Hoag Memorial Hospital Presbyterian

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff had evaluated the nursing care for one of eight sampled patients (Patient 3) as evidenced by: 1. The pain assessment was not performed as per the hospital’s P&P. 2. The nursing assessment in L&D unit was not performed as per the hospital’s P&P. These failures had the potential for unsafe care to the patient. Findings: On 7/30/26, Patient 3’s medical record was reviewed. Patient 3’s medical record showed Patient 3 was admitted to the hospital on 8/1/26 and was discharged on 8/5/26. 1. Review of the hospital’s P&P titled Pain Management dated 10/21/24, showed attempts should be made to obtain self-report of pain from all patients. When self-report is absent or limited, explain why self-report cannot be used and further investigation and observation are needed. Character of pain (pain characteristics), intensity, location, duration, precipitating factors, alleviating factors (pain relief), and goal for pain relief is assessed with each change in care giver and with changes in the location of pain and type of pain. Review of the Labor & Delivery Timeline dated 8/2/26 at 0012 hours, showed Patient 3 reported pain at uterine cramping/contractions seven out of 10 (zero being no pain and 10 being the worst pain). However, further medical record failed to show pain characteristics, intensity, duration, precipitating factors, pain relief, and goal for pain relief. 2. Review of the hospital’s P&P titled Vaginal Delivery Bed Placement dated 7/8/24, showed the initial physical assessment of the patient and review of patient history is performed within two hours of admission to determine maternal or newborn risk or risk factors. Review of the Labor & Delivery Timeline dated 8/2/26 at 0049 hours, showed to admit Patient 3 to L&D unit. On 7/3/26 at 0950 hours, an interview and concurrent medical record was conducted the Director L&D with Director of Nursing in the presence of the Senior Principal, Regulatory Compliance and Corporate Facilities and Accreditation and Regulatory Compliance Manager. The Director L&D stated the Admission Navigator was part of nursing admission assessment. Review of the Labor & Delivery Timeline dated 8/2/26 at 0315 hours, showed the Admission Navigator was performed (two hours and 26 minutes after the admission order) On 7/31/26 at 1115 hours, the Director L&D and the Director of Nursing acknowledged the above findings.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the medication was administered for one of eight sampled patients (Patient 3) as per the physician’s order. This failure created the risk of medication errors and poor health outcomes to the patient. Findings: Review of the hospital’s P&P titled Pain Management dated 10/21/24, showed pain should be assessed within two hours of admission, change in caregiver, condition, or location/description. Patients have a right to receive an initial pain assessment, on-going evaluation, treatment, pain relief and education. On 7/30/26, Patient 3’s medical record was reviewed. Patient 3’s medical record showed Patient 3 was admitted to the hospital on 8/1/26 and was discharged on 8/5/26. Review of the physician’s order dated 8/2/26 at 0004 hours, showed to administer fentanyl (a pain medication) injection 50 to 100 mcg IV every one hour as needed for severe pain (7-10). Review of the Labor & Delivery Timeline dated 8/2/26 at 0012 hours, showed Patient 3 reported pain at uterine cramping/contractions with the pain level of seven out of 10 (zero being no pain and 10 being the worst pain). However, acetaminophen (a pain medication) 650 mg was administered at 0302 hours (two hours and 50 minutes later). In addition, the MAR showed the acetaminophen was for zero to three of pain level and “may given only after the delivery.” Patient 3’s baby was born at 0348 hours. On 7/31/26 at 1115 hours, the Director L&D and Director of Nursing verified the above findings.”

“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: 36703 Based on interview and record review, the hospital failed to ensure a thorough grievance investigation for one of eight sampled patient (Patient 2), including failure to review all allegations identified by the patient before issuing the resolution letter. This failure resulted in an incomplete grievance review and created a risk that the patient’s concerns were not fully addressed. Findings: During a review of the hospital’s P&P titled “Patient Complaints and Grievances,” dated 6/4/25, the P&P showed it is the responsibility of the Department Director or designee to review and evaluate all the grievances from a patient related to issues within the scope of responsibility and initiate appropriate action to investigate and resolve the grievance. During a concurrent interview and record review on 6/24/26 at 1124 hours, with the Senior Principal of Risk Management and the Senior Principal of Regulatory Compliance and Corporate Facilities, Patient 2’s internal reporting record was reviewed. The hospital internal reporting system showed Patient 2’s grievance was received and entered into the system on 3/12/26. The system also showed that the hospital issued a resolution letter to Patient 2 on 3/23/26. During a concurrent interview and record review on 6/24/26 at 1124 hours, with the Senior Principal of Risk Management and the Senior Principal of Regulatory Compliance and Corporate Facilities, the grievance documentation showed an allegation the medical record was falsified, was not entered into the grievance tracking system or investigated prior to issuing the resolution letter. The Senior Principal of Risk Management stated they were unaware of the allegation and confirmed it was not investigated. The Senior Principal of Risk Management and the Senior Principal of Regulatory Compliance and Corporate Facilities acknowledged the above findings.”

“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: 37663 Based on interview and record review the hospital failed to ensure the 75 minutes goal for a C-section basis was met to bring a patient to the operation room for a C-section delivery for one of eight sampled patients (Patient 1). This failure posed an increased risk of substandard health outcomes for the patient. Findings: During a concurrent interview and Patient 1’s record review on 6/23/26 at 0954 hours, with the Director Post Partum, the Director L&D, and the Patient Safety Program Manager. Review of Patient 1’s medical record showed the patient was admitted to the hospital on 9/5/25. During a review of the H&P dated 9/5/25 at 0614 hours, the H&P showed Patient 1 was pregnant at 39 weeks 0 days with an estimated date of delivery of 9/12/25. Patient 1 presented with a chief complaint of leaking fluid, occasional contractions, and normal fetal movement. The plan was to admit Patient 1 to the Operation Room for a Low Transverse Cesarean Section. During a review of the Labor & Delivery Timeline for Patent 1, the Labor & Delivery Timeline showed Patient 1 arrived at the hospital on 9/5/2025 at 0455 hours with rupture membrane (BOW). At 0500 hours, the decision for caesarian delivery was made. During a review of the Delivery Summary Audit Trail dated 9/5/25, the Delivery Summary Audit Trail showed the decision time for an emergent C-section was at 0500 hours, and at 0617 hours the C-section classification was III-A, for which the goal was within 75 minutes. During an interview on 6/23/26 at 0954 hours, with the Executive Director Maternal Child, the Director Post Partum, and the Director L&D, the Executive Director Maternal Child stated the goal time from decision to perform but he was sighting about jumping up or getting over. a C-section to the patient being in the operation room was 75 minutes. However, the decision for C-section was at 0500 hours and the patient was in the operation room at 0621 hours (6 minutes late). The Executive Director Maternal Child, the Director the L&D, and the Director Post Partum, the Executive Director Maternal Child, Director of L&D, Director of Post Partum verified the above findings.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 29558 Based on interview and record review, the hospital failed to ensure the Obstetrics physician’s documentation was accurate and completed for one of eight sampled patients (Patient 1). This posed a risk of incomplete medical record documentation for the patient. Findings: During a review of the hospital’s Rules and Regulations of the Medical Staff dated July 2025, the Rules and Regulations of the Medical Staff showed the section of 2.8 Invasive/Surgical showing for those procedures requiring sedation or anesthesia, a completed operative/procedural report is to be dictated or entered electronically into the patient’s medical record immediately after a surgery or invasive procedure. An interview and Patient 1’s record review was conducted on 6/23/26 at 0954 hours, with the Director Post Partum, the Director L&D, and the Patient Safety Program Manager. Review of Patient 1’s medical record showed the patient was admitted to the hospital on 9/5/25. During a review of the H&P dated 9/5/25 at 0614 hours, the H&P showed Patient 1 was pregnant at 39 weeks 0 days with an estimated date of delivery of 9/12/25. Patient 1 presented with a chief complaint of leaking fluid and occasional contraction, with normal fetal movement. The plan was to admit Patient 1 to the operation room for a low transverse cesarean section. Review of Case Information showed the incision/case was started on 9/5/25 at 0656 hours, and finished at 0710 hours. During a review of the Operative Report, the Operative Report did not show documentation the OB MD performed a bimanual vaginal examination after the infant was delivered. However, during a telephone interview with the OB MD on 6/23/26 at 1216 hours, the OB MD verified the bimanual vaginal examination was performed as a standard post-partum examination for c section after the patient delivered to reduce post-partum bleeding. During an interview with the Director L&D on 6/23/26 at 1320 hours, the Director L&D verified the above findings.”

“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: 35310 Intakes: CA00991099, CA00991230 Based on interview and record review, the hospital failed to implement its P&P for suspected child abuse and late entry documentation for one of six sampled patients (Patient 1). These failures had the potential to result in unsafe care and poor clinical outcomes for the patient. Findings: 1. During a review of the hospital’s P&P titled “Abuse Reporting,” dated 12/14/25, the P&P showed the following: “...3. Reporting Requirements for Suspected Child Abuse: A. The mandated reporter who is responsible for reporting the alleged child abuse will immediately or, as soon as practical, call the Orange County Child Abuse Registry. B. The mandated reporter that filed the abuse report will complete the Suspected Child Abuse Form and fax within 36 hours. Include cover sheet with confidentiality statement for faxed reports. Fax report to the number provided by the CPS hot-line...” During a review of Patient 1’s medical record on 4/21/26, Patient 1’s medical record showed Patient 1 arrived to the ED on 10/30/25 at 0933 hours and left the ED at 1119 hours. During a review of the ED Blank Note Addendum showed “11/22/25 1017 Addendum to 10/30/25:” The ED Blank Note Addendum showed after discussion with both the PA and Charge RN, RN 5 decided to contact the law enforcement as well as fax a report due to the concerns for abuse. During a review of Patient 1’s medical record, the medical record failed to show evidence the suspected abuse was reported to Orange County Child Abuse Registry, as required by the hospital’s P&P. 2. During a review of the hospital’s P&P titled “Medical Record Documentation,” dated 2/9/24, the P&P showed under E. Addition, Alterations, and Corrections: late and out-of-sequence entries should be clearly identified as such, with the date and time of the entry, as well as the date and time of occurrence (e.g., 4/3/2020 charting for 4/1/2020). During a review of Patient 1’s medical records on 4/21/26, the medical record showed Patient 1 arrived to the ED on 10/30/25 at 0933 hours and left the ED at 1119 hours. Review of the Emergency Department History and Physical dated 10/30/25, showed the Emergency Department History and Physical was signed by the PA on 10/30/25 at 1900 hours. Further review of the medical record showed the same documentation was signed by the PA on 11/25/25 at 1018 hours. Review of the Emergency Department History and Physical edited on 10/30/25 at 1956 hours, and again on 11/25/25 at 1018 hours, showed the entry dated 11/25/25 at 1018 hours, contained additional information. The late entry documentation did not identify the 11/25/25, note as a late entry, contrary to policy requirements. During an interview on 4/22/26 at 1130 hours, with the Senior Principal, Regulatory Compliance and Corporate Facilities and Accreditation and Regulatory Compliance Manager, they acknowledged the above findings.”

“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: 38660 Based on interview and record review, the hospital failed to ensure the nursing staff implemented its P&P for pain management for one of four sampled patients (Patient 2). The nursing did not provide non-medical interventions, reassess a 10/10 pain level (on the 0-10 pain scale, zero = no pain and 10 = the most severe pain), or notify the physician for pain medication for Patient 2. This failure resulted in delay in pain relief and negatively impacted the patient’s health and caused anxiety. Findings: During a review of the hospital’s P&P titled, “Pain management,” dated 10/21/24, the P&P showed: * Patients have the right for appropriated assessment and management of pain, information about pain, pain relief measures and to participate in pain management decisions. * RN will assess the patient at the beginning of each shift and document the pain assessment. The assessment of pain includes the patient’s self-reported pain level, physical or behavioral symptoms of pain, vital signs, conditions known to cause pain for this patient and patient’s history of pain and interventions used to alleviate the pain. * Based on the above assessment, the RN begins to formulate a plan of care to alleviate the patient’s pain. Non-medical forms of treatment may be utilized e.g., back rub, position change, dimming lights, music, etc. Pain may not only be caused by physical aspects but others as wee. Therefore, pain management methods should be taken into consideration and address the physical, emotional, psychological, behavioral, cultural, spiritual, and social situations. * If non- medical measures do not adequately alleviate the patient’s pain, the RN may utilize pain medication ordered by the patient’s provider/ Licensed Independent Provider (LIP). If no pain medication is ordered, the RN can notify the Provider/LIP of patient’s pain and receive medication order for the patient. The RN then assigns a premedication assessment number value (0-10) to the patient’s pain and documents that on the Pain/Comfort/Sleep portion of the Adult Flowsheet. The RN administers the prescribed medication to the patient. During a review of the hospital’s P&P titled, “Emergency Department Triage,” dated 3/5/24, the P&P showed * The purpose of the policy is to facilitate the process of triage for Emergency Department patients using Emergency Severity Index (ESI) method. * ESI: Emergency Severity Index-A five-level tool used as a guide to prioritize the care of patients within the emergency department based on acuity and estimated resources needed. * Triage Assessment: RN to perform a brief assessment and screening for life-threatening conditions related to airway, breathing, circulation, and disability. An ESI criteria will be utilized to assign an acuity level depending on severity and resource needs. * Reassessment: while waiting for a treatment space to become available, ED lobby patients will have a reassessment every four hours to include: Patient condition as it relates to the chief complaint; a complete set of vital signs to be performed at a minimum every four hours and may be delegated to an Emergency Care Technician (ECT) to complete; vital signs for adult and pediatric patients will be performed according to ESI tables in Appendix A. - Temperature - Pulse rate - Blood pressure - Pulse oximetry - Respiratory rate - Pain Scale (if no pain, enter zero) - Non-verbal pain-scale can be used to obtain number for pain as appropriate * Reassessments may be more frequently based on the patient presentation, changes in condition, medication/treatment provided, and nursing judgment. During a review of “Appendix A: ESI Triage Algorithm,” the ESI Triage Algorithm showed * If it is a high-risk situation or if the patient is confused/lethargic/disoriented or severe pain/distress, the ESI level is 2. If there are no high-risk vital signs, the acuity level will be 3, 4, or 5. * High-risk situation: may become unstable, have high risk for deterioration, or exhibit newly altered mental status. Severe pain or distress is determined by patient reports, corroborated with clinical observation. * High-risk vital signs: reassess to determine whether the patient warrants a higher acuity level if a patient has one or more vital signs outside the normal parameters for the patient. During a concurrent review of Patient 2’s medical record on 12/18/25 at 0900 hours, with the Senior Principal, Regulatory Compliance and Corporate Facilities and the Accreditation and Regulatory Compliance Quality Management, Patient 2’s medical record showed Patient 2 came to the hospital ED on 10/16/25 at 1234 hours, with a complaint of chest wall pain and anxiety. During a review of Patient Care Timeline dated 10/16/25, the Patient Care Timeline showed Patient 2 was seen in Triage room at 1237 hours, with a chief complaint of chest wall pain and anxiety; Patient 2 was tearful, stated pain throughout her body. The Vitals and Pain Assessment section showed at 1240 hours, Patient 2 had constant generalized pain with a pain level of 10/10, BP of 140/96 mmHg, heart rate of 93 bpm, respiratory rate of 18 breaths per minute. At 1242 hours, the patient was assigned with the acuity level 3. At 1242 hours, the PA ordered a Chest X-ray, ECG, and laboratory tests. And Patient 2 returned to the lobby waiting. During a review of the ED Provider Notes dated 10/16/25 at 1452 hours, the ED Provider Notes showed Patient 2 presented to the ED for acute chronic full body pain for three days. Patient 2 complained of stabbing pains which the patient stated the patient experienced with loud sounds. The patient was tearful during the interview. Review of the Patient Care Timeline dated 10/16/25 at 1442 hours, the Patient Care Timeline showed Patient 2 moved to an ED room and assigned to RN 4. At 1500 hours, the physician ordered NS (normal saline, an IV solution) bolus, acetaminophen (analgesic and antipyretic drug) IVPB 1000 mg, ketorolac (nonsteroidal anti-inflammatory drug) injection 15 mg, famotidine (acid reflux reduction) injection 20 mg. At 1606 hours, a pain assessment showed Patient 2 had generalized pain with a pain level of 9/10. Ketorolac injection 15 mg and acetaminophen were administered. During a concurrent interview and review of Patient 2’s medical record on 12/23/25 at 0824 hours, with RN 5 and ED Director 2, Patient 2’s medical record was reviewed. The patient’s medical record showed Patient 2 had a pain level of 10/10 and waited three hours and 29 minutes before receiving pain medications. RN 5 stated reassessments depended on patient acuity and pain should be addressed in real time. RN 5 stated the provider in triage (PIT) was a PA who assisted patients in the lobby for pain management, especially during busy mornings. RN 5 stated, once a patient was transferred from the lobby to a room, the primary nurse and physician would take over, and 90% of physician orders are made in triage, and oral medication could start there. RN 5 further stated that when a patient was moved to the ED room, the nurse could track their location by receiving texts, assigning them to a room, or viewing the track board. The nurse would greet the patient within five minutes, ensure they had a call lights, then return to caring for a critical patient if needed, and check back later. RN 5 stated the nurse adjusted care based on nursing judgment rather than tying it to vital signs. ED Director 2 stated the nurse did not have a specific time frame to see patients for each acuity level. ED Director 2 acknowledged Patient 2 waited three hours and 29 minutes for their 10/10 pain to be addressed and to receive medications. During a concurrent interview and review of Patient 2’s medical record on 12/23/25 at 1124 hours, with the Senior Principal, Regulatory Compliance and Corporate Facilities, the Senior Principal, Regulatory Compliance and Corporate Facilities confirmed Patient 2 had a pain level of 10/10, and the nurse did not provide any non-medical intervention or called the physician to address the pain for Patient 2 according to the hospital’s P&P.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the admitting assessment was performed for one of two sampled patients (Patient 2) as per the hospital’s P&P, creating a risk of substandard care. Findings: Review of the hospital’s P&P titled Admitting Assessment dated 3/8/24, showed admit-arrival navigator in the hospital’s EHR documentation is initiated for all inpatient admissions (critical care, med-surg, adolescents 16 years old and over) within 2 hours of arrival on the unit and documented in four hours. Review of the hospital’s P&P titled Fall Prevention and Management dated 10/2/24, showed the following: * The purpose of the P&P is to maintain a safe environment for inpatients and outpatients, the fall prevention procedure is intended to increase awareness and identify patients who are at risk of falling. * Patient will be assessed for fall risk on admission/transfer to another unit. On 7/28/25, Patient 2’s open medical record was reviewed with the Patient Relations. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 7/28/25 at 0640 hours. The Patient Relations showed Patient 2’s nursing assessment on 7/28/25 at 1330 hours. There was no documented admitting assessment. On 7/28/25 at 1415 hours, the Sr. Principle Regulatory Compliance and Corporate Facilities verified the above findings.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 35310 Based on observation, interview, and record review, the hospital failed to ensure the medication was administered as per the hospital’s P&P for one of two sampled patients (Patient 2), creating the risk of medication errors and poor health outcomes to the patient. Findings: Review of the hospital’s P&P titled Medication Administration dated 10/24/23, showed unless the administration is time critical, scheduled medications shall be administered no more than 60 minutes before and 60 minutes after its computer scheduled time. On 7/28/25 at 1110 hours, RN 1 was observed administering aspirin (a medication used to treat pain, reduce fever, and treat or prevent heart attack or stroke) 81 mg 1 tablet by mouth to Patient 2. On 7/28/25, Patient 2’s open medical record was reviewed with Patient Relations. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 7/28/25. Review of the Summary showed Patient 2 arrived on the unit on 7/28/25 at 0709 hours. Review of the Physician’s Order dated 7/28/25 at 0640 hours, showed: - Aspirin chewable tablet 81 mg - Scheduled Start Date/Time: 7/28/25 at 0900 hours - “First Dose: As Scheduled” At 0647 hours, the medication order was acknowledged by the nurse. On 7/28/25 at 1415 hours, the Sr. Principle Regulatory Compliance and Corporate Facilities verified the above findings.”

“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: 35310 Based on interview and record review, the hospital failed to ensure the weight was measured as per the hospital’s P&P and physician’s order for two of three sampled patients (Patients 1 and 2). This failure had the potential to result in unsafe care and poor clinical outcomes to the patient. Findings: Review of the hospital’s P&P titled Weighing the Patient dated 8/9/22, showed all patients will be weighed on admission. 1. On 4/24/25, Patient 1’s closed medical record was reviewed with the Accreditation and Regulatory Compliance Supervisor in the presence of the Sr. Principle Regulatory Compliance and Corporate Facilities. Patient 1’s medical record showed the following: * Patient 1 was admitted to the ICU on 2/25/25 and was transferred to the Medical-Surgical-Telemetry unit on 3/3/25. * Patient 1 was transferred to the ICU on 3/4/25. * Patient 1 was admitted to the ARU on 3/8/25 and was transferred to the ICU on 3/31/25. * Patient 1 was discharged on 4/23/25. Review of the Physician’s Order dated 2/25/25 at 1633 hours, showed to weigh Patient 1 daily. Review of the Physician’s Order dated 3/8/25 at 1350 hours, showed to weigh Patient 1 on admission to the ARU. Review of the Weights documentation showed Patient 1 was not weighed daily as per the physician’s order. The Weights documentation showed Patient 1 was weighed on 2/25, 2/26, 3/1, 3/2, 3/3, 3/4, 3/5, 3/10, 3/16, 3/27, and 3/31/25. 2. On 4/24/25, Patient 2’s medical record was reviewed with the Accreditation and Regulatory Compliance Supervisor in the presence of the Sr. Principle Regulatory Compliance and Corporate Facilities. Patient 2’s medical record showed Patient 2 was admitted on 4/8/25. Review of the Weights documentation showed Patient 2 was not weighed upon admission on 4/8/25. The first weight measurement documented, was on 4/10/25 (two days after the admission). On 4/24/25 at 1550 hours, the Accreditation and Regulatory Compliance Supervisor and Sr. Principle Regulatory Compliance and Corporate Facilities verified the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the discontinuation of the restraint was documented for one of three sampled patients (Patient 3). This failure posed the risk of substandard outcomes to the patient. Findings: Review of the hospital’s P&P titled Use of Restraints and Restraint Reduction dated 10/4/24, showed RESTRAINT DOCUMENTATION...the following must be documented in the electronic health record (EHR): * A description of the patient’s behavior and the intervention used... * The reason for early removal (if applicable). On 4/24/25, Patient 3’s closed medical record was reviewed. Patient 3’s closed medical record showed Patient 3 was admitted to the hospital on 2/28/25. Review of the Physician’s Order for restraints violent or self-destructive adult dated 3/1/25 at 0001 hours, showed to apply hard restraints to the right and left wrists and to the right and left ankles. Review of the Emergency Department History and Physical dated 2/28/25, showed the ED physician performed the face-to-face assessment on 3/1/25 at 0003 hours. Review of the Nursing Flowsheets under Restraint Type dated 3/1/25, showed the restraints were initiated at 0001 hours and continued at 0100 and 0200 hours. Review of the medical record did not show documentation when the hard restrains were discontinued. On 4/24/25 at 1550 hours, the Accreditation and Regulatory Compliance Supervisor and Sr. Principle Regulatory Compliance and Corporate Facilities verified the above findings.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the pain reassessment and management for one of nine sampled patients (Patient 5) was conducted as per the hospital’s P&P. This failure had the potential for unsafe care to the patient. Findings: Review of the hospital’s P&P titled Pain Management dated 10/21/24, showed the following: * Interventions for Pain Relief: - Non-pharmacological interventions include but are not limited to the following examples: 1. Turning or repositioning 2. Cold or heat application which is hospital approved - Pharmacological interventions * Documentation: - Documentation of pre and post medication administration is done on the Pain/Comfort/Sleep portion of the Flowsheet in the EHR. A number value of 0-10 based on the patient’s self-evaluation and/or the RN’s evaluation of all variables is used. - Document pain level (if self-report) or APP (if unable to self-report) prior to administration of analgesic. Document re-assessment or self-report pain level after designated timeframe. On 2/6/25 at 0907 hours, Patient 5’s closed medical record was reviewed with Nursing Director 1 in the presence of the Accreditation and Regulatory Compliance Supervisor. Patient 5’s closed medical record showed Patient 5 was admitted to the hospital on 12/3/24 and discharged on 12/5/24. Review of the flowsheets for the pain and medication administration records showed the following: * On 12/4/24 at 0802 hours, Patient 5 complained of pain eight out of 10 (on a 0 to 10 pain scale, 0 being no pain and 10 being the worst pain). Patient 5 received Dilaudid (a pain medication) 0.4 mg IVP at 0802 hours. Further review of Patient 5’s the medical record showed on 12/4/24 at 0832 hours, “pain reduced.” However, there was no documented evidence showing the patient’s pain level as per the hospital’s P&P. * On 12/4/24 at 1139 hours, Patient 5 complained of pain five out of 10. Patient 5 received tramadol (a pain medication) 50 mg by mouth at 1139 hours. At 1239 hours, Patient 5 reported the pain intervention was not effective. * On 12/4/24 at 1348 hours, Patient 5 complained of pain eight out of 10. Patient 5 received Dilaudid 0.4 mg IVP at 1348 hours. Further review of Patient 5’s medical record showed on 12/4/24 at 1418 hours, “pain reduced interventions effective.” However, there was no documented evidence showing the patient’s pain level as per the hospital’s P&P. When asked, Nursing Director 1 stated Dilaudid 0.4 mg was ordered to administer to the patient every two hours as needed. Patient 5 received Dilaudid 0.4 mg on 12/4/24 at 0802 and 1348 hours. Further review of Patient 5’s medical record failed to show any pain intervention provided to the patient when Patient 5 reported the pain intervention was not effective for one hour nine minutes. The Accreditation and Regulatory Compliance Supervisor and Nursing Director 1 verified the above findings.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure the ED nursing staff provided the pain medication to one of nine sampled patients (Patient 1) as ordered by the physician, creating the risk of unrelieved pain for the patient and substandard outcomes. Findings: Review of the hospital’s P&P titled Emergency Department: Patient Assessment, and Reassessment dated 9/17/24, showed the purpose of the P&P is to guide the RN with assessing and documenting the primary assessment, secondary assessment, and reassessments of ED patients. It serves to provide a patient data base for the identification of patient chief complaints, plan of care, documentation of nursing interventions, and evaluation of the care given. The primary RN who assumes care will perform complaint-based assessments and reassessments throughout the patient stay. On 2/5/25 at 1021 hours, Patient 1’s closed medical record was initiated with the Sr. Principle Regulatory Compliance and Corporate Facilities. Patient 1’s closed medical record showed Patient 1 visited the ED on 1/4/25, was admitted to the hospital and discharged on 1/5/25. Review of the Patient Care Timeline showed Patient 1 arrived to the ED on 1/4/25 at 1217 hours. At 1241 hours, the patient reported increased flank pain and fever. By 1243 hours, a pain assessment recorded a numeric pain score of 10 out of 10 with the patient describing constant, sharp pain in the bilateral back. Review of the physician’s order dated 1/4/25 at 1600 hours, showed to administer morphine (a pain medication) 4 mg/ ml IV every 20 minutes for severe pain (7-10) and to discontinue at 1949 hours after two doses. Review of the Pain Monitoring assessments and the MAR showed Patient 1 reported severe pain; however, the morphine was not administered to the patient as ordered. For example: - On 2/4/25 at 1700 hours, Patient 1 stated a pain level of seven out of 10 (or severe pain). Morphine was not administered, and no additional interventions to address the pain was documented. - At 1816 hours, Patient 1 stated a pain level of 10 out of 10 (or severe pain) and was administered 4 mg morphine IV. - At 1854 hours, Patient 1 stated a pain level of 8 out of 10 (or severe pain). However, morphine was not administered and no additional interventions to address the pain was documented. - At 1949 hours, Patient 1 stated a pain level of eight out of 10 (or severe pain). Morphine 4 mg IV was administered to the patient. On 2/6/25 at 1004 hours, the above findings were shared with the Sr. Principle Regulatory Compliance and Corporate Facilities.”

“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: 38660 Based on interview and record review, the hospital failed to ensure the patient’s family member was informed when one of five sampled patients (Patient 1) was admitted to the hospital, coded, and expired for as per the hospital’s P&P. This failure posed the risk of the patient’s family member not being involved in decision-making process for the patient care. Findings: Review of the hospital’s P&P titled Code Blue dated 2/11/22, showed the Responsibility of Staff to Code Blue section showing the following: - Code Team Lead Physician: functions as the code team leader, clearly delegates tasks to the Code Blue team, manages the airway, orders medications and ancillary testing, communicates with the patient’s attending and family members as indicated, and debriefs with the Code Blue team members as soon after the code as feasible possible based on patient needs. - Nursing House Supervisor: maintains crowd control, cares and notifies the patient’s family, facilitates in patient transfer as applicable, and ensures a staff person is assigned to remain with family member who desires to be present during the code. - Pastoral Care or Social Work: responds if available, provide support to families of patients either directly or indirectly involved with Code Blue. Review of the hospital’s P&P titled Handling of Expired Patient and Property dated 4/12/22, showed the purpose is to establish a procedure and consistent guidelines for the proper management of an expired patient and his or her personal property. All expirations require pronouncement of death by a physician or authorized Department Director/Charge Nurse/Nursing Supervisor/RN. The hours of death will be the time of the official pronouncement. The physician should contact the next-of-kin. On 12/30/24, review of Patient 1’s closed medical record was conducted with the Accreditation and Regulatory Compliance Supervisor. Review of the Emergency Department History and Physical dated 1/19/24 at 0227 hours, showed Patient 1 was brought to the ED on 1/19/24, with cardiac arrest. Patient 1 arrived to the ED and was intubated with CPR in progress. The CPR was resumed in the ED. Review of the Patient Care Timeline dated 1/19/24, showed Patient 1 had survived at 0258 hours. Review of the Emergency Department History and Physical dated 1/19/24 at 0227 hours, showed Patient 1 was admitted to ICU from the ED at 0516 hours. Review of the Critical Care Communication Progress Note dated 1/19/24 at 0410 hours, showed to continue full code. Patient 1 was unresponsive. Patient 1’s family member was unavailable. Review of the Critical Care Communication Progress Note dated 1/19/24 at 0643 hours, showed Patient 1 was unstable and likely to have another cardiac arrest. Patient 1’s pupils were fixed and dilated. Patient 1 was unresponsive and off sedation. Patient 1 would be made DNR as it would be medically futile, and the medical staff was unable to reverse the causes. No family contact information was available at that time. Review of Critical Care Death Pronouncement Note dated 1/19/24 at 0705 hours, showed Patient 1’s time of death occurred on 1/19/24 at 0703 hours. Review of the nurse’s End of Shift Summary dated 1/19/24 at 0739 hours, showed Patient 1 continued to decline. The intensivist changed Patient 1’s code status to DNR. Patient 1 became asystolic. The intensivist was at bedside. Patient 1’s family member was unable to reach. Review of the LCSW note dated 1/19/24 at 0856 hours, showed the LCSW located the number for the next-of-kin. The LCSW located four phone numbers listed in Patient 1’s previous record, possibly from Patient 1’s family members. The LCSW updated the Charge RN and RN with these phone numbers. Further review of Patient 1’s medical record showed no documented evidence showing Patient 1’s family member was notified during the resuscitation, after the resuscitation, and when Patient 1 expired on 1/19/24. On 12/30/24 at 1402 hours, an interview and concurrent review of Patient 1’s closed medical record was conducted with the LCSW. When asked about the process of notifying a patient’s family member, the LCSW stated she searched for Patient 1’s next-of kin, found the contact numbers of Patient 1’s family members, and provided them to the RN and Charge RN. When asked who would contact the patient’s family member at night, the LCSW stated the House Supervisor, the physician, or the nurse could have contacted the patient’s family member; the nurses or House Supervisor were able to find the contact information of the patient’s family member from the previous admission. When asked who called the patient’s family member after the LSCW gave the contact numbers of the patient’s family members to the RN and Charge RN, the LCSW stated she was not sure who called Patient 1’s family member. The LCSW stated she would contact the family during the resuscitation, but Patient 1 had already passed, and she gave the contact numbers to the nurses to call the coroner. On 12/31/24 at 1013 hours, an interview and concurrent review of Patient 1’s closed medical record was conducted with the VP of Nursing Operation and the Accreditation and Regulatory Compliance Supervisor. The VP of Nursing Operation stated at night, the on-call CM in ED would contact the patient’s family, and the ED team including the House Supervisor and physician were also involved. If the CM was not available, the ED team would facilitate to locate the patient’s family. The VP of Nursing Operation and the Accreditation and Regulatory Compliance Supervisor confirmed there was no documentation showing Patient 1’s family member was contacted. On 12/31/24 at 1055 hours, an interview was conducted with the complainant. The complainant stated when the complainant could not find Patient 1, the complainant called all the hospitals in the area, jails, and coroners’ offices and found Patient 1 12 hours after Patient 1 had passed. The complainant confirmed one of four phone numbers was the phone number of Patient 1’s Family Member 1, but Patient 1’s Family Member 1 had not received the phone call from the hospital.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 45560 Based on interview and record review, the hospital failed to ensure the RN supervised and evaluated the nursing care for one of five sampled patients (Patient 2) as evidenced by: 1. The nursing staff did not monitor and document Patient 2’s vital signs every four hours as per the hospital’s P&P. 2. The nursing staff did not perform a focused patient assessment for Patient 2 every four hours as per the hospital’s P&P. These failures created the increased risk of poor health outcomes to the patient with the potential to cause death due to aspiration. Findings: On 12/30/24, review of Patient 2’s closed medical record was initiated. Patient 2 medical record showed the patient was admitted to the hospital on 10/27/24 at 0719 hours. 1. Review of the hospital’s P&P titled Frequency and Reporting of Vital Signs, and Intake and Output dated 3/20/23, showed for Medical/Surgical/Telemetry units, routine vital signs are taken every four hours. On 12/30/24 at 1300 hours, an interview and concurrent interview of Patient 2’s medical record was conducted with the Patient Safety Lead RN. Review of Patient 2’s vital sign flowsheet showed Patient 2’s vital signs was documented on 10/27/24 at 1200 hours. The Patient Safety Lead RN was unable to locate documentation of the patient’s vital signs for 10/27/24 at 1600 hours. The Patient Safety Lead RN acknowledged that vital signs should be taken and documented every four hours. On 12/30/24 at 1530 hours, an interview was conducted with CNA 1. CNA 1 acknowledged the vital signs should be completed every four hours and was not sure why Patient 2’s vital signs were not taken on 10/27/24 at 1600 hours. On 12/31/24 at 1310 hours, the Accreditation and Regulatory Compliance Supervisor and Patient Safety Lead RN were notified and acknowledged the above findings. 2. Review of the hospital’s P&P titled Department Scope of Service dated 11/4/24, showed for the 8 west Oncology, assessment and reassessment timeframes is “Unless otherwise ordered or indicated, timeframes are as followed: Head-to-toe assessment every shift with focused reassessment q4H.” On 12/31/24 at 0830 hours, and interview and concurrent review of Patient 2’s medical record was conducted with the Patient Safety Lead RN. Review Patient 2’s medical record showed the head-to-toe assessment was completed on 10/27/24 at 0849 hours. The Patient Safety Lead RN was unable to locate any additional assessments prior to 10/27/24 at 1846 hours. On 12/31/24 at 1310 hours, the Accreditation and Regulatory Compliance Supervisor and Patient Safety Lead RN were notified and acknowledged the above findings.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 32097 Based on observation, interview, and record review, the hospital failed to ensure: 1. Sensorcaine-MPF with Epinephrine was protected from light as specified by the manufacturer. 2. Outdated biological was removed and not available in stock for patient’s use. These failures had the potential for patients to receive decreased potency or efficacy of the medication and/or biological resulting in poor/adverse outcomes. Findings: Review of the hospital’s P&P titled Medication Labeling, Storage and Security last review 7/6/23, showed storage areas shall be free of expired medications. Review of Sensorcaine-MPF with Epinephrine manufacturer’s package insert showed it should be protected from light. 1. On 11/5/24 at 0930 hours, during an observation and concurrent interview in the main hospital pharmacy medication storage areas in the presence of the Chief Pharmacy Services, Pharmacy Operation Manager, Pharmacy Clinical Manager, and Medication Safety Pharmacist, three 30 ml vials of Sensorcaine-MPF 0.75% (bupivacaine hydrochloride and epinephrine 1:200,000 as bitartrate) used for local or regional anesthesia or analgesia for surgery, were observed on the shelf exposed to light. The Pharmacy Operation Manager stated different manufacturers had different storage conditions. On examining the Sensorcaine-MPF with Epinephrine vial, the Pharmacy Operation Manager verified the vials were labeled to be protected from light. 2. On 11/5/24 at 1000 hours, during an observation and concurrent interview in the main hospital pharmacy in the presence of the Chief Pharmacy Services, Pharmacy Operation Manager, Pharmacy Clinical Manager, and Medication Safety Pharmacist, a vial of ChiRhoStim (a hormone used for the stimulation of pancreatic secretions, including bicarbonate, to aid in the diagnosis of pancreatic exocrine dysfunction) with expiration date of 2/17 was observed in the medication/biological freezer. The Pharmacy Operation Manager stated ChiRhoStim was not a Pharmacy bought product, it was a clinical trial product stored in the pharmacy freezer. The Pharmacy Operation Manager verified the vial was expired.”

“RESPIRATORY CARE SERVICES POLICIES CFR(s): 482.57(b) Services must be delivered in accordance with medical staff directives. This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure the RCP notified the physician as per the hospital’s P&P when one of four sampled patients (Patient 3) refused the breathing treatment. This failure created the increased risk of poor health outcomes to the patients’ receiving services in the hospital. Findings: Review of the hospital’s P&P titled Respiratory Care Delivery or Treatment Scheduling effective date 9/12/24, showed in part: * Purpose is to provide a schedule and process for therapeutic procedures provided by the Respiratory Care Department, and to ensure all respiratory care procedures and medications prescribed by a physician are administered and documented. * Refusal and or non-delivery of ordered intervention: - The RN who is assigned to the patient is to be notified immediately of non-delivery and the reason for non-delivery. If the patient’s assigned RN is not available, the unit Charge Nurse should be informed of the missed therapy. - If a patient consistently refuses therapy, the RCP will notify the ordering physician and Charge RT after three consecutive missed treatments. On 9/19/24 at 0830 hours, an interview and concurrent record review was conducted with Patient Safety Lead RN 3, Chief Patient Safety Officer, Sr Principal Regulatory Compliance & Corporate Facilities, Director 1, Nurse Manager 1, and Patient Safety Lead RN 2. Patient 3’s medical record showed Patient 3 was admitted to the hospital on 9/1/24, to the medical surgical unit. Review of the H&P examination dated 9/1/24 at 1820 hours, showed Patient 3 had a history of asthma and reported to have chronic cough and wheezing for the last several weeks. The Assessment and Plan was to give DuoNeb (combination of medications to open airways and reduce inflammation) every six hours and as needed. Review of the physician’s order dated 9/1/24 at 1938 hours, showed to give albuterol-ipratropium (DuoNeb) 2.5 - 0.5 mg per 3 ml nebulizer, give 3 ml, RT every six hours (frequency) via nebulization. On 9/19/24 at 0920 hours, an interview and concurrent review of the medication administration record was conducted with Patient Safety Lead RN 3, Chief Patient Safety Officer, Sr Principal Regulatory Compliance & Corporate Facilities, Director 1, Nurse Manager 1, Patient Safety Lead RN 2, Director 2, and Respiratory Clinical Educator Supervisor. The medication administration record dated 9/2/24 at 0658 hours to 9/4/24 at 0717 hours, showed Patient 3 refused the nebulization treatments nine times. Director 2 and Respiratory Clinical Educator Supervisor verified the findings and confirmed the physician had not been notified as per the hospital’s P&P.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 39796 Based on interview and record review, the hospital failed to ensure the nursing services were provided for two of two sampled patients (Patients 1 and 2) as evidenced by: 1. The nursing staff did not ensure the pain management for Patients 1 and 2 as per the hospital’s P&P. 2. The nursing staff did not irrigate the NG tube at least one per shift on 9/1 and 9/3/24, during the night shifts as per the hospital’s P&P. These failures created the increased risk of poor health outcomes to the patients receiving services in the hospital. Findings: 1. Review of the hospital’s P&P titled Pain Management dated 3/19/24, showed the general principles include the RN will assess the patient at the beginning of each shift and documenting the pain assessment. The RN is responsible for reassessing (post medication) the patient’s pain after the medication is administered. Reassessment occurs between 30 to 60 minutes of administration: within 30 minutes for medications given IV route and 60 minutes for medications administered via oral or parenteral (SQ, IM) route. The RN notes the patient’s reassessment number value (on a scale of 0 to 10 with 0 = no pain and 10 = most severe pain) and documents this in the Pain/Comfort/Sleep Flowsheet. a. Review of Patient 1’s closed medical record was initiated on 9/4/24 at 0815 hours. Patient 1’s medical record showed the patient was admitted to the hospital on 8/8/24, and discharged on 8/26/24. Review of the pain flowsheet showed on 8/15/24 at 1701 hours, showed Patient 1 had pain at the abdomen and the patient’s pain level was 10 out of 10. Review of the MAR showed Patient 1 was administered with hydromorphone (narcotic) 0.4 mg IV for pain level of 10 out of 10. However, review of Patient 1’s medical record failed to show documented evidenced of the pain level was reassessed 30 minutes after the pain medication was administered to the patient as per hospitals’ P&P. On 9/4/24 at 1043 hours, an interview and concurrent review of Patient 1’s medical record was conducted with RN 1. RN 1 was asked if the pain assessment was completed. RN 1 stated the documentation was incomplete. RN 1 was further asked if they needed to reassess the pain level after the medication was given. RN 1 stated yes but it was not documented. RN 1 was further asked for the timeline of the reassessment after the medication was given. RN 1 stated half an hour after the intravenous pain medication was given. RN 1 was informed and acknowledged the findings. On 9/4/24 at 1318 hours, the findings were shared with the Senior Principal Regulatory Compliance & Corporate Facilities, Chief Patient Safety Officer, Director of MS & Oncology, Manager of MS & Oncology, Patient Safety Lead RNs 1, 2 and 3. They reviewed the patient’s medical record and hospital’s P&P. They were informed the medical record was reviewed with the RN 1 and acknowledged the findings. 39199 b. On 9/4/24 at 1038 hours, review of Patient 2’s medical record was conducted with Patient Safety Lead RN 1 and the Director of MS & Oncology. Patient 2’s medical record showed the patient was admitted to the hospital on 8/25/24. Review of Patient 2’s History and Physical examination dated 8/25/24, showed the patient had a right pubic rami fracture (a break in one of the bones that make up the lower pelvis) after sustaining a fall. Review of Patient 2’s medical record did not show the RN had assessed Patient 2 for pain during the morning shift on 9/3/24. In addition, review of Patient 2’s medical record did not show the RN had reassessed the patient’s pain after the patient reported a pain level of 8 out of 10 at the hip and was administered an IV pain medication on 9/4/24 at 0600 hours. On 9/4/24 at 1122 hours, Patient Safety Lead RN 1 and the Director of MS and Oncology verified the above findings. 2. Review of the hospital’s P&P titled Insertion, Irrigation and Removal of Nasogastric Tube dated 3/22/22, showed the NG tube will be checked for patency and irrigated at least once per shift and more often as per the nursing discretion. On 9/4/24 at 1038 hours, review of Patient 2’s medical record was conducted with Patient Safety Lead RN 1 and the Director of MS & Oncology. Patient 2’s medical record showed the patient was admitted to the hospital on 8/25/24. Review of Patient 2’s medical record showed the patient had a NG tube inserted on 8/31/24 at 1745 hours. However, review of Patient 2’s medical record did not show the RN had irrigated the patient’s NG tube at least once per shift (on the night shift) on 9/1 and 9/3/24. On 9/4/24 at 1122 hours, Patient Safety Lead RN 1 and the Director of MS & Oncology verified the above findings.”

“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: 29558 Based on interview and record review, the hospital failed to comply with the 24 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. This failure had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services. Findings: 1. The hospital failed to ensure the MSE was provided in a timely manner to determine whether or not an EMC existed for two of 20 sampled patients (Patients 5 and 11). Cross reference to A2406. 2. The hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for one of 20 sampled patients (Patient 4) when the ED staff did not ensure the pain management for Patient 4 as per the hospital’s P&P. Cross reference to A2407.”

“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: 36703 Based on interview and record review, the hospital failed to ensure the MSE was provided in a timely manner to determine whether or not an EMC existed for two of 20 sampled patients (Patients 5 and 11) when the ED staff failed to ensure the circumstances for Patients 5 and 11 leaving the ED prior to being seen by the physician for medical screening was documented as per the hospital’s P&P. These failures had the potential to result in poor clinical outcomes and serious adverse events to the patients receiving the ED services in the hospital. Findings: Review of the hospital’s P&P titled Patient Transfers to Equal or Higher Level of Care - EMTALA dated 4/11/23, showed if the patient leaves before having a medical screening exam and has left without notice to personnel of his/her intent to leave, the circumstances should be documented on the patient’s record. a. On 7/29/24, Patient 5’s closed medical record review was conducted with the ED Director. Patient 5’s medical record showed the patient visited the ED on 2/25/24 at 2219 hours, with a chief complaint of an arm injury. Review of the Patient Care Timeline showed on 2/25/24 at 2233 hours, RN 2 documented Patient 5 left without being seen before triage. On 7/29/24 at 1417 hours, the ED Director acknowledged Patient 5’s medical record did not have documentation as to the circumstances of Patient 5 leaving the ED. 39199 b. On 7/29/24 at 1300 hours, an interview and concurrent record review was conducted with RN 1. Review of the ED central log showed Patient 11 arrived at the ED on 4/26/24 at 2101 hours, presenting with complaints of a fall with head injury and had left before being triaged. However, review of Patient 11’s medical record did not show the staff had documented the circumstances surrounding the patient’s departure prior to being triaged and having a medical screening exam. RN 1 verified the findings during the concurrent interview and record review and stated the triage nurse would make at least three attempts to locate the patient in the lobby, restroom, or outside of the ED, and document these attempts. On 7/30/24 at 0940 hours, an interview was conducted with the ED Director who verified the above process for locating patients.”

“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: 36703 Based on interview and record review, the hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for one of 20 sampled patients (Patient 4) when the ED staff did not ensure the pain management for Patient 4 as per the hospital’s P&P. This failure had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services. Findings: Review of the hospital’s P&P titled Emergency Department: Patient Assessment, and Reassessment dated 10/11/23, showed ED patients in a treatment area will have a reassessment performed a minimum of every one hours and will include an update on patient condition. The reassessment of pain level is to be documented with routine vital signs, along with before and after pain interventions. Review of the hospital’s P&P titled Pain Management dated 3/19/24, showed the RN will assess the patient’s pain and document the pain assessment. The assessment of pain includes the patient’s self-reported pain level, physical or behavioral symptoms of pain, vital signs, conditions known to cause pain for this patient, and the patient’s history of pain and interventions used to alleviate the pain. Based on the assessment, the RN begins to formulate a plan of care to alleviate the patient’s pain. Non-medical forms of treatment may be utilized e.g., back rub, position change, etc. Pain management methods should be taken into the consideration and address the physical, emotional, psychological, behavioral, cultural, spiritual, social, and economic faces of pain. If non-medical measures do not alleviate the patient’s pain adequately, the RN may utilize pain medication as ordered by the physician. The reassessment of pain occurs between 30 to 60 minutes of administration: within 30 minutes for medication given IV route and 60 minutes for medications administered via oral, subcutaneous, or intramuscular routes. One of the hospital’s pain assessment tools is the numeric, 0-10 pain scale (zero indicates the patient has no pain and 10 indicates the patient has the most severe pain). Review of the Vital and Pain Assessment Flowsheet showed the following prompts for the pain assessment: - Pain rating - Pain onset and duration - Pain side and orientation - Pain description - Pain radiation to - Nonverbal indicators of pain - Pain management interventions - Response to pain interventions On 7/29/24, Patient 4’s closed medical record review was conducted with the ED Director. Patient 4’s medical record showed Patient 4 came to ED on 2/18/24 at 0127 hours, with a chief complaint of shortness of breath and chest pain. Review of the pain assessment showed on 2/18/24 at 0136 hours, Patient 4’s numeric pain rating was “8” or severe pain. However, there was no documentation of another pain assessment until 0417 hours, when Patient 4’s numeric pain rating was “6”, or moderate pain. Additionally, further review of the medical record failed to show any non-medical interventions or reassessment of Patient 4’s pain was documented for the patient on 2/18/24 from 0136 to 0417 hours. On 7/30/24 at 1003 hours, the above findings were shared and acknowledged by the ED Director.”