Garden Grove Hospital & Medical Center

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff provided the necessary nursing care as per the hospital’s P&Ps for two of 10 sampled patients (Patients 1 and 9) as evidenced by: 1. For Patient 1: a. The nursing staff failed to document wound classification upon admission for Patient 1 and failed to assess skin impairment when the photograph was taken for the skin impairment for Patient 1. In addition, there was no wound care consultation per the order for Patient 1. b. The nursing staff failed to perform complete nursing admission assessment as per the hospital’s P&P for Patient 1. 2. For Patient 9: a. The nursing staff failed to notify the physician when the femoral central line was accidentally removed for Patient 9 and failed to examine the removed femoral central catheter’s length and tip for Patient 9. b. The nursing staff inaccurately documented the reason for central line removal and catheter tip culture for Patient 9. These failures increased the risk of substandard healthcare outcomes for the patients. Findings: 1. On 6/26/26, Patient 1’s closed medical record was reviewed. Review of Patient 1’s medical record showed Patient 1 was admitted to the hospital on 2/25/26 and was discharged on 3/4/26. a. Review of the hospital’s P&P titled Skin Integrity dated 12/3/25, showed the following: * Skin assessment is a component of the initial admission nursing assessment. If it is determined at the time of the admission nursing assessment that the patient is at high risk for developing a wound or if the patient admits with a wound, the nurse will initiate prevention protocols and wound care orders. A wound care consultation will be ordered, and a further detailed assessment will be completed by the wound care nurse. * Staging of pressure injury will be deferred to wound care RN (WCC or WOCN), NP, PA, designated health professionals, and physicians. * Detailed Assessment. Detailed assessment should be completed within 24 hours of admission and then weekly thereafter, with a change of condition, and upon discovery of a new wound. * Photographing. Photographed alterations in skin integrity, open wounds, and pressure injuries are to be uploaded in the EMR. On 6/26/26 at 1240 hours, Patient 1’s medical record was reviewed with RN 1. * Review of the photography dated 2/25/26, showed the photo of Patient 1’s sacrum was taken. The photo showed skin darkness on the sacrum. When asked about the wound classification, RN 1 stated there was no nursing documentation about the skin on the sacrum. * Review of the photography dated 2/25/26, showed the photo of Patient 1’s sacrum was taken. Review of the photography dated 3/1/26, showed the photo of Patient 1’s left hip was taken. The photography dated 3/1/26, showed dark color of circular shape on the left hip. When requested to provide described nursing assessment, RN 1 stated she was not able to find documented nursing skin assessment in Patient 1’s EMR. * Review of the order dated 2/27/26 at 2007 hours, showed to consult to wound/ostomy care team. Review of the Orders dated 3/3/26 at 1220 hours, showed to consult to wound/ostomy care team. However, further medical record review failed to show the consultation of the wound care team. b. Review of the hospital’s P&P titled Assessment & Reassessment- Patient dated 12/3/25, showed an initial assessment will be completed within 24 hours of admission of all inpatients. Review of the order dated 2/25/26 at 1300 hours, showed to admit Patient 1 to stepdown unit. Review of the Nursing Note dated 2/27/26 at 2244 hours, showed Patient 1 arrived to the unit at 2000 hours. The Patient 1 stayed in ED until 2/27/26 at 2244 hours. When asked, RN 1 stated the nursing staff was to complete Admission tab under Navigators. Review of the Admission tab included psychosocial, nutrition, ADL screening, and vaccination, discharge planning etc. Further review of Patient 1’s medical record showed the Admission tab was completed on 2/27/26 at 2000 hours (55 hours after the inpatient order). 2. On 6/29/26, Patient 9’s closed medical record was reviewed. Review of Patient 9’s record showed Patient 9 was admitted to the hospital on 4/7/26 and was discharged on 4/11/26. a. Review of the hospital’s P&P titled Central Line Bundle dated 6/4/25, showed * The purpose of the P&P is to provide short-term, intermediate, and/or long-term vascular access for the purpose of administering total parenteral nutrition, chemotherapy, IV fluids and medications, drawing of blood specimens and administering transfusions, to a patient. * Under 7.0 Removal of Central Lines, showed to examine catheter length and tip to ascertain that catheter was removed intact. Review of the hospital’s P&P titled Physician Notification or Physician Unavailability dated 6/4/25, showed the physician responsible for the patient’s care shall be informed immediately of changes in the patient’s condition by the nurse responsible for the patient’s care. Review of the Nursing Note dated 4/8/26 at 1435 hours, showed the central line was removed unexpected during dressing change following line draw for the laboratory test at 1600 hours. However, further review of Patient 9’s medical record failed to show the central line remove by accident was reported to the physician who was responsible for Patient 9; and failed to show the central line catheter length and tip were examined as per the hospital’s P&P. b. Review of the Nursing Note dated 4/8/26 at 1435 hours, showed the central line was removed unexpected during dressing change following line draw for the laboratory test at 1600 hours. Review of the CVC Properties dated 4/10/26 at 1630 hours, showed the triple lumen to right femoral was removed due to being infiltrated and the catheter tip was cultured. During an interview and concurrent medical record review with RN 1 on 6/29/26 at 1000 hours, RN 1 stated there was no culture was performed for the catheter tip. On 6/29/26 at 1510 hours, the CNO and Director of ED and ICU 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 as per the physician’s order for one of 10 sampled patients (Patient 10). This failure created the risk of medication errors and poor health outcomes to the patient. Findings: On 6/29/26, Patient 10’s closed medical record was reviewed. Review of Patient 10’s medical record showed Patient 10 was admitted to the hospital on 2/13/26. 1. Review of the physician’s order dated 4/11/26 at 1231 hours, showed to initiate norepinephrine (a medication used to treat low blood pressure) infusion at 0.1 mcg/kg/min and titrate by 0.03 mcg/kg/min every five minutes to maintain MAP 65 to 75 mmHg. The maximum dose was 1 mcg/kg/min. Review of the Nursing Note dated 4/11/26 at 1350 hours, showed Patient 10 was transferred to ICU at 1300 hours. Review of the MAR and Flowsheet History dated 4/11/26, showed the following: * At 1306 hours, BP was 57/32 mmHg and MAP was 42 mmHg. Norepinephrine was infusing at 0.1mcg/kg/min. .... * At 1315 hours, BP was 58/40 mmHg and MAP was 46 mmHg. Norepinephrine was infusing at 0.8mcg/kg/min. * At 1320 hours, BP was 73/40 mmHg and MAP was 51 mmHg. Norepinephrine was infusing at 0.8mcg/kg/min. (norepinephrine was not titrated up). ..... * At 1355 hours, BP was 78/49 mmHg and MAP was 59 mmHg. Norepinephrine was infusing at 0.8mcg/kg/min. (norepinephrine was not titrated up). * From 1400 hours to 1415 hours, Patient 10’s MAP did not meet between 65 to 75 mmHg. * At 1420 hours, BP was 118/63 mmHg and MAP was 73 mmHg. * From 1425 hours to 1450 hours, Patient 10’s MAP did not meet between 65 to 75 mmHg. However, norepinephrine was not titrated up until at 1450 hours. * At 1450 hours, norepinephrine was infusing at 1 mcg/kg/min. 2. Review of the physician’s order dated 4/11/26 at 1425 hours, showed to administer sodium bicarbonate (a mineral and electrolyte) 8.4 % injection 100 mEq once. Review of the MAR dated 4/11/26 at 1430 hours, showed the sodium bicarbonate 8.4% injection 100 mEq was not administered. On 6/29/26 at 1510 hours, the CNO and Director of ED and ICU acknowledged the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 45560 Based on interview and record review, the hospital failed to ensure that the plan of care for one of four sampled patients (Patient 4) was updated to reflect the use of restraints. This failure posed a risk of substandard outcomes for the patient. Findings: Review of the hospital’s P&P titled Restraints: Non-Violent Behavior reviewed June 2025 showed the use of restraints is in accordance with a written modification to the patient’s plan of care. The Documentation section showed to use Electronic Medical Record Restraint Flow Sheet, restraint order forms and narrative notes to document all pertinent information in the medical record including but not limited to plan of care/treatment plan - include criteria for discontinuation when applicable. During a concurrent interview and record review on 12/18/25 at 1330 hours, with the Director of Med/Surg-Tele and the Director of Performance Improvement, Patient 4’s electronic medical record was reviewed. Patient 4’s medical record showed the patient was admitted to the hospital on 12/15/25. Review of Patient 4’s orders showed an order dated 12/16/25 at 0105 hours, to place a Posey Belt on Patient 4 due to interference with medical treatment. Review of Patient 4’s medical record did not show Patient 4’s plan of care was updated to reflect the use of restraints. On 12/18/25 at 1400 hours, the Director of Med/Surg-Tele and the Director of Performance Improvement acknowledged and verified the 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: 45560 Based on interview and record review, the hospital failed to ensure the staff reassessed and monitored one of four sampled patients (Patient 4) as per the hospital’s P&P while Patient 4 was restrained. This failure had the potential to result in unsafe care for the patient. Findings: Review of the hospital’s P&P titled Restraints: Non-Violent Behavior reviewed June 2025 showed a patient in restraints is monitored at least every two hours or more often as applicable to the patient. Monitoring is accomplished by observation, interaction with the patient, or related direct examination of the patient by qualified staff. Monitoring includes: the patient’s physical and emotional well-being; the patient’s rights, dignity and safety are maintained; if less restrictive methods are possible; changes in the patient’s behavior or clinical condition needed to initiate the removal of restraints. Care includes: toileting, positioning, circulation checks, range of motion, and food/fluids offered. During a concurrent interview and record review on 12/18/25 at 1330 hours, with the Director of Med/Surg-Tele and the Director of Performance Improvement, Patient 4’s electronic medical record was reviewed. Patient 4’s medical record showed the patient was admitted to the hospital on 12/15/25. Review of Patient 4’s orders showed an order dated 12/16/25 at 0105 hours, to place a Posey Belt on Patient 4 due to interference with medical treatment. Patient 4’s order for restraint was renewed on 12/17/25 at 0055 hours. Review of Patient 4’s Restraint Flowsheet dated 2/16/25, showed no restraint monitoring documentation on 2/16/25 from 2200 hours to 0600 hours on 2/17/25 (eight hours). Review of Patient 4’s Restraint Flowsheet dated 2/17/25, showed no restraint monitoring documentation on 2/17/25 from 1400 to 1800 hours (four hours). On 12/18/25 at 1400 hours, the Director of Med/Surg-Tele and the Director of Performance Improvement acknowledged and verified the 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: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff provided the necessary care to one of four sampled patients (Patient 1) in the ED as evidenced by: 1. The nursing staff failed to perform the reassessment including the vital signs for Patient 1 as per the hospital’s P&P. 2. The nursing staff failed to perform the pain reassessment after the pain medication was administered for Patient 1 as per the hospital’s P&P. These failures had the potential to result in substandard care to the patients. Findings: On 5/20/25, Patient 1’s closed medical record was reviewed. Patient 1’s medical record showed Patient 1 arrived in the ED on 5/3/25 at 1240 hours, and was discharged from the ED on 5/3/25 at 1704 hours. 1. Review of the hospital’s P&P titled Assessment- Reassessment, Patient dated 3/2/23, showed the following: * Repeat vital signs to be measured and documented as follows: - For Level III, at least every 60 minutes with the understanding that more frequent assessment is often indicated and will be expected until vital signs are stable. If vital signs are stable, they will be measured every 30 to 60 minutes until patient is assessed at a higher acuity level. * The nurse assigned to the patient is responsible for continual assessing/reassessing of the patient’s condition: - Obtaining and documenting vital signs per patient acuity or condition - Abnormal vital signs will be checked prior to discharge - Persistent abnormalities (patient status and/or vital signs) will be reported to physician prior to patient being discharged from the ED - Discharge vital signs and patient condition will be documented on all patients. Review of the Patient Care Timeline for Patient 1 dated 5/3/25, showed the following: * At 1241 hours, Patient 1’s vital signs were measured. * At 1246 hours, Patient 1’s acuity level was 3. * At 1529 hours, the shift assessment was performed. * At 1704 hours, Patient 1 was discharged from the ED. There was no documented evidence to show Patient 1’s vital signs were assessed at least every 60 minutes as per the hospital’s P&P. On 5/20/25 at 1330 hours, the Director of ED verified the findings. 2. Review of the hospital’s P&P titled Pain Management dated 12/5/24, showed the goal is to maintain a pain rating of the patient’s own comfort level goal. This may be documented with the pain intensity score, by indicating intervention effective, or by patient statement that they do not need treatment for pain. Pain will be reassessed after each pain management intervention. Review of the Patient Care Timeline for Patient 1 dated 5/3/25, showed the following: * At 1241 hours, Patient 1 complained of pain to the right wrist with the pain score of five out of 10 (0 being no pain and 10 being the worst pain). Patient 1 stated pain goal was no pain. * At 1246 hours, Patient 1’s acuity level was 3. * At 1301 hours, the ED Provider evaluated the patient. * At 1419 hours, acetaminophen (a pain medication) tablet 1,000 mg was ordered. * At 1517 hours, Patient 1’s pain score was five out of 10. * At 1518 hours, Patient 1 received acetaminophen tablet 1,000 mg by mouth. * At 1704 hours, Patient 1 was discharged from the ED However, further review of Patient 1’s medical record failed to show Patient 1’s pain reassessment after the pain medication was administered to the patients. On 5/20/25 at 1330 hours, the Director of ED verified the above findings.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 39199 Based on observation, interview, and record review, the hospital failed to ensure the provision of services from other hospital departments was coordinated to provide the appropriate care to three of three sampled patients (Patients 1, 2, and 3) in the ED as evidenced by: 1. For Patient 1, the hospital failed to ensure the required initial assessment and ongoing focused assessments were conducted for Patient 1 after admitted to the ICU (while boarded in the ED). In addition, the hospital failed to ensure norepinephrine (a medication used to increase and maintain blood pressure in patients with severe, acute hypotension) was administered for the patient according to the prescribed order. 2. For Patient 2, the hospital failed to ensure the required initial assessments were completed for the patient after the patient’s level of care was changed to telemetry while boarded in the ED. 3. For Patient 3, the hospital failed to ensure the required initial assessments were completed for the patient after the patient’s level of care was changed to telemetry, while boarded in the ED. These failures had the potential to result in substandard care for the patients. Findings: Review of the hospital’s P&P titled Full Capacity Procedure (Surge Plan) dated 12/5/24, showed boarded patients are defined as patients that have an accepting admitting attending physician and are waiting in the ED for an inpatient bed, greater than 61 minutes. Review of the hospital’s P&P titled Assessment/Reassessment of Patients dated 3/2/23, showed the purpose of the policy is to ensure comprehensive assessment and documentation of both the initial assessment and ongoing reassessments of patients admitted to the hospital. The initial assessment includes evaluation of the patient’s physical, psychological, and social condition; nutrition and hydration status; functional status; and spiritual and cultural considerations for end-of-life care, if indicated. In the Critical Care Unit, the initial assessment is to be completed immediately upon arrival. In the Telemetry Unit, it must be completed within one hour. In the Intensive Care Unit (ICU), a focused assessment or reassessment is performed at least every two hours for any systems that are unstable or deteriorating. 1. On 4/11/25 at 0921 hours, a closed medical record review for Patient 1 was initiated with the Stroke Coordinator, Director of Performance Improvement, Director of ED and ICU, Pharmacist 1, and the CNO. Patient 1’s closed medical record showed the patient was admitted to the hospital ED on 2/20/25. a. Review of the ED Provider Notes dated 2/20/25 at 1848 hours, showed Patient 1 was brought to the ED by ambulance due to altered mental status and vomiting blood. Upon arrival, the patient was noted to be cyanotic and bradycardic with a faint pulse. The provider’s note further showed Patient 1 was intubated upon arrival and shortly thereafter experienced pulseless electrical activity (PEA) cardiac arrest. Review of Patient 1’s Admit to Inpatient order dated 2/20/25, showed the level of care was designated as ICU and started at 2213 hours. Patient 1’s medical record also showed the patient was boarded in the ED while waiting for an available ICU bed. Review of Patient 1’s medical record did not show documented evidence the initial assessment was conducted after the patient’s level of care was changed to ICU, nor the focused assessments/reassessments performed every two hours on systems that were unstable or deteriorating. During the interview and concurrent closed record review, the Director of ED and ICU, along with the CNO, verified the findings and stated the nurses should have completed the comprehensive initial assessment when Patient 1 was boarded in the ED while waiting for an ICU bed, following the admission to the inpatient order. The Director of ED and ICU also verified the focused assessment of Patient 1’s gastrointestinal, respiratory, cardiac, and neurological systems should have been conducted every two hours, but was not. b. Review of the physician’s order dated 2/20/25 at 2130 hours, showed an order to initiate norepinephrine infusion at a rate of 0.1 mcg/kg/minute. The order also specified the dose should be titrated by 0.03 mcg/kg/min every five minutes to maintain a mean arterial pressure (MAP) above 65 mmHg, with a maximum dose of 1 mcg/kg/minute. However, review of Patient 1’s All Administrations of norepinephrine (LEVOPHED) 8 mg in Dextrose 5% 250 ml Infusion showed the norepinephrine was not initiated at the ordered rate of 0.1 mcg/kg/minute, but was initiated at the maximum dose on 2/20/25 at 2208 hours, with no documented justification. Review of Patient 1’s medical record showed a MAP reading was obtained at 2155 hours prior to the initiation of the norepinephrine infusion, but no further MAP readings were obtained to titrate the medication as ordered. During the interview and concurrent record review, the Director of ED and ICU, the CNO, and Pharmacist 1 verified the findings and stated that the medication was not initiated at the ordered dose, and there was no documented evidence that MAP readings were obtained as required. 2. On 4/10/25 at 0905 hours, during the tour of the ED conducted with RN 1, Patient 2 was observed in ED Bed 11. RN 1 stated Patient 2 was boarded in the ED, awaiting a bed in the Telemetry Unit. On 4/10/25 at 1345 hours, a review of Patient 2’s medical record was initiated with the Stroke Coordinator and Director of Performance Improvement. Patient 2’s medical record showed the patient was admitted to the hospital ED on 4/9/25. Review of Patient 2’s Admit to Inpatient order dated 4/9/25, showed the level of care was designated as telemetry and started at 2152 hours. Review of Patient 2’s medical record did not show evidence that an initial assessment was conducted after the patient’s level of care was changed to telemetry. During the interview and concurrent record review, the Stroke Coordinator and Director of Performance Improvement verified the findings. 3. On 4/10/25 at 0905 hours, during the tour of the ED conducted with RN 1, Patient 3 was observed in ED Bed 9. RN 1 stated Patient 3 was boarded in the ED, awaiting a bed in the Telemetry Unit. On 4/10/25 at 1414 hours, a review of Patient 3’s medical record was initiated with the Stroke Coordinator and Director of Performance Improvement. Patient 3’s medical record showed the patient was admitted to the hospital ED on 4/9/25. Review of Patient 3’s Admit to Inpatient order dated 4/10/25, showed the level of care was designated as telemetry and started at 1135 hours. Review of Patient 3’s medical record did not show evidence that an initial assessment was conducted after the patient’s level of care was changed to telemetry. During the interview and concurrent record review, the Stroke Coordinator and Director of Performance Improvement verified the findings.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 38764 Based on interview and record review, the hospital failed to ensure the nursing staff documented an assessment for an advance directive for one of seven sampled patients (Patient 1). This failure posed the potential for not honoring the patient’s wishes. Findings: Review of the hospital’s P&P titled Advance Directives dated 3/2/23, showed the nursing staff is to document the information concerning the advance directives or surrogate decision maker on the “Patient Admission History/Assessment” form and individual patient care card as applicable. Review of Patient 1’s medical record was initiated on 2/7/24. Patient 1’s medical record showed the patient was admitted to the hospital on 2/3/24. Review of the Healthcare Directives tab dated 2/3/24 at 2000 hours, did not show the patient was assessed for an advance directive. On 2/7/24 at 1321 hours, an interview and concurrent record review of Patient 1’s medical record was conducted with RN 12. RN 12 acknowledged the above findings. When asked when the nursing staff assessed the patient for the advance directive, RN 12 stated the patient would be assessed for the advance directive upon admission to the nursing unit. RN 12 stated the nurse who admitted the patient would report to the incoming nurse during the change of shift report if the patient had not been assessed for athe advance directive upon admission. RN 12 was asked about the purpose of assessing the patient for the advance directive. RN 12 stated the purpose of the advance directive was for the healthcare staff to know about the patient’s healthcare decisions. On 2/9/24 at 1145 hours, an interview and concurrent medical record review of Patient 1 was conducted with Nursing Director 1. Nursing Director 1 acknowledged the above findings. Nursing Director 1 stated the admitting personnel would check if the patient had the advance directive; however, the nursing staff in the unit would not know about the information collected by the admitting personnel.”

“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: 40483 Based on interview and record review, the hospital failed to ensure the nursing staff adhered to the hospital’s P&Ps when creating the competencies for one ED LVN (LVN 1). This failure created the risk of substandard health outcomes to the patients in the ED. Findings: Review of the hospital’s P&P titled Competency Assessment, Employee; Organization-wide dated 12/7/23, showed the purpose is to provide a mechanism for directing and validating the competencies required by employees to provide quality healthcare to patients. Competency is defined a combination of observable and measurable knowledge, skills, abilities, and personal attributes that are needed to fulfill organizational, departmental, and work setting requirements. The competency assessment will include core job functions. Core(annual) topics are based on regulatory requirements and completed by clinical and non-clinical staff. Division (annual) topics are based on specific regulatory requirements for a division. Review of the hospital’s P&P titled Triage and Assessment dated 3/2/23, showed the triage assessment shall be performed by the ED RNs who were trained and would validate the competency in the use of the 5-Level Emergency Severity Index. Review of the Emergency Department Registered Nurse Clinical Skills Checklist for Orientation signed by LVN 1 on 7/20/23, showed the following: * Once a skill was competently performed without assistance, the preceptor would initial the column for “Independent Demo.” If the skill was not able to be completed in front of a preceptor, the alternative method such as policy reviewed and discussed was checked in the validation of competency by preceptor. * The Triage section showed LVN 1’s Self-Assessment was competent in triage including properly applying the 5-Level system. The method for validation of competency was policy reviewed and discussed. On 2/7/24 at 1148 hours, an interview was conducted with LVN 1. LVN 1 stated the LVN did not function as a RN and had their own skillset and scope of practice. LVN 1 stated the LVN could not assess the patient as the RN, but the LVN could collect data. LVN 1 stated LVN 1 could not perform triage, assess, and assign the patient with the ESI level. LVN 1 stated these skills were out of her scope of practice. LVN 1 stated she had to inform and remind other ED staff of her scope of practice versus the RN’s scope of practice. On 2/8/24 at 1000 hours, an interview and employee file review was conducted with the Clinical Educator. The Clinical Educator stated the competencies were skill assessments and completed through the unit by a preceptor who assessed their skills. These were completed to show if the staff could do the skills. The Clinical Educator verified LVN 1 was hired as an LVN, not an RN. The Clinical Educator verified LVN had a different scope of practice comparing to the RN. The Clinical Educator stated the LVN could not be held to the same expectations of competency as the RN as they had different scope of practice. The Clinical Educator reviewed and verified the LVN 1’s competency titled Emergency Department Registered Nurse Clinical Skills Checklist for Orientation was created for the RN’s competencies and based on an RN’s skills and scope of practice. The Clinical Educator reviewed the checklist and verified the LVN, based on their scope of practice could not assess the patient and assign the patient with the ESI level. 2/9/24 at 1435 hours, the CNO was made aware of the findings.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 38764 Based on interview and record review, the hospital failed to ensure the nursing staff adhered to the hospital’s P&Ps and implemented the physicians’ orders for two of seven sampled patients (Patients 1 and 2) as evidenced by: 1. For Patient 1, the nursing staff failed to ensure the patient was continuously monitored for the pulse oximetry levels as per the physician’s order. 2. For Patient 2, the nursing staff failed to ensure the patient was assessed consistently by the hemodialysis nurse during the hemodialysis treatment as per the hospital’s P&P. These failures had the potential to result in poor health outcomes for the patients in the hospital. Findings: 1. Review of the hospital’s P&P titled Physician’s Orders dated 3/2/23, showed the following: - The purpose of the P&P is to establish a practice and inform licensed healthcare professionals with the methodology involved in acknowledgment, coordination, and implementation of the diagnostic and therapeutic orders of medical staff members. Review of Patient 1’s medical record was initiated on 2/7/24. Patient 1’s medical record showed the patient was admitted to the hospital on 2/3/24. Review of the H&P examination dated 2/4/24 at 0800 hours, showed Patient 1 had a chief complaint of shortness of breath. The patient was admitted to the telemetry unit. Review of Patient 1’s physician’s order dated 2/3/24 at 2019 hours, showed to start the continuous pulse oximetry for the patient on 2/3/14 at 2020 hours. On 2/7/24 at 0800 hours, this physician’s order was discontinued. Review of Patient 1’s Tabular Trends did not show Patient 1 was monitored continuously for the pulse oximetry levels as per the physician’s order. The oxygen saturation level column of the Tabular Trends did not show the numeric values of the patient’s oxygen saturation levels. For example: - On 2/5/24 from 1400 hours to 2030 hours (approximately seven hours), - On 2/6/24 from 2200 hours to 2330 hours (approximately two hours), - On 2/7/24 from 0000 hours to 0730 hours (approximately eight hours). On 2/7/24 at 0950 hours, an interview and concurrent review of Patient 1’s medical record was conducted with Monitor Technicians 1 and 2. Monitor Technicians 1 and 2 acknowledged the documentation on the Tabular Trends for Patient 1 as described above. Monitor Technicians 1 and 2 were asked about the reason why there were no documentation of Patient 1’s oxygen saturation level. Monitor Technician 1 stated there were no documentation of Patient 1’s oxygen saturation level because the patient was in room air (patient had no oxygen supplement) and the patient was not connected to a pulse oximetry. Monitor Technicians 1 and 2 was asked how the monitor technicians would know if the patient needed continuous monitoring of oxygen saturation levels. Monitor Technician 1 stated the nurse would inform the monitoring technician if the patient needed continuous oxygen monitoring. On 2/7/24 at 1321 hours, an interview and concurrent review of Patient 1’s medical record was conducted with RN 12 and Nursing Director 1. RN 12 acknowledged the physician’s order of continuous pulse oximetry, as described above, for Patient 1. RN 12 was asked about the reason why there was no documentation to show Patient 1 was no longer on a continuous pulse oximetry. RN 12 stated the telemetry unit had a protocol to discontinue a continuous pulse oximetry when a patient was already on a room air. RN 12 stated the RN would follow up about the telemetry unit protocol about discontinuance of a continuous pulse oximetry for a patient as described above. On 2/8/24 at 0850 hours, a follow-up interview was conducted with Nursing Director 1. Nursing Director stated there was no unit protocol to discontinue a continuous pulse oximetry when a patient was on a room air. The Nursing Director 1 acknowledged the physician’s order was required to discontinue the continuous pulse oximetry for Patient 1. 2. Review of the hospital’s P&P titled Dialysis Nursing Assessment and Care of the Hemodialysis Patient dated 3/2/23, showed the following: * Nursing documentation is completed in the attached Hemodialysis Treatment Record for the following initial assessment and commencement of hemodialysis treatment. The following is to be documented every 15 minutes: BP, pulse, BFR, arterial/venous pressure, TMP, UFR, total fluid removed, fluid given, conductivity, and DFR. * Post Hemodialysis section showed to obtain and document the patient’s including weights. Review of the dialysis supplier’s Job Description for the acute dialysis RN (undated) showed the RN’s duties and responsibilities include to keep the complete and accurate documentation of all records in a timely manner; and make frequent patient assessments to ensure safety practices. Review of Patient 2’s medical record was initiated on 2/7/24. Patient 2’s medical record showed the patient was admitted to the hospital on 2/3/24. Review of the physician’s order dated 2/5/24 at 2323 hours, showed an order to administer hemodialysis treatments for Patient 2, starting on 2/6/24 at 1200 hours. The duration of the hemodialysis treatment was three hours. Review of the Pre-Hemodialysis Assessment dated 2/6/24 at 1330 hours, showed Patient 2 was identified using the patient’s name and date of birth and a pre-hemodialysis report was received from the nursing staff of the unit. Review of the Vitals flowsheet dated 2/6/24 from 1330 hours to 1600 hours, did not show Patient 2 was assessed for the BPs and pulse rates every 15 minutes as per the hospital’s P&P. Review of the During Hemodialysis Assessment dated 2/6/24 from 1330 hours to 1600 hours, did not show documented evidence the BFR, arterial/venous pressures, TMP, UFR, total fluid removed, fluid given, onductivity, and DRR were assessed every 15 minutes as per the hospital’s P&P. Review of the Post-Hemodialysis Assessment dated 2/6/24 at 1600 hours, showed Patient 2 was stable. The post treatment report was given the nursing staff. However, there was no documented evidence the patient’s weight was assessed after the hemodialysis treatment. The above flowsheets did not show the start time and completion time of Patient 2’s hemodialysis treatment. Review of the Nursing Note dated 2/6/24 at 1933 hours, showed Patient 2 received the hemodialysis treatment and had the fluid output of two liters. On 2/7/24 at 1544 hours, an interview and concurrent record review of Patient 2’s medical record was conducted with the dialysis supplier’s CEO. The dialysis supplier’s CEO acknowledged the above findings. The dialysis supplier’s CEO confirmed Patient 2 received the hemodialysis treatment on 2/6/24; however, the dialysis supplier’s CEO acknowledged the dialysis nurse who provided the hemodialysis treatment to the patient, did not document the start time and completion time of the hemodialysis treatment. On 2/8/24 at 0900 hours, an interview and concurrent review of Patient 2’s medical record review was conducted with Nursing Director 1 and RN 11. Nursing Director 1 and RN 11 acknowledged the above findings.”