Ahmc Anaheim Regional Medical Center

“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: The hospital failed to ensure the L&D department maintained a central log of the patients who received emergency services in the L&D department. Cross reference to A2405.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 35310 Based on observation, interview, and record review, the hospital failed to ensure the L&D department maintained a central log of the patients who received emergency services in the L&D department. This failure had the potential to result in the hospital not being able to accurately track the care provided to the patients who presented to the ED for treatment for an emergency medical condition. Findings: During a review of the hospital’s P&P titled “EMTALA (Emergency Medical Treatment and Active Labor Act): Patient Access to Care,” dated 4/23/25, the P&P showed under Central log: Each dedicated emergency department of the Hospital will maintain a central log recording the names of individuals who come to the emergency department. The central log will record the name of each person who presents for emergency services and whether the person refused treatment, was refused treatment by the Hospital or whether the individual was transferred, admitted and treated, stabilized and transferred or discharged. During a tour of the main ED on 2/17/26 at 0920 hours, with the ED Director and Director of Quality, the ED Director stated that pregnant patients who were greater than 20 weeks gestation, with an obstetric related chief complaint would be escorted to the L&D ED. During a tour to L&D ED on 2/17/26 at 0957 hours, with the Director of Inpatient Services and RN 2. The board at the nursing station was observed showing the patients’ list with different colors. RN 2 stated patients with a green color were post partum patients and patients with a red color were labor patients. RN 2 also stated all the patients coming to the L&D department would be logged in the L&D triage book. On 2/18/26 at 0946 hours, Clinical Shift Manager 2 was interviewed in the presence of the Director of Quality and the ED Director. Clinical Shift Manager 2 stated all the patients coming to the L&D department would be logged in the L&D triage book. The ED Director stated even when L&D patients came to the ED, if the L&D patients were greater than 20 weeks gestation, and the chief complaint was related to OB, then the patients would not be in the main ED log. Clinical Shift Manager 2 stated the patients coming to the L&D with a hospital’s privileged physician would be colored in red, and the patients without a hospital physician who had no privileges at the hospital would be colored in black. During an interview on 2/18/26 at 1001 hours, with Clinical Shift Manager 2 in the presence of Director of Quality and ED Director on, Clinical Shift Manager 2 stated any patients coming to the L&D including scheduled C-section, induction, outpatient testing, or L&D ED patients would be logged in the triage book. When asked if only L&D ED patients could be identified in the triage book, Clinical Shift Manager 2 stated they could not. The Director of Quality and ED Director stated there was no central ED log specifically maintained in L&D ED.”

“DISPOSAL OF TRASH CFR(s): 482.41(b)(6) (4) The hospital must have procedures for the proper routine storage and prompt disposal of trash. This Standard is not met as evidenced by: 45560 Based on observation and interview, the hospital failed to properly store and dispose of trash, creating a potential risk of exposure to hazards for employees and visitors. Findings: During an observation on 1/29/26 at 1030 hours at the hospital’s loading dock, a large accumulation of trash including office chairs, mattresses, wooden pallets and small appliances was observed piled directly on the ground. During a concurrent observation and interview on 1/29/26 at 1040 hours, with the Facilities Manager at the loading dock, the Facilities Manager stated trash that was left on the ground at the loading dock should have been put into a dumpster. The Facilities Manager also acknowledged the trash left on the ground could attract rodents. During an interview with the Director of Quality Department on 1/29/26 at 1530 hours, the DOQ was notified and acknowledged the above findings.”

“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 nurse-to-patient ratio was maintained at all times in the L&D unit as required. This failure had the potential for patient care needs not being met when the staffing ratio was not maintained as required. Findings: Review of the hospital’s P&P titled Staffing Perinatal Services, Labor and Delivery, Couplet Care and Ante-Partum dated 6/22/22, showed the following: * Minimum staffing in Labor and Delivery when 0 patient is 2 licensed staff and 1 RN on call. * Nurse/Patient Ratio: 1:2 Patients in labor 1:1 Patients in active pushing phase of second-stage labor... 1:1 Continuous bedside nursing attendance during initiation of epidural anesthesia until condition is stable (or at least the first 30 minutes after the initial dose) ... 2:1 At birth: 1 nurse responsible for the mother and 1 nurse responsible for the baby until stable... On 7/23/25 at 0830 hours, Clinical Shift Manager 1 was interviewed. Clinical Shift Manager 1 stated the nurse-to-patient ratio should be 1:1 for at least 30 minutes after the epidural anesthesia initiation and one hour after the baby was delivered. On 7/23/25, Patient 1’s closed medical record was reviewed. The record showed Patient 1 was admitted to the hospital on 6/27/25 and discharged on 6/29/25. Review of the Patient Progress Notes dated 6/28/25, showed the following: * At 0120 hours, the epidural catheter was inserted, and test dose was given. * At 0230 hours, Patient 1 was pushing and the physician enroute. * At 0252 hours, normal spontaneous vaginal delivery. Review of the L&D Assignment Sheet dated 6/27/25 for the night shift (from 1800 to 0600 hours), showed the following: * From 0120 hours to 0150 hours (for 30 minutes), RN 1 was assigned to Patient 1 who was in active labor and to one L&D patient. * From 0230 hours to 0352 hours (for one hour and 22 minutes), RN 1 was assigned to Patient 1 who had just given birth and to one L&D patient. On 7/23/25 at 1010 hours, Clinical Shift Manager 1 verified the above findings. The nurse-to-patient ratio was not maintained at all times in the L&D unit as required.”

“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: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff developed the nursing care plan for one of two sampled patients (Patient 2) when the blood transfusion was administered, creating the risk of not providing necessary care and services to meet the care needs for the patient. Findings: Review of the hospital’s P&P titled Interdisciplinary Plan of Care dated 2/28/24, showed the following: * Patient problems identified in the plan of care are reviewed by all disciplines caring for the patient. * The plan of care is updated every 72 hours or when there is a change in the patient’s condition. Updates are done by any discipline providing care to the patient. * The plan of care consists of patient problems, expected outcomes, goals, and interventions/approaches. On 7/23/25, Patient 2’s medical record was reviewed. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 7/17/25. Review of the physician’s order dated 7/21/25 at 1912 hours, showed to administer blood product. Review of the Transfusion Information dated 7/21 and 7/22/25, showed three units of blood were administered to Patient 2. The Interdisciplinary Plan of Care for Patient 2 was reviewed. The record failed to show the nursing care plan for blood transfusion. On 7/23/25 at 1300 hours, the CNO and the Director of Quality Department verified the above findings.”

“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: 22553 Based on interview and record review, the hospital failed to ensure an informed consent for the hypothermia care was obtained for one of two sampled patients (Patient 1) as per the hospital’s P&P. This failure created the risk of the patient or the patient’s family member not being allowed to make decisions about their health care. Findings: Review of the hospital’s P&P titled Hypothermia Care, Post Cardiac Arrest, effective 12/4/24, showed the mechanisms responsible for brain damage after a cardiac arrest are multi-factorial. The lack of perfusion to the brain during arrest leads to ischemia and possible anoxic brain damage. * Purpose: To establish the multidisciplinary approach and method for instituting immediate mild-moderate hypothermia (core temperature 33-36 degrees Celsius) in patients who meet inclusion criteria presenting in coma following cardiac arrest. * Scope: All patients meeting eligibility after cardiac arrest. * Responsibility: Physicians-ED /Intensivist/Cardiologist/Neurologist, Rapid Response Nurse, ED/CVU/ICU/Cath Lab Registered Nurse, Respiratory Therapists, and Pharmacists. * Procedure: - After full arrest review inclusion and exclusion criteria for patients with a return of spontaneous circulation following cardiac arrest. - Physician assesses the patient inclusion and exclusion criteria and orders Hypothermia Intervention. - Obtain Hypothermia Pre-printed Orders and informed consent per hospital policy... On 4/30/25 at 0830 hours, Patient 1’s closed medical record review was conducted with the CNO and Director of Quality Department. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 2/24/25. Review of the closed medical record showed the preprinted orders for Hypothermia After Cardiac Arrest dated 3/9/25 at 2130 hours. Further review of Patient 1’s medical record did not show an informed consent had been obtained for the hypothermia care. On 4/30/25 at 1705 hours, the Director of Quality Department confirmed there was no documented evidence the care team had obtained an informed consent from the patient’s family member for the hypothermia care as per the hospital’s P&P.”

“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: 22553 Based on interview and record review, the hospital failed to ensure one of two sampled patients (Patient 1) received care in a safe setting as evidenced by: 1. There was no documented evidence of the Hypothermia Inclusion/Exclusion Criteria for Patient 1’s hypothermia therapy as per the hospital’s P&P. 2. The hospital failed to obtain a complete physician’s order for ventilator settings and for IV FLUID maintenance. 3. The hospital failed to show documented evidence of monitoring the CVP for the IV FLUID target goal as per the Physician’s order. 4. The hospital failed to show documented evidence of the size of the cooling pads used on Patient 1 for hypothermia therapy. These failures created an unsafe environment for the patient receiving hypothermia therapy. Findings: Review of the hospital’s P&P titled Hypothermia Care, Post Cardiac Arrest, effective 12/4/2024, showed the mechanisms responsible for brain damage after a cardiac arrest are multi-factorial. The lack of perfusion to the brain during arrest leads to ischemia and possible anoxic brain damage. * Purpose: - To establish the multidisciplinary approach and method for instituting immediate mild-moderate hypothermia (Core temperature 33-36 Celsius) in patients who meet inclusion criteria presenting in coma following cardiac arrest. - To describe the methodology to induce hypothermia for up to 24 hours, and identifies specific steps used in the re-warming phase to bring the patients safely back to normothermia. * Responsibility: - Physicians-ED /Intensivist/Cardiologist/Neurologist, Rapid Response Nurses, ED/CVU/ICU/Cath Lab Registered Nurses, Respiratory Therapists, and Pharmacists. * Policy: - Patients post cardiac arrest with a return of spontaneous circulation (ROSC). The health care team will evaluate potential candidates for Hypothermia using the Inclusion/Exclusion Criteria Progress Note. * Procedure: - Physician assesses patient inclusion and exclusion criteria and orders Hypothermia Interventions. - Obtain Hypothermia Pre-printed Orders... - Assure that the following equipment is available...CVP and/or PA catheter to assess fluid volume/hemodynamic status. - Assess the clinical status, prior to initiating hypothermia therapy:..assess respiratory rate and ventilatory function... - Obtain physician order for initiation of sedation and analgesia for cooling...anticipate need for BP support... - Use fluids to maintain euvolemia. Target CVP: 6-10 mm Hg... Review of the hospital’s P&P titled Physician Orders: Telephone, Verbal, and Written, effective 12/4/2024, showed verbal and telephone Orders...are e-signed by the prescriber within 48 hours... On 4/30/25 at 0830 hours, Patient 1’s closed medical record was reviewed with the CNO and the Director of Quality Department. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 2/24/25. Patient 1 expired on 4/3/25. Review of the Cardiopulmonary Resuscitation Record dated 3/9/25, showed CPR started at 0959 hours and resuscitation event ended at 1023 hours. The Outcome section showed “Reason Resuscitation Ended: Return of Circulation (greater than 20 min.).” The hypothermia criteria showed the patient was identified as a candidate for hypothermia therapy. The patient was admitted to ICU. On 4/30/25 at 1437 hours, ICU RN 1 was interviewed about hypothermia therapy. ICU RN 1 stated hypothermia therapy started with the physician’s assessment for criteria. The assessment would be documented on the Hypothermia Inclusion/Exclusion Criteria Progress Note. The preprinted orders set for Hypothermia After Cardiac Arrest would be completed by the providers (ED physicians, Intensivist, Pulmonologists, Cardiologists, or Neurologists) by checking the boxes where there was a choice of orders or by filling in the blanks. The Therapeutic Hypothermia Nursing Worksheet was used to document the size of the cooling pad used on the patient and the monitoring of the patient’s CVP during the hypothermia therapy. On 4/30/25 at 1705 hours, Patient 1’s closed medical record was reviewed with the Director of Quality Department. The Director of Quality Department confirmed the following findings: * There was no documented evidence of the provider’s assessment on the Hypothermia Inclusion/Exclusion Criteria Progress Note. * The PREPRINTED ORDERS FOR: Hypothermia After Cardiac Arrest did not show orders for the ventilator settings; the Ventilator Mode, RR, TV, FiO2, PEEP, PS sections were left blank. * The PREPRINTED ORDERS FOR: Hypothermia After Cardiac Arrest showed, “TORB (Telephone Order Read Back) by Dr.1” on 3/9/25 at 2130 hours, and was “Noted by RN” on 3/9/25 at 2135 hours. The orders showed Dr. 1 electronically signed the PREPRINTED ORDERS FOR: Hypothermia After Cardiac Arrest on 4/8/25 at 1447 hours. * The medical record showed the patient had a CVP monitor line but there was no documentation showing the CVP reading during hypothermia therapy. * The size of the cooling pad used on the patient was not documented on the Therapeutic Hypothermia Nursing Worksheet.”

“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: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff developed the nursing care plan for one of 12 sampled patients (Patient 9) who received the blood transfusion, creating the risk of not providing necessary care and services to meet the care needs for this patient. Findings: Review of the hospital’s P&P titled Interdisciplinary Plan of Care dated 2/28/24, showed the following: * Patient problems identified in the plan of care are reviewed by all disciplines caring for the patient. * The plan of care is updated every 72 hours or when there is a change in the patient’s condition. Updates are done by any discipline providing care to the patient. * The plan of care consists of patient problems, expected outcomes, goals, and interventions/approaches. On 4/17/25, Patient 9’s medical record was reviewed. Patient 9’s medical record showed Patient 9 was admitted to the hospital on 4/10/25. Review of the physician’s order dated 4/14/25 at 1833 hours, showed to administer blood product scheduled on 4/15/25 at 1400 hour Review of the Transfusion Information dated 4/15/25, showed the blood transfusion was started at 1311 hours and ended at 1405 hours. The Interdisciplinary Plan of Care for Patient 9 was reviewed. However, further review of Patient 9’s medical record failed to show the nursing care plan for the blood transfusion. On 4/18/25 at 1105 hours, the CNO and Director of Quality verified the above findings.”

“SCOPE OF RADIOLOGIC SERVICES CFR(s): 482.26(a) [§482.26 Condition of Participation: Radiologic Services The hospital must maintain, or have available, diagnostic radiologic services...] §482.26(a) Standard: Radiologic Services The hospital must maintain, or have available, radiologic services according to the needs of the patients. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the written guideline related to transporting patients to other hospital for the MRI examination included the expected turnaround time for the STAT and routine MRIs orders. This failure had the potential to affect overall health and safety of the patients receiving radiologic services. Findings: Review of the hospital’s P&P titled STAT Diagnostic Testing dated 9/27/23, showed the following: * Definition of Terms: - STAT: Tests ordered with an expected turnaround time of approximately one hour. - ASAP: Tests ordered with an expected turnaround time of approximately two to four hours. - Routine: Tests generally completed within four to six hours in normal course of the business. Routine imaging studies have a 12- 24 hours turnaround time. * Policy: - STAT services are provided on STAT ordered procedures (usually in the case of emergency) within one hour from the time of receipt until the result is released to the unit. - In the Imaging Services Departments, STAT services are provided on STAT ordered procedures (usually in the case of emergency) in an expected turnaround of approximately one hour from the receipt of order in the Imaging Services clerical department with the exception of head CT’s. Turnaround times can be impacted by internal and external variables such as length of exams and equipment. CT scans and diagnostic radiology are available 24 hours, seven days a week. - For after hours and/or holidays the Nuclear Medicine, MRI, and Ultrasound departments are on call on a 24/7 basis based on patient needs. Time frames can vary due to the re-opening of the department for the exam. On 4/16/25 at 1000 hours, the Director of Imaging Services was interviewed. When asked, Director of Imaging Services stated the MRI in house was broken since 1/17/25. The Director of Imaging Services stated the MRI would be performed at the sister hospitals. The list of the patients who received MRI orders was requested. Random patients were selected to be reviewed. On 4/17/25, the medical records of Patients 3, 5, and 7 was reviewed. 1. Patient 3’s closed medical record showed Patient 3 was admitted to the hospital on 1/19/25 and discharged on 1/29/25. Review of the physician’s order dated 1/19/25 at 1107 hours, showed to perform MRI brain without contrast STAT. Review of the Radiology Report dated 1/22/25 at 1358 hours, showed the MRI was completed (three days later). 2. Patient 5’s medical record showed Patient 5 was admitted to the hospital on 4/10/25. Review of the physician’s order dated 4/11/25 at 1047 and 1702 hours, showed to perform routine MRI of T Spine with and without contrast and MRI of L Spine with and without contrast respectively. Review of the Radiology Report dated 4/16/25 at 0809 hours, showed the MRI was completed (five days later). 3. Patient 7’s closed medical record showed Patient 7 was admitted on 1/28/25 and discharged on 2/2/25. Review of the physician’s order dated 1/28/25 at 1507 hours, showed to perform STAT MRI of brain without contrast. Review of the physician’s order dated 1/29/25 at 2238 hours, showed the perform routine MRI of brain without contrast. However, the order was canceled on 1/30/25 at 0835 hours, due to duplicate order. Review of the physician’s order dated 1/31/25 at 0831 hours, showed the STAT MRI of brain without contrast originally ordered on 1/28/25 was canceled (three days later). On 4/17/25 at 0919 hours, the Director of Imaging Services was interviewed. When asked, the Director of Imaging Services stated the written guidelines were developed for the patients who transported to the sister hospitals for the MRI examination. Review of the documents for transporting the patients to the sister hospitals (undated) failed to show the expected turnaround time for the STAT or routine MRI orders. On 4/17/25 at 0919 hours,, the Director of Imaging Services verified the above findings.”

“SAFETY POLICY AND PROCEDURES CFR(s): 482.26(b) [§482.26 Condition of Participation: Radiologic Services §. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications.] §482.26(b) Standard: Safety for Patients and Personnel The radiologic services, particularly ionizing radiology procedures, must be free from hazards for patients and personnel. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the system for the alternative MRI process was tracked and reviewed for the turnaround time of the MRI orders which were performed at their other hospitals. This failure had the risk of not identifying the concerns and missing the opportunity to improve performance. Findings: Review of the hospital’s Radiology Subsection Rules and Regulations (undated) showed the radiology section will participate in the identification of important aspects of care, indicators used to monitor the quality of the important aspects of care, and evaluation of the indicators. Evaluation of care will be to note trends and patterns of performance to determine if problems or opportunities to improve care exist. When problems or opportunities to improve care are identified, actions will be taken and assessed for effectiveness in accordance with the performance improvement plan. The radiology section shall meet on an Ad-Hoc basis and may schedule regular meetings. On 4/16/25 at 1000 hours, the Director of Imaging Services was interviewed. When asked, Director of Imaging Services stated the MRI in house was broken since 1/17/25. The Director of Imaging Services stated the MRI would be performed at the sister hospitals. When requested, the hospital provided the list of patients with MRI orders. Review of the list showed there were 139 MRI orders from 1/17/25 to 4/16/25. During an interview and record review with the Director of Imaging Service on 4/16 and 4/17/25, the Director of Imaging Services verified the hospital’s written guideline related to transporting patients to other hospital for the MRI examination did not include the expected turnaround time for the STAT and routine MRIs orders. Cross reference to A529. On 4/17/25 at 1430 hours, the Director of Quality was interviewed. When asked, the Director of Quality stated the Radiation Safety Committee meet every three months. Review of the Radiation Safety Committee Meeting dated 10/10/24 and 1/28/25, failed to show documented evidence of reviewing the turnaround time for MRI orders, which performed in hospital’s sister hospitals. On 4/17/25 at 0919 hours, the Director of Imaging Services verified the above findings.”

“PERIODIC EQUIPMENT MAINTENANCE CFR(s): 482.26(b)(2) Periodic inspection of equipment must be made and hazards identified must be promptly corrected. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the identified issues from the physicist’s annual inspections for the MRI, fluoroscopy, and x-ray machines were properly followed up, creating the increased risk of radiation safety hazards. Findings: Review of the hospital’s Radiology Subsection Rules and Regulations (undated) showed the radiology section will participate in the identification of important aspects of care, indicators used to monitor the quality of the important aspects of care, and evaluation of the indicators. Evaluation of care will be to note trends and patterns of performance to determine if problems or opportunities to improve care exist. When problems or opportunities to improve care are identified, actions will be taken and assessed for effectiveness in accordance with the performance improvement plan. The radiology section shall meet on an Ad-Hoc basis and may schedule regular meetings. 1. Review of the MRI Annual System Performance Evaluation dated 7/15/24, showed “during the survey it was noticed that the foot/ankle coil is falling apart. There is a tear in the cord, the base is cracked, pieces are falling off. This is a hazard to the patient and should no longer be used until it can be replaced.” On 4/18/25 at 1020 hours, the Director of Quality was interviewed in the presence of the CNO. When asked, the Director of Quality stated the foot/ankle coil was not used. The radiology department was able to use other coils. When asked, if the resolution was followed up on the recommendations, the Director of Quality was not providing the answer. 2. Review of the Medical Physicist’s Annual Survey for Fluoroscopy machine used in Angiography suite dated 7/9/24, showed the test for Disp. Air Kerma was failed. Review of the Medical Physicist’s Annual Survey for C- Arm Fluoroscopy used in Cath Lab A dated 7/9/24, showed the test for exposure rate was failed. Review of the Medical Physicist’s Annual Survey for Fluoroscopy machine used in Cath Lab A dated 7/9/24, showed the test for exposure rate and Disp. Air Kerma were failed. Review of the Medical Physicist’s Annual Survey for Fluoroscopy machine used in Cath Lab B dated 7/9/24, showed the test for the Disp. Air Kerma were failed. Review of the Medical Physicist’s Annual Survey for X-ray Machine used in dated 7/9/24, showed the test for the Disp. Air Kerma were failed. Review of the Radiation Safety Committee Meeting dated 10/10/24 and 1/28/25, failed to show documented evidence the above physicist’s reports had been reviewed. On 4/18/25 at 1105 hours, the CNO and the Director of Quality verified the above findings.”

“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: 45560 Based on interview and record review, the hospital failed to ensure the nurse-to-patient ratios were maintained at all times for the Telemetry unit as required. This failure had the potential for the care needs of the patients not being met when the staffing ratio were not maintained as required. Findings: Review of the hospital’s P&P titled Staffing and Ratio Guidelines dated 12/4/24, showed under the policy section, Anaheim Regional Medical Center (ARMC) follows California State Nurse Patient Ratio Laws. The California Code of Regulations, Title 22, Division 5, Chapter 1, Article 3, 70217, (a) showed the following: (10) The licensed nurse-to-patient ratio in a telemetry unit shall be 1:4 or fewer at all times. On 2/5/25 at 1445 hours, an interview was conducted with RN 7. RN 7 stated on 1/20/25 day shift, three nurses began the shift at 0600 hours, which was out of ratio with a 1:5 (one nurse to five patients) ratio. RN 7 stated the charge nurse was able to locate an additional RN to work that morning, arrived at 1020 hours, and by 1030 hours, the RNs were at a 1:4 ratio. RN 7 stated the ratio on Telemetry should be 1:4. 1. Review of the hospital’s P&P titled Staffing Ratio Guidelines dated 12/4/24, showed telemetry nurse to patient ratio is 1:4 per California state ratios. Review of the Staffing Assignment for Tower 2 Telemetry dated 1/20/25, for the day shift showed the following: * RN 1 was assigned four telemetry and one medical/surgical patients from 0600-1030 hours. * RN 2 was assigned five telemetry patients from 0600-1030 hours. * RN 3 was assigned three telemetry and three medical/surgical patients from 0600-1030 hours. On 2/6/25 at 1123 hours an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated when the nurses were assigned a mix assignment, that meant the assignements included the patients with different admission status orders such as telemetry and medical/surgical, the ratio assigned would base on the highest acuity patient, for example, one telemetry patient with three medical/surgical patients would be assigned at a telemetry ratio of 1:4. On 2/6/25 at 1155 hours the CNO, Director of Quality and Risk Manager were notified and acknowledged the above findings.”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure one of four medical staff (Physician 3) met the requirement for Category II Basic Interventional Radiology Procedures. This failure created the risk for substandard health outcomes to the patients. Findings: Review of the hospital’s Medical Staff General Rules and Regulation dated 5/24/23, showed it is expressly understood that the contents of the credential files constitute records and proceedings of Medical Staff and Peer Review Committees that are responsible for evaluation and improving the quality of care provided in the hospital. On 10/1/24 at 1056 hours, a concurrent interview and record review was conducted with the Medical Staff Director and Director of Quality. Review of Physician 3’s credential file showed the Radiology Clinical Privilege Request Form dated 10/10/23, showing Category II Basic Interventional Procedures were requested, approved, and required proctoring. The form showed the category II required the board certification in radiology. The form also showed the date of credentials committee approval was 1/10/24, date of Medical Executive approval was 1/15/24, and date of GB approval showed 1/24/24. The Medical Staff Director stated Physician 3 was released for Category 1 to 3 on March 2024 and currently working on Category 3B. The Medical Staff Director was asked for Physician 3’s board certification in radiology. The Medical Staff Director stated Physician 3 had not taken his board certification as of yet. Physician 3 had to complete the list of steps to be eligible to take the board exam. The Medical Staff Director stated the verbiage on the Radiology Clinical Privilege Request Form for Category II Basic Interventional Procedures should be the same as the other categories to be Board Certified or Residency Trained in Radiology. However, the Radiology Clinical Privilege Request Form showed Category II required Board Certification in Radiology. The findings were shared with the Director of Quality.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure the hospital’s medical staff general rules and regulations were enforced for one of one sampled patient (Patient 1) when Patient 1’s medical record was not maintained accurately. This failure created the risk of substandard medical care to the patients. Findings: Review of the hospital’s Medical Staff General Rules and Regulations dated 5/24/23, showed the P&P establishes for medical records and approved by the MEC and the Boards will be followed by all members and medical Staff. Review of the hospital’s P&P tilted Protocol for Medical Charting effective dated 6/23/21, showed the following: * All significant clinical information pertaining to a patient is entered in the medical records as soon as possible after its occurrence. * Medical Records Requirements: - All medical records include diagnostic and therapeutic orders, clinical observations including the results of therapy, reports of procedures, tests, and their results. * Progress Notes: Progress notes give a pertinent chronological report of the patient’s course in the hospital and reflect any change in condition and the result of treatment. On 9/25/24 at 0746 hours, an interview and record review was conducted with the Director of Quality. 1. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 9/7/24 and discharged on 9/10/24. Review of the H&P examination electronically signed on 9/7/24 at 0430 hours, showed Patient 1 complained of headache after a fall from home. Review of the Progress Note electronically signed by Physician 4 on 9/7/24 at 2028 hours, showed to continue IV antibiotic and pending cultures. Review of the Progress Note electronically signed by Physician 4 on 9/8/24 at 1718 hours, showed to continue IV antibiotic and pending cultures. The Director of Quality was asked about the pending cultures that was written on Physician 4’s progress notes. The Director of Quality stated there was no order for cultures and there was no result of cultures for Patient 1. 2. Patient 1’s medical record showed Patient 1 came to the hospital’s ED on 9/10/24 at 2123 hours (or approximately three hours after the patient was discharged from the hospital). Review of the ED Physician’s Chart dated 9/10/24 at 2123 hours, showed Patient 1 was tachycardic and had slight increased work of breathing with some faint wheezing. The patient was treated for suspected asthma exacerbation. The decision was to admit the patient to ICU. Patient 1 was given three IV pushes of bicarb (a medication used to treat metabolic acidosis) for metabolic acidosis with pH of 7.04 (normal range is from 7.35 - 7.45). Review of the H&P examination electronically signed by Physician 2 on 9/11/24 at 0953 hours, showed Patient 1 was discharged from the hospital to the family member. The patient was short of breath and was on room air. The patient was brought back to the ED because of SOB. The patient became much more obtunded. The laboratory demonstrated acidosis. The patient’s HR was very tachycardic at 130’s. The Assessment/Plan section showed the patient had acute metabolic encephalopathy; the cause was unclear, possible stroke but the brain CT was negative. The Director of Quality was asked for the brain CT performed in the ED prior to admission to ICU. The Director of Quality stated there was no order for the CT scan of the brain in the ED. The findings were shared with the Director of Quality.”

“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: 37663 Based on interview and record review, the hospital failed to ensure the nursing services were provided to one of one sampled patient (Patient 1) as evidenced by: a. The nursing staff did not perform the neuro checks every four hours for Patient 1 as per the physician’s order. b. The telemetry RN failed to ensure Patient 1’s reassessment was documented for a change of condition as per the hospital’s P&P. c. The telemetry RN failed to ensure Patient 1 reassessment was performed every six hours as per the hospital’s P&P. d. The ED RN failed to perform the focused assessment for Patient 1 for the patient’s change in condition. e. The nursing staff failed to ensure the treatment for MASD was implemented. These failures created the risk for substandard health outcomes for the patients. Findings: Review of the hospital’s P&P titled Assessment and Reassessment of Patient effective date 2/28/24 showed: * Purpose: To provide guidelines to support a standardized approach for comprehensive and collaborative patients assessments. * Definition of Terms: - Physical Assessment: The assessment of the patient’s physical status including vital signs, height, weight, systems assessment, and evaluation of pain. - Focused Exam: concise assessment based on patient’s chief complaint and immediate physiological needs. * Policy: Throughout the patient’s stay, the healthcare team performs reassessments based on individualized and prioritized needs to determine response to treatment, therapy, or educational sessions and to determine the effectiveness of the interventions undertaken by the healthcare team. The healthcare team also performs reassessments when there is a significant change in the patient’s diagnosis or condition that necessitates change in the care plan. The physician is notified upon completion of the reassessment and informed of the changes. The RN should accompany the patient’s physician during the physician’s daily rounds whenever possible to provide updates on the patient’s status and discuss any issues or concerns pertaining to the care and treatment. * For telemetry unit, patient assessment and reassessment parameters include, but are not limited to: - The reassessment time frame: the reassessment is to be performed every six hours and when condition changes. On 9/25/24 at 0800 hours, an interview and concurrent review of Patient 1’s medical record was conducted with the Director of Quality. Patient 1’s medical record showed the patient came to the hospital ED on 9/6/24 after a fall at home, complaining of headache. Patient 1 was discharged home with the home health on 9/10/24 at 1828 hours. The patient was returned to the hospital ED on 9/10/24 at 2131 hours. a. Review of the physician’s order dated 9/7/24 at 0425 hours, showed to perform neuro checks every four hours. Review of the RN’s assessment dated 9/9/24, showed the neurological assessment were performed at 0635 hours, 1248 hours (after approximately 6 hours and 30 minutes), 1840 hours (after approximately six hours); and on 9/10/24 at 0100 hours (after approximately 6 hours), and 0700 hours (after 6 hours). The Director of Quality was asked for the documented evidence showing the neuro checks were performed every four hours for Patient 1. The Director of Quality was unable to show the documentation of neuro checks performed every four hours. The Director of Quality was asked if the physician’s order for neuro checks every four hours was discontinued. The Director of Quality stated no. The Director of Quality verified the neuro checks every four hours was not performed for Patient 1 as ordered by the physician. b. Review of the physician’s order dated 9/9/24 at 1932 hours, showed albuterol (bronchodilator, a medication that make breathing easier) 2.5 mg per 3 ml, 2.5 mg via HHN PRN every 4 hours for SOB or wheezing. Review of the physician’s order dated 9/10/24 at 0248 hours, showed albuterol 2.5. mg per 3 ml, 2.5 mg via HHN every 4 hours for SOB or wheezing to be given by the RT. Review of the RN’s pulmonary assessment for Patient 1 on 9/9/24 night shift (1800 to 0600 hours) did not show there was a focus assessment when Patient 1 needed a breathing treatment order. Review of the RT’ s progress notes showed the albuterol HHN respiratory treatments were administered for Patient 1’s wheezing on 9/9/24 at 2037 hours, 9/10/24 at 0144 hours, 0328, 0730 hours, 1103 hours, and 1557 hours. However, review of the RN’s assessment on 9/9/24 at 1932 hours and 9/10/24 at 0248 hours did not show the nursing staff conducted the patient’s pulmonary assessment for the change in condition. The Director of Quality was asked to show the RN’s focused assessment at the time Patient 1 had a change in condition. The Director of Quality could not show the RN’s documentation to show the nursing staff assessed Patient 1’s change in condition. The findings were shared with the Director of Quality. c. Review of RN’s assessment and reassessment on 9/10/24 day shift (0600 to 1800 hours), showed the telemetry RN performed physical assessment for Patient 1 at 0700 hours. Patient 1’s pulmonary assessment showed Patient 1 had dyspnea on exertion and wheezing breath sounds. However, there was no reassessment documented after six hours (or at 1300 hours) as per the hospital’s P&P. The Director of Quality was asked for the frequency of the patient assessment required for the telemetry RNs. The Director of Quality stated the reassessments were to be performed every six hours. However, the RN failed to show documented evidence Patient 1’s reassessment was performed after 0700 hours on 9/10/24. The findings were verified with the Director of Quality. d. Review of the hospital’s P&P titled Triage, Medical Screening Examination and Nursing Assessment dated 9/28/22, showed in part: * Policy: A standardized 5 level Triage Acuity tool will be utilized to prioritize patients into categories based upon assessed severity of illness. - Level 3 - Urgent - Requires prompt care, but some delay will not cause loss of limb or life. These conditions required diagnostic and therapeutic intervention to prevent complications and relieve suffering. These are potentially serious nature. Stable vital signs. Reassessment every 2 to 4 hours and as needed, to include full set of vital signs and again 30 minutes prior to discharge or admission. * Nursing Assessment and Reassessment: - Triage: Nursing triage assessment is performed on every patient in the ED. - Patients then will be taken to the treatment area for further assessment, care, and treatment. Nursing care is based upon the assessment of patient needs by a RN starting with the initial complaint-focused assessment done at the time of presentation to the ED. - Collaboration with other disciplines: Goals of collaboration with other discipline include to enhance the comprehensiveness of the assessment and improve effectiveness of the plan. - Assessment and Reassessment by the Treatment RN includes but is not limited to: assessment and reassessment area continuing process during the patient’s length of stay in the ED. Assessments are documented electronically in EHR. Further on-going assessment or reassessment is determined by changes in patient’s condition, patient’s response to treatment plan, or implementation of interventions. Review of the Nursing Chart dated 9/10/24 at 2123 hours, showed Patient 1 was brought back to the ED (approximately three hours after discharged) by the ambulance. Per EMS, the family member called 911 when the patient’s family member noticed the patient had difficulty of breathing while lying in bed. Patient 1 was admitted on 9/6/24 for UTI and was discharged on 9/11/24 at 1830 hours. Patient 1’s chief complaint was fever five days ago. The patient’s temperature level was 99.7 degrees F orally. Patient 1’s symptoms included cough and shortness of breath. There was associated cough, lethargy, and weakness. The form showed the Triage Acuity level was 3 (urgent). Review of the ED RN’s Focus Assessment and Treatment Notes documentation for Patient 1 showed the following: * On 9/10/24: - At 2150 hours, the patient’s RR was 30 breaths per minute and the patient’s oxygen saturation was 96 %. The patient’s cardiac rhythm was normal sinus rhythm. The patient’s respiration was even and non labored. However, there was no documented evidence the ED RN assessed Patient 1’s breath sounds. The ED RN documented the patient had a history of asthma. - At 2155 hours, the patient’s HR was 85 bpm. The patient’s RR was 28 breaths per minute and the patient’s oxygen saturation was 98 %. The patient was sitting and awake. - At 2258 hours, Patient 1 was given prednisone (steroid) 50 mg by mouth. - At 2328 hours, Patient 1’s troponin level was 1.050 ng/ml (the normal level is from 0 - 0.04 ng/ml) - At 2353 hours, Patient 1 was given the nebulizer treatment once. * On 9/11/24: - At 0051 hours, 3 liters/nc oxygen was provided to Patient 1. - At 0454 hours, the patient’s BP was 157/98 mmHg. The patient’s HR was 150 bpm. The patient’s cardiac rhythm was ST. The patient’s RR was 28 breaths per minute. The patient’s oxygen saturation was 98%. The patient was awake. The patient was given 3 liters/nc oxygen. - At 0455 hours, Patient 1’s HR was 140’s to 150’s. The patient had tachycardia. The patient appeared diaphoretic and had decreased in mentation. The ED Physician was informed of Patient 1’s condition and gave an order to repeat the EKG. However, there was no documented evidence ED RN performed a focused assessment for the decreased mentation. The Director of Quality was asked for the focused assessment for Patient 1 with the change in condition for the decreased in mentation. The Director of Quality stated the ED RN’s focus assessment was the patient’s decreased mentation, the patient’s HR as of 150’s, and diaphoretic. When asked for neurological assessment, the Director of Quality could not show the neurological assessment as the focused assessment for the change in mentation. The findings were shared with the Director of Quality. e. Review of hospital’s P&P titled Skin Care Protocol: Prevention and Management of Skin Breakdown dated 10/26/22, showed in part: * The purpose is to identify patient at risk for skin breakdown and to outline wound management plan for patients with the potential or actual skin breakdown. * Moisture Associated Skin Damage (MASD) is a general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus. * Patients and families are notified of skin impairment or deteriorating changes in skin integrity by the bedside nurses or wound care specialist. * The attending physician or surgeon is notified of skin impairment or deteriorating changes in skin integrity by the bedside registered nurse or wound care specialist. * The Protocol includes the following: - Initiate Skin Protocol for a Braden Scale of 18 or less and or wounds. - Prevention interventions are followed per protocol. The Braden Scale of 12-10 indicates the patient is high risk for developing PI. * The Nursing Care Interventions include the following: - Prevention and Management of MASD include to apply barrier cream or spray and keep patient clean and dry. * Documentation: - Initial skin assessment is documented in the integumentary section of Interdisciplinary Plan of Care electronic form. - Subsequent skin assessments are documented in the integumentary section of the assessment flow chart. - Dressing changes and wound assessment are documented on the Skin and Wound Management Flowchart. - Skin and Wound Management Flowchart and photographs are completed for patients with actual skin impairment. Review of Patient 1’s medical record was conducted with the Director of Quality on 10/1/24 at 1305 hours. Patient 1’s medical record showed on 9/11/24 at 0839 hours, Patient 1 was admitted to ICU. The initial skin assessment showed no skin breakdown. Patient 1’s Braden Scale on admission was 12. Review of Patient 1’s Skin Assessment showed on 9/19/24 at 2100 hours, Patient 1 was assessed with the inner thigh skin tear or rash. The site was cleaned with NS and zinc cream. The Wound Care was consulted. Review of the wound consult Progress Note dated 9/20/24 at 1112 hours, showed Patient 1 had a MASD. The wound location was at the right posterior thigh and perirectal. The wound bed was as erythemic rash with superficial skin rash and denuded skin surface. The WC recommended to clean the MASD with NS (normal saline, a solution of salt and water) or wound cleanser, apply zinc oxide (a topical ointment helping the wound healing) cream every 12 hours and as needed after pericare. Review of the RNs documentation of treatment performed for Patient 1’s MASD showed the following: - On 9/20/24 at 1632 and at 1905 hours, the wound was cleaned with NS. - On 9/2124 at 1403 hours, the wound was cleaned with NS. The Director of Quality verified the prevention and management for Patient 1’s MASD was not implemented. The findings were shared with the Director of Quality.”

“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: 37663 Based on interview and record review, the hospital failed to ensure the plan of care was developed and updated for one of one sampled patient (Patient 1). This failure posed the potential to negatively impact the patient’s health outcomes. Findings: On 9/26/24 at 1400 hours, an interview and record review were conducted with the Director of Quality. Patient 1’s medical record showed the patient was admitted to the hospital on 9/7/24, and discharged on 9/10/24 at 1828 hours. The patient was returned to the hospital ED on 9/10/24 at 2131 hours. a. Review of the H&P examination dated 9/7/24, showed Patient 1’s potassium level was 3.0 mmol/L (the normal level is from 3.6 to 5.0 mmol/L). Review of the laboratory results showed the following: - On 9/7/24 at 0821 hours, the patient’s potassium level was 4.1 mmol/L. - On 9/8/24 at 0623 hours, the patient’s potassium level was 3.5 mmol/L. - On 9/9/24 at 0600 hours, the patient’s potassium level was 3.1 mmol/L. - On 9/10/24 at 1369 hours, the patient’s potassium level was 2.7 mmol/L. Review of physician’s orders showed the following: - On 9/9/24 at 1933 hours, administer one dose of potassium chloride (a supplement) 20 mEq. - On 9/10/24 at 1702 hours, administer one dose of potassium chloride 20 mEq tablet. b. Review of the laboratory results showed the following: - On 9/8/24 at 0623 hours, the patient’s CO2 level was 17 mmol/L (the normal level is from 22 - 30 mmol/L) - On 9/9/24 at 0600 hours, the patient’s CO2 level was 15 mmol/L. - On 9/10/24 at 1369 hours, the patient’s CO2 level was 19 mmol/L. Review of physician’s orders showed on 9/9/24 at 2100 hours, sodium bicarb drip 1/2 NS 1000 ml added sodium bicarb 50 mEq per 50 ml to run at 80 ml per hour. c. Review of physician’s orders dated 9/7/24 at 0425 hours, showed to perform neuro checks every four hours. d. Review of RN’s Integumentary Assessment for Patient 1 dated 9/9/24 at 1025 hours, showed Patient 1 had skin tear at the right inner thigh buttock crease. However, review of Patient 1’s Interdisciplinary Plan of Care did not show the plan of care was developed for neurological intervention including the frequency of neurological assessment every four hours, cardiovascular including the expected or goals for fluid and electrolyte balance, and discharge planning. In addition, the patient’s plan of care related to the integumentary was not updated when the patient had developed an impaired skin integrity at the right inner buttock crease. The findings were verified with the Director of Quality.”

“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: 37663 Based on interview and record review, the hospital failed to ensure one of one sampled patient (Patient 1) was administered the drugs as evidenced by: a. Patient 1 was placed on the oxygen therapy without physician’s order. b. The RN did not ensure the PTT baseline was obtained before administering the heparin (anticoagulant medication) IV bolus for Patient 1. These failures posed the increased risk for the substandard health outcomes to the patient. Findings: On 9/25/24, review of Patient 1 medical record was initiated. Patient 1’s medical record showed the patient was admitted to the hospital on 9/7/24 and discharged on 9/10/24 at 1828 hours. The patient was returned to the hospital ED on 9/10/24 at 2131 hours. a. Review of the hospital’s P&P titled Oxygen Therapy dated 9/27/24, showed oxygen is a drug and requires a physician’s order. RCP and RN can place low flow oxygen on a patient (i.e. nasal cannula). RCP will assess patients in oxygen therapy once per shift. Review of the RN’s vital signs documentation showed on 9/10/24 at 1159 hours, the patient was on 1 liter/nc oxygen. Review of the RT’s assessment for Patient 1 dated 9/10/24, showed at 1557 hours, the patient was on 1 liter/nc oxygen. On 9/30/24 at 1040 hours, an interview and concurrent review of Patient 1’s medical record was conducted with the Director of Quality. The Director of Quality was asked to show the order for the use of oxygen for Patient 1. The Director of Quality stated there was no order to use oxygen for Patient 1. b. Review of the hospital’s P&P titled Pharmacy Managed Continuous Heparin Protocol dated 11/24/21, showed in part: - When the clinical pharmacy receives an order such as heparin per pharmacy, Heparin per pharmacy protocol, or similar language, the clinical pharmacist is authorized to initiate and adjust orders for continuous IV heparin dose and diagnostic testing such as PTT, PT/INR, CBC, and anti-XA level to monitor heparin therapy. - The clinical pharmacist documents the required orders in the patient’s medical record. - The clinical pharmacist doses and monitors heparin therapy based on the “Guidelines for Continuous IV Heparin Therapy” as approved by the Pharmacy and Therapeutics and Medical Executive Committees. - The clinical pharmacist appropriate appropriately assess the patient prior to initiating heparin therapy and documents the initial assessment in the medical record. The initial assessment includes, but not limited to indication for use; goal PTT; history of previous anticoagulant use; risk factors for adverse events; baseline PTT, PT/INR, H/H, and platelet count; and plan and recommendation. On 9/25/24 at 1432 hours, review and concurrent record review of Patient 1’s record was conducted with the Director of Quality. Patient 1’s medical record showed Patient 1 was readmitted to the hospital ED on 9/10/24 at 2123 hours. Review of the ED Physician Chart dated 9/11/24 at 0726 hours, showed Patient 1’s initial troponin level was markedly elevated 1.05 ng/ml and the repeated troponin level began to rise to 1.14 ng/ml and was concerning for NSTEMI. The EKGs did not show evidence of ischemia. The cardiology was consulted who recommended heparin bolus and infusion. Further review of the ED Physician’s Chart showed the following verbal orders: - At 0500 hours, heparin drip per pharmacy protocol. - At 0503 hours, PT/INR. - At 0504 hours, PTT. - At 0521 hours, heparin 5000 units/ml IV bolus. Review of ED Nursing Chart dated 9/11/24, showed the following: - At 0522 hours, heparin 5000 units/ml IV bolus was administered to Patient 1. - At 0539 hours, the PT/INR and PTT blood tests were performed by ED RN. Review of the laboratory result for PTT showed on 9/11/24 the blood for the PTT was collected at 0520 hours, received at 0539 hour, and resulted at 0638. The PTT level was more than 200 seconds (the normal range is from 25 - 38 seconds). The result was called and verified with the ED MD that Patient 1 was on heparin. On 10/1/24 at 0917 hours, an interview and concurrent review of Patient 1’s medical record review was conducted with the Pharmacy Coordinator, Director of Quality and Director of ED. The Pharmacy Coordinator was asked about the order of heparin drip for Patient 1 and the PTT result. The Pharmacy Coordinator stated there was a mismatch of the RN’s documentation about the blood draw and the administration of heparin bolus with 2 minutes time difference and the result of PTT of over 200 seconds. The baseline PTT was needed for the adjustment of the heparin drip. The Director of ED was asked for the practice in ED. The Director of ED stated the RN would draw the blood and then give the heparin IV bolus. The findings were verified with the Director of Quality.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure the hospital’s P&P for discharge planning was implemented for one of one sampled patient (Patient 1) when Patient 1’s discharge planning was not timely evaluated. This failure posed an increased risk for unsafe discharge the patient. Findings: Review of the hospital’s P&P titled Assessment and Reassessment of Patient effective date 2/28/24, showed an assessment of discharge planning needs is initiated within 24 hours of admission and is ongoing throughout the hospitalization. This is a collaborative process involving patient, family, and qualified individuals of the healthcare teams appropriate. Case management, nursing staff, including CSMs with physicians, and physical therapist or occupational therapist, if available participate in morning huddles to discuss current patient status and safety or other issues affecting the patient from being discharged. Documentation occurs in the Initial Discharge Assessment and is updated every 72 hours on the Case Management Flow Chart in the EMR. The role of the case manager is explained to the patient and or family and document on the Interdisciplinary Plan of Care. Review of the hospital’s P&P titled Discharge Planning dated 1/9/19, showed in part: * Purpose: To provide patients with timely, coordinated, and safe discharge plan for smooth transition from hospital to discharge destination that meets the needs and acuity of the patient. * Policy: - Discharge planning evaluations or services are triggered through the screening process or are available upon request of the physicians, nurses, patient, patient’s representative, and caregiver or family members. * Procedure: - Initial Assessment: Discharge planning begins at admission assessment by the admitting within 24 hours of admission. The RN identifies patient at risk for discharge planning needs and facilitates the interdisciplinary support for requested consultations for continuing care coordination. The CM department (Case Manager, RN, LVN, and Social Workers) have a comprehensive knowledge and experience in discharge planning. A screening process is utilized in determining which patients are at increased risk of adverse health consequences if discharge planning is lacking. Screening for discharge planning needs includes those likely to need post-hospital services, high risk cases and appropriate referrals, but is not limited to: over 65 years of age and lives alone or with someone who is compromised - Discharge Planning: As part of the discharge or transition, planning process the case manager meets with the patient or family on the day of admission or as early as appropriate to understand the patients care needs, insurance benefit limitations or resources, barriers to discharge and to establish realistic care goals and transition plan. The CM or SW will discuss the discharge plan or goals with the patient or patient’s legal representative. - Implementation includes to assess the stability of the patient prior to discharge or transfer, notify the physician of any changes in condition. Review of hospital’s P&P titled Discharge Planning dated 9/25/24, showed the primary are of responsibility for coordinating the discharge planning process rests with the case managers. The clinical social worker will assist as needed. On 9/26/24 at 1118 hours, an interview and concurrent review of Patient 1’s medical record was conducted with the Director of Utilization Management and Director of Quality. Patient 1’s medical record showed the patient was admitted to the hospital on 9/7/24 and discharged on 9/10/24. Review of the Case Management Initial Review dated 9/9/24 at 1522 hours, showed Patient 1 was admitted on 9/7/24. The Director of Utilization Management was asked about the hospital’s discharge process. The Director of Utilization Management stated the hospital had a designated discharge planner. The SW would do the initial assessment for the patient. When asked about the initial screening as per the hospital’s P&P, the Director of Utilization Management stated the SW would do the initial screening. The CM would attend the daily huddles at 0800 hours with the CSM, CNO, houses supervisor and discuss patients who were on observation status, patients who had longer than five days stay, patients who would be discharged home or transferring. On the weekend, they also had huddles and got the reports from the CSMs or bedside RNs. For the newly admitted patients, the discharge process started by the following day of admission. The Director of Quality was asked for the screening for Patient 1’s discharge planning. The Director of Quality could not show documented evidence the screening for the discharge planning was done or performed by the SW. The Director of Quality showed the Case Management Initial Review dated 9/9/24 at 1522 hours; however, the form was not completed. The Director of Utilization Management stated the patient was discharged home on 9/10/24. The findings were verified with the Director of Quality.”

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 39796 Based on observation, interview, and record review, the hospital failed to ensure the temperature level was maintained the SPD Decontamination room on 9/10/24. This failure had the potential to result in poor health outcomes to the patients. Findings: Review of the hospital’s P&P titled Temperature and Humidity Levels: ICU, NICU, Nursery, Delivery Rooms and Operating Rooms dated 9/27/23, showed the following: * The responsibility of the Engineering Department is to ensure that the temperature and humidity levels are maintained within the appropriate range. * The temperatures will be maintained between 60 to 73 degrees Fahrenheit for the Sterile Processing Decontamination room. * Clinical designee or designee will check and document the temperature and humidity levels every morning prior to beginning of the shifts in the temperature and humidity logs for that area. * If the temperature and /or humidity levels are observed to be out of range, the following process will be followed: - If the variance is observed, the clinical personnel will notify/call engineering and follow up every 15 minutes for a response. - Once the temperature and humidity levels are brought back in range, the adjusted temperature and humidity levels will be documented on the log indicating the time of the resolution. On 9/10/24 at 1257 hours, a tour of the SPD decontamination area was conducted with the Sterile Technician. The temperature monitor for the SPD decontamination area was observed. The temperature level was 74.4 degrees Fahrenheit which was out of range and the humidity level was 58.4%. On 9/10/24 at 1316 hours, a tour of the SPD department was conducted with the Quality Director, Director of Surgical Services, Sterile Processing Supervisor, and Sterile Technician. At 1316 hours, the temperature level of the SPD decontamination was 75 degrees Fahrenheit which was out of range and the humidity level was 57.8%. Review of the Daily Temperature and Humidity Log SPD Decontam (Decontamination) for September 2024 showed the acceptable temperature range was 60 to 65 degrees Fahrenheit and the acceptable humidity range was 20 to 60%. The log also showed the staff had performed the temperature and humidity checks daily from 9/1 - 9/9/24, and the temperature and humidity levels were documented as within the acceptable range. However, review of the Daily Temperature and Humidity Log SPD Decontam for September 2024 showed the temperature and humidity levels for 9/10/24 was left blank. The Sterile Technician was asked if the room needed to be on a controlled temperature. The Sterile Technician stated yes, the temperature levels should be around 60 to 65 degrees Fahrenheit and the humidity levels should be 20% and maximum of 60%. When asked if the temperature levels were within the acceptable range, the Sterile Technician stated no. When asked what he needed to do if the temperature levels were out of range, the Sterile Technician stated he usually called the engineering staff for out of range. When asked about the frequency of checking the temperature levels, the Sterile Technician stated every day, no specific hours, and usually in the morning when the Sterile Technician started the shifts. When asked if there was any documented temperature levels of the SPD Decontamination room on 9/10/24, the Sterile Technician stated no, the Sterile Technician forgot to document today, 9/10/24, because the Sterile Technician was busy. The Sterile Technician provided an additional copy Daily Temperature and Humidity Log SPD Decontam for September 2024, which showed on 9/10/24, the temperature was 74 degrees Fahrenheit and the humidity level was 51%. A follow- up interview was conducted with the Quality Director, Director of Surgical Services, Sterile Processing Supervisor, and Sterile Technician. When asked if the temperature was within the normal range, the Director of Surgical Services stated no, but the humidity level was within the normal range. When asked about the intervention when the temperature level was out of range, the Director of Surgical Services stated the staff would call the engineering staff. When asked when the staff needed to document in the log, the Sterile Technician stated just now. The Sterile Processing Supervisor also stated the Sterile Processing Supervisor did not know why the temperature was not checked in the morning. When asked how they knew if the room temperature was within the normal range since this morning. The Sterile Technician stated the Sterile Technician could feel the temperature and usually call the engineering staff to fix it. The Sterile Technician further stated he did not know the temperature in the morning because he was doing something else. The hosptial’s adminstration staff was informed and acknowledged the findings.”