verbal consent is acceptable ... Staff will document in the patient’s medical record when interpreter service are made available to the patient and when an interpreter service [names of services] is utilized. Whenever an interpreter service is used the name of the outside service must be indicated in the medical record along with the interpreter Identification (ID ) ... If the patient elects to have a family member interpret, the [hospital] Staff must document the name of the person who acted as the interpreter and that person’s relationship to the patient ... Translation of documents ... Documents requiring patient’s signature whenever possible will be in the language the patient speaks. If the document is not available in their primary language the interpreter service should be used and the information recorded in the document ... Consents are available in English and Spanish, other languages require the use of the interpreter service ... The name of the interpreter or the interpreter ID number must be documented on the consent ... Discharge instructions will be provide in the patient’s primary language ...” During a review of professional reference titled, “Clinicians’ Obligations to Use Qualified Medical Interpreters When Caring for Patients with Limited English Proficiency,” dated 3/2017, (retrieved from https://journalofethics.ama assn.org/article/clinicians obligations use qualified medical interpreters when caring patients limited english/2017 03) indicated, “ ... Access to language services is a required and foundational component of care for patients with limited English proficiency (LEP) ... In the United States, patients with LEP have a legal right to access health care in their preferred language ...” 2. During a concurrent interview and record review on 10/25/24 at 11:03 a.m. with Manager (Mgr) 4, Pt 18’s “Face Sheet (FS),” dated 10/11/24 was reviewed. Mgr 4 stated the FS indicated Pt 18’s preferred language was Spanish. During a review of Pt 18’s “Consent for Treatment and Conditions for Admission (COA)”, dated 10/10/24, the COA indicated the COA was written in English. During an interview on 10/28/24 at 2:56 p.m. with the Director of Patient Access (DPA), the DPA stated the COA should have been written in the patient’s preferred language when the patient stated his preferred language was not English. During a review of the hospital’s policy and procedure (P&P) titled, “Interpreters”, dated 2/19/19, indicated, “ ... [name of hospital] staff will arrange to use the on demand video remote interpretation (VRI) service or language interpretation line at no cost to facilitate effective communication with a patient ... who is not fluent in English and/or when patient or patient representative has communicated his or her primary language is not English (the documented primary language is considered the patient’s preferred language for receiving information) ... [name of hospital] prohibits the use of outside interpreters other than the VRI or the contracted language line ... If the patient’s documented primary language is considered the patient’s preferred language for receiving information but the patient is fluent in more than one language and that language is English then the patient may elect to receive the information in English. The nurse shall document this in the medical record ... A patient may, after being informed of the availability of the interpreter service, choose to have an adult family member as an interpreter ...the patient must provide written permission to have access to the patient’s personal health information ... When the interpretation is of a medical nature, The VRI ... or language line is utilized ... when the interpretation is of a general nature (basic care no medical decision) any available employee, visitor, or volunteer may be utilized ... If the patient is unable to provide written consent, verbal consent is acceptable ... Staff will document in the patient’s medical record when interpreter service are made available to the patient and when an interpreter service [names of services] is utilized. Whenever an interpreter service is used the name of the outside service must be indicated in the medical record along with the interpreter ID ... If the patient elects to have a family member interpret, the [hospital] Staff must document the name of the person who acted as the interpreter and that person’s relationship to the patient ... Translation of documents ... Documents requiring patient’s signature whenever possible will be in the language the patient speaks. If the document is not available in their primary language the interpreter service should be used and the information recorded in the document ... Consents are available in English and Spanish, other languages require the use of the interpreter service ... The name of the interpreter or the interpreter ID number must be documented on the consent ... Discharge instructions will be provide in the patient’s primary language ...” During a review of professional reference titled, “Clinicians’ Obligations to Use Qualified Medical Interpreters When Caring for Patients with Limited English Proficiency,” dated 3/2017, (retrieved from https://journalofethics.ama assn.org/article/clinicians obligations use qualified medical interpreters when caring patients limited english/2017 03) indicated, “ ... Access to language services is a required and foundational component of care for patients with limited English proficiency (LEP) ... In the United States, patients with LEP have a legal right to access health care in their preferred language ...” 3. During a concurrent interview and record review on 10/23/24 at 2:00 p.m. with Manager (Mgr) 6, Pt 3’s “FS,” dated 10/23/24 and “EMR”” were reviewed. Mgr 6 stated the FS indicated Pt 3’s preferred language was Spanish. Mgr 6 stated she was unable to find any record while in the emergency room that nurses or providers spoke to the patient in her preferred language or used interpreter’s services. Mgr 6 stated it should be documented how staff communicated to Pt 3. During a review of Pt 3’s “Consent for Treatment and Conditions for Admission (COA)”, dated 10/10/24, the COA indicated the COA was written in English. During an interview on 10/28/24 at 2:56 p.m. with the Director of Patient Access (DPA), the DPA stated the COA should have been written in the patient’s preferred language when the patient stated his preferred language was not English. During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated, LNs should be communicating with patients in their preferred language. The CNO stated LNs should be using the hospital resources available, including the video interpreting services or telephone interpreting services. The CNO stated her expectation was for LNs to follow hospital P&P for interpreting services. During a review of the hospital’s policy and procedure (P&P) titled, “Interpreters”, dated 2/19/19, indicated, “ ... [name of hospital] staff will arrange to use the on demand video remote interpretation (VRI) service or language interpretation line at no cost to facilitate effective communication with a patient ... who is not fluent in English and/or when patient or patient representative has communicated his or her primary language is not English (the documented primary language is considered the patient’s preferred language for receiving information) ... [name of hospital] prohibits the use of outside interpreters other than the VRI or the contracted language line ... If the patient’s documented primary language is considered the patient’s preferred language for receiving information but the patient is fluent in more than one language and that language is English then the patient may elect to receive the information in English. The nurse shall document this in the medical record ... A patient may, after being informed of the availability of the interpreter service, choose to have an adult family member as an interpreter ...the patient must provide written permission to have access to the patient’s personal health information ... When the interpretation is of a medical nature, The VRI ... or language line is utilized ... when the interpretation is of a general nature (basic care no medical decision) any available employee, visitor, or volunteer may be utilized ... If the patient is unable to provide written consent, verbal consent is acceptable ... Staff will document in the patient’s medical record when interpreter service are made available to the patient and when an interpreter service [names of services] is utilized. Whenever an interpreter service is used the name of the outside service must be indicated in the medical record along with the interpreter ID ... If the patient elects to have a family member interpret, the [hospital] Staff must document the name of the person who acted as the interpreter and that person’s relationship to the patient ... Translation of documents ... Documents requiring patient’s signature whenever possible will be in the language the patient speaks. If the document is not available in their primary language the interpreter service should be used and the information recorded in the document ... Consents are available in English and Spanish, other languages require the use of the interpreter service ... The name of the interpreter or the interpreter ID number must be documented on the consent ... Discharge instructions will be provide in the patient’s primary language ...” During a review of professional reference titled, “Clinicians’ Obligations to Use Qualified Medical Interpreters When Caring for Patients with Limited English Proficiency,” dated 3/2017, (retrieved from https://journalofethics.ama assn.org/article/clinicians obligations use qualified medical interpreters when caring patients limited english/2017 03) indicated, “ ... Access to language services is a required and foundational component of care for patients with limited English proficiency (LEP) ... In the United States, patients with LEP have a legal right to access health care in their preferred language ...””

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 45977 Based on interview and record review, the hospital failed to have a process for prompt resolution of grievances for one of 32 patients (Pt 1), when Pt 1’s family submitted a grievance, and the hospital did not track and monitor the complaint/grievance process for Pt 1 in order to achieve prompt response in accordance with the hospital’s policy and procedure. The hospital did not develop and implement a log or other process to track the progress for prompt resolution of Pt 1’s complaint/grievance. These failures resulted in not ensuring the rights of Pt 1 and all patients who complaint/grieve, not provide a prompt resolution of complaints/grievances to determine whether the quality of care concerns that were experienced were effectively investigated and resolved and the potential for increased risk of injury and harm to patients. Findings: During a review of Pt 1’s,”History & Physical/ [H&P (H&P the formal document that physicians produce through interview with the patient, physical exam, and the summary of testing either obtained or pending] Admission Notes “, dated 8/22/24, the “H&P “ indicated, Pt 1 was admitted on 8/22/24, “ ... W/ [with] untreated depression (a constant feeling of sadness and loss of interest)/anxiety (a feeling of fear, dread, and uneasiness) and polysubstance [using multiple illicit drugs] use disorder presents due to 2d [secondary] of alcohol withdrawal sxs [symptoms] ...” Pt 1 was admitted with an order for Clinical Institute Withdrawal Assessment Alcohol Scare Revised (CIWA/AR-an instrument used by medical professionals to assess and diagnose the severity of alcohol withdrawal and administer medications based on the severity). During an interview on 10/24/24, at 9:58 a.m ., with RN 16, RN 16 stated patients had the right to complain about the care they receive. RN 16 stated patients could talk to the manager of the unit or even go to administration about issues. RN 16 state, she was unaware that complaints from patients while being cared for on the unit were considered grievances and should be responded to. During a concurrent interview and record review on 10/24/24, at 1:15 p.m., with the Director of Quality (DQ) and the PSO, the complaint/grievance log for August 2024, September 2024 and October 2024 were reviewed. Only one grievance was listed for August 28, 2024 about Pt 1 . The DQ stated, only formal grievances were being tracked. The DQ stated complaints were not being tracked or logged. The DQ stated, they were not following the policy about tracking and trending complaints or handling complaints systematically . The DQ stated, complaints were resolved on the spot by himself or the Patient Safety Officer (PSO). PSO stated the hospital was not tracking the complaints from patients and should have as hospital have done in the past. During an interview on 10/25/24, at 8:41 a.m., with Pt 1’s family member (FM 1), FM 1 stated, Pt 1 had fallen at the hospital and was transferred to another facility due to brain injury. FM 1 stated, he filed a grievance with the hospital Patient Safety Officer (PSO) about the care of Pt 1 as FM 1 felt that the fall was preventable. FM 1 stated, the PSO sent him a letter in response to his complaint about nurses receiving training but did not call him about the complaint resolution. During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated, the DQ reports to the Chief Executive Officer (CEO) and issues about complaints and grievances process should be reported to him. The CNO stated, she was unsure of the process for complaints and was unable to explain the process for how complaints are handled as per the hospital policy. The CNO stated, she would relay the message to the CEO about the findings of the policy not being followed. During a review of the hospital’s record “Patients’ Rights and Responsibilities (PR) [HOSPITAL NAME]” (PR), dated 8/5/2024, the PR indicated, “ ... You have the right to... Express concerns regarding any of these rights in accordance with the grievance process... Complaints: Should you need to file a complaint with this hospital. you may by writing or calling: Administrative Offices, [HOSPITAL ADDRESS] ... For those complaints/grievances filed by patients to hospital staff our policy is as follows: For patient complaints, staff present is to resolve the issue and report the patient complaint through the appropriate means for tracking purposes. Patient grievances (those complaints that are made verbally or writing and cannot be resolved immediately by staff present are to be recorded on the Complaint Form. The Unit Director will investigate the complaint and respond in writing to the patient. For most grievances, this written response will be sent to the patient within seven days of the complaint. If additional time is needed, we will notify the patient in writing that we are continuing our investigation and will respond as soon as possible...” During a review of the hospital’s policy and procedure, “Patient Complaints/Grievances”, dated 8/28/2024, the record indicated, “ ...This policy provides a mechanism for initiation, review, and when possible, prompt resolution of patient complaints concerning the quality of care of service(s) received. ... The Hospital’s process for managing Complaints and Grievances incorporate the following objectives: ... C. Provide a planned, systematic mechanism for receiving and promptly acting upon issues expressed by patients and/or patient representatives... D. Provide an on going system for monitoring and trending patient Complaints and Grievances. ... The Hospital Quality Management Department or the Director of Revenue Analysis (DRA) shall incorporate patient Complaints in the Complaint/Grievance data set for aggregation, analysis, and reporting quarterly to the designated Grievance Committee, Hospital Quality Improvement Committee, the Medical Staff Quality Improvement Committee, Medical Executive Committee (MEC), and Governing Board ... The Hospital’s Quality Management department will maintain a log that provides response to the patient. ... The DCQI [Director, Clinical Quality Improvement] or the Patient Safety Officer is responsible for ensuring that all individuals adhere to the requirements of this policy that these procedures are implemented and followed at the Hospital and that instances of non compliance with this policy are reported to the Chief Nursing Officer (CNO)... “ During a review of a professional reference, titled the “State Operations Manual” (SOM), dated 2020, the “SOM” indicated, “ ... Patient complaints that are considered grievances also include situations where a patient or a patient’s representative telephones the hospital with a complaint regarding the patient’s care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more Condition of Participations (CoPs ) or other CMS requirements. Whenever the patient or the patient’s representative requests that his or her complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, the complaint is considered a grievance and all the requirements apply. ...Data collected regarding patient grievances, as well as other complaints that are not defined as grievances (as determined by the hospital), must be incorporated in the hospital’s Quality Assessment and Performance Improvement (QAPI- a data driven and proactive approach to quality improvement) Program ...””

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 49884 Based on I nterview and record review, the hospital failed to ensure patients were free from restraints (a device that restricts movement) and to ensure restraints were discontinued at the earliest possible time when: 1. Licensed Nurse (LN)s did not implement every two hour monitoring for one of three patients (Pt 25) to determine if the restraints could be released in accordance with hospital policy and procedure (P&P). This failure resulted in Pt 25 not being monitored by LNs, which could have caused injuries from restraints and violated Pt 25’s right to be released from restraints at the earliest possible time . 2. LNs failed to obtain a physician order (PO) for renewal of non violent physical restraints (preventing movement of body and limbs) for one of three patients (Pt 24) while patient remained in non-violent physical restraints , in accordance with hospital P&P. This failure resulted in an unauthorized use of restraint on Pt 24 with the potential to result in inappropriate, unnecessary, and prolonged use of physical restraints . Findings: 1. During a concurrent interview and record review on 10/25/24 at 10 a.m. with Manager (Mgr) 6, Pt 25’s “History & Physical [H&P an assessment from physician including medical history and exam],” dated 10/4/24 at 2:44 p.m. was reviewed. The “H&P” indicated Pt 25 had a past medical history of alcohol abuse and was brought in by ambulance from home to the Emergency Department (ED). Mgr 6 stated Pt 25 was admitted to the hospital as an inpatient (a patient who is admitted to a hospital or other facility and stays overnight to receive medical care) for acute kidney injury (A sudden and often reversible decline in kidney function), rhabdomyolysis (potentially life threatening condition that occurs when muscle tissue breaks down, releasing harmful substances into the bloodstream), acute hypoxic respiratory failure (body doesn’t have enough oxygen in the tissues), and acute encephalopathy (brain dysfunction causing confusion) and moved to the Medical Surgical (MS) Telemetry (hospital floor where patients hearts are continuously monitored) Unit on 10/4/24 at 4:39 p.m. During a concurrent interview and record review on 10/25/24 at 10:05 a.m. with Mgr 6 Pt 25’s “Restraint Monitoring Flowsheet (RMF),” dated 10/09/24 to 10/13/24 were reviewed. The “RMF” indicated Pt 25 was on two point (a mechanical restraint that restricts a patient’s wrist movement) soft limb (soft materials for arm or leg) restraints that were initiated at 9 a.m. on 10/9/24 in the ED. Mgr 6 stated Pt 25’s “RMF” indicated LNs did not document the two hour assessment on 10/12/24 at 10 p.m. Mgr 6 stated hospital expectation and physician orders for non violent restraint monitoring were for LNs to complete a patient assessment at least every two hours. Mgr 6 stated monitoring patients on restraints at least every two hours was important because the patients were “tied down”. Mgr 6 stated LNs needed to assess the patient’s skin under the restraint area, reposition the patient, offer the patient something to drink, to eat, to change the patient or offer toileting. Mgr 6 stated assessing patient’s every two hours also allows LNs to determine if the patient needed to remain restrained. During an interview on 10/29/24 at 11:28 a.m. with the Chief Nursing Officer (CNO), the CNO stated LNs should monitor patients on restraints. The CNO stated if LNs did not monitor patients on restraints there was an increased risk of harm to the patient. The CNO stated her expectation was for LNs to follow the hospital P&P and monitor and document assessments for patients on restraints. During a review of the hospital’s P&P titled, “Restraint & Seclusion,” dated 11/9/23, indicated, “ ... Staff must discontinue Restraint or Seclusion (the act of involuntarily confining a person in a room or area from which they are physically prevented from leaving) at the earliest possible time, regardless of the scheduled expiration of the order ... Monitoring is accomplished by observation, direct face to face interaction with the patient or related direct examination of the patient by trained and competent staff ... Appropriate interval for re assessment is based on the patient needs, condition, and type of Restraint use ... When Restraint or Seclusion is used, there must be documentation in the patient’s medical record of the following: ... A description of the patient’s behavior and the intervention used ...Individual patient assessments and reassessments, and ... Use of Restraint or Seclusion in the Plan of Care ... Monitoring must include, but not be limited to ... Ability to clear airway ... Patient safety and comfort, during and after Restraint is removed ... Care will not be compromised by the use of Restraints and shall include ... Provision of nutritional needs ... Systemic [affecting the entire body] release of the restrained limbs. During a review of professional reference titled, Patient Restraint and Seclusion,” dated 11/14/22, (retrieved from https://www.ncbi.nlm.nih.gov/books/NBK565873/ f (nih.gov) indicated, “ ... Healthcare workers should know that restraint and seclusion can have significant adverse implications on patients and should be deemed a last resort. Healthcare professionals must follow the 4 basic ethical healthcare principles: autonomy [make decisions and act independently without interference from others], justice, beneficence [the doing of good, promoting the well being of others], and non maleficence [doing no harm]. Per beneficence the act of doing good and non maleficence do no harm; healthcare providers must ensure the administration of restraint is implemented as a last resort ... Healthcare workers must also be sure to appropriately monitor the patient following restraint and seclusion to avoid deleterious [causing harm] effects such as pressure ulcers [localized area of damaged skin or tissue that occurs when pressure is applied to skin for a long time], skin breakdown, abrasions [scraping or wearing away] , asphyxia [body deprived of oxygen, suffocation], strangulation, incontinence [involuntary loss of bladder control], depression, social isolation, and drug overdose or interaction ...Document appropriate clinical indications and prepare a standardized checklist for staff to monitor and supply patient needs effectively. Numerous deaths and adverse patient outcomes have been reported due to inappropriate restraint placement and negligent [failing to take proper care] monitoring. After restraint placement, patients should be reevaluated every hour and moved regularly ... Once it is safe, the patient should also be evaluated for medical causes of agitation ...” 2. During a review of Pt 24’s “H&P” dated 10/18/24 at 2:09 a.m., the “H&P” indicated Pt 24 had a past medical history of recently diagnosed untreated lung cancer, congestive heart failure (CHF heart cannot pump enough blood to meet body’s demands), and dementia (a decline in mental ability, loss of thinking, remembering, and reasoning, that worsens over time). Pt 24 was brought into the ED by family due to an increased decline in mental status, and visual hallucinations (hearing, seeing, smelling, tasting, or feeling things that appear but only exist in the mind). Pt 24 was admitted to the hospital as an inpatient for metabolic encephalopathy (brain dysfunction causing confusion caused by a chemical imbalance), and CHF on 10/18/24 at 2:12 a.m. Pt 24 was assigned a sitter (a person who takes care of someone) in the ED for safety purposes. During a concurrent interview and record review on 10/25/24 at 2:05 p.m. with Manager (Mgr) 6, Pt 24’s “Physician Orders (PO)” and Restraint Monitoring Flowsheet (RMF),” dated 10/18/24 to 10/22/24 were reviewed. Mgr 6 stated no “PO” for restraint renewal was ordered for 10/21/24. Mgr 6 stated LN documentation on Pt 24’s “RMF” indicated, Pt 24 was in non violent physical restraints continuously and monitored from 10/20/24 at 11:15 a.m. to 10/22/24 at 3:35 p.m. Mgr 6 stated Pt 24 should have had a “PO” for restraint renewal on 10/21/24. Mgr 6 stated Pt 24’s restraint order must be renewed every calendar day if the patient remained in restraints. Mgr 6 stated patients should not be in restraints without a “PO”. During an interview on 10/29/24 at 11:28 a.m. with the CNO, the CNO stated her expectation was for LNs to contact the physician and get an order to renew restraints every day when patients were in restraints. The CNO stated her expectation was for LNs to follow P&P. During a review of the hospital’s P&P titled, “Restraint & Seclusion,” dated 11/9/23, indicated “ ...Restraint and Seclusion [the involuntary confinement of a patient alone in a room or an area from which the patient is physically prevented from leaving] require an order from a physician or other authorized Licensed Practitioner responsible for the care of the Patient. The order must include reason for Restraint or Seclusion, type of Restraint, and duration of Restraint or Seclusion ... Staff must discontinue Restraint ... at the earliest possible time, regardless of the scheduled expiration order ... Staff will initiate or continue Restraint or Seclusion only upon the order of a physician or authorized Licensed Practitioner following the guidelines ... Trial releases are not permitted as the release of the patient is considered a discontinuation of the Restraint order. If Restraint or Seclusion is discontinued prior to order expiration, a new order must be obtained prior to reinitiating the use of Restraint or Seclusion ... Orders for Restraints based on medical needs/ behaviors must be renewed daily ...””

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 49884 Based on I nterview and record review, the hospital failed to ensure patients were free from restraints (a device that restricts movement) and to ensure restraints were discontinued at the earliest possible time when: 1. Licensed Nurse (LN)s did not implement every two hour monitoring for one of three patients (Pt 25) to determine if the restraints could be released in accordance with hospital policy and procedure (P&P). This failure resulted in Pt 25 not being monitored by LNs, which could have caused injuries from restraints and violated Pt 25’s right to be released from restraints at the earliest possible time . 2. LNs failed to obtain a physician order (PO) for renewal of non violent physical restraints (preventing movement of body and limbs) for one of three patients (Pt 24) while patient remained in non-violent physical restraints , in accordance with hospital P&P. This failure resulted in an unauthorized use of restraint on Pt 24 with the potential to result in inappropriate, unnecessary, and prolonged use of physical restraints . Findings: 1. During a concurrent interview and record review on 10/25/24 at 10 a.m. with Manager (Mgr) 6, Pt 25’s “History & Physical [H&P an assessment from physician including medical history and exam],” dated 10/4/24 at 2:44 p.m. was reviewed. The “H&P” indicated Pt 25 had a past medical history of alcohol abuse and was brought in by ambulance from home to the Emergency Department (ED). Mgr 6 stated Pt 25 was admitted to the hospital as an inpatient (a patient who is admitted to a hospital or other facility and stays overnight to receive medical care) for acute kidney injury (A sudden and often reversible decline in kidney function), rhabdomyolysis (potentially life threatening condition that occurs when muscle tissue breaks down, releasing harmful substances into the bloodstream), acute hypoxic respiratory failure (body doesn’t have enough oxygen in the tissues), and acute encephalopathy (brain dysfunction causing confusion) and moved to the Medical Surgical (MS) Telemetry (hospital floor where patients hearts are continuously monitored) Unit on 10/4/24 at 4:39 p.m. During a concurrent interview and record review on 10/25/24 at 10:05 a.m. with Mgr 6 Pt 25’s “Restraint Monitoring Flowsheet (RMF),” dated 10/09/24 to 10/13/24 were reviewed. The “RMF” indicated Pt 25 was on two point (a mechanical restraint that restricts a patient’s wrist movement) soft limb (soft materials for arm or leg) restraints that were initiated at 9 a.m. on 10/9/24 in the ED. Mgr 6 stated Pt 25’s “RMF” indicated LNs did not document the two hour assessment on 10/12/24 at 10 p.m. Mgr 6 stated hospital expectation and physician orders for non violent restraint monitoring were for LNs to complete a patient assessment at least every two hours. Mgr 6 stated monitoring patients on restraints at least every two hours was important because the patients were “tied down”. Mgr 6 stated LNs needed to assess the patient’s skin under the restraint area, reposition the patient, offer the patient something to drink, to eat, to change the patient or offer toileting. Mgr 6 stated assessing patient’s every two hours also allows LNs to determine if the patient needed to remain restrained. During an interview on 10/29/24 at 11:28 a.m. with the Chief Nursing Officer (CNO), the CNO stated LNs should monitor patients on restraints. The CNO stated if LNs did not monitor patients on restraints there was an increased risk of harm to the patient. The CNO stated her expectation was for LNs to follow the hospital P&P and monitor and document assessments for patients on restraints. During a review of the hospital’s P&P titled, “Restraint & Seclusion,” dated 11/9/23, indicated, “ ... Staff must discontinue Restraint or Seclusion (the act of involuntarily confining a person in a room or area from which they are physically prevented from leaving) at the earliest possible time, regardless of the scheduled expiration of the order ... Monitoring is accomplished by observation, direct face to face interaction with the patient or related direct examination of the patient by trained and competent staff ... Appropriate interval for re assessment is based on the patient needs, condition, and type of Restraint use ... When Restraint or Seclusion is used, there must be documentation in the patient’s medical record of the following: ... A description of the patient’s behavior and the intervention used ...Individual patient assessments and reassessments, and ... Use of Restraint or Seclusion in the Plan of Care ... Monitoring must include, but not be limited to ... Ability to clear airway ... Patient safety and comfort, during and after Restraint is removed ... Care will not be compromised by the use of Restraints and shall include ... Provision of nutritional needs ... Systemic [affecting the entire body] release of the restrained limbs. During a review of professional reference titled, Patient Restraint and Seclusion,” dated 11/14/22, (retrieved from https://www.ncbi.nlm.nih.gov/books/NBK565873/ f (nih.gov) indicated, “ ... Healthcare workers should know that restraint and seclusion can have significant adverse implications on patients and should be deemed a last resort. Healthcare professionals must follow the 4 basic ethical healthcare principles: autonomy [make decisions and act independently without interference from others], justice, beneficence [the doing of good, promoting the well being of others], and non maleficence [doing no harm]. Per beneficence the act of doing good and non maleficence do no harm; healthcare providers must ensure the administration of restraint is implemented as a last resort ... Healthcare workers must also be sure to appropriately monitor the patient following restraint and seclusion to avoid deleterious [causing harm] effects such as pressure ulcers [localized area of damaged skin or tissue that occurs when pressure is applied to skin for a long time], skin breakdown, abrasions [scraping or wearing away] , asphyxia [body deprived of oxygen, suffocation], strangulation, incontinence [involuntary loss of bladder control], depression, social isolation, and drug overdose or interaction ...Document appropriate clinical indications and prepare a standardized checklist for staff to monitor and supply patient needs effectively. Numerous deaths and adverse patient outcomes have been reported due to inappropriate restraint placement and negligent [failing to take proper care] monitoring. After restraint placement, patients should be reevaluated every hour and moved regularly ... Once it is safe, the patient should also be evaluated for medical causes of agitation ...” 2. During a review of Pt 24’s “H&P” dated 10/18/24 at 2:09 a.m., the “H&P” indicated Pt 24 had a past medical history of recently diagnosed untreated lung cancer, congestive heart failure (CHF heart cannot pump enough blood to meet body’s demands), and dementia (a decline in mental ability, loss of thinking, remembering, and reasoning, that worsens over time). Pt 24 was brought into the ED by family due to an increased decline in mental status, and visual hallucinations (hearing, seeing, smelling, tasting, or feeling things that appear but only exist in the mind). Pt 24 was admitted to the hospital as an inpatient for metabolic encephalopathy (brain dysfunction causing confusion caused by a chemical imbalance), and CHF on 10/18/24 at 2:12 a.m. Pt 24 was assigned a sitter (a person who takes care of someone) in the ED for safety purposes. During a concurrent interview and record review on 10/25/24 at 2:05 p.m. with Manager (Mgr) 6, Pt 24’s “Physician Orders (PO)” and Restraint Monitoring Flowsheet (RMF),” dated 10/18/24 to 10/22/24 were reviewed. Mgr 6 stated no “PO” for restraint renewal was ordered for 10/21/24. Mgr 6 stated LN documentation on Pt 24’s “RMF” indicated, Pt 24 was in non violent physical restraints continuously and monitored from 10/20/24 at 11:15 a.m. to 10/22/24 at 3:35 p.m. Mgr 6 stated Pt 24 should have had a “PO” for restraint renewal on 10/21/24. Mgr 6 stated Pt 24’s restraint order must be renewed every calendar day if the patient remained in restraints. Mgr 6 stated patients should not be in restraints without a “PO”. During an interview on 10/29/24 at 11:28 a.m. with the CNO, the CNO stated her expectation was for LNs to contact the physician and get an order to renew restraints every day when patients were in restraints. The CNO stated her expectation was for LNs to follow P&P. During a review of the hospital’s P&P titled, “Restraint & Seclusion,” dated 11/9/23, indicated “ ...Restraint and Seclusion [the involuntary confinement of a patient alone in a room or an area from which the patient is physically prevented from leaving] require an order from a physician or other authorized Licensed Practitioner responsible for the care of the Patient. The order must include reason for Restraint or Seclusion, type of Restraint, and duration of Restraint or Seclusion ... Staff must discontinue Restraint ... at the earliest possible time, regardless of the scheduled expiration order ... Staff will initiate or continue Restraint or Seclusion only upon the order of a physician or authorized Licensed Practitioner following the guidelines ... Trial releases are not permitted as the release of the patient is considered a discontinuation of the Restraint order. If Restraint or Seclusion is discontinued prior to order expiration, a new order must be obtained prior to reinitiating the use of Restraint or Seclusion ... Orders for Restraints based on medical needs/ behaviors must be renewed daily ...””

“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: 49884 Based on observation, interview and record review, the facility failed to ensure all licensed nurses (LNs) adhered to the hospital’s policies and procedures (P&P), when: 1. LNs did not perform quality control (QC- a system of maintaining standards, glucometers- a device for measuring the concentration of glucose in the blood, control Solutions-solution use to test the functionality of meter and strips) checks on One of two glucometers (a small, portable device that measures the amount of glucose, or sugar, in a person’s blood) in the Progressive Care Unit (PCU-a hospital area that provides intermediate care for patients who need more care than a general ward but less than intensive care) according to the facility’s P&P titled, “Blood Glucose (the main sugar found in your blood) Monitoring Using [Brand Name of glucometer] Inform II System,”. This failure placed patients at risk for inadequate blood glucose monitoring and management. 2. LNs did not administer phenobarbital (a medication used to control seizures, relieve anxiety and to prevent withdrawal symptoms) for one of one patient (Pt 1) according to the physician’s order. This failure resulted in Pt 1 receiving phenobarbital when it was not indicated and had the potential for drowsiness and sedation. 3. LNs did not adhere to the hospital’s P&P “Pain Management Policy” for two of six patients (Pt 1 and Pt 18). LNs did not assess pain, reassess pain after administration of pain medication, and did not complete a level of sedation assessment according to hospital policy. These failures placed Pt 1 and Pt 18 at risk for inadequate pain management or oversedation and could negatively affect the physical, emotional, and psychosocial (the influence of both physical and social factors on an individual) well-being of patients. 4. LNs did not complete a skin assessment (a physical examination that involves inspecting and palpating (a method of feeling with the fingers or hands) the skin to evaluate its health) for one of one patient (Pt 1) after Pt 1 had a fall and when Pt 1 was transferred to a different unit according to the facility’s P&P titled, “Standard for Impaired Skin Integrity (Potential/Actual).” This failure resulted in Pt 1’s skin assessment to not be completed which had the potential for any changes to go undetected. 5. LNs did not accurately complete a Physician Certification for Transfer and Patient Acknowledgement/Consent for one of one patient (Pt 1) when Pt 1 was transferred from the facility to another facility according to the facility’s P&P titled, “Transfer of Patients to Other Medical Facilities.” This failure resulted in incomplete transfer forms and had the potential for miscommunication on Pt 1’s condition. 6. LNs did not rotate injection sites for heparin (an anticoagulant you take to prevent blood clots or keep an existing clot from getting worse) administration for two of two patients (Pt 16 and Pt 18) according to nursing standards of practice. This failure had the potential for Pt 18 and Pt 16 to have tissue damage to the injection site and ineffective medication absorption. 7. One of five LNs (RN 16) did not complete the annual fit testing (a procedure to ensure that a respirator is comfortable and provides the expected level of protection to the wearer) according to the facility’s P&P titled, “Saccharin Solution Qualitative Fit Test.” This failure resulted in RN 16 being overdue on her annual fit testing and the potential for inaccurate mask fitting. 8. LNs did not adhere to hospital P&P “Standard for Impaired Skin Integrity [the health of the skin, or whether it is intact, unbroken, and undamaged] Potential/Actual” for three of four patients (Pt 21, Pt 22, and Pt 23). LNs did not document turning/repositioning patients every two hours per physician order. These failures had the potential to result in harm to Pt 21, Pt 22, and Pt 23 by increasing likelihood of skin breakdown and development of pressure injuries (PI- localized damage to the skin and/or underlying soft tissue, usually over a bony area or related to medical or other device damage to the skin and underlying tissue caused by prolonged pressure). Findings: 1. During a concurrent observation and interview on 10/22/24 at 3:40 p.m. with the Director of Critical Care (DCC) and Registered Nurse (RN) 15 in the PCU medication room, a glucometer case had two vials of glucose control solution (solution used to test the functionality of meter and strips) with no opened date written on the vials. RN 15 stated inaccurate results can occur if expired glucose control solutions were used. RN 15 stated the night shift charge nurse was responsible to perform the QC on the glucometers. The DCC stated she expected LNs to label the glucose control solution vial with the expiration date after opening. The DCC stated the glucose control solution vials were good for three months after opening or until the expiration date on the bottle. During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated LNs should be labeling the glucose control solution with the expiration date. The CNO stated she expected LNs to follow the hospital policy. During a review of the facilities P&P titled, “Blood Glucose Monitoring Using [Brand Name of glucometer] Inform II System,” dated 5/17/24, the P&P indicated “ ...QUALITY CONTROL TESTING OF [Brand Name] INFORM SYSTEM ...To insure the [brand name] Inform II meter is functioning properly, Quality Control (QC) are required every 24 hours. Both a level 1 test and a level 2 test will need to be done prior to continuing use of the meter. The meter will lock out until QC has been completed. Quality control should be performed: Once per 24 hours with each [brand name] Inform II monitor in routine use and when prompted ...Each time a new vial or new lot number of strips is utilize ...Whenever a vial of strips has been left uncapped ...If the monitor has been dropped ...Whenever test results disagree with clinical symptoms ...To recertify an operator ...Glucose control solutions (Level 1 and Level 2), for use with the [brand name] Inform II. Date control solution vials with open expiration date. The controls are good for 3 months after opening or until expiration date from manufacturer, whichever comes first ...If either Level 1 or Level 2 Control Test FAIL, chose appropriate comment and repeat the failed test. If one or both tests FAIL again, Check the expiration date of the strips and control solutions, Open fresh controls and repeat the test ...” 2. During a review of Pt 1’s “History and Physical (H &P-an assessment from physician including medical history and exam),” dated 8/22/24, the H&P indicated “ ...[Pt 1] [with] untreated depression [a serious mental health condition that can impact how a person feels, thinks, and functions in daily life] /anxiety [a feeling of fear, dread, and uneasiness] and polysubstance [the use of more than one drug] use disorder presents due to 2 [days] of alcohol withdrawal sxs [symptoms] ...” During a concurrent interview and record review on 10/24/24 at 10:15 a.m. with Manager (Mgr) 4, Pt 1’s “Provider Order (PO),” dated 8/22/24, “CIWA [Clinical Institute Withdrawal Assessment for Alcohol-an instrument used by medical professionals to assess and diagnose the severity of alcohol withdrawal] > [less than] 8 ...” flowsheet, dated 8/23/24 to 8/25/24 and “Medication Administration Record (MAR- a record of drugs administered to a patient),” dated 8/23/24 to 8/25/24 were reviewed. the PO indicated, “ ...Order: PHENobarbital ... Order Start Date/Time: 8/22/2024 [12:55 p.m.] ... Order Details: 130 mg [milligrams-unit of measure] = 1 mL (milliliter-unit of measure] ... IV Push [IVP-injecting a medication or fluid into a patient’s bloodstream through an intravenous (into a vein) line], Q2h [every 2 hours] Awake x 8 per day PRN [as needed] ... Order Comment: PRN CIWA ...” The CIWA on 8/23/24 at 8:30 a.m. indicated Pt 1 had a CIWA score of three (Scores of less than 8 to 10 indicate minimal to mild withdrawal. Scores of 8 to 15 indicate moderate withdrawal; and scores of 15 or more indicate severe withdrawal). The MAR on 8/23/24 at 8:44 a.m. indicated Pt 1 received phenobarbital 130 mg IVP. Mgr 4 stated Pt 1 should not have been administered phenobarbital when the CIWA score was less than eight. The CIWA on 8/23/24 at 5 p.m. indicated Pt 1 had a CIWA score of five. The MAR on 8/23/24 at 5:35 p.m. indicated Pt 1 received phenobarbital 130 mg IVP. Mgr 4 stated Pt 1 should not have been administered phenobarbital when the CIWA score was less than eight. The CIWA on 8/24/24 at 3 p.m. indicated Pt 1 had a CIWA score of two. The MAR on 8/24/24 at 7:45 p.m. indicated Pt 1 received phenobarbital 130 mg IVP. Mgr 4 stated Pt 1 should have had a CIWA completed before receiving phenobarbital. The CIWA on 8/25/24 at 4:45 p.m. indicated Pt 1 had a CIWA score of zero. The MAR on 8/25/24 at 4:57 p.m. indicated Pt 1 received phenobarbital 130 mg IVP. Mgr 4 stated Pt 1 should not have been administered phenobarbital when the CIWA score was less than eight. Mgr 4 stated sedation was a concern when phenobarbital was administered with a CIWA score of zero. Mgr 4 stated LNs were not following the physician’s order when phenobarbital was administered with a CIWA score less than 8. Mgr 4 stated the phenobarbital order indicated it was to be administered when a CIWA score was less than eight. Mgr 4 stated she expected LNs to follow physician’s orders. During an interview on 10/29/24 at 11:25 a.m. with the CNO, the CNO stated she expected LNs to follow the physician’s order when administering phenobarbital. During a review of the facility’s document, untitled, undated, the document indicated, “ ...Alcohol withdrawal syndrome (AWS) involves a group of select symptoms that develop several hours to a few days after an individual with a history of prolonged and heavy alcohol use (e.g., more than eight drinks per day on a daily basis for multiple days) stops or reduces alcohol intake ... Implement appropriate assessments, reassessments, treatments, and other interventions to target alcohol withdrawal symptoms per the practitioner’s orders ...” 3. During a review of Pt 1’s “H&P,” dated 8/22/24, the H&P indicated “[Pt 1] [with] untreated depression/anxiety and polysubstance use disorder presents due to 2 [days] of alcohol withdrawal sxs [symptoms] ...” During a review of Pt 1’s “Provider Order (PO),” dated 8/22/24, the PO indicated, “ ...acetaminophen [treats minor aches and pains, and reduces fever] ... Order Details: 650 mg [milligrams-unit of measure] = 2 tab [tablet] ... Oral, Q4hr [every 4 hours] PRN [as needed] For: Pain Mild ...” During a concurrent interview and record review on 10/24/24 at 10:15 a.m. with Mgr 4, Pt 1’s “Pain Assessment Flowsheet (PAF)”, dated 8/23/24 and “MAR,” dated 8/23/24 were reviewed. Mgr 4 stated the PAF indicated no pain assessment was done prior to pain medication administration and after. The MAR at 4 p.m. indicated Pt 1 was administered acetaminophen 650 mg. Mgr 4 stated the PAF indicated Pt 1 did not have a pain reassessment until 8 p.m. (a lapse of 4 hours and 19 minutes). Mgr 4 stated Pt 1 should have had his pain assessed before a pain medication was administered and reassessed within an hour after. Mgr 4 stated it was important to assess a patient’s pain before a pain medication administration to determine which pain medication should be given. Mgr 4 stated it was important to reassess a patient’s pain to make sure the patient was comfortable and assess the effectiveness of the pain medication. Mgr 4 stated the policy stated to reassess pain within one hour of pain medication administration. Mgr 4 stated she expected LNs to assess and reassess a patient’s pain. During a review of Pt 1’s “PO,” dated 8/22/24, the PO indicated, “ ...oxycodone [a narcotic (a drug that relieves pain and induces drowsiness) used to treat moderate to severe pain] ... Order Details: 5 mg = 1 tab ... Oral, Q4hr PRN For: Pain Moderate ...” During a concurrent interview and record review on 10/24/24 at 10:20 a.m. with M gr 4, Pt 1’s “PAF”, dated 8/25/24 and “MAR,” dated 8/25/24 were reviewed. The PAF at 5:17 a.m. indicated Pt 1 had a pain score of 5 (moderate) out of 10 (Mild Pain=score of 1-3, Moderate Pain=score of 4-6, Severe Pain=score of 7-10). The MAR at 5:17 a.m. indicated Pt 1 was administered oxycodone 5 mg. Mgr 4 stated the PAF indicated Pt 1 did not have a pain reassessment until 7:54 a.m. (a lapse of 2 hours and 37 minutes). Mgr 4 stated Pt 1’s pain should have been reassessed within an hour after receiving oxycodone. Mgr 4 stated the PAF indicated Pt 1 did not have a level of sedation assessment completed before and after oxycodone was administered. During a concurrent interview and record review on 10/25/24 at 10:33 a.m. with Mgr 4, Pt 1’s “PAF”, dated 8/24/24 and “MAR,” dated 8/24/24 were reviewed. The MAR at 7:45 p.m. indicated Pt 1 was administered oxycodone 5 mg. Mgr 4 stated the PAF indicated Pt 1 did not have a level of sedation assessment completed before and after oxycodone was administered. Mgr 4 stated LNs were expected to complete a level of sedation assessment before and after a narcotic was administered. Mgr 4 stated LNs should have completed a level of sedation assessment each time a narcotic was administered to Pt 1. Mgr 4 stated LNs should have followed the policy. During a review of Pt 18’s “H&P,” dated 10/10/24, the H&P indicated, “ ...[Pt 18] with past medical history for pulmonary hypertension [a serious condition that occurs when the blood pressure in the lungs is abnormally high], CAD [Coronary Artery Disease-a condition in which the arteries that supply blood to the heart become narrowed or blocked] ..., hypertension [when the pressure in your blood vessels is too high], ... diabetes type 2 [a long-term condition in which the body has trouble controlling blood sugar and using it for energy] ... presented to the ER [emergency room] from [physician’s name] office for possible left foot debridement [a medical procedure that removes dead, damaged, or infected tissue from a wound to help the healthy tissue heal] ...” During a concurrent interview and record review on 10/25/24 at 11:03 a.m. with Mgr 4, Pt 18’s “PAF”, dated 10/19/24 to 10/20/24 and “MAR,” dated 10/19/24 to 10/20/24 were reviewed. The PAF on 10/19/24 at 6:18 a.m. indicated Pt 18 had a pain score of 5 (moderate) out of 10 and no level of sedation was completed. The MAR on 10/19/24 at 6:18 a.m. indicated Pt 18 was administered acetaminophen 325 mg - hydrocodone 5 mg. Mgr 4 stated Pt 18’s level of sedation should have been completed prior to receiving a narcotic. Mgr 4 stated the PAF indicated Pt 18 did not have a pain reassessment until 10:34 a.m. (a lapse of 4 hours and 16 minutes). Mgr 4 stated Pt 18 should have had a pain reassessment within one hour after pain medication was administered. The PAF on 10/19/24 at 5:10 p.m. indicated Pt 18 had a pain score of 9 (severe) out of 10 and no level of sedation was completed. The MAR on 10/19/24 at 5:10 p.m. indicated Pt 18 was administered acetaminophen 325 mg - hydrocodone 10 mg. Mgr 4 stated the PAF indicated Pt 18 did not have a pain reassessment until 9:20 p.m. (a lapse of 4 hours and 10 minutes). The PAF on 10/20/24 at 2:26 p.m. indicated Pt 18 had a pain score of 6 (moderate) out of 10 and no level of sedation was completed. The MAR on 10/20/24 at 2:26 p.m. indicated Pt 18 was administered acetaminophen 325 mg - hydrocodone 5 mg. Mgr 4 stated the PAF indicated Pt 18 did not have a pain reassessment until 6:12 p.m. (a lapse of 3 hours and 46 minutes). During an interview on 10/29/24 at 11:25 a.m. with the CNO, the CNO stated LNs should be assessing pain and reassessing pain after administering a pain medication. The CNO stated the patient’s level of sedation should be assessed since it was part of the pain assessment and reassessment process. The CNO stated LNs should have followed the pain management policy. During a review of the facility’s P&P titled, “Pain Management,” dated 9/23/24, the P&P indicated, “ ...POLICY ...All patients have a right to appropriate assessment and management of pain ... PROCEDURE ...The pain intensity and pain relief, as reported by patient will be assessed and documented: 1. On admission, 2. After any known pain-producing event, 3. With each new report of pain, 4. With vital signs, 5. A reassessment within one hour of intervention or less as appropriate, 6. When medications are administered, 7. Assess the patient’s level of sedation before and after administering narcotic medication that could be potentially sedating. If the patient becomes over sedated or experiences respiratory depression, following any intervention intended to lessen the patient’s pain- notify the provider and document the measures taken ...” 4. During a review of Pt 1’s “H&P,” dated 8/22/24, the H&P indicated “ ... [Pt 1] with untreated depression/anxiety and polysubstance use disorder presents due to 2 [days] of alcohol withdrawal sxs [symptoms] ...” During a review of Pt 1’s “Electronic Medical Record (EMR-an electronic record of health-related information on an individual),” dated 8/22/24 to 8/27/24, the EMR indicated Pt 1 had a “Skin Assessment Form #3443 (SAF)” completed on 8/22/24 and 8/25/24. The SAF indicated “ ...Fill out a new form on admission, each time patient transfer to a different floor, and each time there is a significant change in patient condition (e.g. intubation ... change to constant observer) ...” During a concurrent interview and record review on 10/24/24 at 10:15 a.m. with Mgr 4, Pt 1’s “EMR,” dated 8/27/24 and “System Review (SR)” flowsheet, dated 8/27/24 were reviewed. Mgr 4 stated the EMR indicated Pt 1 had a fall around 1:45 p.m. Mgr 4 stated the SR indicated Pt 1 did not have a skin assessment completed after the fall. Mgr 4 stated Pt 1’s last skin assessment was completed at 8:58 a.m. The EMR indicated Pt 1 was transferred to the Critical Care Unit (CCU- a hospital department that provides specialized care for patients with life-threatening illnesses or injuries) at 6:20 p.m. Mgr 4 stated Pt 1 did not have a skin assessment completed when transferred to a different unit and it should have been completed. Mgr 4 stated it was important to complete a skin assessment when transferred to obtain a baseline (a starting point used for comparisons) of the patient. During a concurrent interview and record review on 10/24/24 at 1:35 p.m. with RN 7, Pt 1’s “SR” flowsheet, dated 8/27/24 was reviewed. RN 7 stated he cared for Pt 1 on the day of the fall. RN 7 stated the SR indicated there was no documentation a skin assessment was completed after Pt 1’s fall. RN 7 stated he should have completed and documented a skin assessment after Pt 1 fell. RN 7 stated he did not complete a skin assessment form. During a phone interview on 10/25/24 at 9:15 a.m. with RN 8, RN 8 stated he cared for Pt 1 when Pt 1 was transferred into the CCU after sustaining a fall. RN 8 stated a skin assessment should have been completed and documented when a patient was transferred to the unit. RN 8 stated he did not complete a skin assessment form. RN 8 stated it was important to assess a patient to establish a baseline when you received the patient. RN 8 stated a patient could change from the baseline and would want to notify the physician if changes occurred. During a concurrent interview and record review on 10/25/24 at 2:28 p.m. with the Director of Critical Care (DCC), the facility’s P&P titled, “Standard for Impaired Skin Integrity (Potential/Actual),” dated 7/22/24 was reviewed. The P&P indicated, “ ...PROCEDURE ... A. Preventative interventions: Guidelines for potential or actual impairment of skin integrity. 1. Two (2) RNs/ LVNs will do a generalized skin inspection, especially of bony prominences, and complete the Braden Scale Risk Assessment in the EMR and Skin Assessment Form #3443 (man sheet). Patients will receive this assessment: a. At the time of admission. b. At the time of transfer to a different floor, fill out a new Skin Assessment Form #3443 (man sheet). c. At the time of a significant change in patient’s condition (eg: intubation, beginning vasopressors or addition of another vasopressor, change to constant observer, significant change in LOC, in the event of a patient fall ...) fill out a new Skin Assessment Form #3443 (man sheet). d. Every shift, EMR documentation only, unless new skin issues are present ... f. If there are no skin integrity issues at the time of admission, transfer, or change in condition, the Skin Assessment Form #3443 (man sheet) will still be filled out, and the lack of skin issues will be noted on the diagram by writing “Skin Within Normal Limits” ...” The DCC stated RN 8 should have completed and documented a full skin assessment when Pt 1 was transferred to the CCU. The DCC stated RN 8 should have completed the skin assessment form according to the policy. During a concurrent interview and record review on 10/28/24 at 2:10 p.m. with Mgr 4, Pt 1’s EMR, dated 8/22/24 to 8/27/24 were reviewed. Mgr 4 stated Pt 1 had a SAF completed on 8/22/24 and 8/25/24. Mgr 4 stated a SAF was not completed after Pt 1 had a fall and when Pt 1 was transferred to the CCU. Mgr 4 stated a SAF should have been completed after Pt 1 fell to identify changes from Pt 1’s baseline. During an interview on 10/29/24 at 11:25 a.m. with the CNO, the CNO stated LNs should be following the policy for skin assessment to get an accurate view of the patient. 5. During a review of Pt 1’s “H&P,” dated 8/22/24, the H&P indicated “ ... [Pt 1] [with] untreated depression/anxiety and polysubstance use disorder presents due to 2 [days] of alcohol withdrawal sxs [symptoms] ...” During a concurrent interview and record review on 10/24/24 at 10:15 a.m. with Mgr 4, Pt 1’s “Physician Certification for Transfer and Patient Acknowledgement/Consent (Transfer Form), Section II,” dated 8/27/24 was reviewed. Mgr 4 stated the Transfer Form, Section II was signed by Pt 1’s mother. Mgr 4 stated the witness line had no signature. Mgr 4 stated the person who had the mother sign the Transfer Form, Section II should have signed the form as well. During a phone interview on 10/25/24 at 9:15 a.m. with RN 8, RN 8 stated he cared for Pt 1 when Pt 1 was transferred into the CCU after sustaining a fall. RN 8 could not recall if he went over the Transfer Form with Pt 1 and Pt 1’s family. RN 8 stated there should be a witness signature if the form was signed by someone other than the patient. During a concurrent interview and record review on 10/25/24 at 2:15 p.m. with RN 9 and the DCC, the facility’s P&P titled, “Transfer of Patients to Other Medical Facilities,” dated 6/5/24, was reviewed. Pt 1’s “Transfer Form, Section I,” undated and “Transfer Form, Section II,” dated 8/27/24 were reviewed. The P&P indicated, “ ...PURPOSE: To provide guidelines to facilitate a safe and appropriate transfer of patients in compliance with EMTALA [Emergency Medical Treatment and Labor Act is a federal law that ensures patients receive emergency care without regard to their ability to pay or insurance status] and California requirements ... Transfer of the stable patient: 1. If the Medical Screening Exam (MSE) establishes that no Emergency Medical Condition exists, the following steps should be taken: a. The medical record must reflect that the patient does not have an Emergency Medical Condition. b. The patient may be admitted, discharged, or transferred, as medically appropriate ... 2. If an Emergency Medical Condition was found to exist, but the physician determines that the patient’s medical condition is stabilized, the patient may be transferred when the following criteria have been met: a. Treatment to stabilize the patient must be administered within the capabilities of [name of hospital] available staff and services. 3. Physician Certification for Transfer and Patient Acknowledgment/Consent, Section I ...The physician should complete and sign prior to transfer. (Check box pertaining to stable patient.) The patient should sign the acknowledgment/consent prior to transfer. 4. Physician Certification for Transfer and Patient Acknowledgment/Consent, Section II: Patient Transfer Acknowledgment/Consent ...Should be completed to document acknowledgment of notification of the transfer by the patient or their legal representative ... D. Preparation steps prior to transfer: 1. Transferring Physician’s duties ...Complete Physician Certification for Transfer and Patient Acknowledgement/Consent ... 2. Nurse’s duties: ... Complete Physician Certification for Transfer and Patient Acknowledgement/Consent ... 4. Charge Nurse duties: ... Must review all paperwork ... DOCUMENTATION, A. All forms to be complete (no blank lines) ...” RN 9 stated the Transfer Form, Section I did not have an updated status of the patient’s condition. RN 9 stated the Transfer Form, Section I did not have a date and time of when the physician signed the form. RN 9 stated it was not a complete Transfer Form. RN 9 stated the physician should have completed the update on the patient’s condition on the Transfer Form, Section I. RN 9 stated the physician should have written the date and time of when the physician completed and signed the Transfer Form, Section I. RN 9 stated she gave the Transfer Form, Section II to RN 8 to get the patient and/or family consent and signature. RN 9 stated she did not witness the mother’s signature on the Transfer Form, Section II. RN 9 stated the LN who witnessed the mother’s signature should have signed the witness line on the Transfer Form, Section II. RN 9 stated it was her responsibility to review the Transfer Form for accuracy to ensure the safety of the patient’s care. During an interview on 10/25/24 at 2:28 p.m. with the DCC, the DCC stated the Transfer Form was incomplete. The DCC stated the primary RN should complete the first check for accuracy then the charge RN double checks to ensure accuracy and completeness. The DCC stated LNs should have checked the Transfer Form to ensure it was accurately completed. The DCC stated she expected LNs to sign the witness line to validate it was the patient or family’s signature. During an interview on 10/29/24 at 11:25 a.m. with the CNO, the CNO stated she expected transfer forms completed and filled out correctly. 6. During a review of Pt 18’s “H&P,” dated 10/10/24, the H&P indicated, “ ... [Pt 18] with past medical history for pulmonary hypertension, CAD ... hypertension ... diabetes type 2 ... presented to the ER from [physician’s name] office for possible left foot debridement ...” During a review of Pt 18’s “PO,” dated 10/14/24, the PO indicated, “ ...heparin ... 5,000 Unit (s) [unit of measure], 1 mL ... Injection ... Route of administration Subcut [subcutaneous- the injection is given in the fatty tissue, just under the skin] ... Frequency Q12hr ...” During a concurrent interview and record review on 10/25/24 at 11:03 a.m. with Mgr 4, Pt 18’s “MAR,” dated 10/15/24 to 10/17/24 were reviewed. The MAR indicated Pt 18 had heparin administered to his lower left abdomen on 10/15/25 at 9:09 a.m., 9:36 p.m., 10/16/24 at 8:51 a.m., 8:10 p.m., and 10/17/24 at 9:43 a.m. Mgr 4 stated the injection sites were not rotated. Mgr 4 stated it was important to rotate sites, so the patient does not bruise, and to allow for the absorption of the medication. Mgr 4 stated it could cause trauma to the skin, such as tissue damage. Mgr 4 stated LNs are expected to rotate injection sites. Mgr 4 stated LNs should have utilized the facility’s nursing skill platform on how to administer subcutaneous injections. Mgr 4 stated there was an icon on every desktop with the nursing skill platform which was accessible to all LNs. During a review of Pt 16’s “H&P,” dated 8/29/24, the H&P indicated, “ ... [Pt 18] transferred to our facility ... for a second opinion surgical consult. He has a complicated history of ... C1-C2 fracture [a break in the C1 or C2 vertebrae, which are located at the top of the neck and connect the head to the spine], quadriplegia [paralysis of all four limbs], trach [tracheostomy-a surgical procedure that creates an opening in the neck to provide an airway and help with breathing] ... history of hypertension, depression, anxiety, chronic pain ... deep tissue injuries [damage to the soft tissue beneath the skin caused by pressure or shear forces] ... Patient previously had a G-tube [gastrostomy tube-a small, flexible tube that is surgically inserted through the abdominal wall and into the stomach to provide nutrition and fluids], it was removed several weeks ago ... Since then he has a nonclosing gastric fistula [an abnormal opening in the stomach or intestines that allows the contents to leak to another part of the body] ...” During a review of Pt 16’s “PO,” dated 9/2/24, the PO indicated, “ ...heparin ... 5,000 Unit (s), 1 mL ... Injection ... Route of administration Subcut ... Frequency Q8hr ...” During a concurrent interview and record review on 10/25/24 at 1:38 p.m. with Mgr 4, Pt 16’s “MAR,” dated 10/19/24 to 10/24/24 were reviewed. The MAR indicated Pt 16 had heparin administered to his left lower abdomen on 10/19/24 at 2:38 p.m. and 10:15 p.m. The MAR indicated Pt 16 had heparin administered to his left lower abdomen on 10/20/24 at 2:21 p.m. and 10:17 p.m. The MAR indicated Pt 16 had heparin administered to his left lower abdomen on 10/22/24 at 5:50 a.m. and 2:33 p.m. The MAR indicated Pt 16 had heparin administered to his right lower abdomen on 10/23/24 at 2:25 p.m. and 9:18 p.m. The MAR indicated Pt 16 had heparin administered to his left lower abdomen on 10/24/24 at 5:39 a.m. and 1:57 p.m. Mgr 4 stated the injection site should have been rotated if the previous one was given in the same site. During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated LNs are expected to rotate injection sites. The CNO stated there could be harm to the patient if LNs are not rotating the injection sites. During a review of the facility’s document , untitled, undated, the document indicated, “ ...ALERT ... Do not administer the medication into the injection site if the skin is damaged, burned, bruised, hard, inflamed, or swollen ... Select an appropriate injection site based on the subcutaneous tissue mass, medication volume, and the required absorption rate. Inspect the skin surface for bruises, inflammation, or edema. Do not use an area that is bruised or has signs associated with infection. a. When administering heparin, use abdominal injection sites ... c. When administering insulin, systematically rotate the injection site within the same anatomic area (e.g., abdomen). During a professional reference review titled, “Injection Technique 2: Administering Drugs via the Subcutaneous Route,” dated 8/28/18, retrieved from https://www.nursingtimes.net/assessment-skills/injection-technique-2-administering-drugs-via-the-subcutaneous-route-28-08-2018/, the reference indicated, “ ...Complications associated with subcutaneous injections include abscesses and, in patients who require frequent injections, there is a risk of lipohypertrophy [a lump of fatty tissue under your skin caused by repeated injections in the same place]; this is characterized by an accumulation of fat under the skin. Lipohypertrophy occurs when multiple injections are repeatedly administered into the same area of skin. It can be painful and unsightly, and affect drug absorption, but can be prevented by rotating injection sites ...” 7. During a concurrent interview and record review on 10/29/24 at 10:45 a.m. with the Chief Human Resources Officer (CHRO) and the Director of Education (DE), Registered Nurse (RN) 16’s “Personnel File (PF),” undated was reviewed. The DE stated the PF indicated RN 16’s last fit testing was completed on 9/12/23. The DE stated facility staff were responsible to complete a fit testing within 12 months of the previous one. The DE stated facility staff performed the fit testing course on the facility’s learning platform and should complete the courses by the due date. During an interview on 10/29/24 at 11:25 a.m. with the CNO, the CNO stated the facility staff should follow the policy on fit testing. During a review of the facility’s P&P titled, “Saccharin Solution Qualitative Fit Test,” dated 5/22/18, the P&P indicated, “ ...PURPOSE: While caring for patients with actual or suspected mycobacterium tuberculosis disease, each employee will be wearing a respirator which has been fit tested for correct size for that employee ... Employees are fit tested at time of hire and then annually ...” 8. During a concurrent interview and record review on 10/24/24 at 10:24 a.m. with Mgr 6 Pt 21’s “H&P” dated 10/19/24 was reviewed. The “H&P” indicated, Pt 21 had a past medical history (PMH) of advanced dementia (a decline in mental ability, loss of thinking, remembering, and reasoning, that worsens over time), nonverbal status (unable to speak), and was brought in by ambulance for generalized weakness (decreased muscle strength). Mgr 6 stated Pt 21 was admitted for a complicated urinary tract infection (a bacterial infection that occurs when bacteria enter the urinary tract and multiply), adult failure to thrive (FTT- syndrome of weight loss, decreased appetite, poor nutrition, and inactivity), and dehydration (when body loses more fluids than it takes in). Pt 21 was admitted to the hospital as an inpatient and moved to the Medical Surgical (MS) Unit on 10/19/24 at 1:30 p.m. During a review of Pt 21’s “Physician Order (PO),” dated 10/19/24, the “PO” indicated, “ ... Turn Patient ... Requested Start Date/Time: 10/19/24 [2:08 p.m.] ... Frequency: Q2h [every 2 hours] ... Order entered secondary to turn patient every 2 hours documentation ...” During a concurrent interview and record review on 10/24/24 at 10:30 a.m. with Mgr 6, Pt 21’s “Braden Risk Assessment Flowsheet (BRAF) [risk score by LNs determining pressure injury risk]”, dated 10/19/24 to 10/245/24 was reviewed. Pt 21’s “BRAF” on 10/19/21 at 3 p.m. indicated a Braden Score (score given to patients indicating pressure injury risk from 6-23 lower the score higher the risk) of 13 . Mgr 6 stated Pt 21’s “BRAF” indicated a Braden score between 10 to 13 from 10/19/24 to 10/24/24. LNs documented Pt 21 was bedfast (confined to bed), mobility was completely limited, and she was a total assist patient. Mgr 6 stated a score of 10 to 13 indicated a higher risk of developing a pressure injury. Mgr 6 stated total assist patients were dependent on nursing staff to assist with repositioning. Mgr 6 stated all patients scoring less than 18 were considered at risk for PI and reduction strategies must be started. Mgr 6 stated LNs must complete a Braden Score every shift when assessing patients. Mgr 6 stated Pt 21 was supposed to be turned every two hours due to a low Braden score. During a concurrent interview and record review on 10/24/24 at 10:45 a.m. with Mgr 6, Pt 21’s “Activity Daily Living Flowsheet (ADLF)” dated 10/19/24 to 10/25/24 was reviewed. On 10/19/24 Pt 21 had no documented repositioning from 3 p.m. to 6 p.m. Mgr 6 stated Pt 21 should have been repositioned at 5 p.m. On 10/20/24 Pt 21 had no documented repositioning from 1 p.m. to 7:30 p.m. Mgr 6 stated Pt 21 should have been repositioned on 10/20/24 at 3 p.m., 5 p.m. and at 7 p.m. On 10/22/24 Pt 21 had no documented repositioning from 12:32 a.m. to 4:53 a.m. Mgr 6 stated Pt 21 should have been repositioned at 2:30 a.m. and at 4:30 a.m. On 10/23/24 Pt 21 had no documented repositioning from 8:45 a.m. to 12 p.m. Mgr 6 stated Pt 21 should have been repositioned at 10:45 a.m. Mgr 6 stated Pt 21 could have skin breakdown by not being repositioned every two hours. Mgr 6 stated skin breakdown could cause pressure injuries. Mgr 6 stated Pt 21 had many increased risk factors for skin breakdown such as being bedfast, her age, her medical condition, and being immobile. During a concurrent observation and interview on 10/24/24 at 2:46 p.m. with Registered Nurse (RN) 11 in Pt 21’s hospital room, Pt 21 was observed lying on her bed on her right side with the siderails of the bed up, and her head off the pillow close to the right-side rail. Pt 21 was unable to answer questions. RN 11, Pt 21’s primary LN was at bedside. RN 11 stated she determined Pt 21s needs by nonverbal ques (ways to communicate without using words), because Pt 21 was mostly non-verbal. RN 11 stated Pt 21 was supposed to be repositioned every two hours to prevent skin breakdown. Pt 21 was observed being moved up in bed and repositioned to the left side by LNs. RN 11 stated turning Pt 21 every two hours was important to prevent PI. During a concurrent interview and record review on 10/24/24 at 10:50 a.m. with Mgr 6, Pt 22’s “H & P,”, dated 9/17/24 was reviewed. “The “H&P” indicated, Pt 22 had a PMH of left-sided craniotomy (a surgical procedure that involves removing a section of the skull to access the brain), behavioral issues secondary to traumatic brain injury (TBI- a brain injury caused by an external force, such as a blow to the head. TBIs can range from mild to severe, and can affect how a person thinks, feels, acts, and moves), seizure disorder (a chronic brain condition that causes recurring seizures [a temporary episode of abnormal electrical activity in the brain that causes sudden change of behavior, movement, or consciousness]), due to TBI, and high blood pressure. Pt 22’s “H&P” indicated, “ ... presented to the ER [Emergency Room] on 9/5/24 for a 5150 hold [a California law that allows for the involuntary psychiatric detention of a person for up to 72 hours] ... Patient has been in the ER close to 2 weeks, been trying to get placement ...”. Mgr 6 stated Pt 22 was moved to the inpatient Medical Surgical (MS) Unit on 9/17/24 at 6:55 p.m. During a review of Pt 22’s “PO,” dated 10/12/24, the “PO” indicated, “ ... Turn Patient ... Requested Start Date/Time: 10/12/24 [1:05 a.m.] ... Frequency: Q2h [every 2 hours] ...” During a concurrent interview and record review on 10/24/24 at 11:30 a.m. with Mgr 6, Pt 22’s “BRAF”, dated 10/3/24 to 10/25/24 was reviewed. Pt 22’s “BRAF” on 10/23/21 at 8:12 a.m. indicated a Braden Score of 15. LNs documented Pt 22 was chairfast (severely limited or non-existent ability to walk, cannot hold own weight), mobility was very limited, and he was a maximum assist patient. Mgr 6 stated a score of 15 indicated a higher risk of developing a PI. Mgr 6 stated maximum assist patients were mostly dependent on nursing staff to assist with repositioning. Mgr 6 stated Pt 22 was supposed to be turned every two hours due to a low Braden score. During a concurrent interview and record review on 10/24/24 at 11:40 a.m. with Mgr 6, Pt 22’s “Patient Position Flowsheet (PPF)” dated 10/3/24 to 10/25/24 was reviewed. On 10/22/24 Pt 22 had no documented repositioning from 7:32 p.m. to 10/23/24 at 8:12 a.m., over 12 hours. Mgr 6 stated Pt 22 should have been repositioned on 10/22/24 at 9:30 p.m., and11:30 p.m. Mgr 6 stated on 10/23/24 Pt 22 should have been repositioned at 1:30 a.m., 3:30 a.m., 5:30 a.m., and 7:30 a.m. Mgr 6 stated Pt 22 could have skin breakdown by not being repositioned every two hours. Mgr 6 stated skin breakdown could cause pressure injuries. During a concurrent observation and interview on 10/25/24 at 3:15 with The Director of Medical Surgical (DMS) in Pt 22’s hospital room. Pt 22 was observed lying on his back with his eyes open, with his right arm lying at his side on the bed and his left arm over his chest. Pt 22 was lying with his head slightly elevated with a pillow. Pt 22’s right arm was not elevated on any surfaces. The DMS stated Pt 22 was unable to move his right arm. Pt 22’s right thumb had a dime sized open wound to the knuckle area. Pt 22 did not respond to questions when asked in English. Pt 22 had delayed responses when responding to questions in Spanish. Pt 22’s right hand had slight swelling. The DMS stated Pt 22 required LNs assistance for positioning into and out of his wheelchair and positioning of his right arm. During a concurrent interview and record review on 10/28/24 at 11:25 a.m. with Mgr 4, Pt 22’s “Electronic Medical Record” was reviewed. Mgr 4 stated Pt 22 was incontinent of stool (involuntary release of feces due to an inability to control bowel movements). Mgr 4 stated Pt 22 was not ambulatory (capable of walking) and was dependent on staff for positioning and getting into and out of his wheelchair. Mgr 4 stated Pt 22 was a higher risk of skin breakdown due to incontinence, low mobility, and being chairfast. Mgr 4 stated LNs should reposition Pt 22 every two hours, and if he was up in the wheelchair assure, he was shifting his weight in the chair to prevent PI. Mgr 4 stated LN documentation indicated Pt 22 was not being repositioned every two hours. During a review of Pt 23’s “H&P”, dated 10/19/24, the “H&P” indicated Pt 23 had a PMH of mild dementia, and suspected congestive heart failure (CHF - heart cannot pump blood efficiently) who presented to the hospital due to weakness. Pt 23 was admitted to the hospital as an inpatient for pneumonia (an infection that inflames the air sacs in one or both lungs) on 10/19/24 and moved to the MS unit. During a review of Pt 23’s “PO,” dated 10/20/24, the “PO” indicated, “ ... Turn Patient ... Requested Start Date/Time: 10/20/24 [1:04 a.m.] ... Frequency: Q2h [every 2 hours] ... Order entered secondary to turn patient every 2 hours documentation ...” During a concurrent interview and record review on 10/24/24 at 1:40 p.m. with Mgr 6, Pt 23’s “BRAF”, dated 10/19/24 to 10/25/24 was reviewed. Pt 23’s “BRAF” on 10/19/21 at 10:11 a.m. indicated a Braden Score of 15. LNs documented Pt 23 was bedfast, her mobility was very limited, and she was a maximum assist patient. Mgr 6 stated a score of 15 indicated a higher risk of skin breakdown that could lead to a PI. Mgr 6 stated Pt 23 was supposed to be turned every two hours due to a low Braden score. Mgr 6 stated Pt 23 had impaired mobility and needed assistance for repositioning. During a concurrent interview and record review on 10/24/24 at 1:45 p.m. with Mgr 6, Pt 23’s “ADLF” dated 10/19/24 to 10/25/24 was reviewed. On 10/20/24 Pt 23 had no documented repositioning from 6 a.m. to 10 a.m. Mgr 6 stated Pt 23 should have been repositioned at 8 a.m. Mgr 6 stated repositioning patients was important to prevent PI. During an interview on 10/29/24 at 11:29 a.m. with the Chief Nursing Officer (CNO), The CNO stated, patients should be repositioned according to policy to prevent skin issues such as pressure injuries. The CNO stated her expectation was for hospital staff to follow P&P. During a review of the hospital’s P&P titled, “Standard for Impaired Skin Integrity (Potential/Actual),” dated 7/22/24, the P&P indicated “ ... When Braden Scale Risk Assessment score is 14 or less, (moderate to high risk for developing pressure injury) or the patient is immobile ... Implement pressure injury prevention measures ... reposition bedbound patients at least every 2 hours, more frequently if indicated by patient’s condition ... Reposition patients in chair at least every hour and have capable patients shift their weight every 15 minutes ...” During professional reference review titled, “The Braden Scale and How it Predicts Pressure Injury Risk”(retrieved from https://blog.wcei.net/braden-scale-score-for-predicting-pressure-injury-risk), March 5, 2024, indicated, “ ...19-23 equals no risk, 15-18 equals mild risk, 13-14 equals moderate risk, 10-12 equals high risk, < 9 [< - less than] equals severe risk ... for pressure injury ...” Each assessment category was scored one through four, with six categories. Category one sensory perception [process of detecting, recognizing, and interpreting things or events from the environment using the senses [touch, sight, smell, taste, and hearing], two moisture, three activity, four mobility, five nutrition, and category six friction [rubbing of one surface against another] and shear the force that causes internal body structures and skin tissues to move in opposite directions] ...” During a review of professional reference titled, “Turning and Repositioning Frequency to Prevent Hospital-Acquired Pressure Injuries Among Adult Patients: Systematic Review,” dated 2023, indicated “ ... Turning and repositioning is considered one of the strategies to reduce the incidence of pressure injuries (PI)s among hospitalized patients, as it helps to redistribute and minimize direct pressure on targeted skin and enhance blood perfusion [the process of blood flowing through a tissue delivering oxygen and nutrients and removing waste products] in the affected areas ...””

“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: 49538 Based on observation, interview and record review, the facility failed to ensure all licensed nurses (LNs) adhered to the hospital’s policies and procedures (P&P), when: 1. LNs did not perform quality control (QC- a system of maintaining standards, glucometers- a device for measuring the concentration of glucose in the blood, control Solutions-solution use to test the functionality of meter and strips) checks on One of two glucometers (a small, portable device that measures the amount of glucose, or sugar, in a person’s blood) in the Progressive Care Unit (PCU-a hospital area that provides intermediate care for patients who need more care than a general ward but less than intensive care) according to the facility’s P&P titled, “Blood Glucose (the main sugar found in your blood) Monitoring Using [Brand Name of glucometer] Inform II System”. This failure placed patients at risk for inadequate blood glucose monitoring and management. 2. LNs did not administer phenobarbital (a medication used to control seizures, relieve anxiety and to prevent withdrawal symptoms) for one of one patient (Pt 1) according to the physician’s order. This failure resulted in Pt 1 receiving phenobarbital when it was not indicated and had the potential for drowsiness and sedation. 3. LNs did not adhere to the hospital’s P&P “Pain Management Policy” for two of six patients (Pt 1 and Pt 18). LNs did not assess pain, reassess pain after administration of pain medication, and did not complete a level of sedation assessment according to hospital policy. These failures placed Pt 1 and Pt 18 at risk for inadequate pain management or oversedation and could negatively affect the physical, emotional, and psychosocial (the influence of both physical and social factors on an individual) well-being of patients. 4. LNs did not complete a skin assessment (a physical examination that involves inspecting and palpating (a method of feeling with the fingers or hands) the skin to evaluate its health) for one of one patient (Pt 1) after Pt 1 had a fall and when Pt 1 was transferred to a different unit according to the facility’s P&P titled, “Standard for Impaired Skin Integrity (Potential/Actual).” This failure resulted in Pt 1’s skin assessment to not be completed which had the potential for any changes to go undetected. 5. LNs did not accurately complete a Physician Certification for Transfer and Patient Acknowledgement/Consent for one of one patient (Pt 1) when Pt 1 was transferred from the facility to another facility according to the facility’s P&P titled, “Transfer of Patients to Other Medical Facilities.” This failure resulted in incomplete transfer forms and had the potential for miscommunication on Pt 1’s condition. 6. LNs did not rotate injection sites for heparin (an anticoagulant you take to prevent blood clots or keep an existing clot from getting worse) administration for two of two patients (Pt 16 and Pt 18) according to nursing standards of practice. This failure had the potential for Pt 18 and Pt 16 to have tissue damage to the injection site and ineffective medication absorption. 7. One of five LNs (RN 16) did not complete the annual fit testing (a procedure to ensure that a respirator is comfortable and provides the expected level of protection to the wearer) according to the facility’s P&P titled, “Saccharin Solution Qualitative Fit Test.” This failure resulted in RN 16 being overdue on her annual fit testing and the potential for inaccurate mask fitting. 8. LNs did not adhere to hospital P&P “Standard for Impaired Skin Integrity [the health of the skin, or whether it is intact, unbroken, and undamaged] Potential/Actual” for three of four patients (Pt 21, Pt 22, and Pt 23). LNs did not document turning/repositioning patients every two hours per physician order. These failures had the potential to result in harm to Pt 21, Pt 22, and Pt 23 by increasing likelihood of skin breakdown and development of pressure injuries (PI- localized damage to the skin and/or underlying soft tissue, usually over a bony area or related to medical or other device damage to the skin and underlying tissue caused by prolonged pressure). Findings: 1. During a concurrent observation and interview on 10/22/24 at 3:40 p.m. with the Director of Critical Care (DCC) and Registered Nurse (RN) 15 in the PCU medication room, a glucometer case had two vials of glucose control solution (solution used to test the functionality of meter and strips) with no opened date written on the vials. RN 15 stated inaccurate results can occur if expired glucose control solutions were used. RN 15 stated the night shift charge nurse was responsible to perform the QC on the glucometers. The DCC stated she expected LNs to label the glucose control solution vial with the expiration date after opening. The DCC stated the glucose control solution vials were good for three months after opening or until the expiration date on the bottle. During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated LNs should be labeling the glucose control solution with the expiration date. The CNO stated she expected LNs to follow the hospital policy. During a review of the facilities P&P titled, “Blood Glucose Monitoring Using [Brand Name of glucometer] Inform II System,” dated 5/17/24, the P&P indicated “ ...QUALITY CONTROL TESTING OF [Brand Name] INFORM SYSTEM ...To insure the [brand name] Inform II meter is functioning properly, Quality Control (QC) are required every 24 hours. Both a level 1 test and a level 2 test will need to be done prior to continuing use of the meter. The meter will lock out until QC has been completed. Quality control should be performed: Once per 24 hours with each [brand name] Inform II monitor in routine use and when prompted ...Each time a new vial or new lot number of strips is utilize ...Whenever a vial of strips has been left uncapped ...If the monitor has been dropped ...Whenever test results disagree with clinical symptoms ...To recertify an operator ...Glucose control solutions (Level 1 and Level 2), for use with the [brand name] Inform II. Date control solution vials with open expiration date. The controls are good for 3 months after opening or until expiration date from manufacturer, whichever comes first ...If either Level 1 or Level 2 Control Test FAIL, chose appropriate comment and repeat the failed test. If one or both tests FAIL again, Check the expiration date of the strips and control solutions, Open fresh controls and repeat the test ...” 2. During a review of Pt 1’s “History and Physical (H &P-an assessment from physician including medical history and exam),” dated 8/22/24, the H&P indicated “ ...[Pt 1] [with] untreated depression [a serious mental health condition that can impact how a person feels, thinks, and functions in daily life] /anxiety [a feeling of fear, dread, and uneasiness] and polysubstance [the use of more than one drug] use disorder presents due to 2 [days] of alcohol withdrawal sxs [symptoms] ...” During a concurrent interview and record review on 10/24/24 at 10:15 a.m. with Manager (Mgr) 4, Pt 1’s “Provider Order (PO),” dated 8/22/24, “CIWA [Clinical Institute Withdrawal Assessment for Alcohol-an instrument used by medical professionals to assess and diagnose the severity of alcohol withdrawal] > [less than] 8 ...” flowsheet, dated 8/23/24 to 8/25/24 and “Medication Administration Record (MAR- a record of drugs administered to a patient),” dated 8/23/24 to 8/25/24 were reviewed. the PO indicated, “ ...Order: PHENobarbital ... Order Start Date/Time: 8/22/2024 [12:55 p.m.] ... Order Details: 130 mg [milligrams-unit of measure] = 1 mL (milliliter-unit of measure] ... IV Push [IVP-injecting a medication or fluid into a patient’s bloodstream through an intravenous (into a vein) line], Q2h [every 2 hours] Awake x 8 per day PRN [as needed] ... Order Comment: PRN CIWA ...” The CIWA on 8/23/24 at 8:30 a.m. indicated Pt 1 had a CIWA score of three (Scores of less than 8 to 10 indicate minimal to mild withdrawal. Scores of 8 to 15 indicate moderate withdrawal; and scores of 15 or more indicate severe withdrawal). The MAR on 8/23/24 at 8:44 a.m. indicated Pt 1 received phenobarbital 130 mg IVP. Mgr 4 stated Pt 1 should not have been administered phenobarbital when the CIWA score was less than eight. The CIWA on 8/23/24 at 5 p.m. indicated Pt 1 had a CIWA score of five. The MAR on 8/23/24 at 5:35 p.m. indicated Pt 1 received phenobarbital 130 mg IVP. Mgr 4 stated Pt 1 should not have been administered phenobarbital when the CIWA score was less than eight. The CIWA on 8/24/24 at 3 p.m. indicated Pt 1 had a CIWA score of two. The MAR on 8/24/24 at 7:45 p.m. indicated Pt 1 received phenobarbital 130 mg IVP. Mgr 4 stated Pt 1 should have had a CIWA completed before receiving phenobarbital. The CIWA on 8/25/24 at 4:45 p.m. indicated Pt 1 had a CIWA score of zero. The MAR on 8/25/24 at 4:57 p.m. indicated Pt 1 received phenobarbital 130 mg IVP. Mgr 4 stated Pt 1 should not have been administered phenobarbital when the CIWA score was less than eight. Mgr 4 stated sedation was a concern when phenobarbital was administered with a CIWA score of zero. Mgr 4 stated LNs were not following the physician’s order when phenobarbital was administered with a CIWA score less than 8. Mgr 4 stated the phenobarbital order indicated it was to be administered when a CIWA score was less than eight. Mgr 4 stated she expected LNs to follow physician’s orders. During an interview on 10/29/24 at 11:25 a.m. with the CNO, the CNO stated she expected LNs to follow the physician’s order when administering phenobarbital. During a review of the facility’s document, untitled, undated, the document indicated, “ ...Alcohol withdrawal syndrome (AWS) involves a group of select symptoms that develop several hours to a few days after an individual with a history of prolonged and heavy alcohol use (e.g., more than eight drinks per day on a daily basis for multiple days) stops or reduces alcohol intake ... Implement appropriate assessments, reassessments, treatments, and other interventions to target alcohol withdrawal symptoms per the practitioner’s orders ...” 3. During a review of Pt 1’s “H&P,” dated 8/22/24, the H&P indicated “[Pt 1] [with] untreated depression/anxiety and polysubstance use disorder presents due to 2 [days] of alcohol withdrawal sxs [symptoms] ...” During a review of Pt 1’s “Provider Order (PO),” dated 8/22/24, the PO indicated, “ ...acetaminophen [treats minor aches and pains, and reduces fever] ... Order Details: 650 mg [milligrams-unit of measure] = 2 tab [tablet] ... Oral, Q4hr [every 4 hours] PRN [as needed] For: Pain Mild ...” During a concurrent interview and record review on 10/24/24 at 10:15 a.m. with Mgr 4, Pt 1’s “Pain Assessment Flowsheet (PAF)”, dated 8/23/24 and “MAR,” dated 8/23/24 were reviewed. Mgr 4 stated the PAF indicated no pain assessment was done prior to pain medication administration and after. The MAR at 4 p.m. indicated Pt 1 was administered acetaminophen 650 mg. Mgr 4 stated the PAF indicated Pt 1 did not have a pain reassessment until 8 p.m. (a lapse of 4 hours and 19 minutes). Mgr 4 stated Pt 1 should have had his pain assessed before a pain medication was administered and reassessed within an hour after. Mgr 4 stated it was important to assess a patient’s pain before a pain medication administration to determine which pain medication should be given. Mgr 4 stated it was important to reassess a patient’s pain to make sure the patient was comfortable and assess the effectiveness of the pain medication. Mgr 4 stated the policy stated to reassess pain within one hour of pain medication administration. Mgr 4 stated she expected LNs to assess and reassess a patient’s pain. During a review of Pt 1’s “PO,” dated 8/22/24, the PO indicated, “ ...oxycodone [a narcotic (a drug that relieves pain and induces drowsiness) used to treat moderate to severe pain] ... Order Details: 5 mg = 1 tab ... Oral, Q4hr PRN For: Pain Moderate ...” During a concurrent interview and record review on 10/24/24 at 10:20 a.m. with M gr 4, Pt 1’s “PAF”, dated 8/25/24 and “MAR,” dated 8/25/24 were reviewed. The PAF at 5:17 a.m. indicated Pt 1 had a pain score of 5 (moderate) out of 10 (Mild Pain=score of 1-3, Moderate Pain=score of 4-6, Severe Pain=score of 7-10). The MAR at 5:17 a.m. indicated Pt 1 was administered oxycodone 5 mg. Mgr 4 stated the PAF indicated Pt 1 did not have a pain reassessment until 7:54 a.m. (a lapse of 2 hours and 37 minutes). Mgr 4 stated Pt 1’s pain should have been reassessed within an hour after receiving oxycodone. Mgr 4 stated the PAF indicated Pt 1 did not have a level of sedation assessment completed before and after oxycodone was administered. During a concurrent interview and record review on 10/25/24 at 10:33 a.m. with Mgr 4, Pt 1’s “PAF”, dated 8/24/24 and “MAR,” dated 8/24/24 were reviewed. The MAR at 7:45 p.m. indicated Pt 1 was administered oxycodone 5 mg. Mgr 4 stated the PAF indicated Pt 1 did not have a level of sedation assessment completed before and after oxycodone was administered. Mgr 4 stated LNs were expected to complete a level of sedation assessment before and after a narcotic was administered. Mgr 4 stated LNs should have completed a level of sedation assessment each time a narcotic was administered to Pt 1. Mgr 4 stated LNs should have followed the policy. During a review of Pt 18’s “H&P,” dated 10/10/24, the H&P indicated, “ ...[Pt 18] with past medical history for pulmonary hypertension [a serious condition that occurs when the blood pressure in the lungs is abnormally high], CAD [Coronary Artery Disease-a condition in which the arteries that supply blood to the heart become narrowed or blocked] ..., hypertension [when the pressure in your blood vessels is too high], ... diabetes type 2 [a long-term condition in which the body has trouble controlling blood sugar and using it for energy] ... presented to the ER [emergency room] from [physician’s name] office for possible left foot debridement [a medical procedure that removes dead, damaged, or infected tissue from a wound to help the healthy tissue heal] ...” During a concurrent interview and record review on 10/25/24 at 11:03 a.m. with Mgr 4, Pt 18’s “PAF”, dated 10/19/24 to 10/20/24 and “MAR,” dated 10/19/24 to 10/20/24 were reviewed. The PAF on 10/19/24 at 6:18 a.m. indicated Pt 18 had a pain score of 5 (moderate) out of 10 and no level of sedation was completed. The MAR on 10/19/24 at 6:18 a.m. indicated Pt 18 was administered acetaminophen 325 mg - hydrocodone 5 mg. Mgr 4 stated Pt 18’s level of sedation should have been completed prior to receiving a narcotic. Mgr 4 stated the PAF indicated Pt 18 did not have a pain reassessment until 10:34 a.m. (a lapse of 4 hours and 16 minutes). Mgr 4 stated Pt 18 should have had a pain reassessment within one hour after pain medication was administered. The PAF on 10/19/24 at 5:10 p.m. indicated Pt 18 had a pain score of 9 (severe) out of 10 and no level of sedation was completed. The MAR on 10/19/24 at 5:10 p.m. indicated Pt 18 was administered acetaminophen 325 mg - hydrocodone 10 mg. Mgr 4 stated the PAF indicated Pt 18 did not have a pain reassessment until 9:20 p.m. (a lapse of 4 hours and 10 minutes). The PAF on 10/20/24 at 2:26 p.m. indicated Pt 18 had a pain score of 6 (moderate) out of 10 and no level of sedation was completed. The MAR on 10/20/24 at 2:26 p.m. indicated Pt 18 was administered acetaminophen 325 mg - hydrocodone 5 mg. Mgr 4 stated the PAF indicated Pt 18 did not have a pain reassessment until 6:12 p.m. (a lapse of 3 hours and 46 minutes). During an interview on 10/29/24 at 11:25 a.m. with the CNO, the CNO stated LNs should be assessing pain and reassessing pain after administering a pain medication. The CNO stated the patient’s level of sedation should be assessed since it was part of the pain assessment and reassessment process. The CNO stated LNs should have followed the pain management policy. During a review of the facility’s P&P titled, “Pain Management,” dated 9/23/24, the P&P indicated, “ ...POLICY ...All patients have a right to appropriate assessment and management of pain ... PROCEDURE ...The pain intensity and pain relief, as reported by patient will be assessed and documented: 1. On admission, 2. After any known pain-producing event, 3. With each new report of pain, 4. With vital signs, 5. A reassessment within one hour of intervention or less as appropriate, 6. When medications are administered, 7. Assess the patient’s level of sedation before and after administering narcotic medication that could be potentially sedating. If the patient becomes over sedated or experiences respiratory depression, following any intervention intended to lessen the patient’s pain- notify the provider and document the measures taken ...” 4. During a review of Pt 1’s “H&P,” dated 8/22/24, the H&P indicated “ ... [Pt 1] with untreated depression/anxiety and polysubstance use disorder presents due to 2 [days] of alcohol withdrawal sxs [symptoms] ...” During a review of Pt 1’s “Electronic Medical Record (EMR-an electronic record of health-related information on an individual),” dated 8/22/24 to 8/27/24, the EMR indicated Pt 1 had a “Skin Assessment Form #3443 (SAF)” completed on 8/22/24 and 8/25/24. The SAF indicated “ ...Fill out a new form on admission, each time patient transfer to a different floor, and each time there is a significant change in patient condition (e.g. intubation ... change to constant observer) ...” During a concurrent interview and record review on 10/24/24 at 10:15 a.m. with Mgr 4, Pt 1’s “EMR,” dated 8/27/24 and “System Review (SR)” flowsheet, dated 8/27/24 were reviewed. Mgr 4 stated the EMR indicated Pt 1 had a fall around 1:45 p.m. Mgr 4 stated the SR indicated Pt 1 did not have a skin assessment completed after the fall. Mgr 4 stated Pt 1’s last skin assessment was completed at 8:58 a.m. The EMR indicated Pt 1 was transferred to the Critical Care Unit (CCU- a hospital department that provides specialized care for patients with life-threatening illnesses or injuries) at 6:20 p.m. Mgr 4 stated Pt 1 did not have a skin assessment completed when transferred to a different unit and it should have been completed. Mgr 4 stated it was important to complete a skin assessment when transferred to obtain a baseline (a starting point used for comparisons) of the patient. During a concurrent interview and record review on 10/24/24 at 1:35 p.m. with RN 7, Pt 1’s “SR” flowsheet, dated 8/27/24 was reviewed. RN 7 stated he cared for Pt 1 on the day of the fall. RN 7 stated the SR indicated there was no documentation a skin assessment was completed after Pt 1’s fall. RN 7 stated he should have completed and documented a skin assessment after Pt 1 fell. RN 7 stated he did not complete a skin assessment form. During a phone interview on 10/25/24 at 9:15 a.m. with RN 8, RN 8 stated he cared for Pt 1 when Pt 1 was transferred into the CCU after sustaining a fall. RN 8 stated a skin assessment should have been completed and documented when a patient was transferred to the unit. RN 8 stated he did not complete a skin assessment form. RN 8 stated it was important to assess a patient to establish a baseline when you received the patient. RN 8 stated a patient could change from the baseline and would want to notify the physician if changes occurred. During a concurrent interview and record review on 10/25/24 at 2:28 p.m. with the Director of Critical Care (DCC), the facility’s P&P titled, “Standard for Impaired Skin Integrity (Potential/Actual),” dated 7/22/24 was reviewed. The P&P indicated, “ ...PROCEDURE ... A. Preventative interventions: Guidelines for potential or actual impairment of skin integrity. 1. Two (2) RNs/ LVNs will do a generalized skin inspection, especially of bony prominences, and complete the Braden Scale Risk Assessment in the EMR and Skin Assessment Form #3443 (man sheet). Patients will receive this assessment: a. At the time of admission. b. At the time of transfer to a different floor, fill out a new Skin Assessment Form #3443 (man sheet). c. At the time of a significant change in patient’s condition (eg: intubation, beginning vasopressors or addition of another vasopressor, change to constant observer, significant change in LOC, in the event of a patient fall ...) fill out a new Skin Assessment Form #3443 (man sheet). d. Every shift, EMR documentation only, unless new skin issues are present ... f. If there are no skin integrity issues at the time of admission, transfer, or change in condition, the Skin Assessment Form #3443 (man sheet) will still be filled out, and the lack of skin issues will be noted on the diagram by writing “Skin Within Normal Limits” ...” The DCC stated RN 8 should have completed and documented a full skin assessment when Pt 1 was transferred to the CCU. The DCC stated RN 8 should have completed the skin assessment form according to the policy. During a concurrent interview and record review on 10/28/24 at 2:10 p.m. with Mgr 4, Pt 1’s EMR, dated 8/22/24 to 8/27/24 were reviewed. Mgr 4 stated Pt 1 had a SAF completed on 8/22/24 and 8/25/24. Mgr 4 stated a SAF was not completed after Pt 1 had a fall and when Pt 1 was transferred to the CCU. Mgr 4 stated a SAF should have been completed after Pt 1 fell to identify changes from Pt 1’s baseline. During an interview on 10/29/24 at 11:25 a.m. with the CNO, the CNO stated LNs should be following the policy for skin assessment to get an accurate view of the patient. 5. During a review of Pt 1’s “H&P,” dated 8/22/24, the H&P indicated “ ... [Pt 1] [with] untreated depression/anxiety and polysubstance use disorder presents due to 2 [days] of alcohol withdrawal sxs [symptoms] ...” During a concurrent interview and record review on 10/24/24 at 10:15 a.m. with Mgr 4, Pt 1’s “Physician Certification for Transfer and Patient Acknowledgement/Consent (Transfer Form), Section II,” dated 8/27/24 was reviewed. Mgr 4 stated the Transfer Form, Section II was signed by Pt 1’s mother. Mgr 4 stated the witness line had no signature. Mgr 4 stated the person who had the mother sign the Transfer Form, Section II should have signed the form as well. During a phone interview on 10/25/24 at 9:15 a.m. with RN 8, RN 8 stated he cared for Pt 1 when Pt 1 was transferred into the CCU after sustaining a fall. RN 8 could not recall if he went over the Transfer Form with Pt 1 and Pt 1’s family. RN 8 stated there should be a witness signature if the form was signed by someone other than the patient. During a concurrent interview and record review on 10/25/24 at 2:15 p.m. with RN 9 and the DCC, the facility’s P&P titled, “Transfer of Patients to Other Medical Facilities,” dated 6/5/24, was reviewed. Pt 1’s “Transfer Form, Section I,” undated and “Transfer Form, Section II,” dated 8/27/24 were reviewed. The P&P indicated, “ ...PURPOSE: To provide guidelines to facilitate a safe and appropriate transfer of patients in compliance with EMTALA [Emergency Medical Treatment and Labor Act is a federal law that ensures patients receive emergency care without regard to their ability to pay or insurance status] and California requirements ... Transfer of the stable patient: 1. If the Medical Screening Exam (MSE) establishes that no Emergency Medical Condition exists, the following steps should be taken: a. The medical record must reflect that the patient does not have an Emergency Medical Condition. b. The patient may be admitted, discharged, or transferred, as medically appropriate ... 2. If an Emergency Medical Condition was found to exist, but the physician determines that the patient’s medical condition is stabilized, the patient may be transferred when the following criteria have been met: a. Treatment to stabilize the patient must be administered within the capabilities of [name of hospital] available staff and services. 3. Physician Certification for Transfer and Patient Acknowledgment/Consent, Section I ...The physician should complete and sign prior to transfer. (Check box pertaining to stable patient.) The patient should sign the acknowledgment/consent prior to transfer. 4. Physician Certification for Transfer and Patient Acknowledgment/Consent, Section II: Patient Transfer Acknowledgment/Consent ...Should be completed to document acknowledgment of notification of the transfer by the patient or their legal representative ... D. Preparation steps prior to transfer: 1. Transferring Physician’s duties ...Complete Physician Certification for Transfer and Patient Acknowledgement/Consent ... 2. Nurse’s duties: ... Complete Physician Certification for Transfer and Patient Acknowledgement/Consent ... 4. Charge Nurse duties: ... Must review all paperwork ... DOCUMENTATION, A. All forms to be complete (no blank lines) ...” RN 9 stated the Transfer Form, Section I did not have an updated status of the patient’s condition. RN 9 stated the Transfer Form, Section I did not have a date and time of when the physician signed the form. RN 9 stated it was not a complete Transfer Form. RN 9 stated the physician should have completed the update on the patient’s condition on the Transfer Form, Section I. RN 9 stated the physician should have written the date and time of when the physician completed and signed the Transfer Form, Section I. RN 9 stated she gave the Transfer Form, Section II to RN 8 to get the patient and/or family consent and signature. RN 9 stated she did not witness the mother’s signature on the Transfer Form, Section II. RN 9 stated the LN who witnessed the mother’s signature should have signed the witness line on the Transfer Form, Section II. RN 9 stated it was her responsibility to review the Transfer Form for accuracy to ensure the safety of the patient’s care. During an interview on 10/25/24 at 2:28 p.m. with the DCC, the DCC stated the Transfer Form was incomplete. The DCC stated the primary RN should complete the first check for accuracy then the charge RN double checks to ensure accuracy and completeness. The DCC stated LNs should have checked the Transfer Form to ensure it was accurately completed. The DCC stated she expected LNs to sign the witness line to validate it was the patient or family’s signature. During an interview on 10/29/24 at 11:25 a.m. with the CNO, the CNO stated she expected transfer forms completed and filled out correctly. 6. During a review of Pt 18’s “H&P,” dated 10/10/24, the H&P indicated, “ ... [Pt 18] with past medical history for pulmonary hypertension, CAD ... hypertension ... diabetes type 2 ... presented to the ER from [physician’s name] office for possible left foot debridement ...” During a review of Pt 18’s “PO,” dated 10/14/24, the PO indicated, “ ...heparin ... 5,000 Unit (s) [unit of measure], 1 mL ... Injection ... Route of administration Subcut [subcutaneous- the injection is given in the fatty tissue, just under the skin] ... Frequency Q12hr ...” During a concurrent interview and record review on 10/25/24 at 11:03 a.m. with Mgr 4, Pt 18’s “MAR,” dated 10/15/24 to 10/17/24 were reviewed. The MAR indicated Pt 18 had heparin administered to his lower left abdomen on 10/15/25 at 9:09 a.m., 9:36 p.m., 10/16/24 at 8:51 a.m., 8:10 p.m., and 10/17/24 at 9:43 a.m. Mgr 4 stated the injection sites were not rotated. Mgr 4 stated it was important to rotate sites, so the patient does not bruise, and to allow for the absorption of the medication. Mgr 4 stated it could cause trauma to the skin, such as tissue damage. Mgr 4 stated LNs are expected to rotate injection sites. Mgr 4 stated LNs should have utilized the facility’s nursing skill platform on how to administer subcutaneous injections. Mgr 4 stated there was an icon on every desktop with the nursing skill platform which was accessible to all LNs. During a review of Pt 16’s “H&P,” dated 8/29/24, the H&P indicated, “ ... [Pt 18] transferred to our facility ... for a second opinion surgical consult. He has a complicated history of ... C1-C2 fracture [a break in the C1 or C2 vertebrae, which are located at the top of the neck and connect the head to the spine], quadriplegia [paralysis of all four limbs], trach [tracheostomy-a surgical procedure that creates an opening in the neck to provide an airway and help with breathing] ... history of hypertension, depression, anxiety, chronic pain ... deep tissue injuries [damage to the soft tissue beneath the skin caused by pressure or shear forces] ... Patient previously had a G-tube [gastrostomy tube-a small, flexible tube that is surgically inserted through the abdominal wall and into the stomach to provide nutrition and fluids], it was removed several weeks ago ... Since then he has a nonclosing gastric fistula [an abnormal opening in the stomach or intestines that allows the contents to leak to another part of the body] ...” During a review of Pt 16’s “PO,” dated 9/2/24, the PO indicated, “ ...heparin ... 5,000 Unit (s), 1 mL ... Injection ... Route of administration Subcut ... Frequency Q8hr ...” During a concurrent interview and record review on 10/25/24 at 1:38 p.m. with Mgr 4, Pt 16’s “MAR,” dated 10/19/24 to 10/24/24 were reviewed. The MAR indicated Pt 16 had heparin administered to his left lower abdomen on 10/19/24 at 2:38 p.m. and 10:15 p.m. The MAR indicated Pt 16 had heparin administered to his left lower abdomen on 10/20/24 at 2:21 p.m. and 10:17 p.m. The MAR indicated Pt 16 had heparin administered to his left lower abdomen on 10/22/24 at 5:50 a.m. and 2:33 p.m. The MAR indicated Pt 16 had heparin administered to his right lower abdomen on 10/23/24 at 2:25 p.m. and 9:18 p.m. The MAR indicated Pt 16 had heparin administered to his left lower abdomen on 10/24/24 at 5:39 a.m. and 1:57 p.m. Mgr 4 stated the injection site should have been rotated if the previous one was given in the same site. During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated LNs are expected to rotate injection sites. The CNO stated there could be harm to the patient if LNs are not rotating the injection sites. During a review of the facility’s document , untitled, undated, the document indicated, “ ...ALERT ... Do not administer the medication into the injection site if the skin is damaged, burned, bruised, hard, inflamed, or swollen ... Select an appropriate injection site based on the subcutaneous tissue mass, medication volume, and the required absorption rate. Inspect the skin surface for bruises, inflammation, or edema. Do not use an area that is bruised or has signs associated with infection. a. When administering heparin, use abdominal injection sites ... c. When administering insulin, systematically rotate the injection site within the same anatomic area (e.g., abdomen). During a professional reference review titled, “Injection Technique 2: Administering Drugs via the Subcutaneous Route,” dated 8/28/18, retrieved from https://www.nursingtimes.net/assessment-skills/injection-technique-2-administering-drugs-via-the-subcutaneous-route-28-08-2018/, the reference indicated, “ ...Complications associated with subcutaneous injections include abscesses and, in patients who require frequent injections, there is a risk of lipohypertrophy [a lump of fatty tissue under your skin caused by repeated injections in the same place]; this is characterized by an accumulation of fat under the skin. Lipohypertrophy occurs when multiple injections are repeatedly administered into the same area of skin. It can be painful and unsightly, and affect drug absorption, but can be prevented by rotating injection sites ...” 7. During a concurrent interview and record review on 10/29/24 at 10:45 a.m. with the Chief Human Resources Officer (CHRO) and the Director of Education (DE), Registered Nurse (RN) 16’s “Personnel File (PF),” undated was reviewed. The DE stated the PF indicated RN 16’s last fit testing was completed on 9/12/23. The DE stated facility staff were responsible to complete a fit testing within 12 months of the previous one. The DE stated facility staff performed the fit testing course on the facility’s learning platform and should complete the courses by the due date. During an interview on 10/29/24 at 11:25 a.m. with the CNO, the CNO stated the facility staff should follow the policy on fit testing. During a review of the facility’s P&P titled, “Saccharin Solution Qualitative Fit Test,” dated 5/22/18, the P&P indicated, “ ...PURPOSE: While caring for patients with actual or suspected mycobacterium tuberculosis disease, each employee will be wearing a respirator which has been fit tested for correct size for that employee ... Employees are fit tested at time of hire and then annually ...” 8. During a concurrent interview and record review on 10/24/24 at 10:24 a.m. with Mgr 6 Pt 21’s “H&P” dated 10/19/24 was reviewed. The “H&P” indicated, Pt 21 had a past medical history (PMH) of advanced dementia (a decline in mental ability, loss of thinking, remembering, and reasoning, that worsens over time), nonverbal status (unable to speak), and was brought in by ambulance for generalized weakness (decreased muscle strength). Mgr 6 stated Pt 21 was admitted for a complicated urinary tract infection (a bacterial infection that occurs when bacteria enter the urinary tract and multiply), adult failure to thrive (FTT- syndrome of weight loss, decreased appetite, poor nutrition, and inactivity), and dehydration (when body loses more fluids than it takes in). Pt 21 was admitted to the hospital as an inpatient and moved to the Medical Surgical (MS) Unit on 10/19/24 at 1:30 p.m. During a review of Pt 21’s “Physician Order (PO),” dated 10/19/24, the “PO” indicated, “ ... Turn Patient ... Requested Start Date/Time: 10/19/24 [2:08 p.m.] ... Frequency: Q2h [every 2 hours] ... Order entered secondary to turn patient every 2 hours documentation ...” During a concurrent interview and record review on 10/24/24 at 10:30 a.m. with Mgr 6, Pt 21’s “Braden Risk Assessment Flowsheet (BRAF) [risk score by LNs determining pressure injury risk]”, dated 10/19/24 to 10/24/24 was reviewed. Pt 21’s “BRAF” on 10/19/21 at 3 p.m. indicated a Braden Score (score given to patients indicating pressure injury risk from 6-23 lower the score higher the risk) of 13 . Mgr 6 stated Pt 21’s “BRAF” indicated a Braden score between 10 to 13 from 10/19/24 to 10/24/24. LNs documented Pt 21 was bedfast (confined to bed), mobility was completely limited, and she was a total assist patient. Mgr 6 stated a score of 10 to 13 indicated a higher risk of developing a pressure injury. Mgr 6 stated total assist patients were dependent on nursing staff to assist with repositioning. Mgr 6 stated all patients scoring less than 18 were considered at risk for PI and reduction strategies must be started. Mgr 6 stated LNs must complete a Braden Score every shift when assessing patients. Mgr 6 stated Pt 21 was supposed to be turned every two hours due to a low Braden score. During a concurrent interview and record review on 10/24/24 at 10:45 a.m. with Mgr 6, Pt 21’s “Activity Daily Living Flowsheet (ADLF)” dated 10/19/24 to 10/25/24 was reviewed. On 10/19/24 Pt 21 had no documented repositioning from 3 p.m. to 6 p.m. Mgr 6 stated Pt 21 should have been repositioned at 5 p.m. On 10/20/24 Pt 21 had no documented repositioning from 1 p.m. to 7:30 p.m. Mgr 6 stated Pt 21 should have been repositioned on 10/20/24 at 3 p.m., 5 p.m. and at 7 p.m. On 10/22/24 Pt 21 had no documented repositioning from 12:32 a.m. to 4:53 a.m. Mgr 6 stated Pt 21 should have been repositioned at 2:30 a.m. and at 4:30 a.m. On 10/23/24 Pt 21 had no documented repositioning from 8:45 a.m. to 12 p.m. Mgr 6 stated Pt 21 should have been repositioned at 10:45 a.m. Mgr 6 stated Pt 21 could have skin breakdown by not being repositioned every two hours. Mgr 6 stated skin breakdown could cause pressure injuries. Mgr 6 stated Pt 21 had many increased risk factors for skin breakdown such as being bedfast, her age, her medical condition, and being immobile. During a concurrent observation and interview on 10/24/24 at 2:46 p.m. with Registered Nurse (RN) 11 in Pt 21’s hospital room, Pt 21 was observed lying on her bed on her right side with the siderails of the bed up, and her head off the pillow close to the right-side rail. Pt 21 was unable to answer questions. RN 11, Pt 21’s primary LN was at bedside. RN 11 stated she determined Pt 21s needs by nonverbal ques (ways to communicate without using words), because Pt 21 was mostly non-verbal. RN 11 stated Pt 21 was supposed to be repositioned every two hours to prevent skin breakdown. Pt 21 was observed being moved up in bed and repositioned to the left side by LNs. RN 11 stated turning Pt 21 every two hours was important to prevent PI. During a concurrent interview and record review on 10/24/24 at 10:50 a.m. with Mgr 6, Pt 22’s “H & P,”, dated 9/17/24 was reviewed. “The “H&P” indicated, Pt 22 had a PMH of left-sided craniotomy (a surgical procedure that involves removing a section of the skull to access the brain), behavioral issues secondary to traumatic brain injury (TBI- a brain injury caused by an external force, such as a blow to the head. TBIs can range from mild to severe, and can affect how a person thinks, feels, acts, and moves), seizure disorder (a chronic brain condition that causes recurring seizures [a temporary episode of abnormal electrical activity in the brain that causes sudden change of behavior, movement, or consciousness]), due to TBI, and high blood pressure. Pt 22’s “H&P” indicated, “ ... presented to the ER [Emergency Room] on 9/5/24 for a 5150 hold [a California law that allows for the involuntary psychiatric detention of a person for up to 72 hours] ... Patient has been in the ER close to 2 weeks, been trying to get placement ...” Mgr 6 stated Pt 22 was moved to the inpatient Medical Surgical (MS) Unit on 9/17/24 at 6:55 p.m. During a review of Pt 22’s “PO,” dated 10/12/24, the “PO” indicated, “ ... Turn Patient ... Requested Start Date/Time: 10/12/24 [1:05 a.m.] ... Frequency: Q2h [every 2 hours] ...”. During a concurrent interview and record review on 10/24/24 at 11:30 a.m. with Mgr 6, Pt 22’s “BRAF”, dated 10/3/24 to 10/25/24 was reviewed. Pt 22’s “BRAF” on 10/23/21 at 8:12 a.m. indicated a Braden Score of 15. LNs documented Pt 22 was chairfast (severely limited or non-existent ability to walk, cannot hold own weight), mobility was very limited, and he was a maximum assist patient. Mgr 6 stated a score of 15 indicated a higher risk of developing a PI. Mgr 6 stated maximum assist patients were mostly dependent on nursing staff to assist with repositioning. Mgr 6 stated Pt 22 was supposed to be turned every two hours due to a low Braden score. During a concurrent interview and record review on 10/24/24 at 11:40 a.m. with Mgr 6, Pt 22’s “Patient Position Flowsheet (PPF)” dated 10/3/24 to 10/25/24 was reviewed. On 10/22/24 Pt 22 had no documented repositioning from 7:32 p.m. to 10/23/24 at 8:12 a.m., over 12 hours. Mgr 6 stated Pt 22 should have been repositioned on 10/22/24 at 9:30 p.m., and11:30 p.m. Mgr 6 stated on 10/23/24 Pt 22 should have been repositioned at 1:30 a.m., 3:30 a.m., 5:30 a.m., and 7:30 a.m. Mgr 6 stated Pt 22 could have skin breakdown by not being repositioned every two hours. Mgr 6 stated skin breakdown could cause pressure injuries. During a concurrent observation and interview on 10/25/24 at 3:15 with The Director of Medical Surgical (DMS) in Pt 22’s hospital room. Pt 22 was observed lying on his back with his eyes open, with his right arm lying at his side on the bed and his left arm over his chest. Pt 22 was lying with his head slightly elevated with a pillow. Pt 22’s right arm was not elevated on any surfaces. The DMS stated Pt 22 was unable to move his right arm. Pt 22’s right thumb had a dime sized open wound to the knuckle area. Pt 22 did not respond to questions when asked in English. Pt 22 had delayed responses when responding to questions in Spanish. Pt 22’s right hand had slight swelling. The DMS stated Pt 22 required LNs assistance for positioning into and out of his wheelchair and positioning of his right arm. During a concurrent interview and record review on 10/28/24 at 11:25 a.m. with Mgr 4, Pt 22’s “Electronic Medical Record” was reviewed. Mgr 4 stated Pt 22 was incontinent of stool (involuntary release of feces due to an inability to control bowel movements). Mgr 4 stated Pt 22 was not ambulatory (capable of walking) and was dependent on staff for positioning and getting into and out of his wheelchair. Mgr 4 stated Pt 22 was a higher risk of skin breakdown due to incontinence, low mobility, and being chairfast. Mgr 4 stated LNs should reposition Pt 22 every two hours, and if he was up in the wheelchair assure, he was shifting his weight in the chair to prevent PI. Mgr 4 stated LN documentation indicated Pt 22 was not being repositioned every two hours. During a review of Pt 23’s “H&P”, dated 10/19/24, the “H&P” indicated Pt 23 had a PMH of mild dementia, and suspected congestive heart failure (CHF - heart cannot pump blood efficiently) who presented to the hospital due to weakness. Pt 23 was admitted to the hospital as an inpatient for pneumonia (an infection that inflames the air sacs in one or both lungs) on 10/19/24 and moved to the MS unit. During a review of Pt 23’s “PO,” dated 10/20/24, the “PO” indicated, “ ... Turn Patient ... Requested Start Date/Time: 10/20/24 [1:04 a.m.] ... Frequency: Q2h [every 2 hours] ... Order entered secondary to turn patient every 2 hours documentation ...” During a concurrent interview and record review on 10/24/24 at 1:40 p.m. with Mgr 6, Pt 23’s “BRAF”, dated 10/19/24 to 10/25/24 was reviewed. Pt 23’s “BRAF” on 10/19/21 at 10:11 a.m. indicated a Braden Score of 15. LNs documented Pt 23 was bedfast, her mobility was very limited, and she was a maximum assist patient. Mgr 6 stated a score of 15 indicated a higher risk of skin breakdown that could lead to a PI. Mgr 6 stated Pt 23 was supposed to be turned every two hours due to a low Braden score. Mgr 6 stated Pt 23 had impaired mobility and needed assistance for repositioning. During a concurrent interview and record review on 10/24/24 at 1:45 p.m. with Mgr 6, Pt 23’s “ADLF” dated 10/19/24 to 10/25/24 was reviewed. On 10/20/24 Pt 23 had no documented repositioning from 6 a.m. to 10 a.m. Mgr 6 stated Pt 23 should have been repositioned at 8 a.m. Mgr 6 stated repositioning patients was important to prevent PI. During an interview on 10/29/24 at 11:29 a.m. with the Chief Nursing Officer (CNO), The CNO stated, patients should be repositioned according to policy to prevent skin issues such as pressure injuries. The CNO stated her expectation was for hospital staff to follow P&P. During a review of the hospital’s P&P titled, “Standard for Impaired Skin Integrity (Potential/Actual),” dated 7/22/24, the P&P indicated “ ... When Braden Scale Risk Assessment score is 14 or less, (moderate to high risk for developing pressure injury) or the patient is immobile ... Implement pressure injury prevention measures ... reposition bedbound patients at least every 2 hours, more frequently if indicated by patient’s condition ... Reposition patients in chair at least every hour and have capable patients shift their weight every 15 minutes ...” During professional reference review titled, “The Braden Scale and How it Predicts Pressure Injury Risk”(retrieved from https://blog.wcei.net/braden-scale-score-for-predicting-pressure-injury-risk), March 5, 2024, indicated, “ ...19-23 equals no risk, 15-18 equals mild risk, 13-14 equals moderate risk, 10-12 equals high risk, < 9 [< - less than] equals severe risk ... for pressure injury ...” Each assessment category was scored one through four, with six categories. Category one sensory perception [process of detecting, recognizing, and interpreting things or events from the environment using the senses [touch, sight, smell, taste, and hearing], two moisture, three activity, four mobility, five nutrition, and category six friction [rubbing of one surface against another] and shear the force that causes internal body structures and skin tissues to move in opposite directions] ...” During a review of professional reference titled, “Turning and Repositioning Frequency to Prevent Hospital-Acquired Pressure Injuries Among Adult Patients: Systematic Review,” dated 2023, indicated “ ... Turning and repositioning is considered one of the strategies to reduce the incidence of pressure injuries (PI)s among hospitalized patients, as it helps to redistribute and minimize direct pressure on targeted skin and enhance blood perfusion [the process of blood flowing through a tissue delivering oxygen and nutrients and removing waste products] in the affected areas ...” 49884”

“ACCESS TO LOCKED AREAS CFR(s): 482.25(b)(2)(iii) Only authorized personnel may have access to locked areas. This Standard is not met as evidenced by: 45977 Based on observation, interview, and record review, the facility failed to ensure medications were securely stored from unauthorized staff when medications were left unsecured in a bin on top of the locked medication refrigerator in the patient care area of the Post Anesthesia Care Unit (PACU- the treatment a patient will receive in a nursing facility while recovering from an illness or surgery). These failures resulted in the availability of medications to be diverted by unauthorized staff, patients and visitors. Findings: During an observation and interview on 10/23/24, at 10:30 a.m., with Registered Nurse (RN18), in the PACU, next to the nurse’s station, on top of the medication refrigerator, there was an unlocked bin with medications. The bin was labeled, “Return Medications to Pharmacy.” RN 18 stated, she was the charge nurse for the area and there were three medications in the return bin. RN 18 stated, medications should be secured from those who are not authorized to access medications as for example, environmental services. RN 18 stated, medications should be secured at all times, and they will have to come up with a different solution to ensure the medications were secure. During interview on 10/28/24, at 11:15 a.m., with the Pharmacy Director (PD), PD stated, medications should be kept secure and medications in the return bin in the open area of the PACU was not secure. PD stated unauthorized staff had access to the medications by having the return bin unsecured on top of the medication refrigerator. PD stated, they corrected the situation to follow the hospital’s policy. During a review facility’s policy and procedure (P&P) titled, “Storage of Medications in Patient Care Areas,” dated 7/26/24. The P&P indicated “... PURPOSE ... To ensure the safe and secure handling and storage of medications on patient care units, including the storage of medication ... All medications are stored in a secure environment that limits access to authorized personnel as defined by hospital policy. ... Categories of personnel are authorized access to secure medication areas based on the organization’s need for the individual to perform their assigned duties and in accordance with federal, state and local regulations. ... Medications that are not securely locked must be under constant surveillance ...””

“ACCESS TO LOCKED AREAS CFR(s): 482.25(b)(2)(iii) Only authorized personnel may have access to locked areas. This Standard is not met as evidenced by: 45977 Based on observation, interview, and record review, the facility failed to ensure medications were securely stored from unauthorized staff when medications were left unsecured in a bin on top of the locked medication refrigerator in the patient care area of the Post Anesthesia Care Unit (PACU- the treatment a patient will receive in a nursing facility while recovering from an illness or surgery). These failures resulted in the availability of medications to be diverted by unauthorized staff, patients and visitors. Findings: 1. During an observation and interview on 10/23/24, at 10:30 a.m., with Registered Nurse (RN18), in the PACU, next to the nurse’s station, on top of the medication refrigerator, there was an unlocked bin with medications. The bin was labeled, “Return Medications to Pharmacy.” RN 18 stated, she was the charge nurse for the area and there were three medications in the return bin. RN 18 stated, medications should be secured from those who are not authorized to access medications as for example, environmental services. RN 18 stated, medications should be secured at all times, and they will have to come up with a different solution to ensure the medications were secure. During interview on 10/28/24, at 11:15 a.m., with the Pharmacy Director (PD), PD stated, medications should be kept secure and medications in the return bin in the open area of the PACU was not secure. PD stated unauthorized staff had access to the medications by having the return bin unsecured on top of the medication refrigerator. PD stated, they corrected the situation to follow the hospital’s policy. During a review facility’s policy and procedure (P&P) titled, “Storage of Medications in Patient Care Areas,” dated 7/26/24. The P&P indicated “... PURPOSE ... To ensure the safe and secure handling and storage of medications on patient care units, including the storage of medication ... All medications are stored in a secure environment that limits access to authorized personnel as defined by hospital policy. ... Categories of personnel are authorized access to secure medication areas based on the organization’s need for the individual to perform their assigned duties and in accordance with federal, state and local regulations. ... Medications that are not securely locked must be under constant surveillance ...””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 49538 Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection when: 1. Fourteen of fourteen expired microbiology swabs (a collection and transport system used for culture testing) were found in the Progressive Care Unit’s (PCU-a hospital area that provides intermediate care for patients who need more care than a general ward but less than intensive care) medication room according to the facility’s policy and procedure (P&P) titled, “Procurement and Supply Chain (PSC) Management,” This failure had the potential to result in inaccurate results which could lead to ineffective treatment. 2. Hospital Staff did not adhere to the standard of care for patient hygiene or hospital job descriptions for one of three patients (Pt 22) when Pt 22 was observed to have a brown substance under the fingernails of his left hand. This failure had the potential for Pt 22 to have cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) from the substance under his fingernails to get into his mouth or onto the open wound on his right hand which could lead to infection. 3. Two of two Licensed Nurses (LNs) (Registered Nurse (RN) 10 and the Wound Nurse (WN)) failed to follow facility P&P titled, “Hand Hygiene” and “Transmission-Based Precautions” for one of two patients (Pt 5) when LNs were observed not performing hand hygiene (practice of cleaning hands to remove germs, dirt, or other harmful substances) and/or performing it incorrectly, before putting on non-sterile gloves, after taking off non-sterile gloves, and after touching the patient. LNs applied personal protective equipment (PPE - protective clothing designed to protect the wearers body from injury or infection) incorrectly when entering isolation rooms (room requiring PPE to prevent the spread of infection). LNs touched Pt 5’s bed side rails, bedside table, room curtain, the translator tablet, and LN face with contaminated gloves. These failures placed Pt 5, all patients being cared for by RN 10 and the WN, and staff were at risk for transmission of infections (an infectious agent is transferred from a reservoir to a susceptible host), cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and increased the potential for hospital acquired infections and illnesses. Findings: 1. During a concurrent observation and interview on 10/22/24 at 3:40 p.m. with the Director of Critical Care (DCC) and Registered Nurse (RN) 15, in the PCU medication room, 24 microbiology swabs were expired. The DCC stated there were three microbiology swabs with an expiration date of 9/18/24, seven with an expiration date of 10/12/24, ten with an expiration date of 10/14/24, and four with an expiration date of 10/17/24. The DCC stated the microbiology swabs were used to swab a wound, tissue, or eye for culture testing. The DCC stated the microbiology swab was also used to test for methicillin-resistant staphylococcus aureus (MRSA-a bacteria that causes infections in different parts of the body). RN 15 stated if an expired microbiology swab was used to collect a sample, it would give an inaccurate result which would lead to an inaccurate diagnosis. RN 15 stated laboratory staff stocked the unit with the microbiology swabs. The DCC stated she expected LNs to dispose of the microbiology swabs when it expired. The DCC stated it was every one’s responsibility to check for expiration dates. During an interview on 10/28/24 at 1:46 p.m. with the Infection Preventionist (IP), the IP stated expired items should not be on the units. The IP stated the staff who delivered the items to the unit should have checked for expiration dates when coming to the unit to restock. The IP stated LNs check should check for expiration dates on items before using it. The IP stated an inaccurate result could occur if the item was expired. During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated LNs should look at an item’s expiration date and remove it if it was expired. During a review of the facility’s P&P titled, “Procurement and Supply Chain (PSC) Management,” dated 5/20/22, the P&P indicated, “ ...All manufactured sterile supply items maintained in the Bulk Storage, Central Service, and Par Level areas will be reviewed weekly and upon issuance in respect to the expiration date of the product. A. All manufactured sterile supply items maintained in the inventory control system will be reviewed weekly and upon issuance in respect to expiration dates. B. All expired items shall be immediately removed from the storage area and proper disposition be made of the items ... D. It is the responsibility of each individual department within the hospital to ensure that all manufactured sterile items that are maintained and used within the department are reviewed in respect to the expiration date of the item prior to using. Further, ii is the responsibility of each department to periodically review all manufactured sterile items maintained within the department for expiration dates ...” 2. During a concurrent interview and record review on 10/24/24 at 10:50 a.m. with Manager (Mgr) 6, Pt 22’s “History and Physical (H &P-an assessment from physician including medical history and exam),” dated 9/17/24 was reviewed. The “H&P” indicated, Pt 22 had a Past Medical History (PMH) of left-sided craniotomy (a surgical procedure that involves removing a section of the skull to access the brain), behavioral issues secondary to traumatic brain injury (TBI- a brain injury caused by an external force, such as a blow to the head. TBIs can range from mild to severe, and can affect how a person thinks, feels, acts, and moves), seizure disorder (a chronic brain condition that causes recurring seizures [a temporary episode of abnormal electrical activity in the brain that causes sudden change of behavior, movement, or consciousness]), due to TBI, and high blood pressure. Pt 22’s “H&P” indicated, “ ... presented to the ER [Emergency Room] on 9/5/24 for a 5150 hold [a California law that allows for the involuntary psychiatric detention of a person for up to 72 hours] ... Patient has been in the ER close to 2 weeks, been trying to get placement ...”. Pt 22 was moved to the inpatient Medical Surgical (MS) Unit on 9/17/24 at 6:55 p.m. During an interview on 10/25/24 at 1:10 p.m. with Family Member (FM) 2 on the telephone, FM 2 stated she was unhappy with the care her father was receiving from LNs at the hospital. FM 2 stated Pt 22’s room had an odor and Pt 22 had body odor. FM 2 stated Pt 22 had only been showered one time since his arrival to the hospital on 9/4/24. FM 2 stated Pt 22 was only able to use his left hand for eating and brushing his teeth and his hand was dirty. FM 2 stated Pt 22 “had a bunch of poop inside his nails” FM 2 stated she told staff about Pt 22’s dirty nails on 10/23/24 and asked for a file or something to clean out under his nails and was told the hospital did not have anything. During a review of Pt 22’s “physician order (PO)”, dated 10/4/24, the “PO” indicated Pt 22 was on contact isolation precautions (set of safety measures used to prevent spread of infection through direct or indirect contact) for Methicillin-resistant Staphylococcus aureus (MRSA - a type of bacteria that has become resistant to many antibiotics, can spread in hospitals) in his urine. During a concurrent observation and interview on 10/25/24 at 2:50 p.m. with the Director of Medical Surgical (DMS) in Pt 22’s hospital room, Pt 22 was observed lying in his hospital bed on his back with his eyes open. Pt 22’s hospital room had isolation gowns and gloves outside the door. Pt 22’s hospital room had a contact isolation sign posted. Pt 22 was lying with his left hand on his chest close to his throat. Pt 22’s fingernails on his left hand were to the tips of his fingers. Pt 22 had a dark brown substance under the first, second, and third fingernails of his left hand. Pt 22’s right hand was flat on the hospital bed and had a quarter sized open wound to the top of his thumb knuckle. Pt 22’s right hand fingernails were clean. Pt 22’s room had no odor. Pt 22’s gown and bed linens were clean. The DMS stated Pt 22 should have clean hands and should not have brown substances under his fingernails. The DMS stated Pt 22’s hands should be clean; Pt 22 was non ambulatory and depended on hospital staff to ensure hand hygiene was done. The DMS stated risk of infection increased when patients were not kept clean. During a concurrent interview and record review on 10/28/24 at 11:25 a.m. with Manager (Mgr) 4, Pt 22’s “Electronic Medical Record” was reviewed. Mgr 4 stated Pt 22 was bathed every day using the chlorhexidine gluconate (CHG- antiseptic-germ killing) bath wipes. Mgr 4 stated Pt 22 was incontinent of stool (inability to control bowel movements) but not incontinent (inability to control) of urine. Mgr 4 stated Pt 22’s nails should have been cleaned by staff when he was bathed, before eating, or when visibly dirty. Mgr 4 stated her expectation was for staff to keep patients clean, to reduce risk of infection. During an interview on 10/28/24 at 1:17 p.m. with Patient Care Technician (PCT)1, PCT 1 stated her role was to provide baths, oral care, hair washing, showers, and toileting (changing) patients. PCT 1 stated baths with the CHG wipes were done once per day unless the patient refused. PCT 1 stated showers needed a physician order. PCT 1 stated if a patient was very dirty, she would use a basin with water to clean the patient. PCT 1 stated Pt 22 required help to set up his food but he fed himself. PCT 1 stated Pt 22 required help with his oral care. PCT 1 stated Pt 22 required assistance to get into his wheelchair. PCT 1 stated Pt 22 required changing when he had a bowel movement because he was incontinent of stool. PCT 1 stated Pt 22 required assistance to clean his hands because he did not walk. PCT 1 stated PCTs received training during the orientation period how to bathe patients. PCT 1 stated Pt 22 should have his hands cleaned because infections could happen if feces was left under the fingernails. During a review of hospital hand out “CHG: Bathing with Chlorhexidine Gluconate Wipes Patient Education,” dated 5/17, the “hand out” indicated, “ ... CHG wipes are antiseptic (germ-killing) cloths used to wash the skin. The living skin is a constant source of germs. CHG kills 99% of the germs on the skin to help to prevent germs from getting into an open wound or your bloodstream causing serious infection ...” During a review of “Unit Tech-PCT [Patient Care Technician] Licensed [job description],” dated 4/3/19, the “Job Description” indicated, “ ...The Nursing Assistant [NA] performs duties under the direction of the Registered Nurse [RN] ... Responsible for providing high quality basic care activities ... assistance with activities of daily living, such as bathing, feeding, ambulating, toileting ... Provides for the hygiene of the assigned patient population ... Gives all types of baths personal hygiene ...” During a review of professional reference titled, “Assisting Patients with Personal Hygiene,” (retrieved from https://www.ncbi.nlm.nih.gov/books/NBK563155/) dated 9/26/22, the professional reference indicated, “ ... Preventing the spread of contamination from the medical provider to the patient and vice versa is essential ... A lack of hygiene can result in many adverse effects, such as hospital-acquired infections ... Basic adult hygiene includes oral hygiene, bathing, eliminating, shaving, brushing, and styling hair ... These may seem like basic procedures but are vital to maintaining the patient’s health ... The inability to properly maintain hygienic conditions for patients can lead to many adverse effects ... Bathing patients regularly, particularly those in the intensive care unit, can help prevent ... infections ... Bathing helps the patient feel clean and gain a sense of normalcy, removes dirt, perspiration, bacteria, and dead skin, and promotes blood circulation ... Regular nail care can remove bacteria underneath the fingernails to help prevent infections ...” 3. During a review of Pt 5’s H&P, dated 10/22/24, the “H&P” indicated Pt 5 had a PMH of severe alcohol use disorder and he presented to the ED due to right lower extremity (leg) popliteal (the hollow at the back of the knee) lesion (wound) that was worsening and painful. Pt 5 was admitted to the hospital as an inpatient on 10/22/24 for sepsis (serious infection that can lead to lead to tissue damage organ failure or death). During a concurrent observation and interview on 10/23/24 at 11:29 a.m. with the WN and RN 10 in Pt 5’s hospital room, Pt 5 was sitting up in his hospital bed at a 90-degree angle with his legs on a disposable pad. The WN was at the foot of the patient bed communicating with Pt 5 using the interpreter tablet at Pt 5’s bedside. Pt 5’s privacy curtain was closed. Pt 5 was in a contact isolation room, and the WN was wearing a yellow isolation gown and blue non-sterile gloves. Pt 5’s bedside table was at the foot of the bed with wound supplies sitting on it. Pt 5 had a golf ball sized purulent (pus) draining wound to the back of his right knee. The wound appeared red and swollen. Pt 5 stated it hurt when the LNs pushed on the area. The WN failed to complete hand hygiene a total of five separate times in a 15 minute span, after removing Pt 5’s old dressing and putting the dressing into the red biohazard bag, after cleaning the wound, after obtaining a doppler pulse (a handheld tool commonly used in healthcare settings to monitor blood flow in vessels), after measuring the wound, and after obtaining a wound culture sample (a small amount of fluid, tissue, or cells from a wound that is used to test for the presence of bacteria, viruses, or fungi that may be causing an infection). The WN changed gloves between each task but did not perform hand hygiene. The WN also touched Pt 5’s siderail, bedside table, and the privacy curtain with contaminated gloves. During an observation on 10/23/24 at 11:33 a.m. in Pt 5’s hospital room, RN 10 was observed assisting the WN with Pt 5’s dressing change. RN 10 was observed putting on a pair of non-sterile gloves first and then the isolation gown by pushing her thumbs through the sleeves to create a hole near the cuff of the gown. RN 10 had the cuff of the isolation gown across the palm and back of the hand (to mid hand) of the non-sterile gloves. RN 10 put on a second pair of gloves over the first. RN 10 would remove the second pair of gloves and use hand sanitizer over the first set of gloves whenever changing gloves between tasks. RN 10 washed Pt 5’s legs with a washcloth, took photos of wound, retrieved more supplies, applied ointment to legs, and retrieved the doppler. RN 10 removed second gloves and sanitized the first a total of 5 times. RN 10’s isolation gown would have hand sanitizer across the palm and inside cuff of the isolation gown each time the gloves were sanitized. RN 10 eventually removed the second set of gloves, did not put on a new second pair then assisted the WN to collect a wound culture sample, and held up Pt 5’s leg with the isolation gown across the palm of the glove. RN 10 then touched her face with the back of her contaminated gloved hand. RN 10 also touched Pt 5’s privacy curtain, the bedside table, and the interpreter tablet with contaminated gloves. The camera used to take photos of the wound was set on the bedside table next to the used washcloths and was not wiped with disinfecting wipes. During an interview on 10/23/24 at 12:15 p.m. the WN, the WN stated she washed her hands before she started a dressing change and after. The WN stated her practice was not to perform hand hygiene between glove changes. The WN stated she washed her hands between patients and dressing changes were performed with the clean technique (a procedure that involves reducing the risk of spreading microorganisms by using clean gloves, sterile instruments, and a clean environment) to reduce infection. During an interview on 10/23/24 at 12:20 p.m. with RN 10, RN 10 stated she should not have worn the isolation gown on top of her non-sterile gloves. RN 10 stated her isolation gown should be under the gloves. RN 10 stated clean hands were important to patient safety, and nurses should perform hand hygiene between glove changes. RN 10 stated having the isolation gown on the outside palm of gloves could cause cross contamination. During an interview on 10/24/24 at 2:35 p.m. with the DCC, the DCC stated her expectation was for staff to follow the P&P for hand hygiene. The DCC stated LNs should complete hand hygiene between glove changes, after touching a patient and when entering and exiting a room. The DCC stated if the hands were visibly soiled LNs should use soap and water. The DCC stated LNs should wear PPE correctly and not put holes in the sleeves. The DCC stated LNs should not have isolation gowns over gloves because it could cause cross contamination. The DCC stated isolation gowns should be discarded if they become wet or soiled. The DCC stated LNs and should not use hand sanitizer on the gloves because it may break down the glove material making them less effective. The DCC stated LNs should avoid touching areas around the patient room with soiled gloves. The DCC stated LNs could pass bacteria to other rooms on their clothing by not using PPE correctly and by touching areas around the room with contaminated gloves. During an interview on 10/29/24 at 11:37 a.m. with the CNO, the CNO stated her expectation was for LNs to perform hand hygiene according to hospital policy. The CNO stated her expectation was for LNs to not touch their face with contaminated gloves. During a review of the hospital’s P&P titled, “Hand Hygiene,” dated 40/20/18, indicated, “ ... Indications for hand washing and hand antisepsis ... before touching a patient ... On entering the patient zone ... Before performing a clean/aseptic procedure ... If moving from a contaminated body site to a clean body site during patient care ... After body fluid exposure risk ... After removing gloves ... After contact with body fluids ... or wound dressings ... After touching a patient ... After contact with inanimate objects ... in the immediate vicinity of the patient ... For example ... monitoring alarm, holding a bed rail, clearing the bedside table ... Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled ... Hand hygiene technique ... when decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry ...” During a review of the hospital’s P&P titled, “Transmission-Based Precautions,” dated 5/22/23, indicated, “ ...Transmission-Based Precautions are designed to reduce the transmission of pathogens [an organism that can cause disease in a host] by ... contact route ... During patient care, change gloves after having contact with infective material that may contain high concentrations of microorganisms [living things too small to see with naked eye] (e.g. if you needed to wear gloves to perform the task, you need to perform hand hygiene when the task ends) ... Remove gloves and perform hand hygiene ... Gown ... Wear a gown when entering room if you are within 3 feet of the patient ... Remove gown and observe hand hygiene before leaving patient’s environment ... After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environments ... Patient-Care Equipment ... If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another patient. During a review of a professional reference from the Centers for Disease Control ( CDC) titled, “The Basics of Standard Precautions”, dated 2007, the professional reference indicated “ ... Perform hand hygiene after PPE removal ... Wear gloves when anticipating contact with a patient’s ... blood or body substance ... Mucous membranes (nasal, oral, genital area) ... Non-intact skin ... Extend to cover wrist, over isolation gown if worn ... Sequence of PPE donning [putting on] ... gloves are often the last item to be put on ... gloves are usually the first item to be removed ... A gown should not be worn in hallways or corridors ...” During a review of professional reference from the CDC titled, “Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, the professional reference indicated, “ ... Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with Handwashing with water and soap (e.g., plain soap or with an antiseptic). Antiseptic hand rub (alcohol-based foam or gel hand sanitizer) ... Cleaning your hands reduces: The potential spread of deadly germs to patients. The spread of germs, including those resistant to antibiotics ... Know when to clean your hands ... Immediately before touching a patient ... Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices ... Before moving from work on a soiled body site to a clean body site on the same patient ... After touching a patient or patient’s surroundings ... After contact with blood, body fluids, or contaminated surfaces ... Immediately after glove removal ...”. During a review of professional reference from the World Health Organization (WHO) titled, “Glove Use Information Leaflet”, August 2009, the professional reference indicated, “ ... As medical gloves are single-use items, glove decontamination ...are not recommended and should be avoided ... 49884”

“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: 45929 Based on observations, interviews, and record review, that facility failed to have a well-organized and effective nursing service when: 1. Licensed nurses (LN) did not document the status of Pt 1, including late, and prolonged decelerations, did not complete accurate electronic fetal monitoring assessments, did not notify the physician, and did not document complete cervical exams for Pt 2 in accordance with the Association of Women’s Health Obstetric and Neonatal Nurses (AWHONN, is a leader in research, education, and advocacy in the field of women’s health, obstetrics, and neonatal health) guidelines and hospital policy and procedure (P&P) for two of 14 sampled patients (Pt), Pt 1 (baby) and Pt 2 (mom of Pt 1). (Refer to A398 Finding 1) 2. LNs did not assess pain (Pt 40, Pt 55) and/or reassessed pain (Pt 22, Pt 29) after pain medication was administered in accordance with the hospital’s P&P titled, “Pain Management” for four of 36 sampled patients (Pt 22, Pt 29, and Pt 40). (Refer to A398 Finding 2) 3. One of two patients (Pt 40) were not assessed by LNs in the Labor and Delivery (L&D) unit when a magnesium sulfate medication infusion was administered, according to the P&P “Guidelines for Magnesium Sulfate Administration” and “Severe Intrapartum or Postpartum Hypertension Emergency”. (magnesium sulfate - a high-risk medication used in pregnancy for patients diagnosed with preeclampsia [high blood pressure and signs of liver or kidney damage after the 20th week of pregnancy] to help prevent seizures-[a sudden, uncontrolled burst of electrical activity in the brain]). (Refer to A398 Finding 3) 4. LNs did not follow physician orders for notification of elevated blood pressures (BP) for one of seven patients (Pt 29) in the L&D unit according to the “P&P” titled,”Severe Intrapartum or Postpartum Hypertension Emergency”. (Refer to A398 Finding 4) 5. One of seven (Pt 40) patients did not have documented fundal (top of uterus), or lochia (vaginal discharge after birth, bleeding) assessments by LNs after delivery in the L&D and Postpartum (PP) units from 2/1/24 at 8:15 p.m. to 2/3/24 at 9:11 a.m., according to facility procedure and AWHONN standards of practice. (Refer to A398 Finding 5) 6. One of three sampled glucometers in the telemetry (heart monitoring) unit had quality controls (QC) performed by LNs with control solutions that did not have the date the control solution would expire written on the vial according to the facility’s policy and procedure (P&P) titled, “Blood Glucose Monitoring Using [Brand Name of glucometer] Inform II System,”. (QC-a system of maintaining standards, glucometers- a device for measuring the concentration of glucose in the blood, control Solutions-solution use to test the functionality of meter and strips). (Refer to A398 Finding 6) 7. LNs in the Emergency Department did not complete ongoing assessments or reassess vitals for 13 of 22 sampled patients (Pt 54, Pt 55, Pt 60, Pt 61, Pt 62, Pt 63, Pt 64, Pt 65, Pt 66, Pt 67, Pt 68, Pt 69, and Pt 70) in accordance with hospital “P&P” titled, “Assessment and Documentation” and “Triage.” (Refer to A398 Finding 7) The cumulative effect of these deficient practices resulted in the facility’s inability to provide care in a safe and effective manner.”

“COMPLIANCE WITH LAWS CFR(s): 482.11(a) The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. This Standard is not met as evidenced by: 45929 Based on observations, interviews and record review, the facility failed to comply with state regulations when they placed five portable air conditioner (A/C) units in the Laboratory (Lab), Pharmacy and Sterile Processing Department (SPD) without following the process of Policy Intent Notice (PIN) for approval with California Department of Health Care Access and information (HCAI). This failure resulted in potential for non-compliant equipment and potential harm to staff or patients. Findings: During a concurrent observation and interview on 7/31/24 at 12:05 p.m. in the Lab with the Lab Manager (LM), three portable A/C units were in use. The LM stated they had been using the portable A/C units for approximately two weeks. The LM stated the hospital’s main Heating, Ventilation and Air Conditioning (HVAC) system had not been able to keep up with local heat wave and the portable A/C units were put in place. During a concurrent observation and interview on 7/31/24 at 12:35 p.m. in the Pharmacy with the Pharmacy Director (PD), one portable A/C unit was in use. The PD stated the portable A/C unit had been in use for approximately a month. During a concurrent observation and interview on 8/1/24 at 9:50 a.m. in the SPD with the Operating Room Manager (ORM), one portable A/C unit was in use. The ORM stated the portable A/C unit had been in use for approximately two years. The ORM stated the room gets warm when all the washers and sterilizers (a machine used to sterilize surgical instruments) are in operation. During a review of “Invoice 1”, dated 7/7/24; “Invoice 2”, dated 7/13/24: and “Invoice 3” dated, 7/13/24; “Invoice 1” indicated two Portable A/C units were placed in the Lab. “Invoice 2” indicated one unit was placed in Pharmacy. “Invoice 3” indicated one unit was placed in the Lab. During an interview on 8/1/24 at 3:04 p.m. with the Director of Facility Services (DFS), the DFS stated he has never had to notify HCAI of the intent to use portable A/C units and has never had to get authorization for the units. During the review of “HCAI Email 1 (HCAI 1)”, dated 8/5/24, from the Regional Compliance Officer (CO) for the office of Statewide Hospital Planning and Development of HCAI, the CO was asked the hospital was required to get approval for portable A/C units prior to installing. The CO stated, “ ... Yes, they are to follow Policy Intent Notice (PIN) 72 for approval of the authorization of Emergency Work ...”. During the review of “HCAI Email 2 (HCAI 2)”, dated 8/5/24, from the CO, the CO was asked in the hospital notified HCAI prior to installing the portable A/C units. The CO stated, “ ... I am unable to locate anything within the Facility file, so I understand they have not ...”. During a review of “Policy intent Notice (PIN) 72 (PIN 72)”, dated 6/15/22, the “PIN 72” indicated, “ ... Emergency Work Authorization ... HCAI will consider and may issue an Emergency Authorization to Proceed (EAP) with emergency work prior to plan approval and building permit based on emergency conditions and necessity ... Where an emergency situation arises, the facility shall take the following actions: I. Immediate Action ... The facility may take the necessary emergency actions to abate and make safe the emergency condition that poses an imminent danger to life, injury, or property damage. Such emergency actions may proceed prior to contacting HCAI and the HCAI Regional Compliance Officer (RCO) must be contacted immediately thereafter ... Beyond emergency actions to abate the emergency conditions and make safe the emergency conditions, emergency repairs, restoration, or replacement of an element of the building, structure, utility system, or equipment shall be authorized by HCAI prior to proceeding with work ...”.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 45929 Based on interviews and record review, the facility failed to inform six of seven patients (Patient [Pt] 8, 11, 16, 27, 30, 40) and or patient’s representatives of their rights when non- English speaking patients Pt 11 and Pt 27 did not receive information in a language of their preference in accordance with hospital policy and procedure and an interpreter was not utilized when obtaining an informed consent and consents were not in the patient’s preferred language in accordance with hospital policy. These failures had the potential for ineffective communication, misunderstandings, and patient harm. Findings: During a review of Pt 11’s “Face Sheet (FS, a document containing patient information)”, dated 8/1/24, the “FS” indicated Pt 11’s preferred language was Spanish. The “FS” indicated Pt 11 was coming to the hospital for a blood transfusion (procedure in which whole blood or parts of blood are put into a patient’s bloodstream through a vein) of 8/1/24. During a review of Pt 11’s “Consent for Treatment and Conditions for Admission (COA)”, dated 7/30/24, the “COA” indicated the “COA” was written in English and no interpreter signed the document. During a review of Pt 27’s “Face Sheet (FS),” dated 7/28/24, and “Condition of Admission [COA - form with hospital admission information]” dated 7/28/24, the “FS” indicated, Pt 27’s preferred language was SP (Spanish), and the “COA” was in Spanish. During a review of Pt 27’s “Consent to Surgery/Special Procedures (CSSP) 1” form, dated 7/30/24, the “CSSP 1” form indicated Pt 27 was consented for a procedure, hemodialysis [mechanical cleaning of the blood]. The “CSSP 1” form was in English, and no translator information was completed on the form. Pt 27’s “CSSP 1” was signed by Pt 27 and hospital staff witnessed the patient’s signature on 7/30/24 at 7:56 p.m. During a review of Pt 27’s “CSSP 2” form, dated 8/1/24, the “CSSP 2” form indicated Pt 27 was consented for a procedure for amputation of his right third toe, with possible amputation of right second and fourth toes. The “CSSP 2” form was in English, and no translator information was completed on the form. Pt 27’s “CSSP 2” was signed by Pt 27 and hospital staff witnessed the patient’s signature on 8/1/24 at 2:06 p.m. During an interview on 8/9/24 at 9:13 a.m. with Manager (MGR) 10 stated, the facility’s “CSSP” form for procedures and surgeries have specific elements that must be completed. MGR 10 stated “CSSP” was another name for “Informed Consent”. MGR 10 stated the “CSSP” must be in the patient’s preferred language if available. MGR 10 stated if the patient’s native language was not English facility staff must use an interpreter and the interpreter number must be included on the form. MGR 10 stated if any of the items were missing the “CSSP” was incomplete. During an interview on 8/9/24 at 11:22 with the Chief Nursing Officer (CNO), the CNO stated it was her expectation staff follow hospital policies and procedures. During a review of the facility’s policy and procedure titled, “Interpreters”, dated 2/19/19, “Interpreters” indicated, “ ... [name of hospital] utilizes an on-demand video remote interpretation service (VRI) and a language interpretation lines to ensure patients are provided with highly skilled and medically trained interpretation services. This service is offered 24 hours a day, 7 days a week, 365 days a year ... staff will arrange to use the on-demand video remote interpretation (VRI) service of language interpretation line ... with a patient or patient representative who is not fluent in English and/or when a patient or patient representative has communicated his or her primary language is not English (the documented primary language is considered the patient’s preferred language for receiving information) ...”. During the review of a professional reference titled, “Safety First: The Importance of Interpreters & Translated Documents in Preventing Patient Harm” (undated), the reference indicated, “ ...Communication barriers between providers and limited English proficiency (LEP) or non-English proficiency (NEP) patients during health care delivery is a major safety concern. Poor, ineffective communication can lead to patient dissatisfaction, misunderstanding about treatments, and even worse, poor health outcomes and patient harm. Studies even suggest that adverse events experienced by LEP patients are more likely to be caused by communication issues when compared to English proficient patients ...”.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 45929 Based on interviews and record review, the facility failed to inform four patients (Patient [Pt] 8, Pt 16, Pt 30 & Pt 40) of the provider’s name performing the procedure in accordance with hospital policy. These failures had the potential for ineffective communication, misunderstandings, and patient harm. Findings: During a review of Pt 8’s “CSSP” dated 7/15/24, for a central line [intravenous line inserted into a large deep vein] placement, the “CPPS” indicated the line for the name of the practitioner performing the procedure was blank. During a review of Pt 8’s “Procedure Note (PN)”, dated 7/15/24, the “PN” indicated a central venous catheter was placed in Pt 8’s internal jugular vein (a large vein in the neck) by Physician 1. During a review of Pt 16’s “CSSP” form, dated 7/31/24, the “CSSP” form indicated, “ ... Your physician has recommended the following operation or procedure bilateral [left and right] peripheral [away from center] angiogram [x-ray using a dye to show blood flow], ... angioplasty [unblocking a blood vessel], ... with possible IVC [inferior vena cava, a large vein] filter and procedural sedation [medication to help calm and relax] ... Name of the practitioner who is performing the procedure or administering the medical treatment ...”. This area was left blank, no physician name was completed. Pt 16 signed the “CSSP” on 7/31/24 at 7:25 a.m. Facility staff signed the “CSSP” as a witness but did not complete the date and time for their signature. During a review of Pt 30’s “CSSP” form, dated 08/1/24, the “CSSP” form indicated, “ ... Your physician has recommended the following operation or procedure Primary [first time] Cesarean Section [C/S-surgical delivery of baby through cut in mother’s stomach and uterus] ... Name of the practitioner who is performing the procedure or administering the medical treatment ...”. This area was left blank, no physician name was completed. Pt 30 signed the “CSSP” on 8/1/24 at 11:46 a.m. and facility staff signed the “CSSP” as a witness and included the date and time of witness signature. During a review of Pt 40’s “CSSP” form, dated 2/1/24, the “CSSP” form indicated, “ ... Your physician has recommended the following operation or procedure Primary Cesarean Section ... Name of the practitioner who is performing the procedure or administering the medical treatment ...”. This area was left blank, no physician name was completed. Pt 40 signed the “CSSP” on 2/1/24 at 5:00 p.m. and facility staff signed the “CSSP” as a witness. Facility staff signed the “CSSP” as a witness but did not complete the date and time for their signature. During an interview on 8/9/24 at 9:09 a.m. with Manager (MGR) 10 stated, the facility’s “CSSP” form for procedures and surgeries have specific elements that must be completed. MGG 10 stated “CSSP” was another name for “Informed Consent”. MGR 10 stated the “CSSP form must include, the type of procedure being performed word for word, the name of physician who is performing the procedure, the date and time patient signs the form, and a witness signature. MGR 10 stated if the patient was a minor the parent or guardian must sign the “CSSP” MGR 10 stated the “CSSP” must be in the patient’s preferred language if available. MGR 10 stated if the patient’s native language was not English facility staff must use an interpreter and the interpreter number must be included on the form. MGR 10 stated if any of the items were missing the “CSSP” was incomplete. During a review of the facility’s policy and procedure titled, “Consents: (1) Surgical, Diagnostic or Invasive Procedures (2) Authorization to Treat Minors (Consents)”, dated 6/21/19, “Consents” indicated, “ ... Patient or designated patient representative shall give informed consent for specified surgical, diagnostic and invasive procedures ... Definition: Informed Consent ... is a process whereby the patient, or his or her surrogate decision maker, is given sufficient information in lay terms and in preferred language which will enable him or her to reach a meaningful, informed decision regarding whether to give consent for the complex treatment or procedure which is proposed ... Surgical, diagnostic and invasive procedure consent forms ... Will contain patient’s name, surgeon’s name of his/her designee, procedure, time, date and patient’s signature ...”.”

“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: 45929 Based on interviews and record review, the facility failed to promote the patients’ right to receive care in a safe environment when two of eleven sampled patient care staff had previously tested positive for tuberculosis (TB, a disease cause by a bacteria that can spread through the air when an infected person coughs, sneezes, or spits. The disease can settle in the lungs and spread to other parts of the body), and their annual TB screening evaluation was not completed in accordance with hospital policy and procedure. These failures had the potential to place patients at risk for contracting TB. Findings: During a concurrent interview and record review on 8/7/24 at 8:00 a.m. with the Chief Human Resources Officer (CHRO), Registered Nurse (RN) 22’s “HCP (Health Care Personnel) Screening for Tuberculosis (TBS, a form with questions regarding exposure and symptoms of TB)”, dated 10/25/23, was reviewed. The CHRO stated the “TBS” form was used to screen all employees for TB annually. RN 22’s “TBS” indicated RN 22 tested positive for TB in 2000. The bottom section of the form indicated a title, “ ... Test Administrator Use Only ...”. The CHRO stated this section of the form was to document actions taken by Human Resource (HR) personnel who evaluated the screening form information. The choice of actions listed in this section of the “TBS” indicated, “ ... Single TST [Tuberculin Skin Test, a small injection under the skin of tuberculin purified protein derivative {PPD} to test to for TB exposure] ... Two-Step TST [two TST a month a part, for people frequently tested for TB] ... IGRA [Interferon Gamma Release Assay, a blood test that measures the body’s immune response to the bacteria that causes TB] results ... sent for CXR [chest x-ray] ... Yes ... No ... CXR ... Negative ... Positive ...Consult Physician ... Referral physician ... NA [not applicable] ... Yes ... Name ... Comments ...”. The section of the “TBS” for actions taken was blank and a line drawn through the section. No signature was present. During a concurrent interview and record review on 8/7/24 at 8:15 a.m. with the CHRO, Labor & Delivery Technician (LDT) 1’s “TBS”, dated 10/11/23, was reviewed. The CHRO stated the “TBS” indicated LDT 1 documented “ ... No ...” in response to “ ... Have you ever had a positive TB Skin or blood test? ...”. The LDT 1’s “TBS” indicated the section for actions taken was blank and a line was drawn through the section. No documentation of PPD skin testing of LDT 1 was evident. No signature was present. During a concurrent interview and record review on 8/7/24 at 9:27 a.m. with the CHRO, the policy and procedure titled, “Tuberculosis Screening for Employees (TSE)”, dated 6/17/16, was reviewed. The “TSE” indicated, “ ... All employees and volunteers will have an annual TB evaluation ... The evaluation will be administered annually under the direction of the Human Resources Department .... Employees and volunteers with no prior history of positive PPD will have a PPD skin test ... persons with a prior history of PPD are to complete a TB Evaluation Questionnaire ... PROCEDURE: Follow-Up Positive PPD Results ... Positive PPD as stated history ... This process is managed by occupational health clinic ... Obtain baseline PA [posterior-anterior, back to front] chest x-ray. If the chest -ray shows no evidence of current or past TB, the employee is considered to have latent tuberculosis [have no symptoms and cannot spreads TB, but if not treated may develop active TB in the future and spread the disease to others] ... Encourage to follow up with their medical provider if they have never had prophylaxis [treatment to attempt to prevent disease] for TB ...”. The CHRO stated persons with a history of a positive PPD were not given a PPD skin test if they had no symptoms. During a concurrent interview and record review on 8/7/24 with the CHRO, LDT 1’s “TBS”, dated 10/11/23, was reviewed. The CHRO stated LDT 1 documented “no” for a history of positive PPD skin test therefore she should have had a skin test done. The CHRO stated she wanted to check records and believed there was a mistake and LDT 1 was given a PPD skin test. The CHRO stated she needed to revise the “TBS” form to include a signature for the HR personnel reviewing the “TBS” and actions taken. The CHRO stated anyone could have drawn the line through the action items, even the employee. During a concurrent interview and record review on 8/7/24 at 10:23 a.m. with the CHRO, five of LDT 1’s “Tuberculosis Exposure Questionnaires (TEQ)”, dated 10/7/15, 10/9/18, 10/17/19, 10/28/20, and 10/26/22, were reviewed. The CHRO stated the 10/7/15, 10/9/18, & 10/26/22 “TEQs” indicated a prior positive PPD history. The CHRO stated the 10/17/19 & 10/28/20 “TEQs” indicated a negative PPD history. The CHRO stated there were inconsistencies in LDT 1’s responses to LDT 1’s PPD result history. The CHRO stated there were also inconsistencies on the five “TEQs” regarding whether a baseline CXR (used to detect abnormalities indicating current or past TB disease) on file including yes, no, and no response indicated. The CHRO stated the “TEQ” dated 10/17/19 indicated yes and no to the same question of if a baseline CXR was on file. The CHRO stated the five past “TEQs” did not indicate any review by HR personnel, and no one was looking at the “TBS” and “TEQs” closely. The CHRO did not have evidence of a 2023 PPD for LDT 1.”

“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: 49884 Based on observation, interview and record review, the facility failed to ensure all licensed nurses adhered to the hospital’s policies and procedures (P&P), when: 1. Licensed nurses (LN) did not document the status of Patient (Pt) 1, including late, and prolonged decelerations, did not complete accurate electronic fetal monitoring assessments, did not notify the physician, and did not document complete cervical exams for Pt 2 in accordance with the Association of Women’s Health Obstetric and Neonatal Nurses (AWHONN, is a leader in research, education, and advocacy in the field of women’s health, obstetrics, and neonatal health) guidelines and hospital policy and procedure (P&P) for two of 14 sampled patients (Pt), Pt 1 (baby) and Pt 2 (mom of Pt 1). These failures resulted in inadequate fetal monitoring of Pt 1, and an incomplete clinical assessment which led to a decline in oxygenation and may have possibly contributed to the death of Pt 1. 2. LNs did not assess pain (Pt 40, Pt 55) and/or reassessed pain (Pt 22, Pt 29) after pain medication was administered in accordance with the hospital’s P&P titled, “Pain Management” for four of 36 sampled patients (Pt 22, Pt 29, Pt 40 and Pt 55). These failures placed Pt 22, Pt 29, Pt 40, and Pt 55 at risk for inadequate pain management and could negatively affect the physical, emotional, and psychosocial (the influence of both physical and social factors on an individual) well-being of patients. 3. One of two patients (Pt 40) was not assessed by LNs in the Labor and Delivery (L&D) unit when a magnesium sulfate medication infusion was administered, according to the P&P “Guidelines for Magnesium Sulfate Administration” and “Severe Intrapartum or Postpartum Hypertension Emergency”. (magnesium sulfate - a high-risk medication used in pregnancy for patients diagnosed with preeclampsia [high blood pressure and signs of liver or kidney damage after the 20th week of pregnancy] to help prevent seizures-[a sudden, uncontrolled burst of electrical activity in the brain]). These failures had the potential for Pt 40’s blood pressure to go unmonitored and untreated. 4. LNs did not follow physician orders for notification of elevated blood pressures (BP) for one of seven patients (Pt 29) in the L&D unit according to the “P&P” titled, “Severe Intrapartum or Postpartum Hypertension Emergency”. These failures had the potential for Pt 40 and Pt 29 to have worsening symptoms of gestational hypertension (high blood pressure in pregnancy) which could lead to a decline in health status including confusion, stroke, and seizure. 5. One of seven (Pt 40) patients did not have documented fundal (top of uterus), or lochia (vaginal discharge after birth, bleeding) assessments by LNs after delivery in the L&D and Postpartum (PP) units from 2/1/24 at 8:15 p.m. to 2/3/24 at 9:11 a.m., according to facility procedure and AWHONN standards of practice. This failure placed Pt 40 at risk for uterine atony (loss of tone), hemorrhage (dangerous complication of excessive bleeding). 6. One of three sampled glucometers (a small, portable device that measures the amount of glucose, or sugar, in a person’s blood) in the telemetry (heart monitoring) unit had quality controls (QC) performed by LNs with control solutions (liquids used to test the accuracy and performance of blood glucometers) that did not have the date the control solution would expire written on the vial according to the facility’s policy and procedure (P&P) titled, “Blood Glucose (the main sugar found in your blood) Monitoring Using [Brand Name of glucometer] Inform II System,”. (QC-a system of maintaining standards, glucometers- a device for measuring the concentration of glucose in the blood, control Solutions-solution use to test the functionality of meter and strips). This failure placed patients at risk for inadequate blood glucose monitoring and management. 7. LNs in the Emergency Department (ED) did not complete ongoing assessments or reassess vital signs for 13 of 22 sampled patients (Pt 54, Pt 55, Pt 60, Pt 61, Pt 62, Pt 63, Pt 64, Pt 65, Pt 66, Pt 67, Pt 68, Pt 69, and Pt 70) in accordance with hospital “P&P” titled, “Assessment and Documentation” and “Triage.” This failure placed patients (Pt 54, Pt 55, Pt 60, Pt 61, Pt 62, Pt 63, Pt 64, Pt 65, Pt 66, Pt 67, Pt 68, Pt 69, and Pt 70) at risk for not having their nursing needs met and possibly delay in addressing the reason for their ED visit. Findings: 1. During a review of Pt 2’s “Electronic Medical Record (EMR - a digital collection of patient’s medical information, that is stored on a computer),” dated 6/24/24 to 6/25/24, the “EMR” indicated Pt 2 was a gravida (the total number of confirmed pregnancies) 1 para (the number of live births) 0, 39 weeks pregnant. The “EMR” indicated Pt 2 was admitted to Labor and Delivery (L&D) on 6/24/24 at 12:39 p.m. for spontaneous rupture of membranes (bag of water broke around baby naturally), and an induction of labor (IOL-when a medical provider starts labor). Pt 2 was transferred to the L&D unit on 6/24/24 at 12:46 p.m. Pt 2’s plan for induction was misoprostol (a medication used to soften the cervix and induce labor) PO (by mouth) every four hours. In the L&D unit Pt 2 was placed on continuous fetal monitoring, to monitor her baby’s heart rate (HR) and contractions (tightening and relaxing of uterus [womb]). Pt 2’s first fetal assessment was documented in L&D on 6/24/24 at 1 p.m., and the baseline Fetal Heart Rate (FHR) of 125 beats per minute (bpm - normal 110-160), accelerations (an increase in HR-shows fetal wellbeing), no decelerations (a decrease in HR below baseline), and moderate variability (fluctuations in baseline that are irregular 6-25 bpm -normal). Pt 2’s first L&D fetal assessment was a Category 1 (normal-indicates no fetal lack of oxygen). Pt 2’s first cervical exam in L&D on 6/24/24 at 3:05 p.m. was incompletely documented. Pt 2 began having late decelerations (gradual decrease in FHR after contraction -sign of placenta [provides oxygen to baby in the uterus] not working effectively) and were not accurately reflected in the documentation or reported to the physician. Pt 2 continued having intermittent (less than half of the contractions) and recurrent (50 percent or more of contractions) decelerations as labor progressed. Pt 2’s LNs reported some late and prolonged decelerations to physicians and the physicians assessed Pt 2 and reviewed the “Fetal Monitoring Strip (FMS- a tracing on paper that shows FHR and contractions)” but did not act on the decelerations by providing a Cesarean Section (C/S, surgical delivery of a baby through a cut in abdomen and uterus). Pt 1 was delivered by operative vaginal delivery (a vacuum extractor applies suction and traction to the baby’s head to help pull baby out) on 6/25/24 at 12:29 p.m. Pt 1 was diagnosed with metabolic acidosis (too much acid in the blood) after delivery and time of death was 6/25/24 at 10:20 p.m. During a review of Pt 2’s “EMR”, dated 6/24/25 to 6/25/25, and “Fetal Monitoring Strip, “ dated 6/24/25 to 6/25/25 the “EMR” indicated Pt 2’s LN reported decelerations to physicians on 6/24/24 at 7:24 p.m., 9:52 p.m., 6/25/24 at 1:26 p.m., 2:47 p.m., 8:44 a.m., 11:40 a.m. and 11:46 a.m. Pt 2’s physicians assessed her and reviewed her “FMS” on 6/24/24 at 7:24 p.m., 6/25/24 at 2:50 a.m., 4:48 a.m., 6:06 a.m., 6:28 a.m., 8:20 a.m.,9:00 a.m., 10:04 a.m., 11:10 a.m., 11:24 a.m., and from 12 p.m. to delivery at 12:29 p.m. Pt 2 had a Category 2 (not clearly known but not a 1 or a 3) “FMS” with recurrent decelerations and minimal variability (when the beat to beat amplitude is less than or equal 5 bpm - may indicate decreased oxygenation) beginning 6/25/24 at 9:30 a.m. that progressed to a category 3 (absent variability with recurrent late, variable, or prolonged decelerations-sign of acidemia) by 6/25/24 at 11:40 a.m. and physicians did not act on it by providing a C/S. During a review of Pt 1’s (baby) “EMR”, dated 6/25/24, the “EMR” indicated Pt 2 had APGAR score ( a test given to newborns soon after birth, 7 and higher indicates a good score) of 2 at one minute, 2 at five minutes, and 2 at 10 minutes, and 2 at 20 minutes. Pt 1 was brought to the warming table immediately after delivery. Pt 1 was blue/pale, floppy (soft and not able to keep a firm shape or position), apneic (a condition in which a person involuntary and temporarily stops breathing) and had a heart rate of 100 beats per minute (normal is 120-160) after one minute of life. Pt 1 was intubated (a tube inserted to provide oxygen into the lungs). Pt 1’s “EMR” indicated, Medical Doctor (MD) 4 requested transfer to a higher level of care Neonatal Intensive Care Unit (NICU). Pt 1’s “EMR” indicated a transfer hospital’s NICU team arrived and attempted to stabilize Pt 1 for transport. Pt 1’s “EMR” indicated Pt 1 could not be stabilized. Pt 1’s “EMR” indicated the transport team met with Pt 2 and family to discuss withdrawing care. Pt 1’s “EMR” indicated on 6/25/24 at around 5:45 p.m. Pt 2 and family agreed to withdraw care for Pt 1. Pt 1’s “EMR” indicated Pt 1 was extubated (breathing tube removed) by the transport team. Pt 1’s “EMR” indicated time of death was called on 6/25/24 at 10:20 p.m. During a review of Pt 1’s “H&P”, dated 6/25/24, “ ... 39 4/7 [39 weeks and 4 days] gestation born by SVD with vacuum assist. Required prolonged resuscitation ... Team arrived to take baby to [other hospital] but because of poor clinical exam and labs, decision to withdraw care was made in consultation with family ...” During a review of Pt 1’s “H&P,” addendum dated 6/26/24, the “H&P” addendum indicated, “ ... Baby noted to be spontaneously breathing and well perfused around an hour after baby was taken off the ventilator (a machine that helps people breathe) and extubated (tube that that supplied oxygen was removed) ... Heart stopped at 10:20 p.m. as narrated by parents and RN [Registered Nurse] ...”During a review of Pt 1’s “Notification of Death”, dated 6/27/24, the “Notification of Death” indicated, “ ... Preliminary cause of death ...Metabolic acidosis ... [a condition in which there is too much acid in the body’s fluids, especially in the blood] ...”. During a review of Pt 2’s “Surgical Pathology Report (a medical report that describes the characteristics of a tissue specimen that is taken from a patient),” dated 7/1/24, the report indicated, “ ... Trivascular [three vessels-normal] umbilical cord with acute fundisitis [an infection of the umbilical cord itself] fetal membranes with acute chorioamnionitis [an infection of the placenta and the amniotic fluid] ...” During a concurrent interview and record review on 8/5/24 at 2:55 p.m. with Registered Nurse (RN) 5, Pt 2’s “Electronic Medical Record (“EMR”)” dated 6/24/24 and 6/25/24 and “FMS”, dated 6/24/24 and 6/25/24 were reviewed. RN 5 stated LNs applied a fetal monitor to Pt 2 when she (Pt 2) arrived in L&D. RN 5 stated fetal monitoring was used to detect fetal wellbeing, and patient contractions. RN 5 stated LNs were expected to accurately document all components of a fetal assessment including, the baseline fetal heart rate (FHR), baseline variability, presence of accelerations, and any decelerations. RN 5 stated LNs must document a minimum of every 30 minutes. RN 5 stated when patients had decelerations LNs had “interventions” they were supposed to do. RN 5 stated the interventions were, repositioning the patient, turning off oxytocin (a medication used to start labor, making contractions stronger and closer together) if infusing, beginning a bolus (large amount) of lactated ringer (electrolyte solution), and giving the patient oxygen by mask (medical device that fits over a person’s nose and mouth to provide oxygen). RN 5 stated LNs must notify physicians of prolonged, late, and recurrent decelerations. RN 5 verified in Pt 2’s “FMS,” documentation, dated 6/24/24, a late deceleration at 1:35 p.m. was not accurately reflected in the documentation at 2 p.m. or reported to the physician. RN 5 stated in Pt 2’s “FMS” documentation, on 6/24/24, recurrent late decelerations were not accurately reflected in the documentation from 4:30 p.m. to 5:30 p.m. or reported to the physician. RN 5 stated Pt 2’s “FMS,” dated 6/24/24, at 5 p.m. and 5:30 p.m., indicated, uterine tachysystole (more than six contractions in 10 minutes), LNs documented a normal contraction pattern (no tachysystole). RN 5 stated LNs should have notified Pt 2’s physician about her recurrent late decelerations and uterine tachysystole (abnormal contraction pattern). RN 5 stated physicians must be notified when patients had decelerations. RN 5 stated complete documentation was important for a clear clinical picture. RN 5 stated LNs must document all components of the fetal assessments to be considered complete and accurate. During a concurrent interview on 8/5/24 at 3:30 p.m. with RN 5, Pt 2’s “FMS” documentation, dated 6/24/24, was reviewed, the “FMS” documentation indicated multiple cervical exams that had incomplete documentation. RN 5 stated LNs must document, who performed the exam, dilation (opening of cervix - measured in centimeters, the lower, narrow end of the uterus (womb) that connects the uterus to the vagina (birth canal), effacement (thinning), station (position of baby’s presenting part in relation to the mother’s pelvis), and cervical position (cervix moves closer to birth canal, to the front when close to delivery), when completing a cervical exam. RN 5 stated on 6/24/24 at 3:05 p.m. the station was not documented, at 4:01 p.m. the effacement and station were not documented. RN 5 stated accurate documentation of cervical exams were important to determine the progress of labor. RN 5 stated without accurate documentation of cervical exams the provider would not know if a patient’s cervix had changed within the designated timeframe for a safe vaginal delivery or if a C/S should be considered. During a concurrent interview and record review on 8/7/24 at 10:10 a.m. with Manager (MGR) 9, Pt 2’s “”EMR”,” dated 6/25/24, were reviewed. Pt 2’s “EMR” indicated MGR 9 was the shift manager on the day Pt 2 delivered. MGR 9 stated she went into Pt 2’s delivery room when MD 3 was at the end of the bed and Pt 2 was pushing. MGR 9 stated MD 3 was beginning to start a vacuum delivery (a medical procedure that uses a vacuum to help move a baby through the birth canal during vaginal childbirth) MGR 9 stated there was a phone call into the department that MD 2 (Pt 2’s primary physician) was almost to the unit. MGR 9 stated MD 2 entered the room as MD 3 was applying the vacuum to Pt 1’s head inside of Pt 2’s vagina. MGR 9 stated whenever a vacuum delivery was going to take place many staff members attended the delivery. MGR 9 stated the Neonatal Intensive Care Unit (NICU) nurses would attend the deliveries, and generally a charge nurse, as well as the primary nurse. MGR 9 stated she made the phone call to MD 4 (pediatrician) to attend delivery due to Pt 2 needing a vacuum delivery. MGR 9 stated NICU, was called to attend due to decelerations and a vacuum. MGR 9 stated when she called MD 4, she was told it would be 20 minutes till the physician arrived, MGR 9 stated the physician arrived in 26 minutes but still arrived before the baby was delivered. MRG 9 stated she was not at Pt 2’s bedside during any of the discussions about a possible C/S. During an interview on 8/7/24 with MGR 9, at 10:30 a.m., MGR 9 stated, Fetal assessment documentation included: FHR baseline, variability, accelerations, and decelerations. MGR 9 stated assessing fetal wellbeing was important. MGR 9 stated fetal assessments were documented into a patient’s medical record and were reported to the physician. MGR 9 stated cervical exam documentation included, dilation, effacement, presentation, station, position, who did it, and if there was any bleeding. MGR 9 stated, cervical exam documentation was important to determine patient progress. MGR 9 stated cervical exams allow the clinical team with assessing labor progress. MGR 9 stated her expectation was for LNs to have complete and accurate documentation. During an interview on 8/7/24 at 11:46 a.m. with MD 1, MD 1 stated, he was Pt 2’s physician on 6/24/24 from 5:00 p.m. until 6/25/24 at 8:30 a.m. MD 1 stated his role was to typically watch patient’s overnight for the primary physician. MD 1 stated he was Pt 2’s physician until the beginning of her second stage of labor (complete cervical dilation and ends with delivery of baby). MD 1 stated Pt 2’s fetal heart tracing initially had a few intermittent (less than half of the contractions) variables then two or three prolonged variables. MD 1 stated Pt 2’s tracing also showed intermittent late decelerations MD 1 stated he had LNs do frequent cervical exams, to ensure she was making labor progress. MD 1 stated despite the intermittent prolonged decelerations Pt 2’s baby had moderate variability (fluctuations in the baseline heart rate that are irregular in amplitude and frequency of 6-25 bpm). MD 1 stated he discussed a C/S on 6/25/24 around 2 a.m. with Pt 2. MD 1 stated he told Pt 2 if her baby continued to have decelerations, she may need a C/S. MD 1 stated he did not tell Pt 2 he “recommended a C/S” because he believed the fetal heart tracing still looked “ok”, the tracing still had variability at the time he discussed the C/S with Pt 2. MD 1 stated, how long he would allow a patient to push was dependent on the fetal heart tracing. MD 1 stated he had a four-hour maximum time that he would allow a patient to push before a C/S or operative vaginal delivery (vacuum delivery) would be indicated (Pt 2 pushed for over 5 hours.) MD 1 stated the fetal head had to be at a +2 station (two centimeters from the pelvic outlet towards the vaginal opening, the head is +4 to +5 when it is coming out) or more in the birth canal for a vacuum to be applied for delivery. MD 1 stated Pt 2 was still pushing when he left the unit (Pt 2 pushed for 2 hours with MD 1 as physician). MD 1 stated at one point he did a cervical exam with scalp stimulation (baby’s scalp is stimulated vaginally in an attempt to cause an increase in the baby’s heart rate) and believed an acceleration occurred. MD 1 stated upon review of the “FMS” there was no acceleration, just a slow return to fetal HR baseline. MD 1 stated the exam “could” have been an indication there was acidosis. MD 1 stated he reported to MD 3 Pt 2’s recurrent and periodic late decelerations, prolonged decelerations, and variables. MD 1 stated he reported to MD 3 Pt 2 had prolonged rupture of membranes. MD 1 stated chronic hypoxia (body’s tissues don’t have enough oxygen), reflected by the recurrent late decelerations (decrease in the fetal heart rate) and a long second stage and neonatal sepsis (bloodstream infection) caused by the chorioamnionitis (a serious infection that affects a person during pregnancy) can cause metabolic acidosis (there is too much acid in your blood). MD 1 stated metabolic acidosis was the cause of death for the baby. MD 1 stated his expectation was for LNs to document the frequency of decelerations, FHR baseline, variability decelerations, accelerations, and possibly the category. MD 1 stated he expected LNs to document cervical exams, including dilation, station, and effacement. MD 1 stated he believed accurate documentation was important. MD 1 stated his expectation was for LNs to notify him when there was a change from Category 1((baseline 110-160 moderate variability, and accelerations, no decelerations except early) that lasted more than 10 minutes. MD 1 stated he expected to be informed of late, variable, and prolonged decelerations. During a review of Pt 2’s “FMS” documentation, dated 6/25/24, the “FMS” documentation indicated Pt 2 began pushing on 6/25/24 at 6:06 a.m. and stopped pushing on 6/25/24 at 8:30 a.m. to “labor down [allow body to move baby down without active pushing]”. Pt 2 began pushing again on 6/25/24 at 10:04 a.m. and delivered Pt 1 at 12:29 a.m. Pt 2 pushed for a total of 4 hours and 49 minutes. During an interview on 8/7/24 at 1:56 p.m. with MD 2, MD 2 stated she was Pt 2’s primary physician and her delivery physician. MD 2 stated she arrived in the L&D unit on 6/25/24 at around 12 p.m. and went directly to Pt 2’s room. MD 2 began the delivery of Pt 1. MD 2 stated Pt 1 had a very tight cord around the neck that needed to be cut prior to the baby being delivered. MD 2 stated Pt 1 delivered on 6/25/24 at 12:29 p.m. and went straight to the resuscitation team. MD 2 stated her expectation was to receive report from LNs on any fetal heart tracing that was not a Category 1. MD 2 stated her expectation was to receive notification from LNs when interventions were being done for a Category 2 (indeterminant, not a Category 1 or a Category 3) strip. MD 2 stated her expectation was notification for late, variable, and prolonged decelerations. MD 2 stated she relied on LNs to chart accurately. MD 2 stated LNs were the physician’s eyes and ears on the floor and helped to decide the plan of care for the patient. During an interview on 8/7/24 at 3:39 p.m. with RN 15, Pt 2’s “EMR” dated 6/24/24 and 6/25/24 and “FMS” dated 6/24/24 and 6/25/24 were reviewed. RN 15 stated she was Pt 2’s primary nurse on 6/24/24 from 7:00 p.m. to 6/25/24 at 7:30 a.m. RN 15 stated she started and stopped Pt 2’s oxytocin (medication to start contractions) multiple times due to Pt 2’s baby having decelerations. Pt 2’s “EMR” indicated oxytocin was started on 6/24/24 8:38 p.m. stopped at 9:44 p.m., started on 6/25/24 at 12:30 a.m. stopped at 1:14 a.m., started at 1:51 a.m. and stopped at 2:40 a.m. for the final time. Pt 2’s “FMS” indicated on 6/25/24 RN 15 documented “Variable, Late, see notes”, no notes were in the documentation. RN 15 stated she talked with Pt 2 about the possibility of a C/S due to a recurrent deceleration and even though Pt 2 preferred a vaginal birth (when a person gives birth through their vagina) she told RN 15 she wanted to do whatever was best for her baby. During a concurrent interview and record review on 8/7/24 at 5:05 p.m. with RN15, Pt 2’s, “EMR,” dated 6/25/24 and “FMS” dated 6/25/24 were reviewed. The “FMS” indicated on 6/25/24 at 3:13 p.m. Pt 2 had a 3-minute-long prolonged deceleration that RN 15 completed interventions for (turned patient) but failed to notify the physician about. RN 15 verified on 6/25/24 Pt 2’s “FMS” indicated, recurrent late decelerations that were not accurately reflected in the documentation from 3 a.m. to 4 a.m. RN 15 stated she should have documented late decelerations and notified Pt 2’s physician. RN 15 stated she should have escalated the “FMS” to the charge nurse more times and had more conversations with the physician about the total number of FHR decelerations. During a concurrent interview on 8/8/24 at 8:33 a.m. with RN 16, Pt 2’s “EMR”, dated 6/25/24 and “FMS,” dated, 6/25/24 were reviewed. RN 16 stated she was Pt 2’s delivery nurse on 6/25/24. RN 16 stated when she received report from RN 15 Pt 2 was pushing. RN 16 stated by 9:30 a.m., Pt 2’s “FMS” remained a Category 2 but had minimal variability. RN 16 stated at around 8:30 a.m. Pt 2 stopped pushing until around 10:04 a.m. RN 16 stated MD 3 spoke to Pt 2 about a C/S around 9 a.m. and Pt 2 stated she was ok with a C/S if it was necessary. RN 16 stated at around 10:15 a.m. she informed the scrub tech to “open the OR [get the OR ready for a C/S]” because of recurrent decelerations while pushing. RN 16 stated she informed MD 3 that the OR was completely ready to take the patient to surgery if needed. MD 3 continued telling RN 16 “a little bit more, a little bit more”. RN 16 stated Pt 2 pushed another 30 minutes after a lengthy deceleration. RN 16 stated she told her charge nurse she wanted the physician to evaluate the “FMS”, “FMS” documentation at 11 a.m., 11:40, and 11:52 verified that physician was at bedside and viewing tracing. RN 16 stated, by 11:40 a.m. the “FMS” was a Category 3 strip. RN 16 stated MD 2 came into room at 12:03 p.m. RN 16 stated the baby delivered at 12:29 p.m. RN 16 stated baby had an odor, like chorioamnionitis (infection affects a person during pregnancy) RN 16 stated Pt 1 was floppy, not crying, and was blue/gray. RN 16 stated she should have escalated, how concerned she was about Pt 2’s “FMS” to the Chief Nursing Officer (CNO) since the supervisor was aware and the director was not in the unit. RN 16 stated contacting the physicians when patients have recurrent decelerations was important because the physician would then have a clear picture how long a baby had been having decelerations. During an interview on 8/8/24 at 12:04 p.m. with MD 3, MD 3 stated he got report from MD 1 on 6/25/24 at 8:30 a.m. and was Pt 2’s physician until MD 2 (delivery physician) took over at 12 p.m. MD 3 stated Pt 2’s fetal strip had some decelerations, that were “not bad”. MD 3 stated Pt 2 was allowed to “labor down” for an hour or so. MD 3 stated close to 10 a.m. LNs contacted him by telephone and asked if they could start pushing with Pt 2 again. MD 3 stated he spoke to Pt 2 and told her he “might consider doing a C/S due to no progressing, and decels (decreases in the fetal heart rate)”. MD 3 stated he told Pt 2, “let’s try again, and see if you progress.” MD 3 stated, “the family was adamant (stubbornly refuse to change your mind about something) they did not want a C/S.” MD 3 stated between 11:30 a.m. to 11:40 a.m. Pt 2’s baby was beginning to lose variability. MD 3 stated, “now the baby is in a little bit of distress, the variability was starting to go” and he knew he needed to do something right away. MD 3 stated by then the baby was too low in her pelvis (the area of the body below the abdomen that is located between the hip bones and contains the bladder and rectum) to take her to the Operating Room (OR). MD 3 stated, “would have been futile to take her to the OR”. MD 3 stated MD 2 called him and said she was on her way. MD 3 went into Pt 3’s room and applied the vacuum to Pt 1’s head. MD 2 came into Pt 2’s room and told MD 3 she would take over care. MD 3 stated maybe he should have forced the C/S a little more, but the nurses told him Pt 2 did not want a C/S. MD 3 stated Pt 1’s preliminary cause of death was metabolic acidosis. MD 3 stated chorioamnionitis, the extended length of time Pt 2 pushed (over five hours), or the tight cord Pt 1 had around the neck would cause metabolic acidosis. During an interview on 8/9/24 at 11:33 a.m. with the CNO, the CNO stated she expected LNs to document completely and accurately. The CNO stated failure to document completely or accurately could affect care if the physician was not told about any issues that were not accurately documented. The CNO stated her expectation was for LNs to follow P&P and standards of practice. During a review of the facility’s P&P titled, “Fetal Heart Rate Monitoring”, dated 10/4/23, indicated, “ ... continuous fetal monitoring is being used, the following intervals apply: ...Low risk ...Assess and document every 30 minutes in the active phase (he cervix opens from 6 cm to 10 cm) of the first stage of labor, and every 15 minutes during the active pushing second stage of labor ... At each interval, record a complete assessment of the FHR tracing, include a baseline rate, baseline variability, presence of accelerations, periodic or episodic decelerations, and changes or trends in the FHR pattern over time. Assign a category to describe the tracing from the three-tier system ... Category I (normal) ... Category II (indeterminant) ... Category III (abnormal) ... If an indeterminant or abnormal FHR pattern is identified, begin physiological-based interventions as appropriate ... Reposition the patient ... Discontinuing oxytocin ... Intravenous fluid bolus the administration of an entire dose of medicine into the veins over a short period of time) ... Notify the patient’s care provider and document maternal and fetal response to interventions, and a change to Category II or III ... documentation ... Vaginal exam and who performed it ... physician communication ...”. During a review of the facility’s P&P titled, Guidelines for Oxytocin Induction or Augmentation of Labor (the process of stimulating the uterus to increase the frequency, duration and intensity of contractions after the onset of spontaneous labour), dated 2/28/18, indicated ... Tachysystole ... More than 5 uterine contractions in a 10 minute period averaged over 30 minutes. ... Contractions that last over 120 seconds ...”. During a professional review titled, “Routine vaginal examinations for assessing progress of labour to improve outcomes for women and babies at term,” (found at Routine vaginal examinations for assessing progress of labour to improve outcomes for women and babies at term - Downe, S - 2013 | Cochrane Library) dated 7/15/13, indicated “ ...Used at regular intervals, either alone or as a component of the partogram (a pre?printed form providing a pictorial overview of the progress of labour), the aim is to assess if labour is progressing physiologically, and to provide an early warning of slow progress. Abnormally slow progress can be a sign of labour dystocia (painful, slow, or difficult delivery), which is associated with maternal and fetal morbidity and mortality ...”. During a professional review titled, First and Second Stage Labor Management, (found at (https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2024/01/first-and-second-stage-labor-management) dated 3/14, indicated “ ...ACOG [American College of Obstetricians and Gynecologists] recommends that prolonged second stage of labor be defined as more than 3 hours of pushing in nulliparous [a female who has never given birth to a live baby] individuals and 2 hours of pushing in multiparous [producing many or more than one at a birth] individuals. An individualized approach should be used to diagnose second-stage arrest; incorporating information regarding progress, clinical factors that may affect the likelihood of vaginal delivery, discussion of risks and benefits of available interventions, and individual patient preference is recommended when time in the second stage is extended beyond these parameters ... Arrest in the second stage can be identified earlier if there is lack of fetal rotation or descent despite adequate contractions, pushing efforts, and time ... ACOG recommends that cesarean delivery be performed in patients with active phase arrest of labor ... Cervical examinations are indicated to determine labor progress, but there is insufficient evidence to provide guidance on the frequency of cervical examinations in labor to assist with labor progress or dystocia ...”. 2. During a concurrent interview and record review on 8/1/24 at 2:15 p.m. with Registered Nurse RN) 1 and RN 6, Pt 22’s “History and Physical (H&P),” dated 7/25/24 was reviewed. The H&P indicated past medical history of osteoporosis (bone mass decrease), peripheral neuropathy (nerve damage that causes weakness, numbness, and pain), and diabetes (disease where sugar is too high in blood) was evaluated before surgery in preparation for right total knee arthroplasty due to osteoarthritis (a joint disease in which the tissues in the joint break down over time). The H&P indicated Pt 22 was admitted to the hospital for a right total knee arthroplasty (total knee replacement) on 7/31/24. During a review of Pt 22’s “Provider Order (PO),” dated 7/31/24, the “PO” indicated, “ ...acetaminophen-hydrocodone [a narcotic pain medication used to treat pain] 325 milligrams [mg- a unit of measurement]-5 mg oral tablets [325 mg acetaminophen and 5 mg hydrocodone] ...Volume dose: 1...Volume dose unit: tab [tablet] ...Route of administration: Oral ... Frequency: Q4hr [every four hours] ... PRN [as needed] ... PRN reason: Pain Moderate ...”. During a concurrent interview and record review on 8/1/24 at 2:30 p.m. with RN 1 and RN 6 Pt 22’s “Medication Administration Record (MAR) [a record of drugs administered to a patient]” flowsheet, dated 7/31/24 to 8/1/24 was reviewed. The “MAR” indicated on 8/1/24 at 11:37 a.m. Pt 22 was administered one tablet of acetaminophen-hydrocodone 5mg-325mg. RN 1 stated the “MAR” flowsheet indicated Pt 22’s pain was not reassessed within the one-hour timeframe per policy. RN 1 stated Pt 22’s “MAR” flowsheet indicated Pt 22’s next pain assessment was on 8/1/24 at 2:39 p.m. when she was administered another dose of pain medication. RN 1 stated Pt 22’s pain should have been re-assessed on 8/1/24 by 12:37 p.m. or sooner. RN 1 stated LNs must reassess pain to determine if the pain medication was effective. During a concurrent interview and record review on 8/2/24 at 1:30 p.m. with RN 11 Pt 29’s H&P, dated 7/31/24, was reviewed. The H&P indicated, “ ...gravida 6 [6-pregnancies] para 2 [2- births] with intrauterine [in uterus] pregnancy at 36 weeks plus ... Induction labor [making contractions begin to deliver baby] ...”. During a concurrent interview and record review on 8/2/24 at 1:40 p.m. with RN 11, Pt 29’s H&P delivery summary, dated 8/1/24, was reviewed. The H&P delivery summary indicated, “ ... The patient began pushing at 0728 [7:28 a.m.] ... she pushed for a total of 7 minutes to deliver a 9lb [pound- a unit of measurement] 8 oz [ounce] male infant at 0735 [7:35 a.m.] hours ...The infant and mother were in stable condition following the delivery ... Complication was 30 second shoulder dystocia [when one or both shoulders get stuck inside the pelvis during childbirth] ...”. During a review of Pt 29’s “Provider Order (PO),” dated 8/1/24, the “PO” indicated, “ ... acetaminophen-hydrocodone [a narcotic pain medication used to treat pain] 325 mg -5 mg oral tablets ...Volume dose: 1...Volume dose unit: tab ... Route of administration: Oral ...Frequency: Q4hr [every four hours] ... PRN [as needed] ... PRN reason: Pain Moderate ...”. During a concurrent interview and record review on 8/2/24 at 1:45 with RN 11, Pt 29’s “MAR” summary, dated 8/1/24 and 8/2/24 were reviewed. The “MAR” summary indicated Pt 29 was administered one tab of acetaminophen-hydrocodone 325 mg-5mg oral tablet on 8/1/24 at 1:40 p.m. RN11 stated the “MAR” summary indicated Pt 29’s pain was not reassessed within the one-hour timeframe per policy. RN 11 stated Pt 29’s pain should have been re-assessed on 8/1/24 by 2:40 p.m. or sooner. RN 11 stated LNs must reassess pain to ensure pain was controlled with the medication that was administered. During an interview on 8/2/24 at 2:40 p.m. with the Director of Women’s Services (DWS), The DWS stated her expectation was that LNs followed up with patients to get a second pain assessment after the administration of medication. During a concurrent interview and record review on 8/6/24 at 2:05 p.m. with RN 11, Pt 40’s H&P, dated 2/1/24, was reviewed. The H&P indicated, “ ...gravida 10 para 0 with intrauterine pregnancy at 32+ ... ... Patient will be delivered here by cesarean section [C/S- surgical delivery of baby through cut in mother’s stomach and uterus] ...”. During a concurrent interview and record review on 8/6/24 at 2:45 p.m. with RN 11, Pt 40’s “Electronic Medical Record (“EMR”)” was reviewed. RN 11 stated Pt 40 was taken to the operating room (OR) for surgery on 2/1/24 at 6:01 p.m., surgery began on 2/1/24 at 6:18 p.m., the baby was delivered on 2/1/24 at 6:20 p.m., and Pt 40 was taken to the recovery room on 2/1/24 at 7:20 p.m. During a concurrent interview and record review on 8/6/24 at 3:00 p.m. with RN 11, Pt 40’s “Pain Assessment Flowsheet (PAF),” dated 8/1/24 and 8/2/24 were reviewed. RN 11 stated Pt 40 arrived in the “Post Anesthesia Recovery Unit (PACU)” on 8/1/24 at 7:20 p.m. RN 11 stated Pt 40 had vital signs (VS) obtained every 15 minutes after arrival to the “PACU”, until transferred to the next unit. RN 11 stated obtaining a pain score was a part of the VS criteria. RN 11 stated the first set of VS in “PACU” was 8/1/24 at 7:30 p.m. RN 11 stated no pain score was documented at 7:30 p.m. RN 11 stated Pt 40’s VS were taken every 15 minutes until 10:00 p.m. RN 11 stated no pain score was documented during the VS that were taken at 8 p.m., 8:15 p.m. 8:30 p.m., 9 p.m., 9:15 p.m., 9:30 p.m., or 9:45 p.m. RN 11 stated the final pain score was obtained on 8/1/24 at 10 p.m. RN 11 stated Pt 40 was transferred to the postpartum (after delivery of baby) unit at 10:50 p.m. RN 11 stated Pt 40 did not have any pain medications administered in “PACU”. RN 11 stated her expectation was, pain should be assessed with each VS. RN 11 stated, assessing pain was important to ensure patients were comfortable and as pain free as possible. During a concurrent interview and record review on 8/1/24 at 2:00 p.m. with RN 9, Patient 55’s “Electronic Medical Record (“EMR”- digital collection of medical information),” undated was reviewed. The “EMR” indicated the “Medication Administration Record Summary (MARS-summary of medication administered to patient)” received Acetaminophen (It can treat minor aches and pains, and reduces fever) 1000 milligrams (mg-unit of measure) on 7/31/24 at 9:59 a.m. The Pain Flowsheet (PF) indicates no pain assessment was done prior to receiving medication or after receiving the medication. RN 9 validated Patient 55’s pain was not documented prior to receiving medication or after receiving the medication. During an interview on 8/9/24 at 11:35 a.m. with the CNO, the CNO stated her expectation was for LNs to assess for pain with vital signs. The CNO stated her expectation was for LNs to assess and reassess patients for pain. The CNO stated her expectation was for LNs to follow P&P. During a review of the facility’s P&P titled, “Pain Management”, dated 6/13/22, the P&P indicated, “ ... Ask patients on initial evaluation his or her comfort goal and as part of regular assessments about the presence, quality and intensity of pain and use patient’s self-report as the primary indicator of pain ... In describing pain, pay special attention to documenting the following: ... Description ... Onset and duration ... Intensity ... Associated signs and symptoms ...The pain intensity and pain relief, as reported by patient will be assessed and documented: ... On admission ... After any known pain-producing event ...with each new report of pain ...With vital signs ...A reassessment within one hour of intervention or less as appropriate ... when medications are administered ... Assess the patient’s level of sedation before and after administering narcotic medication that could be potentially sedating ... For medication administration use the following pain scale rating guidelines ...0 = no pain ...1-3 = mild pain ... 4-6 = moderate pain ...7-10 = severe pain ...”. During a review of the facility’s P&P titled, “Medication Administration,” dated 7/26/23, the P&P indicated, “ ... After the administration of any medication, the medication’s effect on the patient will be monitored and will include an assessment based on the nurse’s observations and the patient’s own perceptions ...”. During a professional reference review titled, “Pain management in hospitals: patients’ satisfaction and related barriers,” dated 9/25/18, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207353/) indicated, “ ... Suboptimal pain control has been frequently reported in healthcare settings and documented to negatively impact patients’ health. Patients’ perception regarding pain management may influence their satisfaction regarding treatment ...”. During a professional reference review titled, “Acute Pain Management Pearls: A Focused Review for the Hospital Clinician,” dated 12/22/22, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9818465/) indicated, “ ... Uncontrolled pain worsens patient outcomes ... Uncontrolled acute pain triggers a complex neurohormonal cascade that is toxic to nearly every organ system, as evidenced by increased rates of renal [kidney] and gastrointestinal [stomach and intestine] dysfunction, infection, cardiopulmonary [heart and lungs] and thrombotic [blood clot] complications, impaired wound healing, adverse psychological effects, and poorer functional recovery and quality of life ... Acute pain management in hospitalized patients should therefore be a clinician and intuitional priority as a key driver of patient outcomes ...”. 3. During a concurrent interview and record review on 8/6/24 at 2:05 p.m. with RN 11, Pt 40’s H&P, dated 2/1/24, was reviewed. The H&P indicated, “ ... gravida 10 para 0 with intrauterine pregnancy at 32+4 days [32 weeks and 4 days of pregnancy] ... presented here with severe headache past few days and chest pain ... Her blood pressure on arrival was 200/90 patient has type 2 diabetes [body doesn’t produce enough insulin or can’t use insulin properly] and morbidly obese [more than 80 to 100 pounds above their ideal body weight] she is on [enoxaparin (blood thinner)] ...”. During a concurrent interview and record review on 8/6/24 at 2:10 p.m. with RN 11 Pt 40’s H&P “Assessment Plan” dated 8/1/24 at 4:37 p.m., was reviewed. The “Assessment Plan” indicated, ... severe preeclampsia [high blood pressure (hypertension) disorder that can occur during pregnancy] ... Patient will be delivered here by cesarean section [surgical delivery of baby through cut in mother’s stomach and uterus] and infant will be transferred to [other hospital] ... She was on magnesium 4 gram [g - a unit of measurement] bolus [single large dose] and 2 grams/hour [g/hr per hour] ...”. During a concurrent interview and record review on 8/6/24 at 2:20 p.m. with RN 11 Pt 40’s “EMR” dated 2/1/24, was reviewed. RN 11 stated Pt 40 arrived in the L&D triage [patients are assessed and seen based on severity of assessment] area on 2/1/24 at 3:12 p.m. for a non-stress test (NST) [brief monitoring of baby’s heartrate to see if changes occur]. RN 11 stated at 3:19 p.m. Pt 40’s VS were obtained, and the first Blood Pressure (BP) was 199/93 indicating the blood pressure was severely elevated. RN 11 stated nursing notes indicated the physician was contacted at 3:25 p.m. and orders were received to begin the hypertensive protocol, and to start the patient on magnesium sulfate 4g bolus and 2 g/hr maintenance infusion. RN 11 stated a second BP of 206/97 was obtained at 3:40 p.m., 23 minutes after the first. RN 11 stated the order for magnesium sulfate was not entered until 4:08 p.m. and was not started until 4:33 p.m., one hour and 13 minutes after a verbal order (order give by phone or face to face) from the MD was received. RN l1 stated one hour and 13 minutes was an extended amount of time for a patient with preeclampsia to go without a magnesium bolus. RN 11 stated Pt 40’s BPs should have been taken every 10 minutes per hypertensive protocol. During a concurrent interview and record review on 8/6/24 at 2:40 p.m. with RN 11 Pt 40’s “MAR” dated 2/1/24, and Vital Signs Flowsheet (VSF)” dated 2/1/24, were reviewed. RN 11 stated, BP, HR, Oxygen Saturation (SpO2, he amount of oxygen you have circulating in your blood), Respiratory Rate (RR), and Deep Tendon Reflexes (DTRs- stretch reflexes are initiated by tapping a tendon) - were supposed to be documented every 15 minutes while the magnesium sulfate bolus was infusing. RN 11 stated LNs did not document Pt 40’s RR or DTR’s during the magnesium bolus or one hour after the 2 g/hr. maintenance infusion was running. RN 11 stated the “MAR” indicated, at 4:33 p.m. a 4-gram (g-a unit of measurement) bolus was initiated. RN 11 stated the “VSF” indicated, at 4:32 p.m. Pt 40’s BP was 203/92, HR 67, and SpO2 99%. RN 11 stated no RR was documented. RN 11 stated at 4:45 p.m. Pt 40’s BP was 211/91, HR 77, and SpO2 99%, no RR was and no DTRs were documented. RN 11 stated at 4:52 p.m. the magnesium sulfate 2g/hr maintenance infusion was started. RN 11 stated at 6 p.m. Pt 40’s BP was 148/74, HR 86, and SpO2 100%, no RR or DTRs were documented. RN 11 stated at 4:52 p.m. and at 5:52 p.m. LNs should have completed a magnesium sulfate assessment on Pt 2 including DTRs, SpO2, HR, and RR. RN 11 stated the patient should have been monitored for magnesium sulfate toxicity (overuse of magnesium containing medication which can lead to loss of reflexes, decreasing respirations and cardiac arrest). RN 11 stated once the magnesium sulfate infusion started, the RN should check their patient’s deep tendon reflexes (DTR-stretch reflexes are initiated by tapping a tendon), respiratory rate (normal rate is 12 to 20 breaths per minute), urine output (normal is greater than 30 milliliters per hour), per the magnesium sulfate policy. RN 11 stated BPs were set for every 15 minutes and not 10 minutes as they should have been. During a concurrent interview and record review on 8/7/24 at 9:30 a.m. with MGR 9, Pt 40’s “Magnesium Sulfate Therapy Assessment (MSTA),” dated 2/1/24, and “MAR” summary, dated 2/1/24, were reviewed. MGR 9 stated Pt 40’s first “MSTA” was on 2/1/24 at 7:20 p.m. MGR 9 stated Pt 40’s magnesium sulfate bolus was started on 2/1/24 at 4:33 p.m. and the first “MSTA” should have been completed at 4:52 p.m. MGR 9 stated a second “MSTA” should have been completed at 5:52 p.m. MGR 9 stated Pt 40 was moved to the OR for her C/S at 6:10 p.m. and to Post anesthesia care unit (PACU) at 7:20 p.m. MGR 9 stated the first “MSTA” was documented when she arrived to PACU at 7:20 p.m. MGR 9 stated her expectation was for LNs to complete the “MTSA” for all patients administered magnesium sulfate per the facility P&P. MGR 9 stated unassessed patients receiving magnesium sulfate could have unrecognized magnesium sulfate toxicity signs and symptoms. During an interview on 8/9/24 at 11:30 a.m. with the CNO, the CNO stated she expected LNs to follow facility P&P and standards of practice. During a review of the facility’s P&P titled, “Guidelines for Magnesium Sulfate Administration,” dated 2/24/17, indicated, “ ... Magnesium sulfate is labeled as a “High Alert” drug by the institute for Safe Medication Practices (ISMP). A high-alert medication is one that may cause significant harm when used incorrectly. Magnesium sulfate is in this category due to the risk of maternal respiratory arrest, hypoxic injury, cardiopulmonary arrest, and death if an overdose occurs ... Signs and symptoms of magnesium toxicity ... Absent deep-tendon reflexes ... Respiratory Depression ... Cardiac arrest ... Have resuscitation equipment readily available. (Suction and oxygen set at the bedside.) ... Monitor patient’s vital signs: pulse, respiration, and blood pressure, every 15 minutes during loading dose, then every one hour during maintenance dose. ... Check deep tendon reflexes (DTR’s) and clonus hourly. ... Continuous fetal monitoring and SPO2 monitoring ...”. During a review of the facility’s P&P titled, “Severe Intrapartum or Postpartum Hypertension Emergency,” dated 10/4/23, indicated, “ ... Preeclampsia: SBP [SBP-systolic blood pressure, top number of BP reading] ?140 or DBP [diastolic BP - bottom number of BP reading] ? 90, measured on at least two occasions at least 4-6 hours apart ... Proteinuria (protein in the urine) ... Preeclampsia with severe features ... SBP ? 160 or DBP ? 110 ... Cerebral [brain] or visual symptoms ... Severe hypertension and/or preeclampsia is an obstetrical emergency requiring standards for early warning signs ...Notify physician after one severe BP value is obtained. The emergency begins at the first measurement of severe hypertension ... Repeat BP in 15 minutes ... This is the blood pressure to confirm hypertension. Obtain orders and begin treatment, should be no longer than 60 minutes after the second BP measurement ... Treatment ... Intravenous Labetalol (Labetalol Algorithm) ... Intravenous Hydralazine (Hydralazine Algorithm) ... Magnesium Sulfate ...Should be used for seizure prophylaxis and controlling seizures in eclampsia ... Monitoring ... Once BP is controlled (<160/110), measure BP ... every 10 minutes for 1 hour ... Every 15 minutes for 1 hour ... Every 30 minutes for 1 hour ... Every hour for 4 hours ... Monitor SaO2, if less than 96% notify physician ... Notify physician of any new complaints of nausea, vomiting, epigastric pain, or heartburn ... Labetalol Algorithm ... Labetalol 20 mg IV over 2 minutes ... Repeat BP in 10 minutes ... if SBP ?160 or DNP ?110 administer 40 mg IV over 2 minutes; ... Repeat BP in 10 minutes ... if SBP ?160 or DNP ?110, administer labetalol 80 mg IV ... repeat in 10 minutes ... if SBP ? 160 or DNP ?110 administer hydralazine10 mg IV over 2 minutes ... repeat BP in 20 minutes ... if SBP ? 160 or DNP ?110 at 20 minutes obtain emergency consultation from specialist in MFM [maternal fetal medicine], internal medicine, anesthesiology, or critical care ...”. During a professional reference review titled, “, Magnesium Toxicity” dated 11/7/22, (found at https://www.ncbi.nlm.nih.gov/books/NBK554593/), indicated, “ ... Magnesium toxicity is commonly caused by the overuse of magnesium-containing medication or under-excretion of magnesium by the kidneys. Early recognition, as well as a high index of suspicion, is critical when diagnosing magnesium toxicity before the onset of fatal complications such as hypotension, respiratory paralysis, and cardiac arrest ... Nurses monitor patients, administer treatment, provide patient education, and report status changes to the rest of the team ...”. 4. During a concurrent interview and record review on 8/2/24 at 1:30 p.m. with RN 11, Pt 29’s H&P, dated 7/31/24, was reviewed. The H&P indicated, “ ... 30-year-old gravida 6 [6-pregnancies] para 2 [2- births] with intrauterine [in uterus] pregnancy at 36 weeks plus with poor control gestational diabetes [high blood sugar during pregnancy]. Severe obesity [overweight]... and had elevated blood pressure was sent to labor and delivery .... with preeclampsia [condition where high blood pressure may cause seizures] ... Induction labor [making contractions begin to deliver baby] ...” During a concurrent interview and record review on 8/2/24 at 1:30 p.m. with RN 11 Pt 29’s “Physician Orders (PO),” dated 7/31/24 to 8/1/24, were reviewed. The “PO” indicated, “ ... Notify Physician/Provider Vital Signs ... Start Date/Time: 7/31/24 12:27 [p.m.] ... Heart rate greater than 120 ... Systolic blood pressure [mmHg-millimeters per mercury - a unit of pressure] greater than ... 140 ...Systolic blood pressure (mmHg) greater than 90 ... entered on 7/31/24 at 12:27 [p.m.] ...” RN 11 stated, the physician order indicated LN’s should have reported any BP’s over 140/90 to physicians. During a concurrent interview and record review on 8/2/24 at 1:35 with RN 11 Pt 29’s “VS” flowsheet, dated 7/31/24 and 8/1/24, and “EMR” were reviewed. The “VS” flowsheet indicated Pt 29’s BP was consistently over the physician notification parameters of 140/90. RN 11 stated no documentation was in the “EMR” indicating Pt 29’s physician was notified of BP’s above ordered parameters. RN 11 stated LNs should have entered a note to indicate communication with the physician about elevated BP’s. During an interview on 8/2/24 at 2:30 p.m. with the DWS the DWS stated her expectation was that LNs follow physician orders as they were written. The DWS stated her expectation was for LNs to contact the physician for clarification of an order or for new orders as needed. During a concurrent interview and record review on 8/7/24 at 10 a.m. with MGR 9, Pt 29s “”EMR”,” dated 7/31/24 to 8/2/24, was reviewed. The “EMR” indicated, Pt 29 had multiple elevated BPs over the physician ordered parameter of 140/90 that were not reported to the physician. MGR 9 stated her expectation was for LNs to follow physician’s orders and report any abnormal BPs. MGR 9 stated her expectation was for LNs to contact the physician for clarification of an order if they do not understand or do not agree with the order. During an interview on 8/7/24 at 11:50 a.m. with MD 1, MD 1 stated his expectation was that LNs followed the orders that he entered. MD 1 stated if LNs do not agree with an order or need clarification of an order, he expects them to call and discuss it with him. MD 1 stated if there was an initial BP of 140/90 he would want to be notified. MD 1 stated after the initial elevated BP with notification to him, he would want to be made aware of any BPs over 160/110 even if they were not sustained (continued). MD 1 stated he would also want to know if patients started to have any signs and symptoms of pre-eclampsia. MD 1 stated some signs and symptoms could be a new or worsening headache, visual changes, decrease in urine output, and upper abdominal pain. During an interview on 8/7/24 at 1:39 p.m. with MD 2, MD 2 stated she was Pt 29’s primary physician during her admission to the facility. MD 2 stated Pt 29s BP were elevated upon arrival to the facility, but after changing the BP cuff to the correct size came down some. MD 2 stated her expectation was for LNs to follow her orders as written. MD 2 stated Pt 29 should have had the hypertensive protocol ordered per the P&P, and she was not aware they were not entered. MD 2 stated her expectation was for nurses to report to her or document speaking to a physician when no orders were received for elevated BPs. MD 2 stated LNs should have contacted her about elevated BPs so she could determine a course of treatment. During a concurrent interview and record review on 8/7/24 at 3 p.m. with RN 14, Pt 29’s “”EMR”,” dated 7/31/24, was reviewed. The “EMR” indicated RN 14 was the nurse that triaged Pt 29 on 7/31/24. RN 14 stated she triaged Pt 29 on 7/31/24. RN 14 stated she did an assessment of the patient but did not document any information about signs and symptoms of pre-eclampsia. RN 14 stated Pt 29 had elevated BPs in triage. RN 14 stated Pt 29 had BPs over 140/90 at 11:13 a.m., 11:20 a.m., 11:30 a.m., 11:50 a.m., 11:51 a.m., and 12 p.m. RN 14 stated she changed Pt 29’s BP cuff to a larger size and the BPs came down a little bit. RN 14 stated the BPs were still consistently over 140/90. RN 14 stated LNs in the L&D unit should have followed the physician order to notify the physician about any elevated BPs over the parameter of 140/90. During a review of Pt 29’s “VS” from the “Fetal Monitoring System”, dated 7/31/24 to 8/1/24, the “VS” indicated, Pt 29 had a total of 27 BPs readings from 7/31/24 at 1:11 p.m. (when they transferred to the L&D department) to 8/1/24 at 7:49 a.m. (when physician D/C BP parameter order). Pt 29 had 24 BP readings that were over the physician ordered parameters of 140/90. Pt 29 only had a total of three BP readings that were under the physician ordered parameters. Pt 29 had three BP readings that were over 160/110 which were in the severe range. During an interview on 8/9/24 at 11:35 a.m. with the CNO, the CNO stated she expected LNs to follow physician orders. The CNO stated if physician orders were not followed care may be compromised. The CNO stated her expectations was for LNs to use their chain of support when they questioned orders from a physician. During a review of the facility’s P&P titled, “Severe Intrapartum or Postpartum Hypertension Emergency,” dated 10/4/23, indicated, “ ... Preeclampsia: SBP [SBP-systolic blood pressure, top number of BP reading] ?140 or DBP [diastolic BP - bottom number of BP reading] ? 90, measured on at least two occasions at least 4-6 hours apart ... Proteinuria (protein in the urine) ... Preeclampsia with severe features ... SBP ? 160 or DBP ? 110 ... Cerebral [brain] or visual symptoms ... Severe hypertension and/or preeclampsia is an obstetrical emergency requiring standards for early warning signs ...Notify physician after one severe BP value is obtained. The emergency begins at the first measurement of severe hypertension ... Repeat BP in 15 minutes ... This is the blood pressure to confirm hypertension. Obtain orders and begin treatment, should be no longer than 60 minutes after the second BP measurement ...”. During a professional reference review titled, “Efficacy of Magnesium Sulfate on Maternal Mortality in Eclampsia, “ dated 8/20/21, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8451518/) indicated, “ ... Eclampsia is a common complication of preeclampsia patients and can be life-threatening for both the mother and the fetus. Hence, timely intervention and appropriate management of this detrimental condition are extremely crucial. Eclampsia is described as the occurrence of generalized convulsions in patients with preeclampsia. Magnesium sulfate (MgSO4) is the drug of choice for treating and preventing eclampsia ...”. During a professional reference review titled, “Hypertension In Pregnancy”, dated 10/3/22, (found at https://www.ncbi.nlm.nih.gov/books/NBK430839/) indicated, Hypertensive disorders of pregnancy, including chronic hypertension with or without superimposed pre-eclampsia/eclampsia, gestational hypertension, preeclampsia with or without severe feature, ... eclampsia present a significant risk of morbidity to both mother and fetus ...”. During a professional reference review titled, “The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review,” dated 1/15/19, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6333367/) indicated, “ ... Vital signs, i.e. respiratory rate, oxygen saturation, pulse, blood pressure and temperature, are regarded as an essential part of monitoring hospitalized patients. Changes in vital signs prior to clinical deterioration are well documented and early detection of preventable outcomes is key to timely intervention ...”. 5. During a concurrent interview and record review on 8/6/24 at 2:05 p.m. with RN 11, Pt 40’s H&P, dated 2/1/24, was reviewed. The H&P indicated, “ ...gravida 10 para 0 with intrauterine pregnancy at 32+4 days [32 weeks 4 days of pregnancy] ... presented here with severe headache past few days and chest pain ... Her blood pressure on arrival was 200/90 patient has type 2 diabetes and morbidly obese she is on [enoxaparin (blood thinner)] ... Patient will be delivered here by cesarean section ...” During a concurrent interview and record review on 8/6/24 at 3:12 p.m. with RN 11, Pt 40’s “VSF,” dated 2/1/24, and “Fundal/Lochia” flowsheet, dated 2/1/24 to 2/3/24, were reviewed. RN 11 stated Pt 40 had a fundal/lochia assessment on 2/1/24 at 7:35 p.m., 7:40 p.m., 8 p.m. and 8:22 p.m. RN 11 stated no fundal/lochia assessments were documented from 2/1/24 at 8:12 p.m. to 2/3/24 at 9:11 a.m. RN 11 stated fundal/lochia assessments were important to ensure patients were not bleeding more than the expected amount. RN 11 stated when the fundal/lochia assessments were not completed a patient could bleed, bleeding could cause hemorrhage, hemorrhage could cause patient to expire (die). RN 11 stated a small amount of bleeding was expected after delivery, but if LNs were not assessing bleeding they would not know if a patient were bleeding more than they should be. During a concurrent interview and record review on 8/7/24 at 9:45 a.m. with MGR 9, Pt 40’s “”EMR”,” dated 2/1/24 to 2/3/24, was reviewed. MGR 9 stated L&D and PP units follow AWHONN and American College of Obstetricians and Gynecologists standards. MGR 9 stated and the standards for fundal/lochia assessments post-delivery were every 15 minutes for the first hour then every 30 minutes for the second hour. MGR 9 stated fundal/lochia assessments continued in the postpartum (PP) unit every four hours for 24 hours, then every shift. MGR 9 stated LNs could assess more frequently based on nursing judgement. MGR 9 stated Pt 40 was moved from the OR on 2/1/24 at 7:19 p.m. and into the PACU on 2/1/24 at 7:20 p.m. MGR 9 verified, Pt 40’s “EMR” indicated, no LN documentation for fundal and bleeding assessments from 2/1/24 at 8:22 p.m. until 2/3/24 at 9:11 a.m. MGR 9 stated Pt 40 was a high risk for hemorrhage due to being on blood thinners. MGR 9 stated fundal assessments were important to monitor bleeding. MGR 9 stated patients can “bleed out (bleed too much)”, and potentially expire (die). During an interview on 8/7/24 at 11:53 a.m. with MD 1, MD 1 stated his expectation was that LNs did fundal/assessments per protocol for both vaginal and C/S deliveries. MD 1 stated when patients were not assessed they may have uterine atony (soft weak uterus), and not have the atony recognized. MD 1 stated, a patient may have bleeding that is held in by blood clots in the uterus. MD 1 stated the hemorrhage would not be recognized until VS instability (were not normal). MD 1 stated fundal/lochia assessments prevent LNs from waiting until there was VS instability. During an interview on 8/7/24 at 1:56 p.m. with MD 2, MD 2 stated Pt 40 should have had fundal/lochia assessments per protocol. MD 2 stated fundal/lochia assessments were important because patients could have uterine atony, incisional bleeding, or a hematoma (a pool of clotted blood that forms beneath the skin). MD 2 stated fundal/lochia assessments were important for all patients but more important for someone on blood thinners. During a concurrent interview and record review on 8/8/24 2:05 p.m. with RN 19, Pt 40’s “Fundal/Lochia” flowsheet, dated 2/1/24 to 2/3/24, were reviewed. The “Fundal/Lochia” indicated, no fundal/lochia assessments were documented from 2/1/24 at 8:22 p.m. until 2/3/24 at 9:11 a.m. RN 19 stated she was Pt 40’s primary nurse on 2/2/24 at 10:59 a.m. until 2/2/24 at 7:30 p.m. RN 19 stated she did not know why there were no fundal and lochia assessment documented during her shift. RN 19 stated Pt 40 should have had a fundal and lochia assessment every four hours from 2/1/24 at 12:22 a.m. until 2/2/24 at 6:10 p.m. then every shift, which was every 12 hours. RN 19 said assessing the patient’s fundus and bleeding was critically important. RN 19 stated when completing the fundal assessment LNs assessed the placement, and the firmness of the fundus. RN 19 stated at the same time LNs were assessing for amount of bleeding, the color of the lochia, and the odor of the lochia. RN 19 stated completing the assessments could possibly prevent a hemorrhage. RN 19 stated LNs were trained to notice if the patients were bleeding more than the previous fundal assessment. RN 19 stated the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) standards of care were practiced at this facility for fundal assessments. During an interview on 8/9/24 at 11:30 a.m. with CNO, the CNO stated her expectation was that all policies and procedures should be followed. During a professional reference review titled, “Core Curriculum for Maternal-Newborn Nursing,” dated 1/17/23, (AWHONN sixth edition, textbook), indicated, “ ... Postpartum Period ... Clinical Assessment ... Physical Changes ... Assessment ... Postpartum maternal assessment: At least every 15 minutes for the first hour, every 30 minutes for 1 hour, and then every 4 hours (or more frequently if complications are present for 12 to 24 hours, “If the mother is stable, some institutions defer the 4-hour assessments after the first 12 hours if the mother is sleeping” ... Uterus ... Consistency and tone ... Position ... Position ... Height ... Tenderness ... Cesarean section incision site, if appropriate ...Lochia ... Type and amount ... Presence of odor ... Presence of clots, especially any larger than a 50 cent piece ... Perineum [the tiny patch of sensitive skin between your genitals] ... Episiotomy [a cut (incision) through the area between your vaginal opening and your anus] ... Bruising, hematoma, edema [swelling caused by too much fluid trapped in the body’s tissues], discharge, and loss of approximation ... reddened areas indicative of infection ...”. During a professional reference review titled, “Postpartum Hemorrhage,” dated 2/5/24, (found at https://www.myamericannurse.com/postpartum-hemorrhage/) indicated, “ ...Postpartum hemorrhage is the most common obstetrical emergency and the leading cause of maternal morbidity and mortality worldwide. Prevention, early identification, and timely management are crucial to prevent maternal death .... in the postpartum unit, the obstetric hemorrhage team focuses on identifying the cause of the bleeding using the four Ts (tone, trauma, tissue, or thrombin) ... PPH [postpartum hemorrhage], the most common obstetrical emergency, is the leading cause of maternal morbidity [illness] and mortality [death]. It’s defined as cumulative blood loss ?1,000 mL or any blood loss accompanied by signs and symptoms of hypovolemia [low blood volume] (such as tachypnea [rapid breathing], tachycardia [rapid HR], hypotension [low bp], weakness, and sweating) within 24 hours of vaginal or cesarean delivery. Uterine atony (the failure of the uterus to contract) is attributed to 70% to 80% of PPH cases ...”. 6. During a concurrent observation and interview on 7/31/21 at 3:46 p.m. with Manager (MGR) 7 in the telemetry medication room, a glucometer was observed to have two vials of glucose control solution (solution used to test the functionality of meter and strips) with no opened date written on the vials. MGR 7 stated, without an opened dated staff would not know if the solution had been opened longer than 90 days. MGR 7 stated the control solutions were good for three months after opening, or until the manufacture expiration date, whichever came first. MGR 7 stated the charge nurses were responsible for opening new glucose control solutions and should have written the date the solution would expire. MGR 7 stated, using a control solution over the 90 days to complete the quality control (QC) checks could give inaccurate results. During an interview on 8/9/24 at 11:35 a.m. with the CNO, the CNO stated she expected her LNs to follow policies and procedures (P&P) for glucometer usage. During a review of the facilities P&P titled, “Blood Glucose Monitoring Using [Brand Name of glucometer] Inform II System,” dated 7/21/97, the P&P indicated “ ...QUALITY CONTROL TESTING OF [Brand Name] INFORM SYSTEM ...To insure the [brand name] Inform II meter is functioning properly, Quality Control (QC) are required every 24 hours. Both a level 1 test and a level 2 test will need to be done prior to continuing use of the meter. The meter will lock out until QC has been completed. Quality control should be performed: Once per 24 hours with each [brand name] Inform II monitor in routine use and when prompted ...Each time a new vial or new lot number of strips is utilized ...Whenever a vial of strips has been left uncapped ...If the monitor has been dropped ...Whenever test results disagree with clinical symptoms ...To recertify an operator ...Glucose control solutions (Level 1 and Level 2), for use with the [brand name] Inform II. Date control solution vials with open expiration date. The controls are good for 3 months after opening or until expiration date from manufacturer, whichever comes first ...If either Level 1 or Level 2 Control Test FAIL, chose appropriate comment and repeat the failed test. If one or both tests FAIL again, Check the expiration date of the strips and control solutions, Open fresh controls and repeat the test ...”. During a review of, “Manufacturer instructions for use (MIFU)” for [brand name] control solutions, dated 2022, the MIFU indicated, “ ...Testing control solutions with known glucose levels establishes that the operator and the system are working acceptably. Control result must be within the defined acceptable ranges before valid patient testing is allowed ...The control solution is stable for 3 months after opening or until the expiration date on bottle label, whichever comes first ...”. 7. During a concurrent interview and record review on 8/1/24 at 2:10 p.m. with RN 9, Pt 54’s “EMR” was reviewed. The “EMR” indicated Patient 55 was assigned an ESI level of three. The Vital Sign Flowsheet (VSF) indicated no vitals assessment was conducted from 7/31/24 at 9:17 a.m. to 7/31/24 at 5:33 p.m. RN 9 validated Pt 54’s vitals assessments were not documented. During a concurrent interview and record review on 8/1/24 at 2:00 p.m. with RN 9, Pt 55’s “EMR” was reviewed. The “EMR” indicated Pt 55 was assigned an ESI level of three. The VSF indicated no vitals assessment was documented from 7/31/24 at 8:27 a.m. to 7/31/24 at 5:47 p.m. RN 9 validated Patient 55’s vitals assessment was not documented. During a concurrent interview and record review on 8/8/24 at 10:10 a.m. with RN 9, Pt 60’s “EMR” was reviewed. The “EMR” indicated Pt 60 was assigned an ESI level of four. Patient 60 arrived at Emergency Department (ED) on 8/7/24 at 3:57 p.m. and was discharged 8/7/24 at 6:11 p.m. The Assessment Flowsheet (AF) indicates no focused assessment was documented during visit. RN 9 validated Pt 60 had no assessment documented. During a concurrent interview and record review on 8/8/24 at 10:00 a.m. with RN 9, Pt 61’s “EMR” was reviewed. The “EMR” indicated Pt 61 was assigned an ESI level of four. Patient 61 arrived at ED on 8/7/24 at 2:11 p.m. and was discharged 8/7/24 at 5:48 p.m. The AF indicated no focused assessment was documented during visit. RN 9 validated Pt 61 had no assessment documented. During a concurrent interview and record review on 8/8/24 at 9:50 a.m. with RN 9, Pt 62’s “EMR” was reviewed. The “EMR” indicated Pt 62 was assigned an ESI level of three. Patient 62 arrived at ED on 8/5/24 at 12:44 p.m. and was discharged 8/5/24 at 7:11 p.m. The AF indicated no focused assessment was documented during visit. RN 9 validated Pt 62 had no assessment documented. During a concurrent interview and record review on 8/8/24 at 9:50 a.m. with RN 9, Pt 62’s “EMR” was reviewed. The “EMR” indicated Pt 62 was assigned an ESI level of three. The VSF indicated the only vitals documented were on 8/5/24 at 1:06 p.m. Patient arrived at ED on 8/5/24 at 12:44 p.m. and was discharged on 8/5/24 at 7:11 p.m. RN 9 validated Pt 62’s vitals assessment was only documented one time. During a concurrent interview and record review on 8/8/24 at 9:20 a.m. with RN 9, Pt 63’s “EMR” was reviewed. The “EMR” indicated Pt 63 received 2 units (unit of measure) of blood for a blood transfusion (the process of receiving blood intravenously [a way of delivering fluid or medicine directly into the bloodstream]). The Blood Transfusion Flowsheet (BTF) indicated the first blood transfusion started on 8/7/24 at 8:55 p.m. The VSF indicates the next vitals entered were on 8/7/24 at 9:08 p.m. The BTF indicated the second blood transfusion started on 8/7/24 at 10:53 p.m. The VSF indicated the next vitals entered on 8/7/24 at 11:07 p.m. RN 9 validated Pt 63’s vitals assessment. RN 9 stated blood transfusion policy was not followed due to not waiting 15 minutes to take vitals after blood transfusion was started. During a concurrent interview and record review on 8/8/24 at 9:30 a.m. with RN 9, Pt 64’s “EMR” was reviewed. The “EMR” indicated Pt 64 was assigned an ESI level of three. Pt 64 arrived at ED on 8/5/24 at 1:45 p.m. and was discharged 8/5/24 at 7:29 p.m. The AF indicated no focused assessment was documented during visit. RN 9 validated Pt 64 had no assessment documented. During a concurrent interview and record review on 8/8/24 at 9:30 a.m. with RN 9, Pt 64’s “EMR” was reviewed. The “EMR” indicated Pt 64 was assigned an ESI level of three. The VSF indicated no vitals assessment was done from 8/5/24 at 2:02 p.m. to 8/5/24 at 7:29 p.m. RN 9 validated Pt 64’s vitals assessment was not documented. During a concurrent interview and record review on 8/8/24 at 9:10 a.m. with RN 9, Pt 65’s “EMR” was reviewed. The “EMR” indicated Pt 65 was assigned an ESI level of three. Pt 65 arrived at ED on 8/7/24 at 3:18 p.m. and was admitted to hospital on 8/7/24 at 6:40 p.m. The AF indicated no focused assessment was documented during ED visit until Pt 65 was admitted to hospital. RN 9 validated Pt 65 had no assessment documented. During a concurrent interview and record review on 8/8/24 at 9:10 a.m. with RN 9, Pt 65’s “EMR” was reviewed. The “EMR” indicated Pt 65 was assigned an ESI level of three. The VSF indicated no vitals assessment was done from 8/7/24 at 3:21 p.m. to 8/7/24 at 9:24 p.m. RN 9 validated Pt 65’s vitals assessment was not documented. During a concurrent interview and record review on 8/8/24 at 10:40 a.m. with RN 9, Pt 66’s “EMR” was reviewed. The “EMR” indicated Pt 70 was assigned an ESI level of four. Pt 66 arrived at ED on 8/5/24 at 3:53 p.m. and was discharged 8/5/24 at 7:34 p.m. The AF indicated no focused assessment was documented during visit. RN 9 validated Pt 66 had no assessment documented. During a concurrent interview and record review on 8/8/24 at 10:40 a.m. with RN 9, Pt 66’s “EMR” was reviewed. The “EMR” indicated Pt 66 was assigned an ESI level of three. The VSF indicated the only vitals documented on 8/5/24 at 4:00 p.m. Pt 66 arrived at ED on 8/5/24 at 3:53 p.m. and was discharged on 8/5/24 at 7:34 p.m. RN 9 validated Pt 66’s vitals assessment was only documented one time. During a concurrent interview and record review on 8/8/24 at 10:20 a.m. with RN 9, Pt 67’s “EMR” was reviewed. The “EMR” indicated Pt 67 was assigned an ESI level of four. Pt 67 arrived at ED on 8/7/24 at 4:10 p.m. and was discharged 8/7/24 at 6:03 p.m. The AF indicated no focused assessment was documented during visit. RN 9 validated Pt 67 had no assessment documented. During a concurrent interview and record review on 8/8/24 at 9:40 a.m. with RN 9, Pt 68’s “EMR” was reviewed. The “EMR” indicated Pt 68 was assigned an ESI level of three. The VSF indicated the only vitals documented were on 8/5/24 at 10:10 a.m. Patient arrived at ED on 8/5/24 at 9:54 a.m. and was discharged on 8/5/24 at 5:41 p.m. RN 9 validated Pt 68’s vitals assessment was only documented one time. During a concurrent interview and record review on 8/8/24 at 10:50 a.m. with RN 9, Pt 69’s “EMR” was reviewed. The “EMR” indicated Pt 69 was assigned an ESI level of four. Pt 69 arrived at ED on 8/5/24 at 4:24 p.m. and was discharged 8/5/24 at 6:07 p.m. The AF indicated no focused assessment was documented during visit. RN 9 validated Pt 66 had no assessment documented. During a concurrent interview and record review on 8/8/24 at 10:30 a.m. with RN 9, Pt 70’s “EMR” was reviewed. The “EMR” indicated Pt 70 was assigned an ESI level of four. Pt 70 arrived at ED on 8/5/24 at 3:37 p.m. and was discharged 8/5/24 at 7:31 p.m. The AF indicated no assessment was documented during visit. RN 9 validated Pt 70 had no assessment documented. During an interview on 8/9/24 at 11:30 a.m. with the Chief Nursing Officer (CNO), the CNO stated all policies and procedures should be followed. The CNO stated all assessments should be done according to policy. During a review of the facility’s P&P titled, “Triage,” dated 10/17/2023, the P&P indicated, “ ... K. Repeat vital signs vitals (an objective measurement of the essential physiological functions including heartbeat, breathing rate, temperature, and blood pressure) to be measured and documented as follow ...Emergency Severity Index (ESI-a five level triage system that categorizes patients based on their acuity. Level 1: Immediate: life threatening. Level 2: Emergency: could become life threatening. Level 3: Urgent: not life threatening. Level 4: Semi-urgent: not life threatening. Level 5: Non-urgent: needs treatment when time permits) Level 3: Upon arrive to the ED (Emergency Department), then as the situation warrants, but no less than every four hours ...”. During a review of the facility’s P&P titled, “Assessment and Documentation,” dated 11/19/2018, the P&P indicated, “ ... Every patient in the Emergency Department will receive an accurate and ongoing assessment by emergency nurses. The assessment will include systematic and pertinent collection of date about the health status of the patient and will be documented on the Emergency Department record/nurses notes ... III. Procedure. The following minimums of the assessment/documentation will be met on all Emergency Department Patient: ... 9. Signature of triage nurse, primary care nurse, and discharge nurse ...”.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 45929 Based on observations, interviews and record review, the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection in accordance with hospital policy and professional standards when: 1. Unused items were stored in a dirty utility room (a room where used items are placed to be cleaned or disposed of) contrary (opposite) to professional standards. 2. A urine sample used for a pregnancy test was left on the counter in the dirty utility room approximately two hours after the sample was collected contrary to professional standards. 3. Used IV (intravenous) tubing from a patient was discarded in a regular trash can rather than a biohazard (a biological substance that poses a threat to the health of living organisms) disposal container contrary to hospital policy and procedure. 4. Four IV catheters (a needle with a tube, used to start IV lines), one medication tubing set (use to connect a medication to an IV), and three saline locks ( a cap that allows access to an IV and keeps blood from flowing out freely) in sterile packaging, were on the floor and two syringes (a tube with a nozzle and bulb) and two sterile IV start kits ( sterile supplies used to start and IV) were open from their sterile packaging and left unattended on the counter of the clean supply room of the Postpartum (PP, after birth) Unit. A syringe and electrocardiogram (ECG, a record or display of a person’s heartbeat) electrodes (electric conductor on sticker to attach to a patient) in their packages were on the floor in the clean supply room in the telemetry (heart monitoring) unit contrary to professional standards. 5. A package containing a wound drainage (fluid that leaks from wounds) collector with barrier (a type of wound dressing, to keep the wound area clean and dry) was found open in a wound treatment cart on the medical surgical (MS) unit contrary to hospital policy. 6. A patient nutrition room food refrigerator had a sticky brown substance, and crumbs were in two drawers where patient food was held in the telemetry unit contrary to hospital policy and procedure. These failures had the potential for cross contamination (the process by which bacteria [microscopic living organisms that cause infections] are unintentionally transferred from one object or to another object or person with a harmful effect) and transmission of infection. Findings: 1. During a concurrent observation and interview on 7/31/24 at 2:55 p.m. with the Director of Critical Care (DCC) in the Progressive Care Unit’s (PCU) dirty utility room an unused sharps container was found in a cabinet. The DCC stated anything in this room is considered dirty and the unused sharps container should not be in this room. During an interview on 8/9/24 at 11:00 a.m. with the Infection Preventionist (IP), the IP stated any item in the dirty utility room was considered dirty and clean items should not be stored in the dirty utility due to cross contamination. During a review of a professional reference from the Agency for Healthcare Research and Quality (AHRQ) titled, “Infection Prevention (IP)” (undated), “IP” indicated, “ ... Providing a sanitary environment ... There is a clear separation of clean and dirty work areas. Clean areas are used for storage and preparation of medications and unused supplies; dirty areas are used for contaminated equipment ...”. 2. During a concurrent observation and interview on 7/31/24 at 12:36 p.m. with Preoperative Shift Manager (PSM) in the dirty utility room, a specimen cup filled with urine was on the counter. The time and date on the label of the specimen was 7/31/2024 10:48 a.m. The PSM stated that the result of the test took a few minutes. The PSM stated specimen should have been discarded immediately after test results. The SPM stated the specimen was not properly disposed. During an interview on 8/9/24 at 11:00 a.m. with the Infection l Preventionist (IP), the IP stated all departments are expected to follow policy and procedure to prevent infection. The IP stated the urine should have been discarded immediately after results to prevent cross contamination. During an interview on 8/9/24 at 11:30 a.m. with the Chief Nursing Officer (CNO), the CNO stated, she expected staff to follow policy and procedure (P&P) to prevent infection. 3. During a concurrent observation and interview on 7/31/24 at 4:06 p.m. with Emergency Department Shift Manager (EDSM) in the emergency department Rapid Patient Movement (RPM) area, an IV tubing was found discarded in a regular trash can outside a patient room. The EDSM stated the IV tubing should not be discarded in the regular trash and should be discarded in a designated blue pharmaceutical waste bin. During an interview on 8/9/24 at 11:00 a.m. with the IP, the IP stated all departments are expected to follow policy and procedure to prevent infection. The IP stated the IV tubing should be discarded into blue bin and no other trash or garbage cans. The IP stated there a possibility of cross contamination of various infections when IV tubing is not properly disposed and policy for disposal of IV tubing was not followed. The IP stated staff, patients, and visitors would be at risk due to improper disposal of IV tubing. During an interview on 8/9/24 at 11:30 a.m. with the Chief Nursing Officer (Chief Nursing Officer), the CNO stated she expected staff to follow hospital Policy and Procedure (P&P) for proper disposal of IV tubing and P&P was not followed. The CNO stated there could have been cross-contamination by the disposal of IV tubing in the regular trash and someone could get sick. During a review of the hospital’s P&P titled, “Pharmaceutical Waste Management” (undated) indicated, “ ... “ ... Non RCRA (Resource Conservation and Recovery Act, enacted in 1976, is the principal Federal law in the U.S. governing the disposal of solid waste and hazardous waste) pharmaceutical Waste (blue bin) ...Description and example of waste ...Examples of Non-RCRA Waste ...Full or partial IV’s with Rx (prescription medication) instilled ...”. 4. During concurrent observation and interview on 7/31/24 at 12:46 p.m. with Manager (MGR) 1 and the Director of Medical Surgical (DMS) unit in the postpartum (PP) unit clean utility room, Four 18-gauge (g-a unit of measurement) Intravenous catheters, one medication tubing set, and three saline locks in sterile packages, were on the floor of the clean supply room. Two 3 milliliter (mL-a unit of measurement) syringes (a tube with a nozzle and bulb) and two sterile IV start kits (containing, dressing, gauze, antiseptic, tourniquet, tape, and identification label) were opened from their sterile packaging and left on a counter in the clean supply room. MGR 1 stated, clean and sterile patient supplies on the clean utility floor were an infection control issue. The DMS stated sterile packaging such as IV kits should not be opened in the clean supply room and unused items left on counters. MGR 1 stated, syringes should be opened in the patient rooms to prevent cross contamination and lower chances of infection. The DMS stated, all items dropped on the floor in the clean utility room were considered dirty and could not be used on patients The DMS stated, items could not be used because of potential microorganisms that could be on the packaging from the floor. During concurrent observation and interview on 7/31/24 at 3:46 p.m. with Registered Nurse (RN) 3 in the telemetry unit clean utility room, a syringe, and ECG electrodes were observed in their packages on the floor. RN 3 stated clean supplies on the floor in the utility room was an infection control issue. RN 3 stated taking supplies that were on the floor into a patient room then using them can spread infection. During an interview on 7/31/24 at 3:47 p.m. with the DMS, the DMS stated clean supplies should not be used on patients if they were on the floor. The DMS stated clean patient supplies dropped on the floor can have microorganisms that can cause infections in patients. During an interview on 8/9/24 at 11:00 a.m. with the IP, the IP stated clean or sterile supplies should not be on the floor in the clean utility storage rooms. The IP stated supplies should be stored from eight to 10 inches above the floor. The IP stated supplies that were on the ground then used on patients could lead to infection. The IP stated supplies should not be opened and left in the supply room. The ICP stated sterile packages should be opened in the patient room. The IP stated any items opened and left unattended would no longer be considered safe to use on a patient. The IP stated opening a sterile package and leaving the contents in the supply room may lead to infection if the supplies were then used on a patient. During a review of the facility’s P&P titled, “Guidelines for storage in Clean & Soiled Utility Rooms”, dated 7/24/2021, indicated, “ ... All patient care supplies must be stored at least 6 inches from the floor and sterile supplies must be stored no closer than 8-10 inches from the floor ...”. During a review of the professional reference titled, “The role of the surface environment in healthcare-associated infections”, dated 8/2013, the professional reference indicated, “ ... Hospital surfaces are frequently contaminated with important healthcare-associated pathogens [bacteria]. Contact with the contaminated environment by healthcare personnel is equally as likely as direct contact with a patient to lead to contamination of the healthcare provider’s hands or gloves that may result in patient-to-patient transmission of nosocomial [originating from the hospital] pathogens ...”. During a review of the professional reference titled, “GOOD STORAGE AND DISTRIBUTION PRACTICES FOR MEDICAL PRODUCTS”, dated 8/2019, the professional reference indicated, “ ... Storage and distribution are important activities in the supply chain management of medical products ... Medical products should be stored off the floor ...”. 5. During a concurrent observation and interview on 7/31/24 at 2:54 p.m. with the DMS in the medical surgical (MS) clean utility room, a package containing a wound drainage collector with barrier was found open in a wound treatment cart. The DMS stated an open wound supply item was an infection control issue. The DMS stated staff could not ensure microorganisms were not in the open package. The DMS stated her expectation was wound supplies were not opened until taken to bedside and used on the patient. During an interview on 8/9/24 at 11:05 a.m. with the IP, the IP stated clean and sterile packages should be opened in the patient room and used soon after opening. The IP stated any items opened and left unattended would no longer be considered safe to use on a patient. The IP stated a microorganism may be on the supplies. The IP stated opening a package and leaving the contents in the supply room or wound cart may lead to infection. During a review of the facility’s P&P titled, “Standard for Impaired Skin Integrity (Potential/Actual)”, dated 8/18/90, indicated, “ ... wound cleansing and wound treatment products ...”. 6. During a concurrent observation and interview on 7/31/24 at 3:50 p.m. with RN 3 in the telemetry unit nutrition room patient food refrigerator, a sticky brown substance and crumbs were observed in both bottom drawers. RN 3 stated, environmental services (EVS) were responsible for cleaning the refrigerator, but nursing staff should notify EVS if necessary to ensure cleanliness. RN 3 stated, microorganisms grow in unclean areas and can attach to the packaging on patient food items that are stored in the refrigerator. RN 3 stated infection risk may increase when microorganisms were present on items given to patients. During an interview on 8/9/24 at 11:10 a.m. with the IP, the IP stated patient food refrigerators should not be stick dirty or grimy. The IP stated anything that was “gross visually” should be cleaned right away. The IP stated dirty areas around food was an infection control issue for patients. During a review of the facility’s P&P titled, “Infection Control”, dated 7/22/16, indicated, “ ... For reach-in refrigerators, spills are cleaned immediately ... Shelves are washed in soapy water, rinsed, sanitized, and left to air dry ...”. During a review of the professional reference titled “Controlling Hospital-Acquired Infection: Focus on the Role of the Environment and New Technologies for Decontamination”, dated 10/27/14, the professional reference indicated, “ ... a large number of reports include cleaning as an important control component for outbreaks of norovirus, VRE, C. Difficile, MRSA, and Multidrug-resistant (MDR) Gram-negative bacilli ... Removing visual and invisible dirt from the hospitals of today and for the future requires sufficient trained staff, ongoing monitoring ...”.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47205 Based on observation interview and record review the facility failed to protect and promote each patient’s rights when: 1. Patient (Pt) 1 was not secured by safety straps on an operating room (OR) table, without a transfer bed (a bed next to the bed the patient is currently in, that the patient will be moved in too after surgery) when transferring or staff member by her side and subsequently, fell off of the table while waking up from anesthesia (the use of medicines to prevent pain during surgery and other procedures) breaking her left humerus (upper arm bone). (Refer to A144 finding 1). 2. Pt 4 had an emergent laparoscopic cholecystectomy (a procedure where a surgeon makes small incisions in your abdomen and a tube with a tiny video camera goes through those incisions. The surgeon watches a video monitor in the operating room while using tools inserted through the other incisions to remove your gallbladder [a small, pear-shaped organ that is located in a persons’ upper right abdomen]) and the gall bladder was never removed due to the surgeon leaving it in Pt 4’s abdominal cavity (the cavity within the abdomen, the space between the abdominal wall and the spine). (Refer to A144 finding 2). 3. The facility did not respond to grievances in accordance with hospital policy for one of three patients (Pt) 1 when the Patient Safety Officer (PSO) did not communicate what events occurred during the procedure that caused her to fall from the OR table and subsequently break her left humerus (upper arm) denying Pt 1 the right to voice concerns, be informed of, and participate in resolving the grievance. (Refer to A118). The cumulative effect of these systemic problems resulted in failure to ensure patients were cared for in a safe manner, and their rights were protected and promoted at all times.”

“ANESTHESIA SERVICES CFR(s): 482.52 If the hospital furnishes anesthesia services, they must be provided in a well-organized manner under the direction of a qualified doctor of medicine or osteopathy. The service is responsible for all anesthesia administered in the hospital. This Condition is not met as evidenced by: 47888 Based on observation, interview and record review, the hospital failed to provide anesthesia services in a well-organized manner when: 1. The hospital failed to ensure anesthesia (use of medicines to prevent pain during surgery and other procedures) services were appropriate to the scope of the services provided, for one of one sampled Patient (Patient 1), when Certified Registered Nurse Anesthetist (CRNA- a Registered Nurse who has specialized training in anesthesia) 1 ordered diagnostics in the post-anesthesia care unit (PACU- a unit where patients go directly after a surgical procedure to recover from the effects of anesthesia) after Patient (Pt) 1 fell off the Operating Room (OR) table and the Anesthesia in Charge (AIC) that day was a CRNA (CRNA 2). (Refer to A 1001) 2. The hospital failed to ensure the safety and well-being of one of one patients (Pt 1), when Pt 1 was under the direct care of the Certified Registered Nurse Anesthetist (CRNA) 1 and fell off of the operating room table while emerging from Anesthesia (the use of medicines to prevent pain during surgery and other procedures). (Refer to A 1002) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare in a safe and responsible manner.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 47205 Based on interview and record review, the facility failed to ensure the rights of one of three patients (Pt 1) were conserved when the facility did not provide Pt 1 and her family with a satisfactory explanation of the events which lead to the patient 1’s fall from the Operating Room (OR) table, action the hospital took to investigate the grievance, resolve the grievance, other actions taken by the hospital as required by facility policy and procedure (P&P) and state and federal regulations. These failures resulted in actual patient physical harm, associated with the adverse event, and an unresolved patient 1’s grievance. Findings: During an interview on 4/23/24 at 11:00 a.m., with Pt 1, Pt 1 stated, “She received a registered letter from the facility five (5) days after the fact. Hospital did an investigation. That is all it said. After all this happened, [it] felt like a slap in the face, extremely cold the hospital. I wanted out before they hurt me some more. Hospital doesn’t seem very concerned about me with just this letter.” During an interview on 6/17/24 at 8:45 a.m., with the Public Safety Officer (PSO), PSO explained any staff member of the hospital can submit a report of an unusual or unexpected occurrence. PSO stated the report was routed to his office for review, investigation, and resolution. PSO stated he was familiar with the adverse event involving Pt 1 who suffered a fall to the OR floor with subsequent injury due to not being secured by safety straps on an OR table; without a transfer bed or staff member by her side; while waking up from anesthesia (the use of medicines to prevent pain during surgery and other procedures) resulting in a fracture of her left humerus (broken upper arm bone). PSO stated for this adverse incident, he responded personally by immediately meeting with the patient stated his process for responding to a report of an adverse event or patient/patient representative complaint or grievance was to meet with the individuals involved in the report and to formulate an investigation plan. spouse to inform him that the patient had fallen from the OR table. PSO stated he informed the spouse he would be starting an investigation into the adverse event. PSO stated he normally includes department managers for their assistance in investigating events such as this one and he did consult with OR department leaders as needed. During a concurrent interview and record review on 6/17/24 at 8:55 a.m., with the PSO and review of the facility patient complaint resolution letter dated 4/12/24, the PSO stated after his investigation was complete, he sent a generic form letter to the patient/patient family informing them “As of the date of this letter, the Grievance Committee has completed its review of your concerns and consider this matter to be resolved ...” PSO stated he communicated the progress of his investigation, via telephone and that he met with the patient while in the facility, however he did not maintain a record of dates and times he telephoned or met face-to-face with the patient/patient family. PSO stated that in his discussions with the patient/patient family, he had not provided the patient/patient family with an explanation of the events, nor did the investigation completion notification letter explain specifically, how the injury occurred (fall from the OR table) to the patient/patient family. PSO stated he saw now the letter was “too generic” and should have been drafted to address the patient/patient family specific questions of the/action taken of this adverse event. PSO stated at minimum he should have documented telephone calls and other meetings with patient/patient family, provided details to meet the patient/patient family rights to be informed of how it came to be that she went in for an elective procedure on her hip and ended up with a left arm fracture after hip surgery. During an interview on 6/18/24 3:00 p.m. with the Chief Nursing Officer (CNO) and Chief Executive Officer, (CEO), the CEO acknowledged there were opportunities to improve upon the grievance and adverse event reporting process. During a review of P&P titled, “Patient Complaints/Grievances” dated12/22, the policy indicated, “ ...II. Purpose: ...This policy provides a mechanism for initiation, review, and when possible, prompt resolution of patient complaints concerning the quality of care of service(s) received ... V. Procedure: ...C. Patient Grievance ...4. Each grievance will be followed up with a written notice of decision ...within 30 days. The written response will contain the following elements: Date of receipt of grievance. Name of the Hospital contact person for patient follow up if needed. Steps taken to investigate. Results of investigation. Date of investigation completion ...5. A grievance is considered resolved when the patient is satisfied with the actions taken on his/her behalf ...””

“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: 47888 Based on interview and record review, the hospital failed to ensure patients (Pt) received care in a safe setting for 2 of 2 sampled Pts (Pt 1 and Pt 4) when, 1. Pt 1 was not secured by safety straps on an operating room (OR) table, without a transfer bed (a bed next to the bed the patient is currently in, that the patient will be moved in too after surgery) when transferring or staff member by her side and subsequently, fell off of the table while waking up from anesthesia (the use of medicines to prevent pain during surgery and other procedures) breaking her left humerus (upper arm bone). 2. Pt 4 had an emergent laparoscopic cholecystectomy (a procedure where a surgeon makes small incisions in your abdomen and a tube with a tiny video camera goes through those incisions. The surgeon watches a video monitor in the operating room while using tools inserted through the other incisions to remove your gallbladder [a small, pear-shaped organ that is located in a persons’ upper right abdomen]) and the gall bladder was never removed due to the surgeon forgetting it in Pt 4’s abdomen cavity (The cavity within the abdomen, the space between the abdominal wall and the spine). These failures resulted in actual harm to Pt 1 and Pt 4. These safety errors caused Pt 1 to break her left upper arm, which resulted in a same-day second surgical procedure and Pt 4 had to incur the risk of a new emergent surgical procedure and anesthesia due to the gall bladder being left behind . Pt 4’s second surgical procedure was 90 minutes after the first one ended. Findings: 1. During a review of Pt 1’s “Pre-operative History and Physical (H&P)”, dated 4/2/24, the H&P indicated, “ ...75-year-old, Female ... Chief Complaint: ... right hip hurts ... Focused Examination: ... The patient does have a bit of a pannus (an apron of excess skin and fat hanging from the abdomen below the waistline) overlapping the proximal (nearer to the center of the body) portion ... deep hip pain ... pain with external and internal rotation ... She has an antalgic gait (limp) ... Impression: Arthritis right hip (a condition in which there is loss of the cartilage [strong, flexible connective tissue that protects your joints and bones] of the head of the thighbone and of the cup-shaped socket of the pelvis where the thighbone fits into the join) ... Diagnosis: Arthritis of right hip, Abdominal pannus ... Recommendation/Plan: ... Proceed with surgical interview involving right total hip arthroplasty (a surgical procedure in which an orthopedic surgeon removes the diseased parts of the hip joint and replaces them with new, artificial parts) ... The potential risks, benefits, complications, outcomes were discussed with the patient who understood, agreed and consented to proceed ... Signature: [Medical Doctor (MD) 7] ... Reviewed Problems: Graves Disease (an immune system [cells that defend the body against infection] condition that affects the thyroid gland [produces hormones for the human body]) - onset 2/1/20, Myasthenia gravis (a chronic autoimmune disorder [A condition in which the body’s immune system mistakes its own healthy tissues as foreign and attacks them] in which antibodies [proteins that protect you when an unwanted substance enters your body] destroy the communication between nerves [a bunch of wires or cables that send signals to and from the brain] and muscle, resulting in weakness of the skeletal muscles), Essential Hypertension (high blood pressure), Coronary Arteriosclerosis (the buildup of fats, cholesterol and other substances in and on the blood vessels causing vessels to narrow blocking blood flow) ...” During a review of Pt 1’s “Operative Note (ON- from MD 7) EMR (Electronic medical record)”, dated 4/8/24, the ON indicated, “ ...Correction to note. Prior to transfer the patient to PACU (Post-anesthesia care unit- a unit where patients go directly after a surgical procedure to recover from the effects of anesthesia), the Pt fell off the bed landing on her left upper extremity and complaining of shoulder pain. She is subsequent to that, was sent to radiology for evaluation and it appeared to have had a fracture of the humeral shaft at the distal third (a break in the lower end of the upper arm bone). I discussed that with family ... will reevaluate when more awake to discuss surgical treatment ... patient ... complaining of left upper extremity pain, the right hip appears to be having no pain ...” During a review of Pt 1’s “Surgical Documentation (SD)”, dated 4/8/24, the SD indicated, “ ...Last modified by: Registered Nurse (RN) 10 [RN 8 note] ... General Comments: Once procedure was complete dressings were placed on incision ted hose (compression stockings that are designed for the lower legs to help reduce risk of blood clot formation) placed on patient. Left arm was freed and placed on chest in order to bring bed to side of table. I turned to move suction and Bovie Electrocauterization [or electrocautery- A procedure that uses heat from an electric current to destroy abnormal tissue] is often used during surgery to remove unwanted or harmful tissue. It can also be used to burn and thus seal blood vessels. This helps reduce or stop bleeding during surgery) out of the way and patient had rolled off of surgical table to the right side. I ran to patient and saw her in a prone position on floor. I asked her if she was okay or hurt and she asked what happened. I then positioned her on her back supporting her head. I placed a pillow under head and covered her with blankets. I did a quick scan assessment checking for abrasions or obvious injuries, I saw no apparent skin injuries ... other staff had come into the room by then and a lift team was called. I was sent to a lunch break and did not witness the lift team placed the patient in bed ... General Comments: (Last modified by RN 8) ... 11:10 a.m. patient fell from bed (post removed) witnessed by RN 8, Certified Registered Nurse Anesthetist (CRNA- is an advanced practice registered nurse who administers anesthesia for procedures and surgeries.) 1, Scrub Technician (ST-is a college-educated operating room assistant who performs multiple job duties, including providing the surgeon with the instruments needed to perform surgery.) 4, patient stabilized while on floor, kept warm inform charge nurse lifting called for patient on bed. MD (Medical Doctor) 7 informed of incident ... 11:30 a.m. patient (1) on bed by lift team ... transferred to PACU ... “ During a review of Pt 1’s “Diagnostic Radiology (DR- a field of medicine that uses non-invasive imaging to diagnose patients)”, dated 4/8/24 at 12:26 p.m., the DR indicated, “ ... Ordering Provider: CRNA 1. Report: XR Humerus Minimum 2 Views Left ... Clinical Information: fall ... Impression: Comminuted angulated fracture (broken bone in at least three places) of the distal humeral (Upper arm) ... Final Report: Dictated by MD 8 ... Signed by: MD 8 ...” During a review of Pt 1’s “Progress Note (PN- from CRNA 1)”, dated 4/8/24, the PN indicated, “ ... I told (Pt 1), surgery is now over. Stay still and don’t move. We are getting you ready to be moved to your bed. (RN 5) removed the tape from the patient’s right arm which was taped over the patient’s chest. I removed the arm strap from the Pt’s left arm which was strapped to an arm board connected to the bed. Patient was still groggy so I reminded the patient to not move ... Pt raised her left arm and rolled over to the right side. Pt fell off of the OR bed and was on the ground face-down with her left arm shielding her face ... I told her not to move and try to stay still while we were getting more help to move her back to the bed ... Pt was unable to move or feel her legs due to the spinal block I had placed earlier for the surgery ... Pt stated that she felt pain in her shoulders. I noted that the Pt’s left-hand squeeze was weaker than the right hand, so I lifted the Pt’s left gown sleeve and observed a suspected fracture in her left upper arm ...” During a review of Pt 1’s “Operative/Procedure Reports (OPR)”, dated 4/9/24, the OPR indicated, “ ...Surgeon: MD 7 ... Anesthesiologist (a medical doctor who specializes in administering anesthesia): MD 9 ... Post-operative diagnosis: Left comminuted and displaced closed distal third humeral shaft fracture ... Indications for Procedure: This is a 74-year-old woman who fell off the operative table after surgical intervention for her right hip today causing her to develop a displaced fracture of the left distal humerus for which require surgical intervention. After discussing this with the staff, the family and the patient herself, we deemed important and necessary to fix this as soon as possible so that we can allow her to be able to ambulate after her hip arthroplasty ... consented to proceed ... Findings: Displaced comminuted humeral shaft fracture ... Implants/Explants: ... humerus plate with ... screws ... Patient Condition: good ...” During an interview on 6/13/24 at 2 p.m., with ST 4, ST 4 stated she was in the room when Pt 1 fell off of the OR table. ST 4 stated she turned her back to push away her surgical instrumentation table and in that moment Pt 1 fell off of the OR table. ST 4 stated the patient did not have any safety belts or arm boards on at the time of the fall. During an interview on 6/13/24 at 3 p.m., with CRNA 1, CRNA 1 stated she was at the head of Pt 1’s OR table when the fall occurred. CRNA 1 stated she was focused on the airway of Pt 1 and did not know where the other members of the OR team were. CRNA 1 stated Pt 1 was “groggy (stunned or confused and slow to react)” but waking up answering questions appropriately. CRNA 1 stated she removed the left arm strap for Pt 1 to make her more comfortable while waking up. CRNA stated Pt 1 than raised up her left arm and rolled off the OR bed to her right side. CRNA 1 stated she thought Pt 1 initiated and was the cause of the fall. CRNA 1 stated “I told her not to move and she moved when I told her don’t move.” CRNA 1 stated the transfer bed was not in the room at the time of the fall. CRNA 1 stated she was not responsible for the transfer bed not being there. CRNA 1 stated she “wished” there were two staff on each side of the patient and “wished” the patient would not have fallen. CRNA 1 stated she would not have done anything differently. During an interview on 6/13/24 at 3:50 p.m., with MD 5 (Anesthesia in Charge), MD 5 stated that he did not think CRNA 1 could have done anything differently. During an interview on 6/14/24 at 8:45 a.m., with RN 8, RN 8 stated he was in the room and was the circulating nurse (works outside the sterile field. Responsible for managing the Pt’s nursing care within the OR) at the time of Pt 1’s fall. RN 8 stated the other people in the room with him were CRNA 1 and ST 4. RN 8 stated he made a call to an intercom system (a communication system within the surgical unit that allows the caller to announce to the entire department what they need) to ask for a transfer bed because the surgical procedure was finished. RN 8 stated while he was waiting for the transfer bed, he removed the perineal post (a post under the bottom region of your pelvic cavity that is used for additional stability and holds patient in place without the need for the patient going Trendelenburg [patient is supine (lying flat on back) on the table with their head declined below their feet]) of the Hana Orthopedic (an area of medicine that focuses on the diagnosis, treatment, prevention, and rehabilitation of injuries and diseases within the musculoskeletal system) Surgical Table (a special orthopedic surgical table designed for total hip replacement surgeries), both safety straps on the arms and placed the patients hands on her chest. RN 8 stated he never put on a safety strap over Pt 1’s abdomen that comes with the Hana Surgical Table. RN 8 stated the Hana Surgical Table was “short and narrow”. RN 8 stated he was on the left side of the patient when he noticed he needed to move the Bovie machine (is a surgical device used to remove unwanted tissue and/or stop bleeding) and suction machine. RN 8 stated Pt 1 was lying comfortably so he turned his back to move those and “she was on the floor next”. RN 8 stated the Pt should have had her safety straps on and the perineal pole in place until the transfer bed was next to the patient in a locked position. RN 8 stated ST 4 and himself had their backs turned to the patient, were not at the bedside and all of Pt 1’s safety straps were off. RN 8 stated due to the lack of communication, all of the staff in that room put Pt 1’s safety at-risk. During an interview on 6/18/24 at 9:55 a.m., with the OR Director (ORD), the ORD stated Pt 1’s safety was put at-risk due to staff having a “lack of awareness” and actual harm occurred. The ORD stated Pt 1’s right to care in safe setting was violated.. The ORD stated the surgical department used Association of Perioperative (the entire patient experience from the beginning of the surgical process until the end) Registered Nurses (AORN) guidelines as their professional reference. During an interview on 6/18/24 at 12:15 p.m., with MD 7, MD 7 stated he was not in the room when Pt 1 fell off of the OR table. MD 7 stated that once the “main part” of the surgery was complete he left the room and his surgical assist finished the case by suturing (a medical provider stitch or stitches; sutures are a medical device used to hold body tissues together and approximate wound edges after an injury or surgery) Pt 1’s wound closed. MD 7stated he left to dictate (process of speaking medical information into a recorder), talk to the family and prepare for his next case. MD 7 stated his surgical assistant told him Pt 1 had fallen off of the table. MD 7 stated he immediately went and told Pt 1’s Husband and he was “devastated and upset”. MD 7 stated Pt 1’s safety was all staff’s responsibility including himself. MD 7 stated the expectation for Pt 1 was to have the surgery and recover with no further injury. MD 7 stated Pt 1’s safety was put at-risk, which resulted in actual Pt harm. During an interview on 6/18/24 at 2 p.m., with the Chief of Anesthesia (COA), the COA stated the role of anesthesia would be to be the “team leader at that moment”. The COA stated when a Pt was coming out of anesthetic, Pt 1 would not be capable of making “rational decisions”. The COA stated it would be “unfair” to expect Pt 1 to follow commands by the CRNA. During an interview on 6/18/24 at 2:40 p.m., with the Chief Executive Officer (CEO), the CEO stated the expectation for Pt 1’s care would be that she would not have been left unsecured on the OR table without staff standing by or a transfer bed in place and locked next to her. The CEO stated Pt 1 should have never been left unsupervised on the OR table. The CEO stated Pt 1 safety was compromised by staff. The CEO stated Hospital policy and procedures were not followed in this case. The CEO stated Pt 1’s rights were violated because she did not receive care in a safe setting. During a review of the facility’s policy and procedure (P&P) titled, “Patient Safety”, dated 1/14/22, the P&P indicated, “ ...PURPOSE: to identify and eliminate potential safety hazards thereby reducing risk to patients, personnel and visitors... POLICY: Patient safety refers to a systematic hospital wide program to minimize preventable physical injuries, accidents and undo psychological stress during hospitalization ... B. PATIENT OBSERVATION: 1. Patients on operating tables are never left unattended. Side rails and/or safety straps are utilized ...” During a review of the facility’s policy and procedure (P&P) titled, “Transferring Patients from Gurney/Bed to Operating Room Table”, dated 1/12/23, the P&P indicated, “ ...PURPOSE: A. To prevent ... patient injuries during the handling, repositioning and transferring of patients ... II. POLICY: A. All employees are responsible to perform in a safe manner and are expected to identify and report potentially unsafe work practices and conditions. B. Patients will be transferred from gurneys/bed to the OR table in a safe manner ...” Review of AORNguidelines.org Professional Reference titled, “Guideline for Positioning the Patient” dated 5/17/22, (found at https://aornguidelines.org/guidelines/content?sectionid=173734066&view=book&expand=true) indicated, “ ... 3.1. Identify potential hazards associated with positioning activities and establish safe practices. Positioning patients and using positioning equipment and devices during perioperative care is a high-risk task that can result in injury to patients or personnel. Identifying potential hazards and establishing safe practices may reduce the risk for patient and personnel injury ... 3.2. Perioperative team members should proactively determine who is responsible for attending to the patient (for example, remaining present at the patient’s side) while the patient is on the OR bed. Patients are at risk for falls in the perioperative setting. It is the responsibility of the entire perioperative team to proactively discuss patient observation responsibilities for all phases of the intraoperative period and consider crucial periods, such as induction (putting the patient to sleep with Anesthesia medications) and emergence (waking up) from anesthesia and periods of sedation during which patients are not yet positioned or restrained in their final positions. To minimize or eliminate the risk of patient injuries from falls, perioperative team members must remain vigilant (paying attention) to the infrequent but potentially devastating consequences of a patient’s fall from the OR bed. A lack of clear communication about who is responsible for attending the patient after the safety straps are removed or before the patient is transferred to the OR bed has been reported as a contributing factor for patient falls in the perioperative setting ... 3.21. Apply safety restraints in a manner that safely secures the patient. Applying safety restraints reduces the patient’s risk of falling off the OR bed ...” During a review of the “Owner’s Manual- Hana Orthopedic Surgery Table (OM)”, dated 2017, the OM indicated, “ ...Standard Components ... Patient Safety Strap: The patient safety strap secures the patient in place when positioned on the table the 90-inch strap slides around the foot-end of the table ... Anterior (in the front of) Total Hip Arthroplasty ... Table Setup for ... Right Total Hip Arthroplasty ... 7. Slide the Patient Safety Strap in Place (picture of safety strap fastened over the belly-button area of patient) ...” 2. During a review of Pt 4’s “Admission History and Physical (H&P)”, dated 4/5/23, the H&P indicated, “ ...CHIEF COMPLAINT: Complaint of abdominal pain, has gallstones (hard, pebble-like pieces of material, usually made of cholesterol or bilirubin (yellowish pigment that is made during the breakdown of red blood cells), that form in your gallbladder. Gallstones can range in size from a grain of sand to a golf ball), needs to have cholecystectomy but has had it cancelled in the past. HISTORY OF PRESENT ILLNESS: 42-year-old female with known cholelithiasis (gallstones) for years, came in with acutely worsening abdominal pain few hours ago today, described as sharp located in the right upper quadrant with radiation to the back. Associated with nausea and vomiting. Admits to some vague urinary symptoms for the last two days like difficulty voiding (urinating) but patient not able to specify any further. Says it was painful urination ... PHYSICIAL EXAM: ... Abdomen: ... right-sided tenderness ... ASSESSMENT/PLAN: 1. Acute cholecystitis (is inflammation of the gallbladder that occurs due to occlusion [a complete or partial blockage of a blood vessel] or impaired emptying of the gallbladder) ...” During a review of Pt 4’s “Consult Note (CN)”, dated 4/5/23, the CN indicated, “ ... Reason for Hospital Consultation: Acute Cholecystitis, right upper quadrant pain (abdominal pain), nausea and vomiting ... RECOMMENDATION: the patient was given informed consent (A process in which patients are given important information, including possible risks and benefits, about a medical procedure) and explained the option for a laparoscopic cholecystectomy The patient will be added to the OR schedule ...” During a review of Pt 4’s “Intra-op Record (IR)”, dated 4/5/23 at 9:38 p.m., the IR indicated, “ ... Intra-op Specimens/Cultures ... Description: gall bladder ... Specimen number: 1 ... Specimen Site: Abdomen ... Last modified by RN 10 ...”. The gall bladder was retained during this surgical procedure and RN 10 never obtained a specimen. During a review of Pt 4’s “Operative Note (ON)”, dated 4/5/23 at 10:18 p.m., the ON indicated, “OPERATIVE REPORT: ... POSTOPERATIVE DIAGNOSIS: Acute on Chronic Cholecystitis ... OPERATIVE PROCEDURE: Laparoscopic cholecystectomy ... SURGEON: MD 6 ... DESCRIPTION OF PROCEDURE: ... the patient was given informed consent regarding the operation. The patient understood all the risk, alternatives and benefits associated with the operation and agreed to proceed with the operation ... gallbladder was bluntly dissected (surgical separation of tissue layers by means of an instrument) and electrocauterized away from the gallbladder fossa (location of gallbladder in the human body). No bleeding occurred at the gallbladder fossa. The entire gallbladder was then removed from the umbilical port (a small surgical incision on the belly button, frequently used for surgical instrumentation to enter and extend to retrieve the surgical specimen) using an endoscopic catch bag (a pouch that consists of a long cylindrical tube and pouch that minimizes spillage and intraoperative contamination by isolating and containing specimens) the rest of the abdomen was then inspected, no bleeding occurred anywhere at the gallbladder fossa site ... the patient was returned to the recovery room in stable condition...” During a review of Pt 4’s “Operative Note (ON)”, dated 4/6/23 at 12:02 a.m., the ON indicated, “ ...OPERATIVE REPORT: ... PREOPERATIVE DIAGNOSIS: post operative retained intra-abdominal gallbladder ... POSTOPERATIVE DIAGNOSIS: Same ... OPERATION: 1. Diagnostic laparoscopy (A procedure that uses a laparoscope, inserted through the abdominal wall, to examine the inside of the abdomen) 2. Laparoscopic removal of retained postoperative intra-abdominal gallbladder. SURGEON: MD 6 ... INDICATIONS: The patient is a 42-year-old female who is in PACU after a laparoscopic cholecystectomy. It was discovered during the post operative. That the gallbladder was normal in the specimen container [documentation error- gallbladder was not in the specimen container] and that the endoscopic catch bag from the prior operation was not used at this point the decision was made to perform a diagnostic laparoscopy for retrieval of retained post operative intra-abdominal gallbladder the consent was obtained by two physician and the patient in the post operative PACU ... DESCRIPTION OF THE OPERATION: ... Upon entering the abdominal cavity, the gallbladder specimen was seen on top of the omentum (thin tissue that lines the abdomen that surrounds the stomach and other organs in the abdomen). The gallbladder was retrieved with an endoscopic catch bag ... the gallbladder was then removed with the endoscopic catch bag ... the gallbladder specimen was passed off to the back table ...” During an interview on 6/14/24 at 2:50 p.m., with MD 6, MD 6 stated he was the surgeon for Pt 4 and it was “difficult” to remove her gallbladder. MD 6 stated as he was moving the gallbladder through Pt 4’s abdomen she had a bleed on the liver he needed to get under control. MD 6 stated after he stopped the bleed, he forgot he had not removed the gall bladder. MD 6 stated he deflated Pt 4’s abdomen and “closed” her up. MD 6 stated he was contacted by RN 10 when the case was completed and Pt 4 was already in the PACU. MD 6 stated RN 10 told him staff did not have the specimen in the OR and could not find it. MD 6 stated that he told RN 10 the gallbladder must be in the patient still. MD 6 stated he never put the “catch bag” into the patient during the procedure to obtain the gallbladder and it “must have slipped his mind”. MD 6 stated when Pt 4 went back for the second surgery, he saw the gallbladder in the right lower quadrant of the abdomen. MD 6 stated the expected outcome for Pt 4 was to have a successful first surgery and that was not the case. MD 6 stated Pt 4’s safety was put at-risk due to needing a second surgery due to the retained gallbladder. MD 6 stated Pt 4 could have had an anesthesia complication that could have resulted in a heart attack, or stroke. MD 6 stated Hospital protocols and procedures were not followed for safety and specimen collection. MD 6 stated he was “to blame” for Pt 4 needing a second operation for the retained gallbladder. During an interview on 6/18/24 at 8:45 a.m., with ST 5, ST 5 stated she was the ST during Pt 4’s retained gallbladder surgery. ST 5 stated MD 6 asked for the catch-bag at the end of the procedure and she placed on MD 6’s mayo stand (a small, movable stand or table that is designed to hold sterile instruments and supplies during surgeries). ST 5 stated she never noticed that MD 6 did not use the catch bag and never removed the gallbladder. ST 5 stated she did not notice because she was getting supplies ready for the closure of the procedure. ST 5 stated her and the MD 6 never did a “read-back” in regard to specimen collection. ST 5 stated she should have worried about the specimen and not the closing portion of the procedure. ST 5 stated “we absolutely” put the patient’s safety at-risk by leaving the gallbladder inside Pt 4. ST 5 stated “a patient should not have to come back for a second surgery.” ST 5 stated the procedure should have been done correctly the first time. ST 5 stated we should have been “100 percent focused” and we were not. ST 5 stated Pt 4’s rights were violated by not having care in a safe setting. ST 5 stated the P&P for Specimen care and handling was not followed. During an interview on 6/18/24 at 9:55 a.m., with the OR Director (ORD), the ORD stated the expectation for the Pt 4 was to have surgery and the procedure “Is done as it should be and they recover and go forward.” The ORD stated Pt 4 rights were violated as she had the right to care in a safe setting. The ORD stated because Pt 4 had to go back for a second surgery, she had an increased risk for infection. The ORD stated staff did not follow the P&P for Care and Handling of Specimens. During an interview on 6/18/24 at 11:11 a.m., with RN 10, RN 10 stated he was the circulator during the Pt 4’s retained gall bladder surgical case. RN 10 stated he did not hear a “read-back” of the specimen collection between ST 5 and MD 6. RN 10 stated he never saw the specimen throughout the case. RN 10 stated he took Pt 4 to the PACU and asked RN 9 to get the specimen for him. RN 10 stated RN 9 could not find the specimen in the OR. RN 10 stated he told MD 6 they could not find the specimen and he completed an incident report. RN 10 stated the OR team put the patient safety at-risk. RN 10 stated Pt 4 was put at “extra risk” because of the additional surgery. RN 10 stated he did not follow the P&P for specimen collection and did not document the specimen correctly. During an interview on 6/18/24 at 2:40 p.m., with the CEO, the CEO stated MD 6 placed the gallbladder aside in the abdomen to address bleeding and “forgot” to remove the gallbladder. The CEO stated the expectation was for MD 6 to remove the gallbladder prior to closure. The CEO stated Pt 4’s rights were violated in terms of care in safe setting due to “reoperation”. During a review of the facility’s policy and procedure (P&P) titled, “Care and Handling of Specimens”, dated 4/13/23, the P&P indicated, “ ... I. PURPOSE: A. To establish a guideline for proper appropriate care and handling of specimens used in determining or confirming a diagnosis ... III. OUTCOME: A. They’re not care and handling of the specimen will include proper identification of the patient, the item/tissue removed, use of the correct preservative, as well as complete and accurate specimen documentation ... IV. PROCEDURE: A. Care and Handling of Specimens ... 3. Specimens Requiring Special Handling ... 1. The specimen is handed off the sterile field and placed in a properly labeled, dry specimen container, or an appropriate labeled and sealed plastic bag. 2. RN Circulator will order specimen exam in electronic health record (EHR) per surgeon’s verbal order ... C. The RN Circulator is responsible for: Completely and accurately documenting all specimens in Perioperative Documentation in EHR. 2. Correctly caring for and handling of all specimens per policy ...”. Review of AORNguidelines.org Professional Reference titled, “Guideline for Specimen Management. In: Guidelines for Perioperative Practice”, dated 9/28/20, (found at https://aornguidelines.org/faq/content?gbosid=403556) indicated, “ ... What is the process for verifying patient and specimen information before transferring a specimen off the sterile field? The process should include using a read-back method to verify the patient and specimen identification on the label, pathology requisition form, and patient health record with the surgeon. The label should not be placed on the specimen container until after the specimen is placed in the container ...””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 40644 Based on interview and record review, the hospital failed to track adverse patient events and analyze their causes to implement effective preventive actions for two of two sampled patients, Patient (Pt) 1 and Patient 4, when: 1. An effective root cause analysis was not conducted to determine all factors that could have led to Patient 1’s fall from the Operating Room (OR) table. Pt 1 had a surgical procedure on 4/8/2024 dated and in the process of transferring the Patient 1 from the Operating Room (OR) table to the patient gurney, Patient 1 fell to the floor fracturing her arm. 2. Required reporting for adverse events to the California Department of Public Health was not done for Pt 1’s avoidable fall with injury and a situation with Pt 4 where Pt 4’s gall bladder was unintentionally left inside Pt 4 for a procedure meant to remove the gall bladder. These failures resulted in the potential harm of not implementing effective quality improvement actions to keep patients safe. Findings: 1. During a review of the clinical record for Pt 1 indicated, Pt 1 was not secured by safety straps on an operating room (OR) table, without a transfer bed or staff member by her side and subsequently fell off of the table while waking up from anesthesia (the use of medicines to prevent pain during surgery and other procedures) breaking her left humerus (upper arm bone). Pt 1 had to return to the OR for surgery for her broken arm. Registered Nurse (RN) 8, Certified Registered Nurse Anesthetist (CRNA-is an advanced practice registered nurse who administers anesthesia for procedures and surgeries.) 1, Scrub Technician (ST- is a college-educated operating room assistant who performs multiple job duties, including providing the surgeon with the instruments needed to perform surgery.) 4 witnessed the fall of Pt 1. During a review of Pt 1’s “Pre-operative History and Physical (H&P)”, dated 4/2/24, the H&P indicated, “ ...75-year-old, Female ... Chief Complaint: ... right hip hurts ... Focused Examination: ... The patient does have a bit of a pannus (an apron of excess skin and fat hanging from the abdomen below the waistline) overlapping the proximal (nearer to the center of the body) portion ... deep hip pain ... pain with external and internal rotation ... She has an antalgic gait (limp) ... Impression: Arthritis right hip (a condition in which there is loss of the cartilage [strong, flexible connective tissue that protects your joints and bones] of the head of the thighbone and of the cup-shaped socket of the pelvis where the thighbone fits into the join) ... Diagnosis: Arthritis of right hip, Abdominal pannus ... Recommendation/Plan: ... Proceed with surgical interview involving right total hip arthroplasty (a surgical procedure in which an orthopedic surgeon removes the diseased parts of the hip joint and replaces them with new, artificial parts) ... The potential risks, benefits, complications, outcomes were discussed with the patient who understood, agreed and consented to proceed ... Signature: [Medical Doctor (MD) 7] ... Reviewed Problems: Graves Disease (an immune system condition that affects the thyroid gland) - onset 2/1/20, Myasthenia gravis (a chronic autoimmune disorder in which antibodies destroy the communication between nerves and muscle, resulting in weakness of the skeletal muscles), Essential Hypertension (high blood pressure), Coronary Arteriosclerosis (the buildup of fats, cholesterol and other substances in and on the blood vessels causing vessels to narrow blocking blood flow) ...” During a review of Pt 1’s “Surgical Documentation (SD)”, dated 4/8/24, the SD indicated, “ ...Last modified by: Registered Nurse (RN) 10 [RN 8 note] ... General Comments: Once procedure was complete dressings were placed on incision ted hose placed on patient. Left arm was freed and placed on chest in order to bring bed to side of table. I turned to move suction and Bovie out of the way and patient had rolled off of surgical table to the right side. I ran to patient and saw her in a prone position on floor. I asked her if she was okay or hurt and she asked what happened. I then positioned her on her back supporting her head. I placed a pillow under head and covered her with blankets. I did a quick scan assessment checking for abrasions or obvious injuries, I saw no apparent skin injuries ... other staff had come into the room by then and a lift team was called. I was sent to a lunch break and did not witness the lift team placed the patient in bed ... General Comments: (Last modified by RN 8) ... 11:10 a.m. patient fell from bed (post removed) witnessed by RN 8, Certified Registered Nurse Anesthetist (CRNA) 1, Scrub Technician (ST) 4, patient stabilized while on floor, kept warm inform charge nurse lifting called for patient on bed. MD 7 informed of incident ... 11:30 a.m. patient (1) on bed by lift team ... transferred to PACU ... “ During a review of Pt 1’s “Diagnostic Radiology (DR)”, dated 4/8/24 at 12:26 p.m., the DR indicated, “ ... Ordering Provider: CRNA 1. Report: XR Humerus Minimum 2 Views Left ... Clinical Information: fall ... Impression: Comminuted, angulated fracture of the distal humeral (Upper arm bone broken in at least three places) ... Final Report: Dictated by MD 8 ... Signed by: MD 8 ...” During a review of Pt 1’s “Progress Note (PN- from CRNA 1)”, dated 4/8/24, the PN indicated, “ ... I told (Pt 1), surgery is now over. Stay still and don’t move. We are getting you ready to be moved to your bed. (RN 5) removed the tape from the patient’s right arm which was taped over the patient’s chest. I removed the arm strap from the Pt’s left arm which was strapped to an arm board connected to the bed. Patient was still groggy so I reminded the patient to not move ... Pt raised her left arm and rolled over to the right side. Pt fell off of the OR (Operating Room) bed and was on the ground face-down with her left arm shielding her face ... I told her not to move and try to stay still while we were getting more help to move her back to the bed ... Pt was unable to move or feel her legs due to the spinal block (a temporary loss of feeling in the abdomen and/or the lower part of the body) I had placed earlier for the surgery ... Pt stated that she felt pain in her shoulders. I noted that the Pt’s left-hand squeeze was weaker than the right hand so I lifted the Pt’s left gown sleeve and observed a suspected fracture in her left upper arm ...” During a review of Pt 1’s “Operative/Procedure Reports (OPR)”, dated 4/9/24, the OPR indicated, “ ...Surgeon: MD 7 ... Anesthesiologist: MD 9 ... Post-operative diagnosis: Left comminuted and displaced closed distal third humeral shaft fracture ... Indications for Procedure: This is a 74-year-old woman who fell off the operative table after surgical intervention for her right hip today causing her to develop a displaced fracture of the left distal humerus for which require surgical intervention. After discussing this with the staff, the family and the patient herself, we deemed important and necessary to fix this as soon as possible so that we can allow her to be able to ambulate after her hip arthroplasty ... consented to proceed ... Findings: Displaced comminuted humeral shaft fracture ... Implants/Explants: ... humerus plate with ... screws ... Patient Condition: good ...” During a concurrent interview and record review on 6/11/24 at 4:35 p.m., with the Patient Safety Officer (PSO) and Designated Nurse Executive (DNE), the PSO and DNE provided information regarding the investigation after Pt 1 fell off the table in OR. The facility document titled, “Root Case Analysis” (RCA) was reviewed. The RCA described the event, and the root cause was determined to be “nurse error” and the plan for correction was, “disciplinary action was put into place” and “Education provided”. The PSO did not have an answer to questions about possible systemic issues that may have contributed to the fall, including appropriate staffing, why the bed was not already in the room before the patient was released for surgical restraints, and if it was appropriate for the surgeon and surgical assistant to leave the room prior to the patient being transferred to the gurney, and whether actions or inactions from other team members may have contributed to the fall. These possible contributing factors were not explored in the RCA. The PSO stated the nurse “admitted that he shouldn’t have left the patient’s side to get the transfer bed.” The PSO stated that looking back, it should have been considered a team responsibility. During a review of the hospital document titled, “Quality Assurance and Performance Improvement Program,” dated 5/23 2022, the document indicated, “ ...Administration and Management: The Governing Board and the medical staff delegate the development, implementation, and evaluation of this program to the Medical Center Administration and Management team. Administration and Management are responsible for improving the quality of care, safety, and service provided by the Medical Center and its staff. The Administration and Management team have developed structures and processes to carry out this responsibility...” During a review of the hospital policy and Procedure (P&P) titled, “Patient Safety Program” dated 4/13/23, the P&P indicated, “ ...VIII. Sentinel Event Status. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The “risk thereof” includes any process variation for which a recurrence carries a significant chance of serious adverse outcomes...” During a review of professional reference titled, “Root Cause Analysis and Medical Error Prevention” from www.nih.gov dated May 2, 2022, the reference indicated, “ ...A root cause analysis can provide a beneficial resolution for healthcare professionals and patients to further understand and combat medical error and prevent future occurrences ... [the RCA] process highlights the interprofessional team’s role in preventing medical errors and sentinel events within the healthcare organization...” 2. During an interview on 6/14/24 at 4:05 p.m. with the Director of Quality (DQ), the DQ stated that both Pt 1 and Pt 4 should have been reported to the California Department of Public Health (CDPH) because both Pt 1 and Pt 2 had to return to surgery because of errors made by the hospital. The DQ stated he was under the impression that because the incidents did not result in death, they did not need to be reported. The DQ stated he understood that unusual occurrences that result in patient harm, should be reported to appropriate regulatory agencies. During a concurrent interview and record review on 6/17/24 at 8:45 a.m., with the PSO, the facility’s P&P was reviewed. The PSO stated the incident resulting in serious bodily injury to a patient when the patient fell from the OR table met the criteria for reporting to CDPH, however, due to a misinterpretation of the facility’s P&P, he did not submit a report to CDPH. The PSO reviewed the hospital policy titled, “Adverse Event Reporting to the California Department of Health Services,” dated 8/4/22, P&P indicated, “ ...(7) An adverse event or series of adverse events that cause the death or serious disability of a patient, personnel, or visitor. As used in the foregoing list of events the term “serious disability” means a physical or mental impairment that substantially limits one or more of the major life activities of an individual, or the loss of bodily function, if the impairment or loss lasts more than seven days or is still present at the time of discharge from an inpatient health care facility or the loss of a body part...” The PSO stated, after reviewing their facility P&P again, he should have reported the adverse event to CDPH. During an interview on 6/18/24 3:00 p.m. with the Chief Nursing Officer (CNO) and Chief Executive Officer, (CEO), the CEO acknowledged opportunities to improve upon the adverse event reporting process.”

“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: 47205 Based on observation, interview and record review, the facility failed to ensure the Licensed Nurse (LN) identified and/or recognized the complex needs of one of two sampled patients (Pt 27), when the LN did not develop, revise, or implement interventions and goals for Pt 27’s skin integrity (skin health) care plan (CP- a road map for the care of a patient and a necessary tool in following the nursing process) that reflected the nursing care to be provided to meet Pt 27’s needs as required by facility policy and procedure (P&P). These failures had the potential for harm due to delayed healing of a wound, formation of new wounds, infection including death. Findings: During a concurrent observation and interview on 6/12/24 at 11:31 a.m., on the Medical Surgical unit, at the bedside with Pt 27 and Wound Registered Nurse (WRN) 1 and WRN 2, WRN 1 stated Pt 27 was admitted from a local nursing home for a wound to her left coccyx (tail bone) area. WRN 1 stated she was responding to a wound nurse consultation request and would be changing Pt 27’s dressing. After removal of the old dressing, WRN 1 stated the wound appeared to be old, slow healing, with a discharge of white/yellow colored fluid, possibly puss given the presentation of the wound, with deep tunneling (a wound that’s progressed to form passageways underneath the surface of the skin). WRN 1 stated Pt 27 was at high risk for developing additional wounds and poor healing of existing wound due to her medical history and clinical presentation (the appearance in a patient of illness or disease-or signs or symptoms). During a review of Pt 27’s “Admission H&P (history and physical),” dated 6/11/24, indicated Pt 27’s past medical history included: atrial fibrillation (A-fib- an irregular and often very rapid heart rhythm) with anticoagulation medication (blood thinner), breast cancer in remission, depression, diabetes (high blood sugar), hypertension (high blood pressure), hyperthyroidism (overactive thyroid gland), pacemaker (surgically inserted device that helps regulate irregular heart rhythm).” During a review of Pt 27’s “Wound Care Note (note)” dated 6/12/24, the note indicated the WRN recommended “ ...3. Nutritional optimization as patient’s medical condition allows. Registered Dietician (RD) consult may be warranted, if not already requested ...” During a concurrent interview and record review on 6/13/24 at 9:40 a.m., of Pt 27’s Electronic Medical Record (EMR) with Nurse Manager (NM) 3, the skin assessment and physician’s order were reviewed, the skin assessment indicated, Pt 27’s admission Braden Scale Score (a standardized tool used to help determine the risk of a patient developing a pressure injury risk scores can be categorized as low (19-23), mild (15-18), moderate (13-14, high (10-12), and severe (9) risk) was “15” indicating Pt 27 was at “mild risk” of developing a pressure wound. NM 3 stated the physician orders indicated Pt 27 had a “regular diet” ordered on 6/11/24, and a wound nurse consult ordered on 6/11/24 at 3:47 p.m. NM 3 stated the physician orders indicated there was no order for a nutrition consultation or nutrition supplements in the EMR. NM 3 stated it was her expectation that LNs would follow facility P&P’s in preventing deterioration of wounds and the formation of any new wounds by documenting interventions that were planned and performed in the patient’s care plan. During a concurrent interview and record review on 6/14/24 at 8:48 a.m., with Registered Nurse (RN) 6, RN 6 stated Pt 27 was admitted to the hospital from a local nursing home for a non-healing wound to her coccyx area. RN 6 validated Pt 27’s Braden Scale Score was 15. RN 6 stated not sure exactly what the score means but the patient is on a “brand name” low-air loss bed (a mattress designed to prevent and treat pressure wounds), heels are being floated (elevated with pillows so heels do not touch the mattress) to prevent formation of pressure wounds to heels, and turning and repositioning is being done every two hours to prevent new wounds and promote healing of the existing wound. RN 6 stated she did not believe that Pt 27 had a risk for nutrition deficit (a lack or shortage of something that the body needs to work properly ). RN 6 stated knowing today that Pt 27 had had poor oral intake the last several meals she may have considered adding nutrition as a concern on the CP. RN 6 stated nutrition was required for wound healing; if nutrition was inadequate wound healing would not be possible. RN 6 stated a nutrition consult should have been submitted for Pt 27 and it was not. RN 6 stated she would add nutrition risk to Pt 27’s CP.RN 6 stated the purpose of the CP is it helps guide the care the nurse provides. RN 6 validated Pt 27’s EMR did not show a nutrition risk CP had been initiated. RN 6 stated the potential harm in not having a patient’s specific care plan was “the reason they are here [reason for admission] will not be resolved.” RN 6 validated a CP had been established and it indicated the goal of nursing interventions was for Pt 27 to reach a “Braden Scale Score of 18 by the end of the shift.” RN 6 stated that in reviewing the skin integrity care plan more closely, she did not believe the goal was realistic for Pt 27. RN 6 stated nursing CPs are revised and updated daily. During an interview on 6/14/24 at 9:25 a.m., with Wound RN (WRN) 1, and WRN 3, WRN 1 stated with wounds, nutrition is very important, “You are treating the whole patient and not just the hole in the patient. Taste bud changes and poor appetite are all a part of the aging process; so you consider supplementation to give the wound the optimal healing environment.” During an interview on 6/14/24 at 9:10 a.m., with Nursing Director (ND) 1, ND 1 stated there are opportunities for the Medical Surgical RN staff education to the Braden Scale Scoring tool and the nursing interventions to be implemented based on the patient’s risk score. ND 1 stated it was her expectation that nurses would be able to verbalize understanding of the Braden Scale Score and assign an appropriate and realistic patient goal on the CP. ND 1 stated given Pt 27’s medical history, wound and nutritional intake she would expect the Braden Scale Score goal of 18 might be unattainable. During a concurrent observation and interview on 6/14/24 at 9:57 a.m., with Certified Nurse Assistant (CNA) 1 via telephone, CNA 1 stated she assists with meal tray distribution, set up and collection when patients were done eating. CNA 1 stated Pt 27 “doesn’t eat much, doesn’t want what is offered.” CNA 1 stated that if they [patients] don’t eat much [she] offers a substitute. Sometimes tells the nurse if observe that the patient is not eating nothing.” CNA 1 stated she knows Pt 27 had the wound on her left buttock because the nurses told her. CNA 1 stated she spoke with the patient’s nurse yesterday (6/13/24). CNA 1 stated Pt 27 told her she likes “brand name” nutritional supplement drink in the chocolate flavor only. CNA 1 stated she was helping with the turning and repositioning every two hours, she does not document, the primary RN does. During an interview on 6/17/24 at 9:55 a.m., with Registered Dietician (RD) 1, RD 1 stated the goal was to complete a nutrition consult within 48-hours of receipt. RD 1 stated that most referrals made to his department were “auto-generated, nurse/provider generated, or facility policy is, that all inpatients are evaluated by RD for any Length of Stay (LOS-the duration of a single episode of hospitalization.) of greater than or equal to seven (7) days. RD 1 stated other factors, such as Braden Scale Score of 16 or below was an auto-consult; MST- Malnutrition Screening Tool, decreased appetite, and weight loss (based on how much weight lost; it increases the number count) 2 criteria met generates a consult. RD 1 stated it was his practice to review the chart and speak with nurses regarding the patient when completing a nutrition assessment. RD 1 stated RD nutritional assessment was not done due to Pt 27’s admission Braden scale of 15, a nutrition consultation should have been generated, but it did not. During a concurrent interview and record review of Pt 27’s EMR on 6/17/24 at 4:00 p.m., with RN 5, RN 5 stated in reviewing the Pt 27’s EMR, an order for a nutrition consultation was entered on 6/13/24 at 12:16 p.m. and had not yet been done to her knowledge. RN 5 stated she spoke with the doctor and asked for a nutrition consult after her manager told her she might consider Pt 27’s nutritional needs. RN 5 stated Pt 27’s meal intake was “sometimes good and sometimes not so good.” RN 5 stated Pt 27 was a “picky eater.” RN 5 stated the goal for Pt 27 was to heal the existing wound and prevent any new ones from forming, so may need to add some supplements and foods that patient might prefer. RN 5 stated she had not done an assessment of the preferred foods with Pt 27, this was to be done by the RD. RN 5 stated she was aware there was a gap in the documentation of repositioning and turning on 6/12/24 at 3:00 p.m., 5:00 p.m., and 7:00 p.m. and stated the Pt 27 was turned, but she “didn’t document [the turns] and dropped the ball on that.” RN 5 stated the harm in not turning and repositioning was risk for further deterioration of Pt 27’s skin and formation of new wounds. RN 5 stated it was important to track meal intake for proper nutrition and wound healing. RN 5 stated Pt 27’s meals should have been documented because it gave us (caregivers) a picture of what was happening with the patient, and would allow for trending and nurse intervention. RN 5 stated she did not review the WRN’s consultation note yesterday [6/16/24]. RN 5 stated that if she had reviewed the WRN consultation note she would have seen the WRN’s recommendation for considering a nutrition consult and performed a nutrition assessment. RN 5 stated Pt 27’s CP goal of a Braden Scale Score of 18 by the end of the shift was not a realistic goal. During an interview on 6/18/24 3:00 p.m. with the Chief Nursing Officer (CNO) and Chief Executive Officer, (CEO) the CEO, the CEO stated he was aware of this case and had talked with nursing and medical providers, in addition to the dietician in this case as it is a team effort to understand why there was a delay in the ordering of a nutrition consult. During a review of P&P titled, “Standard for Impaired Skin Integrity (Potential/Actual)” dated11/22/19, the P&P indicated, “ ...I POLICY A. Using the nursing process, RN/LVNs [LNs] will organize, coordinate, and direct nursing care to prevent the development of pressure injuries, promote healing of pressure injuries, or prevent the deterioration of existing pressure injuries. B. Using the guidelines provided RN/LVNs will identify skin impairment issues and implement a plan of care appropriate for each wound. C. A multidisciplinary process will be use, with RN/LVNs collaborating with physicians the wound care team, the infection control nurse(s), dieticians ...” PURPOSE A. To identify patients at risk for development of pressure injuries. B. To prevent the development of pressure injuries in patients identified as at risk. C. To promote healing of existing pressure injuries by implementation of a consistent structured intervention process. D. To prevent the deterioration of existing pressure injuries. E. To promote healing of existing skin impairment issues ...””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 40644 Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection when: 1. Three of three sampled sinks in Intensive Care Unit Nutrition Room, Medical Unit Nutrition Room, and Labor & Delivery Nurses Station had residue on the countertops. 2. One of two “Brand Name” endoscope re-processors [machine that cleans and disinfects the (endoscope- a thin, tube-like instrument used to look at tissues inside the body)] had residue on the top of loading basin and front panel cabinet. 3. Certified Registered Nurse Anesthetist [CRNA- a Registered Nurse who has specialized training in (anesthesia-A loss of feeling or awareness caused by drugs or other substances.)] 1 was starting a spinal block (a temporary loss of feeling in the abdomen and/or the lower part of the body) on Patient (PT) 28 and did not do hand hygiene prior to putting on sterile gloves (gloves that are free from all microorganisms) for a spinal block procedure. 4. CRNA 1 disposed of her sharps (needles) from Pt 28’s spinal block in a blue pharmaceutical waste (drug that may be expired, is unused, or left over after medical treatment or surgical procedure) container and not in a red sharps container. These failures placed staff and patients at risk of cross contamination and infection, including the intensive care unit, the medical unit, the labor and delivery unit, the endoscopy unit and the operating rooms. Findings: 1. During a concurrent observation and interview on 6/10/24 at 1:47 p.m. in the Intensive Care Unit (ICU) Nutrition Room with the Designated Nurse Executive (DNE), the countertop next to the ice machine was covered with a sticky residue, as if something had been taped on the counter previously and the adhesive had not been removed. The DNE stated she could feel the stickiness when she rubbed her hand across it. The DNE stated sticky surfaces can harbor (hold onto) organisms (An individual animal, plant, or single-celled life form) and could cause the spread of infection. During a concurrent observation and interview on 6/10/24 at 3:10 p.m. in the Medical Unit nutrition room with a Nursing Director (ND),1 the sink where food was prepared, and hands were washed had a white residue around it. ND 1 felt the surface around the sink and stated it felt like mineral deposits. ND 1 stated the buildup causes a risk of infection because organisms can harbor on the surface. During a concurrent observation and interview on 6/11/24 at 10:45 a.m. with ND 1 and the Director of Environmental Services (DES) in the labor and delivery unit at the nursing station, a white residue was surrounding the sink. The DES stated, “it’s an infection control concern.” The DES stated the textured surface can allow for the spread of bacteria. During an interview on 6/18/24 3:00 p.m. with the Chief Nursing Officer (CNO) and Chief Executive Officer, (CEO) the CEO stated having sinks, equipment and fixtures that could not be cleaned thoroughly due to buildup of mineral deposits concerned him, because it would put patients at risk of infection. During a review of policy and procedure (P&P) titled, “Cleaning of Clean Utility Room” dated 01/24, the P&P indicated, “ ... B... While cleaning, use all-purpose cleaner to remove adhesives and tape ... E. Clean sinks with cream cleanser and scrubbing pad ...” According to the Centers for Disease Control (CDC), undated, retrieved 6/21/24 from https://www.cdc.gov/infection-control/hcp/environmental-control/appendix-c-water.html, “ ...Microorganisms (An organism that can be seen only through a microscope) have a tendency to associate with, and stick to surfaces ... These adherent organisms can initiate and develop biofilms (a thin layer of bacteria that adheres to the surface.)...” 2. During a concurrent observation and interview on 6/11/24 at 1:56 p.m. in the Endoscopy (a medical procedure where a doctor puts a tube-like instrument with a camera into the body to look inside) unit, with Surgical Tech (ST) 3 the “brand name” endoscope re-processor machine had visible, white-colored residue on edges around and between surfaces inside the top loading basin and on the front panel cabinet. ST3 stated despite following the facility’s P&P and [brand name] instruction for use (IFU) for cleaning and maintaining the machine, the white residue remained. ST3 stated the residue may be hard water stains. ST3 stated it was important to ensure the machine was cleaned per manufacturer’s instruction to prevent the spread of infection from one patient to the next. During a concurrent observation and interview on 6/11/24 at 2:15 p.m. in the endoscope processing room, with the Out-Patient Surgery Nurse Manager (NM) 2, the top loading basin and front control panel were observed to have residue on the top of loading basin and front of the panel cabinet. NM 2 stated her expectation was that staff reprocessing dirty endoscopes follow the facility P&P and the manufacturer IFUs to ensure cleaning and maintenance of the endoscopes were safe to use on patients. During a concurrent observation and interview on 6/11/24 at 2:30 p.m. with ST 3 and NM 2 expired sterile and reusable equipment labeled “misc-inst GI[Gastrointestinal- of, relating to, affecting, or including both stomach and intestine]” was found in the endoscope reprocessing room in an overhead cabinet. ST3 stated he was not sure what the equipment was used for, but the date on the sticker “23822” was “expired.” NM2 stated the date could be year 2022 or year 2023, regardless the reusable equipment should have been removed and sent to the Sterile Processing Department (SPD-comprises that service within the hospital in which medical/surgical supplies and equipment, both sterile and, are cleaned, prepared, processed, stored, and issued for patient care) for [re]-sterilization.) NM2 stated her expectation was that staff would not use expired equipment on a patient because using SPD equipment beyond the expiration date could affect equipment’s performance. During an interview on 6/12/24 at 4:11p.m. with the Infection Prevention nurse (IP), the IP stated, “We try to minimize the buildup (the deposits on the wet sinks) on equipment and fixtures. If it is close to the work area, it could be a source of infection. It have been addressed previously and corrected after reports to leaders. It is fixable.” The IP stated it was a housekeeping issue, and that EVS needs to be more diligent in cleaning the areas around the sinks to help prevent the spread of infection. During an interview on 6/18/24 3:00 p.m. with the Chief Nursing Officer (CNO) and Chief Executive Officer, (CEO), the CEO stated having sinks, equipment and fixtures that could not be cleaned thoroughly due to buildup of mineral deposits concerned him, because it would put patients at risk of infection. During a review of policy titled, “Cleaning of Clean Utility Room” last reviewed 01/24, the policy indicated, “ ... B... While cleaning, use all-purpose cleaner to remove adhesives and tape ... E. Clean sinks with cream cleanser and scrubbing pad ...” According to the professional reference titled, “Using the Health Care Physical Environment to Prevent and Control Infection, a project conducted by The Health Research & Educational Trust of the American Hospital Association, undated, retrieved 6/21/24 from: https://www.ashe.org/sites/default/files/ashe/CDCfullbookDIGITAL.pdf, “ ...Health care facility design can contribute either in a positive way by contributing to prevention of infection or negatively by contributing to transmission ... An example of a negative impact would be handwashing sinks not designed ... to minimize risk of splashing onto nearby countertops where staff prepare food, medications, or dressings, resulting in surface contamination that may lead to infection ...” According to the professional reference titled, “Using the Health Care Physical Environment to Prevent and Control Infection,” a project conducted by The Health Research & Educational Trust of the American Hospital Association, undated, retrieved 6/21/24 from: https://www.ashe.org/sites/default/files/ashe/CDCfullbookDIGITAL.pdf, “ ...Areas in a hospital where sterilization and high-level disinfection are performed should be designed to permit effective workflow and maintain maximum cleanliness ...” According to the Centers for Disease Control (CDC), undated, retrieved 6/21/24 from https://www.cdc.gov/infection-control/hcp/environmental-control/appendix-c-water.html, “ Microorganisms have a tendency to associate with, and stick to surfaces ... These adherent organisms can initiate and develop biofilms (a thin layer of bacteria that adheres to the surface.)” According to the “[Brand Name] Endoscope Re-processor Operation Manual (OM),” undated, the “OM” indicated “ ...Chapter 5 Endo-of-Day Checks,” page 149, “ ...Using a clean cloth moistened with neutral detergent, clean every part of the device including the front and back of the lid, the lid packaging, the edge and inside of the reprocessing basin and the control panel, then wipe with a dry clean cloth. To prevent growth of microorganisms, it is also recommended to wipe every part of the equipment with a cloth moistened with 70% ethyl alcohol or isopropyl alcohol figure 5.1...Chapter 7 Routine Maintenance,” page 186, “To ensure safe operation of the device, it should be cleaned and inspected regularly ... WARNING ... Be sure to perform all the inspections, cleaning, replacement of consumables and other tasks as described in this chapter. Otherwise, this equipment may not continue to operate and perform as expected...” 47205 47888 3. During an observation on 6/12/24 at 9:45 a.m., in Operating Room (OR) 4, CRNA 1 did not complete hand hygiene right before she put on the sterile gloves for the procedure. CRNA 1 was observed touching IV tubing, OR bed sheets and the spinal block tray (includes devices used for the procedure) prior to putting on the sterile gloves. During an interview on 6/12/24 at 4:10 p.m., with the Infection Preventionist (IP), the IP stated the expectation for CRNA 1 was to do hand hygiene, let it dry and then put on the sterile gloves prior to the procedure. The IP stated this was “very basic” and hand hygiene was the “number one” prevention of the spread of infection. The IP stated because the CRNA did not do hand hygiene properly, Pt 28 could have been potentially cross-contaminated (the physical movement or transfer of harmful bacteria from one person, object or place to another) and could develop an infection. During an interview on 6/13/24 at 3 p.m., with CRNA 1, CRNA 1 stated she did not sanitize (get rid of germs) her hands right before she put on the sterile gloves. CRNA 1 stated the expectation was for her to do hand hygiene right before she put on the gloves. CRNA 1 stated by not completing the hand hygiene she could have given the patient an infection. During an interview on 6/18/24 at 9:55 a.m., with the OR Director (ORD), the ORD stated the CRNA should have done hand hygiene right before she put her sterile gloves on. The ORD stated Pt 28’s safety was put at-risk by not doing hand hygiene properly. The ORD stated Pt 28 would have an increased infection risk. The ORD stated the CRNA `1 did not follow hospital’s policies. During an interview on 6/18/24 at 2:40 p.m., with the Chief Executive Officer (CEO), the CEO stated infection control was a “foundational” and “critical component” of patient safety at the hospital. The CEO stated hospital leadership already spoke to the CRNA 1 and reinforced the importance of hand hygiene. During a review of the facility’s policy and procedure (P&P) titled, “Prevention and Surgical Infections and Complications”, dated 6/28/18, the P&P indicated, “ ...I. POLICY: [Hospital] implements national standards of surgical care and best practices for surgical site infection prevention. II. PURPOSE: to implement processes that scientific based evidence associates with reduced surgical site infections and other potential complications of surgery. III. PROCEDURE: ... 6. Hand Hygiene: ... b. Strict adherence to hand hygiene for staff between each point of contact with the patient, required also between patient tasks and/or contact with equipment or surfaces ...” During a review of facility’s P&P titled, “Hand Hygiene”, dated 6/18/21, the P&P indicated, “ ...I. POLICY: [Hospital] promotes excellence in hand hygiene practice. II. PURPOSE: excellence in hand hygiene is known to reduce the transmission of pathogenic organisms between patients and health care workers ... V. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: ... 2. Moment 2: Before performing a clean/aseptic procedure ...” During a review of facility’s P&P titled, “Infection Control Responsibilities for Anesthesia”, dated 2/28/19, the P&P indicated, “ ... I. PURPOSE: to prevent cross contamination of patients during the administration of anesthesia. II. POLICY: A. Anesthesia personnel will follow all appropriate infection control measures for the OR ... III. RESPONSIBILITIES: A. Anesthesia personnel responsible for abiding by infection control policies and procedures of the OR ... B. All OR ... personnel will perform patient care activities in a manner that decreases the possibility of cross contamination. C. Strict hand washing will be observed at all times between different patient contacts ...” 4. During an observation on 6/12/24 at 9: 50 a.m., in Operating Room (OR) 4, CRNA 1 threw away three sharps/needles that were used in Patient 28’s spinal block in a blue waste container. Two of the needles are attached to syringes without labels, and one 18-gauge (size of the hole in the needle) needle was by itself. Directly above the blue waste container was a document labeled “EMC Pharmaceutical Waste Management” that distinguished what waste should be discarded (thrown away) and what container should be used. During a review of the facilities “EMC Pharmaceutical Waste Management Document (PWD) (located on the wall directly above the blue waste container the sharps were discarded in)”, the PWD indicated, “ ...[Blue waste container] Non-RCRA (Resource Conservation and Recovery Act- established the framework for proper management of hazardous wastes) Pharmaceutical Waste ... Examples: Pills & Tablets, Full or Partial Vials, Full or Partial IV’s (intravenous tubing) with Medication Instilled [keep tubing attached and place in re closable bag] Lotions, Creams and Ointments must be capped ... [Red Waste Container] Sharps, Infectious Waste ... Sharp waste capable of inflicting puncture or cuts ... Objects that are contaminated with an infectious substance ... Examples: Needles, Broken Glass, Vials/Ampules (a small sealed vial which is used to contain and preserve a sample, usually a solid or liquid) Blood/Syringe, Scalpels/Blades/Lancets, Razors, Staples, Guidewire ...” During an interview on 6/12/24 at 4:10 p.m., with the Infection Preventionist (IP), the IP stated the expectation for CRNA 1 was to discard of the two needles she used in the spinal block procedure into a red sharps container. The IP stated there were red sharps containers available in every OR room. The IP stated there were “no exceptions” in the OR, sharps would go into the red sharps containers. The IP stated a staff member could have had a sharps injury due to not disposing into the correct container. The IP stated cross-contamination to the patient could occur and a subsequent infection. During an interview on 6/13/24 at 3 p.m., with CRNA 1, CRNA 1 stated she threw her sharps from the spinal block away in the blue waste container. CRNA 1 stated “she thought the container said sharps”. CRNA 1 stated she was unsure on what other container she could have used. CRNA 1 stated that container was “what is there” so “I threw it all in there”. CRNA 1 stated the PWD says needles go in red “but I think we can put in blue”. During an interview on 6/18/24 at 9:55 a.m., with the Operating Room Director (ORD), the ORD stated any sharp needed to go in an approved sharps container. The ORD stated she needed to confer with hospital leadership if the blue waste container was appropriate. During a review of a facility document (provided by ORD) titled “Pharmaceutical Waste Management”, undated, the document indicated, “ ...Blue Non-RCRA Pharmaceutical Waste ... 2 Gallon Sharps Container: syringes, ampules or sharps with residual non-RCRA medication. No controlled substance ...”. [This document was different than the PWD directly above the blue waste container in OR 4 that was observed]. During an interview on 6/18/24 at 2 p.m., with the Chief of Anesthesia (COA), the COA stated there is a “big red sharps container” in every OR. The COA stated needles always go in a sharps container. The COA stated that can be “red or blue”. The COA stated that if the spinal tray has “bloody stuff” on it than he would put it in the red container. During an interview on 6/18/24 at 2:40 p.m., with the Chief Executive Officer (CEO), the CEO stated he was taught for the proceduralist (practitioner completing the procedure) to sort the sharps and medications and put them in the appropriate bin. The CEO stated that sharps could be in the “larger blue bin”. During a review of the facility’s P&P titled, “Biohazardous (waste contaminated with potentially infectious agents or other materials that are deemed a threat to public health or the environment) Waste Management Plan (BWMP)”, dated 1/2/24, the BWMP indicated, “ ... I. PURPOSE: the biohazardous waste management plan has been developed to ensure the health and safety of employees, patients and visitors. Information regarding medical waste will be provided by the proper identification, labeling, containment and handling of biohazardous waste ... IV. CONTAINMENT AND LABELING: all biohazardous waste is contained separately from other waste ... biohazardous waste shall be contained in red biohazard bags or rigid puncture-resistant containers as appropriate ... any container used shall be labeled with biohazardous waste and/or the international biohazard symbol. Containers must be labeled on all sides notifying container is for biohazard product ... Sharps waste shall be contained in “sharps container” which are rigid, puncture resistant when sealed, labeled “Sharps Waste” or “Biohazardous Waste” with the international biohazard symbol ... Facility areas containing biohazard containers ... OR (Operating Room) Surgical Units (Main OR ...): Rigid Biohazard Container, Rigid Pharmaceutical Container, Rigid Control Substance Container ...”. During a review of United States Environmental Protection Agency (EPA) Professional Reference titled, “A 10-Step Blueprint for Managing Pharmaceutical Waste in US Healthcare Facilities”, dated 2022, (found at https://hercenter.org/10_step_blueprint_guide_final_9-22.pdf) indicated, “ ...The purpose of this document is to provide a practical guide to help healthcare facilities, including hospitals ... STEP NINE: Training Programs ... Other departments ... such as ... surgery ... can use the nursing training material and apply it to their specific situation ... Figure 9: Model #3: Full Sorting of Hazardous and Non-hazardous in ... Nursing ... Non-Hazardous Pharmaceutical Waste [Blue color] ... All non-RCRA, Non-antineoplastic (waste that could kill cancerous cells or inhibit their growth), NO NEEDLES ... Red Sharps [Red color] ... Bio-hazardous drugs, Empty syringes with needles, NO OTHER DRUGS ...””

“ORGANIZATION OF ANESTHESIA SERVICES CFR(s): 482.52(a), (c) The organization of anesthesia services must be appropriate to the scope of the services offered. Anesthesia must be administered only by: (1) A qualified anesthesiologist; (2) A doctor of medicine or osteopathy (other than an anesthesiologist); (3) A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under State law; (4) A certified registered nurse anesthetist (CRNA), as defined in §410.69(b) of this chapter, who, unless exempted in accordance with paragraph (c) of this section, is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed; or (5) An anesthesiologist’s assistant, as defined in Sec. 410.69(b) of this chapter, who is under the supervision of an anesthesiologist who is immediately available if needed. State Exemption (1) A hospital may be exempted from the requirement for MD/DO supervision of CRNAs as described in paragraph (a)(4) of this section, if the State in which the hospital is located submits a letter to CMS signed by the Governor, following consultation with the State’s Boards of Medicine and Nursing, requesting exemption from MD/DO supervision of CRNAs. The letter from the Governor must attest that he or she has consulted with State Boards of Medicine and Nursing about issues related to access to and the quality of anesthesia services in the State and has concluded that it is in the best interests of the State’s citizens to opt-out of the current MD/DO supervision requirement, and that the opt-out is consistent with State law. (2) The request for exemption and recognition of State laws, and the withdrawal of the request may be submitted at any time, and are effective upon submission. This Standard is not met as evidenced by: 47888 Based on interview and record review, the hospital failed to ensure anesthesia (use of medicines to prevent pain during surgery and other procedures) services were appropriate to the scope of the services provided, for one of one Patient (Patient 1), when Certified Registered Nurse Anesthetist (CRNA- a Registered Nurse who has specialized training in anesthesia) 1 ordered diagnostics in the post-anesthesia care unit (PACU- a unit where patients go directly after a surgical procedure to recover from the effects of anesthesia) after Patient (Pt) 1 fell off the Operating Room (OR) table. The Anesthesia in Charge (AIC) that day was a CRNA (CRNA 2). These failures resulted in CRNA’s working out of their scope and the patient not receiving the benefit of having care provided by an Anesthesiologist. Findings: During a review of Pt 1’s “Pre-operative History and Physical (H&P)”, dated 4/2/24, the H&P indicated, “ ...75-year-old, Female ... Chief Complaint: ... right hip hurts ... Focused Examination: ... The patient does have a bit of a pannus (an apron of excess skin and fat hanging from the abdomen below the waistline) overlapping the proximal (nearer to the center of the body) portion ... deep hip pain ... pain with external and internal rotation ... She has an antalgic gait (limp) ... Impression: Arthritis right hip (a condition in which there is loss of the cartilage [strong, flexible connective tissue that protects your joints and bones] of the head of the thighbone and of the cup-shaped socket of the pelvis where the thighbone fits into the join) ... Diagnosis: Arthritis of right hip, Abdominal pannus ... Recommendation/Plan: ... Proceed with surgical interview involving right total hip arthroplasty (a surgical procedure in which an orthopedic surgeon removes the diseased parts of the hip joint and replaces them with new, artificial parts) ... The potential risks, benefits, complications, outcomes were discussed with the patient who understood, agreed and consented to proceed ... Signature: [Medical Doctor (MD) 7] ... Reviewed Problems: Graves Disease (an immune system condition that affects the thyroid gland) - onset 2/1/20, Myasthenia gravis (a chronic autoimmune disorder in which antibodies destroy the communication between nerves and muscle, resulting in weakness of the skeletal muscles), Essential Hypertension (high blood pressure), Coronary Arteriosclerosis (the buildup of fats, cholesterol and other substances in and on the blood vessels causing vessels to narrow blocking blood flow) ...” During a review of Pt 1’s “Surgical Documentation (SD)”, dated 4/8/24, the SD indicated, “ ...Last modified by: Registered Nurse (RN) 10 [RN 8 note] ... General Comments: Once procedure was complete dressings were placed on incision ted hose placed on patient. Left arm was freed and placed on chest in order to bring bed to side of table. I turned to move suction and Bovie (Electrocauterization [or electrocautery- A procedure that uses heat from an electric current to destroy abnormal tissue] is often used during surgery to remove unwanted or harmful tissue. It can also be used to burn and thus seal blood vessels. This helps reduce or stop bleeding during surgery) out of the way and patient had rolled off of surgical table to the right side. I ran to patient and saw her in a prone position on floor. I asked her if she was okay or hurt and she asked what happened. I then positioned her on her back supporting her head. I placed a pillow under head and covered her with blankets. I did a quick scan assessment checking for abrasions or obvious injuries, I saw no apparent skin injuries ... other staff had come into the room by then and a lift team was called. I was sent to a lunch break and did not witness the lift team placed the patient in bed ... General Comments: (Last modified by RN 8) ... 11:10 a.m. patient fell from bed (post removed) witnessed by RN 8, Certified Registered Nurse Anesthetist (CRNA) 1, Scrub Technician (ST) 4, patient stabilized while on floor, kept warm inform charge nurse lifting called for patient on bed. MD 7 informed of incident ... 11:30 a.m. patient (1) on bed by lift team ... transferred to PACU ...” During a review of Pt 1’s “Progress Note (PN- from CRNA 1)”, dated 4/8/24, the PN indicated, “ ... I told (Pt 1), surgery is now over. Stay still and don’t move. We are getting you ready to be moved to your bed. (RN 5) removed the tape from the patient’s right arm which was taped over the patient’s chest. I removed the arm strap from the Pt’s left arm which was strapped to an arm board connected to the bed. Patient was still groggy so I reminded the patient to not move ... Pt raised her left arm and rolled over to the right side. Pt fell off of the OR (Operating Room) bed and was on the ground face-down with her left arm shielding her face ... I told her not to move and try to stay still while we were getting more help to move her back to the bed ... Pt was unable to move or feel her legs due to the spinal block (a temporary loss of feeling in the abdomen and/or the lower part of the body) I had placed earlier for the surgery ... Pt stated that she felt pain in her shoulders. I noted that the Pt’s left-hand squeeze was weaker than the right hand so I lifted the Pt’s left gown sleeve and observed a suspected fracture in her left upper arm ... in the PACU I placed orders for a head/neck CT and X-ray of bilateral shoulders and arms ...” During a review of Pt 1’s “Diagnostic Radiology (DR)”, dated 4/8/24 at 12:26 p.m., the DR indicated, “ ... Ordering Provider: CRNA 1. Report: XR (x-ray Humerus (upper arm bone) Minimum 2 Views Left ... Clinical Information: fall ... Impression: Comminuted, angulated fracture of the distal humeral (Upper arm bone broken in at least three places) ... Final Report: Dictated by MD 8 ... Signed by: MD 8 ...”. During a review of Pt 1’s “DR”, dated 4/8/24 at 12:26 p.m., the DR indicated, “ ...Procedure: XR Forearm 2 Views Right ... Ordering Provider: CRNA 1 ... Impression: No evidence of fracture ... Final Report: Dictated by MD 8 ... Signed by: MD 8 ...” During a review of Pt 1’s “DR”, dated 4/8/24 at 12:26 p.m., the DR indicated, “ ...Procedure: XR Forearm 2 Views Right ... Ordering Provider: CRNA 1 ... Impression: No evidence of fracture ... Final Report: Dictated by MD 8 ... Signed by: MD 8 ...” During a review of Pt 1’s “Computed Tomography (CT- A procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body)”, dated 4/8/24 at 1:14 p.m., the CT indicated, “ ...Procedure: CT Spine Cervical (top of the spine) without contrast ... Ordering Provider: CRNA 1 ... Clinical Information: Trauma-Acute Intracranial Injury/Pain ... Impression: No evidence of acute cervical spine osseous pathology ... Final Report: Dictated by MD 8 ... Signed by: MD 8 ...” During a review of Pt 1’s “CT”, dated 4/8/24 at 1:14 p.m., the CT indicated, “ ...Procedure: CT Head or Brain without contrast ... Ordering Provider: CRNA 1 ... Clinical Information: Trauma-Acute Intracranial Injury/Pain (Head injury or blow to the head) ... Impression: No evidence of acute cervical spine osseous pathology ... Final Report: Dictated by MD 8 ... Signed by: MD 8 ...” During a review of “Valley Regional Anesthesia Associates- [Hospital] Schedule”, dated 4/8/24 to 4/19/24, the Schedule indicated, a CRNA was assigned to be the AIC for 4/8/24 (date of Pt 1 fall), 4/10/24, 4/11/24, 4/16/24 and 4/19/24. During an interview on 6/13/24 at 3 p.m., with CRNA 1, CRNA 1 stated the AIC was always an Anesthesiologist. CRNA 1 stated she would consult the AIC if had questions or needed guidance on a “difficult” case. CRNA 1 stated she did not have questions prior to the fall and this was a “normal” surgery with no issues prior to Pt 1’s fall. CRNA 1 stated she did not order diagnostics in Pt 1’s case, but according to her scope she could if needed. According to Pt 1’s Electronic Medical Record (EMR) she ordered three XR’s and two CT’s without a documented order form with MD 7 or another physician. During an interview on 6/13/24 at 3:50 p.m., with MD 5 (Anesthesia in Charge), MD 5 stated in the last month changes have been made to the role of the CRNA. MD 5 stated the AIC or physician available writes all orders in the pre-operative and post-operative phase since the change. MD 5 stated that before CRNA orders used to “roll-over” into the post-operative phase, but as of today they did not. During an interview on 6/17/24 at 12:06 p.m., with CRNA 3, CRNA 3 stated the hospital requested a physician co-sign on CRNA orders that started in May or June of 2024. CRNA 3 stated the AIC could suggest changes to the anesthesia plan developed for a patient and the practice was collaborative. During an interview on 6/18/24 at 2 p.m., with the Chief of Anesthesia (COA), the COA stated a CRNA ordering diagnostics “could be borderline”. The COA stated CRNA can “interpret those things” and that if a Pt aspirated (accidental breathing in of fluid into the lungs. This can cause serious problems, such as pneumonia and other lung problems) under their care, they should be able to order an x-ray. The COA stated the “MD’s” are the AIC’s and not CRNA’s. The COA stated the role of the AIC was to make clinical decisions, interact with consultants and other MD’s. During an interview on 6/18/24 at 2:40 p.m., with the Chief Executive Officer (CEO), the CEO stated the scope of the CRNA was to assess the Pt intraoperatively (during the surgical procedure), put together a plan of anesthesia for them with consultation (when someone ask someone for their advice or guidance) from an MD and know when to ask for assistance. During a review of the Board of Registered Nursing (BRN) definition of a Nurse Anesthetist, indicated a “ ...nurse anesthetist is a registered nurse who provides anesthesia services ordered by a physician ... and is certified by the BRN in this specialty”. https://www.rn.ca.gov, accessed 1/12/2024 ...” During a review of California’s Business and Professions Code, “BPC, 2725(b)(2)- Practice of Nursing”, the BPC indicated, “ ...Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents (treating a disease), necessary to implement a treatment, disease prevention, or rehabilitative regimen (schedule) ordered by and within the scope of licensure of a physician ...” During a review of BPC, “2833.5. Practice of Nurse Anesthetist to Not Confer Authority to Practice Medicine or Surgery Except as provided in Section 2725”, the BPC indicated, “ ... in this section, the practice of nurse anesthetist does not confer authority to practice medicine or surgery. (Added by Stats. 1983, c. 696, § 7. and as defined by Section 1316.5 of the Health and Safety Code ) ...”. During a review of BPC “2051 Medical (Doctor) Licensing”, the BPC indicated, “ ...authorizes the physician to “diagnose” or “diagnosis” using any method, device, or procedure whatsoever, and whether gratuitous (free) or not, to ascertain (learn with certainty) or establish whether a person is suffering from any physical or mental disorder ...” During a review of the facility’s policy and procedure (P&P) titled, “Allied Health Professional Certified Registered Nurse Anesthetist Job Description/Protocol”, dated 1/23/20, the P&P indicated, “ ...Policy: With the overall anesthesia service being supervised by an anesthesiologist credentialed by the medical staff a CRNA ... may administer anesthesia and provide the following anesthesia-related care in the following general categories ordered by a physician ... who is a current member in good standing of the [Hospital] Medical Staff and has personally evaluated the patient ... General Scope or Services/Functions. A CRNA may perform the following functions: 1. Performing and documenting a pre-anesthetic assessment and evaluation of the patient including requesting consultations and diagnostic studies; selecting, obtaining, or administering pre anesthetic medications and fluids; and obtaining informed consent for anesthesia ... 11. CRNA’s must contact the AOC (Anesthesiologist on call) or the AIC (Anesthesiologist in charge) as directed by departmental P&P, which includes ... as a direct by the AIC/AOC on a case-by-case basis ...””

“DELIVERY OF ANESTHESIA SERVICES CFR(s): 482.52(b) Anesthesia services must be consistent with needs and resources. Policies on anesthesia procedures must include the delineation of pre-anesthesia and post-anesthesia responsibilities. The policies must ensure that the following are provided for each patient: This Standard is not met as evidenced by: 47888 Based on interview and record review the hospital failed to ensure the safety and well-being of one of one patients (Pt 1), when Pt 1 was under the direct care of the Certified Registered Nurse Anesthetist (CRNA- a Registered Nurse who has specialized training in anesthesia) 1 and fell off of the operating room table while emerging from Anesthesia (the use of medicines to prevent pain during surgery and other procedures). This failure resulted in Pt 1 suffering a significant injury, breaking her left arm in multiple places. Findings: During a review of Pt 1’s “Pre-operative History and Physical (H&P)”, dated 4/2/24, the H&P indicated, “ ...75-year-old, Female ... Chief Complaint: ... right hip hurts ... Focused Examination: ... The patient does have a bit of a pannus (an apron of excess skin and fat hanging from the abdomen below the waistline) overlapping the proximal (nearer to the center of the body) portion ... deep hip pain ... pain with external and internal rotation ... She has an antalgic gait (limp) ... Impression: Arthritis right hip (a condition in which there is loss of the cartilage [strong, flexible connective tissue that protects your joints and bones] of the head of the thighbone and of the cup-shaped socket of the pelvis where the thighbone fits into the join) ... Diagnosis: Arthritis of right hip, Abdominal pannus ... Recommendation/Plan: ... Proceed with surgical interview involving right total hip arthroplasty (a surgical procedure in which an orthopedic surgeon removes the diseased parts of the hip joint and replaces them with new, artificial parts) ... The potential risks, benefits, complications, outcomes were discussed with the patient who understood, agreed and consented to proceed ... Signature: [Medical Doctor (MD) 7] ... Reviewed Problems: Graves Disease (an immune system condition that affects the thyroid gland) - onset 2/1/20, Myasthenia gravis (a chronic autoimmune disorder in which antibodies destroy the communication between nerves and muscle, resulting in weakness of the skeletal muscles), Essential Hypertension (high blood pressure), Coronary Arteriosclerosis (the buildup of fats, cholesterol and other substances in and on the blood vessels causing vessels to narrow blocking blood flow) ...” During a review of Pt 1’s “Surgical Documentation (SD)”, dated 4/8/24, the SD indicated, “ ...Last modified by: Registered Nurse (RN) 10 [RN 8 note] ... General Comments: Once procedure was complete dressings were placed on incision ted hose placed on patient. Left arm was freed and placed on chest in order to bring bed to side of table. I turned to move suction and Bovie out of the way and patient had rolled off of surgical table to the right side. I ran to patient and saw her in a prone position on floor. I asked her if she was okay or hurt and she asked what happened. I then positioned her on her back supporting her head. I placed a pillow under head and covered her with blankets. I did a quick scan assessment checking for abrasions or obvious injuries, I saw no apparent skin injuries ... other staff had come into the room by then and a lift team was called. I was sent to a lunch break and did not witness the lift team placed the patient in bed ... General Comments: (Last modified by RN 8) ... 11:10 a.m. patient fell from bed (post removed) witnessed by RN 8, Certified Registered Nurse Anesthetist (CRNA) 1, Scrub Technician (ST) 4, patient stabilized while on floor, kept warm inform charge nurse lifting called for patient on bed. MD 7 informed of incident ... 11:30 a.m. patient (1) on bed by lift team ... transferred to PACU ... “ During a review of Pt 1’s “Diagnostic Radiology (DR)”, dated 4/8/24 at 12:26 p.m., the DR indicated, “ ... Ordering Provider: CRNA 1. Report: XR Humerus Minimum 2 Views Left ... Clinical Information: fall ... Impression: Comminuted, angulated fracture of the distal humeral (Upper arm bone broken in at least three places) ... Final Report: Dictated by MD 8 ... Signed by: MD 8 ...” During a review of Pt 1’s “Progress Note (PN- from CRNA 1)”, dated 4/8/24, the PN indicated, “ ... I told (Pt 1), surgery is now over. Stay still and don’t move. We are getting you ready to be moved to your bed. (RN 5) removed the tape from the patient’s right arm which was taped over the patient’s chest. I removed the arm strap from the Pt’s left arm which was strapped to an arm board connected to the bed. Patient was still groggy so I reminded the patient to not move ... Pt raised her left arm and rolled over to the right side. Pt fell off of the OR (Operating Room) bed and was on the ground face-down with her left arm shielding her face ... I told her not to move and try to stay still while we were getting more help to move her back to the bed ... Pt was unable to move or feel her legs due to the spinal block (a temporary loss of feeling in the abdomen and/or the lower part of the body) I had placed earlier for the surgery ... Pt stated that she felt pain in her shoulders. I noted that the Pt’s left-hand squeeze was weaker than the right hand so I lifted the Pt’s left gown sleeve and observed a suspected fracture in her left upper arm ...” During a review of Pt 1’s “Operative/Procedure Reports (OPR)”, dated 4/9/24, the OPR indicated, “ ...Surgeon: MD 7 ... Anesthesiologist: MD 9 ... Post-operative diagnosis: Left comminuted and displaced closed distal third humeral shaft fracture ... Indications for Procedure: This is a 74-year-old woman who fell off the operative table after surgical intervention for her right hip today causing her to develop a displaced fracture of the left distal humerus for which require surgical intervention. After discussing this with the staff, the family and the patient herself, we deemed important and necessary to fix this as soon as possible so that we can allow her to be able to ambulate after her hip arthroplasty ... consented to proceed ... Findings: Displaced comminuted humeral shaft fracture ... Implants/Explants: ... humerus plate with ... screws ... Patient Condition: good ...” During an interview on 6/13/24 at 3 p.m., with CRNA 1, CRNA 1 stated she was at the head of Pt 1 when the fall occurred. CRNA 1 stated she was focused on the airway of Pt 1 and did not know where the other members of the OR team were. CRNA 1 stated Pt 1 was “groggy (stunned or confused and slow to react)” but waking up answering questions appropriately. CRNA 1 stated she removed the left arm strap for Pt 1 to make her more comfortable while waking up. CRNA stated Pt 1 than raised up her left arm and rolled off the OR bed to her right side. CRNA 1 stated she thought Pt 1 initiated and was the cause of the fall. CRNA 1 stated “I told her not to move and she moved when I told her don’t move”. CRNA 1 stated the transfer bed was not in the room at the time of the fall. CRNA 1 stated she was not responsible for the transfer bed not being there. CRNA 1 stated she “wished” there were two staff on each side of the patient and “wished” the patient would not have fallen. CRNA 1 stated she would not have done anything differently. During an interview on 6/13/24 at 3:50 p.m., with MD 5 (Anesthesia in Charge), MD 5 stated that he did not think CRNA 1 could have done anything differently. During an interview on 6/18/24 at 9:55 a.m., with the OR Director (ORD), the ORD stated Pt 1’s safety was put at-risk due to staff having a “lack of awareness” and actual harm occurred. The ORD stated Pt 1’s right to care in safe setting was violated “unintentionally”. The ORD stated the surgical department used Association of Perioperative Registered Nurses (AORN) guidelines as their professional reference. During an interview on 6/18/24 at 2 p.m., with the Chief of Anesthesia (COA), the COA stated the role of anesthesia (CRNA 1) would be to be the “team leader at that moment”. The COA stated when a Pt was coming out of anesthetic, Pt 1 would not be capable of making “rational decisions”. The COA stated it would be “unfair” to expect Pt 1 to follow commands by the CRNA. During an interview on 6/18/24 at 2:40 p.m., with the Chief Executive Officer (CEO), the CEO stated Pt 1 should have never been left unsupervised on the OR table. The CEO stated Pt 1’s safety was compromised by staff. The CEO stated Hospital policy and procedures were not followed in this case. The CEO stated Pt 1’s rights were violated because she did not receive care in a safe setting. During a review of the facility’s policy and procedure (P&P) for Anesthesia titled, “Patient Safety”, dated 1/14/22, the P&P indicated, “...PURPOSE: to identify and eliminate potential safety hazards thereby reducing risk to patients, personnel and visitors... POLICY: Patient safety refers to a systematic hospital wide program to minimize preventable physical injuries, accidents and undo psychological stress during hospitalization ... B. PATIENT OBSERVATION: 1. Patients on operating tables are never left unattended. Side rails and/or safety straps are utilized ... 2. Special care is ensured by provision of an adequate number of personnel when moving patients to and from the operating table, or when positioning patients on the operating table...” During a review of the facility’s policy and procedure (P&P) titled, “Transferring Patients from Gurney/Bed to Operating Room Table”, dated 1/12/23, the P&P indicated, “...PURPOSE: A. To prevent ... patient injuries during the handling, repositioning and transferring of patients ... II. POLICY: A. All employees are responsible to perform in a safe manner and are expected to identify and report potentially unsafe work practices and conditions. B. Patients will be transferred from gurney/bed to the OR table in a safe manner ...” Review of AORNguidelines.org Professional Reference titled, “Guideline for Positioning the Patient” dated 5/17/22, (found at https://aornguidelines.org/guidelines/content?sectionid=173734066&view=book&expand=true) indicated, “ ... 3.1. Identify potential hazards associated with positioning activities and establish safe practices. Positioning patients and using positioning equipment and devices during perioperative care is a high-risk task that can result in injury to patients or personnel. Identifying potential hazards and establishing safe practices may reduce the risk for patient and personnel injury ... 3.2. Perioperative team members should proactively determine who is responsible for attending to the patient (for example, remaining present at the patient’s side) while the patient is on the OR bed. Patients are at risk for falls in the perioperative setting. It is the responsibility of the entire perioperative team to proactively discuss patient observation responsibilities for all phases of the intraoperative period and consider crucial periods, such as induction and emergence from anesthesia and periods of sedation during which patients are not yet positioned or restrained in their final positions. To minimize or eliminate the risk of patient injuries from falls, perioperative team members must remain vigilant to the infrequent but potentially devastating consequences of a patient’s fall from the OR bed. A lack of clear communication about who is responsible for attending the patient after the safety straps are removed or before the patient is transferred to the OR bed has been reported as a contributing factor for patient falls in the perioperative setting ... 3.21. Apply safety restraints in a manner that safely secures the patient. Applying safety restraints reduces the patient’s risk of falling off the OR bed ...” During a review of the “Owner’s Manual- Hana Orthopedic Surgery Table (OM)”, dated 2017, the OM indicated, “ ...Standard Components ... Patient Safety Strap: The patient safety strap secures the patient in place when positioned on the table the 90-inch strap slides around the foot-end of the table ... Anterior (in the front of) Approach Total Hip Arthroplasty ... Table Setup for ... Right Total Hip Arthroplasty ... 7. Slide the Patient Safety Strap in Place (picture of safety strap fastened over the belly-button area of patient) ...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 39795 Based on interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA when: 1. The hospital failed to ensure an emergency medical condition (EMC) and stabilizing measures were provided prior to discharge for three of 24 Patients (Patient 1, Patient 7, and Patient 8) (Refer A2407) 2. The hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [EMC] exists) for one of 24 sampled patients (Patient 10). (Refer to A2406) Because of the potential serious harm to Patient 1 and Patient 7, and all pediatric patients in Hospital A who had an Emergency Medical Condition (EMC) and not provided an appropriate Medical Screening Exam (MSE) and stabilizing measures, an Immediate Jeopardy (IJ) situation was called for CFR 489.24 (b)(d)(1)(i) A2407 on 4/26/24 at 4:30 p.m., with the Chief Executive Officer (CEO), Chief Financial Officer (CFO), Interim Chief Nursing Officer (ICNO), Director of Quality (DQ), Patient Safety Officer (PSO), and Associate Administrator (AA) and were provided the IJ template which documented the immediate actions necessary to address the IJ situation. The hospital submitted an acceptable IJ Plan of Removal (Version 2) on 4/29/24 at 9:46 a.m. The IJ Plan of Removal included but was not limited to the following: 1) Primary care physician (PCP) referrals and chief complaints must be clarified with the PCP and/ or patient designated responsible person(s), 2) The QMP always conducts an appropriate MSE that includes a complete set of vital signs for pediatric patients and determine stabilizing measures when an EMC is identified, 3) Parent(s) of pediatric patients are provided a clear explanation of services available to treat and stabilize an EMC 4) All patients in psychiatric crises are properly placed and receive an appropriate psychiatric evaluation to ensure the safety of the patient, staff, visitors, and community 5) Proper follow up is provided for all patients who leave the ED with an identified EMC or in psychiatric crises which includes proper notification to the QMP, patient designated responsible person(s), and/ or local police department. On 4/9/24, the components of the IJ Plan of removal were validated onsite through observations, interviews, and record review. The IJ was removed on 4/29/2024 at 1:20 p.m. with the CEO, Group Chief Nursing Officer (GCNO), AA, ICNO, DQ, and PSO. Following the IJ removal, the facility remained in substantial non-compliance. The cumulative effect of these systemic failures resulted in the inability of the hospital to provide care in a safe and quality manner in the Emergency Department and was not in compliance with the statutory requirement of EMTALA.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 39795 Based on interview and record review, the hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [EMC] exists) for one of 24 sampled patients (Patient 10) when Patient 10 was brought in by ambulance (BIBA) on a 5150 (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness for up to 72-hours) psychiatric hold for a danger to self and her chief complaint of a psychiatric hold was never evaluated by a QMP before she was transferred from the hospital to another facility. This failure resulted in Patient 10 not receiving an appropriate MSE by QMP, and placed Patient 10 in danger of self-harm. The hospital failed to determine whether an emergency psychiatric condition existed for Patient 10 and did not initiate measures to ensure Patient 10’s safety prior to being transferred. Findings: During a review of Patient 10’s “Welfare and Institutions Code section 5150 (WIC)” dated 2/7/24, the WIC indicated, Patient 10 was placed on a 5150 hold on 2/7/24 at 10:48 a.m. for danger to self. During a review of Patient 10’s “ED Note Physician- Final Report (FR)”, the FR indicated, “ ...Chief Complaint: BIBA 5150 hold ... History of Present Illness: 64-year-old female BIBA on 5150 hold after being seen at her counseling clinic. Per Emergency Medical Services (EMS) report, patient fell from her wheelchair at the appointment and proceeded to hit herself, becoming hysterical uncooperative and verbally abusive ... she does not give further history due to being uncooperative ... Physical Exam: ... General: Alert, no acute distress ...Psychiatric: Appropriate mood and affect ... Medical Decision Making: Patient at this point is deemed medically stable for psychiatric evaluation ... Impression/Plan: suicidal ideation, depression and agitation ... Consultation: behavioral health consultation ...”. During a concurrent interview and record review on 4/24/24 at 10 a.m., with the Interim ED Clinical Manager (EDCM), Patient 10’s entire Electronic Medical Record (EMR) dated 2/7/24 was reviewed. The EMR indicated, Patient 10 came in on a 5150 hold from a community clinic. The EDCM stated Patient 10 was calmed down, per a Licensed Vocational Nurse (LVN) note, by verbal de-escalation once in the ED room. The EDCM stated Patient 10 was medically cleared (no physical issues causing the psychiatric behavior) by an ED physician and the patient was ready to be evaluated psychiatrically. The EDCM stated Patient 10 did not have insurance in Stanislaus County and could have been transferred to a local psychiatric hospital. The EDCM stated when this happened, the ED unit secretary contacted Community Emergency Services Response Team (CERT- an outside program through Stanislaus County that delivers behavioral health services). The EDCM stated the CERT program was sent all of Patient 10’s medical records via fax and they “acted like” a social worker to find mental health placement for the patient. The EDCM stated the CERT program does come to the hospital and does mental health evaluations in the ED with the ability to place 5150’s or remove them; however, in this case they only found placement for the patient and never did a psychiatric evaluation to potentially clear the 5150. The EDCM stated the CERT program found placement at a [name of the Psychiatric Health Facility](16 bed inpatient acute psych hospital) in [location of the facility] and a physician at the psychiatric facility accepted the patient via the CERT program. The EDCM stated, transfer documentation was signed (by patient and ED physician- deemed stable) and the ED nurse gave report to the nurse at that psychiatric facility. The EDCM stated the patient was transported via ambulance to that facility. On 4/24/24 at 10:10 a.m., the LVN note when LVN calmed Patient 10 verbally was requested but not provided. On 4/24/24 at 10:35 a.m., CERT transfer policy and/or contract was requested and but not provided. During an interview on 4/25/24 at 9:30 a.m., with Emergency Medicine Physician (EMP) 1, the EMP 1 stated he was the EMP who examined Patient 10 and cleared her medically. EMP 1 stated Patient 10 came in on a 5150 but was calmed by a staff member. EMP 1 stated he ordered [Brand name]Intramuscular (IM) injection, but it was never administered because Patient 10 was calm and had appropriate mood and affect on physical exam. The EMP 1 stated he was not qualified to evaluate the patient’s 5150 status. The EMP 1 stated he could not place a 5150 or remove a 5150 hold. The EMP 1 stated he believed he “corroborated (to make certain or confirm) the 5150” by his physical exam having a psychiatric component and providing a psychiatric diagnosis. EMP 1 stated a specific exam for the patient’s mental status in relation to the 5150 would have been “redundant”. The EMP 1 stated the hospital does not employ or have a contract with any Psychiatrist, Psychologist or Mental Health Clinician that would be able to do a full psychiatric evaluation. The EMP 1 stated he never spoke to the receiving mental health hospital physician and said that is the “common practice”. During an interview on 4/26/24 at 11:10 p.m. with the Chief Executive Officer (CEO), the CEO stated to his understanding the CERT team was to complete a “purely psychiatric” evaluation after the patient was medically stable. The CEO stated medically stable meant there was no medical reason, such as an infection or electrolyte (minerals in your blood and other body fluids that carry an electric charge that affect how your body functions) abnormality that had caused the patient to be psychiatrically unstable. The CEO stated CERT was supposed to complete their evaluation before the patient was placed into another facility. The CEO stated the hospital responsibility was to reach out to CERT and defer to their expertise (high level of skill or knowledge). During a review of the facility’s policy and procedure (P&P) titled, “Management and Transfer of Acutely Psychotic, Aggressive, or Potentially Violent Patients in the ED”, dated 2/14/23, indicated, “ I. POLICY: patients who are potentially dangerous to themselves and/or others will receive careful consideration of both physical and psychological needs. EMC staff will make every attempt to maintain patient rights while providing for the safety of all patients and staff ... PURPOSE: To provide medical evaluation while preventing injury and ensuring safety to all patients and staff ... IV. INTERFACILITY TRANSFER TO A MENTAL HEALTH FACILITY: ... 2. Review the patient’s Facesheet to determine whether the patient should be referred for services with the CERT ... a. CERT Transfer Process: 1. Phone the access line at (telephone number) to initiate mobile mental health evaluation. 2. Once placement is arranged by CERT, arrange transport with EMS ...”.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 39795 Based on interview and record review, the hospital failed to ensure an appropriate Medical Screening Exam (MSE) and stabilizing measures were provided for three of 24 Patients (Patient 1, Patient 7, and Patient 8) when: 1. Patient (Pt) 1, a pediatric patient, was sent by her primary care physician (PCP) to Hospital A’s emergency department (ED) on 2/21/24 at 12:30 p.m. with a chief complaint of physician reported hemoglobin (Hgb- protein in blood that carries oxygen to vital organs) level 5.5 and pallor (skin paleness). No diagnostic or laboratory studies were conducted for Pt 1 to determine the need for stabilizing measures for the abnormally low hemoglobin in a pediatric-age patient. Pt 1’s blood pressure (BP) was not evaluated to determine whether additional stabilizing measures were needed. before Pt 1 was discharged to home on 2/21/24 at 1:14 p.m. from the ED. After Pt 1’s discharge from Hospital A, Pt 1 was transported by family 79 miles in a private vehicle to Hospital B seeking emergent care. Pt 1 arrived at Hospital B, on 2/21/24 at 4:36 p.m., tachycardic (abnormally fast heartbeat) and pale. Labs drawn at Hospital B indicated Pt 1’s Hgb level was 5.4. Pt 1 was given a blood transfusion (blood is put into the bloodstream) on 2/21/24, in Hospital B’s ED and Pt 1’s clinical status was stabilized. This failure resulted in Pt 1 being discharged home from Hospital A with abnormally low Hgb levels and the EMC was not stabilized prior to discharge; and had the potential to cause injury, harm and/or stroke in Patient 1, a pediatric patient. 2. Patient 7 was brought in by ambulance to the ED on 3/16/24 at 4:18 a.m. with a chief complaint of head pain and hearing voices. Pt 7’s family reported Pt 7’s recent behavioral changes along with a history of underlying mental health problems. Pt 7’s triage (a process used to prioritize who needs emergency medical attention first) assessment identified a behavioral health concern (thoughts of hurting people) and was given an emergency severity index (ESI- tool used to prioritize care) score of “2”, emergent. The hospital’s behavioral health screening tool indicated further screening by a qualified medical professional (QMP) was warranted. Evaluation of Pt 7’s emergent psychiatric condition was not completed. Pt 7 was inappropriately placed in the ED waiting room where he later eloped (unsupervised/ undetected departure) on 3/16/24 from the ED. Pt 7 was called for care on 3/16/24 at 6:10 a.m., 8:31a.m., and 8:50 a.m. with no response from Pt 7. There was no documented evidence in Pt 7’s electronic medical record (EMR) that indicated Pt 7’s emergency contact, family, or local police department were contacted. This failure resulted in Pt 7’s emergent psychiatric problem not being stabilized and had the potential to worsen, lead to injury, harm, or death for Pt 7 and others who have a psychiatric emergency. 3. Patient 8 came to the ED via car on 3/21/24 for chief complaints of hyperglycemia (high blood sugar) and dizziness, where he received labs; results were abnormal, and patient left without being aware of those results. Patient 8 was not provided stabilizing treatment for the EMC and no Nurse, Physician nor staff member attempted to contact Pt 8, or the emergency contact after leaving the ED. This failure resulted in Pt 8’s blood glucose not being stabilized and had the potential for Pt 8’s condition to worsen, lead to injury, harm, or death. Because of the potential serious harm to Patient 1 and Patient 7, and all pediatric patients in Hospital A who had an Emergency Medical Condition (EMC) and not provided an appropriate Medical Screening Exam (MSE) and stabilizing measures, an Immediate Jeopardy (IJ) situation was called for CFR 489.24 (b)(d)(1)(i) A2407 on 4/26/24 at 4:30 p.m., with the Chief Executive Officer (CEO), Chief Financial Officer (CFO), Interim Chief Nursing Officer (ICNO), Director of Quality (DQ), Patient Safety Officer (PSO), and Associate Administrator (AA) and were provided the IJ template which documented the immediate actions necessary to address the IJ situation. The hospital submitted an acceptable IJ Plan of Removal (Version 2) on 4/29/24 at 9:46 a.m. The IJ Plan of Removal included but was not limited to the following: 1) Primary care physician (PCP) referrals and chief complaints must be clarified with the PCP and/ or patient designated responsible person(s), 2) The QMP always conducts an appropriate MSE that includes a complete set of vital signs for pediatric patients and determine stabilizing measures when an EMC is identified, 3) Parent(s) of pediatric patients are provided a clear explanation of services available to treat and stabilize an EMC 4) All patients in psychiatric crises are properly placed and receive an appropriate psychiatric evaluation to ensure the safety of the patient, staff, visitors, and community 5) Proper follow up is provided for all patients who leave the ED with an identified EMC or in psychiatric crises which includes proper notification to the QMP, patient designated responsible person(s), and/ or local police department. On 4/9/24, the components of the IJ Plan of removal were validated onsite through observations, interviews, and record review. The IJ was removed on 4/29/2024 at 1:20 p.m. with the CEO, Group Chief Nursing Officer (GCNO), AA, ICNO, DQ, and PSO. Following the IJ removal, the facility remained in substantial non-compliance. Findings: 1. During an interview on 4/18/24 at 1:15 p.m., with Pt 1’s parent (P1P), P1P stated Pt 1 had a history of severe iron deficiency anemia (iron level in blood drops too low to support normal red blood cell production). Pt 1 was not tolerating iron supplements and her Hgb levels were trending downward over the last “several months.” P1P stated Pt 1 was evaluated by her PCP on 2/21/24 and was told Pt 1 had “very low Hgb.” Pt 1 was sent by the PCP to Hospital A ED for “immediate treatment” on 2/21/24, after the PCP visit. P1P stated she provided Pt 1’s history and Hgb results (5.5) to “the nurse” and explained that Pt 1’s behavior was different; Pt 1 looked “discolored or pale” and was “very tired.” P1P stated she provided to the ED Physician (MD 2) Pt 1’s Hgb results and asked if Pt 1 required a blood transfusion. P1P stated MD 2 told her that Pt 1’s condition was not urgent, and the anemia could be managed as an outpatient. P1P stated she was told that results obtained from PCP clinics were inaccurate and Hospital A ED did not provide “transfusions.” P1P stated she explained to MD 2 that Pt 1’s Hgb level was 5.5 and that Pt 1 was referred by her PCP to the ED for a “blood” transfusion. P1P stated MD 2 offered to draw labs but the hospital would not “transfuse” Pt 1. P1P stated she refused the labs and told MD 2 she would have Pt 1 evaluated at Hospital B. Pt 1 was discharged to home on 2/21/24, from Hospital A. P1P stated she called Pt 1’s PCP after discharge and the PCP referred Pt 1 to Hospital B the same day. P1P stated on 2/21/24, she drove Pt 1 to Hospital B, “an approximate one to two hour” commute from Hospital A. P1P stated Hospital B found Pt 1 to be anemic (not enough red blood cells to carry oxygen to body tissues) and was given a blood transfusion in the ED. P1P stated she made two attempts to contact Hospital A’s ED Director to inquire why Pt 1’s condition was not treated on 2/21/24, but stated she never received a return call from Hospital A. During a review of Pt 1’s “ED Provider Notes” obtained from Hospital B, dated 2/21/24 at 4:36 p.m., indicated, “ ... Patient information was obtained from parent... Patient has history of iron deficiency anemia diagnosed on outpatient labs about eight months ago 6/2023 hemoglobin 8.5, as low as 6.9 a few months ago but today 5.5 at PCP office... Per mother she [Pt 1] has been more pale, fatigued/tired, no vomiting, no fevers ... has not been seen by hematology [a branch of medicine that studies blood and blood disorders] in clinic yet, no referral made yet... BP ... 106/46... Pulse [HR- heart rate] ...94... Temp [T- temperature] ... 97° F [Fahrenheit]... Resp [RR- respirations] ... 24... SpO2 [oxygen saturation] ... 98%... Well appearing, and no acute distress... Awake, alert, interactive... Repeat labs here show isolated microcytic anemia [red blood cells smaller than usual, probably due to not enough iron] with low iron studies... iron deficiency anemia. Will discuss with hematology... is symptomatic with tachycardia, fatigue [tiredness], pallor [paleness]... HGB 5.4... Hospitalist and hematologist OK with transfusion in ED... clinical impressions: Severe anemia...” During a review of Pt 1’s “Care Timeline” obtained from Hospital B, dated 2/21/24, indicated, “ ... 1636 [4:36 pm]... Arrived...1741 [5:41 pm] ... Comprehensive metabolic panel [a routine blood test that measures 14 different substances found in blood] (Abnormal [not normal])... LDH, lactate dehydrogenase [blood test to check for tissue damage] (Abnormal)... type and screen [a set of tests that looks for harmful interactions between your blood and donor blood]... CBC and differential [blood test that measures components of blood] (Abnormal) ... Iron Panel- Iron + Transfusion + TIBC [total iron binding capacity] + Ferritin [protein found in blood that stores iron] (Abnormal) ... 2336 [11:36 pm] ... Transfuse Red Blood Cells (in mL up to 200 mL’s): 64mL ... 02/22 0141 [1:41 am] ... Transfuse Red Blood Cells (in mL up to 200 mL’s): 64mL ...” During a concurrent interview and record review on 4/23/24 at 12:30 p.m., with the Interim ED Clinical Manager (EDCM), Pt 1’s electronic medical record (EMR) was reviewed. The “ED Note- Physician (EN-P)” dated 2/21/24, indicated Pt 1 was a pediatric patient with a history of iron deficiency anemia who was referred to the ED by an urgent care clinic; brought in by parents for evaluation of anemia with 5.5 Hgb level and requesting an iron infusion. The record indicated Pt 1’s family noted that the patient was pale, otherwise acting normally. Pt 1 was triaged at 1:14 p.m. and Emergency Severity Index (ESI) of “3” was assigned. Pt 1’s vital signs (BP, HR, RR, T, and SpO2) at triage, were HR 130, RR 24, T 36.4 C (degrees Celsius) (37.5 degrees F), and SpO2 98%. No BP for Pt 1 was documented. Lab orders were placed on 2/21/24 at 1:26 p.m., for CBC, basic metabolic panel (BMP- blood test that measures fluid balance and electrolytes), iron level, transferrin (protein in blood the plays a role in iron metabolism), ferritin, iron binding (TIBC), and type and cross (type and screen), then cancelled on 2/21/24 at 2:01 p.m. Pt 1 was discharged to home on 2/21/24 at 1:58 p.m. with instructions to seek referral to pediatric hematologist (internal medicine doctors or pediatricians who have extra training in disorders related to blood) and iron infusion appointment. The EDCM stated based on the clinical presentation, Pt 1 “appeared stable” for discharge. The EDCM stated there was no way to prove Pt 1 had an actual 5.5 Hgb level because labs were cancelled and not drawn. The EDCM acknowledged Pt 1’s BP was not evaluated. The EDCM stated it was not the ED’s practice to obtain BPs on pediatric patients. During a concurrent interview and record review on 4/24/24 at 10:10 a.m., with Emergency Physician (MD 2), Pt 1’s medical record was reviewed. MD 2 stated on 2/21/24 at 1:21 p.m., she evaluated Pt 1 in Hospital A ED. MD 2 stated the “EN-P” indicated Pt 1 was a pediatric patient that presented to the ED on 2/21/24, with a Hgb 5.5 and family was requesting an iron infusion. MD 2 stated she could not recall if Pt 1’s family provided a prescription or if the family verbally reported the Hgb value. MD 2 stated she informed Pt 1’s family that iron infusions were not given in the ED. MD 2 stated she “offered” to have labs drawn but Pt 1’s family refused. MD 2 stated Pt 1 was awake, alert, and showed no signs of distress. Pt 1’s family reported Pt 1 was pale, but “my documented assessment did not indicate such.” MD 2 stated pediatric patients could not always express what bothered them and she relied heavily on family to reporting. However, based on her assessment documented in the “EN-P” , Pt 1 was interactive, appropriate, and “looked stable” despite Pt 1’s family reporting patient was pale and fatigued. MD 2 stated Pt 1 had a history of chronic (persistent) anemia which could be managed outpatient. MD 2 stated Pt 1’s vital signs were stable, and Pt 1 did not display symptoms of blood loss or distress. MD 2 stated Pt 1 was stable to be discharged home. MD 2 stated she did not need to evaluate Pt 1’s BP. MD 2 stated hospital practice was not to take blood pressures on pediatric patients. MD 2 stated Pt 1’s EMC did not warrant a consult with the pediatric hospitalist on call. MD 2 stated she could not recall if Pt 1’s family requested a blood or iron transfusion, but based on her documentation it appeared Pt 1’s family requested an iron transfusion. MD 2 stated she did not attempt to clarify this with Pt 1’s referring physician because Pt 1 “came from urgent care and when you call over there, you usually can’t get ahold of the person that sent them to the ED.” During a concurrent interview and record review on 4/24/24 at 10:25 a.m., with the Director of Emergency Services (DES) and PSO, Pt 1’s EMR was reviewed. The DES stated the EMR indicated Pt 1 came from urgent care for an iron transfusion. Pt 1 was assigned an ESI of 3 which was “appropriate- not urgent.” The DES stated Pt 1’s vital signs were stable, and Pt 1 presented with no active signs of bleeding or any other clinical symptoms other than the family stating Pt 1’s Hgb was 5.5. The DES stated Pt 1’s Hgb level “may have changed” and since lab work was refused, MD 2 could not validate the family reported Hgb level. The DES stated, “Can’t just go off of what is verbally reported.” The DES stated the ED did not perform iron transfusions and Pt 1 was appropriate for outpatient services. The DES stated Pt 1 was alert and interactive and vital signs were “normal” for her age. The DES stated a BP reading was not needed to determine if Pt 1 was stable for discharge. The DES stated hospital practice was not to take BPs on pediatric patients unless there was a clinical indication, according to Emergency Nurses Association (ENA- a professional organization that provides education and publishes professional guidelines for emergency nurses) professional standards for patients less than 10 years old. The DES stated Pt 1 “ appeared” healthy and was sent home with education on anemia and instructions to follow up with her PCP. During a concurrent interview and record review on 4/25/24 at 2:35 p.m., with Hospital A’s Pediatric Hospitalist (MD 3), MD 3 reviewed Pt 1’s medical record and a second record used as a comparison of care provided to pediatric patients of similar ages and chief complaint. MD 3 stated Pt 1 presented to the ED with a physician reported Hgb level of 5.5 which was half of what a normal Hgb level was for a child her age. MD 3 stated she considered 10 to 10.5 a “normal” Hgb for Pt 1. MD 3 stated Pt 1 had a history of chronic anemia and pallor would be an expected symptom. However, if Pt 1 experienced other symptoms in addition to pallor such as fatigue, low blood pressure, and tachycardia, then Pt 1 should have been looked at more closely because “most likely” Pt 1 required some type of intervention or blood transfusion. MD 3 stated a pediatric patient cannot always report or describe their symptoms. MD 3 stated Pt 1’s parent declined lab work but “I would have pushed for it.” MD 3 stated she was surprised to hear that Pt 1’s BP was not taken on 2/21/24, when Pt 1 presented to the ED with the low Hgb level. MD 3 stated, “Not sure what the practice of this ED is, but report of Hgb 5.5, BP should have been taken.” MD 3 stated the American Academy of Pediatrics (AAP- largest professional association of pediatricians in the United States) recommended to start taking BP readings on children at 2 years of age. MD 3 reviewed the PCP’s “After Visit Summary (AVS)” note, dated 2/21/24 at 11:30 a.m., that was presented to the ED by Pt 1’s parent. MD 3 stated the “AVS” note indicated Pt 1 was not tolerating oral iron, Hgb had been dropping, and Pt 1’s HR was148 during the PCP visit. MD 3 stated based on this note, hematology should have been contacted, regardless of whether labs were collected or the ED’s inability to provide an iron infusion. MD 3 stated for pediatric patients of Pt 1’s age, ED physicians should consult hematology or pediatrics for Hgb levels less than 6. MD 3 stated pediatric patients of Pt 1’s age with severe anemia and Hgb “that low” are at risk for stroke (a loss of blood flow to part of the brain, which damages brain tissue). MD 3 stated it would have been prudent to consult with a hematologist prior to discharging Pt 1. MD 3 then reviewed Pt 2’s medical record (comparison record). MD 3 stated Pt 2 was the same age as Pt 1 and presented to the ED with similar symptoms (low Hgb, pallor, and fatigue). MD 3 stated the medical care provided to the Pt 2 was “more appropriate.” During review of Pt 2’s “EN-P” dated 2/7/24 at 7:43 p.m., the “EN-P” indicated, “ ... CHIEF COMPLAINT: Mother states seen by PMP [primary medical physician] for blood work was called and told to be seen due to low HGB ... pt is pale hurts to walk and fatigues easily ... sent for possible anemia ...” During review of Pt 2’s “EN-P” dated 2/7/24 at 7:43 p.m., the “EN-P” indicated Pt 2’s vital signs taken on 2/7/24 at 8:46 p.m. were T 36.7degC (98.1 degrees F), HR 137, RR 26, BP 106/55, and spO2 100%. Pt 2’s BP was obtained during triage, physical re-evaluations, and upon discharge. During review of Pt 2’s “EN-P” dated 2/7/24 at 7:43 p.m., the “EN-P” indicated laboratory and diagnostic testing were collected on 2/7/23 at 9:27 p.m., as part of Pt 2’s medical screening exam. A CBC with differential (CBC with number of each type of white blood cell), Chem Panel (CMP- includes the same eight tests as a BMP, plus six more tests), Ammonia level (measures the amount of ammonia (NH3) in blood), TSH (test to diagnose a thyroid [gland that releases hormones] disorder), folate study (measure the concentration of folate [Vitamin B9] and vitamin B12) procalcitonin (measures a hormone specific for bacterial infections), B12 level (measures vitamin in blood), venous blood gases (measures oxygen and carbon dioxide in blood), coagulation studies (measures the ability of blood to clot), PT/ INR (measures how long blood takes to clot), fibrinogen (protein that helps blood to clot), D-dimer (checks for blood clotting problems), type and screen, hepatitis panel (checks for liver infections), ethanol level (a metabolite [a substance made or used when the body breaks down food, drugs, or own tissue] in blood) used when the body, chest x-ray (imaging test to look at structures of the chest), and ultrasound (imaging test that uses sound waves) of the abdomen were obtained as part of Pt 2’s ongoing examination and evaluations. Pt 2 was transferred via ambulance on 2/8/24 at 1:15 a.m., to Hospital B in stable condition. During an interview on 4/26/24 at 9:49 a.m., with ED Licensed Vocational Nurse (LVN) 2, LVN 2 stated his role in the ED was to assist registered nurses with patient management by medicating patients within his scope as an LVN, checking vital signs, and discharging patients. LVN 2 stated a complete set of vital signs included BP, HR, RR, T, and SpO2. LVN 2 stated vital signs were routinely checked in the ED and at discharge to ensure patients were stable during the ED visit and prior to going home. LVN 2 stated it was important to monitor BP because it provided information of how well a patient was perfusing (supply organs and tissues with blood). LVN 2 stated it was not necessary to check the BP of children less than 5 years of age if their “general appearance” was good. LVN 2 stated not checking the BP of children under 5 years was the routine practice in the ED. During a concurrent interview and record review on 4/26/24 at 10:20 a.m., with ED Registered Nurse (RN) 2, stated a complete set of vital signs included BP, HR, RR, SpO2, and T. RN 2 stated a BP should be checked on all patients, regardless of their age. RN 2 stated it was important to check BP to ensure effective output (volume of blood pumped). RN 2 reviewed Pt 1’s medical record and stated on 2/21/24, he triaged Pt 1. RN 2 stated Pt 1 came to the ED to be evaluated for low Hgb. RN 2 acknowledged no BP was documented for Pt 1. RN 2 stated Pt 1’s low Hgb warranted a BP to be taken, however Pt 1’s behavior was age appropriate, and Pt 1 was “moving, awake, tracking, and not lethargic [fatigue, drowsiness, sleepiness].” RN 2 stated Pt 1 appeared stable . During an interview on 4/26/24 at 11:10 a.m., with the Chief Executive Officer (CEO) and physician advisor (MD 4), the CEO stated a medical screening exam (MSE) was the ED provider’s initial assessment conducted to determine whether or not an EMC existed. The MSE continued until the ED provider determined the patient was stable for discharge. The CEO stated patient stability depended on whether or not the EMC was stabilized, or the patient was transferred to a higher level of care. The CEO stated Pt 1 was not stabilized when discharged on 2/21/24 from the ED. The CEO stated an appropriate MSE and patient stabilization could not have occurred without a complete set of vital signs (BP, HR, T, RR, SpO2). The CEO stated for a pediatric patient with a history of anemia and reported Hgb of 5.5, at minimum he expected a complete set of vital signs and orders for Hgb and hematocrit [volume of red blood cells] blood draw to ensure with certainty that Pt 1 was safe to be discharged home. The CEO stated the expectation was that a complete set of vital signs, including BP, were checked on every patient that came to the ED seeking emergent care and at discharge . A review of the professional reference from the Journal of Emergency Nursing titled “Pediatric Readiness in the Emergency Department,” dated 2018, indicated, “ ...This policy statement delineates the recommended resources necessary to prepare emergency departments (EDs) to care for pediatric patients ... These recommendations are intended to apply to all EDs that provide care for children ... the [American Academy of Pediatrics- largest professional association of pediatricians in the United States] AAP released the revised policy statement ... Policies, procedures, and protocols for the emergency care of children are age specific and include neonates, infants, children, adolescents, and children with special health care needs ... These include, but are not limited to, the following ... Documentation of a full set of pediatric vital signs, including core temperature, respiratory rate, pulse oximetry, heart rate, blood pressure (including manual confirmation), pain, and mental status when indicated ... All EDs must be continually prepared to receive, accurately assess, and, at a minimum, stabilize and safely transfer acutely ill or injured children ...” A review of the professional reference at https://publications.aap.org/pediatriccare/articleabstract/doi/10.1542/aap.ppcqr.396051/1543/Anemia-and-Pallor?redirectedFrom=fulltext titled “AAP Point of Care Quick Reference ... Anemia and Pallor,” dated 3/12/24, indicated, “ ... Anemia and pallor are clinical manifestations of an underlying disease process... Children younger than five years, women of reproductive age, and those in the older population are the groups who are most vulnerable for anemia... For diagnosis, initial workup will include complete blood cell count with differential, reticulocyte site count ... ferritin... other tests are performed as second tier tests to go further identify the etiology of anemia... early diagnosis and treatment of iron deficiency anemia is important to prevent permanent neurocognitive issues...” During a review of the “Pediatric Assessment, Recognition, and Stabilization (PEARS) Pediatric Reference Chart,” from the American Heart Association [Organization dedicated to fighting heart disease and stroke] and AAP, undated, indicated, “ ...Vital Signs in Children ... Normal Heart Rates (beats/min [minute])... Toddler... 98-140... Normal respiratory Rates (breathes/ min)... Toddler... 22-37... Normal Blood Pressure... Toddler (1-2 y [years])... Systolic Pressure [pressure in arteries when heart is contracting]... 86-106... Diastolic Pressure [pressure in arteries when heart is at rest] ... Toddler... 42-63... Primary Assessment... A rapid hands- on ABCDE approach to evaluate respiratory, cardiac [heart], and neurological [brain] function: this step includes assessment of vital signs...” 2. During a concurrent interview and record review on 4/25/24 at 10:40 a.m., with the EDCM, Pt 7’s EMR was reviewed. The EMR indicated Pt 7 was brought to the ED on 3/16/24 at 4:18 a.m., via ambulance with chief complaint head pain, hearing voices, chest pain (CP), and shortness of breath. Pt 7 was triaged at 4:33 a.m. and ESI of “2”- critical was assigned. Pt 7’s vital signs at triage were BP 138/87, HR 129, RR 20, T 36.6 C (37.9 F), and SpO2 95%. The ED Physician Assistant (PA 2) indicated in the “EN-P” note that Pt 7’s medical history included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and bipolar disorder (a mental health condition characterized by periodic, intense emotional states affecting a person’s mood, energy, and ability to function) who reported mild chest pain , difficulty breathing, and headache for two weeks. The Columbia- Suicide Severity Rating Scale (suicide risk assessment tool) completed on 3/16/24 at 4:33 a.m. indicated Pt 7 had a “behavioral complaint” and a full suicide screening (SI) assessment by a qualified medical professional (QMP) was indicated. The full SI assessment was not done, and Pt 7 was placed to wait in the ED lobby to wait for further testing. The EDCM stated labs, chest x-ray, and EKG were completed, however Pt 7 eloped from the ED before being evaluated by the ED physician. The EDCM stated the last documented contact with Pt 7 was on 3/16/24 at 5:55 a.m. Pt 7 was called for care on 3/16/24 at 6:10 a.m., 8:31a.m., and 8:50 a.m. with no response. The EDCM stated there was no documented evidence in Pt 7’s EMR to indicate Pt 7’s emergency contact, family, or local police department were contacted. The EDCM stated patients brought in by ambulance (BIBA) in psychiatric crises were placed in the main ED area so they could be supervised. The EDCM stated Pt 7 was inappropriately placed in the ED which contributed to his elopement. The EDCM stated the record did not indicate why Pt 7 was placed in the lobby to wait, however it was a safety concern. During review of Pt 7’s ambulance run sheet (medical record for ambulance services) document “Ambulance Report,” dated 3/16/24, the document indicated, “ ... arrived on scene to find a 46 y/o mail who was with his family in his front yard. Upon contact with the pt family reported him returning from walking in the middle of the night and report feeling as if her was being followed by people. His family reported recent behavior changes along with a Hx. [history] of underlying mental health problems. Pt reported a complaint of Asthma, CP/ abdominal pain, dehydration and being tired ... His family reported that they’d like to get him seen for behavioral changes ... Chief Complaint ... psych episode ... History of Present Illness ... Hx. Schizophrenia ...” During review of Pt 7’s “MICN [mobile intensive care nurse] Hospital Report Form” dated 3/16/24 at 4:08 a.m., indicated, “ ... Complaint ... Psychiatric episode; CP, abdopain [abdominal pain], asthma [respiratory condition that affects lung airways] ...” During review of Pt 7’The “ED-N” indicated Pt 7 “had been hearing voices in his head since young and the voices tell him to hurt other people. Pt on psychiatric medications (Brand name) ... I have reviewed the patient’s chief complaint... As well as completed a focused, limited exam and determined that he/ she is stable at this time. Labs and medications were ordered, but the patient will require further evaluation by the ED physician. The patient was moved to the waiting room per ED hospital staff protocol and will be given an ED bed upon availability. The patient is aware to notify staff if any symptoms change while waiting, as a patient’s status can deteriorate before they are able to receive an ED bed. The ED physician on staff will assume full care of this patient at this point... Electronically Signed [PA 2] 3/16/24 05:46 ... “ During review of Pt 7’s “History and Screening” document dated 3/16/24 at 4:33 a.m., indicated, “ ... BIBA [Brought in by Ambulance] HEAD PAIN AND HEARING VOICES ...” During a concurrent interview and record review on 4/24/24 at 10:25 a.m., with the Director of Emergency Services (DES) and PSO, the DES described the process for the flow of patients through the ED. The DES stated patients BIBA were triaged in the back between the main ED hallway and rapid patient management (RPM) area where a triage nurse entered the patients’ chief complaints and pertinent information. The triage nurse then assigned an ESI score 1-5 depending on patient acuity and patients were placed in different areas of the ED based on their needs and priority (ESI). The DES stated patients assigned ESI scores 1 or 2 were assessed as “critical or very ill” and per ED protocol, placed in the main ED rooms in the back. The DES stated all patients in psychiatric crises were assigned ESI 2 and placed in the main ED for supervision and safety. During concurrent interview and record review on 4/28/24 at 3:54 p.m., with PA 2, PA 2 reviewed Pt 7’s medical record. PA 2 stated she recalled evaluating Pt 7 on 3/16/24, in the ED. PA 2 stated during the MSE, Pt 7 indicated he was short of breath with mild CP for which she ordered labs, an EKG, and chest x-ray. PA 2 stated Pt 7 did not exhibit suicidal/ homicidal behaviors during his examination. PA 2 stated he had a history of “hearing voices to hurt others” but was on appropriate medications that treated psychiatric illness. PA 2 stated it was not communicated to her that Pt 7 exhibited psychiatric symptoms prior his arrival to the ED. PA 2 reviewed the ambulance run sheet for Pt 7’s visit to the ED on 3/16/24. PA 2 stated “this is very concerning.” PA 2 stated it was apparent Pt 7 had a psychiatric medical emergency that she did not identify during her MSE. PA 2 stated “many times EMS does not report” and often times there were huge disparities between how patients presented to the ED and what was reported. PA 2 stated she would have changed her assessment if she had the information listed in the run sheet beforehand. PA 2 stated she was aware of Pt 7’s responses in Columbia Suicide Severity Rating Scale (CSS-R , screening tool used to identify and assess individuals at risk for suicide) but did not follow up with Pt 7 after he was triaged. PA 2 stated she assumed Pt 7 “got care” because he fell off her provider screen. PA 2 stated Pt 7 was appropriately assigned an ESI 2 but could not recall why Pt 7 was placed in the ED main lobby. PA 2 stated she was not made aware that Pt 2 eloped on 3/16/24 from the hospital prior to being seen by the ED physician and stabilized for his psychiatric emergency. PA 2 stated Pt 7’s condition could have worsened and was at risk for harm to self or others. 3. During a review of Patient 8’s “Discharge Summary (DS)” dated 3/21/24, the DS indicated Patient 8’s, “ ...Visit Reason: Hyperglycemia (there’s too much sugar (glucose) in your blood. It’s also called high blood sugar or high blood glucose) - symptomatic; Dizziness, feeling tired, heart patient ... Arrival time: 8:58 a.m. Emergency Department (ED) Discharge Time: 11:36 a.m. ... Chief Complaint: c/o hyperglycemia throughout the night, cannot get it down and complaint of dizziness ... Major Tests and Procedures: ... Urine Screen ... Blood- Stat Collect (immediately) ... Emergency Department (ED) EKG- Stat ...”. During a review of Patient 8’s “ED Discharge Form (EDF)”, dated 3/21/24, the EDF indicated, “ ... (Hospital Name) Disposition: ED Disposition: Eloped ... 3/21/24 11:34 a.m. ...”. During a review of Patient 8’s “Flowsheet Laboratory (FL)”, dated 3/21/24, the FL indicated, “ ...Routine Chemistry: Sodium level 134 (L- low) ... Glucose Level 360 (H- high) ... Blood Urea Nitrogen (BUN- lab result in relation to kidney function) 31 (H) Creatinine level 1.73 (H- lab result in relation to kidney function) ...”. Requested document where staff called Patient 8 to see a provider at 10:02 a.m., 10:30 a.m. and 11:35 a.m. but was not provided. During a concurrent interview and record review on 4/24/24 at 10 a.m., with the Interim ED Clinical Manager (EDCM), Patient 8’s Electronic Medical Record (EMR) dated 3/21/24 was reviewed. The EMR indicated Patient 8 came for hyperglycemia and dizziness. The EDCM stated Patient 8 was triaged at 9:04 a.m. at an ESI of 2 and was placed in the lobby. The EDCM stated Patient 8 had his blood drawn and an EKG completed within ten minutes of triage. The EDCM stated staff called Patient 8 to see a provider at 10:02 a.m., 10:30 a.m. and 11:35 a.m. and he was discharged as eloped (a patient who is incapable of adequately protecting himself and who departs the health care facility unsupervised and undetected) at 11:34 a.m. The EDCM stated there was “nowhere in the chart” that showed any nurse, Physician or staff member attempted to contact Patient 8, his emergency contact or the police after he eloped. During an interview on 4/25/24 at 11:30 a.m., with the Director of Emergency Services (DES), the DES stated staff should have tried to contact Patient 8, or their emergency contact and notify charge nurse. During an interview on 4/28/24 at 8 p.m., with ED Triage Registered Nurse (RN) 1, RN 1 stated if a patient had left with abnormal lab values, that patient should have been contacted immediately by staff. RN 1 stated when a patient elopes the nurse was to call the emergency contact and a possible wellness check from the police department. RN 1 stated she would have also told the charge nurse the situation. During an interview on 4/28/24 at 8 p.m., with the ED Triage Physician Assistant (PA) 1, PA 1 stated staff needed to contact the patient or emergency contact. PA 1 stated staff should have attempted the contact at least twice, thirty minutes apart and left a message. PA 1 stated that the patient could have deteriorated, and their condition could have gotten worse. PA 1 stated the hospital should have done their due diligence. Interview requested with Registered Nurse involved with Patient 8 and the Hospital was unable to locate her. Interview requested with ED Physician who was involved with Patient 8, and he did not work for the Hospital anymore; he was unable to be located. During a review of the hospital’s policy and procedure (P&P) titled “EMTALA”, dated 1/12/24, indicated, “ ... the purpose of this policy is to set forth policies and procedures for Hospital’s use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA) ... “Emergency Medical Condition” means ... a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in either ... Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or ... Serious impairment to bodily functions, or ... Serious dysfunction of any bodily organ or part ... “ Medical Screening Exam” or “MSE” means the screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist ... With respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer or discharge of the individual from the hospital ... the hospital will provide an appropriate medical screening examination within the capability of the Hospital’s Dedicated Emergency Department, including ancillary services routinely available, to determine whether or not an emergency medical condition exists; and The Hospital will ... provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to stabilize the emergency medical condition, or ... arrange for transfer of the individual to another medical facility in accordance with the procedures set forth ...” Requested policy and procedure for Elopement, but the facility could not provide. Requested policy and procedure for “Care of the Pediatric Patient in the ED”, but the facility could not provide.”