Glendale Adventist Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50516 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient’s Rights was met, as evidenced by: 1. The facility failed to ensure that one of 50 sampled patients (Patient 2) was informed of intraoperative care interventions (interventions performed while the patient is in the operating room, such as positioning, monitoring, and the use of safety or stabilizing devices), specifically the use of safety straps prior to surgery, in accordance with the facility’s policy regarding patient rights (fundamental rules and guarantees that ensure patients are treated with respect, dignity, and fairness while receiving medical care. Example: right to be informed). The facility’s nursing staff did not provide pre-operative education to Patient 2 regarding the application and purpose of safety straps used to secure patients on the operating room table. This deficient practice resulted in a violation of Patient 2’s right to be informed (meaning to receive information in a manner they can understand regarding the care, procedures, and interventions planned for them) and created a potential risk for unanticipated discomfort, injury, or worsening of existing physical limitations. (Refer to A-0129) 2. The facility failed to ensure that one (1) of 50 sampled patients (Patient 1), who was receiving continuous BiPAP (Bilevel Positive Airway Pressure, a non-invasive ventilation device that assists breathing by delivering pressurized air through a mask)/NPPV therapy (Non-invasive positive pressure ventilation [NPPV or NIV], a non-invasive ventilation method that assists breathing by delivering pressurized air through a mask), was assessed every two (2) hours, in accordance with the facility’s policy titled “Non-invasive positive pressure ventilation (NPPV/NIV),” (last revised 9/4/2020), which required Q2-hour (every 2-hours) assessments of both the machine settings and the patient’s clinical status (a patient’s current medical condition or state of health). This deficient practice had the potential to result in delayed recognition of respiratory decline (the gradual weakening of the body’s breathing system) for Patient 1, including worsening work of breathing, unsafe drops in oxygen saturation (the percentage of hemoglobin in the blood carrying oxygen), mask or equipment malfunction, or failure of the ordered therapy. In addition, this deficient practice had the potential to increase the risk that Patient 1’s clinical deterioration (when a patient’s health gets worse) could go unrecognized and untreated in a timely manner, placing the patient at risk for further respiratory compromise (a dangerous state where a person’s breathing becomes impaired, making it hard to get enough oxygen) or the need for emergency escalation of care (the process of getting a patient more help or a higher level of medical attention when their condition worsens). (Refer to A-0129) 3. The facility failed to ensure that one of 50 sampled patients (Patient 38), received the results of an ultrasound (US, a safe painless imaging test that uses high-frequency sound waves to create real-time pictures of the inside of your body) of the leg in a timely manner (within 24 hours). Patient 38 received the results on the patient portal of the US, four (4) days after the test was conducted (Imaging test was done on 1/1/2026 and the final report was made available on 1/5/2026 in the patient’s portal [a secure website or mobile app that lets the patient view their personal health records and easily communicate with their healthcare team]). This deficient practice resulted in a violation of Patient 38’s right to be informed (meaning to receive information in a manner they can understand regarding the care, procedures, and interventions planned for them) and created a potential risk for unanticipated discomfort, injury, or worsening of existing physical limitations. (Refer to A-0129) 4. The facility failed to ensure one of 50 sampled patient’s (Patient 31) designated representatives were informed by the facility’s nursing staff regarding Patient 31’s worsening condition, in accordance with the facility’s policy regarding nursing standards of care. This deficient practice had the potential to create distrust and miscommunication among Patient 31’s representative and the healthcare team, which could have impacted Patient 31’s overall care plan. (Refer to A-0131) 5. The facility’s Emergency Department (ED) failed to ensure that one (1) of the 50 sampled patients (Patient 8), received care in a safe setting. The ED did not provide a required safety assessment or assign a one-to-one sitter (a caregiver or aide assigned to constantly observe a single vulnerable patient-someone at risk of falling, wandering, or self-harm) despite the psychiatrist’s documented plan for constant observation and despite Patient 8 having been assessed as high risk for aggression (behavior aimed at opposing or attacking someone), in accordance with the facility’s policy titled “Utilization of Safety Attendants for Patients.” This deficient practice resulted in Patient 8 assaulting (an intentional act that puts someone in reasonable fear of being physically harmed) a regional center staff member on 6/11/2025 at 6:18 p.m. and the ED’s failure to implement any additional safety interventions after the assault further exposed Patient 8 and others to harm. Subsequently, at approximately 6:32 p.m. (on 6/11/2025), Patient 8 entered the bathroom with the same non-facility staff member (regional center staff member) and repeatedly struck his (Patient 8) own head against the wall, resulting in a three-centimeter facial laceration (a tear or rip in the skin) requiring sutures (a medical stitch to hold the edges of a wound together so it can heal properly). (Refer to A-0144) 6. The facility failed to ensure care was provided in a safe setting for one of 50 sampled patients (Patient 18) when the facility did not implement suicide prevention interventions after staff became aware of the patient’s suicidal ideation (SI, the contemplation, planning, or desire to end one’s own life), in accordance with the facility’s policy regarding suicide prevention. This deficient practice had the potential to place Patient 18 and other patients at risk for self-harm, suicide attempt, serious injury, or death. Additionally, the failure to implement timely interventions may have resulted in inadequate monitoring and protection of a patient identified as being at risk of suicide. (Refer to A-0144) 7. The facility failed to provide a safe environment, in accordance with the facility’s policies regarding provision of safe nursing care and patient elopement prevention, in the Behavioral Health Unit area (BHU, a secure hospital or psychiatric ward designed to stabilize patients experiencing acute mental health crisis) for one of 50 sampled patients (Patient 30), when Patient 30 was able to slip through unit door (Door 1) after Certified Nursing Assistants (CNA 1 and CNA 2), entered the unit (BHU) and left the door (Door 1) partially opened. Patient 30, who was standing near the door (Door 1), subsequently eloped (ran away or left the facility without authorization or formal discharge) from the facility. This deficient practice placed Patient 30’s safety at risk including but not limited to various dangers outside the facility (example: being involved in an accident), self-harm or injury. (Refer to A-0144) 8. The facility failed to ensure that one of 50 sampled patients (Patient 1) received care in a safe environment, when Patient 1 did not receive continuous pulse oximetry monitoring (ongoing tracking of oxygen levels in the blood using a fingertip sensor), in accordance with the facility’s respiratory care policy titled “Non-invasive positive pressure ventilation (NPPV or NIV, a breathing support treatment that delivers pressurized air into the lungs through a tight-fitting face or nasal mask. It helps patients breathe easier and keeps their airways open without the need for a surgically implanted breathing tube).” This deficient practice had the potential to result in Patient 1’s oxygen level to drop quickly without anyone noticing in time, leading to serious breathing problems that might require more intensive treatment, such as placing a breathing tube or transferring the patient to an intensive care unit. (Refer to A-0144) 9. The facility failed to ensure staff provided a safe environment for one of 50 sample patients (Patient 46), in accordance with the facility’s policies regarding patient observation and fall prevention/management, when nursing staff failed to: 9.a. complete the required hourly patient rounding and accurately document the completion of hourly rounds (structured, proactive check-ins where nurses visit patients at scheduled intervals to monitor their mental and physical well-being) for Patient 46. 9.b. promptly notify the physician regarding Patient 46’s fall incident as soon as Patient 46 was found on the floor. These deficient practices resulted in a delay in implementation of necessary interventions such as MD evaluation and diagnostic tests. Patient 46 was subsequently found to have suffered a leg fracture following the fall incident. (Refer to A-0144) 10. The facility failed to ensure that the allegation of abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish) for one of 50 sampled patients (Patient 28) was reported to the Department, in accordance with the facility’s policy regarding abuse reporting. This deficient practice had the potential for Patient 28’ abuse allegation to go unreported and hinder the regulatory agency’s investigation, thereby increasing the risk of Patient 28 and other patients being subjected to ongoing abuse. (Refer to A-0145) 11. The facility failed to ensure that one of 50 sampled patient’s (Patient 1) designated patient representative (R1), was provided access to Patient 1’s medical records in a timely manner, within the timeframe required by regulation and the facility’s policy regarding medical records release. This deficient practice resulted in the violation of Patient 1’s representative’s patient’s rights (defined as the basic rights that ensure patients, and their representatives can receive information, make decisions, and access the patient’s own medical records), limiting Patient 1’s and Patient 1’s designated representative’s right to obtain information contained in Patient 1’s clinical record. (Refer to A-0148) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 50516 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Quality Assurance & Performance Improvement (QAPI) was met, as evidenced by: 1. The facility failed to ensure the Quality Assessment and Performance Improvement (QAPI, a data-driven program used to monitor, assess, and improve the quality and safety of patient care) program implemented a process to collect, measure, analyze, and monitor data to determine the effectiveness of corrective actions following an identified patient safety event for one (1) of 50 sampled patients (Patient 7), in accordance with the facility’s QAPI program plan. After a Root Cause Analysis (RCA, a structured process used to identify underlying cause of adverse events) identified that nursing staff failed to activate a Rapid Response Team (RRT, a hospital team that responds immediately to a patient’s acute clinical deterioration) when Patient 7 experienced bradycardia (an abnormally slow heart rate, typically less than 60 beat per minute) and decreased responsiveness, the facility implemented staff education but failed establish a measurable process to evaluate the effectiveness of the corrective action, track performance over time, and ensure sustained improvement. This deficient practice had the potential to prevent the facility from identifying continued failures in escalation of care and delayed recognition of patient deterioration which may result in another patient related safety event or near-miss (a medical error or unsafe situation that could have caused patient harm but did not, either by chance or because it was caught before reaching the patient), patient harm and/or death. (Refer to A-0283) 2. The facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) program (a hospital-wide program that uses data to monitor, assess, and improve the quality and safety of patient care) identified, analyzed, and implemented performance improvement activities related to patient safety events for one (1) of 50 sampled patients (Patient 8). The facility’s Root Cause Analysis (RCA, a structured process used to identify underlying system causes of adverse events) failed to identify that Emergency Department (ED) staff used a non-facility staff member as a one-to-one sitter (a caregiver assigned to provide continuous observation of a patient), failed to identify the lack of safety interventions to prevent further harm when Patient 8 and the non-facility staff member were not separated after Patient 8 struck the individual (the non-facility staff member) in the chest, and failed to identify that Patient 8 was not reassessed after a significant change in condition and aggressive behavior. The RCA failed to identify multiple deviations from facility policies regarding observation, reassessment, management of high-risk behavioral health patients, and failed to develop corrective actions addressing those contributing factors. This deficient practice resulted in the QAPI program’s failure to identify contributing factors, analyze deviations from facility policy, implement corrective actions, and evaluate whether interventions were effective, increasing the potential for recurrence of similar patient safety events involving high-risk behavioral health patients. (Refer to A-0286) 3. The facility failed to ensure its Quality Assessment and Performance Improvement (QAPI, a data-driven program used to monitor, assess, and improve the quality and safety of patient care) team analyzed and discussed the appropriate use for the facility’s patient video monitoring for patients prone to wandering, during a root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution), for two of 50 sampled patients’ (Patient 23 and Patient 22) patient safety related events regarding elopement, in order determine what preventive actions and mechanisms could be implemented and prevent recurrence. Patient 23 eloped from the facility (first incident) in a wheelchair on 3/28/2026 despite being under the facility’s patient video monitoring (PVM, a virtual patient observation system used in hospitals utilizing video camera, two-way audio and technology to allow hospital staff to remotely and continuously observe multiple patients are once from a central command center). On 4/8/2026, a week after Patient 23’s elopement, Patient 22 also eloped from the facility despite Patient 22 being monitored by PVM (second incident). This deficient practice had the potential to result in ongoing inappropriate utilization of PVM as PVM technicians are unable to maintain a clear visual on patients who could be wandering in their patient room and not being properly monitored which could lead to other patient safety concerns including but not limited to elopement. (Refer to A-0286) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 50516 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by: 1. The facility failed to ensure Nursing staff called a Rapid Response Team (RRT, a hospital team that responds immediately to a patient’s acute clinical deterioration) for one (1) of 50 sampled patients (Patient 7), when Patient 7’s heart rate (HR, the number of heart beats per minute) dipped into the 30s and Patient 7 was less responsive than the previous shift while housed on the Behavioral Health Unit (BHU, a specialized hospital unit for mental health care) on 2/27/2026, and also failed to reassess the abnormal vital signs (measurements of body functions such as heart rate, blood pressure, temperature, and breathing rate) and notify the physician of the change in condition, in accordance with the facility’s policies regarding Rapid Response Team, Assessment/Reassessment. This deficient practice resulted in delayed Rapid Response activation for Patient 7 and had the potential to result in delayed treatment for clinical deterioration (when a patient’s health gets worse). (Refer to A-0395) 2. The facility failed to ensure nursing staff followed up on an infectious disease specialist to obtain a wound care consult for one (1) of 50 sampled patients (Patient 7), who had wounds on both lower legs, in accordance with the facility’s policies regarding escalation for resolution of clinical patient safety concerns and plan for provision of nursing care. This deficient practice resulted in Patient 7 not receiving a wound care specialist assessment or treatment recommendations for the bilateral (both) lower leg wounds from 2/16/2026 -2/25/2026. As a result, Patient 7 did not receive necessary treatment for wounds that were reddened, weeping, and swollen, which may lead to further deterioration or infection. (Refer to A-0395) 3. The facility failed to ensure that a registered nurse supervised and evaluated the nursing care for one patient of 50 sampled patients (Patient 1) and failed to ensure that intake and output (I&O, meaning the measurement and documentation of all fluid a patient takes in and all fluid a patient eliminates) and oral food intake, including fluid intake, were consistently and accurately monitored, evaluated, and documented by nursing staff during Patient 1’s admission (from 12/19/2025 through 12/23/2025), in accordance with the facility’s policies regarding nursing standards of care and telemetry standards of practice. This deficient practice had the potential to place Patient 1 at risk for fluid imbalance (when your body has either too much or too little fluid compared to the amount of salt and minerals [electrolytes] it needs to function), worsening respiratory status (reflection of a patient’s effort to breathe and oxygen levels in the blood) , and delayed recognition of clinical deterioration (when a patient’s health gets worse), especially given Patient 1’s admitting diagnoses, which included, but were not limited to, pulmonary edema (meaning excess fluid in the lungs that impairs breathing) and congestive heart failure (meaning the heart cannot pump blood effectively, leading to fluid buildup throughout the body). (Refer to A-0395) 4. The facility failed to ensure its nursing staff provided adequate supervision and care, in accordance with the facility’s policy regarding provision of nursing care, to prevent one of 50 sampled patients (Patient 23), who was under temporary conservatorship (legal arrangement where a judge appoints a responsible individual to make decision for the patient who is deemed unable to care for themselves) from eloping (a person attempts to leave the facility, when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility on 3/28/2026 when: 4.a. Patient 23’s primary Registered Nurse (RN 21) did not escalate supervision despite Patient 23 having verbalized wanting to leave two times on 3/28/2026 at 11 a.m. and 3 p.m.; 4.b. Nursing staff did not respond to facility’s patient video monitoring (PVM, a virtual patient observation system used in hospitals utilizing video camera, two-way audio and technology to allow hospital staff to remotely and continuously observe multiple patients are once from a central command center) technician’s call when Patient 23 was out of PVM camera view on 3/28/2026 at 4 p.m.; 4.c. RN 21 did not provide supervision for Patient 23 (on temporary conservatorship) on 3/28/2026 from 3:30 p.m. - 5 p.m.; 4.d. RN 21 delayed calling a Code Green (signals a missing patient so the hospital can activate its procedure to locate the missing patient). Patient 23 was found missing on 3/28/2026 at 5:02 p.m. but Code Green was called at 5:12 p.m. (ten minutes later). These deficient practices resulted in Patient 23 eloping from the facility on 3/28/2026 and placed Patient 23 at risk for dangers such as accidental injury, falls, traffic accidents and may also pose danger to others (Patient 23 was admitted for acute [new onset] psychosis [severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality]). (Refer to A-0395) 5. The facility failed to ensure its nursing staff provided continuous visual monitoring for one of 50 sampled patients (Patient 22), who was under a legal 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment), when a Certified Nursing Assistant (CNA 6) failed to notify the supervising Registered Nurse or Charge Nurse to provide continuous monitoring and observation on Patient 22 when CNA 6 had to go to the bathroom on 4/8/2026. This deficient practice resulted in Patient 22 eloping (a person attempts to leave the facility, when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility on 4/8/2026 putting Patient 22 at risk for dangers and harm outside the facility. (Refer to A-0398) 6. The facility failed to ensure nursing staff reassessed one (1) of 50 sampled patients (Patient 8) after a significant change in condition (a major shift in clinical, physical, or behavioral status), when Patient 8 assaulted (an intentional act that puts someone in reasonable fear of being harmed) a Regional Center staff (staff from an agency providing support services to individuals with developmental disabilities). Nursing staff did not separate the two individuals, did not perform a nursing assessment (a systematic clinical evaluation conducted by a licensed nurse), and did not repeat a behavioral risk evaluation (a structured assessment of risk for aggression or harm) or vital signs (temperature, pulse, breathing rate, and blood pressure), as required by the facility’s policy titled “Assessment/Reassessment, Interdisciplinary.” This deficient practice resulted in Patient 8 sustaining an additional head injury 14 minutes later after entering the bathroom with the same caregiver (Regional Center staff) and repeatedly striking his (Patient 8) head against the wall, requiring sutures (stitches used to close a wound). (Refer to A-0398) 7. The facility failed to ensure the facility’s Emergency Department (ED) followed the facility’s policy titled “Utilization of Safety Attendants for Patients,” when the facility assigned a Regional Center caregiver (non-hospital staff), who was not hospital trained, not competency validated (not assessed for required clinical knowledge or skills), and not authorized under the hospital’s policy to serve as a sitter (a staff member assigned to provide continuous, direct observation) for one (1) of 50 sampled patients (Patient 8). Patient 8 had been assessed as high risk for aggression and required constant observation (continuous, uninterrupted monitoring). This deficient practice resulted in an unauthorized caregiver being left responsible for monitoring a high-risk patient, which contributed to the patient (Patient 8) assaulting the caregiver and subsequently with Patient 8 sustaining a head injury requiring sutures, after banging his (Patient 8) head on the facility’s bathroom wall. (Refer to A-0398) 8. The facility failed to ensure nursing staff documented to what degree one of 50 sampled patient (Patient 1) desaturated (how low Patient 1’s oxygen level dropped) after Patient 1 was found “desaturating” by nursing staff. The nursing staff also failed to document what immediate interventions were taken to stabilize the patient (Patient 1) before or after the provider (MD 10) was notified of Patient 1’s change in condition (desaturation event), in accordance with the facility’s policy regarding medical record content and nursing standards of practice. This deficient practice had the potential to result in continued or worsening breathing problems for Patient 1 and could also lead to incomplete information being passed on to the receiving care team, which may delay needed treatment or monitoring. (Refer to A-0398) 9. The facility failed to ensure the correct breast milk was administered to one of 50 sampled patients (Patient 41), when Registered Nurse (RN 23) did not double check the label of the breast milk with another nurse and did not scan the label prior to administering the breast milk to Patient 41, in accordance with the facility’s Breast Milk Storage and Handling of Expressed Milk policy. This deficient practice resulted in Patient 41 receiving 15 milliliters (ml, a unit of measurement) of breast milk from another mother and had the potential for Patient 41 to be exposed to risks associated infectious pathogens (such as HIV [Human Immunodeficiency Virus, is a virus that attacks the body’s immune system by destroying white blood cells. If left untreated, it severely weakens the body’s ability to fight off infections and diseases], Hepatitis B [a contagious viral infection that attacks the liver], and Hepatitis C [a viral infection that causes inflammation and damage to the liver. Spread through contact with infected blood]). (Refer to A-0398) 10. The facility failed to ensure its Registered Nurses (RNs) administered Morphine drip intravenously (IV, through the vein) per physician order and in accordance with the facility’s Medication Administration policy for two of 50 sampled patients (Patient 20 and Patient 19) when: 10.a. For Patient 20, nursing staff did not administer Morphine (a strong opiate pain medication) 2 milligrams (mg, unit of measure) loading dose (an initial, larger-than-normal dose of a medication designed to quickly raise the drug’s concentration in the body to a therapeutic level) per physician’s order, did not increase Morphine by 0.5 milligrams per hour (mg/hr, infusion rate) as ordered by physician and did not document Patient 20’s baseline CPOT (Critical-Care Pain Observation Tool, score of 0 to 2 indicates minimal to no pain and 3 to 8 indicated moderate to severe pain) score and did not follow up on the CPOT score when morphine 2 mg bolus (a single, relatively large dose of a drug administered over a short period. Its primary purpose is to rapidly raise the concentration of the medication in the bloodstream to an effective, therapeutic level) was given each time, to assess whether the morphine drip dosage had met the physician’s prescribed goal. 10.b. For Patient 19, nursing staff did not administer Morphine 2 mg loading dose as prescribed by the physician, did not give two (2) Morphine 2 mg boluses prior to increasing the Morphine drip dosage, and did not document Patient 19’s baseline CPOT score and follow up the CPOT score when the Morphine drip dosage was increased. These deficient practices had the potential to result in Patient 20 and Patient 19 receiving too little or too much for Morphine. Administering too high a dose could lead to shallow breathing, dangerously low oxygen levels, and/or death. Too low a dose could result to uncontrolled pain and physiological distress. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 46238 Based on observation, interview, and record review, the facility failed to: 1. Ensure that one of 50 sampled patients (Patient 2) was informed of intraoperative care interventions (interventions performed while the patient is in the operating room, such as positioning, monitoring, and the use of safety or stabilizing devices), specifically the use of safety straps prior to surgery, in accordance with the facility’s policy regarding patient rights (fundamental rules and guarantees that ensure patients are treated with respect, dignity, and fairness while receiving medical care. Example: right to be informed). The facility’s nursing staff did not provide pre-operative education to Patient 2 regarding the application and purpose of safety straps used to secure patients on the operating room table. This deficient practice resulted in a violation of Patient 2’s right to be informed (meaning to receive information in a manner they can understand regarding the care, procedures, and interventions planned for them) and created a potential risk for unanticipated discomfort, injury, or worsening of existing physical limitations. 2. Ensure that one (1) of 50 sampled patients (Patient 1), who was receiving continuous BiPAP (Bilevel Positive Airway Pressure, a non-invasive ventilation device that assists breathing by delivering pressurized air through a mask)/NPPV therapy (Non-invasive positive pressure ventilation [NPPV or NIV], a non-invasive ventilation method that assists breathing by delivering pressurized air through a mask), was assessed every two (2) hours, in accordance with the facility’s policy titled “Non-invasive positive pressure ventilation (NPPV/NIV),” (last revised 9/4/2020), which required Q2-hour (every 2-hours) assessments of both the machine settings and the patient’s clinical status (a patient’s current medical condition or state of health). This deficient practice had the potential to result in delayed recognition of respiratory decline (the gradual weakening of the body’s breathing system) for Patient 1, including worsening work of breathing, unsafe drops in oxygen saturation (the percentage of hemoglobin in the blood carrying oxygen), mask or equipment malfunction, or failure of the ordered therapy. In addition, this deficient practice had the potential to increase the risk that Patient 1’s clinical deterioration (when a patient’s health gets worse) could go unrecognized and untreated in a timely manner, placing the patient at risk for further respiratory compromise (a dangerous state where a person’s breathing becomes impaired, making it hard to get enough oxygen) or the need for emergency escalation of care (the process of getting a patient more help or a higher level of medical attention when their condition worsens). 3. Ensure that one of 50 sampled patients (Patient 38), received the results of an ultrasound (US, a safe painless imaging test that uses high-frequency sound waves to create real-time pictures of the inside of your body) of the leg in a timely manner (within 24 hours). Patient 38 received the results on the patient portal of the US, four (4) days after the test was conducted (Imaging test was done on 1/1/2026 and the final report was made available on 1/5/2026 in the patient’s portal [a secure website or mobile app that lets the patient view their personal health records and easily communicate with their healthcare team]). This deficient practice resulted in a violation of Patient 38’s right to be informed (meaning to receive information in a manner they can understand regarding the care, procedures, and interventions planned for them) and created a potential risk for unanticipated discomfort, injury, or worsening of existing physical limitations. Findings: 1. During a review of Patient 2’s Operating Procedure Report (a formal surgical document describing the procedure performed, surgical steps, positioning, and any perioperative events), dated 1/24/2026, the report indicated that on 1/20/2026, Patient 2 underwent a left breast mastectomy, partial (a surgical procedure in which only the portion of the breast containing the tumor is removed, also known as a lumpectomy or partial mastectomy) due to left breast invasive ductal carcinoma (a type of breast cancer that begins in the milk ducts and invades surrounding breast tissue). The record was reviewed with the Director of Operative Services (DIR 11). During a review of Patient 2’s Pre-anesthesia evaluation (the assessment performed by the anesthesia provider before surgery to identify medical conditions, risks, and needs related to anesthesia [a medication that puts a patient to deep sleep where the patient becomes completely unconscious and unaware]), dated 1/20/2026, the record indicated that Patient 2 had the following active (active: currently documented, ongoing, or clinically relevant) problems in her (Patient 2) problem list (problem list: a section of the medical record that identifies all current diagnoses, conditions, and health issues requiring monitoring or treatment): back pain; bilateral (both) knee pain; left hip pain; and lumbar degenerative disc disease (a chronic spine condition in which the discs between vertebrae break down, causing pain, stiffness, and limited mobility). The record was reviewed with the Director of Operative Services (DIR 11). During a review of Patient 2’s Intraoperative (the portion of the medical record that documents all events, assessments, and actions taken during the surgical procedure) record, dated 1/20/2026, the record indicated that on 1/20/2026 at 11:45 a.m., Patient 2 remained in the supine body position (lying flat on the back with the face upward, the standard position used for many surgical procedures to allow full access to the chest and abdomen); a protector for the head was applied, and positioner safety straps (used to secure, immobilize, and properly position patients on the operating room [OR] table. They prevent inadvertent shifting or falls while the patient is under anesthesia) were also applied. The record further indicated that at 1:01 p.m., Patient 2 was free of signs and symptoms of injury related to positioning and skin was intact (skin intact: no evidence of redness, breakdown, bruising, pressure injury, or other compromise to the skin’s surface). The record was reviewed with the Director of Operative Services (DIR 11). During an interview on 5/28/2026 at 9:43 a.m. with the Director of Operative Services (DIR 11), DIR 11 said that the facility’s process included staff interviewing patients regarding their pre-existing conditions (medical issues, diagnoses, or physical limitations the patient already has prior to surgery), tell patients what to expect in the operating room, such as, “ We will lay you on the gurney and will put straps...” During a concurrent interview and record review on 5/29/2026 at 3:35 p.m. with the Director of Operative Services (DIR 11), DIR 11 verified that Patient 2 did not have pre-operative documentation indicating that safety straps and positioning were discussed pre-operatively with Patient 2. DIR 11 also said that documentation of education was not typically documented in the electronic medical record (EMR, the digital charting system used by the facility to store patient assessments, orders, documentation, and educational information), but there was an option to enter free-text in the area allocated for education documentation (a section within the EMR where staff can manually type individualized education provided to the patient) under “other.” During an observation on 5/28/2026 at 10:44 a.m. in the pre-operative room (the area where patients are prepared for surgery, assessed, and educated prior to entering the operating room), during a surgical tracer (a direct observation method used to follow a patient through a clinical process to evaluate staff performance, workflow, communication, and compliance with policies) of a sampled patient (Patient 5- sampled patients are randomly or systematically selected by surveyors from a broader patient population to represent the facility’s overall standard of care), a registered nurse (RN 13) prepared Patient 5 for the procedure by asking the patient (Patient 5) to verify her (Patient 5) name and date of birth, reviewed expected intraoperative steps, and reviewed positioning of the patient; however, the nurse (RN 13) did not discuss the application of safety straps and did not verify any pre-existing injuries that may interfere with Patient 5’s position during the procedure. During a surgical tracer observation of Patient 5 on 5/28/2026 from 11:20 a.m. through 12:10 p.m., the operating nurse (RN 13) did not discuss positioning on the gurney or the application of positioning safety straps until after the straps were applied on Patient 5. After the safety straps were applied on Patient 5, it was at that time, Patient 5 was then informed that the straps were going to be applied for safety after the anesthesia plan was reviewed and a time out was quickly initiated (time out: a required safety pause conducted prior to surgery to verify the patient’s identity, procedure, site, consents, and critical safety elements before the operation begins). During a review of the facility’s policy and procedure (P&P) titled “Patient’s Rights and Responsibilities,” dated 4/17/2024, the policy stated that patients have the right to: “1. Considerate and respectful care and to be made comfortable ... 4. Receive information about health status, diagnosis, prognosis, course of treatment, prospects for recovery, and outcomes of care (including unanticipated outcomes) in terms one can understand ... 5. Make decisions regarding medical care and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment ... 8. Reasonable responses to any reasonable requests made for service.” During a review of the facility’s policy and procedure (P&P) titled “Perioperative Patient Education,” dated 12/2024, the policy indicated the following: “Perioperative education in relation to health information refers to different aspects of the information provided to patients before surgery, including details of the procedure, preoperative preparation or environment, postoperative expectations, anticipated sensations, details of anesthesia, and possible outcomes.” The policy further indicated: “By assisting the perioperative patient to understand the surgical procedure and sequence of events, the anxiety related to the surgical experience is minimized.” a. “The perioperative education will be specific to age, cultural/religious practices, emotional barriers, physical and/or cognitive limitations, and language barriers of the patient.” b. “Provide information related to the proposed surgical procedure and sequence of events. Include appropriate personnel as needed (i.e., anesthesiologist/surgeon).” c. “Evaluate perioperative education by observing that the patient/family is ready to proceed with the surgical procedure and has had the opportunity to verbalize questions and concerns.” d. “Document perioperative education by including assessment, intervention, and evaluation as appropriate in the electronic health record.” 2. During a review of Patient 1’s History and Physical (H&P, a comprehensive medical assessment that describes the patient’s current condition and medical history), dated 12/19/2025, the H&P indicated that Patient 1 was admitted on 12/19/2025 due to severe shortness of breath (difficulty breathing) and an oxygen saturation rate of 70% (percentage of oxygen in the blood; 70% is a critically low level requiring immediate medical intervention). The H&P further indicated that Patient 1 required the use of BIPAP therapy (Bilevel Positive Airway Pressure, a non-invasive ventilation device that assists breathing by delivering pressurized air through a mask). During a review of Patient 1’s Physician Orders, dated 12/20/2026, the record indicated that the physician (MD 10) ordered BiPAP management with the following special instructions: “Keep O2 sat (oxygen saturation, the percentage of hemoglobin in the blood carrying oxygen) more than 92%, PRN (as needed) during the daytime, and continuous at night.” During an interview on 5/26/2026 at 11:11 a.m. with the interim manager of telemetry (NM 10), on the telemetry floor (a hospital unit where patients receive continuous heart monitoring and close observation by nursing and monitor technicians), NM 10 stated that “management of BiPAP required coordination among the entire care team ... Respiratory Therapists (RTs) were responsible for setting up the BiPAP device, adjusting the settings, and assessing both the machine and the patient ...” During an interview on 5/26/2026 at 11:11 a.m. with the Respiratory Services Manager (NM 9), NM 9 stated that BiPAP patients were supposed to be checked every 3 hours, and that the same three?hour interval applied to documenting the assessment of both the machine and the patient. NM 9 explained that Respiratory Therapists (RTs) checked the BiPAP settings to ensure they matched the physician’s ordered settings, evaluated whether the settings met the patient’s needs, and assessed whether the patient was improving or declining. NM 9 also said that RTs reviewed the notes as part of their assessment process. During an interview on 5/27/2026 at 10:16 a.m. with the Director of Respiratory Services (DIR 10), DIR 10 stated that the frequency of required assessments for patients on BiPAP depended on the patient’s location. DIR 10 said that patients in the telemetry unit (a hospital floor where patients receive continuous heart monitoring and closer observation) were assessed less frequently than patients in higher acuity (patient who is severely ill, unstable, or has complex medical needs. They require immediate, constant attention, frequent monitoring, and specialized care from trained professionals) units. DIR 10 explained that on a DOU (Definitive Observation Unit, also known as a step?down unit for patients needing more monitoring than a regular medical-surgical floor) and in the ICU (Intensive Care Unit), BiPAP assessments were required every three hours, while on the telemetry floor, assessments were generally required at least every 4 hours, depending on the patient’s condition. DIR 10 also stated that she (DIR 10) was not sure whether a specific BiPAP policy existed that clearly outlined these required assessment intervals and expectations. During a review of Patient 1’s Non-Invasive Ventilator (NIV, a breathing machine that helps the patient breathe through a mask instead of a breathing tube) assessment records, dated 12/19/2025 through 12/23/2025, the record showed that respiratory therapists performed checks of the machine and the patient [Patient 1] at the following times [because the physician ordered BiPAP to be used continuously at night and as needed during the day, these entries reflect only the nighttime assessments between 7 p.m. and 7 a.m.]: -On 12/19/2025, two full assessments were done at 7:40 p.m. and 10:00 p.m., about 2 hours and 20 minutes apart. -On 12/20/2025, full assessments were done at 12:17 a.m., 3:46 a.m., and 7:13 a.m., each about 3½ hours apart. -On 12/21/2025, two full assessments were completed at 7:30 p.m. and 10:40 p.m., about 3 hours apart. -On 12/22/2025, full assessments were documented at 12:30 a.m., 3:25 a.m., and 7:21 a.m., with intervals of about 3 hours, and again at 8:40 p.m. and 10:40 p.m., about 2 hours apart. -On 12/23/2025, full assessments were done at 1:26 a.m., 4:30 a.m., and 9:00 a.m., with intervals of about 3 hours and 4½ hours. -The record was reviewed on 5/26/2026 with the Director of the Medical-Surgical Unit (DMS 1). During an interview on 5/29/2026 at 12:00 p.m. with a respiratory therapist (RT 1), RT 1 said that ever since COVID-19 (a viral respiratory infection that significantly increased the number of patients requiring non?invasive and mechanical ventilation), BiPAP assessments had been performed every three hours, regardless of the patient’s acuity (the level of illness severity and the amount of clinical attention a patient requires) or the hospital unit. -RT 1 said that respiratory therapists typically assessed patients on BiPAP to make sure the mask was fitting properly, that any air leak was minimized (a leak meaning air escaping around the mask instead of entering the lungs), and that the patient had a protected airway (meaning the patient was positioned safely and able to maintain a clear breathing passage). -RT 1 also explained that some nurses knew how to operate BiPAP machines, such as nurses in higher acuity areas such as the DOU and ICU, while others were less familiar depending on their experience. RT 1 stated that respiratory therapists were responsible for documenting BiPAP care, including whether the patient was taken off BiPAP or placed on oxygen, the patient assessment, and all ventilator parameters. During an interview on 5/29/2026 at 12:09 p.m. with a respiratory therapist (RT 1), RT 1 said that BIPAP desaturation (oxygen level dropping while on BIPAP) would be a more serious event [compared to regular oxygen therapy] and that closer monitoring was needed because the patient could decline faster since BIPAP was one of the last steps before needing intubation (placing a breathing tube into the airway to connect the patient to a ventilator). During a review of the facility’s policy and procedure (P&P) titled, “Non-invasive positive pressure ventilation (NPPV/NIV),” last revised 9/4/2020, the P&P indicated that: “A. Patients receiving NPPV must have a physician’s order ...B. Patients on continuous NPPV are to be checked every 2 hours (Q2hrs) and as needed.” 3. During a review of Patient 38’s Face sheet (provides healthcare providers with quick, actionable access to vital information, including personal demographics, insurance details, emergency contacts, and a high-level overview of the patient’s medical history), dated 1/1/2026, Patient 38 was admitted to the Emergency room department on 1/1/2026 at 14:03 (2:03 p.m.) and discharged on 1/1/2026 at 17:27 (5:27 p.m.). During a review of Patient 38’s Emergency Department (ED) Physician note, dated 1/1/2026 and timed at 17:17 (5:17 p.m.), the ED physician note indicated that Patient 38 presented to the ED with bilateral (both) leg pain and swelling for 3 days. During an interview on 5/26/2026 at 11:26 a.m. with the Director of Imaging (DIR 9), DIR 9 stated that once the radiologist creates the report, the report would be uploaded to the patient’s electronic medical record directly. DIR 9 stated that the radiologist would read images within a 30 minute-60-minute window during the daytime and 30 minutes to 3-hour window during the nighttime. DIR 9 stated that after 5 p.m. and during the weekend and holidays, that there was no radiologist onsite and images were read/interpreted remotely. During an interview on 5/29/2026 at 11:19 a.m. with Radiology Technologist 1 (RAD 1) and Radiology Technologist 2 (RAD 2), RAD 2 stated radiology orders conducted were based on priority. STAT orders were urgent and should be completed within a two-hour time frame. RAD 1 stated once the order was completed, the imaging would be uploaded to PACs (Picture Archiving and Communication System, a digital system where images can be stored and retrieved) where the radiologist (special physician who reads and interprets images) could read the image, interpret and create a report for every patient test. During a concurrent interview and record review on 5/27/2026 at 11:11 a.m. with the Director of Emergency Department (DIR 2) and the Manager of Emergency Department (NM 1), Patient 38’s Physician Order, dated 1/1/2026 at 14:11 (2:11p.m.), was reviewed. The Physician Order indicated Patient 38 had a STAT order “US Lower Extremity (legs) Vein Duplex (Ultrasound [US], painless imaging test that uses high-frequency sound waves to create real-time pictures of the inside of a patient’s body) Bilat (bilateral [both]).” DIR 2 confirmed that Patient 38 had a STAT order. During a concurrent interview and record review on 5/28/2026 at 11:13 a.m. with the Regulatory Specialist and Accreditation (RSA), the facility’s document titled “Release of Electronic Health Information to the Patient Portal (FAQ),” date unknown was reviewed. The document indicated that “Imaging results will be released upon signing of the imaging report.” RSA stated that once the doctor (the radiologist) had finalized the report, it (the image report) would be uploaded to the patient portal (a secure website or mobile app that lets the patient view their personal health records and easily communicate with their healthcare team). During a concurrent telephone interview and record review on 5/29/2026 at 1:45 p.m. with the Medical Director of Radiology (MD 6) Patient 38’s “US Lower Extremity Vein Duplex Bilateral,” dated 1/1/2026 and timed 15:07 (3:07 p.m.), was reviewed. MD 6 stated that Final Radiology reports had a “turnaround time of 24 hours and MD 6 could confirm why the final report was read 4 days later (on 1/5/2026). During a review of the facility’s policy and procedure (P&P) titled “Patient’s Rights and Responsibilities,” dated 4/17/2024, the policy stated that patients have the right to: “4. Receive information about health status, diagnosis, prognosis, course of treatment, prospects for recovery, and outcomes of care (including unanticipated outcomes) in terms one can understand ...” During a review of the facility’s document titled “Teleradiology Services Agreement,” dated 7/4/2025, the document indicated “Response Time: Provider shall use its best efforts to provide a preliminary diagnostic reading no more than an average of thirty (30) minutes after receipt of images of CT scan, MRI, ultrasound or plain X-ray and its requisition order at least ninety percent (90%) of the time.””

“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: 50516 Based on interview and record review, the facility failed to ensure one of 50 sampled patient’s (Patient 31) designated representatives were informed by the facility’s nursing staff regarding Patient 31’s worsening condition, in accordance with the facility’s policy regarding nursing standards of care. This deficient practice had the potential to create distrust and miscommunication among Patient 31’s representative and the healthcare team, which could have impacted Patient 31’s overall care plan. Findings: During a review of Patient 31’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/25/2024, the record indicated Patient 31 was admitted to the facility for abnormal (not within normal range) laboratory values (a specific numerical score or measurement derived from testing a sample of a patient’s blood, urine, or body tissue. Doctors use the results to diagnose medical conditions) with abdominal pain and hematemesis (vomiting blood). Patient 31’s medical history included Hepatocellular carcinoma (HCC, most common type of primary liver cancer), liver cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure), hypertension (HTN, high blood pressure) and Coronary Artery Bypass Graft (CABG, heart surgery to create new blood flow to the heart). During a review of Patient 31’s “Discharge Summary (an official clinical document prepared by healthcare professionals that outlines the details of a patient’s hospitalization. It acts as a bridge between the hospital and a patient’s ongoing care),” dated 4/26/2024, the record indicated Patient 31 was admitted to the Intensive Care Unit (ICU, special unit that provide treatment and monitoring for people who are very ill), and Patient 31 deteriorated (condition became worse) and died on 4/26/2024. During a concurrent interview and record review on 6/1/2026 at 9:20 a.m. with the Manager of Step Down Unit (an in-between hospital ward for patients who require closer monitoring than a general medical-surgical floor, but are no longer critically ill enough to need the Intensive Care Unit) (MSD 1) and the Intensive Care Unit Charge Nurse (CN) 2, Patient 31’s “Clinical Nursing Notes,” dated 4/25/2024 and 4/26/2024 were reviewed and indicated there was no documentation Patient 31’s nurse communicated with the family (Patient 31’s family) about Patient 31’s worsening condition. CN 2 stated bedside nurses were expected to notify family if the patient’s situation was getting worse. MSD 1 and CN 2 both acknowledged it was part of their process for nurses to keep a patient’s family representatives informed about a patient’s condition and to document family notification. CN 2 stated the documentation was important for everyone to know the family was called for an update and let the family know the situation. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Standards of Care,” dated 2/27/2025, the P&P indicated, “Patients have the right and responsibility to participate in all decisions related to their health care. Patients also have the right to receive accurate information and will be assisted as needed to make informed health care decisions ...Patients who are unable to participate in treatment decisions have the right to be represented by parents, guardians, family members, health care agents, or conservators.””

“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: 46333 Based on observation, interview, and record review: 1. The facility’s Emergency Department (ED) failed to ensure that one (1) of the 50 sampled patients (Patient 8), received care in a safe setting. The ED did not provide a required safety assessment or assign a one-to-one sitter (a caregiver or aide assigned to constantly observe a single vulnerable patient-someone at risk of falling, wandering, or self-harm) despite the psychiatrist’s documented plan for constant observation and despite Patient 8 having been assessed as high risk for aggression (behavior aimed at opposing or attacking someone), in accordance with the facility’s policy titled “Utilization of Safety Attendants for Patients.” This deficient practice resulted in Patient 8 assaulting (an intentional act that puts someone in reasonable fear of being physically harmed) a regional center staff member on 6/11/2025 at 6:18 p.m. and the ED’s failure to implement any additional safety interventions after the assault further exposed Patient 8 and others to harm. Subsequently, at approximately 6:32 p.m. (on 6/11/2025), Patient 8 entered the bathroom with the same non-facility staff member (regional center staff member) and repeatedly struck his (Patient 8) own head against the wall, resulting in a three-centimeter facial laceration (a tear or rip in the skin) requiring sutures (a medical stitch to hold the edges of a wound together so it can heal properly). 2. The facility failed to ensure care was provided in a safe setting for one of 50 sampled patients (Patient 18) when the facility did not implement suicide prevention interventions after staff became aware of the patient’s suicidal ideation (SI, the contemplation, planning, or desire to end one’s own life), in accordance with the facility’s policy regarding suicide prevention. This deficient practice had the potential to place Patient 18 and other patients at risk for self-harm, suicide attempt, serious injury, or death. Additionally, the failure to implement timely interventions may have resulted in inadequate monitoring and protection of a patient identified as being at risk of suicide. 3. The facility failed to provide a safe environment, in accordance with the facility’s policies regarding provision of safe nursing care and patient elopement prevention, in the Behavioral Health Unit area (BHU, a secure hospital or psychiatric ward designed to stabilize patients experiencing acute mental health crisis) for one of 50 sampled patients (Patient 30), when Patient 30 was able to slip through unit door (Door 1) after Certified Nursing Assistants (CNA 1 and CNA 2), entered the unit (BHU) and left the door (Door 1) partially opened. Patient 30, who was standing near the door (Door 1), subsequently eloped (ran away or left the facility without authorization or formal discharge) from the facility. This deficient practice placed Patient 30’s safety at risk including but not limited to various dangers outside the facility (example: being involved in an accident), self-harm or injury. 4. The facility failed to ensure that one of 50 sampled patients (Patient 1) received care in a safe environment, when Patient 1 did not receive continuous pulse oximetry monitoring (ongoing tracking of oxygen levels in the blood using a fingertip sensor), in accordance with the facility’s respiratory care policy titled “Non-invasive positive pressure ventilation (NPPV or NIV, a breathing support treatment that delivers pressurized air into the lungs through a tight-fitting face or nasal mask. It helps patients breathe easier and keeps their airways open without the need for a surgically implanted breathing tube).” This deficient practice had the potential to result in Patient 1’s oxygen level to drop quickly without anyone noticing in time, leading to serious breathing problems that might require more intensive treatment, such as placing a breathing tube or transferring the patient to an intensive care unit. 5. The facility failed to ensure staff provided a safe environment for one of 50 sample patients (Patient 46), in accordance with the facility’s policies regarding patient observation and fall prevention/management, when nursing staff failed to: 5.a. complete the required hourly patient rounding and accurately document the completion of hourly rounds (structured, proactive check-ins where nurses visit patients at scheduled intervals to monitor their mental and physical well-being) for Patient 46. 5.b. promptly notify the physician regarding Patient 46’s fall incident as soon as Patient 46 was found on the floor. These deficient practices resulted in a delay in implementation of necessary interventions such as MD evaluation and diagnostic tests. Patient 46 was subsequently found to have suffered a leg fracture following the fall incident. Findings: 1. During a review of Patient 8’s “ED Physician Notes,” dated 6/11/2025, the record indicated, Patient 8 was brought in by staff from a group home (a supervised residential setting where individuals who need help with daily living receive staff support) for psychiatric evaluations (a medical assessment of a person’s mental, emotional, and behavioral condition to determine symptoms, risks, diagnosis, and treatment needs). The record further indicated that staff from the group home reported that Patient 8 “has been breaking multiple objects in home, attacking staff and harming self.” The record further indicated that Patient 8’s past medical history included: Schizophrenia (a chronic mental health disorder that affects thinking, emotions, and behavior), bipolar disorder (a mood disorder characterized by episodes of depression and elevated or irritable mood), and autism (a developmental disorder that affects communication, behavior, and social interaction). During a review of Patient 8’s “Clinical Note Behavioral Health (BH, care related to mental health, including how thoughts and behaviors affect overall well-being),” documented by behavioral health nurse (RN 2), dated 6/11/2025, the note indicated, Patient 8 was “unstable patient (Patient 8) who exhibited aggressive and self-injurious behaviors.” The note further indicated the plan for Patient 8 was to “remain in the ER (Emergency Room) on constant observation, and (name of MD1) will see him (Patient 8) later today. The ER healthcare team is aware of the above-mentioned plan ...” During a concurrent observation and interview on 5/26/2026 at 10:54 a.m. with RN 6 and the Emergency Department Director (DIR 2), RN 6 demonstrated how to access policies and procedures and displayed the facility’s policy titled “Utilization of a Safety Attendant for Patient Safety,” dated 3/24/2025. The policy indicated, “All departments/services involved in patient care at the Medical Center are affected by this policy ...” the policy required reassessment every shift using the Clinical Safety Reassessment Nursing Assessment Form #2202 to determine interventions attempted, their effectiveness, and whether a safety attendant was warranted. DIR 2 stated, “We do not follow this process in the ED,” and confirmed the ED did not complete the required reassessment form. During an interview on 5/26/2026 at 1:47 p.m. with the Emergency Department Manager (NM 1), NM 1 stated, “To assign a one-to-one sitter (a caregiver or aide assigned to constantly observe a single vulnerable patient-someone at risk of falling, wandering, or self-harm) for monitoring a patient, an order from a physician is not required; this is a nursing clinical judgment.” NM 1 stated Patient 8 was “not assigned a one-to-one sitter because Patient 8 was not suicidal (thoughts of taking one’s own life), not on a psychiatric hold (a legal process that allows a person in a mental health crisis to be kept in a hospital or treatment facility for evaluation and care, usually for 72 hours), and staff had identified no behavioral management concerns.” However, NM 1 confirmed that the ED was aware Patient 8 came to the facility after harming others and himself, and that Patient 8 presented with an “open wound” to the head from repeatedly banging his (Patient 8) head against a wall for the past 5 days. During a concurrent interview and record review on 5/26/2026 at 2:10 p.m. with Nurse Manager (NM)1, Patient 8’s “Clinical Note Behavioral Health,” dated 6/11/2025, documented by behavior health RN (RN 3), was reviewed. The note indicated, “Pt (Patient 8) has been impulsively banging his (Patient 8) forehead on the ground/wall for the past 5 years on and off. Pt (Patient 8) observed to have a large skin flap/open wound at the site.” NM 1 confirmed that Patient 8 came into the facility with an open wound to forehead. During a concurrent interview and record review on 5/26/2026 at 2:20 p.m. with Nurse Manager (NM)1, Patient 8’s Dynamic Appraisal of Situation Aggression (DASA, a screening tool used to assess a patient’s short?term risk of aggressive behavior) documentation, dated 6/11/2025 at 1:35 a.m., showed that RN 2 documented a score of 7, indicating “High Risk,” due to Patient 8 being physically aggressive, irritable, impulsive, unwilling to follow directions, sensitive to perceived provocation, easily angered, displaying negative attitudes, and making verbal threats. During a concurrent interview and record review on 5/26/2026 at 2:30 p.m. with NM 1, Patient 8’s “Clinical Note ED (nursing note),” dated 6/11/2025 at 6:18 p.m., was reviewed. The note indicated, Patient 8 “hit Regional Center staff (a non-staff member of the facility; a staff that came with Patient 8 from the group home) on the chest.” NM 1 stated after Patient 8 hit the Regional Center staff, RN 1 asked if the Regional Center staff wanted to call security, but the Regional Center staff refused. NM 1 also confirmed that Patient 8, and the Regional Center staff were not separated. During a concurrent interview and record review on 5/26/2026 at 3:05 p.m. with Emergency Department Director (DIR 2), Patient 8’s “ED Physician Notes,” dated 6/11/2025, were reviewed. The note indicated a “3-centimeter (cm, a unit of measure) simple linear wound located on the face.” DIR 2 stated Patient 8 struck the Regional Center staff member in the chest on 6/11/2025 at 6:18 p.m., and later, at approximately 6:32 p.m., when the Regional Center staff accompanied Patient 8 to the bathroom, Patient 8 banged his (Patient8) head against the bathroom wall and sustained an injury (facial laceration). DIR 2 confirmed that Patient 8 was accompanied to the bathroom by the Regional Center staff. During an interview on 05/28/26 at 10:04 a.m. with Registered Nurse trained in conducting assessment of patients with behavioral health concern (RN 3), RN 3 stated, “This patient (Patient 8) requires observation and needs a 1:1 sitter.” RN 3 further explained that because of the patient’s (Patient 8) unpredictable behavior, a sitter was needed. RN 3 stated, “If this patient (Patient 8) hits a staff member, call security to stand by to increase monitoring on the patient (Patient 8) because we do not know if he (Patient 8) will do it again; he is impulsive.” During a concurrent interview and record review on 5/26/2026 at 3:30 p.m. with NM 1, Patient 8’s medical record (MR) document titled, “Order,” dated 6/11/2025, was reviewed. The MR indicated there was a request for a one-to-one sitter on 6/11/2025 at 7:28 p.m. by RN 5. NM 1 confirmed that the request for a one-to-one sitter was made after Patient 8 sustained a 3-cm laceration to the face that required sutures while in the ED bathroom with the Regional Center staff. During an interview on 5/27/2026 at 9:50 a.m. with Registered Nurse (RN) 1, who was assigned to Patient 8 on 6/11/2025, when Patient 8 assaulted the Regional Center staff member and later sustained a facial laceration in the bathroom, RN 1 stated that after Patient 8 struck the Regional Center staff member in the chest, RN 1 did not separate Patient 8 from the Regional Center staff member. RN 1 further confirmed that no Code Gray (an emergency response activated for a patient who is exhibiting aggressive, combative, or violent behavior) was called to increase monitoring. RN 1 stated that when entering Patient 8’s room, the Regional Center staff member was sitting, and Patient 8 was in the bed. RN 1 stated they (the ED staff) did not assess Patient 8. RN 1 also stated they (the ED staff) asked the Regional Center staff member whether they (the Regional staff member) needed medical evaluation, and the Regional Center staff member declined. During a review of the facility’s policy and procedure (P&P) titled, “Utilization of Safety Attendants for Patients,” dated 3/24/2025, the P&P indicated, “The purpose of this policy is to provide guidelines for safety attendant placement for patients with high risk behaviors, high fall risk, or other behaviors that place the patient at risk for injury... Safety attendants may be instituted for patients with high risk behaviors or those with high risk for fall or other injury including: a. Danger to self b. Danger to others c. Grave disability d. Potential for injury... 2. Assigned attendant will be a trained Registered Nurse, Licensed Vocational Nurse, Certified Nursing Assistant. Nursing Assistant. Mental Health Technician, Licensed Psychiatric Technician, or Emergency Medical Technician. 3. A family member or volunteer may not provide monitoring/observation for patients with high-risk behaviors. 4. The staff member assigned to the patient shall have received education on management of patients at high risk for falls, injury. and high-risk behaviors. 5. The Safety Attendant will accompany the patient at all times.” Once a patient is identified as needing a safety attendant, the Nurse Manager/Charge Nurse will reassess the patient every shift using the Clinical Safety Reassessment Nursing Assessment Form #2202 (see attached) to determine: i. Specific interventions attempted ii. Whether or not the interventions have been successful iii. Whether or not more time is needed for the interventions to be effective iv. Whether or not additional Interventions should be implemented v. If the high risk behaviors have resolved, and the patient no longer requires Clinical Safety Reassessments vi. If the clinical safety attendant is warranted or can be discontinued... The Safety Attendant will accompany the patient at all times. For Patients at high risk for falls or other injuries: a. Requests for a Safety Attendant are called to the House Supervisor for evaluation... For patients with a history of a Behavioral Health diagnosis displaying behaviors of danger to self or others: a. Requests for a Safety Attendant for patients not on a hold are called to the House Supervisor for evaluation.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Risk Aggression Assessment,” dated 7/3/2024, the P&P indicated, “Dynamic Appraisal of Situational Aggression (DASA): Inpatient Version is a validated, predictive risk evaluation tool used to identify a patient’s likelihood of aggression within hospital settings ... Screening: Early identification of a patient at risk for aggression is crucial. Complete the DASA risk evaluation tool for all patients 12 years of age and older who are being evaluated and/or treated for behavioral health conditions as the primary reason for care or any patient displaying behavior patterns described in the DASA tool. Interventions for High Risk: (Score 4-7): a. Notify provider. b. Notify security for awareness and possible stand by assistance. c. Limit setting and de-escalation. d. Consider a PSA for Constant 1 :1 observation of the patient ...Consider additional resources. i.e., code gray, law enforcement ...Patients initially screened will be re-screened every shift. In addition, re-screen anytime there is a change in the patient’s behavior, following an incident of aggression, upon staff recognition of suspected stressors, and/or if self-reported distress or agitation. Re-screening may increase the interventions. Notify licensed practitioner of any increase of risk level.” During a review of the facility’s policy and procedure (P&P) titled, “Behavioral Health Patients, Emergency Department, Management of,” dated 1/18/2023, the P&P indicated, “1. Risk Level Identification: Emergency Department staff will perform initial assessment of Behavioral Health (BH) patient upon arrival including risk assessment. Based on the results of the risk assessment, behavioral health patients shall be identified at low, moderate, or high risk for harm to self or others. Interventions to assure patient safety should be Initiated based on the Identified risk level. The following actions should be considered for the behavioral health patients assessed as being at risk for danger to self or others: Appropriate interventions listed under the patient assessed as being a risk for danger to others. The organization’s security force and law enforcement personnel If Indicated, should be notified of the patient’s location and status and perform Intake alert ... Moderate and High Risk (patient with Immediate threat to self or others): A. Security personnel or law enforcement may be called to assist as appropriate ... H. Security or trained safety attendant will provide continuous monitoring to ensure a safe environment ... d. Security will provide continuous monitoring with RN oversight until safety attendant becomes available.” During a review of the facility’s policy and procedure (P&P) titled, “Management of High Risk Behaviors,” dated 5/28/2024, the P&P indicated: “For a situation in which a high risk patient behavior is a likely consequence or is taking place, de-escalation of the high risk behavior is the first course of action to employ. Specific de-escalation tactics are determined by clinical staff on scene and vary from situation to situation (I.e.: decrease stimulation around the patient, separate the patient from a dangerous situation, provide the patient with medication as ordered, etc.), but a de-escalation strategy is based on these core actions: Make contact with the patient and engage; assess needs of the patient in this situation as rapidly as possible; provide immediate, practical and concrete interventions that will facilitate patient coping skill development in this situation and that can be replicated to some extent in future situations.” During a review of the facility’s policy and procedure (P&P) titled, “Code Gray- Patient De-escalation,” dated 8/25/2025, the P&P indicated, “To assure a timely response to situations involving an actual or potential physical threat to physicians, employees, visitors or property...The following prompt actions will be taken to stabilized situations that could lead to injuries or property damage. When an associate or provider become concerned that a patient may become or has become verbally or physically threatened, they should maintain observation of the patient from a safe vantage point and call the hospital operator...stating ‘Code Gray’...and giving the exact location... When the Code Gray Team arrives at the scene, they will obtain information regarding the concern from any person(s) in contact with the patient who is causing the concern... Any course of action to address aggressive, assaultive or abusive patient behavior will be guided by measures congruent with nonviolent crisis intervention.” 2. During a review of Patient 18’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 3/14/2026, the H&P indicated that Patient 18 was admitted to the Medical Surgical Unit (a general hospital floor that cares for adult patients recovering from surgery or being treated for acute illnesses) and had a past medical history significant for status post coronary artery stent placement (a minimally invasive procedure that widens blocked or narrowed heart arteries), hypertension (HTN, high blood pressure), hyperlipidemia (HLD, the medical term for having too many fats [lipids], such as cholesterol and triglycerides, in the blood), and Type 2 diabetes mellitus (a chronic condition where the body cannot effectively use insulin [turns food into energy] or make enough of it). The H&P also indicated that Patient 18 presented to the facility following a trip and fall with loss of consciousness (when a person is suddenly neither awake nor aware of their surroundings). During a review of Patient 18’s Case Management/Social Work note titled “CM/SW Note Document,” dated 3/21/2026 at 3:47 p.m., the noted indicated that Patient 18 stated, “If I (Patient 18) go home, I will kill myself,” and further verbalized, “I can’t live like this.” The note indicated that due to the patient’s (Patient 18) suicidal ideation, a psychiatric evaluation (a medical assessment of a person’s mental, emotional, and behavioral condition to determine symptoms, risks, diagnosis, and treatment needs) was requested. During a review of Patient 18’s “Behavioral Health Consultation,” dated 3/21/2026 at 8:27 p.m., the note indicated ... “the patient (Patient 18) complained that there was “something wrong with my (Patient 18) brain” and again stated, “If I go home, I will kill myself.” ... Recommendation: ... “It is very obvious that the patient (Patient 18) is using suicidal statements to manipulate and prevent from being discharged.” During a review of Patient 18’s psychiatric consultation titled “Consulting MD (Medical Doctor),” dated 3/23/2026 at 3:01 p.m., the MD consultation note indicated the following: -“Requested start date: 3/21/2026 at 3:43 PM. -Reason for consult: Suicidal Ideation. -Unit Staff to call: Yes.” -The consultation documentation further indicated that the consultation had been reviewed by the Registered Nurse in the Medical Surgical Unit where Patient 18 was admitted. During a concurrent interview and record review on 5/28/2026 at 9:47 a.m. with the Clinical Educator for Medical-Surgical Services (ED 3), Patient 18’s medical records were reviewed. ED 3 stated that interventions for patients expressing suicidal ideation would include placing the patient on one-to-one observation (1:1- when a caregiver is assigned to provide continuous observation of a patient), moving the patient closer to the nurses’ station for close monitoring, conducting hourly rounds (structured, proactive check-ins where nurses visit patients at scheduled intervals to monitor their mental and physical well-being), removing items that could cause self-harm, and performing suicide screening assessments every shift. ED 3 verified that the medical record failed to identify documentation that suicide precautions or other suicide prevention interventions were implemented after the patient (Patient 18) verbalized suicidal ideation on 3/21/2026. Specifically, there was no documented evidence the patient (Patient 18) was placed on one-to-one observation, relocated closer to the nurses’ station for increased monitoring, subjected to enhanced safety rounds, screened for suicide risk each shift, or had potentially harmful items removed from the patient environment. During an interview on 5/28/2026 at 2:30 p.m. with Psychiatrist (MD 2), MD 2 stated whenever there was a consultation placed, the nurses were always notified, therefore the nurses were made aware of Patient 18’s suicidal ideation. MD 2 stated “I was not concerned about the patient being suicidal. Patient (Patient 18) was constantly presenting complaints that did not make any sense, everyday there were new complaints from this patient (Patient 18).” During a concurrent interview and record review on 5/29/2026 at 10:12 a.m. with the Director of Medical Surgical (DMS 1), Patient 18’s medical records, were reviewed. DMS 1 stated “The case manager should have had a conversation with the nurses when the patient verbalized suicidal ideation. The nurses did not implement suicidal prevention interventions based on the policy and procedure. If the nurses were notified, there should have been documentation.” During an interview on 5/29/2026 at 3:14 p.m. with the Director of Case Management (DCM 1), DCM 1 stated the following ... -“Our process is to notify the charge nurse and the attending doctor and receive an order for psychiatrist consultation when the patient has suicidal ideation. -We needed to let the nurses and the charge nurse know about the patient’s suicidal ideation. -We did not document that the nurses were notified of the patient’s suicidal ideation -Suicidal ideation is serious, we are not psych nurses and do not have psychiatric background, so we notify the doctor because it’s a risk. We are not trained to make that assessment. Now we must start to think about other discharge planning for the patient’s safety.” DCM 1 verified through record review that a nurse was made aware of Patient 18’s suicidal ideation when the psychiatric consultation was verified by Registered Nurse 29 (RN 29). During an interview on 6/1/2026 at 9:35 a.m. with the Medical Surgical Registered Nurse (RN 4), RN 4 stated the following: -“If made aware of a patient’s suicidal ideation, I would go directly to the patient room and assess, I would note if the patient has any active plans to follow through with suicide, complete the CSSRS (Columbia-Suicide Severity Rating Scale [C-SSRS], also known as the Columbia Protocol, is an evidence-based suicide risk assessment tool. It uses a brief series of simple, plain-language questions to identify whether a patient is at risk for suicide, gauge the severity and intensity of that risk, and determine the necessary level of care) to assess, Check the room for any hazards that could hurt the patient. If the patient has verbalized (thoughts of self-harm), I would call the charge nurse but would not leave the room. I will let the charge escalate to the chain of command. Call the Psych (psychiatry) intake coordinator to do an assessment of the patient. I will have a sitter order. I will make sure to follow the process and chain of command.” -“I will still implement the same steps when made aware of the patient’s suicidal ideation from the psychiatric consultation, it would be treated as a critical lab (critical laboratory result in which it requires immediate assessment and physician notification). -Even if the patient is verbalizing suicidal ideation to stay (as a means to prolong stay) in the hospital, nurses should still treat the suicidal ideation as if it is real and further assess the patient for the patient’s safety.” During an interview on 6/1/2026 at 9:45 a.m. with DMS 1, DMS 1 stated that the expectation would be for the nurses to initiate interventions for suicide prevention once the nurse had become aware that the patient had verbalized suicidal ideation. During a review of the facility’s Policy and Procedure (P&P) titled “Model Policy: Suicide Prevention,” (no date), The P&P indicated ... “Patient safety Plan- ... C. Interventions for non-behavioral health settings: Risk reduction strategies and safety measures should be initiated by the registered Nurse based upon screening, clinical judgment, and any additional assessments. 1. Interventions for low risk: a. Notify the LIP (Licensed Independent Practitioner. b. Document interventions to include at minimum: i. Offer patient education regarding warning signs and provide suicide prevention phone number. ii. Encourage patients to speak with clinicians if expressing warning signs. iii. At LIP’s discretion, provide referral to Outpatient Behavioral Health. iv. Review interventions with the patient upon discharge.” 3. During a review of Patient 30’s “Behavioral Health History and Physical (a comprehensive clinical assessment that combines psychiatric and behavioral background with medical examination),” dated 1/17/2025, the Behavioral Health History and Physical note indicated, Patient 30 was admitted to the facility with chief complaint of psychosis (collection of symptoms when a person has difficulty telling the difference of what’s real and what’s not). The record further indicated, Patient 30 was on a 5150 hold (is the number of the section of the Welfare and Institutions Code [establishes programs and public social services for promoting the public welfare] which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72 hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) for danger to others (DTO, where an individual poses a risk of harm to others) and being gravely disabled (GD, unable to take care of themselves). The record also indicated Patient 30 was 15 weeks pregnant. During a review of Patient 30’s “Clinical Note Nursing,” dated 8/20/2025, the “Clinical Note Nursing” indicated, Patient 30 was, “focused on discharge (leaving the facility) with no viable plan for self-care.” During a concurrent interview and record review on 5/26/2026 at 1:52 p.m. with Registered Nurse (RN) 7, Registered Nurse (RN) 12, and the Manager of Behavioral Health (NM) 3, Patient 30’s “Clinical Note Nursing,” dated 8/21/2025, was reviewed. The “Clinical Note Nursing” indicated, “At approximately 0725 (7:25 a.m.), ...the patient (Patient 30) was not present on the unit and was believed to have eloped (ran away) from the facility ...” During an interview on 5/26/2026 at 1:52 p.m. with Registered Nurse (RN 12) and the Manager of Behavioral Health (NM 3), RN 12 stated that on 8/21/2025, Patient 30 eloped from the unit (Door 1) when CNA 1 opened (Door 1) and Patient 30 was then able to slip through Unit 1 (Door 1), passed through the Unit 1 double door (Door 2) and on to the corridor door and then exited the facility. RN 12 stated at the time of Patient 30’s elopement, the double door (Door 2) did not require a badge for access or keyed access. RN 12 stated that the double door (Door 2), that comes after Door 1, was freely accessed by staff and should not have patients in that hall area. NM 3 stated that after the incident involving Patient 30, the facility implemented on 4/1/2026 a new process using 24/7 camera monitoring in which they (facility staff) had assigned alternating Certified Nursing Assistants (CNAs,) who rotate every 2 hours to monitor the camera (shows who is going in and out of the doors). NM 3 further stated that they (the designated CNAs for monitoring) were not expected to leave or take a break unless a substitute was available. During an interview on 5/26/2026 at 3:30 p.m. with the Director of Behavioral Health (DIR) 1, Registered Nurse (RN 7) and Registered Nurse (RN 12), RN 7 stated Patient 30 was on hold for GD, had no sitter (a healthcare worker or non-clinical caregiver who provides continuous observation to ensure the safety of the patient) at the time of elopement, and after the incident of elopement, and after being returned to the facility’s BHU, Patient 30 was transferred to a higher level unit (environment that provides more intensive monitoring, and safety). RN 12 stated it was important for BHU door (Door 1) to remain locked to prevent patients from leaving the facility for safety concerns, due to danger to self, danger to others, under the influence of illegal drugs, or intoxicated with alcohol. DIR 1 stated it was human error and that Certified Nursing Assistant (CNA) 1 was not paying attention of the surroundings. DIR 1 also stated the expectation in the locked unit was to ensure the door (Door 1) was closed and ensure there were no patients behind the staff or following the staff after opening it (which may pose the risk for patient elopement). During a concurrent observation, interview and record review on 5/29/2026 at 10:28 a.m. with the Manager of Behavioral Health (NM) 3, the Director of Security (DIR) 6, the Manager of Accreditation, Regulatory and Licensing (MARL), the Licensed Clinical Social Worker (SW) 1 and the System Director, Accreditation, Regulatory, and Licensing (DARL), Patient 30’s video surveillance footage, dated 8/21/20205 from 7:16 a.m. to 7:26 a.m., was reviewed and indicated the following: -7:17 a.m., There was one patient seen sitting at the corner table. -7:23 a.m., Patient 30 was observed walking towards the pay phone. NM 3 stated Patient 30 appeared to be using the phone. -7:25 a.m., Two staff members were observed standing at (Door 1). NM3 stated the two staff were CNA 1 and CNA 2, and that CNA1 was with orientee CNA 2 (new employee undergoing a period of training). Subsequently, Patient 30 was seen walking toward (Door 1) and standing near the door (Door 1). CNA 1 entered and left the door (Door 1) partially opened, followed by CNA 2. Both CNA 1 and CNA 2, after walking through the door (Door 1), made a right turn and did not look back to ensure Door 1 was completely closed. NM 3 stated CNA 1 and CNA 2 were not aware Patient 30 was near the door (Door 1) or they (CNA 1 and CNA 2) were distracted. -7: 26 a.m., Patient 30 was able to slip through the partially opened door (Door 1) where CNA 1 and CNA 2 walked thorough. NM 3 stated that Door 1 was left partially opened (by CNA 1 and CNA 2) and a person can fit through it. NM 3 stated Patient 30 waited, held the door (Door 1), slipped through the cracked open door (Door 1) while CNA 1 and CNA 2 (both unaware of the partially opened Door 1) went to the west side area. During the same interview on 5/29/2026 at 10:28 a.m. with NM 3, NM 3 added that, because the Behavioral Health Unit was a locked unit, they (CNA 1 and CNA 2) should have waited to ensure the door (Door 1) was fully closed, confirmed that no one was behind them, and checked their surroundings first to look out for any patients who might be nearby. NM 3 stated Patient 30 could have exited the corridor door leading to outside facility parking. NM 3 further stated Patient 30 was pregnant, a safety risk and Patient 30 could have been hurt or hurt herself. NM 3 stated Patient 30 was later found nearby and brought back to the facility BHU by the police department. During an interview on 6/1/2026 at 12:02 p.m. with the Director of Behavioral Health (DIR 1), DIR 1 verified “Orientation Handbook CNA” were provided to CNAs upon hire during orientation. DIR 1 further stated BHU was a locked unit and staff hired to work in the unit were expected to know how to ensure that the door remained secured (to ensure the safety of patients). During a review of facility’s document titled, “Orientation Handbook CNA,” undated, the document indicated, “General Unit Principles ...9. Keep the safety of the patients and staff members in mind with all your activities (i.e. be aware of who is behind you, ensure doors close securely, make sure you exit is not blocked ...).” During a review of the facility’s policy and procedure (P&P) titled, “Policy: Hospital Plan for the Provision of Nursing Care,” revised 9/15/2023, the P&P indicated, “The purpose of this policy is to provide guidelines for safe and competent nursing care, based on the needs and acuity of the patient ...8. Comply with performance standards of care area ...” During a review of the facility’s policy and procedure (P&P) titled, “Policy: Patients’ Rights and Responsibilities,” Reviewed date 9/9/2024, the P&P indicated, “It is a responsibility of the Medical Center to ensure that these rights are preserved for their patients ...Attachment A Patient Rights ...14. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation, or harassment. You have the right to access protective and advocacy services including notifying government agencies of neglect or abuse ...” During a review of the facility’s policy and procedure (P&P) titled, “Policy: Code Green- Patient Elopement,” Revised 2/27/2025, the P&P indicated, “High-Risk Patient for Elopement/Patient Elopement: A patient who fits the following criteria or who leaves the patient care unit without permission who is: ...On a legal hold (danger to themselves or others) ...Gravely disabled -unable to provide food, shelter or clothing ...All reasonable measures will be taken to prevent the elopement of high-risk patients from the hospital ...” 4. During a review of Patient 1’s History and Physical (H&P, a comprehensive medical assessment that describes the patient’s current condition and medical history), dated 12/19/2025, the H&P indicated that Patient 1 was admitted on 12/19/2026 due to severe shortness of breath (difficulty breathing) and an oxygen saturation rate of 70% (percentage of oxygen in the blood; 70% is a critically low level requiring immediate medical intervention). The H&P further indicated that Patient 1 required the use of BIPAP (Bilevel Positive Airway Pressure) therapy (a non?invasive ventilation device that assists breathing by delivering pressurized air through a mask). During a review of Patient 1’s Physician Orders, dated 12/20/2026, the record indicated that the physician (MD 10) ordered BiPAP management with the following special instructions: “Keep O? sat (oxygen saturation, the percentage of hemoglobin in the blood carrying oxygen) more than 92%, PRN (as needed) during the daytime, and continuous at night.” During an interview on 5/26/2026 at 11:11 a.m. on the telemetry floor (a hospital unit where patients receive continuous heart monitoring and close observation by nursing and monitor technicians), with the interim manager of telemetry (NM 10), NM 10 stated that management of BiPAP required coordination among the entire care team. NM 10 said that this coordination was necessary because physicians had to order the BiPAP settings (the pressures, oxygen level, and how long or how often the device should be used), Respiratory Therapists (RTs) were responsible for setting up the device, adjusting the settings, and assessing both the machine and the patient, while the nursing staff monitored the patient and the machine and contacted RTs whenever assistance was needed. During an interview on 5/29/2026 at 12:09 p.m. with a respiratory therapist (RT 1), RT 1 said that patients on BIPAP required continuous oxygen monitoring and were ideally connected to a [Brand] vital signs machine (a device that tracks oxygen levels, heart rate, and blood pressure). RT 1 explained that these patients may or may not be placed closer to the nursing stations depending on room availability and staffing. RT 1 stated that BiPAP desaturation (oxygen level dropping while on BiPAP) would be a more serious event compared to regular oxygen therapy, and that closer monitoring was needed because a patient on BiPAP could decline faster, as BiPAP was one of the last steps before requiring intubation (placing a breathing tube into the airway to connect the patient to a ventilator). During a concurrent interview and record review on 6/1/2026 at 9:34 a.m. with the Interim Manager of the Telemetry floor (NM 10), Patient 1’s physician orders, dated 12/19/2026 through 12/23/2026, were reviewed. The record showed no order for continuous pulse oximetry (continuous monitoring of oxygen saturation and heart rate using a sensor placed on either the finger, ear, or forehead) during Patient 1’s admission. NM 10 reviewed the record and verified that there was no physician order for continuous pulse oximetry in Patient 1’s medical chart and further acknowledged that continuous pulse oximetry was not documented continuously, indicating that Patient 1’s oxygen saturation rate was not continuously monitored in accordance with the facility’s practices. During an interview on 6/1/2026 at 9:36 a.m. with the Interim Manager of the Telemetry floor (NM 10), NM 10 said that continuous oxygen monitoring (continuous pulse oximetry, a device that continuously measures the patient’s oxygen saturation and heart rate) was typically ordered when a patient was admitted to the telemetry floor, and that it was usually an admission order for patients receiving oxygen therapy. NM 10 stated that the physician should have placed an order for continuous pulse oximetry (continuous monitoring of oxygen levels using a sensor placed on the finger, ear, or forehead). NM 10 also said that respiratory therapists and nurses could request an order for continuous pulse oximetry because “we want to make sure the intervention [referring to oxygen therapy] is effective.” During an interview on 6/1/2026 at 11:35 a.m. with the hospitalist (MD 10), MD 10 verified that anytime a patient required oxygen therapy, there should be a physician order for continuous pulse oximetry. During a review of the facility’s policy and procedure (P&P) titled “Non-invasive positive pressure ventilation (NPPV/NIV),” last revised 9/4/2020, the P&P indicated that: A. Patients receiving NPPV must have a physician’s order. Patients should be maintained on continuous pulse oximetry monitoring (a device that continuously measures oxygen levels) unless otherwise indicated by a physician’s order. 5. During a review of Patient 46’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 3/26/2026, the “H&P” indicated the following: Patient 46 was admitted to the hospital on 3/26/2026 to the psychiatric unit. Patient 46 was noted to be wandering the streets and left home. Patient 46 had a history of fall and degenerative joint disease. The H&P further indicated that Patient 46 was not too communicative and the treatment plan included management of behavioral issues. During a review of Patient 46’s “Clinical Note Nursing,” documented by behavioral health Registered Nurse (RN 26), dated 4/03/2026 at 4:19 a.m., the “Clinical Note Nursing” indicated, Patient 46 had poor insight (the reduced or absent ability to recognize that a patient has an illness or condition, or to understand how it affects their behavior and reality) and impaired judgment (losing the ability to make good, logical choices). The note also indicated that intervention was to continue every 15-minute rounding (a structured practice in healthcare where care team members regularly visit patients to proactively manage their needs, improve safety, and enhance communication) by floor staff (referring to the Mental Health Technicians [MHTs]) and hourly rounding by Registered Nurses. During a review of Patient 46’s “Clinical Note Nursing,” documented by behavioral health Charge Nurse (CN 6), dated 4/03/2026 at 7:02 a.m., the “Clinical Note Nursing” indicated, “At the beginning of this shift (referring to day shift on 4/3/2026), night shift (from 4/2/2026; 7 p.m. to 7 a.m.) staff reported this patient (Patient 46) has been unsteady and was provided with wheelchair.” During a review of Patient 46’s “Clinical Note Nursing,” documented by behavioral health Charge Nurse (CN 6), dated 4/03/2026 at 4:02 p.m., the “Clinical Note Nursing” indicated, “Doctor came by and saw this patient (Patient 46) and ordered Xray (high-energy light that can pass through the body to create a picture of the bones and internal organs) of left Femur (commonly known as thigh bone). Xray of left femur was positive for fracture (break in the bone) of left femur neck.” During a review of Patient 46’s “Clinical Note Nursing,” documented by behavioral health charge nurse (CN 6), dated 4/03/2026 at 5:21 p.m., the “Clinical Note Nursing” indicated, “Around 4:00 p.m. (4/3/2026), patient (Patient 46) reported to staff that patient (Patient 46) fell early in morning (of 4/3/2026 around 6 a.m.) when trying to get out of bed. Doctors were made aware. Patient’s (Patient 46’s) wife was made aware of the fracture to left femur.” During a review of Patient 46’s “Clinical Note Nursing,” documented by behavioral health Registered Nurse (RN 26), dated 4/03/2026 at 10:41 p.m., the “Clinical Note Nursing” indicated the following: Addendum: “Regarding unwitnessed fall incident that had occurred at 6:30 a.m. (4/3/2026). Around 6:30 a.m., (Patient 46) was found sitting in room by floor staff and writer (RN 26) was notified. Upon arrival to room, patient (Patient 46) was sitting on the floor, not getting up, feeling hopeless and stated ‘it doesn’t matter’ when prompted to return to bed. Writer (RN 26) and floor staff assisted patient (Patient 46) back to bed. Patient (Patient 46) denied having fallen in his room. Later on, around 6:50 a.m. (4/3/2026), staff had come to assist patient, (Patient 46) appeared unsteadily on feet. Writer (RN 26) was notified and brought wheelchair to patient’s (Patient 46) room. Patient (Patient 46) sat in wheelchair but repeatedly attempted to stand up despite instruction by floor staff to remain sitting down. Patient (Patient 46) needed repeated redirection to stay in chair. Evening staff stayed with patient (Patient 46) until morning staff arrived to monitor patient (Patient 46).” During a review of Patient 46’s “Clinical Note Nursing,” documented by behavioral health Registered Nurse (RN 27), dated 4/04/2026 at 5:23 p.m., the “Clinical Note Nursing” indicated, Patient 46 was transferred to another unit (Orthopedics Department, a medical and surgical unit that specializes in the diagnosis, treatment, and prevention of injuries and diseases of the musculoskeletal system) at 6:05 p.m. During a review of Patient 46’s “X-Ray Report,” dated 4/03/2026, the “X-Ray report” indicated, “Reason for exam: Pain, Findings: Acute mildly displaced and impacted transcervical fracture (a break across the mid-portion of the femoral neck [the narrow, bridge-like section of bone that connects the “ball” of your hip joint (the femoral head) to the main shaft of your thigh bone (the femur)], separating the femoral head from the rest of the femur) of the femoral neck. Impression: Acute left femoral neck fracture.” During a review of Patient’s 46’s “Behavioral Health Progress Notes,” dated 4/03/2026, the “Behavioral Health Progress Notes” indicated the following: “Patient (Patient 46) refused to take medication in the morning, and it took a lot of persuasion by staff before patient (Patient 46) took the medications. Patient (Patient 46) has poor insight with patient’s illness and behavior. Patient (Patient 46) fell this morning (4/3/2026) and Xray showed acute mildly displaced and impacted transcervical fracture of the femoral neck. Patient (Patient 46) is awaiting orthopedic surgeon consult and will be transferred to the medical floor for further treatment of the fractured of the femur.” During a review of Patient’s 46’ “Behavioral Health Progress Notes,” dated 4/04/2026, the “Behavioral Health Progress Notes” indicated the following: Patient (Patient 46) fell yesterday (4/3/2026) and sustained a fracture. Patient (Patient 46) is being transferred to medical floor for further treatment.” During a review of Patient’s 46’ “Behavioral Health Discharge Summary,” dated 4/04/2026, the “Behavioral Health Discharge Summary” indicated the following: On 4/4/2026 Patient 46 was transferred to Ortho (Orthopedics) department due to hip fracture. During a concurrent observation, interview, and record review on 5/28/2026 at 2:39 p.m. with the Director of Security (DIR) 6, and the Director of Behavioral Health (DIR) 1, Patient 46’s video surveillance, dated 4/03/2026 from 2 a.m. to 7 a.m., was reviewed and indicated the following: -2:20 a.m., Registered Nurse (RN 26) hourly rounding was completed. -3:20 a.m., Registered Nurse (RN 26) hourly rounding was not completed. -4:20 a.m., Registered Nurse (RN 26) hourly rounding was not completed. -5:20 a.m., Registered Nurse (RN 26) hourly rounding was not completed. -6:25 a.m., Registered Nurse (RN) 26 entered Patient 46’s room with wheelchair, RN 26 placed Patient 46 in a wheelchair, and left the patient’s room. - DIR 1 stated the following: Confirmed nurse responsible for hourly rounding was RN 26. Confirmed RN 26 was not present in the video footage at 3:20 a.m., 4:20 a.m., and 5:20 a.m. (when RN 26 was supposed to be conducting hourly rounds). During a concurrent interview and record review on 5/29/2026 at 9:40 a.m. with the Director of Behavioral Health (DIR) 1, Patient’s 46’s “Licensed Patient Observation Sheet,” dated 4/03/2026, was reviewed. The record showed the following: A Licensed staff (referring to RNs and LVNs [Licensed Vocational Staff]) must document at a minimum hourly. Write in the time and your observations with each rounding. Registered Nurse (RN 26) documented and signed that hourly rounding was completed for Patient 46 at 3:20 a.m., at 4:20 a.m., and at 5:20 a.m. DIR 1 reviewed the record and confirmed RN 26 did not accurately document hourly rounding observations for Patient 46. DIR 1 stated that RN 26 inaccurately documented hourly rounding because RN 26 was observed in the video footage as not completing hourly rounding on Patient 46 at 3:20 a.m., at 4:20 a.m., and at 5:20 a.m. DIR 1 stated that something bad could happen to Patient 46 if no hourly rounding was done. Patient 46 could have fallen when Patient 46 needed to use the bathroom without available assistance from staff. During the same interview on 5/29/2026 at 9:40 a.m. with the Director of Behavioral Health (DIR) 1, DIR 1 stated if Patient 46 was found on the floor, RN 26 should have completed a post fall assessment, notified the doctor, and should have called a Code Star for fall. DIR 1 said that RN 26 should have notified the physician when Patient 46 was found on the floor. Also, RN 26 should have given report to the next shift nurse regarding the fall incident so they (the incoming day shift staff) would know what was going on. DIR 1 stated, when the next shift (day shift staff) came on, they were questioning the condition of Patient 46. Also, DIR 1 confirmed that there was a delay in identifying Patient 46’s injury because no report was provided to the next shift (day shift staff). During an interview on 5/29/2026 at 1:01 p.m. with the Interim Risk and Safety (RS), RS stated the following: RS reviewed the report regarding the fall incident involving Patient 46 and emphasized that RN 26 should not have relied on the patient’s (Patient 46) self- assessment after finding Patient 46 on the floor. RS stated that RN 26 should have escalated the situation to the attending physician for further evaluation. RS also highlighted the importance of initiating a Code Star immediately following Patient 46’s fall incident, as Code Star was the protocol that staff followed for such events within the facility. During an interview on 5/29/2026 at 1:41 p.m. with Charge Nurse (CN 6), CN 6 stated the following: Confirmed CN 6 was the charge nurse on the day shift (4/4/2026) when it was found out Patient 46 had a leg fracture. CN 6 stated that the Certified Nursing Assistants were tasked with conducting a 15-minute rounding on patients and the Registered Nurses performed the hourly rounding on the patients. During the hourly rounding the Registered Nurses conducted a more in-depth assessment of the patients and made sure the patients were okay. CN 6 confirmed that at the start of the shift (on 4/6/2026), no report was given by the night shift staff regarding Patient 46’s condition (information about the fall incident). CN 6 recalled Patient 46 was unsteady, and CN 6 notified the doctor after Patient 46 complained about leg pain. Xray was ordered and Patient 46 was positive for fracture. CN 6 stated that the nurse (RN 26) who found Patient 46 on the floor, should have called a Code Star immediately. CN 6 stated Code star was a code for fall and “we follow it for patients with a fall. We should not see patients on the floor.” During an interview on 5/29/2026 at 2:15 p.m. with the Manager of Rehab (NM) 8, NM 8 stated the following: Code Star was part of the fall prevention and intervention policy. It provided nurses with guidance for handling patients who fell. NM 8 further stated that nurses called a designated number, and a team responded immediately upon activation of a Code Star to ensure patient safety. During a review of the facility’s policy and procedure (P&P) titled “Standard Policy: Fall Prevention Program,” dated 4/20/2022, the P&P indicated the following: Policy intent: “To identify patients who are at risk of falling so that appropriate preventive measures can be implemented in clinical settings. A Fall is any unplanned descent to the floor with or without assistance. Assessment may only be conducted by a licensed clinical individual. Complete post fall assessment and documentation in the Electronic Health Record.” During a review of facility’s policy and procedure (P&P) titled “Policy: Patient Observation Compliance,” dated 07/18/2025, the P&P indicated the following: “Policy intent: Patients admitted to the Center for Behavioral Health & Recovery shall be routinely observed and monitored by staff every shift to promote safety and provide timely intervention in the event of changes in behavior, risk of harm, or other clinical concerns. To ensure patient safety and regulatory compliance through consistent, structured observation and monitoring practices on all Behavioral Health units. All observation must be face to face. Frequent Patient Observation Sheets and Licensed Patient Observation Sheets are part of the patient’s electronic medical record. All forms must be signed, initialed, dated, and appropriate precautions circled in right upper hand box. Documentation should be completed in real time and accurately reflect the patients’ presentation during the round. Staff must intervene promptly in any situation where a patient is at risk or engaging in unsafe behavior and seek additional support as necessary.””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 50594 Based on interview and record review, the facility failed to ensure that the allegation of abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish) for one of 50 sampled patients (Patient 28) was reported to the Department, in accordance with the facility’s policy regarding abuse reporting. This deficient practice had the potential for Patient 28’ abuse allegation to go unreported and hinder the regulatory agency’s investigation, thereby increasing the risk of Patient 28 and other patients being subjected to ongoing abuse. Findings: During a review of Patient 27’s (aggressor) “Behavioral Health History & Physical (a comprehensive clinical assessment combines psychiatric and behavioral background with medical examination),” dated 1/4/2026, the Behavioral Health History & Physical indicated, Patient 27, “ ...is delusional (a strong, fixed belief that is completely untrue, but which a person holds onto unshakably, even when presented with obvious proof that they are wrong) and has thoughts of harming self and others.” During a review of Patient 28’s (the victim), “History and Physical Examination (H&P, a formal and complete assessment of the patient and the problem), dated 1/7/2026, the H&P indicated, Patient 28 was admitted to the facility with chief complaint indicated as “Called 911 for help because I (Patient 28) was anxious, depressed and having thought to harm myself ...” The document further indicated Patient 28 was on 5150 hold (is the number of the section of the Welfare and Institutions Code [establishes programs and public social services for promoting the public welfare] which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72 hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled [unable to take care of themselves]). During a concurrent interview and record review on 5/28/2026 at 2:18 p.m. with the Manager of Behavioral Health (NM) 3, Patient 28’s “Clinical Note Nursing,” dated 1/11/2026, was reviewed, the note indicated, “I got hit by that pt (referring to patient 27- the aggressor) on my left side ...” NM 3 verified Patient 28 was assaulted (an intentional act that puts someone in reasonable fear of being harmed) by another patient (Patient 27) and this statement (made by Patient 28 about being hit) could be considered as an allegation of abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish). During the same concurrent interview and record review on 5/28/2026 at 2:18 p.m. with the Manager of Behavioral Health (NM) 3, NM 3 stated that the facility’s post violence checklist included notifying behavioral health unit leadership, house supervisor, submit APS (Adult Protective Services, a state mandated program dedicated to maintaining the health and safety of elders and dependent adults subjected to neglect, abuse, or exploitation, or who are unable to protect their own interests) report, contacting the patients’ family, separating the patients, informing the physicians, and investigating the incident. NM 3 further stated that reporting of abuse allegations to CDPH (California Department of Public Health, the state agency responsible for protecting and improving the health and well-being of all Californians) was determined by the facility’s regulatory department. During a concurrent interview and record review on 5/28/2026 at 3:00 p.m. with the Manager of Accreditation, Regulatory, and Licensing (MARL) and the Manager of Behavioral Health (NM) 3, Patient 28’s (the victim) “Clinical Note Nursing,” dated 1/11/2026, was reviewed. MARL stated she (MARL)would consider Patient 28’s statement “I got hit by that pt (Patient 27) on my left side ...” as an allegation of abuse. MARL stated any allegation of abuse, including patient to patient abuse, the facility should notify CDPH as soon as possible within 24 hours via phone call first, then once the facility gathered all the details of the abuse, the facility would then submit a formal report to CDPH within 3-5 days. During a concurrent interview and record review on 5/28/2026 at 3:19 p.m. with NM 3, Patient 27’s (the aggressor) “Clinical Note Nursing,” dated 1/10/2026, was reviewed. The “Clinical Note Nursing” indicated Patient 27 impulsively struck another patient (Patient 28) on the backside of the left shoulder of (Patient 28’s) paralytic arm (an upper limb affected by paralysis meaning it has lost muscle function or ability to move voluntarily). NM 3 stated Patient 27 had a 1:1 sitter (a health care support role where a staff member is assigned to continuously observe and care for a single patient) for fall risk. During an interview on 5/29/2026 at 9:12 a.m. with MARL, MARL stated that the Accreditation, Regulatory, and Licensing Department was responsible for reporting any abuse allegations to CDPH. MARL stated Patient 28’s (victim) video surveillance was reviewed by the Behavioral Health Unit leadership (BHU, a hospital psychiatric or mental health ward), the risk manager, the quality director, and the chief medical officer (CMO). MARL stated the video footage showed Patient 27 (aggressor) performing a knuckle-punch type of massage on Patient 28. MARL said that after the video surveillance was reviewed, the facility’s team determined the interaction (between Patient 27 and Patient 28) was consensual and did not constitute assault or abuse; therefore, it was not reported by the facility to CDPH. During the same interview on 5/29/2026 at 9:12 a.m. with MARL, MARL stated it was important to report all threats or potential harm to CDPH for proper investigation of abuse allegations. MARL added that reporting to CDPH was part of the facility’s investigation process. MARL further stated the facility should follow Title 22 regulations (refer to the section of California Code of Regulations that establishes the minimum health, safety, and operation standards for state-licensed care facilities) in reporting an allegation of abuse. During a review of the facility’s policy and procedure (P&P) titled, “Policy : Assault and Abuse Reporting for Staff and Management,” revision Date 5/28/2025, the P&P indicated, “This policy serves to: ...4. Comply with state law mandating the prompt reporting of suspected/alleged assault and abuse ...The hospital internally and externally reports cases of suspected abuse and neglect in accordance with law and regulation ...” During a review of the facility’s policy and procedure (P&P) titled, “Policy: Patients’ Rights and Responsibilities,” Reviewed date 9/9/2024, the P&P indicated, “It is a responsibility of the Medical Center to ensure that these rights are preserved for their patients ...Attachment A Patient Rights ...14. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation, or harassment. You have the right to access protective and advocacy services including notifying government agencies of neglect or abuse ...” During a review of facility’s policy and procedure (P&P) titled, “Model Policy: Adverse Event Reporting -California,” Revised 5/9/2023, the P&P indicated, “This policy ensures compliance with the requirements of applicable federal and state laws and the standards of applicable accrediting organizations as they relate to reportable event requirements ...Unusual Occurrences: Nothing in this section shall be interpreted to change or otherwise affect hospital reporting requirements regarding reportable diseases or unusual occurrences, as provided in Section 70737 of Title 22 of the California Code of Regulations ... An adverse event must be reported to the department no later than five (5) days after the adverse event has been detected, or if that event is an ongoing ...””

“PATIENT RIGHTS: ACCESS TO MEDICAL RECORD CFR(s): 482.13(d)(2) The patient has the right to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual. If it is readily producible in such form and format (including in an electronic form or format when such medical records are maintained electronically); or if not, in a readable hard copy form or such other form or format as agreed by the facility and the individual, and within a reasonable timeframe. The hospital must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record keeping system permits. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that one of 50 sampled patient’s (Patient 1) designated patient representative (R1), was provided access to Patient 1’s medical records, in a timely manner, within the timeframe required by regulation and the facility’s policy regarding medical records release. This deficient practice resulted in the violation of Patient 1’s representative’s patient’s rights (defined as the basic rights that ensure patients, and their representatives can receive information, make decisions, and access the patient’s own medical records), limiting Patient 1’s and Patient 1’s designated representative’s right to obtain information contained in Patient 1’s clinical record. Findings: During a review of Patient 1’s History and Physical (H&P, a comprehensive medical assessment that describes the patient’s current condition and medical history), dated 12/19/2025, the H&P indicated that Patient 1 was admitted on 12/19/2025 due to severe shortness of breath (difficulty breathing) and an oxygen saturation rate of 70% (percentage of oxygen in the blood; 70% is a critically low level requiring immediate medical attention). During a review of Patient 1’s Discharge Summary (an official clinical document prepared by healthcare professionals that outlines the details of a patient’s hospitalization. It acts as a bridge between the hospital and a patient’s ongoing care), dated 12/23/2025, the record indicated that Patient 1 was transferred to another facility per family’s request on 12/23/2025. During an interview on 6/1/2026 at 10:16 a.m. with Network Director (DIR 14), DIR 14 said that there were multiple requests for record release from Patient 1’s next of kin/representative. DIR 14 said that Patient 1’s next of kin/representative (R1) requested records on 1/2/2026, and the records requested were released to R1 even though the R1 did not provide proof of the next of kin and death certificate was not requested (a death certificate is an official government-issued document that verifies the date, place, and cause of a person’s death) as required by the facility’s policy regarding medical record release. During an interview on 6/1/2026 at 12:39 p.m. with Network Director (DIR 14), DIR 14 said that there was another request on 3/30/2026 from Patient 1’s representative, and the request was not fulfilled as Patient 1’s representative had to provide the address where the documents should be sent, and there was no follow?up from Patient 1’s representative. Therefore, the records were not released for this request (3/30/2026). DIR 14 said that after that request (on 3/30/2026), there was one more request from Patient 1’s representative, which was not fulfilled in a timely manner, and the patient did not receive the requested records until 5/12/2026, even though the records should have been released much sooner, around 4/26/2026, when the request was re-submitted by Patient 1’s representative, and there was no reason not to release the medical records at that time. During the same interview on 6/1/2026 at 12:39 p.m. with Network Director (DIR 14), DIR 14 said there were three (3) more record release requests that came from Patient 1’s lawyer, but none of the requests were fulfilled due to missing documents such as “missing authorization (an authorization is a signed document permitting the release of protected health information to a specified individual or entity)” and lack of “proof of next of kin” documents. However, after reviewing the documents, DIR 14 then said that based on the information reviewed, Patient 1’s medical record release request that came from Patient 1’s lawyer firm should have been released on 3/16/2026 but was not. DIR 14 then confirmed that Patient 1’s lawyer’s medical record release request has never been fulfilled. During a review of the facility’s policy and procedure (P&P) titled “Release of Information - Medical Records”, dated 4/8/2026, the policy indicated that standards for disclosing patient health information are governed by state and federal laws to ensure confidentiality and protection of medical records. The policy states that patients or their personal representatives have the right to timely access to their protected health information (PHI). The specific time frames for allowing access may vary depending on the requester, and exceptions may apply in emergent situations as determined by the Release of Information (ROI) Leadership. The policy indicated that “Attorneys may use statutory form AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION PURSUANT TO EVIDENCE CODE SECTION 1158.” (This means that when an attorney is requesting a patient’s medical records before a lawsuit is filed, state law (Evidence Code §1158) allows the attorney to obtain the patient’s health information using a specific legally recognized authorization form).””

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI, a data-driven program used to monitor, assess, and improve the quality and safety of patient care) program implemented a process to collect, measure, analyze, and monitor data to determine the effectiveness of corrective actions following an identified patient safety event for one (1) of 50 sampled patients (Patient 7), in accordance with the facility’s QAPI program plan. After a Root Cause Analysis (RCA, a structured process used to identify underlying cause of adverse events) identified that nursing staff failed to activate a Rapid Response Team (RRT, a hospital team that responds immediately to a patient’s acute clinical deterioration) when Patient 7 experienced bradycardia (an abnormally slow heart rate, typically less than 60 beat per minute) and decreased responsiveness, the facility implemented staff education but failed establish a measurable process to evaluate the effectiveness of the corrective action, track performance over time, and ensure sustained improvement. This deficient practice had the potential to prevent the facility from identifying continued failures in escalation of care and delayed recognition of patient deterioration which may result in another patient related safety event or near-miss (a medical error or unsafe situation that could have caused patient harm but did not, either by chance or because it was caught before reaching the patient), patient harm and/or death. Findings: During a review of Patient 7’s “History and Physical (H&P, a formal comprehensive medical evaluation and assessment used by healthcare providers),” dated 2/7/2026, the H&P indicated Patient 7 was admitted to the behavioral Health Unit (BHU, a specialized hospital unit for mental health care) after treatment of lower extremity wounds. The H&P indicated Patient 7 had been evaluated by infectious Disease (a medical specialty that diagnoses and treats infections) and was cleared for continuation of care in BHU. During a concurrent interview and record review on 5/27/2026 at 10:55 a.m. with Registered Nurse (RN) 7, Patient 7’s electronic medical record (EMR, electronic version of a medical record) document titled “Vital Signs (measurements of body functions such as heart rate, blood pressure, temperature, and breathing rate),” dated 2/6/2026 through 2/28/2026, was reviewed. The EMR indicated that upon admission to the BHU on 2/6/2026 at 1:00 p.m., Patient 7’s heart rate (HR, the number of heart beats per minute) was 106. The EMR indicated that on 2/26/2026 at 8:00 a.m., Patient 7’s HR was 59. RN 7 confirmed there was no reassessment of the abnormal vital signs (drop in HR from 106 to 59 then to 57) and no provider notification. The EMR further indicated that on 2/26/2026 at 7:15 p.m., Patient 7’s HR was 57. RN 7 confirmed there was no reassessment of the HR and no physician notification despite the HR being significantly lower than Patient 7’s baseline HR in the 100s. During the same concurrent interview and record review on 5/27/2026 at 10:55 a.m. with RN 7, RN 7 confirmed Patient 7’s HR of 57 represented bradycardia (an abnormally slow heart rate, typically less than 60 beat per minute) compared to Patient 7’s baseline (the normal, expected, or starting level of a patient’s condition, vital signs, behavior, functioning, or clinical status before any change) HR and that no physician notification occurred. During a concurrent interview and record review on 5/27/2026 at 11:15 a.m. with RN 7, the EMR documented titled “Physician Notification,” was reviewed. The EMR indicated Patient 7’s HR decreased to the 30s and Patient 7 was less responsive than during the previous shift. RN 7 stated a Rapid Response (RRT, a hospital team that responds immediately to a patient’s acute clinical deterioration) should have been activated and confirmed a Rapid Response was not called before Patient 7 was transferred to telemetry (continuous cardiac monitoring) on 2/28/2026. During an interview on 5/28/2026 at 10:20 a.m. with Behavioral Health Unit Manager (MN 3), MN 3 stated nursing staff should have activated a Rapid Response when Patient 7’s HR decreased into the 30s and the patient (Patient 7) became less responsive. During an interview on 5/29/2026 at 10:38 a.m. with the interim Risk and Safety Manager (RS), RS stated the event was identified through an incident report submitted on 3/2/2026 after Patient 7 experienced agonal breathing (abnormal, ineffective gasping respirations associated with sever medical deterioration), a Code Blue (emergency response for cardiac or respiration) was activated, and Patient 7 later expired (died). During the same interview on 5/29/2026 at 10:38 a.m. with RS, RS stated a RCA (Root Cause Analysis, a structured process used to identify underlying cause of adverse events) was completed on 3/2/2026. RS stated the RCA identified that the Behavioral Health nurse failed to activate Rapid Response despite recognition that Patient 7’s HR was low. RS stated corrective action included education regarding Rapid Response activation, escalation of care, and responding to changes in patient condition for Behavioral Health Unit and telemetry staff between 3/9/2026 and 4/28/2026. During the same interview on 5/29/2026 at 10:38 a.m. with RS, RS stated that the effectiveness of the corrective action was monitored through reviews of incident reports, Rapid Response events, Code Blue events, and weekly unannounced staff rounding. RS stated staff were asked whether they knew how and when to activate a Rapid Response. RS further stated the QAPI department did not maintain documentation of the rounding activities, did not collect or trend data from the rounding process, did not maintain audit results, and did not record findings unless there was something significant to report. RS further stated incident reports were reviewed for additional events; however, incident reports were not considered formal audits and only identified issues after an event or a near-miss event (an incident that could have resulted in harm to a patient but did not, either because it was caught in time, prevented by chance, or mitigated before injury occurred) had already occurred. During an interview on 5/29/2026 at 10:45 a.m. with the Director of Quality (DQA), DQA confirmed that although the facility implemented corrective measures after the event involving Patient 7, the QAPI program did not collect data to evaluate whether those measures were effective or needed adjustment. During a review of the facility’s “Quality Assessment and Performance Improvement (QAPI) Program Plan,” dated 10/27/2025, the plan indicated leaders were responsible for identifying the frequency of data collection for performance improvement activities, measuring performance improvement process, identifying cause of variation and deficiencies, monitoring performance improvement efforts and sustaining improvement over time.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to: 1. Ensure the Quality Assessment and Performance Improvement (QAPI) program (a hospital-wide program that uses data to monitor, assess, and improve the quality and safety of patient care) identified, analyzed, and implemented performance improvement activities related to patient safety events for one (1) of 50 sampled patients (Patient 8). The facility’s Root Cause Analysis (RCA, a structured process used to identify underlying system causes of adverse events) failed to identify that Emergency Department (ED) staff used a non-facility staff member as a one-to-one sitter (a caregiver assigned to provide continuous observation of a patient), failed to identify the lack of safety interventions to prevent further harm when Patient 8 and the non-facility staff member were not separated after Patient 8 struck the individual (the non-facility staff member) in the chest, and failed to identify that Patient 8 was not reassessed after a significant change in condition and aggressive behavior. The RCA failed to identify multiple deviations from facility policies regarding observation, reassessment, management of high-risk behavioral health patients, and failed to develop corrective actions addressing those contributing factors. This deficient practice resulted in the QAPI program’s failure to identify contributing factors, analyze deviations from facility policy, implement corrective actions, and evaluate whether interventions were effective, increasing the potential for recurrence of similar patient safety events involving high-risk behavioral health patients. 2. Ensure its Quality Assessment and Performance Improvement (QAPI, a data-driven program used to monitor, assess, and improve the quality and safety of patient care) team analyzed and discussed the appropriate use for the facility’s patient video monitoring for patients prone to wandering, during a root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution), for two of 50 sampled patients’ (Patient 23 and Patient 22) patient safety related events regarding elopement, in order determine what preventive actions and mechanisms could be implemented and prevent recurrence. Patient 23 eloped from the facility (first incident) in a wheelchair on 3/28/2026 despite being under the facility’s patient video monitoring (PVM, a virtual patient observation system used in hospitals utilizing video camera, two-way audio and technology to allow hospital staff to remotely and continuously observe multiple patients at once from a central command center). On 4/8/2026, a week after Patient 23’s elopement, Patient 22 also eloped from the facility despite Patient 22 being monitored by PVM (second incident). This deficient practice had the potential to result in ongoing inappropriate utilization of PVM as PVM technicians are unable to maintain a clear visual on patients who could be wandering in their patient room and not being properly monitored which could lead to other patient safety concerns including but not limited to elopement. Findings: 1. During a review of Patient 8’s “ED Physician Notes,” dated 6/11/2025, the record indicated Patient 8 was brought in by staff from a group home (a supervised residential setting where individuals who need help with daily living receive staff support) for a psychiatric evaluation (a medical assessment of a person’s mental, emotional, and behavioral condition). The record indicated group home staff reported Patient 8 “has been breaking multiple objects in home, attacking staff and harming self.” The record indicated Patient 8’s past medical history included schizophrenia (a chronic mental health disorder), bipolar disorder (a mood disorder involving depressive and elevated mood episodes), and autism (a developmental disorder affecting communication and social interaction). During a review of Patient 8’s “Clinical Note Behavioral Health (BH),” documented by Registered Nurse (RN) 2 and dated 6/11/2025, the note indicated Patient 8 was “unstable” and exhibited aggressive and self-injurious behaviors. The note indicated the plan was for Patient 8 to remain in the ED on constant observation and be evaluated later by a physician. During a concurrent interview and record review on 5/26/2026 at 2:10 p.m. with Nurse Manager (NM) 1, Patient 8’s “Clinical Note Behavioral Health,” dated 6/11/2025 and documented by RN 3, was reviewed. The note indicated Patient 8 had been “impulsively banging his forehead on the ground/wall for the past five years on and off” and had a “large skin flap/open wound at the site.” NM 1 stated Patient 8 arrived at the facility with an open wound to the forehead. During a concurrent interview and record review on 5/26/2026 at 2:10 p.m. with NM 1, Patient 8’s Dynamic Appraisal of Situational Aggression (DASA, a screening tool used to assess a patient’s short-term risk of aggressive behavior), was reviewed. The DASA, dated 6/11/2025 at 1:35 a.m., indicated RN 2 documented a score of 7, indicating “High Risk,” due to Patient 8 being physically aggressive, irritable, impulsive, unwilling to follow directions, sensitive to perceived provocation, easily angered, displaying negative attitudes, and making verbal threats. During an interview on 5/26/2026 at 3:30 p.m. with the Director of the Emergency Department (DIR 2) and NM 1, DIR 2 stated they (DIR 2 and NM 1) participated in the RCA (Root Cause Analysis, a structured process used to identify underlying system causes of adverse events) and the RCA identified no nursing fallouts because, based on protocol, Patient 8 did not require a sitter (a caregiver assigned to provide continuous observation of a patient). NM 1 stated Patient 8 was not suicidal (having thoughts of taking one’s own life) and was not on an involuntary psychiatric hold (a legal detention for psychiatric evaluation) and therefore did not require a sitter. DIR 2 stated the RCA concluded that care had been appropriate and there were no nursing fallouts despite Patient 8 having a DASA score of 7 (High Risk for harming self or others), remaining with an untrained non-facility caregiver following an assault (an intentional act that puts someone in reasonable fear of being harmed), not being reassessed after aggressive behavior, and not receiving a repeat DASA screening as required by facility policy. During an interview on 5/28/2026 at 10:10 a.m. with Behavioral Health Nurse Manager (NM 3), NM 3 stated that when Regional Center staff (non-facility caregivers accompanying a patient) remain with a patient, the decision was usually discussed between the unit leaders and the Regional Center leadership. NM 3 stated the facility did not know the training of Regional Center staff and did not have a contract with the Regional Center. During an interview on 5/29/2026 at 10:38 a.m. with the Director of Quality (DQA), Interim Risk and Safety Manager (RS), and the Program Manager of Performance Improvement, the DQA stated Patient 8’s event had been reviewed by the previous Risk Manager, and an analysis had been completed. The DQA stated the RCA did not identify that ED staff used the Regional Center staff member as a one-to-one sitter. The DQA stated the RCA did not identify that using a Regional Center staff member as a sitter was inappropriate. The DQA further confirmed that the RCA did not identify the failure to separate Patient 8 from the Regional Center staff member after the assault, did not identify the failure to reassess Patient 8 following the change in condition and aggressive behavior, and therefore did not result in corrective actions addressing those issues. During a concurrent interview and record review on 5/26/2026 at 2:30 p.m. with NM 1, Patient 8’s “Clinical Note ED,” dated 6/11/2025 at 6:18 p.m., was reviewed. The note indicated Patient 8 struck the Regional Center staff member in the chest. NM 1 stated Patient 8 and the Regional Center staff member were not separated following the assault. During an interview on 5/27/2026 at 9:50 a.m. with RN 1 (assigned to Patient 8 on 6/11/2025), RN 1 stated Patient 8 was not separated from the Regional Center staff member after Patient 8 struck the Regional Center staff member in the chest, a Code Gray (an emergency response for aggressive or violent behavior) was not initiated, and Patient 8 was not reassessed following the assault. During a concurrent interview and record review on 5/26/2026 at 3:05 p.m. with NM 1 and DIR 2, Patient 8’s “ED Physician Note,” dated 6/11/2025, was reviewed. The note indicated Patient 8 sustained a three?centimeter facial laceration (a tear or rip in the skin). NM 1 stated that after striking the Regional Center staff member, Patient 8 was later accompanied by the same Regional Center staff member into the bathroom, where Patient 8 struck his (Patient 8) head against the wall repeatedly and sustained the facial laceration. Despite Patient 8 sustaining a three-centimeter facial laceration after the assault (an intentional act that puts someone in reasonable fear of being harmed) and subsequent self-injurious behavior, DIR 2 and NM 1 stated the RC concluded there were no nursing fallouts and care had been appropriate. During an interview on 5/27/2026 at 10:18 a.m. with DIR 2 and NM 1, NM 1 stated no repeat DASA assessment was completed after Patient 8 assaulted the Regional Center staff member or after Patient 8 sustained the facial injury. During the same interview on 5/27/2026 at 10:18 a.m. with DIR 2 and NM 1, NM 1 stated no additional focus assessment was completed after Patient 8 struck the Regional Center staff member and no vital signs (measurements of body functions such as heart rate, blood pressure, temperature, and breathing rate) were attempted to be obtained after Patient 8 sustained the facial laceration. During an interview on 5/27/2026 at 10:23 a.m. with the Director of Behavioral Health (DIR 1), DIR 1 stated the DASA should be repeated when there was a change in patient condition, including when a patient strikes another person. During an interview on 5/26/2026 at 10:46 a.m. with DIR 2, DIR 2 stated the purpose of a sitter was to keep a patient safe. DIR 2 stated if a patient was harming themselves, the patient would require one-to-one observation. DIR 2 stated that if a caregiver (from an outside facility) accompanied a patient, the patient would still be assigned a sitter (provided by the receiving facility) and the caregiver (from an outside facility) would be encouraged to remain with the patient. During a review of the facility’s policy and procedure (P&P) titled “Quality Assessment and Performance Improvement (QAPI) Program Plan,” dated 10/27/2025, the P&P indicated leaders would proactively identify processes needing improvement to prevent medical errors and harm, identify causes of variation and deficiencies, measure performance improvement activities, and monitor and sustain improvement processes. The P&P indicated patient safety activities were integrated into the QAPI program and cause analyses were used to assess risks and prioritize areas for improvement. During a review of the facility document titled “Cause Analysis Toolkit - Safety Event Response System Root Cause Analysis (RCA) vs Apparent Cause Analysis (ACA),” dated January 2025, the document indicated cause analysis tools were used to determine what happened, how it happened, and how to prevent recurrence. The document indicated a RCA identifies active errors (errors occurring at the point of care) and latent errors (hidden system problems contributing to adverse events). During a review of the facility’s policy and procedure (P&P) titled, “Utilization of Safety Attendants for Patients,” dated 3/24/2025, the P&P indicated, “The purpose of this policy is to provide guidelines for safety attendant placement for patients with high risk behaviors, high fall risk, or other behaviors that place the patient at risk for injury... Safety attendants may be instituted for patients with high risk behaviors or those with high risk for fall or other injury including: a. Danger to self b. Danger to others c. Grave disability d. Potential for injury... 2. Assigned attendant will be a trained Registered Nurse, Licensed Vocational Nurse, Certified Nursing Assistant. Nursing Assistant. Mental Health Technician, Licensed Psychiatric Technician, or Emergency Medical Technician. 3. A family member or volunteer may not provide monitoring/observation for patients with high-risk behaviors. 4. The staff member assigned to the patient shall have received education on management of patients at high risk for falls, injury. and high risk behaviors. 5. The Safety Attendant will accompany the patient at all times.” During a review of the facility’s P&P titled “Patient Risk Aggression Assessment,” dated 7/3/2024, the P&P indicated interventions for patients with a high-risk DASA score included notifying the provider, notifying security, considering a Patient Safety Attendant (PSA, personnel assigned to continuously observe a patient), considering constant one-to-one observation, considering a Code Gray, and re-screening patients after any incident of aggression or change in behavior. During a review of the facility’s P&P titled “Behavioral Health Patients, Emergency Department, Management of,” dated 1/18/2023, the P&P indicated moderate and high-risk behavioral health patients who are a danger to themselves or others should receive continuous monitoring by security personnel or a trained safety attendant. During a review of the facility’s P&P titled “Management of High-Risk Behaviors,” dated 5/28/2024, the P&P indicated de-escalation strategies include separating a patient from a dangerous situation when high-risk behavior is occurring or likely to occur. 2. During a review of Patient 23’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/6/2026, the “H&P” indicated, Patient 23 was admitted to the facility with diagnoses including but not limited to severe lymphedema (persistent swelling most commonly in the arms and legs) of bilateral (both) lower extremities, schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and acute (new onset) psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality). During a review of Patient 23’s “Behavioral Health Progress Note (Psychiatrist [physician specializes in mental health] progress note),” dated 3/11/2026, the “Behavioral Health Progress Note” indicated, Patient 23 was on temporary conservatorship (legal arrangement where a judge appoints a responsible individual to make decision for the patient who is deemed unable to care for themselves) status. During an interview on 5/26/2026 at 11:54 a.m. with RN 17, RN 17 stated patients on legal hold (involuntary detention forces a patient to remain in a healthcare facility for evaluation and treatment) were the ones who could not care for themselves, they may hurt themselves or others. RN 17 further stated patients on legal hold could not leave the hospital without a physician discharge order. During an interview on 5/26/2026 at 11:55 a.m. with Charge Nurse (CN 5), CN 5 stated patients on conservatorship could not leave the facility without physician discharge order. CN 5 further stated patients on conservatorship were like patients on legal hold. During a concurrent interview and record review on 5/28/2026 at 10:09 a.m. with Interim (temporary) Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) Manager (NM 10) and Registered Nurse (RN)19, Patient 23’s physician order, dated 2/7/2026 and 3/2/2026, were reviewed. The physician order dated 2/7/2026 indicated, “patient (Patient 23) may sleep under the camera, no need for sitter.” The physician order, dated 3/2/2026, indicated “camera room for safety.” NM 10 stated, where there was a physician order for camera, the patient would be placed in a patient room equipped with the facility’s patient video monitoring (PVM, a virtual patient observation system used in hospitals utilizing video camera, two-way audio and technology to allow hospital staff to remotely and continuously observe multiple patients are once from a central command center). NM 10 further stated there was a PVM technician watching over all patients under PVM. NM 10 also stated a virtual guardrail (green box) would be set on the video monitoring system to limit how far the patient was allowed to move while in the patient room equipped with PVM. NM 10 stated, once the patient moved outside the green box, the PVM technician would notify the nursing unit immediately to have nursing staff to go to the room to check on the patient. During an interview on 5/28/2026 at 10:35 a.m. with RN 19, RN 19 stated a patient with camera monitoring order must be under PVM technician’s view at all times, once the patient was out of view under PVM, the PVM technician should call the nursing staff to check on the patient immediately. During a review of Patient 23’s “Clinical Note Nursing (nursing narrative note),” dated 3/28/2026, the “Clinical Note Nursing” indicated, on 3/28/2026, “at 11 a.m. patient (Patient 23) wants to go home ... at 11:59 a.m., physician (MD 11) was notified that patient (Patient 23) wanted to go home and as per MD (MD11) that patient (Patient 23) was on a hold (due to temporary conservatorship) and cannot go home ... at 3 p.m. patient (Patient 23) asked about going home ... explained that she (Patient 23) cannot go home due to hold ... at 5:02 p.m. staff called RN (RN 21) that patient (Patient 23) is not in her (Patient 23’s) room while she (Patient 23’s) passing the dinner tray. Immediately I (RN 21) went to look around the Unit, the Lobby ... cafeteria ground floor and basement and patient (Patient 23) cannot be found. At 5:12 p.m. Code Green (signals a missing patient so the hospital can activate its procedure to locate the missing patient) was announced ...” During a review of the facility’s VPM “No Response Log (document from PVM technician calling the nursing unit when patient was out of PVM camera view),” dated 3/28/2026, the “No Response Log” indicated, on 3/28/2026 at 4 p.m. a call was placed to Patient 23’s unit and the unit secretary was notified about Patient 23 not being seen on the PVM camera view for ten (10) minutes. During an interview on 5/28/2026 at 1:42 p.m. with the Director (DIR 4) of Critical Care (specialist hospital wards that provide treatment and monitoring for people who are very ill), DIR 4 stated PVM could be used to monitor safety for patients who were at high risk for fall, getting out of bed and elopement risk. DIR 4 stated PVM technician was supposed to notify nursing staff to check on the patient once the patient was out of PVM camera view. DIR 4 stated Patient 23 was able to move around in her (Patient 23’s) wheelchair that made it difficult for the PVM technician to get a full visual on the patient (Patient 23). DIR 4 further stated there was no specific policy or guidelines regarding PVM use. During a review of Patient 22’s “Hospitalist Progress Note (physician progress notes),” dated 4/8/2026, the “Hospitalist Progress Note” indicated, Patient 22 was admitted to the facility with diagnoses including but not limited to metabolic encephalopathy (acute or chronic impairment of brain function caused by underlying chemical imbalance, systemic illness, or organ dysfunction) and opiate overdose (when the toxic levels of opioids [opiates, substance used to treat pain or cause sleep] overwhelm the body). The “Hospitalist Progress Note” also indicated, Patient 22 was placed on legal hold (involuntary detention forces a patient to remain in a healthcare facility for evaluation and treatment) on 4/8/2026 and was with a bedside sitter (a healthcare worker who stays continuously at a patient’s bedside to provide one-to-one supervision, and safety monitoring) in place. During a review of Patient 22’s 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment), dated 4/8/2026, the 5150-hold indicated, Patient 22 was placed on 72-hour involuntary hold for grave disability (inability to care for oneself) due to mental disorder. During a review of Patient 22’s “physician order,” dated 4/8/2026, the “physician order” indicated, “camera for safety.” During a review of Patient 22’s “Clinical Note Nursing (nursing notes),” dated 4/8/2026, the “Clinical Note Nursing” indicated, (on 4/8/2026) at 5:45 p.m. “[nursing staff] was notified by transport that there was a patient leaving the unit by the elevator. Ran to the room, patient (Patient 22) and sitter (CNA 6) were not in the room ... Phone call made to NA (CNA 6) and he (CNA 6) replied at 5:48 p.m. that he (CNA 6) was in the restroom and patient (Patient 22) was left with family members. Code Green (signals a missing patient so the hospital can activate its procedure to locate the missing patient) at 5:48 p.m.” During an interview on 5/28/2026 at 11:59 a.m. with Charge Nurse (CN) 5, CN 5 stated on 4/8/2026, Patient 22 was in a room equipped with PVM but the camera did not capture Patient 22. CN 5 stated Patient 22 left the room without PVM technician knowing. During an interview on 5/28/2026 at 11:37 a.m. with the Patient Safety and Risk Manager (RS), RS stated root cause analysis meetings (RCA, the process of discovering the root causes of problems in order to identify appropriate solution) were done for both Patient 23 and Patient 22 because of their (Patient 23 and Patient 22) high risk status (Patient 23 was on temporary conservatorship and Patient 22 was on 5150-hold). RS stated the purpose for RCA was to identify root cause to analyze the incident, how it happened, why it happened and how to prevent it from happening again. RS stated the RCA meetings involved interdisciplinary team (consists of professionals from diverse fields who collaborate interdependently to achieved a shared goal) including the Quality Assessment and Performance Improvement (QAPI, a data-driven program used to monitor, assess, and improve the quality and safety of patient care) team to collaborate and get input as a team. During an interview on 5/28/2026 at 1:52 p.m. with DIR 4, DIR 4 stated she (DIR 4) participated in both root cause analysis (RCA) meetings for Patient 23 and Patient 22. DIR 4 stated for Patient 23’s elopement incident, Patient 23’s nurse (RN 21) allowed Patient 23 to be in the hallway, thus the PVM technician lost sight on Patient 23 from the PVM camera view. DIR 4 stated for Patient 22’s elopement, the PVM camera view did not get a good visual on Patient 22. DIR 4 stated the PVM technician only saw someone’s feet in the camera and mistaken those feet were Patient 22’s. DIR 4 stated the PVM technician did not know Patient 22 was not in the room until Code Green was overhead paged. DIR 4 stated PVM use was not ideal for patients who were able to walk around in the room. During an interview on 5/28/2026 at 2:34 p.m. with the Patient Safety and Risk Manager (RS), RS stated during the RCA meeting for Patient 23’s elopement, the team identified concern about PVM use including PVM technician not getting Patient 23’s view and the delayed response from nursing staff despite PVM technician calling the nursing staff on 3/28/2026 at 4 p.m. RS stated he (RS) was not sure if there were any discussion regarding the problems identified related to PVM use. During an interview on 5/28/2026 at 11:56 a.m. with RS, RS stated during the RCA for Patient 22’s elopement, the team identified that the PVM did not capture a good view on Patient 22 because Patient 22 was wandering around in the room. RS stated there was no further discussion about PVM regarding the problem identified because the team believed that the root cause was the sitter’s (CNA 6) failure to notify other nursing staff to cover before leaving Patient 22. RS was unable to answer if there was a policy or guideline on PVM use. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment and Performance Improvement (QAPI) Program Plan,” dated 5/2025, the P&P indicated, “The Quality Assessment & Performance Improvement (QAPI) Program is a proactive, interdisciplinary, systematic approach to designing or redesigning patient-centered systems to improve quality of care and patient safety, in alignment with regulatory standards ... Structure and Accountability ... [the facility] leadership is responsible for identifying priorities, supporting change management, and allocating resources for [facility] QAPI program. Leadership is responsible for improving quality of care, safety, and services provided by [facility] staff through established structures and processes ... Patient Safety Program... Patient safety integrates with all quality assessment and performance improvement activities. Cause Analysis and Proactive Risk Assessments ... will be utilized to assess actual and potential risk, failure, points of vulnerability, and prioritized areas for improvement based on impact patient care outcomes.” During a review of the facility document titled “Cause Analysis Toolkit - Safety Event Response System Root Cause Analysis (RCA) vs Apparent Cause Analysis (ACA),” dated January 2025, the document indicated cause analysis tools were used to determine what happened, how it happened, and how to prevent recurrence. The document indicated a RCA identifies active errors (errors occurring at the point of care) and latent errors (hidden system problems contributing to adverse events). During a review of the facility’s policy and procedure (P&P) titled, “Code Green - Patient Elopement,” dated 2/2025, the P&P indicated, “High-Risk Patient for Elopement/Patient Elopement: A patient who fits the following criteria or who leaves the patient care unit without permission who is: a. on a legal hold (dangers to themselves or others); b. high risk for elopement ... g. on psychiatric conservatorship ... All reasonable measures will be taken to prevent the elopement of high-risk patients from the hospital ...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to: 1. Ensure Nursing staff called a Rapid Response Team (RRT, a hospital team that responds immediately to a patient’s acute clinical deterioration) for one (1) of 50 sampled patients (Patient 7), when Patient 7’s heart rate (HR, the number of heart beats per minute) dipped into the 30s and Patient 7 was less responsive than the previous shift while housed on the Behavioral Health Unit (BHU, a specialized hospital unit for mental health care) on 2/27/2026, and also failed to reassess the abnormal vital signs (measurements of body functions such as heart rate, blood pressure, temperature, and breathing rate) and notify the physician of the change in condition, in accordance with the facility’s policies regarding Rapid Response Team, Assessment/Reassessment. This deficient practice resulted in delayed Rapid Response activation for Patient 7 and had the potential to result in delayed treatment for clinical deterioration (when a patient’s health gets worse). 2. Ensure nursing staff followed up on an infectious disease specialist to obtain a wound care consult for one (1) of 50 sampled patients (Patient 7), who had wounds on both lower legs, in accordance with the facility’s policies regarding escalation for resolution of clinical patient safety concerns and plan for provision of nursing care. This deficient practice resulted in Patient 7 not receiving a wound care specialist assessment or treatment recommendations for the bilateral (both) lower leg wounds from 2/16/2026 -2/25/2026. As a result, Patient 7 did not receive necessary treatment for wounds that were reddened, weeping, and swollen, which may lead to further deterioration or infection. 3. Ensure that a registered nurse supervised and evaluated the nursing care for one patient of 50 sampled patients (Patient 1) and failed to ensure that intake and output (I&O, meaning the measurement and documentation of all fluid a patient takes in and all fluid a patient eliminates) and oral food intake, including fluid intake, were consistently and accurately monitored, evaluated, and documented by nursing staff during Patient 1’s admission (from 12/19/2025 through 12/23/2025), in accordance with the facility’s policies regarding nursing standards of care and telemetry standards of practice. This deficient practice had the potential to place Patient 1 at risk for fluid imbalance (when your body has either too much or too little fluid compared to the amount of salt and minerals [electrolytes] it needs to function), worsening respiratory status (reflection of a patient’s effort to breathe and oxygen levels in the blood) , and delayed recognition of clinical deterioration (when a patient’s health gets worse), especially given Patient 1’s admitting diagnoses, which included, but were not limited to, pulmonary edema (meaning excess fluid in the lungs that impairs breathing) and congestive heart failure (meaning the heart cannot pump blood effectively, leading to fluid buildup throughout the body). 4. Ensure its nursing staff provided adequate supervision and care, in accordance with the facility’s policy regarding provision of nursing care, to prevent one of 50 sampled patients (Patient 23), who was under temporary conservatorship (legal arrangement where a judge appoints a responsible individual to make decision for the patient who is deemed unable to care for themselves) from eloping (a person attempts to leave the facility, when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility on 3/28/2026 when: 4.a. Patient 23’s primary Registered Nurse (RN 21) did not escalate supervision despite Patient 23 having verbalized wanting to leave two times on 3/28/2026 at 11 a.m. and 3 p.m.; 4.b. Nursing staff did not respond to facility’s patient video monitoring (PVM, a virtual patient observation system used in hospitals utilizing video camera, two-way audio and technology to allow hospital staff to remotely and continuously observe multiple patients are once from a central command center) technician’s call when Patient 23 was out of PVM camera view on 3/28/2026 at 4 p.m.; 4.c. RN 21 did not provide supervision for Patient 23 (on temporary conservatorship) on 3/28/2026 from 3:30 p.m. - 5 p.m.; 4.d. RN 21 delayed calling a Code Green (signals a missing patient so the hospital can activate its procedure to locate the missing patient). Patient 23 was found missing on 3/28/2026 at 5:02 p.m. but Code Green was called at 5:12 p.m. (ten minutes later). These deficient practices resulted in Patient 23 eloping from the facility on 3/28/2026 and placed Patient 23 at risk for dangers such as accidental injury, falls, traffic accidents and may also pose danger to others (Patient 23 was admitted for acute [new onset] psychosis [severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality]). Findings: 1. During a review of Patient 7’s “History and Physical (H&P, a formal, comprehensive medical evaluation and assessment used by healthcare providers),” dated 2/7/2026, the H&P indicated Patient 7 “with no significant PMHx (past medical history) presents with LE (lower extremity) wound which was treated with abx (antibiotics, medications that fight bacterial infections). Patient (Patient 7) was evaluated by ID (Infectious Disease-a medical specialty that diagnoses and treats infections). Cleared for continuation of care in BHU (Behavioral Health Unit-a specialized hospital unit for mental health care).” During a concurrent interview and record review on 5/27/2026 at 10:55 a.m. with Registered Nurse BHU (RN 7), Patient 7’s electronic medical record (EMR) document titled “Vital Signs (measurements of body functions such as heart rate, blood pressure, temperature, and breathing rate),” dated 2/6/2026 and 2/26/2026 through 2/28/2026, was reviewed and indicated the following: -The EMR indicated that on 2/6/2026 at 1:00 p.m., upon arrival to the BHU, vital signs included temperature 97.5°F, HR 106, respiratory rate (RR, the number of breaths per minute) 16, blood pressure (BP, the pressure of circulating blood against vessel walls) 130/84, and oxygen saturation (SpO2, the percentage of hemoglobin carrying oxygen) 94 percent on room air (RA, breathing without supplemental oxygen). -The EMR indicated that on 2/26/2026 at 8:00 a.m., Patient 7 had a HR of 59 and BP of 121/68. RN 7 confirmed there was no reassessment of the vital signs and no documentation of provider notification, and that an HR of 59 represented bradycardia (an abnormally slow heart rate, typically under 60 beats per minute) and was not Patient 7’s baseline (the normal, expected, or starting level of a patient’s condition, vital signs, behavior, functioning, or clinical status before any change) HR. -The EMR indicated that on 2/26/2026 at 7:15 p.m., Patient 7’s vital signs included HR 57, BP 106/67, RR 18, and SpO2 96 percent RA. RN 7 confirmed there was no reassessment of the vital signs in particularly the HR and no documentation of provider notification. During the same interview and record review on 5/27/2026 at 10:55 a.m. with RN 7, RN 7 confirmed that Patient 7’s HR of 57 on 2/26/2026 at 7:15 p.m. represented bradycardia compared to the patient’s baseline HR in the 100s documented on admission to the BHU (on 2/6/2026), and that despite the change in condition, the vital signs were not reassessed and no physician notification occurred. During a concurrent interview and record review on 5/27/2026 at 11:15 a.m. with RN 7, the EMR document titled “Physician Notification,” was reviewed. The EMR indicated: “HR 52 at highest, dipping to 30’s, 95 percent oxygen on room air, unable to obtain either oral or axillary temperature, patient (Patient 7’s) skin is cool to touch, pt (patient) alert and obeys commands but not as responsive from previous shift.” RN 7 stated a Rapid Response Team (RRT, a hospital team that responds immediately to a patient’s acute clinical deterioration) should have been activated and confirmed that no Rapid Response was called until Patient 7 was transferred to the telemetry unit (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) on 2/28/2026 at 6:13 a.m. During an interview on 5/27/2026 at 3:17 p.m. with Registered Nurse BHU (RN 9), RN 9 stated that if a patient had a sudden HR drop accompanied by decreased responsiveness, she (RN 9) would immediately call a Rapid Response. RN 9 stated the purpose of Rapid Response activation was to bring needed assistance, such as the house supervisor and specialized staff to assist with patient transfer and care coordination. During an interview on 5/28/2026 at 10:20 a.m. with BHU Manager (MN 3), MN 3 stated the nurse should have called a Rapid Response when Patient 7’s HR dipped into the 30s and when the patient was alert but less responsive (patient has a decreased awareness of their surroundings and reacts more slowly) than previously. During an interview on 5/28/2026 at 3:00 p.m. with Medical Doctor (MD 3), MD 3 stated he (MD 3) received a page that Patient 7 was bradycardic and hypothermic (abnormally low body temperature), ordered intravenous (IV, through the vein) fluids and warming with a Bair Hugger (a warming system that blows heated air through a blanket), and stated Patient 7 required a higher level of care (means more intensive support, closer medical supervision, or more frequent professional assistance) and transfer to telemetry (a continuous cardiac monitoring unit). During a review of the facility’s policy and procedure (P&P) titled “Rapid Response Team,” dated 5/28/2025, the policy indicated: “The front-line registered nurse (RN) will discuss the patient’s status with the charge nurse. RRT will be called when patients show signs of clinical deterioration including but not limited to: acute changes in vital signs or oxygenation (systolic blood pressure [SBP-the top BP number] less than 90, HR less than 45 or greater than 125, RR less than 10 or greater than 30, SpO2 less than 90), signs of respiratory distress (tachypnea-rapid breathing; hyperpnea-abnormally deep breathing; poor air exchange), chest pain, sudden or new altered mental status, or seizures.” During a review of the facility’s policy and procedure (P&P) titled “Assessment/ Reassessment, Interdisciplinary,” dated 9/9/2024, the policy indicated: “An initial assessment is made upon admission or initial patient contact, and further assessments and reassessments are conducted based on the diagnosis, unit setting or service, and patient’s response to care and treatment ... b. Information from the reassessment will be documented in Electronic Health Record. The RN uses information gathered to update the plan of care and prioritize patient needs. c. Reassessment is done: i. When there is a significant change in condition ...” During a review of the facility’s policy and procedure (P&P) titled “Chain of Escalation for Resolution of Clinical Patient Safety Concern,” dated 8/4/2025, the policy indicated: “(facility name) workforce members are responsible for respectful, effective communication that creates a well understood plan of care, enhances teamwork and safe practice, and reduces the risk of delays in treatment. All members of the health care team have a duty to speak up for patient safety concerns even when they are not certain their concerns are based upon an actual threat to patient safety ... I.When front line associate has a patient safety concern, they will reach out to their department leader for assistance (and Rapid Response Team, as needed).” 2. During a review of Patient 7’s “History and Physical (H&P, a formal, comprehensive medical evaluation and assessment used by healthcare providers),” dated 2/7/2026, the H&P indicated Patient 7 “with no significant PMHx (past medical history) presents with LE (lower extremity) wound which was treated with abx (antibiotics, medications that fight bacterial infections). Patient (Patient 7) was evaluated by ID (Infectious Disease, a medical specialty that diagnoses and treats infections). Cleared for continuation of care in BHU (Behavioral Health Unit-a specialized hospital unit for mental health care).” During a review of Patient 7’s electronic medical record (EMR, an electronic version of a patient’s medical chart) titled Infectious Disease Progress Note, dated 2/8/2026, the record indicated that Patient 7 had “large blisters in the BLE (bilateral lower extremities, both legs) filled with clear fluid.” The note further indicated BLE cellulitis (a skin infection causing redness, swelling, and warmth) and chronic wounds, and stated that the plan of care for Patient 7 was to consult wound care (a specialized team that assesses and treats wounds). During an interview on 5/28/2026 at 1:14 p.m. with Nurse Practitioner (NP, an advanced practice nurse who can diagnose and treat medical conditions) 1, who specialized in infectious disease, NP 1 stated that they (NP 1’s team) saw Patient 7 on 1/27/2026 and treated the patient’s wound with an antibiotic, and re-evaluated Patient 7 on 2/16/2026. NP 1 stated that the Infectious Disease team signed off on Patient 7’s care on 2/16/2026 after the last evaluation, when NP 1 instructed the nursing staff to consult the wound care team. NP 1 stated that wound care should have been consulted because Patient 7’s wound required daily examination to ensure it (the wound) did not worsen. During a concurrent interview and record review on 5/28/2026 at 10:30 a.m. with the Nurse Manager of the Behavioral Health Unit (BHU), MN 3, Patient 7’s EMR document titled “Order,” was reviewed. The EMR indicated that Patient 7 had an order to transfer care from the medical-surgical unit (a general hospital floor that cares for adult patients recovering from surgery or being treated for acute illnesses) to the BHU on 2/6/2026. The EMR also indicated that there was no order for a wound consultation. MN 3 confirmed that there were no orders to consult wound care for Patient 7. MN 3 stated that the process required the doctor or NP to place a wound consultation order so that nursing staff can see it. MN 3 confirmed that Patient 7 did not have such an order. MN 3 confirmed that when there was no order, the nurse should contact the physician to clarify. During a concurrent interview and record review on 5/28/2026 at 10:45 a.m. with MN 3, Patient 7’s EMR Clinical Notes, dated 2/8/2026 through 2/20/2026, were reviewed. The EMR indicated that there was no communication to the Infectious Disease team regarding NP 1’s instruction on 2/16/2026 to consult wound care. During an interview on 5/29/2026 at 12:49 p.m. with the Director of BHU (DIR 1), DIR 1 stated that when infectious disease notes included instructions to consult wound care, nursing staff must follow up. DIR 1 stated that nursing staff should call the provider and clarify the instructions. DIR 1 further explained that even though wound care teams do not come to the BHU for other types of wounds, nurses must communicate with the provider for further instructions. During a review of Patient 7’s Nursing Clinical Notes, the notes indicated the following: - 2/6/2026: “Severely dry bilateral legs, scaly with red areas.” - 2/9/2026: “Patient (Patient 7) has cellulitis of the bilateral lower extremities, which continues to ooze tissue fluid when pressure is applied during ambulation (walking).” - 2/12/2026: “BLE swelling, redness, flakiness, and weeping (leaking fluid).” - 2/19/2026: “BLE wounds are red, flaking, and edematous (swollen due to fluid).” - 2/21/2026: “BLE with redness, swelling, and flaking. Patient reports pain in both lower extremities and is requesting additional pain medication.” During a review of the facility’s policy and procedure (P&P, written rules that guide staff actions) titled, Standards of Practice Behavioral Medicine, dated 12/6/2024, the P&P indicated: “The care plan is developed based on collaboration with the patient, physician, and healthcare team to ensure the patient’s safety, comfort, hygiene, disease prevention, and health restoration.” During a review of the facility’s policy and procedure (P&P) titled Chain of Escalation for Resolution of Clinical Patient Safety Concerns, dated 8/4/2025, the P&P indicated: “Recognizing, communicating, and escalating non?urgent concerns in a timely manner is important to preventing situations from becoming urgent. Anyone who implements the Chain of Resolution process in good faith will not be penalized or subjected to retaliation. When a frontline associate has a patient safety concern, they will reach out to their department leader for assistance (and the Rapid Response Team, as needed). If the concern remains unresolved, the department leader (with assistance from the Rapid Response Team, if necessary) will attempt a collaborative dialogue with the appropriate Licensed Independent Practitioner (the practitioner involved, the attending practitioner, or the on?call/back-up practitioner).” During a review of the facility’s policy and procedure (P&P) titled, Hospital Plan for the Provision of Nursing Care, dated 9/15/2023, the P&P indicated: “Evaluation of patient care and progress toward established outcomes will be performed by the RN (Registered Nurse) each shift and when there is a change in the patient’s status. Failure of the patient to progress toward, or regression from, established outcomes will result in the RN collaborating with other disciplines and reassessing the plan of care and interventions.” 3. During a review of Patient 1’s History and Physical (H&P, a comprehensive medical assessment that describes the patient’s current condition and medical history), dated 12/19/2026, the H&P indicated that Patient 1 was admitted on 12/19/2026 due to severe shortness of breath (difficulty breathing) and an oxygen saturation rate of 70% (percentage of oxygen in the blood; 70% is a critically low level requiring immediate medical attention). The H&P also indicated that Patient 1 was admitted with the following diagnoses (including but not limited to): Congestive heart failure exacerbation (worsening of a condition where the heart cannot pump blood well), acute on chronic respiratory failure (a sudden worsening of long-term breathing problems). During a concurrent interview and record review on 5/26/2026 at 1:59 p.m. with Director of Medical Surgical unit (DMS 1), Patient 1’s physician orders record, dated 12/20/2025, was reviewed. The record indicated that the physician (MD 10) placed an order for fluid restriction, specifying that Patient 1 was allowed 1800 milliliters (ml, measuring unit) per day. DMS 1 reviewed the record and verified that the fluid restriction order was in place. During further record review on 5/26/2026 at 2:29 p.m., Patient 1’s Intake and Output (I&O, meaning the measurement and documentation of all fluid a patient takes in and all fluid a patient eliminates) record, dated 12/19/2025 through 12/23/2025, was reviewed. The record indicated the following: -12/19/2025: Total intake documented was 54 ml (milliliters, measuring unit); no output was documented. -12/20/2025: Total intake for 24 hours was not documented. Only a 12-hour intake total of 753 ml was recorded. Output was documented as 500 ml.) -12/21/2025: Total intake was documented as 754 ml, with no output recorded, preventing calculation of a fluid balance (fluid balance requires both intake and output totals to determine whether the patient retained or lost fluid). -12/22/2025: Total intake documented was 8 ml, and total output was 300 ml, resulting in a negative fluid balance of -292 ml. -12/23/2025: Total intake documented was 212.5 ml, with total output of 525 ml, resulting in a negative fluid balance of -312.5 ml (a negative fluid balance means the patient’s body lost more fluid than it received, which may indicate dehydration or inadequate intake depending on clinical context). During an interview on 5/26/2026 at 2:29 p.m. with the Director of the Medical?Surgical Unit (DMS 1), DMS 1 verified that Patient 1’s Intake and Output (I&O) record was not completely documented. DMS 1 stated that no output was recorded for 24 hours on 12/21/2025 and that intake amounts of 54 ml on 12/19/2025 and 8 ml on 12/22/2025 were very low and likely insufficient for Patient 1, which was concerning. During a concurrent interview and record review on 5/26/2026 at 2:45 p.m. with the Director of the Medical?Surgical Unit (DMS 1), Patient 1’s oral intake (PO intake, meaning fluid or food taken by mouth) records, dated 12/19/2025 through 12/23/2025, were reviewed. The records indicated the following: -12/19/2025: Nothing was documented for the entire day. -12/20/2025: Breakfast documented as 100% consumed; no documentation for lunch or dinner. -12/21/2025: Breakfast 50%, lunch 50%, and dinner not documented (no intake recorded). -12/22/2025: No documentation of meals for the entire day. -12/23/2025: Patient was NPO (nothing by mouth) from 7:00 a.m. to 11:43 a.m. Breakfast: not documented Lunch: documented as NPO Dinner: documented as 50% at 6 p.m.; no fluid intake documented Patient was discharged at 7:05 p.m. on 12/23/2025. -DMS 1 also said that while CNAs (Certified Nursing Assistants) documented that fluids were offered to Patient 1 on multiple occasions, the amount of fluids consumed or whether Patient 1 refused, was not documented. DMS 1 added that documentation of activities of daily living (ADLs) should also follow the Standards of Care and referenced the policy (Standards of care are the facility’s written expectations that outline the required nursing actions, assessments, and documentation practices that must be followed to ensure safe, consistent, and appropriate patient care). During a concurrent interview and record review on 5/27/2026 at 10:45 a.m. with the clinical educator (ED 3), Patient 1’s Intake and Output (I&O) records for the entire hospital stay (12/19/2025 through 12/23/2025), were reviewed. ED 3 stated that Patient 1’s I&O documentation during the hospital stay was concerning. ED 3 said that the process for nurses was for the primary nurse to follow up with the CNAs (Certified Nursing Assistants) regarding the patient’s intake and output of fluids and food to ensure it was accurately recorded. ED 3 stated that Patient 1’s daily numbers [I&Os] that appeared insufficient should have been clarified, and that the family could also be asked whether any fluids were offered to the patient by family members. ED 3 further stated that the physician should have been notified if the patient (Patient 1) was not eating or drinking enough. During a concurrent interview and record review on 5/27/2026 at 10:45 a.m. with the interim manager of the telemetry unit (a hospital unit where patients receive continuous cardiac monitoring) (NM 10), NM 10 verified that Patient 1 did not appear to have sufficient fluid intake for any of the days reviewed (including 54 ml on 12/19/2025, no documented total intake for 12/20/2025, 754 ml on 12/21/2025, 8 ml on 12/22/2025, and 212.5 ml on 12/23/2025). NM 10 stated that a nurse should follow up with the medical doctor, present the documented intake amounts, and ask what the plan was for the patient [Patient 1]. NM 10 explained that a nurse could also initiate an appropriate care plan, such as one addressing fluid imbalance (fluid imbalance means the patient’s body has either too much or too little fluid, which can affect organ function), insufficient fluid intake (insufficient fluid intake means the patient is not consuming enough fluids to meet the body’s needs), or failure to thrive (a clinical condition in which a patient is not maintaining adequate nutrition, weight, hydration, or functional status), depending on the identified problem. During an interview on 5/27/2026 at 11:24 a.m. with the interim manager of the telemetry unit (NM 10), NM 10 confirmed that there were no initiated care plans for Patient 1 to address fluid imbalance, insufficient fluid and/or oral intake. During an interview on 5/29/2026 at 12:34 p.m. with the Interim Manager of the Telemetry floor (NM 10), NM 10 stated that meal percentage documentation was important because it reflected the patient’s nutritional intake, including protein and overall nutrient consumption. NM 10 explained that inadequate intake could lead to complications such as skin breakdown, muscle wasting (shrinking and weakening of muscle tissue), inability to participate in PT/OT (physical or occupational therapy), weakness, and could ultimately impact a patient’s recovery and length of stay. NM 10 stated that CNAs (Certified Nursing Assistants) and nurses were equally responsible for monitoring and documenting intake and output (I&O) and meal consumption in patients’ medical records. During a review of the facility’s policy and procedure (P&P) titled “Nursing Standards of Care,” dated 02/27/2025, the policy outlined the hospital’s expectations for how nurses deliver safe, individualized, and accountable patient care. It emphasized that nursing practice must follow recognized professional standards and required nurses to develop and regularly update a patient-specific plan of care that addresses physical, psychological, environmental, and spiritual needs. The policy also outlined that nurses were responsible for coordinating care, collaborating with other disciplines, ensuring continuity throughout the treatment process, safeguarding patient rights, maintaining safety, protecting confidentiality, and acting as patient advocates. The standards required nurses to assess, document, plan, implement, and evaluate care continuously to support optimal outcomes and uphold patient rights. During a review of the facility’s policy and procedure (P&P) titled “Telemetry Standards of Practice,” dated 03/2024, the policy outlined the required assessment, monitoring, and documentation responsibilities for nurses working on telemetry units. These standards mandated frequent and structured assessments, including full system assessments within set timeframes, focused reassessments in response to patient needs, and continuous cardiac monitoring. The policy also indicated that nurses must record vital signs and intake and output at least every four hours, document rhythm strips, complete head-to-toe evaluations when clinically indicated and reassess whenever the patient’s condition changes. The policy also outlined the nursing process for identifying problems, creating and updating individualized care plans, prioritizing interventions, implementing ordered and evidence-based care, and evaluating patient responses each shift. These requirements ensured consistent monitoring, timely recognition of changes, and coordinated care for medically complex telemetry patients. 4. During a review of Patient 23’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/6/2026, the “H&P” indicated, Patient 23 was admitted to the facility with diagnoses including but not limited to severe lymphedema (persistent swelling most commonly in the arms and legs) of bilateral (both) lower extremities, schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and acute (new onset) psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality). During a review of Patient 23’s “Behavioral Health Progress Note (Psychiatrist [physician specializes in mental health] progress note),” dated 3/11/2026, the “Behavioral Health Progress Note” indicated, Patient 23 was on temporary conservatorship (legal arrangement where a judge appoints a responsible individual to make decision for the patient who is deemed unable to care for themselves) status. During an interview on 5/26/2026 at 11:54 a.m. with RN 17, RN 17 stated patients on legal hold (involuntary detention forces a patient to remain in a healthcare facility for evaluation and treatment) were the ones who could not care for themselves, they may hurt themselves or others. RN 17 further stated patients on legal hold could not leave the hospital without a physician discharge order. During an interview on 5/26/2026 at 11:55 a.m. with Charge Nurse (CN 5), CN 5 stated patients on conservatorship could not leave the facility without physician discharge order. CN 5 further stated patients on conservatorship were like patients on legal hold. During a concurrent interview and record review on 5/28/2026 at 10:09 a.m. with Interim (temporary) Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) Manager (NM 10) and Registered Nurse (RN)19, Patient 23’s physician order, dated 2/7/2026 and 3/2/2026, were reviewed. The physician order dated 2/7/2026 indicated, “patient (Patient 23) may sleep under the camera, no need for sitter.” The physician order, dated 3/2/2026, indicated, “camera room for safety.” NM 10 stated, when there was a physician order for camera, the patient would be placed in a patient room equipped with the facility’s patient video monitoring (PVM, a virtual patient observation system used in hospitals utilizing video camera, two-way audio and technology to allow hospital staff to remotely and continuously observe multiple patients are once from a central command center). NM 10 further stated there was a PVM technician watching over all patients under PVM. NM 10 said a virtual guardrail (green box) would be set on the video monitoring system to limit how far the patient was allowed to move. NM 10 also stated, once the patient moved outside the green box, the PVM technician should notify the nursing unit immediately to have nursing staff go to the patient’s room to check on the patient. During an interview on 5/28/2026 at 10:35 a.m. with RN 19, RN 19 stated a patient with camera monitoring order must be under PVM technician’s view at all times, once the patient was out of camera view under PVM, the PVM technician should call the nursing staff to check on the patient immediately. During a review of Patient 23’s “Clinical Note Nursing (nursing narrative note),” dated 3/28/2026, the “Clinical Note Nursing” indicated, on 3/28/2026, “at 11 a.m. patient (Patient 23) wants to go home ... at 11:59 a.m., physician (MD 11) was notified that patient (Patient 23) wanted to go home and as per MD (MD11) that patient (Patient 23) was on a hold (due to temporary conservatorship) and cannot go home ... at 3 p.m. patient (Patient 23) asked about going home ... explained that she (Patient 23) cannot go home due to hold ... at 5:02 p.m. staff (CNA 7) called RN (RN 21) that patient (Patient 23) is not in her (Patient 23’s) room while she (CNA 7) [was] passing the dinner tray.” During a concurrent interview and record review on 5/28/2026 at 10:49 a.m. with NM 10 and RN 19, Patient 23’s “Vital Signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) flowsheet,” the “nursing assessment (patient’s head to toe assessment performed by Registered Nurse) flowsheet,” the “Clinical Note Nursing” and the “Medication Administration Record (MAR, record of medications given to patients),” dated 3/28/2026, were reviewed. The “Vital Signs flowsheet” indicated Patient 23’s vital signs were last taken on 3/28/2026 at 2 p.m. The “nursing assessment flowsheet” indicated, the head-to-toe assessment was done on 3/28/2026 at 7 a.m. The “Clinical Note Nursing” indicated, “approximately between 3 - 3:30 p.m. saw the patient (Patient 23) by the patient (Patient 23’s) room door sitting on the wheelchair ...” The “MAR” indicated Patient 23 refused medication on 3/28/2026 at 2 p.m. RN 19 stated there was no record to indicate where Patient 23 was and what Patient 23 did from 3:30 p.m. to 5 p.m. During a review of the facility’s VPM “No Response Log (document from PVM technician calling the nursing unit when patient was out of PVM camera view),” dated 3/28/2026, the “No Response Log” indicated, on 3/28/2026 at 4 p.m. a call was placed to Patient 23’s unit and the unit secretary was notified about Patient 23 not being seen for ten (10) minutes (in the PVM camera view). During a review of Patient 23’s “Clinical Note Nursing,” dated 3/28/2026, the “Clinical Note Nursing” indicated, on 3/28/2026 at 5:02 p.m., “staff called RN (RN 21) that patient (Patient 23) is not in her (Patient 23’s) room while she (unnamed staff) (was) passing the dinner tray (Patient 23’s dinner tray). Immediately I (RN 21) went to look around the Unit, the Lobby ... cafeteria ground floor and basement and patient (Patient 23) cannot be found. At 5:12 p.m. Code Green (signals a missing patient so the hospital can activate its procedure to locate the missing patient) was announced ...” During an interview on 5/28/2026 at 11:16 a.m. with the Director (DIR 6) of Security, DIR 6 stated security got involved to search for a missing patient when a Code Green was called. DIR 6 stated Code Green should be activated as soon as patient was discovered missing so the search could begin right away. DIR 6 further stated the earlier the Code Green was activated, the earlier the team could potentially locate the missing patient. During an interview on 5/28/2026 at 12:13 p.m. with the Patient Safety and Risk Manager (RS), RS stated a root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution) meeting was held after Patient 23’s elopement (when a patient leaves a treatment area or facility without permission or staff knowledge) incident. RS further stated the team had identified that nursing staff failed to recognize Patient 23 was at risk for elopement, underestimated Patient 23’s ability to elope due to Patient 23 being wheelchair bound (someone who is unable to walk and relies entirely on a wheelchair for mobility) and failed to check Patient 23 when PVM technician reported that Patient 23 was not under PVM camera view. RS also stated there was a delay in activating code green. During an interview on 5/28/2026 at 12:32 p.m. with the Director (DMS 1) of Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery), DMS 1 stated RN 21 should have escalated to do more frequent rounding or obtaining physician order for bedside sitter (a healthcare worker who stays continuously at a patient’s bedside to provide one-to-one supervision, and safety monitoring) for Patient 23 to prevent Patient 23 from eloping. DMS 1 stated RN 21 was relying on the PVM to monitor Patient 23. During an interview on 5/28/2026 at 1:42 p.m. with the Director (DIR 4) of Critical Care (specialist hospital wards that provide treatment and monitoring for people who are very ill), DIR 4 stated PVM could be used to monitor safety for patients who were at high risk for fall, getting out of bed and elopement risk. DIR 4 further stated PVM technician was supposed to notify nursing staff to check on the patient once the patient was out of PVM camera view. DIR 4 stated there was no specific policy regarding PVM use. During a concurrent interview and record review on 5/28/2026 at 2:52 p.m. with DMS 1, a screenshot from facility’s security camera with timestamped on 3/28/2026 at 3:18 p.m., was reviewed. The screenshot indicated Patient 23, who was in her (Patient 23) own clothing, was seen in a wheelchair pushing another wheelchair in front of her (Patient 23) at the facility’s east tower lobby. DMS 1 confirmed it was Patient 23. DMS 1 stated Patient 23 exited the facility through east tower lobby. During a review of Patient 23’s “ED (emergency department, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Physician Notes,” dated 3/28/2026. The “ED Physician Notes” indicated, “patient (Patient 23) brought in by police department from down the street walking with two wheelchairs. Patient (Patient 23) was reported missing from the hospital 3 hours ago.” The ED physician notes indicated Patient 23 was seen at the ED on 3/28/2026 at 8:40 p.m. During a review of the facility’s policy and procedure (P&P) titled, “Code Green - Patient Elopement,” dated 2/2025, the P&P indicated, “High-Risk Patient for Elopement/Patient Elopement: A patient who fits the following criteria or who leaves the patient care unit without permission who is: a. on a legal hold (dangers to themselves or others); b. high risk for elopement ... g. on psychiatric conservatorship ... All reasonable measures will be taken to prevent the elopement of high-risk patients from the hospital ... The hospital will take all reasonable steps necessary to safely retrieve/locate an eloped patient as quickly as possible ... Staff discovering a high-risk patient who is missing or suspected of elopement: notify the facility operator immediately and provide the following information: patient care unit from which the patient eloped. Description of the eloped patient. time and location the patient as last seen.” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for the Provision of Nursing Care,” dated 9/2023, the P&P indicated, “Direct and indirect nursing care insures the safety, comfort, personal hygiene and protection of patients ...Every Registered Nuse (RN) is responsible for coordination of all aspects of patient care to include but is not limited to: Assessment, planning care, delegating tasks, supervision, evaluating care, patient/significant other teaching, and collaboration with other disciplines ... The RN will delegate utilizing ‘The Five Rights of Delegation’: the Right Task ... the Right Circumstances ... the Right Person ... the Right Direction/Communication ... the Right Supervision - appropriate monitoring, evaluation, intervention as needed, and feedback ... The practice of nursing of Licensed Vocational Nurse, Nursing Assistants and Technicians is dictated by scope of practice, educational background, clinical competencies and job description under the direction of a registered nurse.””

“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: 48212 Based on interview and record review, the facility failed to: 1. Ensure its nursing staff provided continuous visual monitoring for one of 50 sampled patients (Patient 22), who was under a legal 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment), when a Certified Nursing Assistant (CNA 6) failed to notify the supervising Registered Nurse or Charge Nurse to provide continuous monitoring and observation on Patient 22 when CNA 6 had to go to the bathroom on 4/8/2026. This deficient practice resulted in Patient 22 eloping (a person attempts to leave the facility, when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility on 4/8/2026 putting Patient 22 at risk for dangers and harm outside the facility. 2. Ensure nursing staff reassessed one (1) of 50 sampled patients (Patient 8) after a significant change in condition (a major shift in clinical, physical, or behavioral status), when Patient 8 assaulted (an intentional act that puts someone in reasonable fear of being harmed) a Regional Center staff (staff from an agency providing support services to individuals with developmental disabilities). Nursing staff did not separate the two individuals, did not perform a nursing assessment (a systematic clinical evaluation conducted by a licensed nurse), and did not repeat a behavioral risk evaluation (a structured assessment of risk for aggression or harm) or vital signs (temperature, pulse, breathing rate, and blood pressure), as required by the facility’s policy titled “Assessment/Reassessment, Interdisciplinary.” This deficient practice resulted in Patient 8 sustaining an additional head injury 14 minutes later after entering the bathroom with the same caregiver (Regional Center staff) and repeatedly striking his (Patient 8) head against the wall, requiring sutures (stitches used to close a wound). 3. Ensure the facility’s Emergency Department (ED) followed the facility’s policy titled “Utilization of Safety Attendants for Patients,” when the facility assigned a Regional Center caregiver (non-hospital staff), who was not hospital trained, not competency validated (not assessed for required clinical knowledge or skills), and not authorized under the hospital’s policy to serve as a sitter (a staff member assigned to provide continuous, direct observation) for one (1) of 50 sampled patients (Patient 8). Patient 8 had been assessed as high risk for aggression and required constant observation (continuous, uninterrupted monitoring). This deficient practice resulted in an unauthorized caregiver being left responsible for monitoring a high-risk patient, which contributed to the patient (Patient 8) assaulting the caregiver and subsequently with Patient 8 sustaining a head injury requiring sutures, after banging his (Patient 8) head on the facility’s bathroom wall. 4. Ensure nursing staff documented to what degree one of 50 sampled patient (Patient 1) desaturated (how low Patient 1’s oxygen level dropped) after Patient 1 was found “desaturating” by nursing staff. The nursing staff also failed to document what immediate interventions were taken to stabilize the patient (Patient 1) before or after the provider (MD 10) was notified of Patient 1’s change in condition (desaturation event), in accordance with the facility’s policy regarding medical record content and nursing standards of practice. This deficient practice had the potential to result in continued or worsening breathing problems for Patient 1 and could also lead to incomplete information being passed on to the receiving care team, which may delay needed treatment or monitoring. 5. Ensure the correct breast milk was administered to one of 50 sampled patients (Patient 41), when Registered Nurse (RN 23) did not double check the label of the breast milk with another nurse and did not scan the label prior to administering the breast milk to Patient 41, in accordance with the facility’s Breast Milk Storage and Handling of Expressed Milk policy. This deficient practice resulted in Patient 41 receiving 15 milliliters (ml, a unit of measurement) of breast milk from another mother and had the potential for Patient 41 to be exposed to risks associated infectious pathogens (such as HIV [Human Immunodeficiency Virus, is a virus that attacks the body’s immune system by destroying white blood cells. If left untreated, it severely weakens the body’s ability to fight off infections and diseases], Hepatitis B [a contagious viral infection that attacks the liver], and Hepatitis C [a viral infection that causes inflammation and damage to the liver. Spread through contact with infected blood]). Findings: 1. During a review of Patient 22’s “Hospitalist Progress Note (physician progress notes),” dated 4/8/2026, the “Hospitalist Progress Note” indicated, Patient 22 was admitted to the facility with diagnoses including but not limited to metabolic encephalopathy (acute or chronic impairment of brain function caused by underlying chemical imbalance, systemic illness, or organ dysfunction) and opiate overdose (when the toxic levels of opioids [opiates, substance used to treat pain or cause sleep] overwhelm the body). The “Hospitalist Progress Note” also indicated, Patient 22 was placed on legal hold (involuntary detention forces a patient to remain in a healthcare facility for evaluation and treatment) on 4/8/2026 with bedside sitter (a healthcare worker who stays continuously at a patient’s bedside to provide one-to-one supervision, and safety monitoring) in place. During a review of Patient 22’s 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment), dated 4/8/2026, the 5150-hold indicated, Patient 22 was placed on 72-hour involuntary hold for grave disability (inability to care for oneself) due to mental disorder. During a review of Patient 22’s “Clinical Note Nursing (nursing notes),” dated 4/8/2026, the “Clinical Note Nursing” indicated, (on 4/8/2026) “at 5:45 p.m. [nursing staff] was notified by transport that there was a patient leaving the unit by the elevator. Ran to the room, patient (Patient 22) and sitter (CNA 6) were not in the room ... Phone call made to NA (CNA 6) and he (CNA 6) replied at 5:48 p.m. that he (CNA 6) was in the restroom and patient (Patient 22) was left with family members. Code Green (signals a missing patient so the hospital can activate its procedure to locate the missing patient) at 5:48 p.m.” During an interview on 5/26/2026 at 11:44 a.m. with Registered Nuse (RN) 17, RN 17 stated bedside sitter was utilized for patients on legal hold to ensure patient safety, to make sure the patient did not hurt himself/herself or others, and to make sure the patient did not leave the facility. RN 17 stated the bedside sitter must maintain constant observation on the patient. During an interview on 5/26/2026 at 3:29 p.m. with the Interim (temporary) Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) Manager (NM 10), NM 10 stated Patient 22 eloped (a person attempts to leave the facility, when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility on 4/8/2026. NM 10 further stated CNA 6 left Patient 22 in the room with family members without calling the unit charge nurse or Patient 22’s primary nurse to cover. NM 10 further stated CNA 6 failed to stay with Patient 22 and to keep an eye on Patient 22 at all times. NM 10 also stated CNA 6 lost the line of sight on Patient 22 therefore Patient 22 was able to freely walk away and left the hospital. NM 10 stated CNA 6 was terminated after the incident. During an interview on 5/28/2026 at 11:25 a.m. with the Director (DIR 6) of Security, DIR 6 stated Patient 22 left the facility’s premises and was found by local police on 4/8/2026. DIR 6 further stated Patient 22 was taken by local police department to custody (detained by law enforcement) due to an active warrant (court-issued legal order that authorized law enforcement to immediately arrest an individual). During a review of the facility’s policy and procedure (P&P) titled, “Utilization of Safety Attendants for Patients,” dated 6/2022, the P&P indicated, “Safety attendants may be instituted for patients with high risk behaviors or those with high risk for fall or other injury including: a. danger to self; b. danger to others; c. grave disability ... 2. Assigned attendant will be a trained Registered Nurse, Licensed Vocational Nurse, Certified Nursing Assistant, Nursing Assistant, Mental Health Technician, Licensed Psychiatric Technician or Emergency Medical Technician. 3. A family member or volunteer may not provide monitoring/observation for patients with high-risk behaviors ... 5. The Safety Attendant will accompany the patient at all times ... Observation/Supervision ... continuous (uninterrupted) observation/supervision of the patient will be provided ...” During a review of the facility’s policy and procedure (P&P) titled, “Code Green - Patient Elopement,” dated 2/2025, the P&P indicated, “High-Risk Patient for Elopement/Patient Elopement: A patient who fits the following criteria or who leaves the patient care unit without permission who is: a. on a legal hold (dangers to themselves or others); b. high risk for elopement ... g. on psychiatric conservatorship ... All reasonable measures will be taken to prevent the elopement of high-risk patients from the hospital ...” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for the Provision of Nursing Care,” dated 9/2023, the P&P indicated, “Direct and indirect nursing care insures the safety, comfort, personal hygiene and protection of patients ...Every Registered Nuse (RN) is responsible for coordination of all aspects of patient care to include but is not limited to: Assessment, planning care, delegating tasks, supervision, evaluating care, patient/significant other teaching, and collaboration with other disciplines ... The RN will delegate utilizing ‘The Five Rights of Delegation’: the Right Task ... the Right Circumstances ... the Right Person ... the Right Direction/Communication ... the Right Supervision - appropriate monitoring, evaluation, intervention as needed, and feedback ... The practice of nursing of Licensed Vocational Nurse, Nursing Assistants and Technicians is dictated by scope of practice, educational background, clinical competencies and job description under the direction of a registered nurse.” 2. During a review of Patient 8’s “ED (Emergency Department) Physician Notes,” dated 6/11/2025, the record indicated Patient 8 was brought to the ED for psychiatric evaluation (a medical assessment of a person’s mental, emotional, and behavioral health) after breaking objects, attacking staff, and engaging in self?harm at the group home (a supervised residential setting where individuals who need assistance with daily living receive staff support). The notes further indicated a medical history of schizophrenia (a chronic mental health disorder that affects thinking, emotions, and behavior) and bipolar disorder (a mood disorder characterized by episodes of depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and episodes of elevated or irritable mood). During a review of Patient 8’s “Clinical Note Behavioral Health (BH, Behavioral Health-care related to mental health and substance use),” documented by RN 2 (Registered Nurse) on 6/11/2025, the note indicated Patient 8 was “cognitively impaired (having reduced ability to think, concentrate, or make decisions),” was “developmentally delayed (having delayed achievement of developmental milestones),” autistic (a developmental disorder affecting communication, behavior, and social interaction), bipolar (a mood disorder characterized by episodes of depression and episodes of elevated or irritable mood), and psychiatrically unstable (experiencing unpredictable or rapidly changing mental health symptoms), and exhibited aggressive (behavior intended to harm or intimidate) and self?injurious behaviors (actions in which a person harms their own body). The note further indicated: “Plan: a male from the group home (a supervised residential setting where individuals who need help with daily living receive staff support) will remain at Patient 8’s bedside; a replacement staff will arrive at 7 a.m. Per psychiatrist (a medical doctor who specializes in mental health), Patient 8 will remain in the ER (Emergency Room) on constant observation, and the ER healthcare team is aware of the plan.” During a review of Patient 8’s Dynamic Appraisal of Situation Aggression (DASA, a screening tool used to assess a patient’s short-term risk of aggressive behavior) screening document, dated 6/11/2025 at 1:35 a.m., RN 2 documented a score of 7 (“High Risk”) based on physical aggression (attempts or actions to physically harm), irritability (easily annoyed or angered), impulsivity (acting without thinking), unwillingness to follow direction, sensitivity to perceived provocation (reacting strongly to something viewed as teasing or challenging), anger, negative attitudes, and verbal threats (spoken statements indicating intent to harm). During a review of Patient 8’s “Clinical Note ED (Emergency Department) nursing note,” dated 6/11/2025 at 6:18 p.m., the note indicated Patient 8 “hit the regional center staff (staff from an agency that provides support services to individuals with developmental disabilities) on the chest.” During a review of Patient 8’s medical record document titled, “Orders,” the orders indicated a sitter (a staff member assigned to provide continuous, direct observation of a patient) was requested at 7:28 p.m. on 6/11/2025, after Patient 8 sustained a three-centimeter facial laceration (a three-centimeter cut on the face) requiring sutures (stitches used to close a wound). During an interview on 5/27/2026 at 8:30 a.m. with RN 1 (Registered Nurse 1, who was assigned for the care of Patient 8 on 6/11/2025), RN 1 stated security was not called after Patient 8 struck the regional center staff member because the caregiver declined assistance. RN 1 stated Patient 8 and the caregiver were not separated after the assault. RN 1 also stated that no reassessment (a repeat nursing evaluation after a change in condition) or vital signs (measurements such as temperature, pulse, breathing rate, and blood pressure) were completed, explaining that the incident occurred near the end of the shift and care was handed off to the incoming RN. During an interview on 5/26/2026 at 1:47 p.m. with Nurse Manager (NM 1), NM 1 stated Patient 8 was not assigned a 1:1 sitter (one staff member assigned to monitor one patient continuously) because Patient 8 was not suicidal (having thoughts of taking one’s own life), not on a psychiatric hold (a legal order allowing involuntary mental health evaluation), and staff had not identified behavioral management concerns. NM 1 confirmed Patient 8 arrived with an “open wound” (a break in the skin exposing underlying tissue) from repeatedly banging his (Patient 8) head against the wall (prior to admission). During an interview with NM 1 on 5/26/2026 at 3:00 p.m., NM 1 confirmed the ED did not implement the level of monitoring described in RN 2’s BH note, which called for constant RN/EMT/Safety Attendant observation (continuous monitoring by a Registered Nurse, Emergency Medical Technician, or designated safety staff). NM 1 stated the facility relied solely on the Regional Center staff (group home caregiver), who was not hospital-trained or competency-validated (when staff has proven they have the specific skills and knowledge required to do a task correctly and safely). During an interview on 5/28/2026 at 10:04 a.m. with RN 3 (a behavioral health nurse who conducts behavioral health assessments in the ED), RN 3 stated that “this patient (Patient 8) requires observation and needs a 1:1 sitter,” adding that sitters provided by the Regional Center were used only because “the facility does not have a contract with the Regional Center and does not know their training or certification.” RN 3 also confirmed that based on the DASA score and presentation of Patient 8, “If this patient (Patient 8) hits a staff member, call security to stand by-he (Patient 8) is impulsive.” During an interview on 5/26/2026 at 2:10 p.m. with Emergency Department Director (DIR 2), DIR 2 confirmed no repeat DASA assessment, and no vital signs were completed after Patient 8 struck the caregiver (from the Regional Care center) and later Patient 8 sustained a head injury (physical harm to the head) from banging his (Patient 8) head on the bathroom wall. During a concurrent interview and record review on 5/26/2026 at 1:47 p.m. with NM 1, Patient 8’s DASA screening, was reviewed, confirming the documented score of 7 (“High Risk”) on 6/11/2025 at 1:35 a.m. NM 1 stated that despite this risk, the facility did not assign a hospital sitter and continued relying on the Regional Center staff. During a review of the facility’s policy titled “Assessment/ Reassessment, Interdisciplinary,” dated 9/9/2024, the P&P indicated: “An initial assessment is made upon admission or initial patient contact, and further assessments and reassessments are conducted based on the diagnosis, unit setting or service, and patient’s response to care and treatment... Assessment of each patient’s physiologic, psychologic, sociocultural, functional and developmental status through screening, observation, and/or examination procedures must be undertaken In order to determine the need for care, the type of care to be provided, the need for further assessment and plan... Reassessment is done: When there is a significant change in condition...Documentation of the reassessment will be placed in the Electronic health Record.” During a review of the facility’s policy and procedure (P&P) titled “Patient Risk of Aggression Assessment,” dated 7/3/2024, the P&P indicated: “Early identification of aggressive risk is crucial. The DASA (Dynamic Appraisal of Situation Aggression) tool must be completed for behavioral health patients or any patient displaying DASA listed behaviors. High-Risk interventions (DASA score 4-7) include: a. Notify provider. b. Notify security for awareness/standby. c. Set limits and use de-escalation. d. Consider PSA/Safety Attendant for constant 1:1 observation; PSA must be trained in safety and risk mitigation, and family/visitors cannot serve as Patient Safety Attendants. e. Staff must be alerted and interventions initiated to prevent subsequent aggression. Patients must be re-screened every shift and anytime behavior changes or after an incident of aggression.” During a review of the facility’s policy and procedure (P&P) titled “Management of High-Risk Behaviors,” dated 5/28/2024, the P&P indicated de-escalation strategies must include: “Making contact with the patient and engaging. Rapid assessment of patient needs. Providing immediate and practical interventions. Separating the patient from dangerous situations when indicated.” 3. During a review of Patient 8’s “ED (Emergency Department) Physician Notes,” dated 6/11/2025, the record indicated Patient 8 was brought to the ED for psychiatric evaluation (a medical assessment of a person’s mental, emotional, and behavioral health) after breaking objects, attacking staff, and engaging in self-harm at the group home (a supervised residential setting where individuals who need assistance with daily living receive staff support). The notes further indicated a medical history of schizophrenia (a chronic mental health disorder that affects thinking, emotions, and behavior) and bipolar disorder (a mood disorder characterized by episodes of depression and episodes of elevated or irritable mood). During an interview on 5/28/2026 at 10:10 a.m. with Behavioral Health Unit (BHU) Manager (MN 3), MN 3 stated Regional Center staff (staff from an agency providing support services to individuals with developmental disabilities) were used as sitters after “discussion with Regional and the Director of BHU, because they (Regional Center staff) know their staff; it is better for the patient.” During an interview on 5/28/2026 at 10:28 a.m. with BHU Manager (MN 3), MN 3 stated the sitter assigned to Patient 8 was from the Regional Center, not the group home (a supervised residential setting where individuals who need assistance with daily living receive support). MN 3 stated, “Regional does not have contracts with the facility,” and further stated the facility did not have information on “the training that the Regional Center staff has.” During an interview on 5/28/2026 at 10:11 a.m. with Licensed Clinical Social Worker (SW 1), SW 1 stated the facility “sometimes uses the Regional Center staff; they will stay based on the patient needs.” SW 1 stated “there is usually a discussion with leadership regarding the stay of a Regional Center staff as the sitter.” During an interview on 5/28/2026 at 10:04 a.m. with RN 3 (a behavioral health nurse who conducts behavioral health assessments in the Emergency Department), RN 3 stated Patient 8 “requires observation and needs a 1:1 sitter,” but stated the facility did not know the training or certification of the Regional Center staff used in this role. RN 3 stated the facility’s leadership typically discusses whether Regional Center staff will remain, despite unknown training status and not competency validated by the facility. During an interview on 5/27/2026 at 3:00 p.m. with Nurse Manager (NM 1), NM 1 stated the Emergency Department did not implement the level of monitoring described in the Behavioral Health note, which called for constant RN/EMT/Safety Attendant observation (continuous monitoring by a Registered Nurse, Emergency Medical Technician, or trained safety staff). NM 1 stated the Regional Center offered to have their staff stay with Patient 8. During a concurrent interview and record review on 5/26/2026 at 2:40 p.m. with NM 1, the Dynamic Appraisal of Situation Aggression (DASA, a screening tool used to assess a patient’s short-term risk for aggressive behavior) screening for Patient 8, dated 6/11/2025, was reviewed. The DASA indicated a score of 7 (“High Risk”). NM 1 stated that despite this high-risk score (score of 7), the facility did not assign a hospital sitter as at the time, Patient 8 was not aggressive, so the Regional Center staff was by Patient 8’s bedside. During interviews on 5/28/2026 at 10:04 a.m. with RN 3 (a behavioral health nurse who conducts behavioral health assessments in the ED), RN 3 stated that sitters provided by the Regional Center were used only because “the facility does not have a contract with the Regional Center and does not know their training or certification.” RN 3 further stated that Patient 8 “requires observation and needs a 1:1 sitter” and that Regional Center staff were not hospital?trained or safety attendant trained as required by the facility’s policy. During an interview on 5/27/2026 at 3:00 p.m. with Nurse Manager (NM 1), NM 1 confirmed the facility relied solely on the group home caregiver to sit with Patient 8 and did not implement RN/EMT/Safety Attendant observation (continuous monitoring provided by hospital-trained personnel), even though Patient 8 was assessed as high-risk for aggression. During a review of the facility’s policy and procedure (P&P) titled “Utilization of Safety Attendants for Patients,” dated 3/24/2025, the P&P indicated safety attendants (hospital personnel assigned to continuously monitor patients with high-risk or unsafe behaviors) may be instituted for patients exhibiting danger to self, danger to others, grave disability (inability to provide for personal basic needs due to mental health impairment), or potential for injury... the assigned attendant must be a trained Registered Nurse (RN), Licensed Vocational Nurse (LVN), Certified Nursing Assistant (CNA), Mental Health Technician (MHT), Licensed Psychiatric Technician (LPT), or Emergency Medical Technician (EMT)... The staff member assigned to the patient shall have received education on management of patients at high risk for falls, injury, and high-risk behaviors... family members or volunteers may not provide monitoring for patients with high-risk behaviors, and the assigned staff member must have education in managing patients at high risk for falls, injury, and high-risk behaviors.” 4. During a review of Patient 1’s History and Physical (H&P, a comprehensive medical assessment that describes the patient’s current condition and medical history), dated 12/19/2025, the H&P indicated that Patient 1 was admitted on 12/19/2025 due to severe shortness of breath (difficulty breathing) and an oxygen saturation rate of 70% (percentage of oxygen in the blood; 70% is a critically low level requiring immediate medical intervention). The H&P further indicated that Patient 1 required the use of BIPAP therapy (Bilevel Positive Airway Pressure, a non-invasive ventilation device that assists breathing by delivering pressurized air through a mask) and to be admitted to telemetry floor (a floor in the hospital where patients receive continuous cardiac [heart] monitoring). During a review of Patient 1’s Physician Orders, dated 12/20/2025, the record indicated that the physician (MD 10) ordered BiPAP management with the following special instructions: “Keep O2 sat (oxygen saturation, the percentage of hemoglobin in the blood carrying oxygen) more than 92%, PRN (as needed) during the daytime, and continuous at night.” During a review of Patient 1’s Cardiology (heart doctor) progress note, dated 12/23/2025, the record indicated that Patient 1’s condition had worsened, described as “more SOB (SOB means shortness of breath, or difficulty breathing)” and “worsening O2 saturation (O? saturation means the percentage of oxygen carried in the blood).” During a review of Patient 1’s Vital Signs (VS basic body measurements such as temperature, heart rate, breathing rate, blood pressure, and oxygen level) record, dated 12/23/2025, the record indicated that Patient 1 had the following oxygen levels documented on 12/23/2025 from 3:03 a.m. through 10:47 a.m.: -At 3:03 a.m., Patient 1’s oxygen saturation (O2 Sats means the percentage of oxygen in the patient’s blood) was 96% (% means the proportion out of 100; levels below 90% are considered low [hypoxemia] and may be dangerous) while on BiPAP (BiPAP means a machine that helps move air in and out of the lungs by delivering two levels of airway pressure). -At 7:45 a.m., oxygen saturation 95% while receiving 7 liters of oxygen (these VS show the patient’s body temperature, heart workload, breathing effort, blood pressure level, and oxygenation status). -At 9:00 a.m., oxygen saturation was documented as 94%. -At 10:47 a.m., oxygen saturation was 96% on BiPAP. -The review of vital signs was conducted with Registered Nurse (RN 19), who verified that no desaturation events were reflected in the record on 12/23/2025 from 3:00 a.m. to 11:00 a.m. During an interview on 6/1/2026 at 9:41 a.m. with Registered Nurse (RN 19), Patient 1’s physician notification note, dated 12/23/2025, was reviewed. The note, documented on 12/23/2025 at 7:41 a.m., indicated that Physician (MD 10) was notified that Patient 1 “is desaturating and we need to transfer her [Patient 1] to higher acuity of care (a patient is sicker, more unstable, or has a more complex medical condition. It requires immediate attention, intensive monitoring, and specialized, 24/7 care from experienced medical professionals compared to lower-acuity patients who are relatively independent or have non-urgent needs) ...,” and per MD 10, Patient 1 “can be transferred.” During the same interview on 6/1/2026 at 9:41 a.m. with Registered Nurse (RN 19), RN 19 said that she (RN 19) could not recall the degree to which Patient 1 was desaturating and explained that she (RN 19) was a relief nurse (a nurse temporarily assisting on the unit but not the primary assigned nurse) on the floor that day, helping the primary nurse for Patient 1 by calling the physician (MD 10) for orders. RN 19 then reviewed the vital signs record for 12/23/2025 but was not able to find documentation of desaturation around the time her (RN 19) note at 7:41 a.m. was made. RN 19 also verified that, according to the vital signs record at 7:45 a.m. on 12/23/2025, Patient 1’s oxygen flow was increased to 7 liters (7 liters per minute, meaning a higher amount of oxygen was delivered to support breathing), and Patient 1 was transferred to the DOU (Definitive Observation Unit, a step?down unit where patients receive closer monitoring than on a regular medical-surgical floor). During an interview on 6/1/2026 at 10:00 a.m. with Registered Nurse (RN 19), RN 19 said that the nursing process (when responding to a change in condition) was to assess the patient first, obtain and document vital signs (VS), and then address the problem. RN 19 stated that because Patient 1 was desaturating, the nurse should “address the desaturation and help the situation and the patient.” RN 19 explained that obtaining a set of vital signs before and after an intervention, including the desaturation rate, “can show if the intervention was successful.” RN 19 further stated that nurses were required to document in real time and be able to escalate the situation (immediately intervene to protect the safety of a patient) in which the real time documentation was not done for Patient 1. RN 19 said that vital signs, including the desaturation rate, should have been documented because “it’s done for the patient’s safety.” During a review of Patient 1’s Pulmonology (Pulmonology means the medical specialty that focuses on the lungs and breathing) progress note, dated 12/23/2025, the record indicated that Patient 1 was transferred to the step-down unit (DOU, which means Definitive Observation Unit, a unit that provides closer monitoring than a regular floor) on BiPAP alternating with high-flow oxygen (high-flow means a type of oxygen therapy that delivers warmed, humidified oxygen at a much higher flow rate than standard oxygen to help a patient breathe more easily). During a review of the facility’s policy and procedure (P&P) titled “Medical Record Content,” dated 2/20/2026, the policy indicated that all clinical entries in the patient’s medical record must be accurately dated, timed, and authenticated, and that the medical record must contain patient-specific documentation that supports diagnoses and facilitates patient care, treatment, and services (e.g., nursing documentation, progress notes, diagnostic information). The policy required complete and accurate documentation to ensure continuity of care and compliance with regulatory standards. During a review of the facility’s policy and procedure (P&P) titled “Hospital Plan for the Provision of Care,” last revised 3/2026, the policy indicated that nurses at the facility were expected to provide safe, effective, and professional nursing care to all patients. The policy indicated that nursing care must follow patient rights (the basic rights patients have to be treated with respect, to receive clear information, and to make decisions about their care), the hospital’s policies, and the Nurses Standards of Practice (national guidelines that describe what safe, competent, and professional nursing practice must include). The policy outlined the core principles nurses must follow, such as giving personalized care, working collaboratively with other healthcare professionals, and ensuring continuity of care. 5. During a review of Patient 41’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/15/2025, the “H&P” indicated, Patient 41 was a newborn baby on 10/15/2025. During review of Patient 41’s “Discharge Summary (an official clinical document prepared by healthcare professionals that outlines the details of a patient’s hospitalization. It acts as a bridge between the hospital and a patient’s ongoing care),” dated 10/18/2025, the record indicated the following: Patient 41 was mistakenly fed 15 ml (milliliter, a unit of measurement) of breast milk from the wrong mother. The Discharge Summary record also indicated that Parents were immediately informed by nursing staff and doctors. Doctors discussed the issue extensively with both parents. Donor milk was negative (for specific substances or bacteria). Doctor discussed with the parents that there was a very low risk of exposure for Patient 41. During an interview on 5/26/2026 at 10:48 a.m. with Clinical Nurse Specialist (CNS 1), CNS 1 stated following: CNS 1 was the specialist for the Neonatal Intensive Care Unit (NICU, a specialized hospital department dedicated to the medical care of newborn infants who are born premature, have low birth weights, or suffer from critical conditions like breathing difficulties, infections, or birth defects). CNS 1 confirmed that RN 23 did not follow the facility’s Breast Milk Administration policy when RN 23 did not double check the label on the breast milk bottle with another nurse. CNS 1 also said that RN 23 did not scan the label prior to administration of breast milk thus Patient 41 received an incorrect breast milk from another mother. During an interview on 5/26/2026 at 11:04 a.m. with Registered Nurse (RN 24), RN 24 stated the following: Breast milk was considered body fluids, which could be harmful if given to the wrong baby. RN 24 said she (RN 24) would double check with another nurse the printed labels containing Medical Record Number (MRN) and last name of the patient. Additionally, RN 24 stated she (RN 24) would electronically scan both the patient’s wrist band and the bottle’s label before administering the breast milk to ensure information matches and the correct baby received the intended milk. During an interview on 5/26/2026 at 2:27 p.m. with Interim Risk and Safety (RS), RS stated the following: RS reviewed the internal hospital report and confirmed that RN 23 reported that on 10/17/2025, the incorrect breast milk was administered to infant (Patient 41) and that the doctor was notified following the incident. During an interview on 5/27/2026 at 2:20 p.m. with Nurse Manager (NM 13), NM 13 confirmed that Patient 41 had received breast milk intended for another patient, and that Registered Nurse 23 did not adhere to established protocols for breast milk administration. NM 13 stated that Registered Nurse 23 should have verified the label and scanned it prior to administering the milk to the patient (Patient 41). In response to this incident, NM 13 shared that all staff members on the unit have since received additional education on the proper procedures to reinforce adherence to policy regarding handling of expressed milk. During an interview on 5/28/2026 at 1:34 p.m. with Registered Nurse (RN 23), RN 23 stated the following: RN 23 felt rushed (at the time when the incorrect breast milk was administered to patient 41) contributing to the omission of essential safety steps. Specifically, RN 23 admitted she (RN 23) did not double check the label on the bottle and did not scan the label prior to handing the bottle to the mother (Patient 41’s mother). RN 23 acknowledged that the established protocol for breast milk administration required both verifying and scanning the label to ensure accuracy and patient safety. During a review of the facility’s policy and procedure (P&P) titled “Policy: Breast Milk Storage and Handling of Expressed,” dated 8/25/2025, the P&P indicated: “2 RNs will verify that labels contain the following correct information and signify the double check has occurred. Correct infant’s name and MRN. All labels belong to same patient ... Take prepared Express Mother’s Milk (EMM) to infant’s bedside. Scan infant’s ID band. Scan EMM label. Administered to infant as soon as possible.””

“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: 48212 Based on interview and record review, the facility failed to ensure its Registered Nurses (RNs) administered Morphine drip intravenously (IV, through the vein) per physician order and in accordance with the facility’s Medication Administration policy for two of 50 sampled patients (Patient 20 and Patient 19) when: 1. For Patient 20, nursing staff did not administer Morphine (a strong opiate pain medication) 2 milligrams (mg, unit of measure) loading dose (an initial, larger-than-normal dose of a medication designed to quickly raise the drug’s concentration in the body to a therapeutic level) per physician’s order, did not increase Morphine by 0.5 milligrams per hour (mg/hr, infusion rate) as ordered by physician and did not document Patient 20’s baseline CPOT (Critical-Care Pain Observation Tool, score of 0 to 2 indicates minimal to no pain and 3 to 8 indicated moderate to severe pain) score and did not follow up on the CPOT score when morphine 2 mg bolus (a single, relatively large dose of a drug administered over a short period. Its primary purpose is to rapidly raise the concentration of the medication in the bloodstream to an effective, therapeutic level) was given each time, to assess whether the morphine drip dosage had met the physician’s prescribed goal. 2. For Patient 19, nursing staff did not administer Morphine 2 mg loading dose as prescribed by the physician, did not give two (2) Morphine 2 mg boluses prior to increasing the Morphine drip dosage, and did not document Patient 19’s baseline CPOT score and follow up the CPOT score when the Morphine drip dosage was increased. These deficient practices had the potential to result in Patient 20 and Patient 19 receiving too little or too much for Morphine. Administering too high a dose could lead to shallow breathing, dangerously low oxygen levels, and/or death. Too low a dose could result to uncontrolled pain and physiological distress. Findings: 1. During a review of Patient 20’s “History and Physical Examination (H&P, a formal and complete assessment of the patient and the problem),” dated 10/18/2024, the “H&P” indicated, Patient 20 was on high flow oxygen with FiO2 (fraction of inspired oxygen, concentration or percentage of oxygen in the gas mixture) 80% on 45 liters per minute (L/min, unit of measure) and was admitted to the facility’s general inpatient hospice care (a special kind of support for people with serious, incurable illnesses) on 10/18/2024. The “H&P” also indicated to start and titrate (increasing or decreasing the infusion rate) Morphine drip (infusion) for comfort measures. During a review of Patient 20’s physician order, dated 10/18/2024, the physician order indicated, “to give Morphine with a loading dose (an initial, larger-than-normal dose of a medication designed to quickly raise the drug’s concentration in the body to a therapeutic level) of 2 milligrams, then begin continuous infusion at 1 milligrams per hour (mg/hr, unit of measure) after the loading dose ... for uncontrolled symptoms and dyspnea (difficulty breathing): bolus (a single, relatively large dose of a drug administered over a short period. Its primary purpose is to rapidly raise the concentration of the medication in the bloodstream to an effective, therapeutic level) with [Morphine] 2 mg every 15 minutes. Increase infusion rate by 0.5 mg/hr if patient required two (2) boluses within two (2) hours ... to reach goal at CPOT (Critical-Care Pain Observation Tool, score of 0 to 2 indicates minimal to no pain and 3 to 8 indicated moderate to severe pain) 0-2.” During a concurrent interview and record review on 5/26/2026 at 3:10 p.m. with Registered Nuse (RN 19), Patient 20’s Medication Administration Record (MAR, record of medications given to patients), dated 10/18/2024, was reviewed. The MAR indicated, RN 28 started Morphine 1 mg/hr on 10/18/2024 at 9:41 p.m. The MAR indicated there was no Morphine 2 mg recorded per the ordered loading dose. RN 19 stated the loading dose of Morphine 2 mg was missing on record. During an interview on 5/27/2026 at 1:43 p.m. with Nurse Manager (MSD 1) Step Down Unit (SDU, a hospital unit that provides an intermediate level of car between the intensive care unit [ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill] and a general medical-surgical floor [Med-Surg, general patient population hospitalized for various causes such as illness and surgery]), MSD 1 stated nursing staff should verify the physician’s order before giving the Morphine drip. MSD 1 stated nursing staff should follow the physician medication order. During a concurrent interview and record review on 5/27/2026 at 1:50 p.m. with MSD 1, Patient 20’s MAR, dated 10/18/2024 and 10/19/2024, were reviewed. The MAR indicated the Morphine was started at 1 mg/hr on 10/18/2024 at 9:41 p.m. The MAR also indicated, on 10/19/2024, the Morphine was increased to 1.5 mg/hr at 1:28 a.m., 2 mg/hr at 2:17 a.m., 2.5 mg/hr at 2:51 a.m., 3 mg/hr at 3:30 a.m., and 4 mg/hr at 8:03 a.m. MSD 1 stated the Morphine was not increased by 0.5 mg increment when the registered nurse increased the Morphine dosage from 3 mg/hr to 4 mg/hr on 10/19/2024 at 8:03 a.m. MSD 1 stated the physician order was not followed. During a concurrent interview and record review on 5/27/2026 at 2:31 p.m. with MSD 1, Patient 20’s MAR, dated 10/18/2024 and 10/19/2024, were reviewed. The MAR indicated the Morphine was started at 1 mg/hr on 10/18/2024 at 9:41 p.m. The MAR also indicated, RN 18 administered eight (8) Morphine 2 mg boluses on 1:14 a.m., 1:29 a.m., 2:03 a.m., 2:18 a.m., 2:34 a.m., 2:50 a.m., 3:38 a.m. and 4:21 a.m. accordingly. The MAR did not indicate any CPOT score and reason for eight (8) Morphine 2 mg boluses that were given. MSD 1 stated the nurse should document CPOT score at the start of Morphine infusion to indicate Patient 20’s baseline. MDS 1 stated the nurse should document CPOT score when Morphine bolus was given each time. MSD 1 stated the CPOT score could help to evaluate how comfortable a patient was and his/her response to the Morphine. MSD 1 stated without the CPOT score, it was unclear if Patient 20 was receiving the appropriate amount of Morphine to meet physician set goal (CPOT 0-2). MSD 1 stated there would be potential for Patient 20 to receive too much or too little Morphine. During an interview on 5/27/2026 at 2:52 p.m. with Interim (temporary) Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) Manager (NM 10), NM 10 stated the facility had no policy for Morphine drip for general inpatient hospice care patients. NM 10 stated the nurses were to follow physician order when administering Morphine. During an interview on 5/29/2026 at 12:02 p.m. with palliative care physician (MD 4), MD 4 stated nursing staff should assess and reassess patients for nonverbal pain using CPOT or FLACC scale (Face, Legs, Activity, Cry, Consolability) in order to adjust and justify the need for increase of Morphine. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 12/2024, the P&P indicated, “Medication administration should be performed by licensed medical staff according to manufacturer’s prescribing information ... Proper documentation, verifying patient specific information, medication security and compliance with specific drug policies should always be taken during medication administration ... Utilize the seven rights for administering medication: a. Right Patient b. Right Dose c. Right Time d. Right Route e. Right Drug ... access eMAR (electronic medication administration record)/MAR and/or physician’s order when administering medications at patient’s bedside ... Observe the patient for signs of therapeutic results or symptoms of toxicity ...” 2. During a review of Patient 19’s “History and Physical (H&P),” dated 4/1/2026, the “H&P” indicated, Patient 19 had acute (new onset) respiratory distress (a condition that occurs when the body needs more oxygen, and can be caused by a number of factors, including infections, chronic illness, or a blocked airway), pneumonia (lung infection), sepsis (a body’s overwhelming and life-threatening response to infection) and encephalopathy (a broad term for any brain disease that alters brain function or structure) and was admitted to the facility’s general inpatient hospice care for end-of-life care (support for people who are near the end of life. Instead of trying to cure an illness, its main goal is to relieve pain, manage symptoms, and provide comfort. It also gives emotional and spiritual support to both the patient and their loved one) and opioid infusion (the continuous delivery of strong pain medication [such as morphine] directly into a patient’s bloodstream). During a review of Patient 19’s physician order, dated 4/1/2026, the physician order indicated, “to give Morphine with a loading dose of 2 milligrams (mg), then begin continuous infusion at 2 milligrams per hour (mg/hr) after the loading dose ... for uncontrolled symptoms and dyspnea: bolus with [Morphine] 2 mg every 15 minutes. Increase infusion rate by 2 mg/hr if patient required 2 boluses within two (2) hours ...goal parameters CPOT (Critical-Care Pain Observation Tool) 0-2.” During a concurrent interview and record review on 5/29/2026 at 2:15 p.m. with Director (DMS 1) of Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery), Patient 19’s “Medication Administration Record (MAR),” dated 4/1/2026, was reviewed. The “MAR” indicated, Morphine 2mg/hr started on 4/1/2026 at 7:33 p.m. without Morphine 2 mg loading dose. DMS 1 stated Morphine 2 mg loading dose should have been given before the Morphine infusion per physician order. DMS 1 stated there was no documentation to show Morphine 2 mg loading dose was given. During a concurrent interview and record review on 5/29/2026 at 2:25 p.m. with DMS 1, Patient 19’s “Medication Administration Record (MAR),” dated 4/1/2026, was reviewed. The “MAR” indicated, Morphine 2mg/hr was started on 4/1/2026 at 7:33 p.m. The “MAR” indicated, a 2mg Morphine bolus was given on 4/1/2026 at 8:11 p.m. and Morphine infusion rate was changed to 4mg/hr at the same time at 8:11 p.m. DMS 1 stated there was only one Morphine 2mg bolus given before Morphine infusion rate was changed to 4 mg/hr. DMS 1 stated there should have been two (2) boluses given within 2 hours before the nurse could increase the Morphine rate to 4mg/hr. DMS 1 stated the nurse did not follow physician order. During a concurrent interview and record review on 5/29/2026 at 2:36 p.m. with DMS 1, Patient 19’s “Medication Administration Record (MAR),” dated 4/1/2026 was reviewed. The “MAR” indicated, Morphine 2mg/hr started on 4/1/2026 at 7:33 p.m. The “MAR” indicated a 2mg Morphine bolus was given on 4/1/2026 at 8:11 p.m. The “MAR” did not indicate any CPOT score and reason when Morphine 2mg bolus was given and when the Morphine infusion rate was increased to 4mg/hr. DMS 1 stated nurse should document reason for each Morphine bolus and rate increase to justify and explain the increase of Morphine administration. DMS 1 stated the nurse should document the CPOT to evaluate if the patient had reached the CPOT goal. During an interview on 5/29/2026 at 12:02 p.m. with palliative care physician (MD 4), MD 4 stated nursing staff should assess and reassess patients for their CPOT or FLACC score for pain in order to adjust the morphine and justify the need for increase of morphine. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 12/2024, the P&P indicated, “Medication administration should be performed by licensed medical staff according to manufacturer’s prescribing information ... Proper documentation, verifying patient specific information, medication security and compliance with specific drug policies should always be taken during medication administration ... Utilize the seven rights for administering medication: a. Right Patient b. Right Dose c. Right Time d. Right Route e. Right Drug ... access eMAR (electronic medication administration record)/MAR and/or physician’s order when administering medications at patient’s bedside ... Observe the patient for signs of therapeutic results or symptoms of toxicity ...””

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to: 1. Document a desaturation (a drop in the amount of oxygen carried in the blood) event for one of 50 sampled patients (Patient 1). The medical record contained no documentation of the desaturation episode on 12/23/2025, the degree of desaturation (severity of oxygen drop), the exact time Patient 1 was transitioned from BiPAP (Bilevel Positive Airway Pressure, machine that helps move air in and out of the lungs by delivering two levels of airway pressure) to nasal cannula (a lightweight, flexible plastic device used to deliver supplemental oxygen to people who need respiratory support. It features two short prongs that are inserted into the nostrils, while the thin tubing loops over the ears and cinches under the chin), or any additional interventions that may have been performed and which should have been documented in Patient 1’s medical records, in accordance with the facility’s policy regarding complete and accurate documentation to support patient care. This deficient practice had the potential to delay timely, life-saving care, prevent accurate clinical evaluation and communication during a change?of?condition event (a change?of?condition event is a change in a patient’s clinical status that requires timely assessment, documentation, and appropriate intervention) due to missing or inaccurate documentation. 2. Ensure that nursing staff documented communication with one of 50 sampled patient’s (Patient 31) family representatives regarding Patient 31’s worsening condition, in accordance with the facility’s policy regarding complete and accurate documentation. This deficient practice had the potential to negatively impact the continuity of patient care when members of the healthcare team who work on different shifts cannot confirm exactly what the family was told resulting in contradictory updates and may also negatively affect family expectations and trust. Findings: 1. During a review of Patient 1’s History and Physical (H&P, a comprehensive medical assessment that describes the patient’s current condition and medical history), dated 12/19/2025, the H&P indicated that Patient 1 was admitted on 12/19/2025 due to severe shortness of breath (difficulty breathing) and an oxygen saturation rate of 70% (percentage of oxygen in the blood; 70% is a critically low level requiring immediate medical intervention). The H&P further indicated that Patient 1 required the use of BIPAP therapy (Bilevel Positive Airway Pressure, a non-invasive ventilation device that assists breathing by delivering pressurized air through a mask). During a review of Patient 1’s Physician Orders, dated 12/20/2025, the record indicated that the physician (MD 10) ordered BiPAP management with the following special instructions: “Keep O2 sat (oxygen saturation, the percentage of hemoglobin in the blood carrying oxygen) more than 92%, PRN (as needed) during the daytime, and continuous at night.” During a review of Patient 1’s Cardiology (heart doctor) progress note, dated 12/23/2025, the record indicated that Patient 1’s condition had worsened, described as “more SOB (SOB means shortness of breath, or difficulty breathing)” and “worsening O2 saturation (O2 saturation means the percentage of oxygen carried in the blood).” During a review of Patient 1’s BIPAP assessment record, dated 12/23/2025, the record indicated that Patient 1 was last documented (prior to a documented desaturation event on 12/23/2025 at 7:41 a.m.) to be on BIPAP at 4:30 a.m. [on 12/23/2025] with an oxygen saturation rate (the amount of oxygen in the blood) of 95% (a normal level showing the blood has enough oxygen). During an interview on 5/26/2026 at 11:11 a.m. with the manager of the respiratory department (NM 9), NM 9 said that nurses can reconvert patients from BiPAP to oxygen via nasal cannula, but they should notify the respiratory therapists before doing so. During a concurrent interview and record review on 5/27/2026 at 10:20 a.m. with the manager of respiratory services (NM 9), Patient 1’s BIPAP assessment record, dated 12/23/2025, was reviewed. The record did not have any notes showing what time Patient 1 was switched from BIPAP to a nasal cannula on the morning of 12/23/2025. NM 9 stated that if the respiratory therapist (RT) switched the patient to a nasal cannula, it should have been documented, and if the nurses made the switch, it also should have been documented, and the RT should have been notified. During an interview on 5/29/2026 at 12:13 p.m. with Respiratory Therapist (RT 1), RT 1 said that if a patient was found in the room desaturating, the patient should be attended to first, the desaturation should be addressed, and then charting typically happens afterward. RT 1 stated that respiratory therapists document the patient’s BiPAP use, what occurred during a desaturation event, when the patient was taken off BiPAP and placed on oxygen via nasal cannula, the assessment of the patient, and the machine’s parameters. During a review of Patient 1’s Vital Signs (VS basic body measurements such as temperature, heart rate, breathing rate, blood pressure, and oxygen level) record, dated 12/23/2025, the record indicated that Patient 1 had the following oxygen levels documented on 12/23/2025 from 3:03 a.m. through 10:47 a.m.: -At 3:03 a.m., Patient 1’s oxygen saturation (O2Sats means the percentage of oxygen in the patient’s blood) was 96% (% means the proportion out of 100; levels below 90% are considered low [hypoxemia] and may be dangerous) while on BiPAP (BiPAP means a machine that helps move air in and out of the lungs by delivering two levels of airway pressure). -At 7:45 a.m., oxygen saturation 95% while receiving 7 liters of oxygen (these VS show the patient’s body temperature, heart workload, breathing effort, blood pressure level, and oxygenation status). -At 9:00 a.m., oxygen saturation was documented as 94%. - At 10:47 a.m., oxygen saturation was 96% on BiPAP. -The review of vital signs was conducted with Registered Nurse (RN 19), who verified that no desaturation events were reflected in the record on 12/23/2025 from 3:00 a.m. to 11:00 a.m. During an interview on 6/1/2026 at 9:41 a.m. with Registered Nurse (RN 19), Patient 1’s physician notification note, dated 12/23/2025, was reviewed. The note, documented on 12/23/2025 at 7:41 a.m., indicated that Physician (MD 10) was notified that Patient 1 “is desaturating (but no documentation as to how low was the oxygen saturation level) and we need to transfer her (Patient 1) to higher acuity of care ...,” and per MD 10, Patient 1 “can be transferred.” During the same interview on 6/1/2026 at 9:41 a.m. with Registered Nurse (RN 19), RN 19 said that she (RN 19) could not recall the degree to which Patient 1 was desaturating and explained that she (RN 19) was a relief nurse (a nurse temporarily assisting on the unit but not the primary assigned nurse) on the floor that day (12/23/2025), helping the primary nurse for Patient 1 by calling the physician (MD 10) for orders. RN 19 then reviewed the vital signs (VS means basic body measurements such as temperature, heart rate, breathing rate, blood pressure, and oxygen level) record for 12/23/2025, but was not able to find documentation of the degree of desaturation (for Patient 1) on 12/23/2025 around the time her (RN 19) note at 7:41 a.m., was made. RN 19 also verified that, according to the vital signs record at 7:45 a.m. on 12/23/2025, Patient 1’s oxygen flow was increased to 7 liters (7 liters per minute, meaning a higher amount of oxygen was delivered to support breathing), and Patient 1 was transferred to the DOU (Definitive Observation Unit, a step?down unit where patients receive closer monitoring than on a regular medical-surgical floor). During an interview on 6/1/2026 at 10:00 a.m. with Registered Nurse (RN 19), RN 19 said that the nursing process [when responding to a change in condition], was to assess the patient first, obtain and document vital signs (VS), and then address the problem. RN 19 stated that because Patient 1 was desaturating, the nurse should “address the desaturation and help the situation and the patient.” RN 19 explained that obtaining a set of vital signs before and after an intervention, including the desaturation rate, “can show if the intervention was successful.” RN 19 further stated that nurses were required to document in real time and be able to escalate the situation (immediately intervene to protect the safety of a patient) which was done for Patient 1 but lacked the specific details. RN 19 said that vital signs, including the desaturation rate, should have been documented because “it’s done for the patient’s safety.” During a review of the facility’s policy and procedure (P&P) titled, Medical Record Content, dated 2/20/2026, the policy indicated that all clinical entries in the patient’s medical record must be accurately dated, timed, and authenticated, and that the medical record must contain patient-specific documentation that supports diagnoses and facilitates patient care, treatment, and services (e.g., nursing documentation, progress notes, diagnostic information). The policy required complete and accurate documentation to ensure continuity of care and compliance with regulatory standards. 2. During a review of Patient 31’s “History and Physical (H&P),” dated 4/25/2024, the record indicated Patient 31 was admitted to the facility for abnormal (not within normal range) laboratory values, with abdominal pain and hematemesis (vomiting blood). Patient 31’s medical history included Hepatocellular carcinoma (HCC, most common type of primary liver cancer), liver cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure), hypertension (HTN, high blood pressure) and Coronary Artery Bypass Graft (CABG, heart surgery to create new blood flow to the heart). During a review of Patient 31’s “Discharge Summary (an official clinical document prepared by healthcare professionals that outlines the details of a patient’s hospitalization. It acts as a bridge between the hospital and a patient’s ongoing care),” dated 4/26/2024, the record indicated Patient 31 was admitted to the Intensive Care Unit (ICU, special unit that provide treatment and monitoring for people who are very ill), and Patient 31 deteriorated (condition became worse) and died on 4/26/2024. During a concurrent interview and record review on 6/1/2026 at 9:20 a.m. with Manager of Step Down (MSD 1) and the Intensive Care Unit Charge Nurse (CN) 2, Patient 31’s “Clinical Nursing Notes,” dated 4/25/2024 and 4/26/2024, were reviewed and indicated there was no documentation that Patient 31’s nurse communicated with the family regarding Patient 31’s worsening condition. CN 2 stated bedside nurses were expected to notify family if the patient’s situation was getting worse. MSD 1 and CN 2 both acknowledged it was part of their process for nurses to document family notification. CN 2 stated the documentation was important to ensure transparency regarding communication with the patient’s family. By recording updates and notifications, staff can confirm that the family was informed about the patient’s (Patient 31) situation, promoting clarity and continuity among the care team. situation. During a review of the facility’s policy and procedure (P&P) titled, “Medical Record Content,” dated 2/20/2026, the P&P indicated, “Ensure the medical record contains patient specific data and information to identify the patient, support the diagnoses, facilitate patient care, treatment and services, serve as the financial and legal record, aid patient research, support decision analysis, justify treatment and guide professional and hospital performance improvement, as well as to ensure a procedure to review all data elements in the patient medical record ...Depending on the patient visit type, but not limited to, the patient medical record shall include the following as applicable ...12. Nursing Documentation.” During a review of the facility’s policy and procedure (P&P) titled, “Nursing Standards of Care,” dated 2/27/2025, the P&P indicated, “Patients have the right and responsibility to participate in all decisions related to their health care. Patients also have the right to receive accurate information and will be assisted as needed to make informed health care decisions ...Patients who are unable to participate in treatment decisions have the right to be represented by parents, guardians, family members, health care agents, or conservators.””

“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: 45743 Based on interview and record review, the facility’s contracted radiology department failed to interpret, finalize and provide to the Emergency Room Doctor, in a timely fashion (within 2 hours), the result of a STAT (medical abbreviation for immediately or without delay) ultrasound (US, a safe painless imaging test that uses high-frequency sound waves to create real-time pictures of the inside of your body) of the leg, ordered for one (1) of 50 sampled patients (Patient 38), in accordance with the facility’s document titled “Teleradiology Services Agreement.” This deficient practice had the potential to delay diagnosis for Patient 38 and potentially place Patient 38 and other patients at risk of harm, including potential death. Findings: During a review of Patient 38’s Face sheet (provides healthcare providers with quick, actionable access to vital information, including personal demographics, insurance details, emergency contacts, and a high-level overview of the patient’s medical history), dated 1/1/2026, Patient 38 was admitted to the Emergency room department on 1/1/2026 at 14:03 (2:03 p.m.) and discharged on 1/1/2026 at 17:27 (5:27 p.m.). During a review of Patient 38’s Emergency Department (ED) Physician note, dated 1/1/2026 and timed at 17:17 (5:17 p.m.), the ED physician note indicated that Patient 38 presented to the ED with bilateral (both) leg pain and swelling for 3 days. During an interview on 5/29/2026 at 11:19 a.m. with Radiology Technologist 1 (RAD 1) and Radiology Technologist 2 (RAD 2), RAD 2 stated radiology orders conducted would be based on priority. STAT orders were urgent and should be completed within a two-hour time frame. RAD 1 stated once the order had been completed, the imaging would be uploaded to PACs (Picture Archiving and Communication System, a digital system where images can be stored and retrieved) where the radiologist (special physician who reads and interprets images) could read the image, interpret and create a report for every patient test. During an interview on 5/26/2026 at 11:26 a.m. with the Director of Imaging (DIR 9), DIR 9 stated that once the radiologist created the report, the report would be uploaded to the patient’s electronic medical record directly. DIR 9 stated that the radiologist would read images within a 30 minute-60 minute window during the daytime and 30 minutes to 3-hour window during the nighttime. DIR 9 stated that after 5 p.m. and during the weekend and holidays, there was no radiologist onsite and images were read/interpreted remotely. During a concurrent interview and record review on 5/27/2026 at 11:11 a.m. with the Director of Emergency Department (DIR 2) and the Manager of Emergency Department (NM 1), Patient 38’s Physician Order, dated 1/1/2026 at 14:11 (2:11 p.m.), was reviewed. The Physician Order indicated Patient 38 had a STAT order “US Lower Extremity (legs) Vein Duplex (Ultrasound [US], painless imaging test that uses high-frequency sound waves to create real-time pictures of the inside of a patient’s body) Bilat (bilateral [both]).” DIR 2 confirmed that Patient 38 had a STAT order. During a concurrent interview and record review on 5/28/2026 at 11:13 a.m. with the Regulatory Specialist and Accreditation (RSA), the facility’s document titled “Release of Electronic Health Information to the Patient Portal (FAQ),” date unknown, was reviewed. The document indicated that “Imaging results will be released upon signing (signed by the radiologist) of the imaging report.” RSA stated that once the doctor (the radiologist) had finalized the report, it (the image report) would be uploaded to the patient portal (a secure website or mobile app that lets the patient view their personal health records and easily communicate with their healthcare team). During a concurrent telephone interview and record review on 5/29/2026 at 1:45 p.m. with the Medical Director of Radiology (MD 6), Patient 38’s “US Lower Extremity Vein Duplex Bilateral,” dated 1/1/2026 and timed 15:07 (3:07 p.m.), was reviewed. MD 6 confirmed that the final report was read by a radiologist on 1/5/2026 at 8:25 a.m. MD 6 stated that Final Radiology reports had a ‘turnaround time of 24 hours’ and MD 6 could confirm why the final report was read 4 days later (on 1/5/2026). During a review of the facility’s document titled “Teleradiology Services Agreement,” dated 7/4/2025, the document indicated “Response Time: Provider shall use its best efforts to provide a preliminary diagnostic reading no more than an average of thirty (30) minutes after receipt of images of CT scan, MRI, ultrasound or plain X-ray and its requisition order at least ninety percent (90%) of the time.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met, as evidenced by: 1.The facility failed to ensure there was a safe transportation process for its Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders)patients on involuntary hold (involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) outside the facility when a BHU staff (Certified Nursing Assistant [CNA])1 escorted one of 30 sampled patients (Patient 1) using the route outside of the facility’s building to the transportation vehicle during pick up and allowing Patient 1 to step out of the transportation vehicle before her (CNA 1) upon returning to the facility from a conservatorship (a judge appoints a responsible person to care for another adult who cannot care for themselves or manage their own finances due to physical or mental limitations) court hearing. This deficient practice had resulted in Patient 1 eloping (leaving the facility without physician’s permission when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility by walking one (1) mile away from the facility and had the potential to result in Patient 1 running into traffic, and accidents leading to injury and death. This deficient practice also had the potential to place all future BHU patients who require going out of the facility for appointments, including the conservatorship court hearing, at risk of eloping and getting injured. This deficient practice resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 46333 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Quality Assurance and Performance Improvement was met, as evidenced by: 1. The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI, the hospital’s program that identifies problems, investigates causes, and make improvements to ensure protection of patients and provide safe care) program was working as required. The facility’s QAPI program did not investigate or respond to problems in how controlled substance (drugs such as morphine [a strong pain medication] and fentanyl, a very strong pain medicine regulated by law because they can be abused) were stored, wasted (discard with a witness), or monitored. Instead, QAPI left the investigation to the Drug Diversion Prevention (DDP) team and expected to hear the result from the DDP team. Because QAPI did not act, unsafe practices continued: -Nurses were allowed to keep unused narcotics (very strong pain medicines such as morphine and fentanyl) for up to 12 hours without a secure place to store them. -lock boxes used to store controlled substances on all units were easily accessible for multiple controlled substances without a witness. - ControlCheck (formally known as Brightsight, the facility’s monitoring system) flagged unsafe handling by Registered Nurse (RN 1), but QAPI did not review or act on the data. -RN 1 was later found unresponsive in the ICU locker room with narcotics and a syringe, while two patients (Patient 11 and Patient 12) were under RN 1’s care. These deficient practices had the potential to jeopardize Patient 11 and Patient 12’s safety due to care provided by Registered Nurse (RN 1) who was under the influence (impairment, to any degree, of an individual’s ability to safely perform work because of drug use), and unaccounted controlled substances, and also placed other patients at risk for harm. (Refer to A-0283) 2. The facility’s Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure oversight on the Quality Assurance and Performance Improvement (QAPI, the hospital’s program that identifies problems, investigates causes, and make improvements to ensure protect patients and provide safe care) committee to ensure there was a thorough analysis of the causes of a patient safety event and identify and implement an effective action plan, when one of 30 sampled patients (Patient 1), from Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) eloped (leaving the facility without physician’s permission when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility on 7/30/2025. This deficient practice resulted in the facility not having a safe transportation process in place to prevent future occurrence of elopement. (Refer to A-0286) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met, as evidenced by: 1. The facility failed to ensure its nursing staff performed reassessment and checked vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) for two of 30 sampled patients (Patient 1 and Patient 5), in accordance with the facility’s policy regarding “Medication Use to Manage a Psychiatric Emergency,” after receiving one-time emergency medication (EM, administering antipsychotic [class of drugs primarily used to manage psychosis, a mental state characterized by a disconnection from reality] medications or intramuscular medications to a patient without the patients’ consent to maintain safety for the patient and other people on the unit) intramuscular (IM, into the muscles) injections when: 1.a. Nursing staff did not reassess and take vital signs for Patient 1 after giving Benadryl (antihistamine [medication that treat allergy symptoms] that can have a calming or sedative [a substance that calms and promotes sleep] effect) 50 milligrams (mg, a unit of measurement), Haldol (medication to treat schizophrenia [mental illness affecting how someone behaves, feels, and thinks] and acute [new onset] agitation [being upset, annoyed, angry and physically disturbed]) 5 mg, and Valium (medication used to treat anxiety [a feeling of unease, worry, or fear] and produce drowsiness (a feeling of sleepiness) and has sedation [a state of calmness or drowsiness induced by drugs] effect)10 mg on 7/30/2025 at 11:25 a.m. This deficient practice had the potential to result in Patient 1 not getting proper evaluation of the effect of the medications and put Patient 1 at risk for respiratory distress (a condition that occurs when the body needs more oxygen, and can be caused by a number of factors, including infections, chronic illness, or a blocked airway) and oversedation (too much sleepiness and/or drowsiness). (Refer to A-0395) 1.b. Nursing staff did not take vital signs for Patient 5 after giving Valium 5 mg on 6/11/2025 at 7:44 p.m., and injections of Haldol 10 mg, Benadryl 50 mg and Valium 5mg IM on 6/11/2025 at 8:31 p.m. These deficient practices had the potential to result in Patient 5 not getting proper evaluation of the effect of the medications and put Patient 5 at risk for respiratory distress (a condition that occurs when the body needs more oxygen, and can be caused by a number of factors, including infections, chronic illness, or a blocked airway) and oversedation (too much sleepiness and/or drowsiness). (Refer to A-0395) 2. The facility failed to ensure nurses followed the hospital policy on medication administration documentation, for one (1) of 31 sampled patients (Patient 27), when there was a delay in wasting or returning a bag of Fentanyl which was removed from the Pyxis (an automated medication dispensing system) on 7/09/2025. This deficient practice had the potential for inaccurate medication administration, medication errors, and/or issues with unaccounted controlled substances (a drug or chemical that is regulated by the government due to potential for abuse or addiction, for example opioids and narcotics). (Refer to A-0398) 3. The facility failed to ensure that nurses measured and documented the amount of controlled substances (medication like morphine or fentanyl that are regulated by law due to their high risk for abuse or addiction) remaining in patient -controlled analgesia (PCA, a pain -management method that allows patients to self-administer small doses of pain medicine through a pump) tubing when discontinuing PCA therapy affecting approximately two (orthopedic patients per month) of 31 sampled patients, who are placed on PCA therapy (Director of Medical Surgical confirmed this information on 8/8/2025 at 12:45 p.m.). This deficient practice placed approximately two orthopedic patients per month at risk for inaccurate medication documentation and unaccounted controlled substances. In addition, this failure resulted in unaccounted narcotics (a drug or other substance that affects mood or behavior and is consumed for nonmedical purposes) being discarded into unsecured bins without measurement or witness verification. This created a risk for diversion (when drugs are used for purposes other than a patient’s prescribed treatment) by staff, which could result in impaired staff providing unsafe care, thereby placing all patients on the orthopedics unit at risk. (Refer to A-0405) 4. The facility failed to ensure that a patient had pain medication orders that addressed the full range of pain on a numeric pain scale utilized by the facility to address patients’ pain (0: No pain,1-3: Mild pain, 4-6: Moderate pain,7-10: Severe pain, and 10: The worst pain imaginable), in accordance with the facility’s policy regarding pain management. For one (1) of 31 sampled patients (Patient 17), the medical record showed that the patient had no medication ordered for mild to moderate pain (1-6). This deficient practice placed Patient 17 at risk for experiencing unnecessary suffering from untreated mild to moderate pain (levels 1-6), which had the potential to cause prolonged discomfort, increased stress on the body, and delay recovery. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure that the Condition of Participation for Pharmaceutical Services was met, as evidenced by: 1. The facility failed to develop policies and procedures for the control and storage of medications, which may negatively impact 31 of 31 sampled patients, as evidenced by: 1.a. Failure to develop a policy and procedure for a contracted vendor software, ControlCheck (formerly called Bluesight, a program that utilizes artificial intelligence and machine learning to monitor and analyze medication transactions, identify unusual patterns, and flags potential drug diversion [unauthorized or illegal transfer of prescription medications from their intended recipients to others, or their use for purposes not intended by the prescriber] events to ensure accountability of medications) that has been in use since 9/12/2018. This deficient practice had the potential for wrong medication, drug diversion, and/or pilferage (stealing medication) that may affect patient safety. (Refer to A-0491) 1.b. Failure to develop a policy and procedure that indicated an acceptable time frame for nurses to return or waste a medication, and the interim secure storage of such medications in the event that the return or the disposal could not happen within the approved period. This deficient practice had the potential for wrong medication, drug diversion, and/or pilferage (stealing medication) that may affect patient safety. (Refer to A-0491) 2. The facility failed to ensure that a record system was properly in place to maintain current and accurate records of the receipt and disposition of scheduled drugs by failing to develop and implement policies and procedures to: - Secure controlled substances (drugs such as morphine [strong opioid pain medication] and fentanyl [a very strong opioid pain medication] that are regulated by law because they can be abused or cause dependence). -Monitor medication handling. - Prevent diversion (when medication is used for reason other than prescribed treatment). This deficient practice involved two (2) of 31 sampled patients (Patient 11 and Patient 12), who were under the care of Registered Nurse (RN) 1, a nurse later confirmed by toxicology testing (laboratory analysis to detect drugs or poisons) to be under the influence (impairment, to any degree, of an individual’s ability to safely perform work because of drug use) of fentanyl (a strong opioid pain medication) and opioids (a drug class includes fentanyl and morphine) while on duty. This deficient practice resulted in Patient 11 and Patient 12 being at immediate risk for harm due to care previously provided by a nurse under the influence of controlled substances. In addition, because the facility continued to allow unsecured storage and inadequate monitoring of controlled substances, other patients in the facility remained at risk for harm from potential diversion, delayed pain treatment, or medication errors. (Refer to A-0494) 3. The facility failed to ensure pharmacy oversight of controlled substances (a drug or chemical that is regulated by the government due to potential for abuse or addiction, for example opioids and narcotics), which may negatively impact 31 of 31 sampled patients, as evidenced by: 3.a. Failure to ensure the pharmacy department manually reviewed the Control Check (formerly called Bluesight, a program that utilizes artificial intelligence and machine learning to monitor and analyze medication transactions, identify unusual patterns, and flags potential drug diversion [unauthorized or illegal transfer of prescription medications from their intended recipients to others, or their use for purposes not intended by the prescriber] events to ensure accountability of medications) alerts for potential diversion of Controlled drugs substances instead of just relying on the Control Check program to identify. This deficient practice placed patients at risk for harm from diversion (when medications are taken or used for purposes other than prescribed), delayed pain treatment (such as when medication was diverted, thus patient did not receive pain medication on time or as prescribed), or medication errors (such as when medication had been tampered with or inaccurate amount of pain medication was administered not following prescription). (Refer to A-0500) 3.b. Failure to investigate an alert for a long lapse (close to 2 hours) between the time of removal from Pyxis (an automated dispensing system that included a secure computerized cabinet that stores and dispenses medication and integrate with the hospital’s electronic medical record system) and the time of administration for a fentanyl (narcotic that is used in anesthesia and pain management) infusion (drip, the process of delivering medication directly into the bloodstream through a needle, typically through a vein, or intravenously/IV) bag on 7/11/2025, for one of 30 sampled patients (Patient 11). This deficient practice placed patients at risk for harm from diversion (when medications are taken or used for purposes other than prescribed), delayed pain treatment (such as when medication was diverted, thus patient did not receive pain medication on time or as prescribed), or medication errors (such as when medication had been tampered with or inaccurate amount of pain medication was administered not following prescription). (Refer to A-0500) 3.c. Failure to ensure that substances (medications regulated by law due to risk of abuse or dependence, such as fentanyl and morphine) stored in medication lock boxes located throughout all units in the facility were secured and protected from unauthorized access, in accordance with the facility’s policy regarding “Distribution, Administration and Accountability of controlled drugs.” Once the lock box was opened by a nurse, that nurse had access to all other controlled substances inside, and there was no requirement for a witness when placing or removing medications. This deficient practice placed patients at risk for harm from diversion (when medications are taken or used for purposes other than prescribed), delayed pain treatment (such as when medication was diverted, thus patient did not receive pain medication on time or as prescribed), or medication errors (such as when medication had been tampered with or inaccurate amount of pain medication was administered not following prescription). (Refer to A-0500) 4. The hospital failed to ensure its sterile (germ-free) compounding process (a process of making sterile intravenous [IV, administered through the vein] medications), was performed in a safe and consistent manner, as evidenced by: 4.a. Failure to ensure the “sterile product preparation tray (a tray that provide surface area for sterile compounding or IV medication preparation)” in one (1) of two (2) sampled medication rooms in the Intensive Care Unit (ICU) was free of stains. This deficient practice had the potential for all patients requiring IV medications to be exposed to preventable contamination leading to infection that may affect patients’ health and safety. (Refer to A-0501) 4.b. Failure to ensure the anteroom (a room serves as a transition area that separates the dirty area from the clean area or room where IV medications are prepared) of the sterile compounding suite (IV room) was clean and free of debris, residues, and/or stains, that could accumulate contaminants and/or microorganisms. This deficient practice had the potential for all patients requiring IV medications to be exposed to preventable contamination leading to infection that may affect patients’ health and safety. (Refer to A-0501) 4.c. Failure to ensure the sterile compounding environment viable sampling plan (a map of sampling locations) used by the vendor that certifies the facility’s IV room was included in the hospital’s procedure of environmental media testing. This deficient practice had the potential for all patients requiring IV medications to be exposed to preventable contamination leading to infection that may affect patients’ health and safety. (Refer to A-0501) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility’s Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure policies and procedures were established to ensure proper accounting of dispensed controlled substances to provide safe and quality care for three of 31 sampled Patients (Patients 1, 11, 12) when there was a failure to: 1. -Secure controlled substances (drugs as morphine [a strong pain medication] and fentanyl [a powerful drug used in the treatment of severe pain] that are regulated by law because they can be abused or cause dependence). This deficient practice had the potential to jeopardize Patient 11 and Patient 12’s safety due to care provided by Registered Nurse (RN 1) who was under the influence (impairment, to any degree, of an individual’s ability to safely perform work because of drug use). This deficient practice also had the potential to impact other patients in the ICU (Intensive Care Unit), where controlled substances are unsecured. -Monitor medication handling and prevent diversion (when medication is taken or used for purposes other than what was prescribed for a patient). This deficient practice had the potential to result in unsafe medication handling, diversion (when medication is taken or used for purpose other than what was prescribed for a patient), and unaccounted controlled substances. This failure placed patients at risk for delayed treatment, untreated pain, or receiving unsafe care from staff who may be impaired by diverted drugs. -Ensure the Quality Assurance and Performance Improvement (QAPI, the facility’s program for identifying problems, investigating causes, and making improvements) program investigated and corrected unsafe practices. This deficient practice jeopardized Patient 11 and Patient 12’s safety due to care provided by Registered Nurse (RN 1) under the influence (impairment, to any degree, of an individual’s ability to safely perform work because of drug use), and unaccounted controlled substances, placing patients at risk for harm. 2. Ensure there was a safe process to transport Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) patients outside the facility for appointments including conservative (a judge appoints a responsible person to care for another adult who cannot care for themselves or manage their own finances due to physical or mental limitations) court hearings. This deficient practice resulted in Patient 1 eloping (leaving the facility without physician’s permission when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility and which had the potential for Patient 1 running into traffic, accident, getting injured and/or death. This deficient practice also had the potential to put other BHU patients requiring transportation outside the facility at risk for elopements. Findings: 1.a. During an interview with the Director of the Intensive Care Unit (DICU) on 8/5/2025 at 3:42 p.m., DICU confirmed RN 1 was found unresponsive (not awake not reacting) in the ICU (Intensive Care Unit, area in hospital that care for the critically ill patients) locker restroom while on duty on 7/26/2025. DICU confirmed that RN 1 was assigned the care of Patient 11 and Patient 12 on the night (7 p.m. to 7 a.m. shift) RN 1 was found unresponsive. During an interview on 8/6/2025 at 2:45 p.m. with the Chief Medical Officer (CMO), the CMO confirmed that RN 1 was in possession of a morphine vial (a small glass container holding a strong pain medicine), used syringe (a device for injecting fluids), uncapped needle (needle without its safety cover), and tourniquet (a tight band used to slow blood flow, often applied before injecting) at the time RN 1 was found unresponsive. The CMO also confirmed toxicology testing (laboratory analysis to detect drugs or poisons) in the Emergency Department (ED, a hospital unit for urgent medical care) was positive for fentanyl (a very strong opioid pain medication) and opioids (a group of drugs that includes morphine [a strong opioid medication] and fentanyl [a very strong opioid medication]). During a review of Patient 11’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/21/2025 , the “H&P” indicated, Patient 11 had past medical history which included pancreatic cancer (a type of cancer that develops in the pancreas, an organ located behind the stomach that plays a crucial role in digestion and blood sugar regulation), on chemotherapy (the treatment of disease by the use of chemical substances). Patient 11 was admitted for worsening abdominal pain, with a care plan including pain control. During a review of Patient 11’s “Medication Administration Record (MAR),” dated 7/26/2025, the MAR indicated Patient 11 had a physician’s order for fentanyl (a very strong opioid pain medication) infusion intravenously (medication administered into the vein). During a concurrent interview and record review on 8/7/2025 at 4:00 p.m. with the Medication Safety Officer (MSO), Patient 11’s “Medication Administration Record (MAR),” dated 7/24/2025, was reviewed. The MAR indicated that RN 1 administered a new bag of fentanyl (a very strong opioid pain medication) 100 milliliters (ml, a unit of measurement) intravenously (IV, administer medication into the vein) infusing for 8 hours. MSO stated the total volume infused was 75 ml when a new bag was changed. MSO confirmed that approximately 25 ml was unaccounted for. MSO stated pharmacy did not know where the unaccounted fentanyl went. During a review of Patient 12’s “History and Physical (H&P),” dated 7/21/2025, the “H&P” indicated, Patient 12 was transferred to this facility due to having an aneurysm (part of an artery wall weakens, allowing it to abnormally balloon out or widen). During a review of Patient 12’s medication dispensing report date 7/25/2025, the report indicated RN 1 removed Morphine (strong opioid pain medication) 3 times in one day (7 a.m. - 7:00 p.m.): at 8:32 p.m., 10:22 p.m., and 3:22 a.m. During a concurrent interview and record review on 8/7/2025 at 12:32 p.m. with the Pharmacy Manager (MP) and the Medication Safety Officer (MSO), RN 1’s audit record in “Control Check (a drug diversion monitoring software, formerly called Bluesight) for period of 7/5/2025 - 8/4/2025, was reviewed. The MSO stated the system flagged alerts for fentanyl infusions given more than 60 minutes after removal from the Pyxis (an automated medication dispensing system). However, RN 1’s IRIS score (individual Risk Identification Score, a risk score for diversion) was 2/5, below the facility’s threshold of 5. Therefore, no investigation occurred. During a concurrent interview and record review on 8/7/2025 at 12:40 p.m. with the Manager of Pharmacy (MP), RN 1’s ControlCheck audit report was reviewed. MP stated the report was run after the incident on 7/26/2025 for the last 30 days (6/27/2025 -7/27/2025). MP stated they did not look into why RN 1’s score was 2.5 because this score was below 5, which was the threshold that the facility would start an investigation. The report indicated the score of 2.5 meant the following: - “RN 1 has a highly unusual number of variances (discrepancies or differences between expected and actual quantities of controlled substances, such as medications, during handling and dispensing), including 4 variances with a status of Closed Reconcile (MP stated the Nurse Manager closed this variance that was flagged by the system).” 2 Variances in Reconcile - Missing either administration, waste, or return, and 2 variances in reconciled - Missing administration.” -“RN 1 logged 5 actions with the time between events exceeding the threshold (60 minutes): 1 action with first dispense (when RN removed the controlled substance) and first administration (when RN 1 gave the medication) for a patient greater than 60 minutes (hospital threshold). 4 actions with first and last touch for a patient greater than 41 minutes (Nursing Average).” During an interview on 8/7/2025 at 12:54 p.m. with the Director of Pharmacy (DOP), the DOP stated the policy titled “Automatic Dispensing Cabinet (a computerized medicine storage and tracking system),” dated 1/3/2024, allowed nurses to keep controlled substances that required wasting (throwing away leftover drugs with witness) for up to 12 hours without defining a secure storage location (locked cabinet or other secure space). DOP confirmed that RNs “keep the medication in their possession until they can waste it with a witness,” and there was no policy on how or where to store the medication securely during this time. During an interview on 8/5/2025 at 10:30 a.m. with the Director of Quality and Accreditation (DQA), the DQA stated “There is no official root cause analysis (RCA, a structured was to find the underlying reason for a problem). The Drug Diversion Response (DDR) team responded and started the investigation on 7/28/2025. QAPI has not had any activity, as this occurred on 7/26/2025 (10 days prior to today).” The Director confirmed that QAPI relied on the DDP (Drug Diversion Prevention) team to complete the investigation and communicate back to QAPI. During an interview on 8/5/2025 at 3:42 p.m. with the Director of Critical Care (DICU), the DICU stated RN 1, the nurse who overdosed (a toxic amount of a drug, or combination of drugs overwhelms the body), had no prior issues. The DICU stated, “After the event, we planned to have a bag or case over the narcotics (a drug or other substance that affects mood or behavior), but it has not been implemented.” The DICU also stated the hospital used ControlCheck (a computer program that scores staff medication handling to detect possible drug diversion). RN 1’s score was 2.5, which was below the hospital’s investigation threshold of 5, thus “we did not look into it.” The DICU also stated the lock boxes on the units could be opened by any nurse, giving access to multiple narcotics, without a witness. During an interview on 8/6/2025 at 12:54 p.m. with the Director of Pharmacy (DOP), the DOP confirmed there was no secure location for staff to hold controlled substances awaiting waste and that nurses carried them until a witness was available. There was no policy or procedure to provide guidance on where the controlled substance should be stored while waiting to be wasted (discard with a witness) or administered. During an interview on 8/8/2025 at 6:26 p.m. with the Chief Medical Officer (CMO), the CMO stated they attend Governing Body (GB) board meetings and was a member of the board. CMO stated they had the responsibility for reporting all clinical matters and resolutions, as well as progress to GB. CMO stated they meet every month to discuss progress of any pending project. The CMO stated, “GB has the ultimate decision of all operations. They are responsible for all activities, facility wide.” During a review of the facility’s “Bylaws of the Community Board of (Name of the facility),” dated 4/25/2024, the Bylaws indicated, “Community Board Role and Responsibility: he Corporation, which owns and operates the Hospital, is controlled and managed by the Corporate Board. All powers and functions with respect to the management and governance of the Hospital are vested in the Corporate Board as set forth in the bylaws of the Corporation (the “Corporate Bylaws”) and the Nonprofit Code. Subject to its own oversight and ultimate authority as required by the Nonprofit Code, the Corporate Board has delegated (a) certain responsibilities and functions to the Community Board as set forth in the Corporate Bylaws and these bylaws of the Community Board (the “Community Board Bylaws” and (b) certain powers and functions to the Corporation’s president for the day- to-day management of the Hospital’s business ... to-day management of the Hospital’s business. The Corporation’s president and the Community ... Providing institutional planning to meet the health care needs of the community the Hospital serves.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment and Performance Improvement (QAPI) Program Plan,” dated 5/28/2025, the P&P indicated, “The Community Board (CB) = Governing Body (GB) is responsible and accountable for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The CB is responsible for evaluating QAPI through periodic review and establishment of clear expectations for quality of care and patient safety. The CB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The CB will delegate the development, implementation, and evaluation of QAPI to respective AHGL committees/teams ...” 1.b. During a review of Patient 1’s “Behavioral Health History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/16/2025, the H&P indicated, Patient 1 was readmitted to the facility’s Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis of acute (new onset) exacerbation (worsening) of chronic (long-term) schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a review of Patient 1’s physician order dated 7/15/2025, the physician order indicated Patient 1 was placed on suicidal (harming self, ending own’s life), elopement (leaving the facility without physician’s permission when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) and fall (an unexpected event where a patient unintentionally comes to rest on the floor or another lower level, such as a bed or chair) precaution. During a review of Patient 1’s legal conservatorship (a judge appoints a responsible person to care for another adult who cannot care for themselves or manage their own finances due to physical or mental limitations) document titled, “Petition for appointment of conservator of the person and estate (and temporary conservatorship of the person),” dated 7/3/2025, the legal conservatorship document indicated, Patient 1 was placed on temporary conservatorship since 6/23/2025. During a review of Patient 1’s letter from Department of Mental Health, dated 7/29/2025, the letter indicated, Patient 1 was scheduled for an in-person conservatorship court hearing in [a city] on 7/30/2025 at 8:30 a.m. During a concurrent observation and interview on 8/7/2025 at 9:40 a.m. with the Director (DIR 2) of BHU and Director (DIR 3) of Security, facility’s security video footage dated 7/30/2025, was reviewed. The following was observed through the security video footage with no audio (video footage showing the time when Patient 1 was picked up from the facility): -7:12:45 a.m.: Patient 1, CNA 1, and the ambulance driver were at the facility’s BHU (Unit 1) waiting area next to nursing station -7:13:55 a.m.: Patient 1, CNA 1 and the ambulance driver left the unit using Unit 1’s side door on foot -7:15:40 a.m.: Patient 1, CNA 1 and the ambulance driver got into the ambulance van -DIR 2 stated Patient 1, CNA 1 and the ambulance driver walked outside of the facility’s building to get to the ambulance van. During a concurrent observation and interview on 8/7/2025 at 9:56 a.m. with DIR 2 and DIR 3, DIR 3 walked 174 steps following the same route Patient 1, CNA and the ambulance driver took from BHU to the ambulance van on 7/30/2025. DIR 2 stated the route was not safe because it was outside of the facility. DIR 2 further stated Patient 1 was exposed to the outside environment and put Patient 1 at risk for elopement (leaving the facility without physician’s permission when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave). During a concurrent observation and interview on 8/6/2025 at 10:28 a.m. with DIR 2 and DIR 3, the facility’s security video footage dated 7/30/2025 was reviewed. The following was observed through the security video footage with no audio (video footage showing the time when Patient 1 was returned to the facility from conservatorship hearing): -10:32:58 a.m.: An ambulance van pulled up to main entrance -10:33:10 a.m.: ambulance driver stepped out from the vehicle and opened the sliding door -10:33:17 a.m.: Patient 1 stepped out from the vehicle ahead of CNA 1 from the vehicle, walked away from the main entrance toward east side of the facility. CNA 1 stepped out after Patient 1 and followed Patient 1 while ambulance driver stayed by the van -10:34:09 a.m.: the ambulance van left the facility -DIR 3 stated CNA 1 stepped out from the vehicle six (6) seconds after Patient 1 had gotten out from the vehicle. DIR 2 stated Patient 1 left the facility’s premises for about twenty (20) minutes then brought back by local police department. During an interview on 8/6/2025 at 11:17 a.m. with the BHU Registered Nurse (RN) 4, RN 4 stated the following: the BHU would send patients out for conservatorship court hearing. The unit would arrange transportation for the patient. Patients would be on one on one (1:1, a patient safety strategy where a designated staff member continuously observes a single patient, remaining in close proximity and able to intervene immediately if needed) monitoring during transportation until return to the unit. There was no elopement risk assessment tool to assess a patient’s elopement risk. RN 4 also stated there were no guidelines or protocols from the facility regarding transporting patients for court hearing. During an interview on 8/6/2025 at 11:54 a.m. with CNA 1, CNA 1 stated the following: she (CNA 1) accompanied Patient 1 to the court on 7/30/2025. Upon return to the facility, the ambulance driver opened the door, Patient 1 stepped out first then she (CNA 1) came after Patient 1. Patient 1 looked around and stated to CNA 1 that she (Patient 1) did not want to go back inside (the facility). Patient 1 started to walk away. CNA 1 used her (CNA 1’s) personal phone to notify the BHU and followed Patient 1. CNA 1 followed Patient 1 all the way across the street. Patient 1 walked in between traffic. CNA 1 had to block the traffic so Patient 1 could cross the street. Patient 1 continued to walk away and hide at the gas station. CNA 1 stated she (CNA 1) did not know where security was. She found out from the facility’s security guard later that they did not follow the patient once the patient had left the facility’s premises. During an interview on 8/6/2025 at 12:15 p.m. with CNA 1, CNA 1 stated the following: it was her (CNA 1’s) first time accompanying a patient to the court. CNA 1 did not remember if she (CNA 1) had received any training before going with Patient 1. CNA 1 further stated, “there are many risks (when patient was outside of the unit). We should get a class or have an orientation.” During an interview on 8/6/2025 at 12:24 p.m. with CNA 2, CNA 2 stated the following: she (CNA 2) had experience of accompanying BHU patients to the court but there was no training or guidelines given to her (CNA 2) regarding transporting patients to court. She (CNA 2) would stay close with the patients because she (CNA 2) liked to be responsible. During a concurrent interview and record review on 8/6/2025 at 3:10 p.m. with RN Educator (EDU 1) of BHU, Patient 1’s physician order dated 7/15/2025, was reviewed. The physician order indicated “Precaution for suicide, elopement and fall.” EDU 1 stated BHU patients on elopement precaution were to remain in the locked unit. EDU 1 further stated if the patient needed to go out of the unit, a staff member would escort the patient to make sure the patient did not elope or run away.” During an interview on 8/6/2025 at 3:15 p.m. with EDU 1, EDU 1 stated the following: the Basic Life Support (BLS) ambulance would drop off and pick up BHU patients next to the BHU nursing station with a gurney. He (EDU 1) never experienced BLS ambulance dropping off a BHU patient at the facility’s lobby. EDU 1 also stated it was unsafe to drop off BHU patients at the facility’s front lobby because there were many risks outside. EDU stated patients could run away, run into traffic and get hurt. During an interview on 8/7/2025 at 10 a.m. with DIR 3, DIR 3 stated Patient 1 walked about one (1) mile away from the facility when Patient 1 eloped on 7/30/2025. During an interview on 8/7/2025 at 10:49 a.m. with DIR 2, DIR 2 stated when the ambulance with Patient 1 returned to the facility, CNA 1 should have stepped out of the vehicle before Patient 1 to prevent Patient 1 from eloping. DIR 2 also stated all BHU patients were at risk for elopement. During a concurrent interview and record review on 8/7/2025 at 10:52 a.m. with DIR 2, the facility’s policy and procedure (P&P) titled, “Transportation,” dated 9/2023, was reviewed. The P&P indicated, “The purpose of this policy is to establish guidelines for transportation of patients to appointment outside [the facility].” DIR 2 stated the P&P did not indicate any staff responsibilities when accompanying patients outside the facility and did not indicate any procedure of how to send out the patient from the BHU unit to the vehicle and how to receive the patient upon ambulance arrival. During an interview on 8/8/2025 at 6 p.m. with the Program Manager of Performance Improvement, the Program Manager of Performance Improvement stated the GB (Governing Body) had oversight for all the policies and procedures. During a concurrent interview and record review on 8/8/2025 at 6:17 p.m. with the Senior Director of Risk Management (SDRM), the facility’s “Apparent Cause Analysis (ACA report),” dated 7/30/2025, was reviewed. The ACA report indicated there were corrective actions implemented in response to Patient 1’s elopement incident on 7/30/2025 including improving communication between transport team and facility upon return to the facility, re-educating on response to patient’s elopement, and offering web-based option for court hearing. The ACA report did not indicate any transport route or steps staff should follow when transporting patient. SDRM stated the following: the ACA meeting was held the same day after Patient 1 eloped from the facility. The ACA did not identify any issue with CNA 1 taking Patient 1 outside of the facility to walk to the ambulance van and CNA 1 letting Patient 1 step out of the vehicle before her (CNA 1). During an interview on 8/8/2025 at 6:26 p.m. with the Chief Medical Officer (CMO), CMO stated there was no patient eloping during transport before and the facility did not transport too often, recently there were more due to the added programs. CMO also stated the GB had the ultimate decision for all hospital operations. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment and Performance Improvement (QAPI) Program Plan,” dated 5/2025, the P&P indicated, “The Quality Assessment & Performance Improvement (QAPI) Program is a proactive, interdisciplinary, systematic approach to designing or redesigning patient-centered systems to improve quality of care and patient safety, in alignment with regulatory standards ... Structure and Accountability ... The Community Board (CB) = Governing Body (GB) is responsible and accountable for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating QAPI through periodic review and establishment of clear expectations for quality of care and patient safety ... [the facility] leadership is responsible for identifying priorities, supporting change management, and allocating resources for [facility] QAPI program. Leadership is responsible for improving quality of care, safety, and serv ices provided by [facility] staff through established structures and processes ... Patient Safety Program... Patient safety integrates with all quality assessment and performance improvement activities. Cause Analysis and Proactive Risk Assessments ... will be utilized to assess actual and potential risk, failure, points of vulnerability, and prioritized areas for improvement based on impact patient care outcomes.” During a review of the facility’s GB Bylaws titled, “Bylaws of the Community Board of [the facility],” dated 4/25/2024, the GB Bylaws indicated, “Community Board Role and Responsibility ... Subject to the oversight and ultimate authority of the Corporate Board, the Corporate Board delegates to the Community Board, and the Community Board shall be responsible to the Corporate Board for, the following responsibilities and functions ... Ensuring a safe environment within the Hospital for employees, medical staff, patients, and visitors.””

“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: 48212 Based on observation, interview and record review, the facility failed to ensure there was a safe transportation process for its Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders)patients on involuntary hold (involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) outside the facility when a BHU staff (Certified Nursing Assistant [CNA])1 escorted one of 30 sampled patients (Patient 1) using the route outside of the facility’s building to the transportation vehicle during pick up and allowing Patient 1 to step out of the transportation vehicle before her (CNA 1) upon returning to the facility from a conservatorship (a judge appoints a responsible person to care for another adult who cannot care for themselves or manage their own finances due to physical or mental limitations) court hearing. This deficient practice had resulted in Patient 1 eloping (leaving the facility without physician’s permission when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility by walking one (1) mile away from the facility and had the potential to result in Patient 1 running into traffic, and accidents leading to injury and death. This deficient practice also had the potential to place all future BHU patients who require going out of the facility for appointments, including the conservatorship court hearing, at risk of eloping and getting injured. On 8/7/2025 at 4:29 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Medical Officer (CMO), Patient Care Executive/Chief Nursing Officer (CNO), Director of Quality (DQ), Administrative Director of Cardiovascular, Peri-Operative, Imaging (AD 1), and the System Director for Accreditation and Licensing (SDAL) who attended via telephone. The facility failed to ensure there was a safe process when clinical staff escorted a Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) patient to conservatorship (a judge appoints a responsible person to care for another adult who cannot care for themselves or manage their own finances due to physical or mental limitations) court hearing outside the facility. A review of the facility’s security footage indicated the following: on 7/30/2025, a BHU patient (Patient 1), on involuntary hold (involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] evaluation and treatment), was escorted by a BHU staff (Certified Nursing Assistant [CNA] 1) and walked outside of the facility building to get to an ambulance van to go to a conservatorship court hearing. Upon returning to the facility, Patient 1 stepped out of the ambulance van ahead of CNA 1. This resulted in Patient 1 eloping (leaving the facility without physician’s permission when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) in the presence of CNA 1. During an interview on 8/7/2025 at 10 a.m. with the Director (DIR) 3 of Security, DIR 3 stated Patient 1 walked through the traffic and walked about one (1) mile away from the facility. During an interview on 8/7/2025 at 10:49 a.m. with the Director (DIR) 2 of BHU, DIR 2 stated CNA 1 should have stepped out of the vehicle before Patient 1 to prevent Patient 1 from eloping. DIR 2 also stated all BHU patients were at risk for elopement. This deficient practice placed Patient 1’s safety at risk of being exposed to traffic, accidents, injury and/or death. On 8/8/2025 at 8:40 p.m. the IJ was removed in the presence of the CMO, CNO, DQ, AD 1, Director (DIR 2) of Behavioral Health Unit, Nurse Manager (NM 2) of BHU, and the SDAL who attended via telephone, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that immediate action taken by the facility were as follows: starting 8/8/2025, BHU staff would complete an elopement risk quick screen on all BHU patients a minimum of every shift and prior to departure to court. Nursing staff would contact physicians for any high elopement risk patients to determine if the patients would be appropriate to go to court hearing in person. A new process for safe and secure BHU patients’ transportation outside facility was developed. A minimum of one BHU staff, two (2) staff for high elopement risk patients, would be assigned as escort for BHU patient transportation to and from a court hearing. When ambulance staff arrive at the facility, the BHU charge nurse would provide a copy of the contracted ambulance staff education material to the ambulance staff for review and have the ambulance staff to sign the “Safe and Secure Transport to Court Hearings” log acknowledging receipt. The BHU charge nurse or designee would contact security to accompany the escort(s) and patient to the facility’s East Tower main lobby. There would be a designated internal hospital route (exit and entry) to and from the transportation vehicle using only the facility’s East Tower main lobby exit. No other hospital exits were permitted. Escort(s) would always enter the transportation vehicle after the patient and would always exit the transportation vehicle prior to patient exit. Upon returning, BHU staff and security would be present at the transportation drop-off location in front of the East Tower main lobby to receive the patient then escort the patient back to BHU. Education on the new transportation process started on 8/8/2025 for all BHU staff and the security team members at the start of shift, and would continue until 100% of staff were trained. BHU director, nurse manager or designee would conduct direct observations and audits to ensure staff understanding and compliance with the newly developed transportation process. Findings: During a review of Patient 1’s “Behavioral Health History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/16/2025, the H&P indicated, Patient 1 was readmitted to the facility’s Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis of acute (new onset) exacerbation (worsening) of chronic (long-term) schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a review of Patient 1’s physician order dated 7/15/2025, the physician order indicated Patient 1 was placed on suicidal (harming self, ending own’s life), elopement (leaving the facility without physician’s permission when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) and fall (an unexpected event where a patient unintentionally comes to rest on the floor or another lower level, such as a bed or chair) precaution. During a review of Patient 1’s legal conservatorship (a judge appoints a responsible person to care for another adult who cannot care for themselves or manage their own finances due to physical or mental limitations) document titled, “Petition for appointment of conservator of the person and estate (and temporary conservatorship of the person),” dated 7/3/2025, the legal conservatorship document indicated, Patient 1 was placed on temporary conservatorship since 6/23/2025. During a review of Patient 1’s letter from the Department of Mental Health dated 7/29/2025, the letter indicated, Patient 1 was scheduled for an in-person conservatorship court hearing in [a city] on 7/30/2025 at 8:30 a.m. During a concurrent observation and interview on 8/7/2025 at 9:40 a.m. with the Director (DIR 2) of BHU and the Director (DIR 3) of Security, the facility’s security video footage dated 7/30/2025, was reviewed. The following was observed through the security video footage with no audio (when Patient 1 was picked up to attend a conservatorship hearing): -7:12:45 a.m.: Patient 1, CNA 1, and the ambulance driver were at the facility’s BHU (Unit 1) waiting area next to nursing station -7:13:55 a.m.: Patient 1, CNA 1 and the ambulance driver left the unit using Unit 1’s side door on foot -7:15:40 a.m.: Patient 1, CNA 1 and the ambulance driver got into the ambulance van During the same concurrent observation and interview on 8/7/2025 at 9:40 a.m. with the Director (DIR 2) of BHU and the Director (DIR 3) of Security, DIR 2 stated Patient 1, CNA 1 and the ambulance driver walked outside of the facility’s building to get to the ambulance van. During a concurrent observation and interview on 8/7/2025 at 9:56 a.m. with DIR 2 and DIR 3, DIR 3 walked 174 steps following the same route, taken by Patient 1, CNA and the ambulance driver, from BHU to the ambulance van on 7/30/2025. DIR 2 stated the route was not safe because it was outside the facility. DIR 2 further stated Patient 1 was exposed to the outside environment and put Patient 1 at risk for elopement (leaving the facility without physician’s permission when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave).During a concurrent observation and interview on 8/6/2025 at 10:28 a.m. with DIR 2 and DIR 3, the facility’s security video footage dated 7/30/2025 was reviewed. The following was observed through the security video footage with no audio (when Patient 1 returned from conservatorship hearing and was dropped off by the ambulance van): -10:32:58 a.m.: An ambulance van pulled up to main entrance -10:33:10 a.m.: ambulance driver stepped out from the vehicle and opened the sliding door -10:33:17 a.m.: Patient 1 stepped out from the vehicle ahead of CNA 1 from the vehicle, walked away from the main entrance toward east side of the facility. CNA 1 stepped out after Patient 1 and followed Patient 1 while ambulance driver stayed by the van -10:34:09 a.m.: the ambulance van left the facility During the same concurrent observation and interview on 8/6/2025 at 10:28 a.m. with DIR 2 and DIR 3, DIR 3 stated CNA 1 stepped out from the vehicle six (6) seconds after Patient 1 had gotten out from the vehicle. DIR 2 stated Patient 1 left the facility’s premises for about twenty (20) minutes then brought back to the facility by local police department. During an interview on 8/6/2025 at 11:17 a.m. with the BHU Registered Nurse (RN) 4, RN 4 stated the following: the BHU would send patients out for conservatorship court hearing. The unit would arrange transportation for the patient. Patients would be on one on one (1:1, a patient safety strategy where a designated staff member continuously observes a single patient, remaining in close proximity and able to intervene immediately if needed) monitoring during transportation until their return to the unit. There was no elopement risk assessment tool to assess a patient’s elopement risk. RN 4 also stated there were no guidelines or protocols from the facility regarding transporting patients for court hearing. During an interview on 8/6/2025 at 11:54 a.m. with CNA 1, CNA 1 stated the following: she (CNA 1) accompanied Patient 1 to the court on 7/30/2025. Upon return to the facility, the ambulance driver opened the door, Patient 1 stepped out first then she (CNA 1) came after Patient 1. Patient 1 looked around and stated to CNA 1 that she (Patient 1) did not want to go back inside (the facility). Patient 1 started to walk away. CNA 1 used her (CNA 1’s) personal phone to notify the BHU and followed Patient 1. CNA 1 followed Patient 1 all the way across the street. Patient 1 walked in between traffic. CNA 1 had to block the traffic so Patient 1 could cross the street. Patient 1 continued to walk away and hide at the gas station. CNA 1 stated she (CNA 1) did not know where security was. She found out from the facility’s security guard later that they did not follow the patient once the patient had left the facility’s premises. During an interview on 8/6/2025 at 12:15 p.m. with CNA 1, CNA 1 stated the following: it was her (CNA 1’s) first time accompanying a patient to the court. CNA 1 did not remember if she (CNA 1) had received any training before going with Patient 1. CNA 1 further stated, “there are many risks (when patient was outside of the unit). We should get a class or have an orientation.” During an interview on 8/6/2025 at 12:24 p.m. with CNA 2, CNA 2 stated the following: she (CNA 2) had experience of accompanying BHU patients to the court but there was no training or guidelines given to her (CNA 2) regarding transporting patients to court. She (CNA 2) would stay close with the patients because she (CNA 2) liked to be responsible. During a concurrent interview and record review on 8/6/2025 at 3:10 p.m. with RN Educator (EDU 1) of BHU, Patient 1’s physician order dated 7/15/2025, was reviewed. The physician order indicated “Precaution for suicide, elopement and fall.” EDU 1 stated BHU patients on elopement precaution were to remain in the locked unit. EDU 1 further stated if the patient needed to go out of the unit, a staff member would escort the patient to make sure the patient did not elope or run away.” During an interview on 8/6/2025 at 3:15 p.m. with EDU 1, EDU 1 stated the following: the Basic Life Support (BLS) ambulance would drop off and pick up BHU patients next to the BHU nursing station with a gurney. He (EDU 1) never experienced BLS ambulance dropping off a BHU patient at the facility’s lobby. EDU 1 also stated it was unsafe to drop off BHU patients at the facility’s front lobby because there were many risks outside. EDU stated patients could run away, run into traffic and get hurt. During an interview on 8/7/2025 at 10 a.m. with DIR 3, DIR 3 stated Patient 1 walked about one (1) mile away from the facility when Patient 1 eloped on 7/30/2025. During an interview on 8/7/2025 at 10:49 a.m. with DIR 2, DIR 2 stated when the ambulance with Patient 1 returned to the facility on 7/30/2025, CNA 1 should have stepped out of the vehicle before Patient 1 to prevent Patient 1 from eloping. DIR 2 also stated all BHU patients were at risk for elopement. During a concurrent interview and record review on 8/7/2025 at 10:52 a.m. with DIR 2, the facility’s policy and procedure (P&P) titled, “Transportation,” dated 9/2023, was reviewed. The P&P indicated, “The purpose of this policy is to establish guidelines for transportation of patients to appointment outside [the facility].” DIR 2 stated the P&P did not indicate any staff responsibilities when accompanying patients outside the facility and did not indicate any procedure of how to send out the patient from the BHU unit to the vehicle and how to receive the patient upon ambulance arrival.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI, the hospital’s program that identifies problems, investigates causes, and make improvements to ensure protection of patients and provide safe care) program was working as required. The facility’s QAPI program did not investigate or respond to problems in how controlled substance (drugs such as morphine [a strong pain medication] and fentanyl, a very strong pain medicine regulated by law because they can be abused) were stored, wasted (discard with a witness), or monitored. Instead, QAPI left the investigation to the Drug Diversion Prevention (DDP) team and expected to hear the result from the DDP team. Because QAPI did not act, unsafe practices continued: -Nurses were allowed to keep unused narcotics (very strong pain medicines such as morphine and fentanyl) for up to 12 hours without a secure place to store them. -lock boxes used to store controlled substances on all units were easily accessible for multiple controlled substances without a witness. - ControlCheck (formally known as Brightsight, the facility’s monitoring system) flagged unsafe handling by Registered Nurse (RN 1), but QAPI did not review or act on the data. -RN 1 was later found unresponsive in the ICU locker room with narcotics and a syringe, while two patients (Patient 11 and Patient 12) were under RN 1’s care. These deficient practices had the potential to jeopardize Patient 11 and Patient 12’s safety due to care provided by Registered Nurse (RN 1) who was under the influence (impairment, to any degree, of an individual’s ability to safely perform work because of drug use), and unaccounted controlled substances, and also placed other patients at risk for harm. Findings: During an interview on 8/5/2025 at 10:30 a.m. with the Director of Quality and Accreditation (DQA), the DQA, stated “There is no official root cause analysis (RCA, a structured was to find the underlying reason for a problem). The Drug Diversion Response team responded and started the investigation on 7/28/2025. QAPI has not had any activity, as this occurred on 7/26/2025 (10 days prior to today). The Director confirmed that QAPI relied on the DDP (Drug Diversion Prevention) team to complete the investigation and communicate back to QAPI. During an interview on 8/5/2025 at 3:42 p.m. with the Director of Critical Care (DICU), DICU stated RN 1, the nurse who overdosed (a toxic amount of a drug, or combination of drugs overwhelms the body), had no prior issues. The DICU stated, “After the event, we planned to have a bag or case over the narcotics (a drug or other substance that affects mood or behavior), but it has not been implemented.” The DICU also stated the hospital used Controlcheck (a computer program that scores staff medication handling to detect possible drug diversion). RN 1’s IRIS score (a tool used by Bluesight’s Control Check to monitor and detect potential drug diversion by healthcare staff) was 2.5, which was below the hospital’s investigation threshold of 5, thus “we did not look into it.” The DICU also stated the lock boxes on the units could be opened by any nurse, giving access to multiple narcotics, without a witness. During a concurrent interview and record review on 8/7/2025 at 12:40 p.m. with the Manager of Pharmacy (MP), RN 1’s ControlCheck audit report, was reviewed. MP stated the report was run after the incident on 7/26/2025 for the last 30 days (6/27/2025 -7/27/2025). MP stated they did not look into why RN 1’s score was 2.5 because this score was below 5, which was the threshold that the facility would start an investigation. The report indicated the score of 2.5 meant the following: - “(Name of RN 1) has a highly unusual number of variances (discrepancies or differences between expected and actual quantities of controlled substances, such as medications, during handling and dispensing), including 4 variances with a status of Closed Reconcile (MP stated the Nurse Manager closed this variance that was flagged by the system).” 2 Variances in Reconcile - Missing either administration, waste, or return, and 2 variances in reconciled - Missing administration.” -“(Name of RN 1) logged 5 actions with the time between events exceeding the threshold (60 minutes): 1 action with first dispense (when RN removed the controlled substance) and first administration (when RN 1 gave the medication) for a patient greater than 60 minutes (hospital threshold). 4 actions with first and last touch for a patient greater than 41 minutes (Nursing Average).” During an interview on 8/6/2025 at 12:54 p.m. with the Director of Pharmacy (DOP), the DOP stated that audit of RN 1’s handling of controlled substances was only reviewed after the overdose. The Director stated that nurses were allowed to hold onto narcotics that needed to be wasted (discard) with a witness for up to 12 hours, and there was no secure place to store them during that time. The Director confirmed QAPI did not address this policy gap. During an interview on 8/6/2025 at 2:45 p.m. with the Chief Medical Officer (CMO), the CMO confirmed that RN 1 was in possession of narcotic (a drug or other substance that affects mood or behavior) medication (morphine vial, a small glass container holding a strong pain medicine), a used syringe (a device for injecting fluids), an uncapped needle (needle without its safety cover), and a tourniquet (a tight band used to slow blood flow, often applied before injecting). The CMO also confirmed that toxicology testing (laboratory test of blood or urine for drugs or poisons) done in the Emergency Department (ED, hospital unit for urgent care) was positive for fentanyl (a very strong opioid pain medication) and opioids (a group of drugs that includes morphine and fentanyl). During an interview with Intensive Care Unit (ICU, area in hospital that care for the critically ill patients) Nurse Manager (NM)1, NM1 stated NM1 did not look into the 2.5 IRIS score in the ControlCheck system for RN 1, and did not know the details of the 2.5 IRIS score as it was below 5. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment and Performance Improvement (QAPI) Program Plan,” dated 5/28/2025, the P&P indicated, “Process improvement indicators will focus on improvement of health outcomes and prevention/reduction of medical errors and will include: Measurement and tracking of medical errors/adverse patient events with analysis of causes ...Data will be intensively assessed when the organization detects or suspects a significant undesirable performance outcome or variation. Intensive analysis is conducted, as follows: Levels of performance, patterns, or trends vary significantly and undesirably from expected, or as compared to peers/recognized standards ... At minimum, the organization will collect data in the following areas ...Adverse Events, including (not limited to): Significant medication errors; adverse drug reactions; medical errors...” During a review of the facility provided user manual titled, “ControlCheck: Learner’s Guide,” dated 2023, the guide indicated, “IRIS (a tool used by Bluesight’s Control Check to monitor and detect potential drug diversion by healthcare staff) The next section on the card is “IRIS.” This will allow you to see your user’s IRIS score or “Individual Risk Identification Score” This score uses our metrics to calculate a score of how anomalous this user is compared to their peers. Each of these variances should be thoroughly reviewed before closing ...””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility’s Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure oversight on the Quality Assurance and Performance Improvement (QAPI, the hospital’s program that identifies problems, investigates causes, and make improvements to ensure protect patients and provide safe care) committee to ensure there was a thorough analysis of the causes of a patient safety event and identify and implement an effective action plan, when one of 30 sampled patients (Patient 1), from Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) eloped (leaving the facility without physician’s permission when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility on 7/30/2025. This deficient practice resulted in the facility not having a safe transportation process in place to prevent future occurrence of elopement. Findings: During a review of Patient 1’s “Behavioral Health History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/16/2025, the H&P indicated, Patient 1 was readmitted to the facility’s Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis of acute (new onset) exacerbation (worsening) of chronic (long-term) schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a review of Patient 1’s physician order, dated 7/15/2025, the physician order indicated Patient 1 was placed on suicidal (harming self, ending own’s life), elopement (leaving the facility without physician’s permission when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) and fall (an unexpected event where a patient unintentionally comes to rest on the floor or another lower level, such as a bed or chair) precaution. During a review of Patient 1’s legal conservatorship (a judge appoints a responsible person to care for another adult who cannot care for themselves or manage their own finances due to physical or mental limitations) document titled, “Petition for appointment of conservator of the person and estate (and temporary conservatorship of the person),” dated 7/3/2025, the legal conservatorship document indicated, Patient 1 was placed on temporary conservatorship since 6/23/2025. During a review of Patient 1’s letter from Department of Mental Health, dated 7/29/2025, the letter indicated, Patient 1 was scheduled for an in-person conservatorship court hearing in [a city] on 7/30/2025 at 8:30 a.m. During a concurrent observation and interview on 8/7/2025 at 9:40 a.m. with the Director (DIR 2) of BHU and Director (DIR 3) of Security, the facility’s security video footage dated 7/30/2025, was reviewed. The following was observed through the security video footage with no audio (video footage that showed when Patient 1 was picked up by the ambulance): -7:12:45 a.m.: Patient 1, CNA 1, and the ambulance driver were at the facility’s BHU (Unit 1) waiting area next to nursing station -7:13:55 a.m.: Patient 1, CNA 1 and the ambulance driver left the unit using Unit 1’s side door on foot -7:15:40 a.m.: Patient 1, CNA 1 and the ambulance driver got into the ambulance van -DIR 2 stated Patient 1, CNA 1 and the ambulance driver walked outside of the facility’s building to get to the ambulance van. During a concurrent observation and interview on 8/7/2025 at 9:56 a.m. with DIR 2 and DIR 3, DIR 3 walked 174 steps following the same route Patient 1, CNA 1 and the ambulance driver took from BHU to the ambulance van on 7/30/2025. DIR 2 stated the route was not safe because it was outside of the facility. DIR 2 further stated Patient 1 was exposed to the outside environment and put Patient 1 at risk for elopement (leaving the facility without physician’s permission when doing so may present an imminent threat to the person’s health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave). During a concurrent observation and interview on 8/6/2025 at 10:28 a.m. with DIR 2 and DIR 3, the facility’s security video footage, dated 7/30/2025, was reviewed. The following was observed through the security video footage with no audio (Video footage that showed when Patient 1 was dropped off at the facility after a conservatorship hearing): -10:32:58 a.m.: An ambulance van pulled up to the main entrance -10:33:10 a.m.: ambulance driver stepped out from the vehicle and opened the sliding door -10:33:17 a.m.: Patient 1 stepped out from the vehicle ahead of CNA 1 from the vehicle, walked away from the main entrance toward east side of the facility. CNA 1 stepped out after Patient 1 and followed Patient 1 while ambulance driver stayed by the van -10:34:09 a.m.: the ambulance van left the facility -DIR 3 stated CNA 1 stepped out from the vehicle six (6) seconds after Patient 1 had gotten out from the vehicle. DIR 2 stated Patient 1 left the facility’s premises for about twenty (20) minutes then Patient 1 was brought back by local police department. During an interview on 8/6/2025 at 11:17 a.m. with the BHU Registered Nurse (RN) 4, RN 4 stated the following: the BHU would send patients out for conservatorship court hearing. The unit would arrange transportation for the patient. Patients would be on one on one (1:1, a patient safety strategy where a designated staff member continuously observes a single patient, remaining in close proximity and able to intervene immediately if needed) monitoring during transportation until return to the unit. There was no elopement risk assessment tool to assess a patient’s elopement risk. RN 4 also stated there were no guidelines or protocols from the facility regarding transporting patients for court hearing. During an interview on 8/6/2025 at 11:54 a.m. with CNA 1, CNA 1 stated the following: she (CNA 1) accompanied Patient 1 to the court on 7/30/2025. Upon return to the facility, the ambulance driver opened the door, Patient 1 stepped out first then she (CNA 1) came after Patient 1. Patient 1 looked around and stated to CNA 1 that she (Patient 1) did not want to go back inside (the facility). Patient 1 started to walk away. CNA 1 used her (CNA 1’s) personal phone to notify the BHU and followed Patient 1. CNA 1 followed Patient 1 all the way across the street. Patient 1 walked in between traffic. CNA 1 had to block the traffic so Patient 1 could cross the street. Patient 1 continued to walk away and hide at the gas station. CNA 1 stated she (CNA 1) did not know where security was. She found out from the facility’s security guard later that they did not follow the patient once the patient had left the facility’s premises. During an interview on 8/6/2025 at 12:15 p.m. with CNA 1, CNA 1 stated the following: it was her (CNA 1’s) first time accompanying a patient to the court. CNA 1 did not remember if she (CNA 1) had received any training before going with Patient 1. CNA 1 further stated, “there are many risks (when patient was outside of the unit). We should get a class or have an orientation.” During an interview on 8/6/2025 at 12:24 p.m. with CNA 2, CNA 2 stated the following: she (CNA 2) had experience of accompanying BHU patients to the court but there was no training or guidelines given to her (CNA 2) regarding transporting patients to court. She (CNA 2) would stay close with the patients because she (CNA 2) liked to be responsible. During a concurrent interview and record review on 8/6/2025 at 3:10 p.m. with RN Educator (EDU 1) of BHU, Patient 1’s physician order, dated 7/15/2025, was reviewed. The physician order indicated “Precaution for suicide, elopement and fall.” EDU 1 stated BHU patients on elopement precaution were to remain in the locked unit. EDU further stated if the patient needed to go out of the unit, a staff member would escort the patient to make sure the patient did not elope or run away.” During an interview on 8/6/2025 at 3:15 p.m. with EDU 1, EDU 1 stated the following: the Basic Life Support (BLS) ambulance would drop off and pick up BHU patients next to the BHU nursing station with a gurney. He (EDU 1) never experienced BLS ambulance dropping off a BHU patient at the facility’s lobby. EDU 1 also stated it was unsafe to drop off BHU patients at the facility’s front lobby because there were many risks outside. EDU stated patients could run away, run into traffic and get hurt. During an interview on 8/7/2025 at 10 a.m. with DIR 3, DIR 3 stated Patient 1 walked about one (1) mile away from the facility when Patient 1 eloped on 7/30/2025. During an interview on 8/7/2025 at 10:49 a.m. with DIR 2, DIR 2 stated when the ambulance with Patient 1 returned to the facility, CNA 1 should have stepped out of the vehicle before Patient 1 to prevent Patient 1 from eloping. DIR 2 also stated all BHU patients were at risk for elopement. During a concurrent interview and record review on 8/7/2025 at 10:52 a.m. with DIR 2, the facility’s policy and procedure (P&P) titled, “Transportation,” dated 9/2023, was reviewed. The P&P indicated, “The purpose of this policy is to establish guidelines for transportation of patients to appointment outside [the facility].” DIR 2 stated the P&P did not indicate any staff responsibilities when accompanying patients outside the facility and did not indicate any procedure of how to send out the patient from the BHU unit to the vehicle and how to receive the patient upon ambulance arrival. During a concurrent interview and record review on 8/8/2025 at 6:17 p.m. with the Senior Director of Risk Management (SDRM), the facility’s “Apparent Cause Analysis (ACA report),” dated 7/30/2025, was reviewed. The ACA report indicated there were corrective actions implemented in response to Patient 1’s elopement incident on 7/30/2025 including improving communication between transport team and facility upon return to the facility, re-educating on response to patient’s elopement, and offering web-based option for court hearing. The ACA report did not indicate any transport route or steps staff should follow when transporting patient. SDRM stated the following: the ACA meeting was held the same day after Patient 1 eloped from the facility. The ACA did not identify any issue with CNA 1 taking Patient 1 outside of the facility to walk to the ambulance van and CNA 1 letting Patient 1 step out of the vehicle before her (CNA 1). During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment and Performance Improvement (QAPI) Program Plan,” dated 5/2025, the P&P indicated, “The Quality Assessment & Performance Improvement (QAPI) Program is a proactive, interdisciplinary, systematic approach to designing or redesigning patient-centered systems to improve quality of care and patient safety, in alignment with regulatory standards ... Structure and Accountability ... [the facility] leadership is responsible for identifying priorities, supporting change management, and allocating resources for [facility] QAPI program. Leadership is responsible for improving quality of care, safety, and serv ices provided by [facility] staff through established structures and processes ... Patient Safety Program... Patient safety integrates with all quality assessment and performance improvement activities. Cause Analysis and Proactive Risk Assessments ... will be utilized to assess actual and potential risk, failure, points of vulnerability, and prioritized areas for improvement based on impact patient care outcomes.””

“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: 48212 Based on interview and record review, the facility failed to ensure its nursing staff performed reassessment and checked vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) for two of 30 sampled patients (Patient 1 and Patient 5), in accordance with the facility’s policy regarding “Medication Use to Manage a Psychiatric Emergency,” after receiving one-time emergency medication (EM, administering antipsychotic [class of drugs primarily used to manage psychosis, a mental state characterized by a disconnection from reality] medications or intramuscular medications to a patient without the patients’ consent to maintain safety for the patient and other people on the unit) intramuscular (IM, into the muscles) injections when: 1. Nursing staff did not reassess and take vital signs for Patient 1 after giving Benadryl (antihistamine [medication that treat allergy symptoms] that can have a calming or sedative [a substance that calms and promotes sleep] effect) 50 milligrams (mg, a unit of measurement), Haldol (medication to treat schizophrenia [mental illness affecting how someone behaves, feels, and thinks] and acute [new onset] agitation [being upset, annoyed, angry and physically disturbed]) 5 mg, and Valium (medication used to treat anxiety [a feeling of unease, worry, or fear] and produce drowsiness (a feeling of sleepiness) and has sedation [a state of calmness or drowsiness induced by drugs] effect)10 mg on 7/30/2025 at 11:25 a.m. 2. Nursing staff did not take vital signs for Patient 5 after giving Valium 5 mg on 6/11/2025 at 7:44 p.m., and injections of Haldol 10 mg, Benadryl 50 mg and Valium 5mg IM on 6/11/2025 at 8:31 p.m. These deficient practices had the potential to result in Patient 1 and Patient 5 not getting proper evaluation of the effect of the medications and put Patient 1 and Patient 5 at risk for respiratory distress (a condition that occurs when the body needs more oxygen, and can be caused by a number of factors, including infections, chronic illness, or a blocked airway) and oversedation (too much sleepiness and/or drowsiness). Findings: 1. During an interview on 8/6/2025 at 3:57 p.m. with the Registered Nurse (RN) Educator (EDU 1) of Behavioral Health Unit (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders), EDU 1 stated the following: a one-time injection of emergency medication (EM, administering antipsychotic [class of drugs primarily used to manage psychosis, a mental state characterized by a disconnection from reality] medications or intramuscular medications to a patient without his consent to maintain safety for the patient and other people on the unit) intramuscular (IM, into the muscles) injections would be given per physician order when a BHU patient presented behavior that was an immediate danger to self or others. EDU 1 said there should be reassessment including checking vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) and behavior assessments performed by the RN after the injections were given. During a review of Patient 1’s “Behavioral Health History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/16/2025, the H&P indicated, Patient 1 was readmitted to the facility’s BHU with diagnosis of acute (new onset) exacerbation (worsening) of chronic (long-term) schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a review of Patient 1’s “Clinical Note Nursing (nurse notes),” dated 7/30/2025, the nurse notes indicated, at 11:30 a.m., “Patient (Patient 1) is agitated (being upset, annoyed, angry, and physically disturbed), tearful and angry for being in the hospital. Question her (Patient 1) admission and does not follow directions. [MD] was notified and emergency IM medication ordered ...” During a concurrent interview and record review on 8/6/2025 at 4 p.m. with EDU 1, Patient 1’s Medication Administration Record (MAR, record of medications given to patients), was reviewed. The MAR indicated Patient 1 received the following medications via intramuscular (IM) on 7/30/2025 at 11:25 a.m.: Benadryl (antihistamine [medication that treat allergy symptoms] that can have a calming or sedative effect) 50 milligrams (mg, a unit of measurement), Haldol (medication to treat schizophrenia [mental illness affecting how someone behaves, feels, and thinks] and acute [new onset] agitation [being upset, annoyed, angry and physically disturbed]) 5 mg, and Valium (medication used to treat anxiety [a feeling of unease, worry, or fear] and produce drowsiness (a feeling of sleepiness) and has sedation [a state of calmness or drowsiness induced by drugs] effect) 10 mg. EDU stated a RN should perform reassessment after the injections. During an interview on 8/6/2025 at 4:09 p.m. with EDU 1, EDU 1 stated there were no vital signs or reassessment completed for Patient 1 after receiving the emergency medications on 7/30/2025. During an interview on 8/7/2025 at 12:41 p.m. with the Nurse Manager (NM 2) of BHU, NM 2 stated RN should take vital signs and re-assess patient’s behavior, mental status and response to the medications within an hour after emergency medication administration, to make sure there was no adverse effects (unintended, harmful, or unpleasant outcomes that occur during or after treatment with a drug, therapy, or other intervention) from the medications including respiratory distress (a condition that occurs when the body needs more oxygen, and can be caused by a number of factors, including infections, chronic illness, or a blocked airway) and oversedation (too much sleepiness and/or drowsiness). During an interview on 8/8/2025 at 3:44 p.m. with the Director (DIR 2) of BHU, DIR 2 stated Valium had sedation side effects. DIR 2 further stated Registered Nurses needed to observe and perform reassessment after giving emergency medication injections to the patients to check for patient’s response to medications and possible side effects. During a review of the facility’s policy and procedure (P&P) titled, “Medication Use to Manage a Psychiatric Emergency,” dated 12/2022, the P&P indicated, “Documentation of Psychiatric Emergency Medication Use ... In admission to the e-MAR documentation, a Nursing Note is to be included in the patient record that describes: i. Reason for the emergency administration ii. Patient understanding of the intervention and patient behaviors during the actual administration iii. Route of administration iv. Observed patient response to the emergency medication.” 2. During a review of Patient 5’s “Psychiatric History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 6/7/2025, the H&P indicated, Patient 5 was admitted to the facility’s Behavioral Health Unit with diagnoses of schizoaffective (a mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]) disorder bipolar (a mental illness that causes unusual shifts in mood, energy, and concentration) type and autistic spectrum disorder (ASD, a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave). During a review of Patient 5’s “Clinical Note Nursing,” dated 6/11/2025, the nurse notes indicated, “At 7:45 p.m. a code gray (an emergency code that signifies a situation involving a combative or aggressive patient) was called due to patient hitting head on the wall, attempting to hit staff, severe agitation, and being non-redirectable. MD notified and ordered Valium 5 (mg) IM STAT (at once). Medication administered...” The nurse notes also indicated, “at 8:33 p.m. a code gray was called due to patient (Patient 5) starting to hit head on the wall again in addition to swinging arms and legs towards staff. Patient (Patient 5) was highly agitated and combative. MD notified and ordered Haldol 10 mg, Valium 5 mg and Benadryl 50 mg IM STAT. Medication administered ...” During a review of Patient 5’s Medication Administration Record (MAR), dated 6/11/2025, the MAR indicated Patient 5 received an injection of Valium 5 mg at 7:44 p.m., and injections of Haldol 10 mg, Benadryl 50 mg and Valium 5mg IM at 8:31 p.m. During an interview on 8/6/2025 at 3:57 p.m. with the Registered Nurse (RN) Educator (EDU 1) of BHU, EDU 1 stated the following: a one-time injection of emergency medication would be given per physician order when a BHU patient presented behavior that was an immediate danger to self or others. There should be reassessment including checking vital signs and behavior assessments, performed by the RN after the injections were given. During an interview on 8/7/2025 at 12:41 p.m. with the Nurse Manager (NM 2) of BHU, NM 2 stated the RN should take vital signs and re-assess patient’s behavior, mental status and response to the medications within an hour after emergency medication administration, to make sure there was no adverse effects from the medications including respiratory distress and oversedation. During a concurrent interview and record review on 8/8/2025 at 3:35 p.m. with Nurse Manager (NM 2) of BHU, Patient 5’s vital signs record titled, “Vital Signs,” dated 6/11/2025, was reviewed. The vital signs record indicated there was only one set of vital signs taken on 6/11/2025 at 7:31 p.m. The vital signs record indicated there were no other vital signs taken on 6/11/2025. NM 2 stated there were no vital signs checked after Patient 5 received emergency medication injections at 7:44 p.m. and at 8:31 p.m. NM 2 stated the reassessment was incomplete. During an interview on 8/8/2025 at 3:44 p.m. with the Director (DIR 2) of BHU, DIR 2 stated Valium had sedation side effects. DIR 2 further stated Registered Nurses needed to observe and perform reassessment after giving emergency medication injections to the patients to check for patient’s response to medications and possible side effects. During a review of the facility’s policy and procedure (P&P) titled, “Medication Use to Manage a Psychiatric Emergency,” dated 12/2022, the P&P indicated, “Documentation of Psychiatric Emergency Medication Use ... In admission to the e-MAR documentation, a Nursing Note is to be included in the patient record that describes: i. Reason for the emergency administration ii. Patient understanding of the intervention and patient behaviors during the actual administration iii. Route of administration iv. Observed patient response to the emergency medication.””

“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: 28851 Based on interview and record review, the facility failed to ensure nurses followed the hospital policy on medication administration documentation, for one (1) of 31 sampled patients (Patient 27), when there was a delay in wasting or returning a bag of Fentanyl which was removed from the Pyxis (an automated medication dispensing system) on 7/09/2025. This deficient practice had the potential for inaccurate medication administration, medication errors, and/or issues with unaccounted controlled substances (a drug or chemical that is regulated by the government due to potential for abuse or addiction, for example opioids and narcotics). Findings: During an interview on 8/7/2025 at 12:50 p.m. with the director of Intensive Care Unit (DICU), the DICU stated medication administration was expected to happen soon after medication removal from the Pyxis (an automated dispensing system that included a secure computerized cabinet that stores and dispenses medication at nursing unit and integrate with the hospital’s electronic medical record system) or dispensed by Pharmacy. During a review of the Pyxis activity report, the pharmacy manager (MP) confirmed there was a premixed bag of fentanyl (narcotic, controlled substances, and a potent opioid to treat pain and used in anesthesia) 1000 micrograms (mcg, unit to measure mass) per 100 milliliter (ml, unit to measure volume) in 100 ml bag was removed on 7/9/2025 at 8:08 a.m. for Patient 27 and returned at 10:58 a.m., two hours and 50 minutes later, on the same date. During a concurrent interview on 8/8/2025 at 4:22 p.m. with the director of pharmacy (DOP), the DOP stated there were 2 hours and 50 mins of unknown activity and/or storage of the fentanyl, which had the potential for diversion, theft, and pilferage. DOP stated nurses should return or waste medication as soon as possible. During an interview on 8/8/2025 at 5:45 p.m., DICU stated, on 7/9/2025 between 9 a.m. to 11 a.m., there was no emergency event documented that might cause a delay in the medication return process, and no documented reason for the delay. During a review of the facility’s policy and procedure (P&P) titled, Medication Administration (revised 12/6/2024), the policy indicated “ ... Documentation ... If medication was not given, document a reason and state ... document reason ...””

“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: 46333 Based on observation, interview, and record review, the facility failed to: 1. Ensure that nurses measured and documented the amount of controlled substances (medication like morphine or fentanyl that are regulated by law due to their high risk for abuse or addiction) remaining in patient -controlled analgesia (PCA, a pain -management method that allows patients to self-administer small doses of pain medicine through a pump) tubing when discontinuing PCA therapy affecting approximately two (orthopedic patients per month) of 31 sampled patients, who are placed on PCA therapy (Director of Medical Surgical confirmed this information on 8/8/2025 at 12:45 p.m.). This deficient practice placed approximately two orthopedic patients per month at risk for inaccurate medication documentation and unaccounted controlled substances. In addition, this failure resulted in unaccounted narcotics (a drug or other substance that affects mood or behavior and is consumed for nonmedical purposes) being discarded into unsecured bins without measurement or witness verification. This created a risk for diversion (when drugs are used for purposes other than a patient’s prescribed treatment) by staff, which could result in impaired staff providing unsafe care, thereby placing all patients on the orthopedics unit at risk. 2. Ensure that a patient had pain medication orders that addressed the full range of pain on a numeric pain scale utilized by the facility to address patients’ pain (0: No pain,1-3: Mild pain, 4-6: Moderate pain,7-10: Severe pain, and 10: The worst pain imaginable), in accordance with the facility’s policy regarding pain management. For one (1) of 31 sampled patients (Patient 17), the medical record showed that the patient had no medication ordered for mild to moderate pain (1-6). This deficient practice placed Patient 17 at risk for experiencing unnecessary suffering from untreated mild to moderate pain (levels 1-6), which had the potential to cause prolonged discomfort, increased stress on the body, and delay recovery. Findings: 1. During an interview on 8/8/2025 with RN 15 and the Director of Medical Surgical (DIR) 1, RN 15 demonstrated PCA (patient -controlled analgesia, a pain -management method that allows patients to self-administer small doses of pain medicine through a pump) discontinuation in the medication room. RN 15 showed how the morphine syringe removed from the PCA would be discarded into the blue bins (non-hazardous medication waste and sharps container). The tubing attached to the syringe, which contained residual medication, was also discarded into the blue bin without measurement of the liquid inside. RN 15 stated, “The liquid in the tubing goes into the blue bin, we don’t measure it.” The DIR 1 confirmed the blue bin had an open lid and can be accessed by anyone having access to the medication room, which included RNs, computer technician, maintenance service, and EVS (environmental services, responsible for maintaining the cleanliness, hygiene, and safety of the hospital premises). During an interview with RN 19 and DIR 1 on 8/8/2025 at 12:19 p.m., RN 19 explained the PCA discontinuation process: obtaining a witness nurse, removing the syringe fluid into a white container, documenting the waste in the MAR (Medication Administration Record), and discarding the syringe with tubing attached into the sharp’s container. However, RN 19 did not mention measuring the amount of medication remaining in the tubing. The Director confirmed that tubing containing controlled substances was also discarded into the blue bin without measurement of the remaining amount so it can be accounted for. During an interview with RN 20 and DIR 1 on 8/8/2025 at 12:37 p.m., RN 20 stated that PCA syringes were emptied into white bins containing solutions designed to cause break down of the controlled substance (disintegration). Tubing was discarded into the blue bin without measuring the residual fluid inside the tubing. DIR 1 confirmed that approximately one to two patients on the orthopedics unit may be placed on PCA therapy in a given month. During an interview with the Clinical Nurse educator (CNE) on 8/8/2025 at 12:55 p.m., the CNE confirmed that during staff training, nurses were taught that both the syringe and the tubing from PCA pumps must be measured for residual controlled substances. The CNE stated, “It is important to account for the medication in the tubing, because it contains controlled substances, and throwing it (tubing with controlled substance residual) away without measurement creates a diversion risk since the bins were accessible. CNE stated the facility did not have written educational material or protocol on measurement of PCA syringe and tubing residual; however, the education department will add this to the training materials. During a concurrent interview and record review on 8/7/2025 at 12:32 p.m. with the Pharmacy Manager (MP), the facility’s policy and procedure (P&P) titled, “Controlled Substance Waste Disposal,” dated 5/28/2025, was reviewed. The P&P indicated, the policy affected departments/services which included Pharmcy Services, Nursing Services, Anesthesia Services, and Environmental Services (EVS), “Unused controlled medications are wasted in a designated controlled substance waste container in accordance with established procedure and documentation requirements.” MP confirmed that the facility did not have a policy and procedure on wasting controlled substances from the PCA with syringe and tubing attached; however, MP stated all of the remaining unused controlled substances should be accounted for and documented during the wasting process. 2. During a review of Patient 17’s History and Physical (H&P, the initial document describing a patient’s medical history and condition), dated 8/1/2025, the H&P indicated that Patient 17 was admitted for possible stroke (a condition where blood supply to part of the brain is interrupted, causing brain tissue damage). The H&P further indicated that Patient 17 reported headaches, right-and left-sided numbness, and an inability to walk. During a concurrent observation, interview, and record review on 8/1/2025 with RN 21, who was assigned to Patient 17’s care, Patient 17 was observed sleeping, but face appeared reddened with a slight elevation of respiration (number of breaths per minute) at 22. In Patient 17’s electronic medical record (EMR, the digital record of a patient’s health information), in the section titled “Orders,” RN 21 confirmed that there were no pain medication orders for pain levels 1-6 on the numeric pain scale (a tool used by healthcare providers where 0: No pain,1-3: Mild pain, 4-6: Moderate pain,7-10: Severe pain, and 10: the worst pain imaginable). RN 21 stated that the only order present was for Morphine (a strong pain medication) 1 milligram (mg, a unit of measurement) every 4 hours for severe pain (level 7-10). During an interview on 8/1/2025 at 12:35 p.m. with the Intensive Care Unit (ICU, area in hospital caring for the critically ill patients) Nurse Manger (NM) 1, NM 1 stated that the standard process was for nurses to contact the physician if a patient did not have pain medications ordered to cover all levels of pain on the numeric scale. NM 1 stated that this process was important because patients may experience varying levels of pain, and the care team must be able to address pain at every level from 1-10. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Pain Management of Patients,” dated 5/28/2024, the P&P indicated, “The purpose of this policy is to promote prompt and effective assessment, diagnosis, and treatment of pain using a collaborative, multidisciplinary approach to pain management with participation of the patient and the patient’s family/significant other... The goals of pain management include Maximum pain relief. Preservation or restoration of function. Achieving the highest possible quality of life based on the patient’s unique needs and condition ...responsivities, Registered Nurse: Collaborates with the patient and providers to establish the effective plan of care and goals for pain management ... To aid in avoiding pain recurrence, analgesics should be scheduled in a manner to maximize comfort and promote level of pain at or below tolerable level ...””

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 28851 Based on interview and record review, the facility failed to develop policies and procedures for the control and storage of medications, which may negatively impact 31 of 31 sampled patients, as evidenced by: 1. Failure to develop a policy and procedure for a contracted vendor software, ControlCheck (formerly called Bluesight, a program that utilizes artificial intelligence and machine learning to monitor and analyze medication transactions, identify unusual patterns, and flags potential drug diversion [unauthorized or illegal transfer of prescription medications from their intended recipients to others, or their use for purposes not intended by the prescriber] events to ensure accountability of medications) that has been in use since 9/12/2018. 2. Failure to develop a policy and procedure that indicated an acceptable time frame for nurses to return or waste a medication, and the interim secure storage of such medications in the event that the return or the disposal could not happen within the approved period. These deficient practices had the potential for wrong medication, drug diversion, and/or pilferage (stealing medication) that may affect patient safety. Findings: 1. During an interview on 8/5/2025 at 12:11 p.m. with the director of pharmacy (DOP), the DOP stated the hospital used a program called Bluesight (now renamed ControlCheck, a program that utilizes artificial intelligence and machine learning to monitor and analyze medication transactions, identify unusual patterns, and flags potential drug diversion [unauthorized or illegal transfer of prescription medications from their intended recipients to others, or their use for purposes not intended by the prescriber] events to ensure accountability of medications) to monitor controlled substances (a drug or chemical that is regulated by the government due to potential for abuse or addiction, for example opioids (a group of drugs that includes morphine [a strong pain medication] and fentanyl [a very strong pain medication]) and narcotics [a drug or other substance that affects mood or behavior]). During a concurrent interview and record review on 8/7/2025 at around 4:18 p.m. with the Director of Quality Accreditation (DQA), the DQA presented the contract for the use of ControlCheck (or Bluesight) and was reviewed. The contract indicated it was effective on 9/12/2018. During an interview on 8/8/2025 at 9:59 a.m. with the Director of Pharmacy (DOP), the DOP stated the hospital did not have a policy and procedure regarding the process of using Blue Sight or Control Check. 2. During a concurrent interview and record review on 8/6/2025 12:44 p.m. with the Director of Pharmacy (DOP), the hospital policy titled, Automated Dispensing Cabinets (ADC, controlled substances: distribution, administration, and accountability, and automated dispensing cabinets), revised 1/3/2024, was reviewed. DOP stated the ADC policy did not indicate where the nurses should keep the unused portion of narcotic medications to be wasted, if waiting to find a witness for the disposition process. DOP stated per policy, nurses had until the end of the shift (each shift is typically 12 hours long), or 4 hours within patient discharge out of the hospital, to enter the wastage in the pyxis (an automated dispensing system that included a secure computerized cabinet that stores and dispenses medication and integrate with the hospital’s electronic medical record system). During an interview on 8/6/2025 at 1:30 p.m., the chief medical officer (CMO) stated nurses could keep used vials or medication in their pockets until they could find a witness to document the wastage. During a review of the Pyxis (an automated dispensing system that included a secure computerized cabinet that stores and dispenses medication and integrate with the hospital’s electronic medical record system) activity report, dated 7/9/2025, the pharmacy manager (MP) confirmed there was a premixed bag of fentanyl (narcotic, controlled substances, and a potent opioid to treat pain and used in anesthesia) 1000 micrograms (mcg, unit to measure mass) per 100 milliliter (ml, unit to measure volume) (in 100 ml bag) removed on 7/9/2025 at 8:08 a.m. for Patient 27 and returned at 10:58 a.m., two hours and 50 minutes later on the same date. During an interview on 8/8/2025 at 4:22 p.m. with the director of pharmacy (DOP), the DOP stated there were two (2) hours and 50 mins of unknown activity and/or storage of the fentanyl, which had the potential for diversion, theft, and pilferage. DOP stated nurses should return or waste medication as soon as possible. During a review of the hospital’s policy and procedure (P&P) titled, Drug Storage (revised 9/29/2022), the P&P indicated “ ... The medication storage areas in the pharmacy and throughout the hospital are under the supervision of the director of pharmacy or designee. ... All medications are stored in locked areas ... Drug storage in patient care areas ... Controlled drugs stored on the unit ... in a locked cabinet in a secured area to prevent diversion ...””

“PHARMACY DRUG RECORDS CFR(s): 482.25(a)(3) Current and accurate records must be kept of the receipt and distribution of all scheduled drugs. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed ensure that a record system was properly in place to maintain current and accurate records of the receipt and disposition of scheduled drugs by failing to develop and implement policies and procedures to: - Secure controlled substances (drugs such as morphine [strong opioid pain medication] and fentanyl [(a very strong opioid pain medication]) that are regulated by law because they can be abused or cause dependence). -Monitor medication handling. - Prevent diversion (when medication is used for reason other than prescribed treatment). This deficient practice involved two (2) of 31 sampled patients (Patient 11 and Patient 12), who were under the care of Registered Nurse (RN) 1, a nurse later confirmed by toxicology testing (laboratory analysis to detect drugs or poisons) to be under the influence (impairment, to any degree, of an individual’s ability to safely perform work because of drug use) of fentanyl (a strong opioid pain medication) and opioids (a drug class includes fentanyl and morphine) while on duty. This deficient practice resulted in Patient 11 and Patient 12 being at immediate risk for harm due to care previously provided by a nurse under the influence of controlled substances. In addition, because the facility continued to allow unsecured storage and inadequate monitoring of controlled substances, other patients in the facility remained at risk for harm from potential diversion, delayed pain treatment, or medication errors. On 8/7/2025 at 4:30 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Medical Officer (CMO), Patient Care Executive/Chief Nursing Officer (CNO), Director of Quality (DQ), Administrative Director of Cardiovascular, Peri-Operative, Imaging (AD 1), and the System Director for Accreditation and Licensing (SDAL) who attended via telephone. The facility failed to develop and carry out effective policies and procedures to: -Secure controlled substances (medication like morphine or fentanyl that are regulated by law due to their high risk for abuse or addiction). - Monitor medication handling. -Prevent diversion (when drugs are used for purposes other than a patient’s prescribed treatment). During an interview with the Director (DICU) of Intensive Care Unit (ICU, area in the hospital that cares for critical ill patients) on 8/5/2025 at 3:42 p.m., DICU stated Registered Nurse (RN) 1 was found unresponsive (not awake and not reacting) in the ICU locker room while on duty. During an interview on 8/6/2025 at 2:45 p.m. with the Chief Medical Officer (CMO), the CMO confirmed that RN 1 was in possession of narcotic (a drug or other substance that affects mood or behavior) medication (morphine vial, a small glass container holding a strong pain medicine), a used syringe (a device for injecting fluids), an uncapped needle (needle without its safety cover), and a tourniquet (a tight band used to slow blood flow, often applied before injecting). The CMO also confirmed that toxicology testing (laboratory test of blood or urine for drugs or poisons) done in the Emergency Department (ED, hospital unit for urgent care) was positive for fentanyl (a very strong opioid pain medication) and opioids (a group of drugs that includes morphine and fentanyl). During a concurrent interview and record review with the Medication Safety Officer (MSO) on 8/7/2025 at 4:00 p.m., Patient 11’s “Medication Administration Record (MAR),” dated 7/24/2025, was reviewed. The MAR indicated that RN 1 started an intravenous (IV, administer medication into the vein) infusion of 100 milliliters (ml, a unit of measurement) intended to run for 10 hours at a rate of 10 ml per hour. The medication was stopped after 8 hours of infusion. MSO confirmed that only 75 ml were documented as infused, and approximately 25 ml were unaccounted for. During a record review of Patient 12’s medication dispensing report indicated that RN 1 removed morphine three times in one day (a 12-hour shift; from 7:00 p.m. through 7 a.m. at 8:32 p.m., 10:22 p.m., and at 3:22 a.m.). During an interview with the Director of Pharmcy (DOP) on 8/7/2025 at 12:54 p.m., the DOP confirmed that the facility’s policy, “Automated Dispensing Cabinet,” dated 1/3/2024, allowed licensed nurses to retain (keep) controlled substances pending waste (leftover medication to be discarded with a witness) for up to 12 hours, but did not require secure interim storage (locked area). During a concurrent interview and record review on 8/7/2025 at 12:32 p.m. with the Pharmacy Manager (MP) and the Medication Safety Officer (MSO), RN 1’s audit record dated from 7/5/2025 through 8/4/2025 from the system called “Control Check (formally known as Blue Sight, a drug diversion detection software). MSO confirmed that the system flagged an alert when a fentanyl drip was administered more than 60 minutes after removal from the dispensing system. However, because RN 1’s IRIS score (Individual Risk Identification Score, a diversion risk score) was 2.5 (below the facility’s investigation threshold of 5), no investigation occurred. This resulted in Patient 11 and Patient 12, and potential other patients being at immediate risk for harm due to care previously provided by a nurse under the influence of controlled substances and the unsecured handling of narcotic medication. On 8/8/2025 at 8:41 p.m. the IJ was removed in the presence of the CMO, CNO, DQ, AD 1, Director (DIR 2) of Behavioral Health Unit, Nurse Manager (NM 2) of BHU, and SDAL who attended via telephone, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated immediate corrective actions which included: Audits (an official inspection) all controlled substance (a drug or chemical whose manufacture, possession, and use are regulated by a government because it may be abused or cause addiction) removed, plan to revise policies, education on new policies process to pharmacy manager and ICU RNs, and immediate monitoring by ICU Charge RN, will monitor the distribution, administration and accountability of controlled drugs and automated dispensing cabinet (ADC, controlled substances: distribution, administration, and accountability, and automated dispensing cabinets) activity report twice a shift. On 8/7/2025 p.m., the ICU Charge RN immediately audited all controlled substances. Starting on 8/7/2025, the Pharmacy Director educated the Pharmacy Manager, Medication Safety Officer, and Pharmacy Supervisor on revised policies and processes for safe and secure monitoring and handling of dispensed controlled substances. Policies will be revised: Distribution, Administration and Accountability of Controlled Drugs and Automated Dispensing Cabinet (ADC) policy. Revision to the ADC Policy regarding partial waste, which will indicate, immediate waste of partial doses (excluding drips, PCAs, compounds) at the time of removal from ADC, must be witnessed by 2 licensed healthcare professionals and recorded in the ADC. This will replace the process of allowing waste by the end of the shift or within 4 hours of patient discharge. If immediate waste is not possible due to urgent patient care (i.e. rapid sequence intubation, code blue), the remaining portion of the medication must be immediately wasted or returned back to pyxis (if unopened). The justification of the delay must be documented during waste transaction at the ADC. Documentation of controlled substances withdrawn from ADC and subsequent waste, must occur with 2 licensed healthcare professionals at times of medications dispensed, except for life threatening emergencies and procedure/procedural areas. Education: Controlled Substances removed from pyxis must be administered immediately (immediate is defined as 15 minutes). Documentation of waste must occur at the time of medication removal from Pyxis by two licensed healthcare professionals. In cases such as procedures & emergencies, the waste will be documented at the completion of the procedure/emergency. The ICU Director met with ICU RNs on shift to provide education on the revised process for the safe and secure handling of controlled substances. Incoming staff will receive training prior to beginning their shift, until 100% active ICU RNs are trained. ICU RNs on leave will be trained upon return to shift. Immediate Monitoring: Starting 8/7/2025, the ICU Charge RN will monitor the ADC activity report twice a shift every 6 hours. Audit includes review of dispensed controlled substances drawn, wasted, administered and reconciled with the MAR. Audit will be conducted for 7 days by the ICU Charge RN and unresolved discrepancies will be escalated to ICU Director or Manager. After 7 days, audit will become integrated into ICU daily operations for 7 days. Any fallout will be immediately addressed and corrective action taken according to just culture algorithm. Unresolved discrepancies will be immediately escalated by the ICU Director or Manager to the Director of Pharmacy who would activate the DDRT if further investigation is required. Findings: During an interview with the Director of the Intensive Care Unit (DICU) on 8/5/2025 at 3:42 p.m., DICU confirmed RN 1 was found unresponsive (not awake not reacting) in the ICU locker restroom while on duty. DICU confirmed that RN 1 was assigned the care of Patient 11 and Patient 12 on the night RN 1 was found unresponsive (a person is not reacting or able to react in a normal way to stimuli like touch, sound, or commands). During an interview on 8/6/2025 at 2:45 p.m. with the Chief Medical Officer (CMO), the CMO confirmed that RN 1 was in possession of a morphine vial (a small glass container holding a strong pain medicine), used syringe (a device for injecting fluids), uncapped needle (needle without its safety cover), and tourniquet (a tight band used to slow blood flow, often applied before injecting) at the time RN 1 was found unresponsive (7/26/2025). The CMO also confirmed toxicology testing (laboratory analysis to detect drugs or poisons) in the Emergency Department (ED, a hospital unit for urgent medical care) was positive for fentanyl (a very strong opioid pain medication) and opioids (a group of drugs that includes morphine and fentanyl). During a review of Patient 11’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/21/2025 , the “H&P” indicated, Patient 11 had past medical history which included pancreatic cancer (a type of cancer that develops in the pancreas, an organ located behind the stomach that plays a crucial role in digestion and blood sugar regulation), on chemotherapy (the treatment of disease by the use of chemical substances). Patient 11 was admitted for worsening abdominal pain, with a care plan including pain control. During a review of Patient 11 ‘s “Medication Administration Record (MAR),” dated 7/26/2025, the MAR indicated Patient 11 had a physician’s order for fentanyl (a very strong opioid pain medication) infusion intravenously (medication administered into the vein). During a concurrent interview and record review on 8/7/2025 at 4:00 p.m. with the Medication Safety Officer (MSO), Patient 11’s “Medication Administration Record (MAR),” dated 7/24/2025, was reviewed. The MAR indicated that RN 1 administered a new bag of fentanyl (a very strong opioid pain medication) 100 milliliters (ml, a unit of measurement) intravenously (IV, administer medication into the vein) infusing for eight (8) hours. MSO stated the total volume infused was 75 ml when a new bag was changed. MSO confirmed that approximately 25 ml was unaccounted for. MSO stated pharmacy did not know where the unaccounted fentanyl went. During a review of Patient 12’s “History and Physical (H&P),” dated 7/21/2025, the “H&P” indicated, Patient 12 was transferred to the facility due to having an aneurysm (part of an artery wall weakens, allowing it to abnormally balloon out or widen). During a review of Patient 12’s medication dispensing report dated, 7/25/2025, the report indicated RN 1 removed Morphine (strong opioid pain medication) three (3) times in one day (7 a.m. - 7:00 p.m.): at 8:32 p.m.,10:22 p.m., and 3:22 a.m. During a concurrent interview and record review on 8/7/2025 at 12:32 p.m. with the Pharmacy Manager (MP) and the Medication Safety Officer (MSO), RN 1’s audit record in “Control Check (a drug diversion monitoring software, formerly called Bluesight) for period of 7/5/2025 - 8/4/2025, was reviewed. The MSO stated the system flagged alerts for fentanyl infusions given more than 60 minutes after removal from the Pyxis (an automated medication dispensing system). However, RN 1’s IRS score (individual Risk Identification Score, a risk score for diversion) was 2.5, below the facility’s threshold of 5. Therefore, no investigation occurred. During a concurrent interview and record review on 8/7/2025 at 12:40 p.m. with the Manager of Pharmacy (MP), RN 1’s ControlCheck audit report, was reviewed. MP stated the report was run after the incident on 7/26/2025 for the last 30 days (6/27/2025 -7/27/2025). MP stated they did not look into why RN 1’s score was 2.5 because this score was below 5, which was the threshold that the facility would start an investigation. The report indicated the score of 2.5 meant the following: - “(Name of RN 1) has a highly unusual number of variances (discrepancies or differences between expected and actual quantities of controlled substances, such as medications, during handling and dispensing), including 4 variances with a status of Closed Reconcile (MP stated the Nurse Manager closed this variance that was flagged by the system).” Two (2) Variances in Reconcile - Missing either administration, waste, or return, and 2 variances in reconciled - Missing administration.” -“Name of RN 1) logged 5 actions with the time between events exceeding the threshold (60 minutes): 1 action with first dispense (when RN removed the controlled substance) and first administration (when RN 1 gave the medication) for a patient greater than 60 minutes (hospital threshold). Four (4) actions with first and last touch for a patient greater than 41 minutes (Nursing Average).” During an interview on 8/7/2025 at 12:54 p.m. with the Director of Pharmacy (DOP), the DOP stated the policy titled, “Automatic Dispensing Cabinet (a computerized medicine storage and tracking system),” dated 1/3/2024 allowed nurses to keep controlled substances that required wasting (throwing away leftover drugs with witness) for up to 12 hours without defining a secure storage location (locked cabinet or other secure space). DOP confirmed that RNs “keep the medication in their possession until they can waste it with a witness,” and there was no policy on how or where to store the medication securely during this time. During an interview on 8/6/2025 at 2:22 p.m. with the Compliance Officer (CO), the CO stated the diversion response team (a group of professionals who focus on diversion prevention and response) was only activated after RN’s overdose (a toxic amount of a drug, or combination of drugs overwhelms the body). During an interview on 8/6/2025 at 3:10 p.m. with the Director (DICU) of Intensive Care Unit (area in hospital that care for the critical ill patients), DICU stated that to waste a medication, two RNs must be present to enter the amount being wasted into the Medication Administration Record (MAR, the electronic log of medications given). Both nurses’ names must be documented. If unable to waste right away, the RN will keep the medication until a witness was available. DICU stated if there were multiple pending wastes, the Pyxis (an automated medication dispensing system) would display them, and ControlCheck will alert the manager that waste required witnessing at the beginning of the next shift. During an interview on 8/7/2025 at 9:48 a.m. with ICU RN, (RN 17), RN 17 stated that if an emergency prevented wasting immediately, the unused narcotic (a drug or other substance that affects mood or behavior) may be placed in a medication lock box. RN 17 stated that “everyone can get the key; anyone can get it with access to Pyxis,” and there was no witness requirement when placing medications in the lock box. RN 17 further stated that all controlled substances placed in the box were accessible to any RN with the key. During an interview on 8/7/2025 at 10:07 a.m. with ICU RN (RN 18), RN 18 confirmed that if waste could not be completed right away, nurses either carried the medication until a witness was available or placed it in the medication lock box. RN 18 confirmed there was no witness requirement for lock box use. During a concurrent observation and interview on 8/7/2025 at 11:51 a.m. with the ICU Nurse Manager (NM) 1 in the ICU’s medication room, on the wall was a mounted transparent medication box. NM 1 confirmed multiple controlled substances could be placed inside and accessed by any nurse with Pyxis access, without a witness. During an interview on 8/8/2025 at 5:00 p.m. with the DOP, DOP confirmed lock boxes existed on all units and that any nurse with Pyxis access could retrieve the key. The DOP stated there was no written policy or protocol for lock box use. During a review of the facility’s policy and procedure (P&P) titled, “Automated Dispensing Cabinet (ADC),” dated 1/3/2024, the P&P indicated, “Wasting a medication: Documentation of waste must occur at the time of medication removal from ADC. Within 4 hours of patient discharge time or by the end of the shift ...” During a review of the facility’s policy and procedure (P&P) titled, “Distribution, Administration and Accountability of controlled drugs,” dated 12/6/2024, the P&P indicated, “The pharmacy department will comply with all applicable State & Federal laws pertaining to control, distribution and accountability of Controlled Substances.” During a review of the facility’s policy and procedure (P&P) titled, “Reasonable Suspicion Drug and Alcohol Guide,” dated August 2024, the P&P indicated, “(Name of the Facility) is committed to the safe and secure workplace for all employees. The philosophy of a drug-free workplace is grounded in the belief that a safe, healthy, and productive work environment is essential for the well-being of employees, patients and the organization ... Ensuring a safe workplace is paramount. Illegal drug use and alcohol misuse can impair judgment, coordination, and reaction times, increasing the risk of accidents and injuries. A drug and alcohol-free workplace policy aims to mitigate these risks and protect employees and patients. Illegal drug use and alcohol misuse negatively affects employee performance, leading to errors, decreased efficiency, and poor decision-making. Maintaining a drug and alcohol-free workplace helps ensure that employees are operating at their highest capacity, contributing to overall organizational success ...” During a review of the facility provided user manual titled, “ControlCheck: Learner’s Guide,” dated 2023, the guide indicated, “IRIS (a tool used by Bluesight’s Control Check to monitor and detect potential drug diversion by healthcare staff) The next section on the card is ‘IRIS.’ This will allow you to see your user’s IRIS score or ‘Individual Risk Identification Score’ This score uses our metrics to calculate a score of how anomalous this user is compared to their peers. When viewing the audit ... Each of these variances should be thoroughly reviewed before closing ...””

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 28851 Based on observation, interview and record review, the facility failed to ensure pharmacy oversight of controlled substances (a drug or chemical that is regulated by the government due to potential for abuse or addiction, for example opioids and narcotics), which may negatively impact 31 of 31 sampled patients, as evidenced by: 1. Failure to ensure the pharmacy department manually reviewed the Control Check (formerly called Bluesight, a program that utilizes artificial intelligence and machine learning to monitor and analyze medication transactions, identify unusual patterns, and flags potential drug diversion [unauthorized or illegal transfer of prescription medications from their intended recipients to others, or their use for purposes not intended by the prescriber] events to ensure accountability of medications) alerts for potential diversion of Controlled drugs substances instead of just relying on the Control Check program to identify. 2. Failure to investigate an alert for a long lapse (close to 2 hours) between the time of removal from Pyxis (an automated dispensing system that included a secure computerized cabinet that stores and dispenses medication and integrate with the hospital’s electronic medical record system) and the time of administration for a fentanyl (narcotic that is used in anesthesia and pain management) infusion (drip, the process of delivering medication directly into the bloodstream through a needle, typically through a vein, or intravenously/IV) bag on 7/11/2025, for one of 30 sampled patients (Patient 11). 3. Failure to ensure that substances (medications regulated by law due to risk of abuse or dependence, such as fentanyl and morphine) stored in medication lock boxes located throughout all units in the facility were secured and protected from unauthorized access, in accordance with the facility’s policy regarding “Distribution, Administration and Accountability of controlled drugs.” Once the lock box was opened by a nurse, that nurse had access to all other controlled substances inside, and there was no requirement for a witness when placing or removing medications. These deficient practices placed patients at risk for harm from diversion (when medications are taken or used for purposes other than prescribed), delayed pain treatment (such as when medication was diverted, thus patient did not receive pain medication on time or as prescribed), or medication errors (such as when medication had been tampered with or inaccurate amount of pain medication was administered not following prescription). Findings: 1. During an interview on 8/5/2025 at 12:11 p.m. with the director of pharmacy (DOP), the DOP stated the hospital used a program called Bluesight (now renamed ControlCheck, a program that utilizes artificial intelligence and machine learning to monitor and analyze medication transactions, identify unusual patterns, and flags potential drug diversion [unauthorized or illegal transfer of prescription medications from their intended recipients to others, or their use for purposes not intended by the prescriber] events to ensure accountability of medications) to monitor controlled substances (CS, a drug or chemical that is regulated by the government due to potential for abuse or addiction, for example opioids and narcotics). During a concurrent interview and record review on 8/7/2025 at 11:29 a.m. with the medical Safety Officer (MSO), the Patient Care Audit function of the ControlCheck program, was reviewed. MSO stated the ControlCheck was not set up to monitor any infusion (or drips, the process of delivering medication directly into the bloodstream through a needle, typically through a vein, or intravenously/IV)) because the program cannot monitor infusion rate, or volume. During an interview on 8/7/2025 at 11:48 a.m. with the MSO, the MSO stated monitoring the ControlCheck was part of her (MSO) daily duty. During an interview on 8/7/2025 at 12:42 p.m. with the MSO, the MSO stated that because the ControlCheck program could not monitor controlled substance drips accurately, the program could not close or reconcile drips with the administration record, and the program would just flag those as audit alerts, which would require the Pharmacist or nursing managers to manually clear the alerts. During a review of the ControlCheck generated Individual Risk Identification Score (IRIS, is a proprietary score the program used to identify and prioritize individuals at higher risk for drug diversion within the healthcare facility) for the registered nurse (RN 1), RN 1’s IRIS score was “0.9” for action time and highlighted in color green; however, below the score, there was an action listed: “ ... first dispense and first [administration] for a patient happened [more than] 60 [minutes] (which was past the hospital threshold)” During a review of the action alert listed under RN 1’s ControlCheck generated Individual Risk Identification Score, the action alert indicated that RN 1 removed a Fentanyl drip bag for Patient 11 on 7/11/2025 at 10:48 p.m. and the administration time was on 7/12/2025 at 12:59 a.m. (which was 2 hours and 11 minutes after the time of removal). During an interview on 8/7/2025 at 12:47 p.m. with the medical safety officer (MSO), the MSO stated she (MSO) did not reconcile the action alert because RN 1’s IRIS score was low (0.9, which was below the facility’s threshold of 5). During an interview on 8/7/2025 at 12:50 p.m. with the director of Intensive Care Unit (DICU). The DICU stated medication administration was expected to happen soon after medication removal from the Pyxis (an automated dispensing system that included a secure computerized cabinet that stores and dispenses medication at nursing unit and integrate with the hospital’s electronic medical record system) or dispensed by Pharmacy. During an interview on 8/7/2025 at 2:40 p.m. with the DICU, the DICU stated there was no critical/emergency event on 7/11/2025 between 10:48 p.m. to 7/12/2025 at 1 a.m., and there were no additional duties assigned to RN 1 that would justify the delay in administration of the fentanyl drip. During an interview on 8/8/2025 at 5:56 p.m. with the medical safety officer (MSO) and the DOP, the MSO stated there was no review of any user activity if the user IRIS score was below 5 (RN 1’s IRIS score was 0.9). MSO stated she (MSO) would forward the individual user report to the supervising nursing manager if the user’s IRIS score was above 5. The DOP said there was no manual pharmacy review of ControlCheck alerts regardless of IRIS scores. During a review of the facility’s policy and procedure (P&P) titled, Controlled and Regulated Substances Stewardship (last revised on 2/15/2024), the P&P indicated the stewardship “ ... to improve, monitor, and evaluate the use of controlled and regulated substances ... Members of the Stewardship Committee should include Medical Staff ... Pharmacy ... provide oversight of controlled and regulated substances utilization ...” During a review of the facility’s policy and procedure (P&P) titled, Pharmacy Scope of Services (last revised on 5/28/2024), the P&P indicated “ ... To collect data about department function, staff performance, and patient care related to medication use for quality management purposes and continuous quality improvement ... to support nursing care based on nursing process and medication management ... To develop, implement, and evaluate standards utilized in the pharmaceutical services ...” 2. During an observation and interview on 8/5/2025 at 12:04 p.m. with the Intensive Care Unit (ICU, area in hospital caring for the critically ill patients) Nurse Manager (NM) 1, in the ICU’s medication room, there was a mounted transparent lock box on the wall, approximately 15 inches by 18 inches, with a key lock. NM 1 stated that medications such as fentanyl (a very strong pain medication) that were sent from pharmacy but not yet administered could be placed in the lock box. NM 1 confirmed that multiple controlled substances could be placed in the same lock box at the same time. NM 1 confirmed that any nurse with Pyxis (an automated medication dispensing system) access could obtain the key to the lock box and open it. Once opened, that nurse could access all medications stored inside, with no witness requirement. During an interview on 8/7/2025 at 9:48 a.m. with ICU Registered Nurse (RN) 17, RN 17 stated that if an emergency prevented wasting (disposing of left over medication with a witness), the unused narcotic (a drug or other substance that affects mood or behavior) could be placed in the medication lock box. RN 17 explained that: -“Everyone can get the key; anyone with Pyxis access can open it.” -“There is no witness when placing meds (medications) into the lock box.” -“If there are multiple medications waiting to be wasted, they are placed together in the box.” -RN 17 confirmed that once the lock box was opened, all controlled substances inside were accessible to any nurse with the key. During an interview on 8/7/2025 at 10:07 a.m. with ICU RN 18, RN 18 confirmed that when the wasting of controlled substances (a drug or chemical whose manufacture, possession, and use are regulated by a government because it may be abused or cause addiction) could not be completed right away, the medication was either “kept on the nurse until a witness was available or placed in the narcotics lock box” and that once accessed, all controlled substances stored in the box could be removed by anyone. During an interview on 8/8/2025 at 5:00 p.m. with the Director of Pharmacy (DOP), the DOP confirmed that lock boxes were installed in all unit medication rooms. DOP confirmed that: -Any nurse could log into the Pyxis, obtain the key, and open the lock box. -Once opened, the nurse had access to all controlled substances inside. -There was no policy or protocol governing the use of the lock box for controlled substances. During a review of the facility’s policy and procedure (P&P) titled, “Drug Storage,” dated 9/29/2022, the P&P indicated, “The medication storage areas in the pharmacy and throughout the hospital are under the supervision of the director of pharmacy or designee ... Drugs are stored under proper conditions of temperature, light, humidity, sanitation, ventilation, and segregation per manufacturer recommendations. In the absence of such recommendations, drugs are stored according to a pharmacist’s instructions. Storage areas are secure and accessible only to designated and authorized personnel ... If there is evidence of tampering or diversion, or if medication security otherwise becomes a problem, the organization will evaluate its current medication control policies and procedures and implement the necessary systems and processes to ensure that the problem is corrected, and that patient health and safety are maintained ...” During a review of the facility’s policy and procedure (P&P) titled, “Distribution, Administration and Accountability of controlled drugs,” dated 12/6/2024, the P&P indicated, “The pharmacy department will comply with all applicable State & Federal laws pertaining to control, distribution and accountability of Controlled Substances.””

“PHARMACIST SUPERVISION OF SERVICES CFR(s): 482.25(b)(1) §482.25(b)(1) - All compounding, packaging, and dispensing of drugs and biologicals must be under the supervision of a pharmacist and performed consistent with State and Federal laws. This Standard is not met as evidenced by: 28851 Based on observation, interview, and record review, the hospital failed to ensure its sterile (germ-free) compounding process (a process of making sterile intravenous [IV, administered through the vein] medications), was performed in a safe and consistent manner, as evidenced by: 1. Failure to ensure the “sterile product preparation tray (a tray that provide surface area for sterile compounding or IV medication preparation)” in one (1) of two (2) sampled medication rooms in the Intensive Care Unit (ICU) was free of stains. 2. Failure to ensure one of one sampled anteroom (a room serves as a transition area that separates the dirty area from the clean area or room where IV medications are prepared) of the sterile compounding suite (IV room) was clean and free of debris, residues, and/or stains, that could accumulate contaminants and/or microorganisms. 3. Failure to ensure the sterile compounding environment viable sampling plan (a map of sampling locations) used by the vendor that certifies the facility’s IV room was included in the hospital’s procedure of environmental media testing. These deficient practices had the potential for all patients requiring IV medications to be exposed to preventable contamination leading to infection that may affect patients’ health and safety. Findings: 1. During an interview on 8/5/2025 at 12:04 p.m. with the ICU nurse manager (NM 1), NM 1 stated there were two (2) medication rooms in the ICU department. During a concurrent observation and interview on 8/5/2025 at 1:01 p.m. with Nurse Manager (NM) 1, in one (1) of two (2) ICU medication rooms (5 North), there was a white tray labeled “sterile product preparation tray” on top of the refrigerator. NM 1 stated there were stains on top (work area) of the tray. NM 1 said the tray was cleaned with Sani Cloth AF3 (used for disinfecting an equipment or surface) by nurses as needed, not routinely. NM 1 stated the expectation was to clean before and after preparation of a sterile product. During a review of the facility’s policy and procedure (P&P) titled, Safe Admixture of Parenteral Products (revised 6/18/2019), the P&P indicated “ ... The intravenous admixture service is provided for good patient care and for safe and sanitary admixture of parenteral products ... Admixtures prepared outside of the IV room (i.e. nursing unit med room) ... Assure cleanliness of work space ...” 2. During an observation on 8/5/2025 at 4:09 p.m. with the pharmacy personnels, in the anteroom of the IV suite, the floors around a bench, a steel table, and a refrigerator had brown stains and debris. During an interview on 8/5/2025 at 4:15 p.m. with the pharmacy manager (MP 2), the MP 2 stated the area was difficult to clean. MP 2 said the technicians cleaned the floor every day. MP 2 agreed that the technicians did not clean the area well. During a review of the facility’s policy and procedure (P&P) titled, IV Room Cleaning and Disinfecting (revised 12/6/2024), the P&P indicated “ ... definitions: ... Cleaning - removing residues, such as debris, microbes and residual drug and chemicals. Disinfection - Destroys fungi, viruses, and bacteria ... The Pharmacy Department is responsible for performing routine cleaning and maintaining sterility of the pharmacy IV clean rooms ...” 3. During a concurrent interview and record review on 8/8/2025 at 4:02 p.m. with the pharmacy manager (MP 2), the “Environmental Sampling locations” in the hospital pharmacy’s standard operating procedures (SOP) “Procedure of Environmental Media Testing, was reviewed. MP 2 stated those sampling locations were the in-house monthly viable sampling test locations. During a concurrent interview and record review on 8/8/2025 at 4:05 p.m. with the director of pharmacy (DOP), the facility’s IV room certification reports, were reviewed. The DOP confirmed the sampling plan used by the vendor (who performed their IV rooms’ bi-annually [twice a year] certifications) was different from the locations listed in the SOP. The DOP stated that the SOP did not match the environment sample plan map used by the vendor. The DOP said the hospital followed the guidance of US Pharmacopeia (USP, a scientific, non-governmental organization that sets standards for medicines) chapter 797 (USP 797, is a chapter of the United States Pharmacopeia that provides guidelines and standards for compounding sterile preparations [CSPs] in healthcare settings, ensuring patient safety by preventing harm from microbial contamination, endotoxins, and other errors. It covers various aspects of sterile compounding, including personnel training, facility requirements, and quality control procedures). During a review of the current edition of USP 797, the chapter indicated “ ... The microbiological air and surface monitoring program must be clearly described in the facility’s SOPs, which must include a diagram of the sampling locations ...””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 36206 Based on observation, interview and record review the facility failed to ensure the Condition of Participation (CoP) for Governing Body, was met as evidenced by: 1.The facility’s governing body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to provide oversight to ensure intravenous (IV, administered into a vein) titratable (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) medications were administered in a safe manner when: 1.a. Orders were not discontinued per physician order by healthcare team members for five of 41 sampled patients (Patient 1, 6, 7, 26 and 27), in accordance with the facility’s policy and procedure regarding IV titration medications. Patient 1 and Patient 27 received IV nicardipine (medication to treat high blood pressure) four (4) days and 26 hours and 50 minutes from last administration, respectively. Patient 6’s IV Norepinephrine (medication to raise blood pressure) and IV Nicardipine, were not discontinued on 5/16/2025 and 5/19/2025, respectively. Patient 7’s Nicardipine drip was not discontinued on 5/26/2025. Patient 26 received IV Propofol infusion (an intravenous medication used for sedation) 39 hours and 50 minutes beyond the last administration date of 5/27/2025. This deficient practice enabled nursing staff to gain access to discontinued medications and administered without physician order. Patient 1 suffered hypotension (low blood pressure) after IV nicardipine (medication to treat high blood pressure) administration. This deficient practice also had the potential to result in putting Patients 6, 7, 26, 27 and other patients, receiving IV titratable medications, at risk for adverse effects such as severe hypotension, excessive sedation (drowsiness or sleep), respiratory depression (a breathing disorder characterized by slow or shallow breathing that doesn’t allow for proper gas exchange in the lungs) and/or death, when the medications were given without valid physician order. (Refer to A-0063) 1.b. There was no parameter range (specific instructions or guidelines to determine the correct administration of a drug) set in the IV titratable medication order (Order set for Nicardipine drip) for one of 41 sampled patients (Patient 6), in accordance with the facility’s policy regarding “Titratable Medication Infusion Administration.” This deficient practice had the potential to put Patient 6 and other patients to receive unnecessary medications, which can compromise patient safety due to adverse medication effects such as severe hypotension. (Refer to A-0063) 2. The facility’s Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision making,) failed to ensure patient care and services rendered under contract with an outside entity (Radiology Services, provide imaging technology to diagnose and treat medical conditions. Radiologists, who are medical doctors specializing in radiology, interpret these images to aid in diagnosis and treatment planning), adhered to Radiology contract service expectations for timely (in less than 30 minutes) computed tomography (CT scan, medical imaging creates detailed images of the inside of the body) interpretation for one of five sampled patients (Patient 4) in the Emergency Department (ED), in accordance with the facility’s policy regarding contract processing and service agreement. This deficient practice resulted in a delay in 2-hours and 24-minutes in the interpretation of Patient 4’s CT of the brain, which delayed potentially life-saving intervention and contributed to a high likelihood of irreversible neurological damage (injury or harm that affects the brain, spinal cord [a bundle of nerves running down the spine]). Additionally, this deficient practice had the potential to cause delays in care for other patients presenting to the emergency department (ED) who require emergent CT interpretation for time-sensitive conditions. (Refer to A-0083) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36206 Based on interview and record review the facility failed to ensure the Condition of Participation for Patient Rights, was met as evidenced by: 1. The facility failed to protect one of 19 sampled patients (Patient 3) in the Psychiatric (relating to mental illness) Acute Care (PAC) unit, from an assault (an act that threatens physical harm to a person, whether or not actual harm is done), in accordance with the facility’s protocol regarding provision of a safe environment of care, when Patient 2 entered Patient 3’s room for approximately 2 to 3 minutes, with no staff members present in the hallway while Patient 2 entered Patient 3’s room. This deficient practice resulted in Patient 2 (male patient) entering Patient 3’s room, resulting in scratches to Patient 3’s (female patient) upper and lower lip and had the potential to result in serious injury or harm. In addition, after the incident, Patient 3 became anxious, watchful, fearful, scared, and constantly looking over her shoulder. (Refer to A-0145) 2. The facility failed to ensure one of two (2) sampled Behavioral Health Unit (BHU, a specialized area within a hospital dedicated to providing mental health care) staff (Licensed Vocational Nurse 2), completed her “Abuse and Neglect” module (training module that discusses the types of abuse [refers to any action or failure to act by a caregiver that causes harm or distress to a patient, encompassing various forms like physical, emotional, sexual, and financial abuse, as well as neglect] and neglect, the related indicators and the reporting responsibilities of health care providers) yearly, in accordance with the facility’s annual education requirements. This deficient practice had the potential for violations of patient rights such as being free from all forms of abuse, due to lack of staff training. (Refer to A-0145) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 36206 Based on interview and record review the facility failed to ensure the Condition of Participation for Quality Assurance and Performance Improvement (QAPI), was met as evidenced by: 1. The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI, a data-driven, facility-wide program designed to monitor, assess, and improve the quality and safety of patient care) program included monitoring and oversight of services provided under contract, specifically radiology services (provide imaging technology to diagnose and treat medical conditions. Radiologists, who are medical doctors specializing in radiology, interpret these images to aid in diagnosis and treatment planning), to ensure timely (in less than 30 minutes) computed tomography (CT scan, medical imaging creates detailed images of the inside of the body) interpretation for one of five sampled patients (Patient 4) in the Emergency Department (ED), in accordance with the facility’s performance improvement policy. Additionally, the hospital failed to establish an ongoing process to measure, analyze, and track performance indicators related to contracted radiology services, as required, to support and improve health outcomes and quality of care. This deficient practice resulted in the lack of timely identification and response to performance issues that directly affected patient care, including delays in emergency CT interpretation for Patient 4. This deficient practice had the potential for delays in the delivery of necessary care interventions for Patient 4 and other patients in the facility. (Refer to A-0273) 2. The facility’s Quality Assurance and Performance Improvement (QAPI, a data-driven, facility-wide program designed to monitor, assess, and improve the quality and safety of patient care) committee failed to Analyze and track an adverse patient event (any unfavorable or unintended occurrence), in accordance with the facility’s policy regarding performance improvement, when it failed to conduct a thorough investigation for an allegation of an assault (an act that threatens physical harm to a person, whether or not actual harm is done) that was reported by one of 41 sampled patients (Patient 3) on 5/7/2025, when Patient 2 entered Patient 3’s room and covered Patient 3’s mouth, which resulted to visible scratches to Patient 3’s upper and lower lip. In addition, the facility failed to report the incident to the regulatory agency within 24 hours of the incident, in accordance with the facility’s policy regarding adverse event reporting. This deficient practice led to an incomplete investigation of the alleged assault on Patient 3 by Patient 2 and resulted in the facility not reporting the assault within 24 hours to the regulatory agency resulting in a delay of investigation of the incident. This deficient practice of not analyzing and tracking adverse patient events also had the potential for the facility’s inability to adequately identify and address issues, leading to an increased risk of preventable harm to patients. (Refer to A-0286) 3. The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) team performed a thorough investigation for one of 41 sampled patient’s (Patient 1) medication safety event on 2/6/2025 (Patient 1 was re-started on a Nicardipine drip [medication to treat high blood pressure] without a proper physician order which caused a sudden drop in Patient 1’s blood pressure) and identify a systemic failure regarding IV titratable medication order discontinuation, in order to prevent two other patients (Patient 26 and 27) from receiving an IV titratable medication that should have been discontinued, in accordance with the facility’s policies regarding performance improvement and IV titratable medications. This deficient practice, regarding the lack of a thorough investigation into Patient 1’s medication safety event, resulted in no action plan implemented to ensure IV titratable medications were discontinued per physician orders, thus leading to other incidents involving other patients (Patient 26 and Patient 27) receiving IV titration medications, which should have been discontinued 23 hours after the last administration, as well as putting patients at risk for harm and potential to experience complications. (Refer to A-0286) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 36206 Based on interview and record review the facility failed to ensure the Condition of Participation for Nursing Services, was met as evidenced by: 1. The facility failed to ensure that for one of 41 sampled patients (Patient 27), nursing staff alternated the peripheral intravenous site (PIV, a small, short, flexible tube [catheter] inserted into a vein, usually in the hand or arm, to administer fluids, medications, or blood products), every 12 hours during continuous infusion of nicardipine (Cardene IV, a medication to treat chest pain or high blood pressure [BP]), through a catheter or needle that is continuously delivering the substance into the body, in accordance with the physician order. This deficient practice had the potential for Patient 27 to develop complications associated with Nicardipine IV administration such as phlebitis (an inflammation of a vein), infiltration (when some of the fluid leaks out into the tissues under the skin where the tube has been put into the vein), or extravasation (the leakage of fluid or substances from a blood vessel or other enclosed space into the surrounding tissues, resulting in pain, swelling), which may go unrecognized and untreated, leading to tissue damage or necrosis (tissue death) and worsening of Patient 27’s condition. (Refer to A-0395) 2. The facility failed to ensure for one of 41 sampled patients (Patient 13), a Clinical Institute Withdrawal Assessment for Alcohol (CIWA, is a tool used to assess the severity of alcohol withdrawal symptoms) assessment was completed and documented per facility’s policy regarding “Inpatient Management of Alcohol Withdrawal (a range of symptoms that can happen if someone stops or significantly reduce alcohol intake after long-term use).” This deficient practice had the potential for delayed recognition of a patient’s withdrawal symptoms (example: increased blood pressure, increased heart rate, and tremor [shakiness] of hands or other body parts), potentially resulting in inappropriate or insufficient treatment for Patient 13. (Refer to A-0395) 3. The facility failed to formulate an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 41 sampled patients (Patient 26), to address Patient 26’s admitting diagnosis of seizures (a sudden, temporary disturbance of the brain’s normal electrical activity, often manifesting as changes in muscle tone, behavior, or awareness), in accordance with the facility’s policy regarding care plans. This deficient practice had the potential for Patient 26’s care needs not to be met when no implementation of individualized care plan for seizures and safety precautions were embedded into Patient 26’s treatment and care plan, which could result in complications such aspiration (the accidental inhalation of foreign materials, such as food, liquid, or stomach contents, into the lungs instead of the digestive tract [the mouth, stomach, and intestines]) leading to breathing problems , prolonged hospitalization, and/or even death. (Refer to A-0396) 4. The facility failed to ensure one of 41 sampled patient’s (Patient 13) plan of care regarding aspiration precaution (measures taken to prevent the accidental inhalation of food, liquid, or other substances into the lungs. These precautions are especially important for individuals with swallowing difficulties or other conditions that increase their risk of aspiration), was developed and implemented upon admission (a process in healthcare that involves evaluating a patient’s condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility’s policy regarding care plans. This deficient practice had the potential for serious complications such as aspiration pneumonia (lung infection that can be particularly dangerous for individuals with weakened immune systems or underlying health conditions), respiratory distress (difficulty breathing), prolonged hospitalization, and/or death. (Refer to A-0396) 5. The facility failed to ensure one of 41 sampled patient’s (Patient 20) plan of care regarding Chest Pain (often related to heart disease, its symptoms due to a heart attack or other heart condition includes Pressure, tightness, pain, squeezing or aching in the chest), was developed and implemented upon admission (a process in healthcare that involves evaluating a patient’s condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility’s policy regarding care plans This deficient practice had the potential to result in Patient 20’s care needs and risks to not be identified and addressed in a timely manner, which may result in complications such as heart failure (a condition where the heart cannot pump enough blood to meet the body’s needs), cardiac arrest (when the heart stops beating), and/or death. (Refer to A-0396) 6. The facility failed to ensure one of 41 sampled patient’s (Patient 22) plan of care regarding Fluid and Electrolyte Imbalance (maintaining a stable internal environment by regulating the amount of fluids and electrolytes [charged molecules] in the body. This balance is crucial for various bodily functions, including nerve and muscle activity, and blood pressure regulation), was developed and implemented upon admission (a process in healthcare that involves evaluating a patient’s condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility’s policy regarding care plans. This deficient practice had the potential for Patient 22’s care needs and risks to not be identified and addressed in a timely manner which may result in complications such as dehydration (a condition that occurs when your body doesn’t have enough fluid to function properly. It happens when you lose more fluids than you take in, which can disrupt various bodily functions like maintaining body temperature, transporting nutrients, and eliminating waste), prolonged recovery, and/or death. (Refer to A-0396) 7. The facility failed to ensure that one of 41 sampled patients (Patient 26), had the RASS (the Richmond Agitation Sedation Scale, is a tool designed to assess the level of alertness and agitated behavior in critically ill patients) documented during the initiation of Precedex infusion (dexmedetomidine, a sedative medication used for sedation in intensive care patients), in accordance with the facility’s policy regarding titratable medications administration (the administration of a medication over time, starting with the least dosage required for improving the medical condition). This deficient practice had the potential for Patient 26 to experience inadequate sedation (drowsiness or sleep) management, including over-sedation or under-sedation, which could lead to increased risk of adverse events such as delayed neurological assessment, respiratory depression (inadequate ventilation, causing a low breathing rate), and unrecognized agitation (a state of extreme restlessness or uneasiness), thereby compromising Patient 26’s safety. (Refer to A-0398) 8. The facility failed to monitor nineteen (19) of 19 sampled patients (Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39) in the Psychiatric (relating to mental or behavior illness) Acute Care (PAC) unit, every 15 minutes, in accordance with the facility’s policy and procedure regarding managing patients with high risk behaviors (actions that significantly increase the potential for harm, injury, or negative consequences, impacting both the individual and potentially others) who are admitted to the Behavioral Health Unit (or PAC unit). This deficient practice placed 19 patients’ safety at risk such as self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence. (Refer to A-0398) 9. The facility failed to ensure its nursing staff communicated and reported critical test results (a test or examination that always requires rapid communication of the results) for one of 41 sampled patients (Patient 1), in accordance with the facility’s policy and procedure regarding critical test result reporting, when there was no evidence that Patient 1’s CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) scans were reported to a physician within required timeframe (within 60 minutes) on 2/6/2025. This deficient practice had the potential to delay for Patient 1’s physician to evaluate Patient 1’s condition and determine appropriate interventions. (Refer to A-0398) 10. The facility failed to ensure its nursing staff performed a National Institute of Health Stroke Scale (NIHSS, a clinical assessment tool used to measure a patient’s neurological status after a stroke to quantify the severity of stroke-related deficits and monitor changes in a patient’s condition over time) assessment, when Stroke Alert (a protocol the facility developed in response to patient experiencing acute [new onset] stroke symptoms) was activated for one of 41 sampled patients (Patient 1) on 2/6/2025, in accordance with the facility’s policy and procedure regarding r stroke protocol. This deficient practice resulted in Patient 1’s severity of stroke not evaluated at the time when stroke alert was called, and had the potential to result in delayed g identification and reporting of the severity of stroke Patient 1 was experiencing, to the physician and the stroke team, thus causing delay in care and treatment. (Refer to A-0398) 11. The facility failed to ensure its nursing staff adhered to physician order and facility’s policy and procedure regarding intravenous (IV, administered into a vein) titratable (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) medications when Nursing staff administered and titrated IV nicardipine (medication to treat high blood pressure) without proper titration (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) and blood pressure (BP, normal blood pressure is generally considered to be less than 120/80 mmHg [millimeters of mercury, unit of measure]) monitoring for two of 41 sampled patients (Patient 1 and Patient 4). This deficient practice resulted in Patient 1’s blood pressure (BP) drop from 222/116millimeters of mercury (mmHg, unit of measure) to 67/40 mmHg within 1 hour and 30 minutes (from 6 p.m. to 7:30 p.m.), compromising Patient 1’s perfusion (process of blood carrying oxygen and nutrients to the body tissues and organs) to the brain. This deficient practice also had the potential to put Patient 4 at risk for hypotension (low blood pressure). (Refer to A-0405) 12. The facility failed to discontinue the nicardipine (Cardine IV infusion, a medication to control blood pressure and prevent cerebral [brain] venous spasm) and obtain a new physician order to restart Nicardipine IV infusion for one of 41 sampled patients (Patient 27), when Nicardipine IV was restarted beyond the 23 hours of its last administration (the order should have been discontinued and deemed inactive), in accordance with the original physician order set and the facility’s policy regarding titratable medications (slowly increasing the dose of a medicine by very small amounts over time [minutes, hours, days, weeks]). This deficient practice resulted in inappropriate administration of nicardipine to Patient 27 (beyond the prescribed duration), placing Patient 27 at increased risk of harm such as severe hypotension (low blood pressure) thus compromising Patient 27’s safety. (Refer to A-0405) 13. The facility failed to discontinue propofol (a medication used for general anesthesia induction and maintenance, sedation during monitored anesthesia care, and sedation) and obtain a new physician order to restart propofol infusion for one of 41 sampled patients (Patient 26), when propofol was continued beyond the 23 hours of its last administration, in accordance with the original physician order set and the facility’s policy regarding titratable medications (slowly increasing the dose of a medicine by very small amounts over time [minutes, hours, days, weeks). This deficient practice resulted in inappropriate administration of propofol to Patient 26 (beyond the prescribed duration), placing Patient 26 at increased risk of harm such as excessive sedation (drowsiness or sleep), respiratory depression (a breathing disorder characterized by slow or shallow breathing that doesn’t allow for proper gas exchange in the lungs) and/or death. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Medical Record Services, was met as evidenced by: 1.The facility failed to ensure that medical records for 20 of 41 sampled patients (Patients 2, 3, 8, 9, 10, 11, 12, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39) were accurately written or documented, in accordance with the facility’s policies regarding medical record content and completeness, when: 1.a. The rounds (a systematic process where a healthcare team member checks on a patient regularly) conducted, every 15 minutes, in the East side of the Psychiatric (relating to mental illness) Acute Care unit, were inaccurately documented in the medical record for 19 of 19 patients (Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39). This deficient practice led to the inaccurate documentation on 5/7/2025 at 4:15 a.m., that 19 patients had been visualized by a staff, when in fact, the round was not conducted at that time. This deficient practice also placed 19 patients’ safety at risk such as self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence. (Refer to A-0438) 1.b. For Patient 27, the electronic medical record (eMR, digital version of paper chart) titled, “Medication Administration Record (MAR),” did not accurately reflect the documentation of the peripheral intravenous line (PIV, a short, flexible plastic tube [catheter] inserted into a vein for the purpose of administering fluids, medications, or blood products) used to administer nicardipine (a medication used to treat hypertension [high blood pressure, a condition where the force of blood pushing against the walls of the arteries is consistently too high]). This deficient practice had the potential for Patient 27’s PIV site to be inadequately monitored for complications such as infiltration (the inadvertent delivery of fluid or medication into surrounding tissue that has the potential to harm the patient), phlebitis (inflammation of the vein), or extravasation (the leakage of fluid or substances from a blood vessel or other enclosed space into the surrounding tissues), leading to tissue damage, tissue ischemia (blood flow to a tissue or organ is restricted or reduced) , or necrosis (death of the tissue), and if undetected, may result in delayed treatment and/or negative health outcomes for Patient 27. (Refer to A-0438) 2. The facility failed to ensure that for one of 41 sampled patients (Patient 5), a death note (a documented record in the medical record to indicate the patient’s death, including the cause and circumstances), was completed and filed in Patient 5’s electronic medical record (eMR, digital version of paper charting) to formally document and record the death of a patient (Patient 5), in accordance with the facility’s policy regarding medical record content and completeness. This deficient practice violated Patient 5’s rights (the legal protections and ethical considerations that ensure individuals receive respectful, equitable, and informed medical care) with regards to the completeness and integrity of the medical record, potentially damaging a patient’s and their family’s trust in the healthcare system and their providers. (Refer to A-0450) 3. The facility failed to ensure that for one of 41 sampled patients (Patient 24), a comprehensive medical history and physical examination (H&P, a formal assessment of a patient that includes gathering their medical history and performing a physical examination) was completed, documented, and filed within 24 hours of Patient 24’s admission and prior to surgery, in accordance with the facility’s policy regarding chart completeness. This deficient practice had the potential to compromise Patient 24’s safety by delaying the identification of underlying health issues, contraindication, or risks that could impact surgical outcomes. In addition, this deficient practice can lead to inappropriate delayed medical interventions for Patient 24, increased risk of perioperative complications, and adverse events, or harm to the patient (Patient 24) due insufficient baseline assessment and incomplete documentation. (Refer to A-0458) 4. The facility failed to ensure that for one of 41 sampled patients (Patient 23), a completed verified informed consent (a voluntary formal confirmation- agreement signed by the patient or their authorized representative that confirms they understand the nature, risks, benefits, and alternatives of a medical procedure before it is performed) for anesthesia (blocking pain signals to the brain, preventing a person from feeling pain during a procedure), was filled out indicating the type of anesthesia to be used during the procedure (laminectomy, a surgical procedure where a surgeon removes a portion of the lamina, which is the back part of the vertebra, to relieve pressure on the spinal cord or nerve roots), initials, date, time and witness signature in the area designated for anesthesia on the consent form, in accordance with the facility’s policy regarding consents. This deficient practice had the potential to negatively affect Patient 23’s rights to decision-making (refers to the process in which patients are actively engaged in making informed choices about their healthcare options), undermining Patient 23’s autonomy (person’s right to make their own decisions) and compromise the legal validity (refers to legitimacy and enforceability of a document) of the consent due to lack of completeness of the medical record (verified informed consent form). (Refer to A-0466) 5. The facility failed to ensure that for one of 41 sampled patients (Patient 26), nursing staff initiated, maintained, and documented a current nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for status epilepticus (a seizure [a sudden, temporary disturbance of the brain’s normal electrical activity, often manifesting as changes in muscle tone, behavior, or awareness] lasting longer than five minutes or recurrent seizures without regaining full consciousness between them) that reflected the patient’s (Patient 26’s) goals and the nursing care to be provided to meet Patient 26’s needs, in accordance with the facility’s policy regarding care plans. This deficient practice had the potential for Patient 26’s care needs not to be met leading to adverse health outcomes for Patient 26, such as increased risk for injury during seizures, delayed recognition and response to seizure activity, lack of safety precautions to minimize the risk of harm during seizures. In addition, the lack of documented implementation of a seizure care plan had the potential to compromise communication among healthcare providers leading to disruptions in the continuity of care and Patient 26’s safety. (Refer to A-0467) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility’s governing body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to provide oversight to ensure intravenous (IV, administered into a vein) titratable (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) medications were administered in a safe manner when: 1. Orders were not discontinued per physician order by healthcare team members for five of 41 sampled patients (Patient 1, 6, 7, 26 and 27), in accordance with the facility’s policy and procedure regarding IV titration medications. Patient 1 and Patient 27 received IV nicardipine (medication to treat high blood pressure) four (4) days and 26 hours and 50 minutes from last administration, respectively. Patient 6’s IV Norepinephrine (medication to raise blood pressure) and IV Nicardipine were not discontinued on 5/16/2025 and 5/19/2025, respectively. Patient 7’s Nicardipine drip was not discontinued on 5/26/2025. Patient 26 received IV Propofol infusion (an intravenous medication used for sedation) 39 hours and 50 minutes beyond the last administration date of 5/27/2025. This deficient practice enabled nursing staff to gain access to discontinued medications and administered without physician order. Patient 1 suffered hypotension (low blood pressure) after IV nicardipine (medication to treat high blood pressure) administration. This deficient practice also had the potential to result in putting Patients 6, 7, 26, 27 and other patients receiving IV titratable medications at risk for adverse effects such as severe hypotension, excessive sedation (drowsiness or sleep), respiratory depression (a breathing disorder characterized by slow or shallow breathing that doesn’t allow for proper gas exchange in the lungs) and/or death, when the medications were given without valid physician order. 2. There was no parameter range (specific instructions or guidelines to determine the correct administration of a drug) set in the IV titratable medication order (Order set for Nicardipine drip) for one of 41 sampled patients (Patient 6), in accordance with the facility’s policy regarding “Titratable Medication Infusion Administration.” This deficient practice had the potential to put Patient 6 and other patients to receive unnecessary medications, which can compromise patient safety due to adverse medication effects such as severe hypotension. Findings: 1.a. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/24/2025, the “H&P” indicated, Patient 1 was admitted to the facility’s Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) with diagnoses including but not limited to subarachnoid hemorrhage (life-threatening type of stroke [a sudden disruption of blood flow to the brain] caused by bleeding into the space surrounding the brain), status post aneurysm coiling (a procedure to treat brain aneurysm [a bulge in the arteries of brain, potentially leading to a stroke if ruptured [burst]) on 1/24/2025 and uncontrolled hypertension (high blood pressure). During a review of Patient 1’s “Order Sheet (physician order sheet, orders written by physicians to direct care and treatment),” dated 1/30/2025, the physician order sheet indicated, to give nicardipine (medication to treat high blood pressure) intravenously (IV, administered into a vein) to keep systolic blood pressure (first number of blood pressure when the heart contracts and pushes out blood) less than 180 milliliters of mercury (mmHg, unit of measure) with initial (starting) rate of infusion (running) at 5 milligrams per hour (mg/hr, unit of measure), increment (an increase) of change at 2.5 mg/hr, frequency (how often) of increment of change every 15 minutes, maximum dose rate at 15 mg/hr. The physician order sheet also indicated, “discontinue order if rate remains at zero (0) for 23 hours.” During an interview on 5/28/2025 at 10:56 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: Patient 1 was found nonresponsive (does not react or move) on 2/6/2025 around 5:20 p.m. by Registered Nurse (RN) 1, Patient 1’s BP (blood pressure) was 222/116 mmHg at 6 p.m. Patient 1 was sent to radiology (a department that utilizes various imaging techniques to diagnose and treat diseases) for STAT (a medical abbreviation for immediately or without delay) CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head scan. RN 2 received Patient 1 at change of shift at 7 p.m. and noted Patient 1 receiving IV nicardipine at 75 ml/hr (15mg/hr, maximum dose). During a review of facility’s medication dispensing (to supply) record titled, “All Transaction Activity Detail Report (dispensing record),” dated 2/6/2025, the dispensing record indicated, RN 1 retrieved one bag of IV nicardipine 40 mg per 200 milliliters (ml, unit of measure) for Patient 1 on 2/6/2025 at 6:22 p.m. During a review of facility’s medication dispensing (to supply) record titled “All Transaction Activity Detail Report (dispensing record),” dated 2/6/2025, the dispensing record indicated, RN 1 retrieved one bag of IV nicardipine 40 mg per 200 milliliters (ml, unit of measure) for Patient 1 on 2/6/2025 at 6:22 p.m. During a concurrent interview and record review on 5/28/2025 at 11:24 a.m. with the Stroke Coordinator (SC) 1, Patient 1’s “Medication Administration Record (MAR, record of medications given to patients),” dated from 1/31/2025 to 2/6/2025, was reviewed. The MAR indicated, Patient 1 received IV nicardipine infusion starting on 1/31/2025 with initial rate at 5 mg/hr and it was titrated (to adjust the dose) to zero (0) on 2/1/2025 at 7:45 a.m. Nicardipine infusion rate was zero (0) from 2/2/2025 to 2/5/2025. The MAR also indicated, on 2/6/2025 at 7p.m., nicardipine was given at 15mg/hr with a comment indicating, “received patient (Patient 1) at this rate.” During the same interview on 5/28/2025 at 11:24 a.m. with the Stroke Coordinator (SC) 1, SC 1 stated the following: IV nicardipine was started for BP control and it was titrated to zero when the BP was within desired range. Patient 1 did not receive any nicardipine from 2/2/2025 to 2/5/2025. The nicardipine order should have been discontinued on 2/2/2025 by 6:45 a.m. since the last administration (2/1/2025) was over 23 hours. There should be a new order to restart IV nicardipine. During a concurrent interview and record review on 5/28/2025 at 11:30 a.m. with SC 1, Patient 1’s “Vital Signs” flowsheet (vital signs flowsheet), dated 2/6/2025, was reviewed. The vital signs flowsheet indicated the following: -At 5:40 p.m.: Heart Rate (HR) = 80 beats per minute (bpm), BP = 204/98 mmHg; -At 6 p.m.: HR = 94 bpm, BP = 222/116 mmHg; -At 7 p.m.: temperature = 97.9 degrees Fahrenheit (F, unit of measure 100.4 degrees Fahrenheit equivalent to 38.0 degrees Celsius) taken orally, no HR, and no BP documented; and -at 7:33 p.m.: HR = 70 bpm, BP = 67/40 mmHg. During the same interview on 5/25/2025 at 11:30 a.m. with the Stroke Coordinator (SC) 1, SC 1 stated the following: there was no monitoring on Patient 1’s blood pressure from 6 p.m. to 7:33 p.m. (1.5 hours) while Patient 1 was receiving IV nicardipine. Patient 1 became hypotensive (low blood pressure). Low blood pressure could affect perfusion (process of blood carrying oxygen and nutrients to the body tissues and organs) to the brain and contribute to no blood flow to brain. During a review of Patient 1’s “Physician Communication (physician communication note, documentation between nurse and physician communication regarding patient’s condition and test result)” note, dated 2/6/2025, the physician communication note indicated, at 7:28 p.m., RN 2 informed physician (MD 2) that Patient 1 was hypotensive, MD 2 ordered to stop nicardipine and start Levophed (norepinephrine, medication used to raise blood pressure in patients with severe hypotension). During a review of Patient 1’s “Neurosurgery Progress Note (neurosurgeon note, physician progress note completed by neurosurgeon),” dated 2/7/2025, the neurosurgeon note indicated, “(Patient 1) had sudden loss of conscious (unresponsive) yesterday. STAT CT showing large frontal (front part of the brain behind the forehead) hemorrhage (bleeding). Was started on Cardene (nicardipine, medication given intravenously [IV, directly into a vein) to lower blood pressure) for blood pressure management ... became bradycardic (low heart rate) and hypotensive (low blood pressure). Started pressor (medication to raise up the blood pressure) ... loss of brain stem reflexes (involuntary motor responses originating from the brainstem that control breathing, heart rate, and balance) were noted ... this morning remains unresponsive. No cough/gag reflex (a natural protective mechanism that prevents objects from entering the throat and potentially causing choking). No pupillary (relating pupil of the eye) or oculocephalic reflexes (a neurological reflex where the eyes move in the opposite direction of a rapid head rotation). No responses to painful stimuli. And not breathing over the ventilator (an appliance for artificial respiration). It was likely the patient has progressed to brain death (irreversible cessation of all brain function).” During an interview on 5/30/2025 at 11:56 a.m. with the ICU Director (DIR 2), DIR 2 stated the following: the order of IV nicardipine showed as active on order set because no one discontinued the order as it should have been. This gave RN 1 access to retrieve the medication (Nicardipine) and administered to Patient 1. During an interview on 5/30/2025 at 12 p.m. with DIR 2, DIR 2 state the following: the facility relied on nurses to check physician orders during shift report to discontinue any IV titration medication when it was not used for over 23 hours. There was room for human error that nurses might forget to remove the order. During an interview on 5/30/2025 at 12:39 p.m. with the ICU physician (MD 2), MD 2 stated the following: in ICU, the healthcare team would go over patient’s titratable medications. The physician could discontinue a medication order, but he (MD 2) expected the nurses to discontinue any IV titratable medications when it was not in use. From the physician’s end, he (MD 2) would not know if nurses were doing it (discontinuing the order) or not. It was possible for someone to overlook and not physically discontinue the order. During an interview on 5/30/2025 at 2:03 p.m. with the Director of Pharmacy (DIR 1), DIR 1 stated the following: the intention to discontinue IV titratable medication after not being used for over 23 hours was to avoid unnecessary medications. If the order remained active, nurses would have access to retrieve the medications. It relied on nursing critical thinking to discontinue the medications. Pharmacy did not have oversight. It was nursing responsibility. DIR 1 also stated the pharmacy was located in the basement and pharmacy staff were not there (in ICU) to check if the IV titratable medications have been stopped for over 23 hours. During an interview on 5/30/2025 at 4 p.m. with the Medication Safety Officer (MSO), MSO stated Patient 1’s nicardipine incident was identified as a medication error because IV nicardipine was restarted despite it (referring to the Nicardipine medication) not used for more than 23 hours (last administration was 2/1/2025) and there was no new order to give IV nicardipine on 2/6/2025. The team performed a root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution) but it (The Nicardipine incident involving Patient 1) was identified as an isolated event. During an interview on 5/30/2025 at 4:16 p.m. with the Senior Director for Risk Management (SDRM), SDRM stated the following: there was a root cause analysis (RCA) completed involving nursing leadership, pharmacy, stroke team, risk management and quality department on 3/13/2025. The facility had identified there was lack of monitoring and documentation with the IV nicardipine administration, but it was only identified as an individual isolated event. There was no action taken with regard to IV titration medication being given beyond the order time. SDRM also stated the RCA was incomplete because the facility did not look further into IV nicardipine order to identify if there was any systemic problem. During an interview on 5/30/2025 at 4:41 p.m. with the Chief Medical Officer (CMO), CMO stated the following: the GB was not aware of Patient 1’s nicardipine incident and the IV titration medication discontinuation and other order issues. It was a systemic problem and GB owned it. GB would need to do what was right for patients’ safety. During a review of the facility’s policy and procedure (P&P) titled, “Titratable Medication Infusion Administration,” dated 9/2021, the P&P indicated, “the purpose of this policy is to define and establish requirements for safe and accurate administration and documentation of titratable infusion medication orders... Discontinuing a titratable medication. 1. A titratable infusion order will include the order detail that the infusion should be discontinued from the MAR when the patient has not received the medication for 23 hours or more.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Errors Reporting,” 9/2022, the P&P indicated, “to establish procedures regarding medication errors and encourage all hospital staff to report all medication error reporting as a tool to enhance patient safety and prevent future errors ... Definitions: A. Medication Error - any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer ... Type of medication errors ... d. Administration error - types of administration errors may include: wrong patient, dose, time, medication, route, rate ... and unauthorized dose given ... Medication Error Prevention Team. 1. The pharmacy will use the findings of the medication error prevention and reduction team to develop pharmacy systems and workflow processes designed to prevent medication errors ... All medication errors discovered, as per definition, are subject to a quality assurance review. 2. The primary purpose of the quality assurance review is to advance error prevention by analyzing the cause and contributing factors such as system or process failures.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital),” dated 3/2024, the P&P indicated, “Scope: As part of performance improvement, leaders (including governing body) will: 1. Set priorities (i.e. high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines. 2. Identify frequency of data collection for performance improvement. 3. Prioritize performance improvement in response to changes within the internal and external environment. 4. Proactively identify processes needing improvement to prevent medical errors. 5. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performances of process improvement/deficiencies, and monitoring/sustaining processes ... Structure and Accountability ... 1. The Community Board (governing body [GB]) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectation for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective [the facility’s] committees/ teams.” 1.b. During a review of Patient 6’s “History and Physical (H&P),” dated 5/14/2025, the “H&P” indicated, Patient 6 was admitted to the facility’s Intensive Care Unit (ICU) with diagnoses including but not limited to subarachnoid hemorrhage (life-threatening type of stroke caused by bleeding into the space surrounding the brain), ruptured (burst) aneurysm (a bulge in the arteries of brain, potentially leading to a stroke if ruptured [burst]) and acute (new onset) hypoxic (deficiency in the amount of oxygen reaching the tissues) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood). During a review of Patient 6’s physician order, dated 5/14/2025, the physician order indicated, to give norepinephrine (medication to raise blood pressure) intravenously (IV) to keep mean arterial pressure (MAP, a measurement of the average arterial blood pressure throughout one cardiac [heart] cycle) greater than 65 mmHg with initial rate of infusion 4 micrograms per minutes (mcg/min, unit of measure), increment of change at 2mcg/min, frequency of increment of change at 2 minutes (min, unit of measure), maximum dose 30mcg/min. The physician order sheet also indicated, “discontinue order if rate remains at zero (0) for 23 hours.” The physician order also indicated the order was discontinued on 5/22/2025. During a review of Patient 6’s physician order, dated 5/15/2025, the physician order indicated, to give nicardipine (medication to treat high blood pressure) intravenously (IV) to keep systolic blood pressure (SBP) less than 160 mmHg, unit of measure with initial rate of infusion at 5 mg/hr, increment of change at 2.5 mg/hr, frequency of increment of change every 15 minutes, maximum dose rate at 15 mg/hr. The physician order sheet also indicated, “discontinue order if rate remains at zero (0) for 23 hours.” The physician order also indicated the order was discontinued on 5/22/2025. During a concurrent interview and record review on 5/29/2025 at 3:44 p.m. with the program manager (PM) 2 for chest pain compliance and audit, Patient 6’s “Medication Administration Record (MAR),” dated from 5/15/2025 to 5/22/2025, was reviewed. The MAR indicated the following: -IV norepinephrine was started on 5/14/2025 at 15 mcg/min and titrated to zero (0) on 5/15/2025 at 2 a.m. There was no IV norepinephrine infusion from 5/16/2025 to 5/22/2025; and -IV nicardipine was started on 5/15/2025 at 5 mg/hr and titrated to zero (0) on 5/18/2025 at 8 a.m. There was no IV nicardipine infusion from 5/19/2025 to 5/22/2025. During the same interview on 5/29/2025 at 3:44 p.m. with the program manager (PM) 2, PM 2 stated the following: IV norepinephrine should be discontinued on 5/16/2025 by 2 a.m., 23 hours from the last administration (5/15/2025 at 2 a.m.) and IV nicardipine should be discontinued on 5/19/2025 by 8 a.m., 23 hours from last administration (5/18/2025 at 8 a.m.). Either the nurse or physician could discontinue the orders. There would be potential for nursing staff to get the medication and give to patient if it was not discontinued. It was out of nursing scope of practice to give medication without a physician order. During an interview on 5/30/2025 at 4:41 p.m. with the Chief Medical Officer (CMO), CMO stated the GB was not aware the IV titration medication discontinuation and other order issues. It was a systemic problem and GB owned it. GB would need to do what was right for patients’ safety. During a review of the facility’s policy and procedure (P&P) titled, “Titratable Medication Infusion Administration,” dated 9/2021, the P&P indicated, “the purpose of this policy is to define and establish requirements for safe and accurate administration and documentation of titratable infusion medication orders... Discontinuing a titratable medication. 1. A titratable infusion order will include the order detail that the infusion should be discontinued from the MAR when the patient has not received the medication for 23 hours or more.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Errors Reporting,” 9/2022, the P&P indicated, “to establish procedures regarding medication errors and encourage all hospital staff to report all medication error reporting as a tool to enhance patient safety and prevent future errors ... Definitions: A. Medication Error - any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer ... Type of medication errors ... d. Administration error - types of administration errors may include: wrong patient, dose, time, medication, route, rate ... and unauthorized dose given ... Medication Error Prevention Team. 1. The pharmacy will use the findings of the medication error prevention and reduction team to develop pharmacy systems and workflow processes designed to prevent medication errors ... All medication errors discovered, as per definition, are subject to a quality assurance review. 2. The primary purpose of the quality assurance review is to advance error prevention by analyzing the cause and contributing factors such as system or process failures.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital),” dated 3/2024, the P&P indicated, “Scope: As part of performance improvement, leaders (including governing body) will: 1. Set priorities (i.e. high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines. 2. Identify frequency of data collection for performance improvement. 3. Prioritize performance improvement in response to changes within the internal and external environment. 4. Proactively identify processes needing improvement to prevent medical errors. 5. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performances of process improvement/deficiencies, and monitoring/sustaining processes ... Structure and Accountability ... 1. The Community Board (governing body [GB]) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectation for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective [the facility’s] committees/ teams.” 1.c. During a review of Patient 7’s “History and Physical (H&P),” dated 5/9/2025, the H&P indicated, Patient 7 was admitted to the facility’s Intensive Care Unit (ICU) with diagnoses including but not limited to acute (new onset) subarachnoid hemorrhage, metabolic encephalopathy (a broad term for any brain disease that alters brain function or structure) and acute ventilator (an appliance for artificial respiration) dependent respiratory failure (a condition where the lungs cannot adequately transfer oxygen into the blood or remove carbon dioxide, leading to a buildup of carbon dioxide and a deficiency of oxygen). During a review of Patient 7’s “Order Sheet (physician order),” dated 5/14/2025, the physician order indicated to give nicardipine intravenously (IV) to keep systolic blood pressure (SBP) less than 180 mmHg with initial rate of infusion at 5 mg/hr, increment of change at 2.5 mg/hr, frequency of increment of change every 15 minutes, maximum dose rate at 15 mg/hr. The physician order sheet also indicated, “discontinue order if rate remains at zero (0) for 23 hours.” The physician order also indicated the order was discontinued on 5/28/2025. During a concurrent interview and record review on 5/29/2025 at 4:23 p.m. with ICU RN 11, Patient 7’s “Medication Administration Record (MAR),” dated from 5/19/2025 to 5/28/2025, was reviewed. The MAR indicated Patient 7 received IV nicardipine infusion from 5/19/2025 to 5/25/2025. IV nicardipine infusion was titrated to zero (0) on 5/25/2025 at 6 a.m. There was no IV nicardipine infusion from 5/26/2025 to 5/28/2025. During the same interview 5/29/2025 at 4:23 p.m. with ICU RN 11, RN 11 stated the following: nurse should have discontinued the order on 5/26/2025 by 5 a.m., 23 hours after the last administration (5/25/2025 at 6 a.m.). The medication was not needed anymore. Nurses could discontinue the order without calling the physician. There would be potential for nurses to restart the medication without communicating with the physician when the order remained active. Nurse should contact the physician when patient had change of condition so the physician could evaluate the patient. During an interview on 5/30/2025 at 4:41 p.m. with the Chief Medical Officer (CMO), CMO stated the GB was not aware the IV titration medication discontinuation and other order issues. It was a systemic problem and GB owned it. GB would need to do what was right for patients’ safety. During a review of the facility’s policy and procedure (P&P) titled, “Titratable Medication Infusion Administration,” dated 9/2021, the P&P indicated, “the purpose of this policy is to define and establish requirements for safe and accurate administration and documentation of titratable infusion medication orders... Discontinuing a titratable medication. 1. A titratable infusion order will include the order detail that the infusion should be discontinued from the MAR when the patient has not received the medication for 23 hours or more.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Errors Reporting,” 9/2022, the P&P indicated, “to establish procedures regarding medication errors and encourage all hospital staff to report all medication error reporting as a tool to enhance patient safety and prevent future errors ... Definitions: A. Medication Error - any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer ... Type of medication errors ... d. Administration error - types of administration errors may include: wrong patient, dose, time, medication, route, rate ... and unauthorized dose given ... Medication Error Prevention Team. 1. The pharmacy will use the findings of the medication error prevention and reduction team to develop pharmacy systems and workflow processes designed to prevent medication errors ... All medication errors discovered, as per definition, are subject to a quality assurance review. 2. The primary purpose of the quality assurance review is to advance error prevention by analyzing the cause and contributing factors such as system or process failures.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital),” dated 3/2024, the P&P indicated, “Scope: As part of performance improvement, leaders (including governing body) will: 1. Set priorities (i.e. high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines. 2. Identify frequency of dada collection for performance improvement. 3. Prioritize performance improvement in response to changes within the internal and external environment. 4. Proactively identify processes needing improvement to prevent medical errors. 5. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performances of process improvement/deficiencies, and monitoring/sustaining processes ... Structure and Accountability ... 1. The Community Board (governing body [GB]) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectation for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective [the facility’s] committees/ teams.” 1.d. During a review of Patient 26’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/19/2025, the H&P indicated that Patient 26 was admitted to the facility with a diagnosis of status epilepticus (a continuous seizure [a temporary disruption of normal electrical activity in the brain that can cause changes in behavior, movement, or awareness] lasting five minutes or more, or recurrent seizures without recovery in between) and had to be intubated (a tube has been inserted into the patient’s windpipe (trachea) through their mouth or nose to help them breathe). During a review of Patient 26’s medical record (MR) titled, “Order Sheet,” dated 5/19/2025, the MR indicated that on 5/19/2025 at 5:58 a.m., the physician placed an order set for propofol (an intravenous medication used for sedation) to be given as a continuous infusion (titratable drip- slowly increasing the dose of a medicine by very small amounts over time) at initial rate of 10 micrograms per kilogram per minute (mcg/kg/min, measuring unit) .... Order comments indicated the following details: -“ ...Discontinue Order if rate remains at zero [0] for 23 hours ...” During a concurrent interview and record review on 5/29/2025 at 3:46 p.m. with registered nurse (RN) 6, Patient 26’s “Medical Administration Record (MAR),” dated 5/19/2025 through 5/29/2025, was reviewed. RN 6 stated that on 5/26/2025 at 10:09 a.m., the recorded (in patient 26’s MAR) rate for propofol was 0 mg/hr. RN 6 said that on 5/28/2025 at 1:59 a.m., propofol drip was restarted at 53.3 mg (over 39 hours and 50 minutes beyond the last administration time on 5/26/2025). RN 6 also said that because the order set for propofol indicated that the medication should be discontinued if the rate remains at zero for 23 hours, this order should have been discontinued, and a new order should have been placed to restart the propofol infusion (on 5/28/2025). During an interview on 5/30/2025 at 11:27 a.m. with the Critical Care Director (Dir 2), the Dir 2 stated, “Nurses have to verify any medication order ...ensuring the order is active before administering a medication ... If the medication order indicated to discontinue after 23 hours of not being used, then nurses should discontinue and obtain a new order if the same medication needs to be administered again ...Nurses cannot make any changes to the order without communicating with the physician [medical provider] first and obtaining the approval .... All verbal orders must be documented in the patient’s medical record, and it is the responsibility of either the nurse or the physician to ensure that this documentation is completed.” During an interview on 5/30/2025 at 4:41 p.m. with the Chief Medical Officer (CMO), CMO stated the GB was not aware about the IV titration medication discontinuation and other order issues. It was a systemic problem and GB owned it. GB would need to do what was right for patients’ safety. During a review of the facility’s policy and procedure (P&P) titled, “Titratable Medication Infusion Administration,” dated 9/2021, the P&P indicated, “the purpose of this policy is to define and establish requirements for safe and accurate administration and documentation of titratable infusion medication orders... Discontinuing a titratable medication. 1. A titratable infusion order will include the order detail that the infusion should be discontinued from the MAR when the patient has not received the medication for 23 hours or more.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Errors Reporting,” 9/2022, the P&P indicated, “to establish procedures regarding medication errors and encourage all hospital staff to report all medication error reporting as a tool to enhance patient safety and prevent future errors ... Definitions: A. Medication Error - any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer ... Type of medication errors ... d. Administration error - types of administration errors may include: wrong patient, dose, time, medication, route, rate ... and unauthorized dose given ... Medication Error Prevention Team. 1. The pharmacy will use the findings of the medication error prevention and reduction team to develop pharmacy systems and workflow processes designed to prevent medication errors ... All medication errors discovered, as per definition, are subject to a quality assurance review. 2. The primary purpose of the quality assurance review is to advance error prevention by analyzing the cause and contributing factors such as system or process failures.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital),” dated 3/2024, the P&P indicated, “Scope: As part of performance improvement, leaders (including governing body) will: 1. Set priorities (i.e. high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines. 2. Identify frequency of dada collection for performance improvement. 3. Prioritize performance improvement in response to changes within the internal and external environment. 4. Proactively identify processes needing improvement to prevent medical errors. 5. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performances of process improvement/deficiencies, and monitoring/sustaining processes ... Structure and Accountability ... 1. The Community Board (governing body [GB]) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectation for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective [the facility’s] committees/ teams.” 1.e. During a review of Patient 27’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/24/2025, the H&P indicated that Patient 27 was admitted to the facility with a diagnosis of subarachnoid hemorrhage (SAH, a type of stroke [a medical emergency that occurs when the brain’s blood supply is disrupted, causing brain damage] caused by bleeding into the subarachnoid space, which is the area between the brain and the thin tissues [meninges] that cover it) and ruptured brain aneurysm (a medical condition where a weakened, bulging area in a blood vessel wall in the brain bursts, causing bleeding within the brain). During a review of Patient 27’s medical record (MR) titled, “Order Sheet,” dated 5/24/2025, the MR indicated that on 5/24/2025 at 8:31 a.m., the physician placed an order set for nicardipine (Cardene I.V., a drip [infusion of a medication intended to lower blood pressure, BP]) to be given as a continuous infusion at a starting dose of 5 milligrams per hour (mg/hr, measuring unit) followed by increments of 2.5 mg/hr every 5 minutes until either reaching a maximal dose of 15 mg/hr or achieving the desired reduction in BP. Order comments indicated the following details: “ ...Discontinue Order if rate remains at zero [0] for 23 hours ...” During a concurrent interview and record review on 5/29/2025 at 11:37 a.m. with registered nurse (RN) 6, Patient 27’s “Medical Administration Record (MAR),” dated 5/23/2025 through 5/29/2025, was reviewed. RN 6 stated that on 5/24/2025 at 3 p.m., the recorded (in Patient 27’s MAR) rate for Cardene I.V. was 0 mg/hr. RN 6 also said that on 5/25/2025 at 6:50 p.m., Cardene I.V. drip was restarted at 2.5 mg/hr (26 hours and 50 minutes beyond the last administration time). RN 6 also said that because the order set for Cardene I.V. indicated that the medication should be discontinued if the rate remains at zero for 23 hours, this order should have been discontinued, and a new order should have been placed to restart the infusion. During an interview on 5/30/2025 at 11:27 a.m. with the Critical Care Director (Dir 2), the Dir 2 stated, “Nurses have to verify any medication order ...ensuring the order is active before administering a medication ... If the medication order indicated to discontinue after 23 hours of not being used, then nurses should discontinue and obtain a new order if the same medication needs to be administered again ...Nurses cannot make any changes to the order without communicating with the physician [medical provider] first and obtaining the approval ... All verbal orders must be documented in the patient’s medical record, and it is the responsibility of either the nurse or the physician to ensure that this documentation is completed.” During an interview on 5/30/2025 at 4:41 p.m. with the Chief Medical Officer (CMO), CMO stated the GB was not aware about the IV titration medication discontinuation and other order issues. It was a systemic problem and GB owned it. GB would need to do what was right for patients’ safety. During a review of the facility’s policy and procedure (P&P) titled, “Titratable Medication Infusion Administration,” dated 9/2021, the P&P indicated, “the purpose of this policy is to define and establish requirements for safe and accurate administration and documentation of titratable infusion medication orders... Discontinuing a titratable medication. 1. A titratable infusion order will include the order detail that the infusion should be discontinued from the MAR when the patient has not received the medication for 23 hours or more.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Errors Reporting,” 9/2022, the P&P indicated, “to establish procedures regarding medication errors and encourage all hospital staff to report all medication error reporting as a tool to enhance patient safety and prevent future errors ... Definitions: A. Medication Error - any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer ... Type of medication errors ... d. Administration error - types of administration errors may include: wrong patient, dose, time, medication, route, rate ... and unauthorized dose given ... Medication Error Prevention Team. 1. The pharmacy will use the findings of the medication error prevention and reduction team to develop pharmacy systems and workflow processes designed to prevent medication errors ... All medication errors discovered, as per definition, are subject to a quality assurance review. 2. The primary purpose of the quality assurance review is to advance error prevention by analyzing the cause and contributing factors such as system or process failures.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital),” dated 3/2024, the P&P indicated, “Scope: As part of performance improvement, leaders (including governing body) will: 1. Set priorities (i.e. high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines. 2. Identify frequency of dada collection for performance improvement. 3. Prioritize performance improvement in response to changes within the internal and external environment. 4. Proactively identify processes needing improvement to prevent medical errors. 5. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performances of process improvement/deficiencies, and monitoring/sustaining processes ... Structure and Accountability ... 1. The Community Board (governing body [GB]) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectation for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective [the facility’s] committees/ teams.” 2. During a review of Patient 6’s “History and Physical (H&P),” dated 5/14/2025, the “H&P” indicated, Patient 6 was admitted to the facility’s Intensive Care Unit (ICU) with diagnoses including but not limited to subarachnoid hemorrhage (life-threatening type of stroke caused by bleeding into the space surrounding the brain), ruptured (burst) aneurysm (a bulge in the arteries of brain, potentially leading to a stroke if ruptured [burst]) and acute (new onset) hypoxic (deficiency in the amount of oxygen reaching the tissues) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood). During a concurrent interview and record review on 5/29/2025 at 3:50 p.m. with the program manager (PM) 2 for chest pain, Patient 6’s physician order, dated 5/15/2025, was reviewed. The physician order indicated, to give nicardipine (medication to treat high blood pressure) intravenously (IV) to keep systolic blood pressure (SBP) less than 160 mmHg, unit of measure with initial rate of infusion at 5 mg/hr, increment of change at 2.5 mg/hr, frequency of increment of change every 15 minutes, maximum dose rate at 15 mg/hr. The physician order sheet also indicated, “discontinue order if rate remains at zero (0) for 23 hours.” PM 2 stated the parameter (specific instructions or guidelines to determine the correct administration of a drug) did not tell nurses how low the BP should be kept at and when to stop the IV nicardipine. During a review of Patient 6’s “Medication Administration Record (MAR),” dated from 5/15/2025 to 5/17/2025, the MAR indicated the following: -IV nicardipine was started on 5/15/2025 at 5 mg/hr and titrated to zero (0) on 5/16/2025 at 2:45 p.m. IV nicardipine was restarted on 5/17/2025 at 9:58 a.m. at 2.5mg/ hr, rate increased to 5 mg/hr at 10:13 a.m. Then the rate was decreased to 2.5 mg/hr at 7 p.m. During a concurrent interview and record review on 5/29/2025 at 3:50 p.m. with the program manager (PM) 2 for chest pain compliance and audit, Patient 6’s “Vital Signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient’s essential body functions) Flowsheet,” dated 5/17/2025, was reviewed. The Vital Signs Flowsheet indicated the following blood pressure (BP) was taken hourly while Patient 6 was receiving IV nicardipine infusion: -At 9 a.m. BP = 136/68, at 9:58 a.m. BP = 152/69, at 10 a.m. BP =161/75, at 11a.m. BP = 147/62, at 12 p.m. BP = 150/60, at 1 p.m. BP = 117/55, at 2 p.m. BP = 120/59, at 3 p.m. BP = 121/63, at 4 p.m. BP = 131/56, at 5 p.m. BP = 131/ 57, at 6 p.m. BP = 130/57, and at 7 p.m. BP = 115/53 During the same interview on 5/29/2025 at 3:50 p.m. with the program manager (PM) 2, PM 2 stated the following: there was missing vital signs when IV nicardipine was increased to 5 mg/hr at 10:13 a.m. Nurse should have decreased the IV nicardipine at 11 a.m. to 2.5 mg/hr when the BP was 147/62 because it was below the ordered parameter (to keep SBP less than 160 mmHg). Nurse should have continuously titrated Patient 6 off from IV nicardipine. Patient 6’s blood pressure was stable and did not need the IV nicardipine for this long. PM stated, “It (IV nicardipine) was not needed.” During an interview on 5/30/2025 at 12:49 p.m. with ICU physician (MD 2), MD 2 stated there should be two (2) numbers (one lower limit and one upper limit) included in the goal parameters in IV titration medication order to keep the goal in desired range. During an interview on 5/30/2025 at 2:13 p.m. with the Director of Pharmacy (DIR 1), DIR 1 stated the goal parameters for IV titratable medication order should have two (2) numbers: one lower limit and one upper limit. The pharmacy staff should contact physician if the parameter was not clear. DIR 1 stated, “it is our responsibility.” During an interview on 5/30/2025 at 4:41 p.m. with the Chief Medical Officer (CMO), CMO stated the following: the GB was not aware of the IV titration medication discontinued and other order issue. It was a systemic problem and GB owned it. GB would need to do what was right for patient’s safety. During a review of the facility’s policy and procedure (P&P) titled, “Titratable Medication Infusion Administration,” dated 9/2021, the P&P indicated, “the purpose of this policy is to define and establish requirements for safe and accurate administration and documentation of titratable infusion medication orders... Policy: A. complete titration order requirements must contain the following items ... 2. Measurable objective clinical goal the infusion must be titrated to achieve (for example goal: RASS [Richmond Agitation Sedation Scale, a tool for assessing a patient’s level of agitation and sedation] 0 to -1) ... B. Titration medication orders ... 2. The nurse must stay within the defined parameters of the medication orders ... D. Titratable medication documentation ... 2. The goal of the titratable medication (i.e. blood pressure, heart rate, RASS, pain, etc.) must be documented prior to initiating the titratable infusion and during each rate change. 3. Documentation will accurately reflect order changes and patient assessment ... E. Pausing a titratable medication ... 2. When the patient no longer meets criteria for the titratable medication infusion based on assessed physiological parameters (measurable characteristics such as vital signs), the nurse may pause the infusion .... A. Pausing an infusion can occur when the goal of the titratable mediation is met, and the infusion is no longer needed. If this occurs, the nurse will titrate down the medication until the infusion is turned off to challenge the patient’s physiological need for the medication. B. Pausing an infusion can also occur when the patient’s physiological parameters meet the hold criteria listed within the medication titration order. If this occurs, the nurse will turn off the infusion immediately instead of titrating the infusion down.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital),” dated 3/2024, the P&P indicated, “Scope: As part of performance improvement, leaders (including governing body) will: 1. Set priorities (ie high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines. 2. Identify frequency of dada collection for performance improvement. 3. Prioritize performance improvement in response to changes within the internal and external environment. 4. Proactively identify processes needing improvement to prevent medical errors. 5. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performances of process improvement/deficiencies, and monitoring/sustaining processes ... Structure and Accountability ... 1. The Community Board (governing body [GB]) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectation for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective [the facility’s] committees/ teams.””

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 46333 Based on interview and record review, the Governing Body (GB), responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision making, failed to ensure patient care and services rendered under contract with an outside entity (Radiology Services, provide imaging technology to diagnose and treat medical conditions. Radiologists, who are medical doctors specializing in radiology, interpret these images to aid in diagnosis and treatment planning), adhered to Radiology contract service expectations for timely (in less than 30 minutes) computed tomography (CT scan, medical imaging creates detailed images of the inside of the body) interpretation for one of five sampled patients (Patient 4) in the Emergency Department (ED), in accordance with the facility’s policy regarding contract processing and service agreement. This deficient practice resulted in a delay in 2-hours and 24-minutes in the interpretation of Patient 4’s CT of the brain, which delayed potentially life-saving intervention and contributed to a high likelihood of irreversible neurological damage (injury or harm that affects the brain, spinal cord [a bundle of nerves running down the spine]). Additionally, this deficient practice had the potential to cause delays in care for other patients presenting to the emergency department (ED) who require emergent CT interpretation for time-sensitive conditions. Findings: During a concurrent interview and record review on 5/28/2025 at 11:30 a.m. with the Stroke Program Manager/Coordinator (SC) 1, Patient 4’s “ED Physician Notes,” documented by ED physician (MD 4) and dated 2/18/2025, were reviewed. The notes indicated Patient 4 was brought to the ED (Emergency Department) for elevated blood pressure and complaints of nausea (a feeling of sickness) and vomiting for 12 hours. Patient 4’s blood pressure was over 200 systolic (the top number in a blood pressure reading). MD 4 documented that Patient 4 appeared drowsy (half-asleep; sleepy) and mildly confused (not be able to think or speak clearly). CT (Computed Tomography- medical imaging creates detailed images of the inside of the body) head and CT abdomen/pelvis were pending. MD 4 noted concern for hypertensive encephalopathy (a serious condition where a sudden, severe elevation in blood pressure causes brain dysfunction). During the same interview on 5/28/2025 at 11:30 a.m. with the Stroke Program Manager/Coordinator (SC) 1, SC 1confirmed that MD 4’s differential diagnoses (process is used to help make a final diagnosis when you have symptoms that don’t have one clear cause) included intercranial bleeding (bleeding in the brain), meningitis (an infection and swelling, called inflammation, of the brain), encephalitis (swelling of the brain), migraine headache (a headache that can cause severe throbbing pain), and cerebrovascular accident (CVA, also known as a stroke), indicating the physician was concerned about Patient 4’s head due to presenting symptoms of hypertension, being drowsy, and mildly confused. During the same interview on 5/28/2025 at 11:30 a.m. with the Stroke Program Manager/Coordinator (SC) 1, Patient 4’s “ED Physician Notes,” documented by ED physician (MD 5), was reviewed. MD 5 documented that the patient (Patient 4) was “signed out to me by my colleague to follow-up on CT results.” Upon rounding, MD 5 found that Patient 4 was very somnolent (abnormally drowsy) and presented with a new neurological deficit (a problem with the normal function of the brain, spinal cord, nerves, or muscles, resulting in abnormal function of a body part), including a right-sided facial droop and inability to move the left upper and lower extremities. A Code Stroke (initiation of an emergency response when a patient is suspected of having a stroke [a medical emergency that occurs when the brain’s blood supply is disrupted, causing brain damage]) was activated. SC 1 confirmed that the CT scan resulted at 6:33 a.m., prior to MD 5 discovering Patient 4 with stroke-like symptoms. During a concurrent interview and record review on 5/28/2025 at 12:00 p.m. with the Stroke Program Manager/Coordinator (SC) 1, Patient 4’s medical record document titled, “Orders,” dated 2/18/2025 at 2:59 a.m., was reviewed. The order indicated that MD 4 requested a STAT (a one-time order that is served immediately due to urgent circumstances) CT of the brain for evaluation of a headache. SC 1 stated the CT scan was completed at 4:09 a.m., and the interpretation was at 6:33 a.m. (after 2-hours and 24-minutes following completion of test). SC 1 said “This represents a delay of 2 hours and 54 minutes beyond the contract agreement with Radiology Services, which requires interpretation within 30 minutes.” During an interview on 5/28/2025 at 2:40 p.m. with the Director of Imaging Services (DIS) 1, DIS 1 stated during after-hours (5 p.m. to 6:30 a.m.), the contracted radiology service interpreted imaging studies. DIS 1 stated that both in-house and contracted radiologists were expected to interpret CT scan within 60 minutes. If interpretation was delayed, radiology technicians were expected to follow up with a call. However, no documentation of such follow-up was required, and none was recorded in Patient 4’s case. During an interview on 5/28/2025 at 4:20 p.m. with the Medical Director of Radiology (MDR) 1, MDR 1 stated that for patients presenting with headache and elevated blood pressure, the expectation was, the CT was to be interpreted within 30 minutes. If the contracted radiology group cannot meet this expectation, the technologist should escalate the request to an on-call radiologist. MDR 1 stated that changes in the radiologist schedule now resulted in the contracted service beginning coverage earlier at 5:00 p.m. instead of 7:00 p.m. During an interview on 5/29/2025 at 11:33 a.m. with the Medical Director of the Emergency Department (MDED), MDED stated, that in-house CT interpretations typically occurred within 10 minutes, but during night shifts when the contracted radiology group was used, reads may take 1 to 2 hours.” MDED stated If the physician was concerned, they may call the radiologist for a read sooner. MDED stated that faster results were critical for timely treatment and clinical decision-making. During an interview on 5/29/2025 at 11:33 a.m. with the ED physician (MD 4), MD 4 confirmed that CT read times were variable and can sometimes take up to two hours or more to receive results. During an interview on 5/30/2025 at 4:40 p.m. with the Director of Quality Assurance and Performance Improvement (DOQ), the DOQ stated that contract performance for radiology services was monitored by the Chief Medical Officer (CMO), who was the contract owner/contract manager responsible for completing an “Annual Review Summary” and “Annual Appraisal of Clinical Patient Care Contracted Services,” in accordance with CMS (Center for Medicare and Medicaid Services) Requirement, Section 482, and submitting them to Quality Assurance and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) committee, which oversees the facility’s quality monitoring and improvement efforts. The DOQ stated that only one Annual Review Summary had been submitted (in 2022) since the contract became effective on 11/1/2020. Reviews for 2021, 2023, and 2024 were not submitted, and therefore not communicated to Governing Body (GB). The DOQ also confirmed that the “Annual Appraisal of Clinical Patient Care Contracted Services” form was never submitted to QAPI. During an interview on 5/30/2025 at 5:00 p.m. with the Chief Medical Officer (CMO), the CMO stated that the position (CMO) had been vacant from August 2024 to March 2025. The current CMO acknowledged being aware of delays in CT interpretations by the contracted radiology service and noted that communication with the vendor had taken place to address the issue. CMO further indicated that the facility was currently exploring options, including the possibility of transitioning to a different radiology contract service to better support timely imaging interpretation. During a review of the facility’s policy and procedure (P&P) titled, “Contract Processing,” dated 2/2/2023, the P&P indicated, “(name of the facility) is committed to ensuring that all contractual arrangements (i) are in compliance with all regulatory and legal requirements ...Contract Manager: The AH employees who have principal responsibility for the drafting, reviewing, processing, and managing of contracts. All nonphysician Contracts are processed within the contract management program by the corporate shared services contract management team & corporate sourcing team. The Contract Manager collaborates with the Business Owners to monitor the contract portfolio for annual reviews, upcoming expirations and/or renewals. Based upon Business Owner input, the Contract Manager terminates or renews contracts as appropriate.” During a review of the facility’s “Radiology Department Professional and Medical Director Services Agreement,” dated 5/29/2025, the Agreement indicated that emergency department study reports were expected to be completed in less than 30 minutes, and all stat studies in less than 45 minutes. Reports must be electronically signed within 24 hours of procedure completion. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI),” dated 3/13/2024, the P&P indicated, “The Community Board (GB) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectations for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective (name of the facility) committees/teams.””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to: 1. Protect one of 19 sampled patients (Patient 3) in the Psychiatric (relating to mental illness) Acute Care (PAC) unit, from an assault (an act that threatens physical harm to a person, whether or not actual harm is done), in accordance with the facility’s protocol regarding provision of a safe environment of care, when Patient 2 entered Patient 3’s room for approximately 2 to 3 minutes, with no staff members present in the hallway while Patient 2 entered Patient 3’s room. This deficient practice resulted in Patient 2 (male patient) entering Patient 3’s room, resulting in scratches to Patient 3’s (female patient) upper and lower lip and had the potential to result in serious injury or harm. In addition, after the incident, Patient 3 became anxious, watchful, fearful, scared, and constantly looking over her shoulder. 2. Ensure one of two sampled Behavioral Health Unit (BHU, a specialized area within a hospital dedicated to providing mental health care) staff (Licensed Vocational Nurse 2), completed her “Abuse and Neglect” module (training module that discusses the types of abuse [refers to any action or failure to act by a caregiver that causes harm or distress to a patient, encompassing various forms like physical, emotional, sexual, and financial abuse, as well as neglect] and neglect, the related indicators and the reporting responsibilities of health care providers) yearly, in accordance with the facility’s annual education requirements. This deficient practice had the potential for violations of patient rights such as being free from all forms of abuse, due to lack of staff training. On 5/29/2025 at 12:22 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Medical Officer (CMO), the Senior Director for Risk Management (SDRM), the Patient Care Executive/Chief Nursing Officer (CNO), the Director of Quality (DOQ), and via telephone, the Director for Accreditation and Licensing (DAL). Patient 2 was admitted to the facility, on 4/19/2025, on a 5150 Hold (72 - hour involuntary hold) for Grave Disability (a person who is unable to care for their basic needs due to a mental health disorder). Patient 3 was admitted to the facility on 5/01/2025, on a 5150 Hold for suicidal ideations (thought of harming oneself). A review of video footage in the Psychiatric Acute Care (PAC) Unit, dated 5/07/2025 indicated the following: At 7:55 a.m., Patient 2 entered Patient 3’s room, located across the hall, no staff (certified nurse assistants, licensed vocational nurses, or registered nurses) were in the hallway at that time. At 7:57 a.m., Patient 2 and Patient 3 walked out of Patient 3’s room. Patient 2 walked back to his (Patient 2) room. Patient 3 lingered in the hallway. At 7:58 a.m., Licensed Vocational Nurse (LVN) 1 was talking to Patient 3 in the hallway. Per LVN 1, Patient 3 reported that Patient 2 entered her (Patient 3) room, placed his (Patient 2) hand over her (Patient 3) mouth, which caused scratches to Patient 3’s face. In addition, Patient 3 was anxious and scared after Patient 2 entered her (Patient 3) room. On 5/30/2025 at 5:49 p.m., the IJ was removed in the presence of the CMO, SDRM, CNO, DOQ, the Regulatory Specialist (RS), and the DAL via telephone. The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The acceptable IJ Removal Plan included the following: Every 15 minutes observation, staff must enter the patient room to verify patient status and document findings in real time. A dedicated hallway observer (either a Mental Health Worker or Certified Nurse Assistant) is assigned each shift. The dedicated hallway observer has no other patient care duties, monitors patient movement and behavior ...prevents cross-room entry by other persons and must call the lead and resource nurse before stepping away. A standardized hourly rounding log was implemented for licensed nursing staff. In-person education was provided to staff on the psychiatric units. In addition, there will be daily, unannounced, observation audits, video surveillance audits 5 times per week, and review of assignment to ensure inclusion of the hallway observer each shift. Findings: 1. During a review on 5/28/2025 at 10:25 a.m., a video footage, dated 5/7/2025, of the East side of the Psychiatric (relating to mental illness) Acute Care Unit, was reviewed. The following was reviewed with Nurse Managers (NM) 1 and NM 2, and the Director of Security (DOS). The video footage indicated the following: At 7:55 a.m., Patient 2 (male) exited his (Patient 2) room and entered Patient 3’s (female) room, located across the hall. No staff (registered nurses [RN] or licensed vocational nurses [LVNs]) were present in the hallway at this time. At 7:57 a.m., Patient 2 and Patient 3 walked out of Patient 3’s room. Patient 2 walked back to his (Patient 2) room across the hall. Patient 3 lingered in the hallway. At 7:58 a.m., Licensed Vocational Nurse (LVN) 1 went into Patient 2’s room, then LVN 1 was seen talking to Patient 3 in the hallway. At 8:15 a.m., Registered Nurse (RN) 5 went into Patient 2’s room. At 8:17 a.m., Registered Nurse (RN) 4 and Patient 2 walked out of Patient 2’s room. Patient 2 was carrying his (Patient 2) belongings. During an interview on 5/28/2025 at 10:25 a.m. with Nurse Managers (NM) 1 and 2, NM 1 and NM 2 verified that Patient 2 entered Patient 3’s room, which was a single room. Patient 3 was alone with Patient 2 for two to three minutes. NM 1 stated Patient 3’s safety was at risk. Patient 2 was moved to another unit following the incident. NM 1 stated Registered nurses were required to conduct hourly rounds on their assigned patients. During an interview on 5/28/2025 at 2:08 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she (LVN 1) saw Patient 2 come out of Patient 3’s room. LVN 1 instructed Patient 2 to go back to his (Patient 2) room. LVN 1 stated Patient 3 said a male patient entered her (Patient 3) room and demonstrated, by placing her (Patient 3) hand over her mouth, that Patient 2 covered her (Patient 3) mouth. LVN 1 further stated Patient 3 had a small red mark on the right side of her nose and right upper lip. Patient 3 was anxious and scared after Patient 2 entered her (Patient 3) room. LVN 1 reported the incident to Registered Nurse (RN) 4 and RN 5. During a second interview on 5/28/2025 at 4:14 p.m. with NM 1, NM 2, NM 1 and NM 2 stated that on 5/7/2025 between 7 a.m. and 8 a.m., it was breakfast time, staff were busy handing out breakfast trays and LVN 1 was conducting rounds (a systematic process where healthcare professionals, like nurses, regularly visit patients to assess their condition) every 15 minutes. NM 1 further stated that since 5/12/2025, the facility implemented a new practice where the RN had to be on the floor and not just at the Nurses station to visualize patient movements at all times. During a review of Patient 2’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/19/2025, the H&P indicated the following: Patient 2 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for Grave Disability (a person who is unable to care for their basic needs due to a mental health disorder). During a review of Patient 3’s History and Physical (H&P), dated 5/01/2025, the H&P indicated Patient 3 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for suicidal ideations (thoughts of harming self). During a review of Patient 3’s “Clinical Note Nursing,” dated 5/7/2025 at 1:54 p.m., the Clinical Note indicated the following: At 7:30 a.m., Patient 3 approached staff stating a male patient entered her (Patient 3) room and put his (Patient 2) hand on her (Patient 3) face: Patient 3 appeared anxious, fearful but refused to give any more information ...Patient 3 observed to have a small, superficial scratches on her right upper lip and one (scratch) on the left lower lip ... During a review of Patient 3’s “Clinical Note Nursing,” dated 5/7/2025 at 4:25 p.m., the Clinical Note indicated the following: “patient (Patient 3) is alert ...appears paranoid, watchful, looking over her shoulder, appears fearful when approached by staff; patient (Patient 3) stated a male patient came into her room at around 7:30 a.m., and put his (Patient 2) hand on her face, causing two superficial scratches on her upper and lower lip ...” During a review of the facility’s policy and procedure (P&P) titled, “Assault and Abuse (refers to any action or failure to act by a caregiver that causes harm or distress to a patient, encompassing various forms like physical, emotional, sexual, and financial abuse, as well as neglect) Reporting for Staff and Management,” dated 9/27/2021, the P&P indicated the following ... Assaultive and/or abusive behavior often results in significant physical and mental suffering to the victim ... This policy serves to: 1. Promote a safer environment for our patients. 2. Heighten awareness of the realities of assault, abuse, neglect, and misconduct against vulnerable members of society ... B. The patient’s safety and welfare is always your first concern. Thoroughly assess the patient (and intervene accordingly) to address any immediate medical or psychosocial needs... During a review of the facility’s “Handbook,” relating to Rights of Individuals in Mental Health Facilities, dated 8/2016, the Handbook indicated the following: Your Right as a Patient ...The person in charge of the facility in which you are receiving treatment is responsible for ensuring that all your rights in this handbook are protected ...The right to be free from abuse or neglect: You have the right to be free from abuse, neglect, or harm ... During a review of a facility’s undated document titled, “Patient Rights,” the document indicated “You have the right to ...Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect ...” 2. During a concurrent interview and record review on 05/29/2025 at 2:30 p.m. with the Director of Behavioral Health (DBH) 1, LVN 2’s “Healthstream (a web-based learning management platform)” training records, was reviewed. The record indicated that LVN 2 failed to complete her (LVN 2) yearly training on abuse. The last abuse training module titled, “[Name of Facility] 2013 Assault and Abuse Reporting RN/LVN Competency,” was completed on 08/09/2017. DBH 1 stated that abuse training must be completed by all direct patient care staff yearly. LVN 2 had no record of completing her annual abuse training. During a concurrent interview and record review on 05/29/2025 at 3:19 p.m. with the Education Manager (EM 1), the personnel records, specifically, the training records titled, “To Do List” for LVN 2, undated, were reviewed. The record indicated that LVN2 failed to complete her yearly training on abuse titled, “SQ: Clinical Rapids Review.” The records indicated that LVN 2’s last completion of training was 09/01/2024. During the same interview on 05/29/2025 at 3:19 p.m. with the Education Manager (EM 1), EM 1 stated that the “Abuse and Neglect” training module was under “SQ: Clinical Rapid Review” Course. This course was mandatory for all direct patient care nurses and must be completed yearly. LVN 2 was a current active employee in BHU and should have completed her annual training on “Abuse and Neglect.” This training was important because it helps staff identify abuse and the facility’s abuse reporting process.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI, a data-driven, facility-wide program designed to monitor, assess, and improve the quality and safety of patient care) program included monitoring and oversight of services provided under contract, specifically radiology services (provide imaging technology to diagnose and treat medical conditions. Radiologists, who are medical doctors specializing in radiology, interpret these images to aid in diagnosis and treatment planning), to ensure timely (in less than 30 minutes) computed tomography (CT scan, medical imaging creates detailed images of the inside of the body) interpretation for one of five sampled patients (Patient 4) in the Emergency Department (ED), in accordance with the facility’s performance improvement policy. Additionally, the hospital failed to establish an ongoing process to measure, analyze, and track performance indicators related to contracted radiology services, as required, to support and improve health outcomes and quality of care. This deficient practice resulted in the lack of timely identification and response to performance issues that directly affected patient care, including delays in emergency CT interpretation for Patient 4. This deficient practice had the potential for delays in the delivery of necessary care interventions for Patient 4 and other patients in the facility. Findings: During a concurrent interview and record review on 5/28/2025 at 11:30 a.m. with the Stroke Program Manager/Coordinator (SC 1), Patient 4’s “ED Physician Notes,” documented by Emergency Department (ED, a hospital facility that provides immediate medical care to patients who need urgent attention) physician (MD 4) and dated 2/18/2025, were reviewed. The notes indicated Patient 4 was brought to the ED for elevated blood pressure and complaints of nausea (a feeling of sickness) and vomiting for 12 hours. Patient 4’s blood pressure was over 200 systolic (the top number in a blood pressure reading). MD 4 noted that Patient 4 appeared “drowsy (half-asleep; sleepy) and mildly confused (not be able to think or speak clearly),” and ordered a STAT (a one-time order that is served immediately due to urgent circumstances) computed tomography (CT scan, medical imaging creates detailed images of the inside of the body) of the brain at 2:59 a.m. SC 1 confirmed that MD 4’s differential diagnoses (process is used to help make a final diagnosis when you have symptoms that don’t have one clear cause) included intercranial bleeding (bleeding in the brain. The scan was completed at 4:09 a.m. but was not interpreted until 6:33 a.m. a delay of 2 hours and 24 minutes. During the same interview on 5/28/2025 at 11:30 a.m. with the Stroke Program Manager/Coordinator (SC 1), Patient 4’s “ED Physician Notes,” documented by ED physician (MD 5), was reviewed. MD 5 noted that the patient (Patient 4) “was signed out to me by my colleague to follow-up on CT results.” Upon rounding (a systematic process where a healthcare team member checks on a patient regularly), MD 5 found that Patient 4 was very somnolent (abnormally drowsy) and presented with a new neurological deficit (a problem with the normal function of the brain, spinal cord, nerves, or muscles, resulting in abnormal function of a body part), including a right-sided facial droop (sagging appearance of one side of the face due to weakness or paralysis of the facial muscles) and inability to move the left upper and lower extremities. A Code Stroke (initiation of an emergency response when a patient is suspected of having a stroke [a medical emergency that occurs when the brain’s blood supply is disrupted, causing brain damage]) was activated. SC 1 stated timely availability of CT scan results was important in the evaluation of patients with suspected stroke, noting that early interpretation was critical for initiating appropriate interventions. The SC 1 confirmed that a delay in CT interpretation could potentially contribute to the delayed recognition and treatment of a suspected stroke, placing the patient at risk for serious, and potentially irreversible neurological (affect the brain as well as the nerves found throughout the human body and the spinal cord) harm. During an interview on 5/30/2025 at 4:40 p.m. with the Director of Quality Assurance and Performance Improvement (DOQ), the DOQ stated that contract performance for radiology services was monitored by the Chief Medical Officer (CMO), who was responsible for completing an “Annual Review Summary” and “Annual Appraisal of Clinical Patient Care Contracted Services,” in accordance with CMS (Centers for Medicare and Medicaid Services) Requirement, Section 482, and submitting them to Quality Assurance and Performance Improvement (QAPI, a data-driven, facility-wide program designed to monitor, assess, and improve the quality and safety of patient care)) committee, which oversees the facility’s quality monitoring and improvement efforts. The DOQ stated both forms were intended to evaluate contractor performance. However, no such evaluations had been submitted for radiology contractor, and no reports or summaries regarding radiology performance were available for review. The DOQ stated that only one Annual Review Summary had been submitted (in 2022) since the contract became effective on 11/1/2020. Reviews for 2021, 2023, and 2024 were not submitted, and therefore not communicated to Governing Body (GB). The DOQ also confirmed that the “Annual Appraisal of Clinical Patient Care Contracted Services” form was never submitted to QAPI. During an interview on 5/30/2025 at 5:00 p.m. with the Chief Medical Officer (CMO), the CMO confirmed that the radiology contract had not been renewed since 2021, and that the oversight process for contract performance had been disrupted due to a vacancy in the CMO role from August 2024 to March 2025. The CMO stated that although discussions had occurred with the radiology vendor after assuming the role in March 2025, performance data had not been consistently provided to QAPI, and no formal analysis or follow-up actions had been initiated regarding CT delays. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI),” dated 3/13/2024, the P&P indicated, “As part of performance Improvement, leaders (including governing body) will: Set priorities (re high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines. Identify frequency of data collection for performance improvement. Prioritize performance improvement in response to changes within the internal and external environment. Proactively identify processes needing improvement to prevent medical errors. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performance of process improvement/deficiencies, and monitoring/sustaining processes. Annually review performance improvement plan/priorities and update to reflect changes in strategic priorities and/or environment. Determine annual performance improvement projects proportional to scope and complexity of hospital services and operations ... Patient safety integrates with all quality assessment and performance Improvement activities. Proactive Risk Assessments ...will be utilized to assess actual and potential risk, failure, points of vulnerability, and prioritized areas for improvement based on impact to patient care outcomes ...””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 36206 Based on interview, and record review, the facility’s Quality Assurance and Performance Improvement (QAPI, a data-driven, facility-wide program designed to monitor, assess, and improve the quality and safety of patient care) committee failed to: 1. Analyze and track an adverse patient event (any unfavorable or unintended occurrence), in accordance with the facility’s policy regarding performance improvement, when it failed to conduct a thorough investigation for an allegation of an assault (an act that threatens physical harm to a person, whether or not actual harm is done) that was reported by one of 41 sampled patients (Patient 3) on 5/7/2025, when Patient 2 entered Patient 3’s room and covered Patient 3’s mouth, which resulted to visible scratches to Patient 3’s upper and lower lip. In addition, the facility failed to report the incident to the regulatory agency within 24 hours of the incident, in accordance with the facility’s policy regarding adverse event reporting. This deficient practice led to an incomplete investigation of the alleged Patient 2 assault on Patient 3 and resulted in the facility not reporting the assault within 24 hours to the regulatory agency resulting in a delay of investigation of the incident. This deficient practice of not analyzing and tracking adverse patient events also had the potential for the facility’s inability to adequately identify and address issues, leading to an increased risk of preventable harm to patients. 2. Ensure its Quality Assurance and Performance Improvement (QAPI) team performed a thorough investigation for one of 41 sampled patient’s (Patient 1) medication safety event on 2/6/2025 (Patient 1 was re-started on a Nicardipine drip [medication to treat high blood pressure] without a proper physician order which caused a sudden drop in Patient 1’s blood pressure) and identify a systemic failure regarding IV titratable medication order discontinuation, in order to prevent two other patients (Patient 26 and 27) from receiving an IV titratable medication that should have been discontinued, in accordance with the facility’s policies regarding performance improvement and IV titratable medications. This deficient practice, regarding the lack of a thorough investigation into Patient 1’s medication safety event, resulted in no action plan implemented to ensure IV titratable medications were discontinued per physician orders, thus leading to other incidents involving other patients (Patient 26 and Patient 27) receiving IV titration medications, which should have been discontinued 23 hours after the last administration, as well as putting patients at risk for harm and potential to experience complications. Findings: 1. During a review on 5/28/2025 at 10:25 a.m., a video footage, dated 5/7/2025 of the East side of the Psychiatric (relating to mental illness) Acute Care Unit, was reviewed. The following was reviewed with Nurse Managers (NM) 1 and NM 2, and the Director of Security (DOS). The video footage indicated the following: At 7:55 a.m., Patient 2 (male patient) exited his (Patient 2) room and entered Patient 3’s (female patient) room, located across the hall. No staff (registered nurses [RN] or licensed vocational nurses [LVNs]) were in the hallway at this time. At 7:57 a.m., Patient 2 and Patient 3 walked out of Patient 3’s room. Patient 2 walked back to his (Patient 2) room across the hall. Patient 3 lingered in the hallway. At 7:58 a.m., Licensed Vocational Nurse (LVN) 1 went into Patient 2’s room, then LVN 1 was seen on video surveillance talking to Patient 3 in the hallway. At 8:15 a.m., Registered Nurse (RN) 5 went into Patient 2’s room. At 8:17 a.m., Registered Nurse (RN) 4 and Patient 2 walked out of Patient 2’s room. Patient 2 was carrying his (Patient 2) belongings. During an interview on 5/30/2025 at 3:30 p.m. with the Regulatory Specialist (RS), the RS stated she (RS) tried to interview Patient 3 about the alleged assault (an act that threatens physical harm to a person, whether or not actual harm is done) that took place on 5/7/2025, but Patient 3 became paranoid (a pattern of thinking where someone experiences intense, irrational distrust and suspicion of others) and asked her (RS) to leave. The RS also stated that she (RS) did not watch the video footage until 5/12/2025 (5 days after the incident occurred), when the state regulatory agency arrived to investigate the incident. During an interview on 5/30/2025 at 3:30 p.m. with the Senior Director of Risk Management (SDRM), the SDRM stated the following: SDRM learned of the allegation by Patient 3 via an incident report submitted by Registered Nurse (RN) 5 on 5/7/2025, which was brought to her (SDRM) attention by the Director of Behavioral Health (DBH) ... DBH attempted to interview Patient 3 but Patient 3 refused to give any further details, other than a male entered her (Patient 3) room and covered her (Patient 3) mouth, which caused scratches to her (Patient 3) face. No attempts were made to watch the video footage. A formal root cause analysis (RCA, a systematic problem-solving method that aims to identify the underlying causes of events, problems, or failures) was not performed. The investigation could have been better. The investigation was not continued. There was not sufficient evidence at that point and the decision was made not to report the incident to the regulatory agency. SDRM stated that Patient 3 suffered an assault on 5/7/2027 and it should have been reported to the regulatory agency within 24 hours, for a prompt investigation and to identify any potential risk to the other patients. During a review of Patient 3’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/01/2025, the H&P indicated Patient 3 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for suicidal ideations (thoughts of harming self). During a review of Patient 3’s “Clinical Note Nursing,” dated 5/7/2025 at 1:54 p.m., the Clinical Note indicated the following: At 7:30 a.m., Patient 3 approached staff stating a male patient entered her (Patient 3) room and put his hand on her (Patient 3) face: Patient 3 appeared anxious, fearful but refused to give any more information ...Patient 3 observed to have a small, superficial scratches on her right upper lip and one (scratch) on the left lower lip ... During a review of Patient 3’s “Clinical Note Nursing,” dated 5/7/2025 at 4:25 p.m., the Clinical Note indicated the following: “patient (Patient 3) is alert ...appears paranoid, watchful, looking over her shoulder, appears fearful when approached by staff; patient (Patient 3) stated a male patient came into her room at around 7:30 a.m., and put his hand on her face, causing two superficial scratches on her upper and lower lip ...” During a review of the facility’s policy and procedure (P&P) titled, “Reporting and Investigation of Incidents and Near Misses Policy,” dated 12/21/2022, the P&P indicated the following. Definitions: Adverse event - Untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. During a review of the facility’s policy and procedure (P&P) titled, “Adverse Event Reporting - California,” dated 5/09/2023, the P&P indicated the following. The purpose of this policy is to facilitate quality improvement in the health care system by establishing a standard process for identifying and reporting adverse events that occur within the Hospitals and affected departments ...A. Identification of Reportable adverse Events ...Criminal Events including the following ...The death or serious injury of a patient or staff member from a physical assault (i.e. battery) that occurs within or on the grounds of a health care facility ....An adverse event or series of adverse events that cause the death or serious disability of a patient, personnel, or visitor ...When an adverse event occurs, staff must follow specific policies regarding documentation and notification processes. It is the responsibility of the assigned department (quality management, risk management, administration, etc.) to verify that the adverse event is reportable to the appropriate state agency or department ...Once the occurrence of an adverse event is confirmed the following shall be submitted to the State Agency (regulatory) ...An adverse event must be reported to the department no later than five (5) days after the adverse event has been detected, or if that event is an ongoing, urgent or emergent threat to the welfare, health, or safety of patients ...not later than 24 hours after the adverse event has been detected ...Investigation: An investigation into the cause of the event shall be under taken, using root cause analysis (RCA, a systematic problem-solving method that aims to identify the underlying causes of events, problems, or failures), intensified review or other approved investigative process. The investigation will be conducted for the purpose of the evaluation and improvement of the quality of care in the health care facility ...Quality Assessment and Performance Improvement (QAPI): The hospital must measure, analyze, and track adverse patient events. Performance improvement activities must track ...adverse events, analyze their causes, and implement preventative actions and mechanisms that include feedback and learning throughout the hospital ... During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment and Performance Improvement (QAPI) Program Plan,” dated 5/28/2025, the P&P indicated the following ...Process improvement indicators will focus on improvement of health outcomes and prevention/reduction of medical error and will include: Measurement and tracking of medical errors/adverse patient events with analysis of causes. Implementation of preventative actions that include feedback and learning throughout the organization. 2. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/24/2025, the “H&P” indicated, Patient 1 was admitted to the facility’s Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) with diagnoses including but not limited to subarachnoid hemorrhage (life-threatening type of stroke caused by bleeding into the space surrounding the brain), status post aneurysm coiling (a procedure to treat brain aneurysm [a bulge in the arteries of brain, potentially leading to a stroke if ruptured [burst]) on 1/24/2025 and uncontrolled hypertension (high blood pressure). During a review of Patient 1’s “Order Sheet (physician order sheet, orders written by physicians to direct care and treatment),” dated 1/30/2025, the physician order sheet indicated, to give nicardipine (medication to treat high blood pressure) intravenously (IV, administered into a vein) to keep systolic blood pressure (first number of blood pressure when the heart contracts and pushes out blood) less than 180 millimetres of mercury (mmHg, unit of measure) with initial (starting) rate of infusion (running) at 5 milligrams per hour (mg/hr, unit of measure), increment (an increase) of change at 2.5 mg/hr, frequency (how often) of increment of change every 15 minutes, maximum dose rate at 15 mg/hr. The physician order sheet also indicated, “discontinue order if rate remains at zero (0) for 23 hours.” During an interview on 5/27/2025 at 3:14 p.m. with the Intensive Care Unit (ICU) Registered Nurse (RN) 3, RN 3 stated the following: nurse should start IV nicardipine at 5mg/hr and titrate (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) per physician order. There should be a set of vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) to coordinate with each titration. During an interview on 5/28/2025 at 10:56 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: Patient 1 was found nonresponsive (does not react or move) on 2/6/2025 around 5:20 p.m. by RN 1, Patient 1’s BP was 222/116 mmHg at 6 p.m. Patient 1 was sent to radiology (a department that utilizes various imaging techniques to diagnose and treat diseases) for STAT (a medical abbreviation for immediately or without delay) CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head scan. RN 2 received Patient 1 at change of shift at 7 p.m. and noted Patient 1 receiving IV nicardipine at 75 ml/hr (15mg/hr, maximum dose). During a review of facility’s medication dispensing (to supply) record titled, “All Transaction Activity Detail Report (dispensing record),” dated 2/6/2025, the dispensing record indicated, RN 1 retrieved one bag of IV nicardipine 40 mg per 200 milliliters (ml, unit of measure) for Patient 1 on 2/6/2025 at 6:22 p.m. During a concurrent interview and record review on 5/28/2025 at 11:24 a.m. with the Stroke Coordinator (SC 1), Patient 1’s “Medication Administration Record (MAR, record of medications given to patients),” dated from 1/31/2025 to 2/6/2025, was reviewed. The MAR indicated, Patient 1 received IV nicardipine infusion starting on 1/31/2025 with initial rate at 5 mg/hr and it was titrated to zero (0) on 2/1/2025 at 7:45 a.m. Nicardipine infusion rate was zero (0) from 2/2/2025 to 2/5/2025. The MAR also indicated, on 2/6/2025 at 7p.m. nicardipine was given at 15mg/hr with a comment indicating, “received patient (Patient 1) at this rate.” During the same interview on 5/28/2025 at 11:24 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: IV nicardipine was started for BP control and it was titrated to zero when the BP was within desired range. Patient 1 did not receive any nicardipine from 2/2/2025 to 2/5/2025. The nicardipine order should have been discontinued on 2/2/2025 by 6:45 a.m. since the last administration (2/1/2025) was over 23 hours. A new order was required to restart IV nicardipine. It was unknown what time and what initial rate nicardipine was restarted on 2/6/2025 because it was not documented. The medication was not titrated correctly. During a concurrent interview and record review on 5/28/2025 at 11:30 a.m. with the Stroke Coordinator (SC 1), Patient 1’s “Vital Signs” flowsheet (vital signs flowsheet), dated 2/6/2025, was reviewed. The vital signs flowsheet indicated the following: -At 5:40 p.m.: Heart Rate (HR) = 80 beats per minute (bpm), BP = 204/98 mmHg; -At 6 p.m.: HR = 94 bpm, BP = 222/116 mmHg; -At 7 p.m.: temperature = 97.9 degrees Fahrenheit (F, unit of measure 100.4 degrees Fahrenheit equivalent to 38.0 degrees Celsius) taken orally, no HR, and no BP documented; and -at 7:33 p.m.: HR = 70 bpm, BP = 67/40 mmHg. During the same interview on 5/25/2025 at 11:30 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: there was no monitoring on Patient 1’s blood pressure from 6 p.m. to 7:33 p.m. (1.5 hours) while Patient 1 was receiving IV nicardipine. Patient 1 became hypotensive (low blood pressure). Low blood pressure could affect perfusion (process of blood carrying oxygen and nutrients to the body tissues and organs) to the brain and contribute to no blood flow to brain. During a concurrent interview and record review on 5/28/2025 at 11:40 a.m. with SC 1, Patient 1’s “Nursing Documentation - Flowsheet (nursing assessment),” dated 2/6/2025, was reviewed. The “Nursing Documentation - Flowsheet” indicated, at 3 p.m., Patient 1’s both pupils were PERRLA (Pupils equal, round, and reactive to light and accommodation, standard eye exam to check the health of eyes and the nervous system) with regular, round, size 3 mm, reaction was brisk (quick and full constriction) and consensual light reflex present; at 7 p.m. Patient 1’s both pupils were not PERRLA with regular, round, size 5 mm, nonreactive. SC 1 stated it was a drastic change in neurological assessment (evaluation the function of the nervous system which comprise with brain, spinal cord and peripheral nerves). Patient 1’s both pupils were blown (pupils were abnormally dilated, fixed and unresponsive to light) indicating there was no brain function, the brain was not perfusing. During a review of Patient 1’s “Physician Communication (physician communication note, documentation between nurse and physician communication regarding patient’s condition and test result)” note, dated 2/6/2025, the physician communication note indicated, at 7:28 p.m., RN 2 informed physician (MD 2) that Patient 1 was hypotensive, MD 2 ordered to stop nicardipine and start Levophed (norepinephrine, medication used to raise blood pressure in patients with severe hypotension). During a review of Patient 1’s “Neurosurgery Progress Note (neurosurgeon note, physician progress note completed by neurosurgeon),” dated 2/7/2025, the neurosurgeon note indicated, “(Patient 1) had sudden loss of consciousness (unresponsive) yesterday. STAT CT showing large frontal (front part of the brain behind the forehead) hemorrhage (bleeding). Was started on Cardene (nicardipine, medication given intravenously [IV, directly into a vein) to lower blood pressure) for blood pressure management ... became bradycardic (low hear rate) and hypotensive (low blood pressure). Started pressor (medication to raise up the blood pressure) ... loss of brain stem reflexes (involuntary motor responses originating from the brainstem that control breathing, heart rate, and balance) were noted ... this morning remains unresponsive. No cough/gag reflex (a natural protective mechanism that prevents objects from entering the throat and potentially causing choking). No pupillary (relating pupil of the eye) or oculocephalic reflexes (a neurological reflex where the eyes move in the opposite direction of a rapid head rotation). No responses to painful stimuli. And not breathing over the ventilator (an appliance for artificial respiration). It was likely the patient has progressed to brain death (irreversible cessation of all brain function).” During an interview on 5/29/2025 at 1:58 p.m. with the Director of Pharmacy (DIR 1), DIR 1 stated each IV titration medication order would include how much to start, how often to titrate, how much to titrate to achieve the set goal. Nurses needed to follow the medication order when titrating medications. During an interview on 5/30/2025 at 11:27 a.m. with the ICU Director (DIR 2), DIR 2 stated the following: nurses must follow physician order when administering any titratable medication. Nurses could not change the medication dose, route, frequency without physician order. Nurses could not titrate nicardipine more frequent than every fifteen minutes per physician order. Nurses should monitor patient’s vital signs throughout titration to evaluate his/her response to the medication. During an interview on 5/30/2025 at 11:56 a.m. with the ICU Director (DIR 2), DIR 2 stated the following: the order of IV nicardipine showed as active on order set because no one discontinued the order as it should have been. This gave RN 1 access to retrieve the medication and administered to Patient 1. During an interview on 5/30/2025 at 12 p.m. with DIR 2, DIR 2 state the following: the facility relied on nurses to check physician orders during shift report to discontinue any IV titration medication when it was not used over 23 hours. There was room for human error that nurses might forget to remove the order. During an interview on 5/30/2025 at 12:39 p.m. with the ICU physician (MD 2), MD 2 stated the following: in ICU, the healthcare team would go over patient’s titratable medications. The physician could discontinue a medication order, but he (MD 2) expected the nurses to discontinue any IV titratable medications when it was not in use. From the physician’s end, he (MD 2) would not know if nurses were doing it (discontinuing the order) or not. It was possible for someone to overlook and not physically discontinue the order. During an interview on 5/30/2025 at 2:03 p.m. with the Director of Pharmacy (DIR 1), DIR 1 stated the following: the intention to discontinue IV titratable medication after not being used over 23 hours was to avoid unnecessary medications. If the order remained active, nurses would have access to retrieve the medications. It relied on nursing critical thinking to discontinue the medications. Pharmacy did not have oversight. It was nursing responsibility. DIR 1 also stated the pharmacy was located in the basement and pharmacy staff were not there (in ICU) to check if the IV titratable medications have been stopped for over 23 hours (from the last administration time). During an interview on 5/30/2025 at 4 p.m. with the Medication Safety Officer (MSO), MSO stated Patient 1’s nicardipine incident was identified as a medication error because IV nicardipine was restarted despite it not used for more than 23 hours (last administration was 2/1/2025) and there was no new order to give IV nicardipine on 2/6/2025. The team performed a root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution), but it was identified as an isolated event. During an interview on 5/30/2025 at 4:16 p.m. with the Senior Director for Risk Management (SDRM), SDRM stated the following: the facility did investigation and root cause analysis (RCA) involving nursing leadership, pharmacy, stroke team, risk management and quality department on 3/13/2025. The facility had identified there was lack of monitoring and documentation with the IV nicardipine administration, but it was only identified as an individual isolated event. There was no action taken with regards to IV titration medication being given beyond the order time. SDRM also stated the RCA was incomplete because the facility did not look further into IV nicardipine order to identify if there was any systemic problem. During a review of Patient 26’s “History and Physical (H&P),” dated 5/19/2025, the H&P indicated that Patient 26 was admitted to the facility with a diagnosis of status epilepticus (a continuous seizure [a temporary disruption of normal electrical activity in the brain that can cause changes in behavior, movement, or awareness] lasting five minutes or more, or recurrent seizures without recovery in between) and had to be intubated (a tube has been inserted into the patient’s windpipe (trachea) through their mouth or nose to help them breathe). During a review of Patient 26’s medical record (MR) titled, “Order Sheet,” dated 5/19/2025, the MR indicated that on 5/19/2025 at 5:58 a.m., the physician placed an order set for propofol (an intravenous medication used for sedation) to be given as a continuous infusion (titratable drip- slowly increasing the dose of a medicine by very small amounts over time) at initial rate of 10 micrograms per kilogram per minute (mcg/kg/min, measuring unit) .... Order comments indicated, “ ...Discontinue Order if rate remains at zero [0] for 23 hours ...” During a review of Patient 26’s “Medical Administration Record (MAR),” dated from 5/19/2025 to 5/29/2025, the MAR indicated propofol infusion rate was 0 mg/hr on 5/26/2025 at 10:09 a.m. The MAR also indicated propofol infusion was restarted on 5/28/2025 at 1:59 a.m. (over 39 and 50 minutes beyond the last administration time). During a review of Patient 27’s History and Physical ( H&P, the most formal and complete assessment of the patient and the problem), dated 5/24/2025, the H&P indicated that Patient 27 was admitted to the facility with a diagnosis of subarachnoid hemorrhage (SAH, a type of stroke [a medical emergency that occurs when the brain’s blood supply is disrupted, causing brain damage] caused by bleeding into the subarachnoid space, which is the area between the brain and the thin tissues [meninges] that cover it) and ruptured brain aneurysm (a medical condition where a weakened, bulging area in a blood vessel wall in the brain bursts, causing bleeding within the brain). During a review of Patient 27’s medical record (MR) titled, “Order Sheet,” dated 5/24/2025, the MR indicated that on 5/24/2025 at 8:31 a.m., the physician placed an order set for nicardipine (Cardene I.V., a drip [infusion of a medication intended to lower blood pressure, BP]) to be given as a continuous infusion at a starting dose of 5 milligrams per hour (mg/hr, measuring unit) followed by increments of 2.5 mg/hr every 5 minutes until either reaching a maximal dose of 15 mg/hr or achieving the desired reduction in BP. Order comments indicated, “ ...Discontinue Order if rate remains at zero [0] for 23 hours ...” During a review of Patient 27’s “Medical Administration Record (MAR),” dated from 5/23/2025 to 5/29/2025, the MAR indicated IV nicardipine was titrated down to zero (0) on 5/24/2025 at 3 p.m. The MAR also indicated IV nicardipine was restarted at 2.5 mg/hr on 5/25/2025 at 6:50 p.m. (almost 28 hours from last administration time on 5/24/2025 at 3 p.m.). During a review of the facility’s policy and procedure (P&P) titled, “Medication Errors Reporting,” 9/2022, the P&P indicated, “to establish procedures regarding medication errors and encourage all hospital staff to report all medication error reporting as a tool to enhance patient safety and prevent future errors ... Definitions: A. Medication Error - any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer ... Type of medication errors ... d. Administration error - types of administration errors may include: wrong patient, dose, time, medication, route, rate ... and unauthorized dose given ... Medication Error Prevention Team. 1. The pharmacy will use the findings of the medication error prevention and reduction team to develop pharmacy systems and workflow processes designed to prevent medication errors ... All medication errors discovered, as per definition, are subject to a quality assurance review. 2. The primary purpose of the quality assurance review is to advance error prevention by analyzing the cause and contributing factors such as system or process failures.” During a review of the facility’s policy and procedure (P&P) titled, “ Reporting and Investigation Incidents and Near Misses Policy,” dated 12/2022, the P&P indicated, “Incident and Near Misses Identification ... Role and Responsibilities ... Departmental file managers/directors are responsible for review and manage incident reports for their assigned areas of responsibility, which includes the following ... timely investigation of incident reports and documentation ... collaborating with other file managers/directors to complete all tasks associated with the investigation of an incident report ... evaluating for trends is the manager/director’s area of responsibility, suggesting RCAs when applicable and recommending process improvement initiatives.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital),” dated 3/2024, the P&P indicated, “Scope: As part of performance improvement, leaders (including governing body) will: 1. Set priorities (i.e. high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines. 2. Identify frequency of dada collection for performance improvement. 3. Prioritize performance improvement in response to changes within the internal and external environment. 4. Proactively identify processes needing improvement to prevent medical errors. 5. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performances of process improvement/deficiencies, and monitoring/sustaining processes ... Structure and Accountability ... 1. The Community Board (governing body [GB]) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectation for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective [the facility’s] committees/ teams ... C. Performance Improvement Committee Functions ... Patient Safety Program ... integrates with all quality assessment and performance improvement activities. Cause analysis and proactive risk assessments, such as FMEA (failure mode effect analysis), will be utilized to assess actual and potential risk, failure, points of vulnerability, and prioritized areas for improvement based on impact to patient care outcomes ... D. Performance Improvement Model ... Process improvement indicators will focus on improvement of health outcomes and prevention/reduction of medical errors, and will include: a. measurement and tracking of medical errors/adverse event with analysis of causes b. implementation of preventative actions that include feedback and learning throughout the organization .... E. Aggregation and Analysis of Data ... 6. At minimum, the organization will collect data in the following areas ... Adverse Events, including (not limited to): significant medication errors; adverse drug reactions; medical errors (prevention and reduction of) ...” During a review of the facility’s policy and procedure (P&P) titled, “Titratable Medication Infusion Administration,” dated 9/2021, the P&P indicated, “the purpose of this policy is to define and establish requirements for safe and accurate administration and documentation of titratable infusion medication orders... Titration medication orders ... the nurse must stay within the defined parameters of the medication orders ... Titratable medication documentation. 1. Titratable medication must be documented at the time of administration within MAR. 2. The goal of the titratable medication ... must be documented prior to initiating the titratable infusion and during each rate change. 3. Documentation will accurately reflect order changes and patient assessments ... Discontinuing a titratable medication. 1. A titratable infusion order will include the order detail that the infusion should be discontinued from the MAR when the patient has not received the medication for 23 hours or more.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 12/2024, the P&P indicated, “Medication Administration should be performed by licensed medical staff according to manufacturer’s prescribing information and in accordance with FDA (Food and Drug Administration, a government agency) regulations. Proper documentation, verifying patient specific information, medication security and compliance with specific drug policies should always be taken during medication administration ... Procedure ... Utilize the seven rights for administering medication: a. Right Patient b. Right Dose c. Right Time d. Right Route e. Right Drug f. Right to Refuse ... g. Right to be Educated ... Check all medications and IV solutions against eMAR (electronic medication administration record)/MAR ... access eMAR/MAR and/or physician order when administering medications at patient’s bedside ... Documentation: 1. Medication administration should be documented immediately after administration, but no later than 1 hour after administration... Documentation should occur in the eMAR/MAR.” During a review of medication package insert (provide medication information and its use) for nicardipine, dated 10/2014, the medication package insert indicated, “Dosage and Administration ... Recommend Dosing ... Dosage for initiation of therapy in a patient not receiving oral nicardipine. Initiate therapy at 25 ml/hr (5mg/hr). If desire blood pressure reduction is not achieved at this dose, the infusion rate may be increased by 12.5ml/hr (2.5mg/hr) every five (5) minutes (for rapid titration) to 15 minutes (for gradual titration) up to a maximum of 75 ml/hr (15mg/hr), until desired blood pressure reduction is achieved. Following achievement of the blood pressure goal utilizing rapid titration, decrease the infusion rate to 15ml/hr (3mg/hr).” During a review of the facility’s policy and procedure (P&P) titled, “Standards of Nursing Practice Critical Care Department (Intensive Care Unit),” dated 2/25/2025, the P&P indicated, “Patients on intravenous (IV) titratable medications: vital signs (except temperature) shall be assessed and documented at a minimum of approximately every 1 hour (or based on patient’s clinical condition) ...When a RN actively titrating continuous intravenous (IV) infusion medications affecting vital signs ... then the frequency of vital signs should further align with the frequency of titrations (unless situation meets criteria for block charting). Patient monitoring and documentation should occur in a way that clearly justifies the need for titration/intervention and includes appropriate post-intervention follow-up by RN indicating the patient’s response to medication titration.””

“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: 42937 Based on interview and record review the facility failed to: 1. Ensure that for one of 41 sampled patients (Patient 27), nursing staff alternated the peripheral intravenous site (PIV, a small, short, flexible tube [catheter] inserted into a vein, usually in the hand or arm, to administer fluids, medications, or blood products), every 12 hours during continuous infusion of nicardipine (Cardene IV, a medication to treat chest pain or high blood pressure [BP]), through a catheter or needle that is continuously delivering the substance into the body, in accordance with the physician order. This deficient practice had the potential for Patient 27 to develop complications associated with Nicardipine I.V. administration such as phlebitis (an inflammation of a vein), infiltration (when some of the fluid leaks out into the tissues under the skin where the tube has been put into the vein), or extravasation (the leakage of fluid or substances from a blood vessel or other enclosed space into the surrounding tissues, resulting in pain, swelling), which may go unrecognized and untreated, leading to tissue damage or necrosis (tissue death) and worsening of Patient 27’s condition. 2. Ensure for one of 41 sampled patients (Patient 13), a Clinical Institute Withdrawal Assessment for Alcohol (CIWA, is a tool used to assess the severity of alcohol withdrawal symptoms) assessment was completed and documented per facility’s policy regarding “Inpatient Management of Alcohol Withdrawal (a range of symptoms that can happen if someone stops or significantly reduce alcohol intake after long-term use).” This deficient practice had the potential for delayed recognition of a patient’s withdrawal symptoms (example: increased blood pressure, increased heart rate, and tremor [shakiness] of hands or other body parts), potentially resulting in inappropriate or insufficient treatment for Patient 13. Findings: 1. During a review of Patient 27’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/24/2025, the H&P indicated that Patient 27 was admitted to the facility with a diagnosis of subarachnoid hemorrhage (SAH, a type of stroke [a medical emergency that occurs when the brain’s blood supply is disrupted, causing brain damage] caused by bleeding into the subarachnoid space, which is the area between the brain and the thin tissues [meninges] that cover it) and ruptured brain aneurysm (a medical condition where a weakened, bulging area in a blood vessel wall in the brain bursts, causing bleeding within the brain). During a review of Patient 27’s medical record (MR) titled, “Order Sheet,” dated 5/24/2025, the MR indicated that Patient 27 had an order for nicardipine drip (the drug [intended to lower blood pressure, BP] is given as a continuous infusion at a starting dose of 5 milligrams per hour [mg/hr, measuring unit] followed by increments of 2.5 mg/hr every 5 minutes until either reaching a maximal dose of 15 mg/hr or achieving the desired reduction in BP), placed on 5/24/2025. During a review of Patient 27’s Medication Administration Record (MAR), particularly administration of the continuous nicardipine drip (infusion) and the associated peripheral intravenous (PIV) site record, dated 5/25/2025 through 5/29/2025, the record indicated that on all occasions, Patient 27’s peripheral intravenous site, was documented to be in the right antecubital (AC, the area of the inner elbow). This information was verified with the registered nurse (RN 6) during record review on 5/29/2025 at 2:56 p.m. During an interview on 5/29/2025 at 3:11 p.m. with registered nurse (RN) 6, RN 6 stated the following: “We [nurses] document the peripheral IV site associated with the administration of a medication to enable tracing of any side effects related to the medication infusion.” RN 6 also said that accurate documentation allowed (nurses) to identify and assess the site for complications such as phlebitis (inflammation of the vein) pain, swelling, or vesicants (substances that can cause tissue damage or blistering if extravasation occurs) which was essential for early detection and timely intervention to prevent tissue injury and ensure patient safety. During a concurrent interview and record review on 5/29/2025 at 3:13 p.m. with Registered Nurse (RN) 6, Patient 27’s “Order Sheet,” was reviewed. The Order Sheet indicated that on 5/24/2025 [at 8:31 a.m.], an order for nicardipine continuous drip was placed with the following order comments: “Minimize peripheral venous infiltration by changing infusion site every 12 hours.” RN 6 reviewed the Nicardipine IV order details and stated that the peripheral IV site should be alternated, in accordance with the physician order. During a review of the nicardipine safety data sheet (SDS, a document that provides information about the potential hazards of a chemical or substance, along with guidance on how to handle, store, and dispose of it safely), dated 10/2014, the SDS indicated the following: “Administer Cardene (Nicardipine) I.V. by a central line or through a large peripheral vein. Change the infusion site every 12 hours if administered through peripheral vein to reduce the possibility of venous thrombosis, phlebitis, local irritation, swelling, extravasation, and the occurrence of vascular impairment. To minimize the risk of peripheral venous infiltration, change the site of the drug infusion every 12 hours.” 2. During a review of Patient’s 13’s “History and Physical,” dated 01/01/2025, the record indicated that Patient 13 arrived at the emergency department (ED) with complaints of left sided numbness, tingling, and weakness on left side of the body. The H&P also indicated alcoholism (an addiction to the consumption of alcoholic liquor) as an active problem, with a blood ethanol level (test that measures the amount of alcohol, or ethanol, in a patient’s blood) of 0.11 grams per deciliter (gm/dL, a unit of measure; a blood alcohol level of 0.11 gm/dL is extremely high and would be associated with severe intoxication, potentially leading to coma or death) During a review of Patient 13’s “Order Plans,” dated 01/01/2025 - 01/03/2025, the Order Plans indicated the following medical orders: 1. CIWA Assessment - NOW, on arrival to unit was ordered on 01/01/2025 at 4:24 a.m. 2. CIWA Assessment - every 6 hours while awake was ordered on 01/01/2025 at 10:24 a.m. During a concurrent interview and record review on 05/28/2025 at 10:47 a.m. with Registered Nurse (RN) 12, Patient 13’s medical record titled, “CIWA,” dated 01/01/2025 - 01/02/2025, was reviewed. Patient 13’s record did not indicate that a CIWA was completed on arrival to the telemetry unit (a specialized area where patients receive continuous monitoring of their vital signs, primarily cardiac rhythms and other physiological data), and the first CIWA was completed only on 01/02/2025 at 12 a.m. RN 12 stated that Patient 13 arrived at the Telemetry Unit on 01/01/2025 at 4:11 a.m. During the same interview on 5/28/2025 at 10:47 a.m. with Registered Nurse (RN) 12, RN 12 said that the admitting nurse failed to follow the “CIWA Assessment” physician order. RN 12 stated the subsequent nurses who provided care to Patient 13 also failed to complete a CIWA on Patient 13. The patient’s (Patient 13) blood alcohol level was 0.11 gm/dL indicating that the patient (Patient 13) may be alcoholic and may suffer from alcohol withdrawals symptoms (a set of symptoms that can develop if one stops or significantly reduce alcohol intake after long-term use). RN 12 added that it was important for nurses to complete the CIWA assessment so they (the nursing staff) could identify withdrawal symptoms, provide early intervention, and prevent further health complications. During a review of the facility’s Policy and Procedure (P&P) titled, “Inpatient Management of Alcohol Withdrawal,” with last revised date of 2/14/2023, the P&P indicated the following: “Alcohol Withdrawal Observations a. The CIWA observation scale is used to monitor patients withdrawing from alcohol or at risk of withdrawing from alcohol.”

“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: 46238 Based on interview and record review, the facility failed to: 1. Formulate an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 41 sampled patients (Patient 26), to address Patient 26’s admitting diagnosis of seizures (a sudden, temporary disturbance of the brain’s normal electrical activity, often manifesting as changes in muscle tone, behavior, or awareness), in accordance with the facility’s policy regarding care plans. This deficient practice had the potential for Patient 26’s care needs not to be met when no implementation of individualized care plan for seizures and safety precautions were embedded into Patient 26’s treatment and care plan, which could result in complications such aspiration (the accidental inhalation of foreign materials, such as food, liquid, or stomach contents, into the lungs instead of the digestive tract [the mouth, stomach, and intestines]) leading to breathing problems, prolonged hospitalization, and/or even death. 2. Ensure one of 41 sampled patient’s (Patient 13) plan of care regarding aspiration precaution (measures taken to prevent the accidental inhalation of food, liquid, or other substances into the lungs. These precautions are especially important for individuals with swallowing difficulties or other conditions that increase their risk of aspiration), was developed and implemented upon admission (a process in healthcare that involves evaluating a patient’s condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility’s policy regarding care plans. This deficient practice had the potential for serious complications such as aspiration pneumonia (lung infection that can be particularly dangerous for individuals with weakened immune systems or underlying health conditions), respiratory distress (difficulty breathing), prolonged hospitalization, and/or death. 3. Ensure one of 41 sampled patient’s (Patient 20) plan of care regarding Chest Pain (often related to heart disease, its symptoms due to a heart attack or other heart condition includes Pressure, tightness, pain, squeezing or aching in the chest), was developed and implemented upon admission (a process in healthcare that involves evaluating a patient’s condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility’s policy regarding care plans This deficient practice had the potential to result in Patient 20’s care needs and risks to not be identified and addressed in a timely manner, which may result in complications such as heart failure (a condition where the heart cannot pump enough blood to meet the body’s needs), cardiac arrest (when the heart stops beating), and/or death. 4. Ensure one of 41 sampled patient’s (Patient 22) plan of care regarding Fluid and Electrolyte Imbalance (maintaining a stable internal environment by regulating the amount of fluids and electrolytes [charged molecules] in the body. This balance is crucial for various bodily functions, including nerve and muscle activity, and blood pressure regulation), was developed and implemented upon admission (a process in healthcare that involves evaluating a patient’s condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility’s policy regarding care plans. This deficient practice had the potential for Patient 22’s care needs and risks to not be identified and addressed in a timely manner which may result in complications such as dehydration (a condition that occurs when your body doesn’t have enough fluid to function properly. It happens when you lose more fluids than you take in, which can disrupt various bodily functions like maintaining body temperature, transporting nutrients, and eliminating waste), prolonged recovery, and/or death. Findings: 1. During a review of Patient 26’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/19/2025, the H&P indicated that Patient 26 was admitted to the facility with a diagnosis of status epilepticus (a continuous seizure [a sudden, temporary disturbance of the brain’s normal electrical activity, often manifesting as changes in muscle tone, behavior, or awareness] lasting five minutes or more, or recurrent seizures without recovery in between) and had to be intubated (a tube has been inserted into the patient’s windpipe [trachea] through their mouth or nose to help them breathe). During a concurrent interview and record review on 5/29/2025 at 1:30 p.m. with registered nurse (RN) 6, Patient 26’s electronic health records (EHR, digital version of paper chart), titled, “Care Plans,” dated 5/18/2025 through 5/29/2025, were reviewed. Patient 26’s Care Plans (documented strategies that outline patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers), had no developed care plan for “Seizures.” RN 6 verified the lack of developed care plan for seizures for Patient 26 throughout the [Patient 26] admission stay at the facility [5/19/2025 through 5/29/2025]. During the same interview on 5/29/2025 at 1:30 p.m. with registered nurse (RN) 6, RN 6 said that based on Patient 26’s admission diagnosis of seizures, a care plan for seizures should have been developed and maintained for Patient 26. RN 6 reviewed Patient 26’s EHR in an attempt to locate nursing documentation of maintaining seizure precautions (safety measures taken before and during a seizure to prevent injury and ensure a person’s well-being) but said that there was no nursing documentation of seizure precautions anywhere in Patient 26’s EHR. RN 6 then reviewed the available care plan for seizures and stated that seizure precautions (padded siderails, suction, oxygen at bedside) can be documented in the intervention section of the care plan once it’s initiated. During an interview on 5/30/2025 at 4:12 p.m. with registered nurse (RN) 6, RN 6 stated that a care plan was developed based on the patient’s identified needs and problems, and it should include the establishment of specific goals to guide the development of appropriate interventions aimed at meeting the patient’s individual needs and achieving the desired outcomes. During a review of the facility’s policy and procedure (P&P) titled, “Standards of Nursing Practice Critical Care Department (Intensive Care Unit),” dated 2/2025, the P&P indicated that “nursing diagnoses and care issues are derived from the assessment data with the patient ...and are prioritized and documented in a manner that facilitates prioritizing outcomes and developing or modifying the plan ...Outcomes are derived from actual or potential diagnoses and care issues, and shall be identified on the care plan by documentation of measurable goals within approximately 24 hours of admission to recognize and incorporate unique patient-centered values and care needs. Outcomes provide direction for continuity of care, and the plan establishes priorities for care .... Care is delivered in a manner that promotes patient safety...” 2. During a review of Patient’s 13’s “History and Physical,” dated 01/01/2025, the H&P indicated that Patient 13 arrived at the emergency department (ED) complaining of left sided numbness, tingling and weakness on left side of body. The H&P also indicated Patient 13 had a past medical history of alcohol withdrawals (Symptoms that can develop if one stops or significantly reduce alcohol intake after long-term use) and stroke (occurs when blood flow to the brain is disrupted, either by a blockage or a burst blood vessel). During a review of Patient’s 13 “Order,” dated 01/01/2025 - 01/03/2025, the record indicated the following medical orders: “Continuous Order, Aspiration Precautions (measures taken to prevent the accidental entry of food, liquid, or other foreign substances into the lungs), was ordered on 01/01/2025 at 8:04 a.m. During a concurrent interview and record review on 05/28/2025 at 10:47 p.m. with Registered Nurse (RN) 12, Patient 13’s medical record titled, “Plan” undated, was reviewed. The record indicated that a plan of care for Aspiration Precaution was not initiated upon admission. RN 12 stated that, admitting nurse should have initiated a plan of care for aspiration precaution. RN 12 further said a plan of care was important because it provided the care team a framework for organizing care, prioritizing needs, promoting communication, and documenting interventions to help meet patient care goals. During a review of the facility’s Policy and Procedure titled, “Standard of Nursing Practice” (Policy No.: 8720.405), with last revised date of 02/27/2025, the P&P indicated the following: The Standards of Practice describe a competent level of nursing care according to the critical thinking model known as the nursing process. 1. Assessment: The RN collects pertinent data and information relative the patient’s health/condition. 2. Diagnosis: The RN analyzes assessment data to determine actual or potential diagnoses, problems, and issues. 3. Outcomes Identification: The RN identifies expected outcomes for a care plan individualized to patient situation/medical conditions. 4. Planning: The RN develops a prioritized care plan that prescribes strategies to attain expected, measurable outcomes. 5. Implementation: The RN implements the identified care plan. a. Coordination of Care: The RN coordinates care delivery. b. Health Teaching and Health Promotion: The RN uses approaches and strategies to promote health, healing and a safe environment. 3. During a review of Patient’s 20’s “History and Physical,” dated 05/24/2025, the H&P indicated that Patient 20 arrived at the facility with complaints of chest pain for 1 day and weakness. Patient 20 had history of hypertension (high blood pressure), diabetes mellitus type 2 (occurs when the body either doesn’t produce enough insulin [regulates blood glucose or blood sugar by allowing cells to absorb glucose from the bloodstream for energy. Insulin also influences the metabolism of fats and proteins] or can’t use insulin effectively, leading to high blood sugar levels) and anxiety orders (mental health conditions characterized by excessive and persistent worry, fear, and anxiety). During a concurrent interview and record review on 05/28/2025 at 1:55 p.m. with Registered Nurse (RN) 12, Patient 20’s medical record titled, “Plan,” undated, was reviewed. The record indicated that a plan of care for Chest Pain was not initiated upon admission. RN 12 stated that, admitting nurse should have initiated a plan of care for Chest Pain. RN 12 said a plan of care was important because it identifies patient care progression toward goal outcome. During a review of the facility’s Policy and Procedure titled, “Standard of Nursing Practice” (Policy No.: 8720.405), with last revised date of 02/27/2025, the P&P indicated the following: The Standards of Practice describe a competent level of nursing care according to the critical thinking model known as the nursing process. 1. Assessment: The RN collects pertinent data and information relative the patient’s health/condition. 2. Diagnosis: The RN analyzes assessment data to determine actual or potential diagnoses, problems, and issues. 3. Outcomes Identification: The RN identifies expected outcomes for a care plan individualized to patient situation/medical conditions. 4. Planning: The RN develops a prioritized care plan that prescribes strategies to attain expected, measurable outcomes. 5. Implementation: The RN implements the identified care plan. a. Coordination of Care: The RN coordinates care delivery. b. Health Teaching and Health Promotion: The RN uses approaches and strategies to promote health, healing and a safe environment. 4. During a review of Patient’s 22’s “History and Physical,” dated 05/10/2025, the H&P indicated that Patient 22 arrived at the facility with complaints of hypotension (low blood pressure). The H&P also indicated that Patient 22 had multiple comorbidities (the presence of two or more medical conditions) including end-stage kidney disease (a severe form of kidney failure where the kidneys can no longer adequately filter waste and fluids from the blood), on hemodialysis (is a treatment that cleans your blood when your kidneys can’t do their job well enough, often due to kidney failure), diabetes mellitus type 2 (occurs when the body either doesn’t produce enough insulin [regulates blood glucose or blood sugar by allowing cells to absorb glucose from the bloodstream for energy. Insulin also influences the metabolism of fats and proteins] or can’t use insulin effectively, leading to high blood sugar levels), dysphagia (difficulty swallowing), on tube feedings (involves delivering nutrients directly into the digestive system via a tube). The H&P also indicated that Patient 22 was a resident of a skilled nursing facility (a facility that provides specialized care and rehabilitation for individuals who need a higher level of medical care than can be provided at home or in an assisted living setting). During a concurrent interview and record review on 05/28/2025 at 2:48 p.m. with Registered Nurse (RN) 12, Patient 22’s medical record titled, “Plan,” undated, was reviewed. The record indicated that a plan of care for Fluid and Electrolyte Imbalance (maintaining a stable internal environment by regulating the amount of fluids and electrolytes [charged molecules] in the body. This balance is crucial for various bodily functions, including nerve and muscle activity, and blood pressure regulation), was not initiated upon admission. RN 12 stated that, admitting nurse should have initiated a plan of care for Fluid and Electrolyte Imbalance. RN 12 further stated that a plan of care was important because it identified patient care progression toward goal outcome. During a review of the facility’s Policy and Procedure titled, “Standard of Nursing Practice” (Policy No.: 8720.405), with last revised date of 02/27/2025, the P&P indicated the following: The Standards of Practice describe a competent level of nursing care according to the critical thinking model known as the nursing process. 1. Assessment: The RN collects pertinent data and information relative the patient’s health/condition. 2. Diagnosis: The RN analyzes assessment data to determine actual or potential diagnoses, problems, and issues. 3. Outcomes Identification: The RN identifies expected outcomes for a care plan individualized to patient situation/medical conditions. 4. Planning: The RN develops a prioritized care plan that prescribes strategies to attain expected, measurable outcomes. 5. Implementation: The RN implements the identified care plan. a. Coordination of Care: The RN coordinates care delivery. b. Health Teaching and Health Promotion: The RN uses approaches and strategies to promote health, healing and a safe environment.”

“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: 46238 Based on interview and record review, the facility failed to: 1. Ensure that one of 41 sampled patients (Patient 26), had the RASS (the Richmond Agitation Sedation Scale, is a tool designed to assess the level of alertness and agitated behavior in critically ill patients) documented during the initiation of Precedex infusion (dexmedetomidine, a sedative medication used for sedation in intensive care patients), in accordance with the facility’s policy regarding titratable medications administration (the administration of a medication over time, starting with the least dosage required for improving the medical condition). This deficient practice had the potential for Patient 26 to experience inadequate sedation (drowsiness or sleep) management, including over-sedation or under-sedation, which could lead to increased risk of adverse events such as delayed neurological assessment, respiratory depression (inadequate ventilation, causing a low breathing rate), and unrecognized agitation (a state of extreme restlessness or uneasiness), thereby compromising Patient 26’s safety. 2. Monitor nineteen (19) of 19 sampled patients (Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39) in the Psychiatric (relating to mental or behavior illness) Acute Care (PAC) unit, every 15 minutes, in accordance with the facility’s policy and procedure regarding managing patients with high risk behaviors (actions that significantly increase the potential for harm, injury, or negative consequences, impacting both the individual and potentially others) who are admitted to the Behavioral Health Unit (or PAC unit). This deficient practice placed 19 patients’ safety at risk such as self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence. 3. Ensure its nursing staff communicated and reported critical test results (a test or examination that always requires rapid communication of the results) for one of 41 sampled patients (Patient 1), in accordance with the facility’s policy and procedure regarding critical test result reporting, when there was no evidence that Patient 1’s CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) scans were reported to a physician within required timeframe (within 60 minutes) on 2/6/2025. This deficient practice had the potential to delay for Patient 1’s physician to evaluate Patient 1’s condition and determine appropriate interventions. 4. Ensure its nursing staff performed a National Institute of Health Stroke Scale (NIHSS, a clinical assessment tool used to measure a patient’s neurological status after a stroke to quantify the severity of stroke-related deficits and monitor changes in a patient’s condition over time) assessment, when Stroke Alert (a protocol the facility developed in response to patient experiencing acute [new onset] stroke symptoms) was activated for one of 41 sampled patients (Patient 1) on 2/6/2025, in accordance with the facility’s policy and procedure regarding r stroke protocol. This deficient practice resulted in Patient 1’s severity of stroke not evaluated at the time when stroke alert was called, and had the potential to result in delayed identification and reporting of the severity of stroke Patient 1 was experiencing, to the physician and the stroke team, thus causing delay in care and treatment. Findings: 1. During a review of Patient 26’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/19/2025, the H&P indicated that Patient 26 was admitted to the facility with a diagnosis of status epilepticus (a continuous seizure [a sudden, temporary disturbance of the brain’s normal electrical activity, often manifesting as changes in muscle tone, behavior, or awareness] lasting five minutes or more, or recurrent seizures without recovery in between) and had to be intubated (a tube has been inserted into the patient’s windpipe (trachea) through their mouth or nose to help them breathe). During a review of Patient 26’s medical record (MR) titled, “Order Sheet,” dated 5/26/2025, the MR indicated that on 5/26/2025 at 10:09 a.m., the physician placed an order set for Precedex infusion (dexmedetomidine, a sedative medication used for sedation in intensive care patients) to be given as a continuous infusion (titratable drip- slowly increasing the dose of a medicine by very small amounts over time) at initial rate of 0.2 micrograms (mcg, measuring unit) micrograms to titrate up and down by 0.1 mcg every 10 minutes. Order comments indicated the following details: “Monitor RASS score (the Richmond Agitation Sedation Scale, is a tool designed to assess the level of alertness and agitated behavior. A score of 0 signifies alert and calm, positive scores represent increasing levels of agitation, and negative scores indicate varying levels of sedation, from drowsiness to unarousable) and titrate to achieve the goal of a RASS of 0 to -2 ... -RASS score levels: 0: Alert and Calm: Patient is alert, awake, and calm. -1: Drowsy: Not fully alert but has sustained awakening (eye opening/eye contact) to voice (greater than 10 seconds). -2: Light Sedation: Briefly awakens to voice with eye contact (less than 10 seconds)]. During a concurrent interview and record review on 5/29/2025 at 3:46 p.m. with registered nurse (RN) 6, Patient 26’s “Medication Administration Record (MAR), dated 5/26/2025, for Precedex administration on 5/26/2025, was reviewed. The MAR indicated that the Precedex drip was initiated on 5/25/2025 at 10:09 a.m. at a rate of 0.2 mcg/kg/hr (micrograms per kilogram per hour, measuring unit). It was titrated upward every 10 minutes to reach 0.8 mcg/kg/hr by 11::10 a.m., then titrated down to 0.7 mcg/kg/hr at 11:20 a.m., and further titrated down to 0/6 mcg/kg/hr. The RASS score was not documented during the titration of Precedex from 10:09 a.m. through 12:00 p.m. During the same interview on 5/29/2025 at 3:46 p.m. with registered nurse (RN) 6, RN 6 stated that when titrating Precedex, the RASS score should be assessed and monitored. RN 6 stated the RASS score indicated the patient’s sedation level and without assessing it, there was no way to know the patient met the goal of a RASS of 0 to -2, as indicated in the physician order. During a review of the facility’s policy and procedure (P&P) titled, “Titratable Medication Infusion Administration,” dated 9/2/2021, the P&P indicated the following: -“Titration orders- are defined as those in which the medication dose is either progressively increased or decreased in response to the patient’s status. D. Titratable medication documentation: 1. Titratable medications must be documented at the time of administration within the MAR. 2. The goal of the titratable medication (i.e. blood pressure, heart rate, RASS, pain, etc.) must be documented prior to initiating the titratable infusion and during each rate change. 3. During a review on 5/28/2025 at 10:25 a.m., a Video footage, dated 5/7/2025 of the East side of the Psychiatric (relating to mental illness) Acute Care Unit, was reviewed. The following was reviewed on video surveillance with Nurse Managers (NM) 1 and NM 2. The video footage indicated that on 5/7/2025 at 4:15 a.m., Licensed Vocational Nurse (LVN) 2 was not seen in the hallway conducting rounds (a systematic process where a healthcare team member checks on a patient regularly) on Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39. NM 1 stated that rounds should be conducted every 15 minutes by going into patient rooms and checking for a safe environment, patients’ condition, behavior, and whether the patient was breathing or sleeping. NM 1 stated that the round on 5/7/2025 at 4:15 a.m., was missed. NM 1 said that LVN 2 documented that she (LVN 2) had conducted rounding at 4:15 a.m., and that the documentation was falsified (false or incorrect). NM 1 stated not rounding every 15 minutes placed patients’ safety at risk. During a review of a document titled, “Patient Observation Checklist - Psych Acute Care - East,” dated 5/7/2025, the document indicated Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39 were on the unit. At 4:15 a.m., Patients 12 and 30 were in their room, awake. At 4:15 a.m., Patients 2, 3, 8, 9, 10, 11, 28, 29, 31, 32, 33, 34, 35, 36, 37, 38, and 39 were in their room, asleep. NM 1 verified that this documentation was false and that the monitoring did not occur. During a review of Patient 2’s Behavioral History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/19/2025, the H&P indicated the following: Patient 2 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for Grave Disability (a person who is unable to care for their basic needs due to a mental health disorder). During a review of Patient 3’s Behavior History and Physical (H&P), dated 5/01/2025, the H&P indicated Patient 3 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for suicidal ideations (thoughts of harming self). During a review of Patient 8’s History and Physical (H&P), dated 4/19/2025, the H&P indicated Patient 8 was admitted to the facility on a 5150 hold for grave disability. During a review of Patient 9’s Behavioral History and Physical (H&P), dated 4/29/2025, the H&P indicated Patient 9 was admitted to the facility on a 5150 hold for danger to self and danger to others. During a review of Patient 10’s Behavioral History and Physical (H&P), dated 5/5/2025, the H&P indicated Patient 10 was admitted to the facility on a 5150 hold for danger to self. Patient 10 had a history of major depression (serious mental disorder characterized by persistent feelings of sadness, loss of interest in activities, and a range of other symptoms that interfere with daily life). During a review of Patient 11’s Behavioral History and Physical (H&P), dated 4/4/2025, the H&P indicated Patient 11 was admitted to the facility on a 5150 hold for grave disability. During a review of Patient 12’s Behavioral History and Physical (H&P), dated 5/2/2025, the H&P indicated Patient 12 was admitted to the facility on a 5150 hold for grave disability. During a review of Patient 28’s Behavioral History and Physical (H&P), dated 4/17/2025, the H&P indicated Patient 28 was admitted to the facility on a 5150 hold for grave disability. During a review of Patient 29’s Behavioral History and Physical (H&P), dated 5/3/2025, the H&P indicated Patient 29 was admitted to the facility on a 5150 hold for grave disability. During a review of Patient 30’s Behavioral History and Physical (H&P), dated 4/30/2025, the H&P indicated Patient 30 was admitted to the facility on a 5150 hold for grave disability and danger to self. During a review of Patient 31’s Behavioral History and Physical (H&P), dated 5/6/2025, the H&P indicated Patient 31 was admitted to the facility on a 5150 hold for danger to self. During a review of Patient 32’s Behavioral History and Physical (H&P), dated 5/04/2025, the H&P indicated Patient 32 was admitted to the facility because of delusions (persistent, false beliefs held with a strong conviction despite evidence to the contrary) and uncontrolled behavior. During a review of Patient 33’s History and Physical (H&P), dated 5/03/2025, the H&P indicated Patient 33 was admitted to the facility on a 5150 hold for being gravely disabled. Patient 33’s diagnosis included psychosis (disconnection from reality) and schizophrenia (disorder that affects a person’s ability to think, feel, and behave clearly). During a review of Patient 34’s History and Physical (H&P), dated 3/22/2025, the H&P indicated Patient 34 was admitted to the facility on a 5150 hold for grave disability. Patient 34’s diagnosis included schizophrenia. During a review of Patient 35’s Behavioral History and Physical (H&P), dated 5/05/2025, the H&P indicated Patient 35 was admitted to the facility on a 5150 hold for being a danger to self (thoughts of harming self). During a review of Patient 36’s History and Physical (H&P), dated 5/04/2025, the H&P indicated Patient 36 was admitted to the facility for psychosis and suicidal ideations. During a review of Patient 37’s Behavioral History and Physical (H&P), dated 4/29/2025, the H&P indicated Patient 37 was admitted to the facility on a 5150 hold for being a danger to self. Patient 37’s diagnosis included schizophrenia. During a review of Patient 38’s Behavioral History and Physical (H&P), dated 1/24/2025, the H&P indicated Patient 38 was admitted to the facility for aggressive behavior and suicidal ideations. Patient 38 was on a 5150 hold for danger to self. During a review of Patient 39’s History and Physical (H&P), dated 3/15/2025, the H&P indicated Patient 39 was admitted to the facility for being agitated and aggressive and on a 5150 hold for being a danger to others and grave disability. During a review of the facility’s policy and procedure (P&P) titled, “Management of High-Risk Behaviors,” dated 09/27/2021, the P&P indicated the following: All patients treated in Behavior Health & Recovery are monitored at 15-minute intervals continuously throughout the day to minimize the occurrence of high-risk behaviors. These safety monitors are to include, at a minimum: 1. Observation of patient’s general physical condition. 2. Location of patient 3. Patient activity at that time the monitoring takes place. 3. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/24/2025, the “H&P” indicated, Patient 1 was admitted to the facility’s Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) with diagnoses including but not limited to subarachnoid hemorrhage (life-threatening type of stroke caused by bleeding into the space surrounding the brain), status post aneurysm coiling (a procedure to treat brain aneurysm [a bulge in the arteries of brain, potentially leading to a stroke if ruptured [burst]) on 1/24/2025 and uncontrolled hypertension (high blood pressure). During an interview on 5/28/2025 at 10:56 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: Patient 1 was found nonresponsive (does not react or move) on 2/6/2025 around 5:20 p.m. by RN 1, Patient 1’s BP was 222/116 mmHg at 6 p.m. Patient 1 was sent to radiology (a department that utilizes various imaging techniques to diagnose and treat diseases) for STAT (a medical abbreviation for immediately or without delay) CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head scan. During a review of Patient 1’s Physician Orders, dated 2/6/2025. The Physician Orders indicated, a STAT CT Brain same as CT head without contrast (a special dye to enhance the visibility of specific areas of the body such as blood vessels and organs on the scan image) was ordered on 2/6/2025 at 5:44 p.m. with reason for subarachnoid hemorrhage. The Physician Orders also indicated, a STAT CT Angio (CT angiography, a medical imaging technique that uses a CT scan along with a contrast dye to visualize blood vessels) Head/Neck with contrast was ordered on 2/6/2025 at 5:45 p.m. with reason for subarachnoid hemorrhage. During a concurrent interview and record review on 5/28/2025 at 10:42 a.m. with SC 1, Patient 1’s CT scan report of “CT Brain without contrast (CT scan report 1),” dated 2/6/2025, was reviewed. The CT scan report 1 indicated, “Evidence of large heterogeneous (composed of different kinds) intracerebral (inside the brain) hematoma (collection of clotted blood outside blood vessel often due to injury or bleeding) in the frontal midline (medial surface of frontal lobe [front part of the brain behind the forehead]), measuring approximately 5.0 x 5.0 x 4.5 centimeters (cm, unit of measure) in dimension, with also evidence of moderate subarachnoid hemorrhage in the midline vertex (the highest point) area and possible hemorrhagic infarction (region of brain tissue that has died due to lack of blood supply) in the frontal lobes bilaterally...” The CT scan report 1 also indicated the result was read to RN 1 on 2/6/2025 at 6:28 p.m. During the same interview on 5/28/2025 at 10:42 a.m. with SC 1, SC 1 stated the following: this result was a critical test result (a test or examination that always requires rapid communication of the results). RN 1 should have reported to neurosurgeon (medical doctor specializing in the diagnosis and treatment affecting brain, spinal cord, and nerves). Neurosurgeon could then determine what to do next based on the CT scan report. During a concurrent interview and record review on 5/28/2025 at 10:48 a.m. with SC 1, Patient 1’s CT scan report of “CT Angio Head/Neck with contrast (CT scan report 2),” dated 2/6/2025, was reviewed. The CT scan report 2 indicated, “Strong suggestion of fusiform aneurysm arising from the anterior communicating artery measuring approximately 1.3 x 5 millimeter (mm, unit of measure), directed superiorly ...” The CT scan report 2 also indicated, the result was read to RN 2 on 2/6/2025 at 6:56 p.m. During the same interview on 5/28/2025 at 10:48 a.m. with SC 1, SC 1 stated the following: this result was a critical test result. RN 2 should have reported to neurosurgeon. Neurosurgeon could then decide to pass on to the neuro-interventionist (medical physician specialized in training in the use of minimal invasive, image-guided techniques to treat complex conditions of the brain, neck and spine) for further intervention or not. During a concurrent interview and record review on 5/28/2025 at 10:54 a.m. with SC 1, Patient 1’s “Communication Physician (documentation by nursing to indicate communication with physician)” note, dated 2/6/2025, was reviewed. The “Communicate Physician” note, indicated there was no documentation regarding RN 1 and RN 2 reporting both CT scan reports (CT scan report 1 and 2) to any physician. SC 1 stated the following: the nursing staff receiving the critical result must contact the neurosurgeon for the critical CT scan results within 60 minutes. There was no documentation indicating RN 1 and RN 2 had reported the critical CT scan results to the physician. During a concurrent interview and record review on 5/28/2025 at 11:11 a.m. with SC 1, Patient 1’s “Critical Care Progress Note (physician note, progress note completed by an intensivist [physician who provides special care for critically ill patients typically in ICU),” dated 2/7/2025, was reviewed. The “Intensivist note,” indicated, “2/7 abruptly became unconscious (unable to respond to people and activities) last night, CT brain with large frontal intraparenchymal hemorrhage (bleeding within the brain tissue), neuro exam (an assessment of a person’s nervous system, including the brain, spinal cord, and nerves) very poor, hypothermic (dangerously low body temperature). I discussed with family last night.” SC 1 stated the physician note did not indicate what time the intensivist received or reviewed the CT scan reports. During a concurrent interview and record review on 5/28/2025 at 11:13 a.m. with SC 1, Patient 1’s “Neurosurgery Progress Note (neurosurgeon note, physician progress note completed by neurosurgeon),” dated 2/7/2025, was reviewed. The neurosurgeon note indicated, “(Patient 1) had sudden loss of conscious (unresponsive) yesterday. STAT CT showing large frontal hemorrhage. Was started on Cardene (nicardipine, medication given intravenously [IV, directly into a vein) to lower blood pressure) for blood pressure management ... became bradycardic (low heart rate) and hypotensive (low blood pressure). Started pressor (medication to raise up the blood pressure) ... loss of brain stem reflexes (involuntary motor responses originating from the brainstem that control breathing, heart rate, and balance) were noted ... this morning remains unresponsive. No cough/ gag reflex (a natural protective mechanism that prevents objects from entering the throat and potentially causing choking). No pupillary (relating pupil of the eye) or oculocephalic reflexes (a neurological reflex where the eyes move in the opposite direction of a rapid head rotation). No responses to painful stimuli. And not breathing over the ventilator (an appliance for artificial respiration). It was likely the patient has progressed to brain death (irreversible cessation of all brain function). Surgical intervention unfortunately will not change the prognosis. Recommend conclusive brain death examination when appropriate.” SC 1 stated the physician note did not indicate what time the neurosurgeon received or reviewed the CT scan report. During an interview on 5/30/2025 at 12:15 p.m. with the ICU Director (DIR 2), DIR 2 stated the following: nurses should report any critical result to the physician and document the communication per facility’s policy so it could establish a timeline and track if interventions provided were done in a timely manner. RN 1 and RN 2 did a lot of work for Patient 1 on 2/6/2025, but the documentation did not reflect those. The intensivist (MD 1) read the CT scan reports of the bleeding and discussed with the team. However, there was nothing documented during that time frame. During a review of the facility’s policy and procedure (P&P) titled, “Critical Tests and Critical Results Reporting Policy,” dated 8/2023, the P&P indicated, “to standardize the process when critical results of tests fall significantly outside the normal range and may indicate a life-threatening situation. The objective of this policy is to provide guidelines for management and reporting of critical tests and critical results of test to provide patients with prompt treatment ... Policy ... B. Reporting/Documenting of Results of Tests: a. for Critical Tests only - once results are available/ validated they are communicated to the ordering provider/ designee or Registered Nurse ... C. Receiving Results/ Reports: 1. Registered Nurse for Inpatients ... a. communicate to ordering provider/designee within 60 minutes and documents the following: i. provider notified (including full name and title), ii. Date/time called, iii. Two patient identifiers confirmed with provider/designee (patient name and date of birth may be used), iv: critical test reported, v. read-back completed, vi: actions taken ... D. Reporting time frames: 1. Critical results of test measurement parameters - the maximum length of time between the availability of critical result(s) and reporting of such critical result(s) to the ordering provider/designee should not exceed 60 minutes.” 4. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/24/2025, the “H&P” indicated, Patient 1 was admitted to the facility’s Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) with diagnoses including but not limited to subarachnoid hemorrhage (life-threatening type of stroke caused by bleeding into the space surrounding the brain), status post aneurysm coiling (a procedure to treat brain aneurysm [a bulge in the arteries of brain, potentially leading to a stroke if ruptured [burst]) on 1/24/2025 and uncontrolled hypertension (high blood pressure). During an interview on 5/27/2025 at 3:19 p.m. with the Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) Registered Nurse (RN) 3, RN 3 stated the following: nurse would activate stroke alert (a protocol the facility developed in response to patient experiencing acute [new onset] stroke symptoms) when a patient experience stroke-like symptoms such as facial drooping (sagging appearance of one side of the face due to weakness or paralysis of the facial muscles), facial asymmetry (condition where the left and right sides of the face are not identical, resulting in an uneven appearance), and slurred speech. Once stroke alert was activated, nurse would perform National Institutes of Health Stroke Scale (NIHSS, a clinical assessment tool used to measure a patient’s neurological status after a stroke to quantify the severity of stroke-related deficits and monitor changes in a patient’s condition over time) assessment right away with the neurological assessment. All ICU nurses were NIHSS certified and able to perform the NIHSS assessment. During an interview on 5/28/2025 at 10:56 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: Patient 1 was found nonresponsive (does not react or move) on 2/6/2025 around 5:20 p.m. by RN 1, Patient 1’s BP was 222/116 milliliter of mercury (mmHg, unit of measure) at 6 p.m. Patient 1 was sent to radiology (a department that utilizes various imaging techniques to diagnose and treat diseases) for STAT (a medical abbreviation for immediately or without delay) CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head scan. During a review of the facility’s “Stroke Alert Log,” dated 2/2025, the “Stroke Alert Log” indicated, Stroke Alert was called on 2/6/2025 at 5:47 p.m. for Patient 1. During a concurrent interview and record review on 5/28/2025 at 11:40 a.m. with SC 1, Patient 1’s “Nursing Documentation - Flowsheet,” dated 2/6/2025 from 7 a.m. to 7 p.m. was reviewed. The “Nursing Documentation - Flowsheet” indicated, at 7 a.m., Patient 1’s NIH stroke score (scoring from NIHSS assessment, a score ranging from zero to 42, where higher scores indicate more severe deficits) was 4 and at 7 p.m., Patient 1’s NIH stroke score became 30. SC 1 stated no NIH stroke score was documented after stroke alert was called. During a review of Patient 1’s “Neurosurgery Progress Note (neurosurgeon note, physician progress note completed by neurosurgeon),” dated 2/7/2025, the neurosurgeon note indicated, “(Patient 1) had sudden loss of consciousness (unresponsive) yesterday. STAT CT showing large frontal (front part of the brain behind the forehead) hemorrhage (bleeding). Was started on Cardene (nicardipine, medication given intravenously [IV, directly into a vein) to lower blood pressure) for blood pressure management ... became bradycardic (low hear rate) and hypotensive (low blood pressure). Started pressor (medication to raise up the blood pressure) ... loss of brain stem reflexes (involuntary motor responses originating from the brainstem that control breathing, heart rate, and balance) were noted ... this morning remains unresponsive. No cough/gag reflex (a natural protective mechanism that prevents objects from entering the throat and potentially causing choking). No pupillary (relating pupil of the eye) or oculocephalic reflexes (a neurological reflex where the eyes move in the opposite direction of a rapid head rotation). No responses to painful stimuli. And not breathing over the ventilator (an appliance for artificial respiration). It was likely the patient (Patient 1) has progressed to brain death (irreversible cessation of all brain function). During an interview on 5/30/2025 at 12:21 p.m. with the Stroke Navigator (SN 2), SN 2 stated the following: nurse should perform the NIHSS assessment to evaluate the severity of the stroke. It could help to see what deficit the patient experiencing and to determine what type of treatment patient would need. The higher the NIH stroke score, the worse is the stroke. During a review of the facility’s policy and procedure (P&P) titled, “In-Patient Stroke Alert/Stroke Alert Team,” dated 9/2024, the P&P indicated, “the purpose of this policy is to establish a procedure for the provision of timely and effective care for [the facility] in-patients exhibiting acute stroke symptoms ... Stroke Alert Process for In-patients: 1. When a hospital in-patient exhibits acute stroke symptoms, the Registered Nurse will initiate the Rapid Response Team (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) ... the Rapid Response Team will verify acute stroke symptoms and initiate a stroke alert on patient exhibiting stroke symptoms with an onset within 24 hours ... Stroke Alert Response ... Roles and Responsibilities: 1. Stroke Program Manager/Stroke Nurse Navigator or Neuro Telemetry Unit Charge Nurse/ Rapid Response Team as designed coverage: a. Stroke Program Manager/Stroke Nurse Navigator or designated coverage (Neuro Telemetry Unit Charge Nurse/ Rapid Response Team) reports to the bedside within 15 minutes of notification. b. performs a National Institutes of Health Stroke Scale (NIHSS) ... 4. Critical Care Registered Nurse: a. performs a National Institutes of Health Stroke Scale (NIHSS) prior to thrombolytic (to dissolve blood clots) agent administration and documents in the electronic medical record.””

“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: 48212 Based on interview and record review, the facility failed to: 1. Ensure its nursing staff adhered to physician order and facility’s policy and procedure regarding intravenous (IV, administered into a vein) titratable (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) medications when Nursing staff administered and titrated IV nicardipine (medication to treat high blood pressure) without proper titration (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) and blood pressure (BP, normal blood pressure is generally considered to be less than 120/80 mmHg [millimeters of mercury, unit of measure]) monitoring for two of 41 sampled patients (Patient 1 and Patient 4). This deficient practice resulted in Patient 1’s blood pressure (BP) drop, from 222/116 millimeters of mercury (mmHg, unit of measure) to 67/40 mmHg within 1 hour and 30 minutes (from 6 p.m. to 7:30 p.m.), compromising Patient 1’s perfusion (process of blood carrying oxygen and nutrients to the body tissues and organs) to the brain. This deficient practice also had the potential to put Patient 4 at risk for hypotension (low blood pressure). 2. Discontinue the nicardipine (Cardine IV infusion, a medication to control blood pressure and prevent cerebral [brain] venous spasm) and obtain a new physician order to restart Nicardipine IV infusion for one of 41 sampled patients (Patient 27), when Nicardipine IV was restarted beyond the 23 hours of its last administration (the order should have been discontinued and deemed inactive), in accordance with the original physician order set and the facility’s policy regarding titratable medications (slowly increasing the dose of a medicine by very small amounts over time [minutes, hours, days, weeks]). This deficient practice resulted in inappropriate administration of nicardipine to Patient 27 (beyond the prescribed duration), placing Patient 27 at increased risk of harm such as severe hypotension (low blood pressure) thus compromising Patient 27’s safety. 3. Discontinue propofol (a medication used for general anesthesia induction and maintenance, sedation during monitored anesthesia care, and sedation) and obtain a new physician order to restart propofol infusion for one of 41 sampled patients (Patient 26), when propofol was continued beyond the 23 hours of its last administration, in accordance with the original physician order set and the facility’s policy regarding titratable medications (slowly increasing the dose of a medicine by very small amounts over time [minutes, hours, days, weeks). This deficient practice resulted in inappropriate administration of propofol to Patient 26 (beyond the prescribed duration), placing Patient 26 at increased risk of harm such as excessive sedation (drowsiness or sleep), respiratory depression (a breathing disorder characterized by slow or shallow breathing that doesn’t allow for proper gas exchange in the lungs) and/or death. On 5/28/2025 at 5:08 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Medical Officer (CMO), the Senior Director for Risk Management (SDRM), the Patient Care Executive/Chief Nursing Officer (CNO), the Director of Quality (DOQ), the Regulatory Specialist (RS) and via telephone, the Director for Accreditation and Licensing (DAL). The facility failed to ensure its nursing staff adhered to the facility’s policy and procedure and physician order in administering nicardipine (medication to treat high blood pressure) intravenously (IV, administered into a vein) to Patient 1, resulting in Patient 1 suffering hypotension (low blood pressure) when Patient 1’s blood pressure (BP, normal blood pressure is generally considered to be less than 120/80 mmHg [millimeters of mercury, unit of measure]) changed from 222/116 millimeters of mercury (mmHg, unit of measure) to 67/40 mmHg within 1 hour and 30 minutes (from 6 p.m. to 7:30 p.m.) on 2/6/2025, compromising Patient 1’s perfusion (process of blood carrying oxygen and nutrients to the body tissues and organs) to the brain. Patient 1’s pupils were found non-reactive (the pupils do not constrict [get smaller] or dilate [get larger] when exposed to light). On 1/24/2025, Patient 1 was admitted to the facility’s Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) due to subarachnoid hemorrhage (life-threatening type of stroke caused by bleeding into the space surrounding the brain). Patient 1 underwent aneurysm coiling (a procedure to treat brain aneurysm [a bulge in the arteries of brain, potentially leading to a stroke if ruptured [burst], where small coils inserted into the aneurysm to block blood flow and prevent it from rupturing [burst]) on 1/24/2025. There was a physician order on 1/30/2025 to give IV nicardipine to keep systolic blood pressure (first number of blood pressure when the heart contracts and pushes out blood) below 180 mmHg with initial (starting) rate of 5 milligram per hour (mg/hr, unit of measure), increment (an increase) change at 2.5 mg/hr, frequency (how often) of increment of change at 15 minutes, and maximum dose of 15 mg/hr. Patient 1 had IV nicardipine for blood pressure control on 1/30/2025 but the medication was not given since 2/1/2025. On 2/6/2025, at 5: 20 p.m., Patient 1 suddenly became unresponsive (does not react or move). At 6 p.m., Patient 1’s blood pressure was 222/116 mmHg. At 7 p.m., Patient 1 was found with IV nicardipine infusing (running) at maximum dose rate at 15 mg/hr. The IV nicardipine was started at an unknown time and unknown initial rate. There was no blood pressure taken during IV nicardipine infusion. At 7:33 p.m., Patient 1’s BP was 67/40 mmHg. IV nicardipine was stopped and IV norepinephrine (medication used to raise blood pressure in patients with severe hypotension) was started per physician order. Patient 1’s pupils were found blown (pupils were abnormally dilated, fixed and unresponsive to light, suggestive brain damage) and non-reactive. On 5/30/2025 at 5:50 p.m., the IJ was removed in the presence of CMO, SDRM, CNO, DOQ, RS and via telephone, the DAL. The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed through observation, interview, and record review. The IJ Removal Plan indicated that for immediate action taken by the facility included a comprehensive review of all patients currently on IV titratable (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) medications to verify adherence to orders and documentation requirements. The facility also implemented to have pharmacy staff to review the blood pressure parameter on IV titratable medication prior to dispensing (to supply) of medication, and two-Registered Nurse (RN) verification (checking) when initiating and/or resuming any IV titratable medications, 2 RNs would verify the order including name of medication, dosing, frequency, parameters, indication and last infusion time. Primary RN would scan the IV titration medication to validate the order and record administration time and initial infusion rate. RN to monitor and document minimum vital signs including blood pressure, heart rate and mean arterial blood pressure (MAP, a critical measurement of blood pressure that reflects the average arterial pressure throughout the cardiac [heart] cycle) prior to IV titratable medication administration, before and after each titration, and when resuming or restarting the infusion until the therapeutic goal was met. Education began on 5/28/2025 with Intensive Care Unit (ICU) nursing staff and pharmacy staff that were on duty on 5/28/2025. This education was also repeated before the shift started for the day shift on 5/29/2025 and will continue to be repeated on all shifts at the beginning of each shift until all nursing and pharmacy staff have been re-educated. All ICU nursing staff would be checked off for competency (assessment of a clinician’s skills, abilities and knowledge to ensure provision of safe and effective care to patients) for titratable medication validation. The IJ removal plan also included monitoring and auditing plans to ensure that nursing staff were administering IV titratable medication properly per physician order, there was proper monitoring of vital signs when patients were receiving IV titratable medications and 2-RN verification would be used. Audits were also done and will continue regarding IV titratable medication administration and monitoring. Findings: 1.a. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/24/2025, the “H&P” indicated, Patient 1 was admitted to the facility’s Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) with diagnoses including but not limited to subarachnoid hemorrhage (life-threatening type of stroke [occurs when blood flow to the brain is disrupted, either by a blockage or a burst blood vessel] caused by bleeding into the space surrounding the brain), status post aneurysm coiling (a procedure to treat brain aneurysm [a bulge in the arteries of brain, potentially leading to a stroke if ruptured [burst]) on 1/24/2025 and uncontrolled hypertension (high blood pressure). During a review of Patient 1’s “Order Sheet (physician order sheet, orders written by physicians to direct care and treatment),” dated 1/30/2025, the physician order sheet indicated, to give nicardipine (medication to treat high blood pressure) intravenously (IV, administered into a vein) to keep systolic blood pressure (first number of blood pressure when the heart contracts and pushes out blood) less than 180 millimetres of mercury (mmHg, unit of measure) with initial (starting) rate of infusion (running) at 5 milligrams per hour (mg/hr, unit of measure), increment (an increase) of change at 2.5 mg/hr, frequency (how often) of increment of change every 15 minutes, maximum dose rate at 15 mg/hr. The physician order sheet also indicated, “discontinue order if rate remains at zero (0) for 23 hours.” During an interview on 5/27/2025 at 3:14 p.m. with the Intensive Care Unit (ICU) Registered Nurse (RN) 3, RN 3 stated the following: nurse should start IV nicardipine at 5mg/hr and titrate (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) per physician order. There should be a set of vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) to coordinate with each titration. During an interview on 5/28/2025 at 10:56 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: RN 1 found Patient 1 nonresponsive (does not react or move) on 2/6/2025 around 5:20 p.m., Patient 1’s BP was 222/116 mmHg at 6 p.m. Patient 1 was sent to radiology (a department that utilizes various imaging techniques to diagnose and treat diseases) for STAT (a medical abbreviation for immediately or without delay) CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head scan. RN 2 received Patient 1 at change of shift at 7 p.m. and noted Patient 1 receiving IV nicardipine at 75 ml/hr (15mg/hr, maximum dose). During a review of facility’s medication dispensing (to supply) record titled, “All Transaction Activity Detail Report (dispensing record),” dated 2/6/2025, the dispensing record indicated, RN 1 retrieved one bag of IV nicardipine 40 mg per 200 milliliters (ml, unit of measure) for Patient 1 on 2/6/2025 at 6:22 p.m. During a concurrent interview and record review on 5/28/2025 at 11:24 a.m. with the Stroke Coordinator (SC 1), Patient 1’s “Medication Administration Record (MAR, record of medications given to patients),” dated from 1/31/2025 to 2/6/2025, was reviewed. The MAR indicated, Patient 1 received IV nicardipine infusion starting on 1/31/2025 with initial rate at 5 mg/hr and it was titrated to zero (0) on 2/1/2025 at 7:45 a.m. Nicardipine infusion rate was zero (0) from 2/2/2025 to 2/5/2025. The MAR also indicated, on 2/6/2025 at 7 p.m., nicardipine was given at 15mg/hr with a comment indicating, “received patient (Patient 1) at this rate.” During the same interview on 5/28/2025 at 11:24 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: IV nicardipine was started for BP control and it was titrated to zero when the BP was within desired range. Patient 1 did not receive any nicardipine from 2/2/2025 to 2/5/2025. The nicardipine order should have been discontinued on 2/2/2025 by 6:45 a.m. since the last administration (2/1/2025) was over 23 hours. A new order was required to restart IV nicardipine. It was unknown what time and what initial rate nicardipine was restarted on 2/6/2025 because it was not documented. The medication was not titrated correctly. During a concurrent interview and record review on 5/28/2025 at 11:30 a.m. with the Stroke Coordinator (SC 1), Patient 1’s “Vital Signs” flowsheet (vital signs flowsheet), dated 2/6/2025, was reviewed. The vital signs flowsheet indicated the following: -At 5:40 p.m.: Heart Rate (HR) = 80 beats per minute (bpm), BP = 204/98 mmHg; -At 6 p.m.: HR = 94 bpm, BP = 222/116 mmHg; -At 7 p.m.: temperature = 97.9 degrees Fahrenheit (F, unit of measure 100.4 degrees Fahrenheit equivalent to 38.0 degrees Celsius) taken orally, no HR, and no BP documented; and -at 7:33 p.m.: HR = 70 bpm, BP = 67/40 mmHg. During the same interview on 5/25/2025 at 11:30 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: there was no monitoring on Patient 1’s blood pressure from 6 p.m. to 7:33 p.m. (1.5 hours) while Patient 1 was receiving IV nicardipine. Patient 1 became hypotensive (low blood pressure). Low blood pressure could affect perfusion (process of blood carrying oxygen and nutrients to the body tissues and organs) to the brain and contribute to no blood flow to brain. During a concurrent interview and record review on 5/28/2025 at 11:40 a.m. with the Stroke Coordinator (SC 1), Patient 1’s “Nursing Documentation - Flowsheet (nursing assessment),” dated 2/6/2025, was reviewed. The “Nursing Documentation - Flowsheet” indicated, at 3 p.m., Patient 1’s both pupils were PERRLA (Pupils equal, round, and reactive to light and accommodation, standard eye exam to check the health of eyes and the nervous system) with regular, round, size 3 mm, reaction was brisk (quick and full constriction) and consensual light reflex present; at 7 p.m. Patient 1’s both pupils were not PERRLA with regular, round, size 5 mm, nonreactive. SC 1 stated it was a drastic change in neurological assessment (evaluation the function of the nervous system which comprise with brain, spinal cord and peripheral nerves). Patient 1’s both pupils were blown (pupils were abnormally dilated, fixed and unresponsive to light) indicating there was no brain function, the brain was not perfusing. During a review of Patient 1’s “Physician Communication (physician communication note, documentation between nurse and physician communication regarding patient’s condition and test result)” note, dated 2/6/2025, the physician communication note indicated, at 7:28 p.m., RN 2 informed physician (MD 2) that Patient 1 was hypotensive, MD 2 ordered to stop nicardipine and start Levophed (norepinephrine, medication used to raise blood pressure in patients with severe hypotension). During a review of Patient 1’s “Neurosurgery Progress Note (neurosurgeon note, physician progress note completed by neurosurgeon),” dated 2/7/2025, the neurosurgeon note indicated, “(Patient 1) had sudden loss of conscious (unresponsive) yesterday. STAT CT showing large frontal (front part of the brain behind the forehead) hemorrhage (bleeding). Was started on Cardene (nicardipine, medication given intravenously [IV, directly into a vein) to lower blood pressure) for blood pressure management ... became bradycardic (low heart rate) and hypotensive (low blood pressure). Started pressor (medication to raise up the blood pressure) ... loss of brain stem reflexes (involuntary motor responses originating from the brainstem that control breathing, heart rate, and balance) were noted ... this morning remains unresponsive. No cough/ gag reflex (a natural protective mechanism that prevents objects from entering the throat and potentially causing choking). No pupillary (relating pupil of the eye) or oculocephalic reflexes (a neurological reflex where the eyes move in the opposite direction of a rapid head rotation). No responses to painful stimuli. And not breathing over the ventilator (an appliance for artificial respiration). It was likely the patient has progressed to brain death (irreversible cessation of all brain function).” During an interview on 5/29/2025 at 1:58 p.m. with the Director of Pharmacy (DIR 1), DIR 1 stated each IV titration medication order would include how much to start, how often to titrate, how much to titrate to achieve the set goal. Nurses needed to follow the medication order when titrating medications. During an interview on 5/30/2025 at 11:27 a.m. with the ICU Director (DIR 2), DIR 2 stated the following: nurses must follow physician order when administering any titratable medication. Nurses could not change the medication dose, route, frequency without physician order. Nurses could not titrate nicardipine more frequent than every fifteen minutes per physician order. Nurses should monitor patient’s vital signs throughout titration to evaluate his/her response to the medication. During an interview on 5/30/2025 at 4 p.m. with the Medication Safety Officer (MSO), MSO stated Patient 1’s nicardipine incident was identified as a medication error because IV nicardipine was restarted despite it not being used for more than 23 hours (last administration was 2/1/2025) and there was no new order to give IV nicardipine on 2/6/2025. During a review of the facility’s policy and procedure (P&P) titled, “Titratable Medication Infusion Administration,” dated 9/2021, the P&P indicated, “the purpose of this policy is to define and establish requirements for safe and accurate administration and documentation of titratable infusion medication orders... Titration medication orders ... the nurse must stay within the defined parameters of the medication orders ... Titratable medication documentation. 1. Titratable medication must be documented at the time of administration within MAR. 2. The goal of the titratable medication ... must be documented prior to initiating the titratable infusion and during each rate change. 3. Documentation will accurately reflect order changes and patient assessments ... Discontinuing a titratable medication. 1. A titratable infusion order will include the order detail that the infusion should be discontinued from the MAR when the patient has not received the medication for 23 hours or more.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 12/2024, the P&P indicated, “Medication Administration should be performed by licensed medical staff according to manufacturer’s prescribing information and in accordance with FDA (Food and Drug Administration, a government agency) regulations. Proper documentation, verifying patient specific information, medication security and compliance with specific drug policies should always be taken during medication administration ... Procedure ... Utilize the seven rights for administering medication: a. Right Patient b. Right Dose c. Right Time d. Right Route e. Right Drug f. Right to Refuse ... g. Right to be Educated ... Check all medications and IV solutions against eMAR (electronic medication administration record)/MAR ... access eMAR/MAR and/or physician order when administering medications at patient’s bedside ... Documentation: 1. Medication administration should be documented immediately after administration, but no later than 1 hour after administration... Documentation should occur in the eMAR/MAR.” During a review of medication package insert (provide medication information and its use) for nicardipine, dated 10/2014, the medication package insert indicated, “Dosage and Administration ... Recommend Dosing ... Dosage for initiation of therapy in a patient not receiving oral nicardipine. Initiate therapy at 25 ml/hr (5mg/hr). If desire blood pressure reduction is not achieved at this dose, the infusion rate may be increased by 12.5ml/hr (2.5mg/hr) every five (5) minutes (for rapid titration) to 15 minutes (for gradual titration) up to a maximum of 75 ml/hr (15mg/hr), until desired blood pressure reduction is achieved. Following achievement of the blood pressure goal utilizing rapid titration, decrease the infusion rate to 15ml/hr (3mg/hr).” During a review of the facility’s policy and procedure (P&P) titled, “Standards of Nursing Practice Critical Care Department (Intensive Care Unit),” dated 2/25/2025, the P&P indicated, “Patients on intravenous (IV) titratable medications: vital signs (except temperature) shall be assessed and documented at a minimum of approximately every 1 hour (or based on patient’s clinical condition) ...When a RN actively titrating continuous intravenous (IV) infusion medications affecting vital signs ... then the frequency of vital signs should further align with the frequency of titrations (unless situation meets criteria for block charting). Patient monitoring and documentation should occur in a way that clearly justifies the need for titration/intervention and includes appropriate post-intervention follow-up by RN indicating the patient’s response to medication titration.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Errors Reporting,” 9/2022, the P&P indicated, “to establish procedures regarding medication errors and encourage all hospital staff to report all medication error reporting as a tool to enhance patient safety and prevent future errors ... Definitions: A. Medication Error - any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer ... Type of medication errors ... d. Administration error - types of administration errors may include: wrong patient, dose, time, medication, route, rate ... and unauthorized dose given.” 1.b. During a review of Patient 4’s “History and Physical,” dated 2/18/2025, the H&P indicated, Patient 4 was admitted to the facility’s Intensive Care Unit (ICU) for acute cerebrovascular accident (CVA, stroke; damage to the brain from interruption of its blood supply), status post thrombectomy (a procedure of removing blood clots from blood vessels) and hypertension (high blood pressure).During a concurrent interview and record review on 5/29/2025 at 10:43 a.m. with ICU RN 10, Patient 4’s “Order Sheet (physician order sheet),” dated 2/18/2025, was reviewed. The physician order sheet indicated, to give nicardipine intravenously (IV) to keep systolic blood pressure (SBP) between 120 and 170 mmHg with initial rate of infusion at 5 mg/hr, increment of change at 2.5 mg/hr, frequency of increment of change every 15 minutes, maximum dose at 15 mg/hr. The physician order sheet also indicated, “discontinue order if rate remains at zero (0) for 23 hours.” RN 10 stated the orders meant RN could only adjust the nicardipine rate at 2.5 mg/hr every 15 minutes each time. During a concurrent interview and record review on 5/29/2025 at 10:44 a.m. with ICU RN 10, Patient 4’s “Rapid Titration” flowsheet (rapid titration flowsheet, documentation recording IV titration mediation block charting [documentation method that can be used when rapid titration medication us necessary in specific urgent/emergent situations]), dated 2/19/2025, was reviewed. The rapid titration flowsheet indicated, “rapid titration medication: nicardipine; titration start time: 2/19/2025 at 10:30 a.m.; titration end time: 2/19/2025 at 10:45 a.m.; maximum dose achieved: 15 (mg/hr).” RN 10 stated RN 9 initiated block charting (a documentation method used in urgent or emergent situations involving rapid titration of medications, typically in discrete time intervals (e.g., 4 hours). It focuses on documenting the starting and ending doses/rates of medications, the maximum dose administered, and the patient’s assessment at the beginning and end of the block) and titrated IV nicardipine and to reach to maximum dose at 15mg/hr within 15 minutes.During a concurrent interview and record review on 5/29/2025 at 11 a.m. with RN 10, Patient 4’s Medication Administration Record (MAR), dated from 2/18/2025 to 2/19/2025, was reviewed. The MAR indicated the following: the IV nicardipine infusion rate was started on 2/18/2025 at 5 mg/hr. It was titrated to zero (0) mg/hr on 2/19/2025 at 1:50 a.m., the rate was changed to 2.5 mg/hr at 7 a.m., next rate changed to 15mg/hr at 10:44 a.m. The MAR indicated there was no rate change between 7 a.m. and 10:44 a.m. During an interview on 5/29/2025 at 11:11 a.m. with RN 10, RN 10 stated the following: RN 9 titrated IV nicardipine from 2.5 mg/hr to 15 mg/hr within 15 minutes. RN 9 titrated IV nicardipine outside what was ordered. RN 9 did not follow the titration frequency in the medication order. It could cause Patient 4’s blood pressure dropping too fast and become hypotensive (low blood pressure). During a concurrent interview and record review on 5/29/2025 at 11:20 a.m. with RN 10, Patient 4’s “Vital Signs” flowsheet (vital signs flowsheet), dated 2/19/2025, was reviewed. The vital signs flowsheet indicated the following: -7 a.m. heart rate (HR) = 79 beats per minutes (bpm) and blood pressure (BP) = 171/85 mmHg; -8 a.m. HR = 77 bpm and BP = 140/80 mmHg; -9 a.m. HR = 76 bpm and BP 143/76 mmHg; -10 a.m. HR = 83 bpm and BP = 167/85 mmHg; -10:29 a.m. HR = 82 bpm and BP = 165/80 mmHg; and -10:44 a.m. HR = 100 bpm and BP = 206/91 mmHg. During the same interview on 5/29/2025 at 11:20 a.m. with RN 10, RN 10 stated the following: Patient 4’s BP at 10:29 a.m. was within ordered parameters (to keep SBP between 120 and 170 mmHg), there was no need to titrate the IV nicardipine. There was missing one set of vital signs to evaluate Patient 4’s response during the IV nicardipine titration (between 10:29 a.m. and 10:44 a.m.). Nurse should have monitored vital signs during block charting to make sure goal was achieved, to evaluate the effectiveness of the medication and to make sure there was no adverse effect. During an interview on 5/30/2025 at 11:27 a.m. with the ICU Director (DIR 2), DIR 2 stated the following: the facility did not have a rapid titration policy. Nurses must follow physician order when administering any titratable medication. Nurses could not change the medication dose, route, frequency without physician order. Nurses could not titrate nicardipine more frequent than every fifteen minutes per physician order. Nurses should monitor patient’s vital signs throughout titration to evaluate his/her response to the medication. During an interview on 5/30/2025 at 11:39 a.m. with the ICU Director (DIR 2), DIR 2 stated Patient 4’s blood pressure on 2/19/2025 at 10:29 a.m. did not meet criteria for emergent or urgent situation. DIR 2 stated there was no indication for block charting. During an interview on 5/30/2025 at 3:51 p.m. with the Medication Safety Officer (MSO), MSO stated Patient 4’s rapid titration of IV nicardipine on 2/6/2025 at 10:30 a.m. should be reported as medication error because the medication was not given how the physician had ordered. MSO stated there was no report on this incident. During a review of the facility’s policy and procedure (P&P) titled, “Titratable Medication Infusion Administration,” dated 9/2021, the P&P indicated, “the purpose of this policy is to define and establish requirements for safe and accurate administration and documentation of titratable infusion medication orders... Titration medication orders ... the nurse must stay within the defined parameters of the medication orders ... Titratable medication documentation. 1. Titratable medication must be documented at the time of administration within MAR. 2. The goal of the titratable medication ... must be documented prior to initiating the titratable infusion and during each rate change. 3. Documentation will accurately reflect order changes and patient assessments. 4. Documenting each individual rate change during an urgent/emergent situation can potentially create undue burden. In these situations, block charting can be instituted. a. Block charting is a method of documenting rapid titrations. b. Documentation of block must be completed in the EHR (electronic health record). c. Block charting includes the initial rate, ending rate, and max rate of medication infusions administered without documenting the incremental titration adjustments within a specific time period to accomplish the desired goal ... f. the minimum elements that must be documented in each block charting episode are: i. Time of initiation and completion of the charting block. ii. Name(s) of medications administered during the block. iii. Initial rate and ending rate of medication infusions administered during the charting block. iv. Maximum rate (dose) of medications administered during the charting block. v. physiological parameters and goal evaluated during the charting block.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 12/2024, the P&P indicated, “Medication Administration should be performed by licensed medical staff according to manufacturer’s prescribing information and in accordance with FDA (Food and Drug Administration, a government agency) regulations. Proper documentation, verifying patient specific information, medication security and compliance with specific drug policies should always be taken during medication administration ... Procedure ... Utilize the seven rights for administering medication: a. Right Patient b. Right Dose c. Right Time d. Right Route e. Right Drug f. Right to Refuse ... g. Right to be Educated ... Check all medications and IV solutions against eMAR (electronic medication administration record)/MAR ... access eMAR/MAR and/or physician order when administering medications at patient’s bedside ... Documentation: 1. Medication administration should be documented immediately after administration, but no later than 1 hour after administration... Documentation should occur in the eMAR/MAR.”During a review of medication package insert (provide medication information and its use) for nicardipine, dated 10/2014, the medication package insert indicated, “Dosage and Administration ... Recommend Dosing ... Dosage for initiation of therapy in a patient not receiving oral nicardipine. Initiate therapy at 25 ml/hr (5mg/hr). If desire blood pressure reduction is not achieved at this dose, the infusion rate may be increased by 12.5ml/hr (2.5mg/hr) every 5 minutes (for rapid titration) to 15 minutes (for gradual titration) up to a maximum of 75 ml/hr (15mg/hr), until desired blood pressure reduction is achieved. Following achievement of the blood pressure goal utilizing rapid titration, decrease the infusion rate to 15ml/hr (3mg/hr).” During a review of the facility’s policy and procedure (P&P) titled, “Standards of Nursing Practice Critical Care Department (Intensive Care Unit),” dated 2/25/2025, the P&P indicated, “Patients on intravenous (IV) titratable medications: vital signs (except temperature) shall be assessed and documented at a minimum of approximately every 1 hour (or based on patient’s clinical condition) ...When a RN actively titrating continuous intravenous (IV) infusion medications affecting vital signs ... then the frequency of vital signs should further align with the frequency of titrations (unless situation meets criteria for block charting). Patient monitoring and documentation should occur in a way that clearly justifies the need for titration/intervention and includes appropriate post-intervention follow-up by RN indicating the patient’s response to medication titration.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Errors Reporting,” 9/2022, the P&P indicated, “to establish procedures regarding medication errors and encourage all hospital staff to report all medication error reporting as a tool to enhance patient safety and prevent future errors ... Definitions: A. Medication Error - any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer ... Type of medication errors ... d. Administration error - types of administration errors may include: wrong patient, dose, time, medication, route, rate ... and unauthorized dose given.” 2. During a review of Patient 27’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/24/2025, the H&P indicated that Patient 27 was admitted to the facility with a diagnosis of subarachnoid hemorrhage (SAH, a type of stroke [a medical emergency that occurs when the brain’s blood supply is disrupted, causing brain damage] caused by bleeding into the subarachnoid space, which is the area between the brain and the thin tissues [meninges] that cover it) and ruptured brain aneurysm (a medical condition where a weakened, bulging area in a blood vessel wall in the brain bursts, causing bleeding within the brain). During a review of Patient 27’s medical record (MR) titled, “Order Sheet,” dated 5/24/2025, the MR indicated that on 5/24/2025 at 8:31 a.m., the physician placed an order set for nicardipine (Cardene IV, a drip [infusion of a medication intended to lower blood pressure, BP] to be given as a continuous infusion at a starting dose of 5 milligrams per hour [mg/hr, measuring unit] followed by increments of 2.5 mg/hr every 5 minutes until either reaching a maximal dose of 15 mg/hr or achieving the desired reduction in BP) placed on 5/24/2025. Order comments indicated the following details: -“ ...Discontinue Order if rate remains at zero [0] for 23 hours ...” During a concurrent interview and record review on 5/29/2025 at 11:37 a.m. with registered nurse (RN) 6, Patient 27’s “Medical Administration Record (MAR),” [dated 5/23/2025 through 5/29/202, was reviewed. RN 6 stated that on 5/24/2025 at 3 p.m., the recorded [in patient 27’s MAR] rate for Nicardipine IV was 0 mg/hr. RN 6 also said that on 5/25/2025 at 6:50 p.m., Nicardipine IV drip was restarted at 2.5 mg/h (over 3 hours and 50 minutes beyond the last administration time). RN 6 also said that because the order set for Nicardipine drip indicated that the medication should be discontinued if the rate remains at zero for 23 hours, this order should have been discontinued, and a new order should have been placed to restart the infusion. During an interview on 5/30/2025 at 11:27 a.m. with the Critical Care Director (Dir 2), the Dir 2 stated, “Nurses have to verify any medication order ...ensuring the order is active before administering a medication ... If the medication order indicated to discontinue after 23 hours of not being used, then nurses should discontinue and obtain a new order if the same medication needs to be administered again ...Nurses cannot make any changes to the order without communicating with the physician [medical provider] first and obtaining the approval ... All verbal orders must be documented in the patient’s medical record, and it is the responsibility of either the nurse or the physician to ensure that this documented is completed.” During an interview on 5/30/2025 at 12:31 p.m. with the physician (MD 2), MD 2 stated that the physicians in the intensive Care Unit (ICU, a specialized unit providing continuous care for critically ill or unstable patients) were always present in the unit 24/7, and patients’ titratable drips were reviewed every day. MD 2 also said that nurses communicated regularly with physicians regarding the drips patients were on. MD 2 said the following, “We are aware of the sentence (in the order set for titratable medications) that says that the order should be discontinued after 23 hours of not being used ... If the nurses don’t use the drip for 23 hours, they should discontinue the order ... either the physician or the nurse can discontinue ... the point is, if the patient is off the medication, then it should be discontinued ... However, in the ICU, the physician decides if it is okay to use the drips or not and the physicians are the ones who will order the drips ...” MD 2 also said, that sometimes, when there was already an existing order for a medication that the MD wanted to restart, the physician may choose not to re-order and continue the existing order by telling the nurses to continue it. During a review of the facility’s policy and procedure (P&P) titled, “Titratable Medication Infusion Administration,” dated 9/2/2021, the P&P indicated the following: “Titration orders- are defined as those in which the medication dose Is either progressively increased or decreased in response to the patient’s status. F. Discontinuing a titratable medication: 1. A titratable infusion order will include the order detail that the infusion should be discontinued from the MAR when the patient has not received the medication for 23 hours or more. 2. If the medication does not include the order detail to discontinue the infusion after 23 hours, the nurse must obtain an order from the provider to discontinue the infusion. 3. During a review of Patient 26’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/19/2025, the H&P indicated that Patient 26 was admitted to the facility with a diagnosis of status epilepticus (a continuous seizure lasting five minutes or more, or recurrent seizures without recovery in between) and had to be intubated (a tube has been inserted into the patient’s windpipe (trachea) through their mouth or nose to help them breathe). During a review of Patient 26’s medical record (MR) titled, “Order Sheet,” dated 5/19/2025, the MR indicated that on 5/19/2025 at 5:58 a.m., the physician placed an order set for propofol (an intravenous medication used for sedation) to be given as a continuous infusion [titratable drip- slowly increasing the dose of a medicine by very small amounts over time] at initial rate of 10 micrograms per kilogram per minute (mcg/kg/min, measuring unit) .... Order comments indicated the following details: “ ...Discontinue Order if rate remains at zero [0] for 23 hours ...” During a concurrent interview and record review on 5/29/2025 at 3:46 p.m., with registered nurse (RN 6), Patient 26’s “Medical Administration Record (MAR),” [dated 5/19/2025 through 5/29/2025] was reviewed. RN 6 stated that on 5/26/2025 at 10:09 a.m., the recorded [in patient 26’s MAR] rate for propofol was 0 mg/hr. RN 6 said that on 5/28/2025 at 1:59 a.m., propofol drip was restarted at 53.3 mg (over 39 hours and 50 minutes beyond the last administration time). RN 6 also said that because the order set for propofol indicated that the medication should be discontinued if the rate remains at zero for 23 hours, this order should have been discontinued, and a new order should have been placed to restart the propofol infusion. During an interview on 5/30/2025 at 11:27 a.m. with the Critical Care Director (Dir 2), the Dir 2 stated, “Nurses have to verify any medication order ...ensuring the order is active before administering a medication ... If the medication order indicated to discontinue after 23 hours of not being used, then nurses should discontinue and obtain a new order if the same medication needs to be administered again ...Nurses cannot make any changes to the order without communicating with the physician [medical provider] first and obtaining the approval ... All verbal orders must be documented in the patient’s medical record, and it is the responsibility of either the nurse or the physician to ensure that this documented is completed.” During an interview on 5/30/2025 at 12:31 p.m. with the physician (MD 2), MD 2 stated that the physicians in the intensive Care Unit (ICU, a specialized unit providing continuous care for critically ill or unstable patients) were always present in the unit 24/7, and patients’ titratable drips were reviewed every day. MD 2 also said that nurses communicated regularly with physicians regarding the drips patients were on. MD 2 said the following, “We are aware of the sentence [in the order set for titratable medications] that says that the order should be discontinued after 23 hours of not being used ... If the nurses don’t use the drip for 23 hours, they should discontinue the order ... either the physician or the nurse can discontinue ... the point is, if the patient is off the medication, then it should be discontinued ... However, in the ICU, the physician decides if it is okay to use the drips or not and the physicians are the ones who will order the drips ....” MD 2 also said, that sometimes, when there was already an existing order for a medication that the MD wants to restart, the physician may choose not to re-order and continue the existing order by telling the nurses to continue it. During a review of the facility’s policy and procedure (P&P), titled “Titratable Medication Infusion Administration,” dated 9/2/2021, the P&P indicated the following: “Titration orders- are defined as those in which the medication dose Is either progressively increased or decreased in response to the patient’s status. F. Discontinuing a titratable medication: 1. A titratable infusion order will include the order detail that the infusion should be discontinued from the MAR when the patient has not received the medication for 23 hours or more. 2. If the medication does not include the order detail to discontinue the infusion after 23 hours, the nurse must obtain an order from the provider to discontinue the infusion.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that medical records for 20 of 41 sampled patients (Patients 2, 3, 8, 9, 10, 11, 12, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39) were accurately written or documented, in accordance with the facility’s policies regarding medical record content and completeness, as evidenced by: 1. The rounds (a systematic process where a healthcare team member checks on a patient regularly) conducted, every 15 minutes, in the East side of the Psychiatric (relating to mental illness) Acute Care unit, were inaccurately documented in the medical record for 19 of 19 patients (Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39). This deficient practice led to the inaccurate documentation on 5/7/2025 at 4:15 a.m., that 19 patients had been visualized by a staff, when in fact, the round was not conducted at that time. This deficient practice also placed 19 patients’ safety at risk such as self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence. 2. For Patient 27, the electronic medical record (eMR, digital version of paper chart) titled, “Medication Administration Record (MAR),” did not accurately reflect the documentation of the peripheral intravenous line (PIV, a short, flexible plastic tube [catheter] inserted into a vein for the purpose of administering fluids, medications, or blood products) used to administer nicardipine (a medication used to treat hypertension [high blood pressure, a condition where the force of blood pushing against the walls of the arteries is consistently too high]). This deficient practice had the potential for Patient 27’s PIV site to be inadequately monitored for complications such as infiltration (the inadvertent delivery of fluid or medication into surrounding tissue that has the potential to harm the patient), phlebitis (inflammation of the vein), or extravasation (the leakage of fluid or substances from a blood vessel or other enclosed space into the surrounding tissues), leading to tissue damage, tissue ischemia (blood flow to a tissue or organ is restricted or reduced) , or necrosis (death of the tissue), and if undetected, may result in delayed treatment and/or negative health outcomes for Patient 27. Findings: 1. During a review on 5/28/2025 at 10:25 a.m., a Video footage, dated 5/7/2025 of the East side of the Psychiatric Acute Care Unit, was reviewed. The following was reviewed with Nurse Managers (NM) 1 and NM 2. The video footage indicated that on 5/7/2025 at 4:15 a.m., Licensed Vocational Nurse (LVN) 2 was not seen in the hallway conducting rounds on Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39. NM 1 stated that rounds should be conducted every 15 minutes by going into patient rooms and checking for a safe environment, patients’ condition, behavior, and whether the patient was breathing or sleeping. NM 1 stated that the round on 5/7/2025 at 4:15 a.m., was missed. NM 1 stated that LVN 2 documented that she (LVN 2) had conducted rounding at 4:15 a.m., and that the documentation was falsified (false or incorrect). During a review of a document titled, “Patient Observation Checklist - Psych Acute Care - East,” dated 5/7/2025, the document indicated Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39 were on the unit. At 4:15 a.m., Patients 12 and 30 were in their room, awake. At 4:15 a.m., Patients 2, 3, 8, 9, 10, 11, 28, 29, 31, 32, 33, 34, 35, 36, 37, 38, and 39 were in their room, asleep. During a review of Patient 2’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/19/2025, the H&P indicated the following: Patient 2 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for Grave Disability (a person who is unable to care for their basic needs due to a mental health disorder). During a review of Patient 3’s History and Physical (H&P), dated 5/01/2025, the H&P indicated Patient 3 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for suicidal ideations (thoughts of harming self). During a review of Patient 8’s History and Physical (H&P), dated 4/19/2025, the H&P indicated Patient 8 was admitted to the facility on a 5150 hold for grave disability. During a review of Patient 9’s Behavioral History and Physical (H&P), dated 4/29/2025, the H&P indicated Patient 9 was admitted to the facility on a 5150 hold for danger to self and danger to others. During a review of Patient 10’s Behavioral History and Physical (H&P), dated 5/5/2025, the H&P indicated Patient 10 was admitted to the facility on a 5150 hold for danger to self. Patient 10 had a history of major depression (serious mental disorder characterized by persistent feelings of sadness, loss of interest in activities, and a range of other symptoms that interfere with daily life). During a review of Patient 11’s Behavioral History and Physical (H&P), dated 4/4/2025, the H&P indicated Patient 11 was admitted to the facility on a 5150 hold for grave disability. During a review of Patient 12’s Behavioral History and Physical (H&P), dated 5/2/2025, the H&P indicated Patient 12 was admitted to the facility on a 5150 hold for grave disability. During a review of Patient 28’s Behavioral History and Physical (H&P), dated 4/17/2025, the H&P indicated Patient 28 was admitted to the facility on a 5150 hold for grave disability. During a review of Patient 29 ‘s Behavioral History and Physical (H&P), dated 5/3/2025, the H&P indicated Patient 29 was admitted to the facility on a 5150 hold for grave disability. During a review of Patient 30 ‘s Behavioral History and Physical (H&P), dated 4/30/2025, the H&P indicated Patient 30 was admitted to the facility on a 5150 hold for grave disability and danger to self. During a review of Patient 31 ‘s Behavioral History and Physical (H&P), dated 5/6/2025, the H&P indicated Patient 31 was admitted to the facility on a 5150 hold for danger to self. During a review of Patient 32’s Behavioral History and Physical (H&P), dated 5/04/2025, the H&P indicated Patient 32 was admitted to the facility because of delusions (persistent, false beliefs held with a strong conviction despite evidence to the contrary) and uncontrolled behavior. During a review of Patient 33’s History and Physical (H&P), dated 5/03/2025, the H&P indicated Patient 33 was admitted to the facility on a 5150 hold for being gravely disabled. Patient 33’s diagnosis included psychosis (disconnection from reality) and schizophrenia (disorder that affects a person’s ability to think, feel, and behave clearly). During a review of Patient 34’s History and Physical (H&P), dated 3/22/2025, the H&P indicated Patient 34 was admitted to the facility on a 5150 hold for grave disability. Patient 34’s diagnosis included schizophrenia. During a review of Patient 35’s Behavioral History and Physical (H&P), dated 5/05/2025, the H&P indicated Patient 35 was admitted to the facility on a 5150 hold for being a danger to self (thoughts of harming self). During a review of Patient 36’s History and Physical (H&P), dated 5/04/2025, the H&P indicated Patient 36 was admitted to the facility for psychosis and suicidal ideations. During a review of Patient 37’s Behavioral History and Physical (H&P), dated 4/29/2025, the H&P indicated Patient 37 was admitted to the facility on a 5150 hold for being a danger to self. Patient 37’s diagnosis included schizophrenia. During a review of Patient 38’s Behavioral History and Physical (H&P), dated 1/25/2025, the H&P indicated Patient 38 was admitted to the facility for aggressive behavior and suicidal ideations. Patient 38 was on a 5150 hold for danger to self. During a review of Patient 39’s History and Physical (H&P), dated 3/15/2025, the H&P indicated Patient 39 was admitted to the facility for being agitated and aggressive and on a 5150 hold for being a danger to others and grave disability. During a review of the facility’s policy and procedure (P&P) titled, “Medical Record Content and Completeness,” dated 12/06/2024, the P&P indicated the following: Policy Summary/Intent: ...To outline the hospital policy to provide a medical record for all patients that is timely, meaningful, an authentic (real, true) and legible description of the patient’s clinical condition and hospital course ...To define complete and properly documented patient medical record that supports patient care, reimbursement, justifies treatment as required ...by regulatory agencies. 2. During a review of Patient 27’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/24/2025, the H&P indicated that Patient 27 was admitted to the facility with a diagnosis of subarachnoid hemorrhage (SAH, a type of stroke [a medical emergency that occurs when the brain’s blood supply is disrupted, causing brain damage] caused by bleeding into the subarachnoid space, which is the area between the brain and the thin tissues [meninges] that cover it) and ruptured brain aneurysm (a medical condition where a weakened, bulging area in a blood vessel wall in the brain bursts, causing bleeding within the brain). During a review of Patient 27’s medical record (MR) titled, “Order Sheet,” dated 5/24/2025, the MR indicated that Patient 27 had an order for nicardipine drip (the drug [intended to lower blood pressure, BP] is given as a continuous infusion at a starting dose of 5 milligrams per hour [mg/hr, measuring unit] followed by increments of 2.5 mg/hr every 5 minutes until either reaching a maximal dose of 15 mg/hr or achieving the desired reduction in BP) placed on 5/24/2025. During a concurrent interview and record review on 5/29/2025 at 3:13 p.m. with Registered Nurse (RN) 6, Patient 27’s “Order Sheet,” was reviewed. The Order Sheet indicated that on 5/24/2025 [at 8:31 a.m.], an order for nicardipine (Cardene I.V.) continuous drip was placed with the following order comments: “Minimize peripheral venous infiltration (the inadvertent delivery of fluid or medication into surrounding tissue that has the potential to harm the patient) by changing infusion site every 12 hours.” RN 6 reviewed Nicardipine IV order details and stated that the peripheral I.V. site documentation should demonstrate the alternation in PIV site during Nicardipine IV infusion. During a review of Patient 27’s Medication Administration Record (MAR), particularly administration of the continuous nicardipine drip (infusion) and the associated peripheral intravenous (PIV) site record, dated 5/25/2025 through 5/29/2025, the record indicated that that on all occasions, Patient 27’s PIV was documented to be in the right antecubital (AC, the area of the inner elbow). This information was verified with the registered nurse (RN 6) during record review on 5/29/2025 at 2:56 p.m. During a review of Patient 27’s nursing flowsheet titled, “Peripheral Intravenous (PIV) Lines,” dated 5/27/2025, the flowsheet indicated that Right antecubital (Rt AC) line was discontinued and removed on 5/27/2025 at 10:43 p.m. and Left antecubital (Lt AC) line was documented to be inserted on 5/27/2025 at 3:15 a.m. During a concurrent interview and record review on 5/29/2025 at 3:13 p.m. with Registered Nurse (RN 6), Patient 27’s Medication Administration Record (MAR), particularly administration of the continuous nicardipine drip (infusion) and the associated peripheral intravenous (PIV) site record, dated 5/25/2025 through 5/29/2025, was reviewed. RN 6 confirmed that nursing staff continued documentation of right antecubital” (Right AC) as the IV site associated with nicardipine infusion through the reviewed date of 5/29/2025 at 3:13 p.m., even though the right antecubital line was recorded to have been discontinued and removed on 5/27/2025 at 3:15 a.m. During an interview on 5/29/2025 at 3:11 p.m. with registered nurse (RN 6), RN 6 stated the following, “We [nurses] document the peripheral IV site associated with the administration of a medication to enable tracing of any side effects related to the medication infusion.” RN 6 also said that accurate documentation allowed [nurses] to identify and assess the site for complications such as phlebitis (inflammation of the vein), pain, swelling, or vesicants (substances that can cause tissue damage or blistering if extravasation occurs) which was essential for early detection and timely intervention to prevent tissue injury and ensure patient safety. During a review of the nicardipine safety data sheet (SDS, a document that provides information about the potential hazards of a chemical or substance, along with guidance on how to handle, store, and dispose of it safely), dated 10/2014, the SDS indicated the following: “Administer Cardene I.V. (Nicardipine) by a central line or through a large peripheral vein. Change the infusion site every 12 hours if administered through peripheral vein to reduce the possibility of venous thrombosis, phlebitis, local irritation, swelling, extravasation, and the occurrence of vascular impairment. To minimize the risk of peripheral venous infiltration, change the site of the drug infusion every 12 hours.””

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that for one of 41 sampled patients (Patient 5), a death note (a documented record in the medical record to indicate the patient’s death, including the cause and circumstances), was completed and filed in Patient 5’s electronic medical record (eMR, digital version of paper charting) to formally document and record the death of a patient (Patient 5), in accordance with the facility’s policy regarding medical record content and completeness. This deficient practice violated Patient 5’s rights (the legal protections and ethical considerations that ensure individuals receive respectful, equitable, and informed medical care) with regards to the completeness and integrity of the medical record, potentially damaging a patient’s and their family’s trust in the healthcare system and their providers. Findings: During a review of Patient History and Physical (H&P, a comprehensive formal assessment used by healthcare providers to evaluate a patient’s health and medical condition, typically during an initial visit or before a procedure), dated 2/26/2025, the H&P indicated that Patient 5 was admitted with a diagnosis of sepsis (a life-threatening medical emergency that occurs when the body’s extreme response to an infection damages its own tissues and organs). During a review of Patient 5’s “Discharge Summary,” dated 1/15/2025, the Discharge Summary indicated, that Patient 5 died after developing a multisystem organ failure (two or more of the organ systems are failing to support the body’s needs) and being on maximum dose of 4 pressors (medications or substances that raise blood pressure). During a concurrent interview and record review on 5/28/2025, at 11:15 a.m. with registered nurse (RN) 13, Patient 5’s electronic health record (EHR), dated 12/26/2023 through 1/1/2024, was reviewed, to locate the death note (the documentation of a patient’s death, including the time and date of death, the reason for death, and other relevant details). RN 13 said that Patient 5’s EHR did not contain a completed and filed death note for Patient 5. RN 13 reviewed the “Discharge Summary,” report, dated 1/1/2024, and stated that the record did not indicate how Patient 5 died and when [date and time]. During an interview on 5/30/2025 at 2:47 p.m. with the Chief Medical Officer (CMO), the CMO reviewed Patient 5’s “Discharge Summary/Death Summary, dated 1/1/2024, and said that this document was solely a discharge summary, not a Death Note. The CMO further said that a death note should include the official statement indicating that the patient had died, including the date and time of death, the cause of death, and the course of treatment prior to the patient’s passing, such as whether a rapid response (RRT, activated when a patient’s condition is deteriorating but not yet in cardiac or respiratory arrest) was called or a code blue (a medical emergency where a patient has stopped breathing or has no heartbeat, requiring immediate resuscitation efforts) was activated. During the same interview on 5/30/2025 at 2:47 p.m., with the Chief Medical Officer (CMO), the CMO stated that both, patient’s discharge summary and death note, were expected to be completed and filed within five to seven days. During a review of the facility’s policy and procedure (P&P) titled, “Medical Record Content and Completeness,” dated 12/6/2024, the P&P indicated that all records are to be available in the Electronic Health Records (EHR) 48 hours of discharge. All clinical entries in the patient medical record shall be considered complete when the required contents are filed in the EHR ... to ensure that the medical record contains patient specific data justifying admission and treatment, patient’s clinical condition and hospital course ... and to ensure that medical documentation follows regulatory requirements...”

“CONTENT OF RECORD: HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(A) All records must document the following, as appropriate: (i) Evidence of-- (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(4)(i)(C) of this section. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that for one of 41 sampled patients (Patient 24), a comprehensive medical history and physical examination (H&P, a formal assessment of a patient that includes gathering their medical history and performing a physical examination) was completed, documented, and filed within 24 hours of Patient 24’s admission and prior to surgery, in accordance with the facility’s policy regarding chart completeness. This deficient practice had the potential to compromise Patient 24’s safety by delaying the identification of underlying health issues, contraindication, or risks that could impact surgical outcomes. In addition, this deficient practice can lead to inappropriate delayed medical interventions for Patient 24, increased risk of perioperative complications, and adverse events, or harm to the patient (Patient 24) due insufficient baseline assessment and incomplete documentation. Findings: During a review of Patient 24’s “Emergency Department (ED) Physician Note,” dated 5/27/2025, the note indicated that on 5/27/2024, Patient 24 was seen and evaluated by the Emergency Department (ED, a hospital facility that provides immediate medical care to patients who need urgent attention) physician due to active bleeding and large volume hemoptysis (coughing up blood or bloody mucus from the respiratory tract (lungs and throat). The ED physician note also indicated that Patient 24 underwent tonsillectomy (a surgical procedure where the tonsils are removed) two weeks ago ... The note further indicated that Patient 24 was going to be taken to the operating room for surgical management of bleeding. During a concurrent interview and record review on 5/29/2025 AT 11:09 a.m. with registered nurse (RN 6), Patient 24’s electronic medical record (EMR, digital version of paper chart), was reviewed. RN 6 stated that History and Physical (H&P, a comprehensive formal assessment used by healthcare providers to evaluate a patient’s health and medical condition, typically during an initial visit or before a procedure) was not filed in Patient 24’s electronic medical record (eMR). During a review of Patient 24’s “Critical Care Consultation Note,” dated 5/27/2025, the note indicated that Patient 24 underwent surgical control of ongoing bleeding and was admitted to the intensive care unit (ICU, a specialized hospital ward designed to provide advanced critical care to patients who are critically ill or injured) on 5/27/2025 for monitoring. During an interview on 5/20/2025 at 2:44 p.m. with the Chief Medical Officer (CMO), the CMO stated the following regarding the facility’s requirement for admitting physicians to complete a medical history and physical examination prior to admitting patient and/or performing a procedure/surgery: “The H&P must be completed within 24 hours of admission ... As patients pass through many departments, it is essential that all staff involved are informed of the patient’s history, contraindication, medications, and allergies to ensure safe and coordinated care.” During a review of the facility’s policy and procedure (P&P) titled, “Chart Completeness upon Discharge,” dated 11/2022, the P&P indicated that History and Physical (H&P) examination shall be recorded in the medical record within 24 hours after admission or prior to surgery/procedure and the following elements are required to complete H&P: I. Identification Data II. Chief Complaint III. History of Present Illness IV. Past Medical History V. Social and Family History VI. Review of Systems VII. Allergies VIII. Medications IX. Physical Examination, to include findings in those organ systems relevant to the presenting illness and to co-existing diagnosis”

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that for one of 41 sampled patients (Patient 23), a completed verified informed consent (a voluntary formal confirmation- agreement signed by the patient or their authorized representative that confirms they understand the nature, risks, benefits, and alternatives of a medical procedure before it is performed) for anesthesia (blocking pain signals to the brain, preventing a person from feeling pain during a procedure), was filled out indicating the type of anesthesia to be used during the procedure (laminectomy, a surgical procedure where a surgeon removes a portion of the lamina, which is the back part of the vertebra, to relieve pressure on the spinal cord or nerve roots), initials, date, time and witness signature in the area designated for anesthesia on the consent form, in accordance with the facility’s policy regarding consents. This deficient practice had the potential to negatively affect Patient 23’s rights to decision-making (refers to the process in which patients are actively engaged in making informed choices about their healthcare options), undermining Patient 23’s autonomy (person’s right to make their own decisions) and compromise the legal validity (refers to legitimacy and enforceability of a document) of the consent due to lack of completeness of the medical record (verified informed consent form). Findings: During a review of Patient 23’s History and Physical (H&P, a comprehensive formal assessment used by healthcare providers to evaluate a patient’s health and medical condition, typically during an initial visit or before a procedure), dated 12/22/2023, the H&P indicated that Patient 23 was admitted for a planned laminectomy (a surgical procedure where a surgeon removes a portion of the lamina, which is the back part of the vertebra, to relieve pressure on the spinal cord or nerve roots) indicated for chronic ( persisting for a long time and constant) back pain. During a review of Patient 23’s History and Physical (H&P), dated 12/22/2023, the H&P also indicated that informed consent discussion took place between the physician, the patient (Patient 23) and Patient 23’s Durable Power of Attorney (DPOA, a legal document that grants someone (the agent) the authority to make decisions on patient’s behalf, even if patient becomes incapacitated or unable to make decisions) and the procedure, risks/benefits/alternatives, rationale for procedure, and anticipated post-operative course were discussed with the patient (Patient 23) and the DPOA, and both elected to proceed with the procedure (laminectomy). During a review of Patient 23’s informed consent for laminectomy, dated 12/25/2023, the consent indicated that the type of anesthesia (to be used during the procedure for laminectomy, [a surgical procedure where a surgeon removes a portion of the lamina, which is the back part of the vertebra, to relieve pressure on the spinal cord or nerve roots]), Patient 23’s initials, date, time and witness signature in the area designated for anesthesia on the consent form, were not completed. This finding was verified during Patient 23’s electronic health record (EHR) review on 5/28/2025 at 11:45 a.m. with registered nurse (RN) 13. During a concurrent interview and record review on 5/28/2025 at 11:56 a.m. with the Director of Perioperative Services (DOP), Patient 23’s informed consent for “Laminectomy,” dated 12/25/2023, was reviewed. The DOP reviewed the consent and stated that the area dedicated to anesthesia was not marked as completed and was left blank. The DOP also said the informed consent was signed, and perhaps the nurse (who witnessed and signed obtaining the informed consent with Patient 23) or the patient (Patient 23) missed completing the anesthesia part of the consent. During the same interview on 5/28/2025 at 11:56 a.m. with the Director of Perioperative Services (DOP), the DOP stated that anesthesia did not require a separate informed consent form and a designated area specifically outlining anesthesia, (which needed to be marked, initialed [by the patient] dated, timed, and witnessed with a signature), was found being missed by the nurses in the past when signing the consent with patients. The DOP also said that the facility recently changed the consent forms, so that the anesthesia section was no longer required to be separately marked and signed. The DOP said that the old, informed consent forms were still circulating within the facility. During a review of the facility’s policy and procedure (P&P) titled, “Consent and Informed Consent,” dated 12/2024, the P&P indicated that consent for surgery or special procedure form should include ... the name of the patient, and when appropriate the patient’s legal representative ... signature of witness, date and time ...”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that for one of 41 sampled patients (Patient 26), nursing staff initiated, maintained, and documented a current nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for status epilepticus (a seizure [a sudden, temporary disturbance of the brain’s normal electrical activity, often manifesting as changes in muscle tone, behavior, or awareness] lasting longer than five minutes or recurrent seizures without regaining full consciousness between them) that reflected the patient’s (Patient 26’s) goals and the nursing care to be provided to meet Patient 26’s needs, in accordance with the facility’s policy regarding care plans. This deficient practice had the potential for Patient 26’s care needs not to be met leading to adverse health outcomes for Patient 26, such as increased risk for injury during seizures, delayed recognition and response to seizure activity, lack of safety precautions to minimize the risk of harm during seizures. In addition, the lack of documented implementation of a seizure care plan had the potential to compromise communication among healthcare providers leading to disruptions in the continuity of care and Patient 26’s safety. Findings: During a review of Patient 26’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/19/2025, the H&P indicated that Patient 26 was admitted to the facility with a diagnosis of status epilepticus (a continuous seizure [a sudden, temporary disturbance of the brain’s normal electrical activity, often manifesting as changes in muscle tone, behavior, or awareness] lasting five minutes or more, or recurrent seizures without recovery in between) and had to be intubated (a tube has been inserted into the patient’s windpipe (trachea) through their mouth or nose to help them breathe). During a concurrent interview and record review on 5/29/2025 at 1:30 p.m. with registered nurse (RN) 6, Patient 26’s electronic health record (EHR, electronic version of paper chart) titled, “Care Plans,” dated 5/18/2025 through 5/29/2025, were reviewed. Patient 23’s Care Plans (documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers), had no documented care plan for “Seizures.” RN 6 verified the lack of developed and documented care plan for seizures for Patient 26 throughout their (Patient 26) admission stay at the facility [5/19/2025 through 5/29/2025]. RN 6 also verified that Patient 26’s admission diagnosis was due to a seizure and stated that seizure precautions must be implemented for a patient admitted with seizures. During the same interview and record review on 5/29/2025, at 1:30 p.m. with registered nurse (RN) 6, RN 6 reviewed Patient 26’s electronic health record (EHR) in an attempt to locate documentation of seizure precautions anywhere in the patient’s (Patient 26) health record. RN 6 verified that seizure precautions (safety measures taken before and during a seizure to prevent injury and ensure a person’s well-being) were not recorded anywhere in Patient 26’s health record (during admission from 5/19/2025 through 5/29/2025]. RN 6 then reviewed the available care plan for seizure precautions and stated that safety precautions can be documented in the intervention section of care plan once it’s initiated. During an interview on 5/30/2025 at 4:12 p.m. with registered nurse (RN) 6, RN 6 stated that a care plan was developed based on the patient’s identified needs and problems, and it should include the establishment of specific goals to guide the development of appropriate interventions aimed at meeting the patient’s individual needs and achieving the desired outcomes. During a review of the facility’s policy and procedure (P&P) titled, “Standards of Nursing Practice Critical Care Department (Intensive Care Unit),” dated 2/2025, the P&P indicated that nursing diagnoses and care issues are derived from the assessment data with the patient...and are prioritized and documented in a manner that facilities prioritizing outcomes and developing or modifying the plan...Outcomes are derived from actual or potential diagnoses and care issues, and shall be identified on the care plan by documentation of measurable goals within approximately 24 hours of admission to recognize and incorporate unique patient-centered values and care needs... The implemented plan and modifications are documented... Outcomes provide direction for continuity of care, and the plan establishes priorities for care.... Care is delivered in a manner that promotes patient safety...”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility’s Governing Body (responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure the Condition of Participation for Governing Body was met as evidenced by: 1. The facility’s Governing Body failed to ensure adequate oversight for the Nursing Services Department in the Intensive Care Department/Unit (ICU, ward that provides the critical care and life support for acutely ill and injured patients), to ensure the facility’s policy and procedure regarding the use of sitters (a trained individual, often a healthcare worker, assigned to provide continuous, one-to-one supervision of a patient to ensure their safety) including fall (an unexpected, unintentional descent of a patient to the ground or another lower surface) prevention, was followed, and to ensure that the QAPI (Quality Assessment and Performance Improvement- a data driven and proactive approach to quality improvement) team effectively tracked patient adverse events (an undesirable outcome that happens during medical care), analyzed their causes, and implemented preventive actions and mechanisms to ensure patient safety for two of 30 sampled patients (Patient 1 and Patient 6), who both fell on the floor while in the ICU. Patient 1 fell on 11/28/2024 and Patient 6 fell on 2/2/2025. This deficient practice resulted in two separate instances of fall involving Patients 1 and 6, which had the potential to result in complications such as fracture (break in the bone), brain bleed, etc., and may result in prolonged hospitalization and delayed recovery for Patients 1 and 6. (Refer to A-0063) 2. The facility’s Governing Body failed to ensure the sterile processing department (SPD, the area in a hospital where cleaning and sterilization of devices used in medical procedures takes place), provided services and competent staff that met current national standard practice regarding reprocessing and sterilization process and adhered to facility’s policies and procedures regarding the reprocessing (the specific process of cleaning, disinfecting [the process of eliminating or reducing harmful germs on surfaces to a level that does not pose a risk of infection], and sterilizing [the process of completely destroying all forms of germs through methods ensuring that medical instruments and equipment are free from any living microbes (germs) before use] reusable medical equipment to ensure it is safe to reuse between patients) of surgical instruments and infection control (practices and procedures implemented to prevent the spread of infections by minimizing the transmission of germs in a healthcare setting). This deficient practice had the potential for improper processing of surgical instruments potentially resulting in increased risk of infection, organ failure, disfigurement, and/or death for patients undergoing surgical procedures. (Refer to A-0063) 3. The facility’s Governing Body failed to ensure its contracted service staff adhered to infection control and prevention practice to disinfect (killing germs and bacteria) one of three sampled hemodialysis (HD, the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) machine (HDM 2) with heat or bleach at the end of day use, after hemodialysis was completed for one of 30 sampled patients (Patient 16), in accordance with the contracted service’s policy and procedure and hemodialysis machine operator manual. This deficient practice had the potential to result in bacterial contamination within the hemodialysis machine and had the potential to introduce bacteria to other patients’ bloodstream who may use the same machine (HDM 2) thus causing infection to patients from hemodialysis treatment. (Refer to A-0083) 4. The facility’s Governing Body failed to ensure that contracted dialysis services adhered to the facility’s “Dialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) Services,” policy and procedure when one of one sampled dialysis machine (HDM 1) was left unattended in a public area, containing intravenous (IV, administered into the vein) fluids, chemical reagents (solutions, typically containing electrolytes used to create the “dialysate” fluid which is circulated through a dialysis machine to filter waste products from a patient’s blood), and patient-identifiable information. This deficient practice had the potential to result in unauthorized access to medical records (the HDM 1 contained patient-identifiable information), contamination, and breaches of patient confidentiality, etc. (Refer to A-0083) 5. The facility’s Governing Body failed to ensure that contracted dialysis services adhered to safe practices and the facility’s policy and procedure regarding safe handling and storage protocols for dialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) machines, when one of one sampled dialysis machine (HDM 1) was left unattended in a public area, containing intravenous (IV, administered into the vein) fluids, chemical reagents (solutions, typically containing electrolytes used to create the “dialysate” fluid which is circulated through a dialysis machine to filter waste products from a patient’s blood), and patient-identifiable information. This deficient practice had the potential to result in unauthorized access to medical records (the HDM 1 contained patient-identifiable information), contamination, and breaches of patient confidentiality, etc. (Refer to A-0084) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by: 1. The facility failed to ensure that one of 30 sampled patients (Patient 25) was properly provided adequate information regarding refusal of blood product transfusion as well as be provided with alternative options to blood transfusion (a medical procedure where blood or blood components from a donor are transferred into the bloodstream of a recipient), as part of the informed consent process (a process that involves discussing treatment options with the patient, including risks and benefits, and getting their agreement to proceed), in accordance with the facility’s policy and procedure regarding informed consent. This deficient practice resulted in Patient 25 receiving three (3) units of packed red blood cells (PRBC- used to increase the oxygen-carrying capacity of the blood in patients with anemia [when the body does not have enough health red blood cells], blood loss, or other conditions that cause a low red blood cell count) during a surgical procedure emergency, which violated Patient 25’s rights regarding informed consent. (Refer to A-0131) 2. The facility failed to follow the physician’s order for one of 30 sampled patients (Patient 1) to provide a bedside sitter (a trained individual, often a healthcare worker or sitter, assigned to provide continuous, one-on-one supervision of a patient to ensure their safety, especially if the patient is at risk of falls [an unexpected, unintentional descent of a patient to the ground or another lower surface], disorientation, or self-harm) for constant supervision to monitor Patient 1’s safety, when: 2.a. On 11/28/2024, in the Intensive Care Unit (ICU, ward that provides the critical care and life support for acutely ill and injured patients), Registered Nurse (RN 1) left Patient 1 unattended while retrieving medications from the medication room resulting in Patient 1 falling to the floor. This deficient practice resulted in Patient 1 experiencing a fall in the ICU on 11/28/2024. This deficient practice also had the potential to result in complications such as fracture (break in the bone), etc. (Refer to A-0144) 2.b. On 12/6/2024, a sitter was not assigned to Patient 1 when Patient 1 was transferred to the Step-Down Unit (SDU, an intermediate care unit for patients who no longer require intensive care but still need close monitoring). From 12/6/2024 through 12/11/2024, Patient 1 remained without a sitter. On 12/11/2024, Patient 1 was found disconnected from the Bilevel Positive Airway Pressure (BIPAP, a non-invasive ventilator that assist patients with breathing difficulties) machine and suffered cardiac arrest (when the heart suddenly stops beating) in the SDU. This deficient practice resulted in a cardiac arrest in the SDU on 12/11/2024 due to Patient 1’s disconnection from the BiPAP machine. In addition, this deficient practice had the potential to place other patients with physician-ordered bedside sitters at risk for similar sentinel event (a patient safety event that results in death, permanent harm, or severe temporary harm) due to inadequate supervision. (Refer to A-0144) 3. The facility failed to protect the confidentiality of information, in accordance with the facility’s policy and procedure regarding Patient Rights (a subset of human rights) and Responsibility, for twenty of twenty sampled patients (who were receiving dialysis for the month of February 2025), when a binder containing medical record numbers (MRNs) was left unattended on a dialysis machine (HDM 1) in a public area (on the East Tower ground floor in front of the elevator). This deficient practice violated patient confidentiality and compromised compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA, is a federal law that protects patients’ health information) regulations. This deficient practice also increased the risk of unauthorized access to protected health information (PHI, any individually identifiable health information about a patient that is held by a covered entity, like a healthcare provider or health plan, and is subject to privacy regulations under the Health Insurance Portability and Accountability Act [HIPAA]), failing to uphold patients’ rights to privacy and confidentiality of their clinical records. (Refer to A-0147) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) was met as evidenced by: 1. The facility failed to identify, analyze, and address deficiencies in ICU (Intensive Care Unit- ward that provides the critical care and life support for acutely ill and injured patients) equipment availability through its Quality Assessment and Performance Improvement (QAPI, a systematic approach to improving the quality of care and safety in a healthcare setting. QAPI combines Quality Assurance [QA] and Performance Improvement [PI] to create a comprehensive, data-driven program) program, resulting in inadequate monitoring for four of 30 sampled Patients (Patient 5, Patient 7, Patient 8, and Patient 9), with an arterial line (A-line, a catheter placed in an artery to monitor blood pressure and obtain blood samples) to ensure they each have a leveler (a device used to ensure proper positioning of the A-line relative to the patient’s photostatic axis [atomical reference point at the 4th intercostal space, mid-axillary line]) at the bedside, to use each time the patient was repositioned to ensure accurate reading of the patient’s blood pressure (the force of blood against artery walls as the heart pumps blood throughout the body), in accordance with the facility’s policy and procedure regarding Monitoring Arterial Blood using a Pressure Transducer (a device that converts the pressure fluctuations of blood within the artery into an electrical signal) System and the policy regarding QAPI. This deficient practice resulted in delays in recalibration of the A-line, and had the potential for inaccurate blood pressure readings which may lead to delays in the implementation of timely interventions, thus compromising patient safety due to complications of unidentified elevated, uncontrolled blood pressure such as stroke (a clot in the brain), damage to vital organs such as kidneys, etc. (Refer to A-0273) 2. The facility failed to track, analyze, and implement preventive actions for adverse patient events (a negative or harmful result experienced by a patient as a consequence of medical care), specifically recurrent patient falls (an unexpected, unintentional descent of a patient to the ground or another lower surface) in the Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill). The Quality Assessment and Performance Improvement (QAPI, a systematic approach to improving the quality of care and safety in a healthcare setting. QAPI combines Quality Assurance [QA] and Performance Improvement [PI] to create a comprehensive, data-driven program) program team did not conduct a Root Cause Analysis (RCA, a systematic process used to identify and analyze the underlying causes of a medical error or adverse event, with the goal of preventing similar incidents from happening again by addressing the root issues rather than just the symptoms; it typically involves a multidisciplinary team to thoroughly investigate the event and develop corrective actions) or established an effective action plan to prevent falls among high-risk patients, in accordance with the facility’s policy and procedure regarding QAPI. This deficient practice resulted in repeated falls in the ICU, including: -Patient 1, who fell on 11/28/2024 unwitnessed while sedated, and was identified as a high fall risk. -Patient 6, who had an unwitnessed fall on 2/2/2025 after heart surgery. The failure to implement an effective fall prevention strategy placed patients at risk for serious harm and compromised patient safety. (Refer to A-0286) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to ensure that four of 30 sampled Patients (Patient 5, Patient 7, Patient 8, and Patient 9), with an arterial line (A-line, a thin, flexible tube that’s inserted into an artery to measure blood pressure and to collect blood samples) had a leveler (a device used to ensure proper positioning of the A-line relative to the patient’s photostatic axis [atomical reference point at the 4th intercostal space, mid-axillary line]) at the bedside to use each time the patients (Patients 5, 7, 8, and 9) were repositioned, to ensure accurate reading of the patient’s blood pressure (the force of blood against artery walls as the heart pumps blood throughout the body), in accordance with the facility’s policy and procedure regarding Monitoring Arterial Blood using a Pressure Transducer (a device that converts the pressure fluctuations of blood within the artery into an electrical signal) System. This deficient practice resulted in delays in recalibration of the A-line, and had the potential for inaccurate blood pressure readings which may lead to delays in the implementation of timely interventions, thus compromising patient safety due to complications of unidentified elevated, uncontrolled blood pressure such as stroke (a clot in the brain), damage to vital organs such as kidneys, etc. (Refer to A-0395) 2. The facility failed to ensure two of two sampled staff (Registered Nurse [RN] 6 and Charge Nurse [CN] 5) were competent and able to implement hemodialysis (HD, the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency take off (a procedure to quickly disconnect a dialysis patient from the dialysis machine in a critical situation) procedure, in accordance with the facility policy and procedure regarding hemodialysis emergency take off procedure, in case of emergency and when a hemodialysis nurse (HD nurse, a Registered Nurse who specialized performing hemodialysis) becomes incapacitated, for one of 30 sampled patients (Patient 13). This deficient practice had the potential to result in Patient 13 being left on hemodialysis machine running with no proper supervision and/or improperly disconnecting Patient 13 from the hemodialysis machine during an emergency, thus causing harm or even death during hemodialysis. (Refer to A-0397) 3. The facility failed to follow its “Utilization of Safety Attendants for Patients” policy and procedure and the physician’s order to provide a bedside sitter (a trained individual, often a healthcare worker, assigned to provide continuous, one-to-one supervision of a patient to ensure their safety, especially if the patient is at risk for falls [a sudden, unintentional descent of a patient to the ground or another lower surface] , disorientation [the condition of having lost one’s sense of direction], or self-harm) for constant supervision for one of 30 sampled patients (Patient 1). This deficient practice resulted in Patient 1 experiencing a fall in the ICU on 11/28/2024, and a cardiac arrest (a sudden loss of heart function, leading to a lack of blood flow to the brain and vital organs) in the SDU (Step Down Unit, specialist hospital wards that serve as a transition point for patients who are no longer critically ill enough to remain in ICU but still require more intensive monitoring and care than a general ward can provide) on 12/11/2024, due to accidentally being disconnected from the Bilevel Positive Airway Pressure (BIPAP machine, a non-invasive ventilator that assist patients with breathing difficulties) machine. In addition, this deficient practice had the potential to place other patients with physician-ordered bedside sitters at risk for similar sentinel events (a patient safety event that results in death, permanent harm, or severe temporary harm) due to inadequate supervision. (A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Infection Prevention, Control and Antibiotic Stewardship Program was met as evidenced by: 1. The facility failed to ensure staff adhered to infection control and prevention practices when: 1.a. One of one sampled staff (Patient Access Representative [PAR1, acts as the first point of contact for patients at a healthcare facility, responsible for greeting them, registering them for appointments, verifying insurance information, collecting necessary paperwork, and generally managing the patient check-in process]) did not perform hand hygiene (the practice of cleaning one’s hands to remove dirt and germs by using soap and water or alcohol-based sanitizer) upon entry and exit from a patient’s room for one of 30 sampled patients (Patient 21), in accordance with the facility’s policy and procedure regarding hand hygiene. This deficient practice had the potential to result in the spread of germs and bacteria from Patient 21 to others including other patients, staff and/or visitors. (A-0749) 1.b. The facility’s one of one sampled contracted service staff (HDN 3) did not disinfect (killing germs and bacteria) one of three sampled hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) machine (HDM 2) with heat or bleach at the end of day use, after hemodialysis was completed for one of 30 sampled patients (Patient 16), in accordance with the contracted service’s policy and procedure and hemodialysis machine operator manual. This deficient practice had the potential to result in bacterial contamination within the hemodialysis machine and introduce bacteria to other patients’ bloodstream, who may end up using the same HD machine (HDM 2), thus causing infection from a hemodialysis treatment. (Refer to A-0749) 2. The facility failed to ensure infection control policies and procedures regarding Employee Health Services were implemented when the facility failed to: 2.a. Ensure that one of two sampled Special Processing Technician (SPT 4, responsible for sterilizing and maintaining medical equipment and instruments), had completed a mandatory N-95 (a disposable mask that filters airborne particles) fit test (a procedure used to evaluate how well a respirator fits am individual, ensuring that it effectively filters out airborne particles to provide adequate respiratory protection), in accordance with the facility’s Employee Health Services Infection Prevention Policies and Employee health testing. This deficient practice had the potential to result in increased risk of exposure to airborne pathogens which could lead to infection for both the employee, the patients, and other staff. (Refer to A-0772) 2.b. Ensure that four out of six employees (E1, E3, E4, E5) had annual screening for tuberculosis (TB, a chronic bacterial infection that primarily affects the lungs) infection by QuantiFERON laboratory test (a blood test used to detect latent or active tuberculosis infection by measuring the immune response to specific TB antigens), in accordance with the regulatory requirements set by the [State] Department of Public Health (DPH) regarding TB testing (checks to see if someone was infected with tuberculosis). This deficient practice increases the risk of tuberculosis transmission among staff, patients and visitors due to inadequate testing/monitoring. (Refer to A-0772) 3. The facility failed to ensure that personnel training and education on the practical applications of infection prevention and control guidelines, policies and procedures were provided, completed and documented when: 3.a. Proof of completion of annual competencies (specific set of skills, knowledge, and abilities required to perform job functions effectively and safely within a particular field) verification and completion of skills check for three of six sampled employee records (Sterile Processing Technicians- responsible for sterilizing [free of germs] and maintaining medical equipment and instruments [SPT 1, SPT 4], and Surgical Scrub technicians- assists the surgeon during surgical procedures [SST 1]), were found to be incomplete with missing signatures from a preceptor (provides supervision during training) to indicate/verify staff competency. This deficient practice had the potential to result in improper training which has the potential for patient safety risks due to improperly sterilized instruments, increased infection rates, etc. (Refer to A-0775) 3.b. Proof of completion of orientation (refers to the process of introducing new employees to an organization, including its policies, procedures, culture, and specific job responsibilities) upon hire, and access to oneSOURCE (a platform commonly used in healthcare settings to provide access to essential information, such as manufacturer’s instructions for use [IFUs], policy documents, and compliance-related materials), were not provided for one of one sampled employee (Sterile Processing Technician- responsible for sterilizing [free of germs] and maintaining medical equipment and instruments [SPT 4]). The facility was also not able to provide copies of completed orientation checklist for SPT 4 for surveyor review. This deficient practice had the potential to result in non-compliance with job related requirements due to lack of knowledge from training and inability to access resources which may lead to potential patient safety risks due to errors in cleaning and sterilization processes (free of germs) for surgical instruments. (Refer to A-0775) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility’s governing body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to: 1. Ensure adequate oversight for the Nursing Services Department in the Intensive Care Department/Unit (ICU, ward that provides the critical care and life support for acutely ill and injured patients), to ensure the facility’s policy and procedure regarding the use of sitters (a trained individual, often a healthcare worker, assigned to provide continuous, one-to-one supervision of a patient to ensure their safety) including fall (an unexpected, unintentional descent of a patient to the ground or another lower surface) prevention, was followed, and to ensure that the QAPI (Quality Assessment and Performance Improvement- a data driven and proactive approach to quality improvement) effectively tracked patient adverse events (an undesirable outcome that happens during medical care), analyzed their causes, and implemented preventive actions and mechanisms to ensure patient safety for two of 30 sampled patients (Patient 1 and Patient 6), who both fell on the floor while in the ICU. Patient 1 fell on 11/28/2024 and Patient 6 fell on 2/2/2025. This deficient practice resulted in two separate instances of fall involving Patients 1 and 6, which had the potential to result in complications such as fracture (break in the bone), brain bleed, etc., and may result in prolonged hospitalization and delayed recovery for Patients 1 and 6. 2. Ensure the sterile processing department (SPD, the area in a hospital where cleaning and sterilization of devices used in medical procedures takes place), provided services and competent staff that met current national standard practice regarding reprocessing and sterilization process and adhered to facility’s policies and procedures regarding the reprocessing (the specific process of cleaning, disinfecting [the process of eliminating or reducing harmful germs on surfaces to a level that does not pose a risk of infection], and sterilizing [the process of completely destroying all forms of germs through methods ensuring that medical instruments and equipment are free from any living microbes (germs) before use] reusable medical equipment to ensure it is safe to reuse between patients) of surgical instruments and infection control (practices and procedures implemented to prevent the spread of infections by minimizing the transmission of germs in a healthcare setting). This deficient practice had the potential for improper processing of surgical instruments potentially resulting in increased risk of infection, organ failure, disfigurement, and/or death for patients undergoing surgical procedures. Findings: 1.a. During a review of Patient 1’s “History and Physical (H&P, a documented comprehensive formal assessment by a healthcare provider who examines the patient and their presenting problem),” dated 11/25/2025, the “H&P” indicated, Patient 1 was brought in by ambulance from home and presented with tachycardia (an abnormally fast heart rate exceeding 100 beats per minutes). The H&P also indicated that Patient 1 had a history of dementia (a disorder causing memory loss and confusion) and atrial fibrillation (a-fib, an irregular and often rapid heart rhythm that increases the risk of stroke [blood clot in the brain], heart failure [a condition where the heart muscle is stiff or weakened, making it unable to pump blood effectively], and other complications). Neurological (relating to the nervous system, which includes the brain, spinal cord, and nerves) assessment indicated: “Unable to assess mental status, patient unable to follow commands.” During a concurrent interview and record review on 2/19/2025 at 3:00 p.m. with the Director of Medical Surgical unit (DIR) 3, Patient 1’s electronic medical record (EMR, a digital version of a patient’s paper chart that contains their medical history) document titled, “Nursing Documentation-Flowsheet (a form that records a patient’s clinical observations over time),” dated 11/28/2024, was reviewed. The flowsheet indicated, on 11/28/2024 at 12:11 a.m., Patient 1 was “found on the floor, lying flat.” DIR 3 stated that the cause of the fall (an unexpected, unintentional descent of a patient to the ground or another lower surface) remained unknown. During an interview on 2/21/2025 at 1:00 p.m. with ICU (Intensive Care Unit. specialist hospital wards that provide treatment and monitoring for people who are very ill) Registered Nurse (RN) 1, RN 1 confirmed that Patient 1 was receiving continuous sedation (a state of relaxation or drowsiness) with Precedex (Dexmedetomidine, an injectable sedative given through the vein) and was being monitored using the Richmond Agitation-Sedation Scale (RASS, is a 10-point scale used to assess a patient’s level of sedation or agitation, ranging from +4 [combative] to -5 [unarousable]), with a target RASS score of 0 to -2. RN 1 stated Patient 1 was at -1 (drowsy, a state of sleepiness and wakeness) on 11/28/2024. RN 1 stated Patient 1 was high risk for falls and was left sleeping while RN 1 retrieved medications from the medication room. Upon returning, RN 1 found Patient 1 on the floor with other staff present. The fall was unwitnessed, and the reason for the fall was unknown. During a concurrent interview and record review on 2/21/2025 at 2:30 p.m. with Registered Nurse (RN) 2, Patient 1’s electronic medical record (EMR, a digital version of a patient’s paper chart that contains their medical history) document titled “Order,” report dated 11/26/2024, was reviewed. The physician (MD 5) ordered bedside sitter for Patient 1 from 11/26/2024 at 12:59 p.m. to 12/17/2024 at 1:02 a.m. RN 2 confirmed that there was no documented evidence that a sitter was monitoring Patient 1 on 11/28/2024. During an interview on 2/21/2025 at 12:33 p.m. with the Co-Chair of the Falls Performance Improvement (PI) Team (RM), RM stated the Falls PI team communicates directly with QAPI (Quality Assurance Performance Improvement- a data driven and proactive approach to quality improvement) and was responsible for fall prevention measures, system assessment, collaboration with other department leaders. RM was unaware of Patient1’s falls until the day of the interview, stating, “I did not review this case (Patient 1’s fall on 11/28/2024) unit this morning.” During an interview on 2/21/2025 at 2:00 p.m. with the Director of ICU (DIR) 2, DIR 2 stated that after a patient fall, a post-fall huddle (a meeting held after a patient falls to determine the cause and prevent future falls) was conducted, but nursing staff were not included in these discussions. Instead, one leader from the unit where the fall occurred, such as the charge nurse, unit manager, or unit representative, will attend. DIR 2 also stated that they did not participate in the post-fall huddle for Patient 1’s fall on 11/28/2024. During an interview on 2/21/2025 at 9:20 p.m. with the Chief Executive Officer (CEO), the CEO stated Governing Body relies heavily on the QAPI department to report on current issues and outline action plan taken in response. CEO emphasized that ultimately, the Governing Body holds the responsibility for ensuring oversight of an ongoing quality improvement plan focused on patient safety, quality of care, organization-wide quality assessment. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement,” dated 12/1/2024, the P&P indicated, “The quality assessment and performance improvement plan (QAPI) is a proactive, interdisciplinary, systematic approach to designing or redesigning patient centered systems to improve quality of care and patient safety in alignment with regulatory standards... As part of performance Improvement, leaders (including governing body) will: 1. Set priorities (le high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines 2. Identify frequency of data collection for performance improvement 3. Prioritize performance improvement in response to changes within the internal and external environment 4. Proactively identify processes needing improvement to prevent medical errors 5. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performance of process improvement/deficiencies, and monitoring/sustaining processes... Structure and Accountability: 1. The Community Board (GB) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectations for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective AHGL committees/teams ...” During a review of the facility’s policy and procedure (P&P) titled, “Performance Improvement Team Charter: 2025 Falls PI Team,” dated 1/10/2012, the P&P indicated, “Define the Issues: Non-compliant behaviors (e.g., patient/family turning off bed alarm, don’t call/wait for assistance).Inconsistencies with bed alarms and zone settings activation (e.g., staff do not set bed in moderate sensitivity setting, do not activate the bed alarm after turning off). Falls from chairs (including commode, wheelchair) because of inconsistencies with using chair alarms. Inconsistent yellow gown and gait belt usage. Reinforce bedside charting, especially for high fall risk patients. Goals of the Process Improvement: Analyze monthly falls and initiate immediate corrective actions to improve performance and compliance with designated interventions. Lead processes that support full compliance with Fall Prevention Policy. Strategize fall prevention measures specific to patient needs and continue to evaluate and modify strategies as appropriate ... How Does This Process Support the Hospital’s Overall Strategic Plan? By working to reduce the number and rate of falls we are focusing on patient safety, patient satisfaction, and prevention of hospital acquired conditions.” During a review of the facility’s policy and procedure (P&P) titled, “Utilization of Safety Attendants for Patients” dated 6/10/2022, the P&P indicated, “The purpose of this policy is to provide guidelines for safety attendant placement for patients with high risk behaviors, high fall risk, or other behaviors that place the patient at risk for injury ... Safety attendant will accompany the patient at all times.” 1.b. During a review of Patient 6’s “Progress Notes (a documented comprehensive formal assessment by a healthcare provider who examines the patient and their presenting problem),” dated 2/3/2025, the note indicated, Patient 6 “The patient presented to the emergency room following the acute (sudden and severe) onset of severe abdominal and chest pain. He (Patient 6) was complaining that he (Patient 6) could not move his right leg. The patient (Patient 6) underwent a CT angiogram (computed tomography angiography, is a medical imaging test that uses X-rays to create pictures of blood vessels and blood flow) which demonstrated evidence of a type A thoracic aortic dissection (a tear in the inner layer of the aorta, the main artery that carries oxygenated blood from the heart to the body).” The Progress Notes also indicated that Patient 6 had undergone emergency heart surgery. During a concurrent interview and record review on 2/20/2025 at 11:30 a.m. with the Nurse Manager (MN) 3 of the Step-Down Unit (SDU, a hospital unit that provides intermediate care for patients who are not ready for general ward care but don’t need intensive care), Patient 6’s EMR (Electronic Medical Record) document titled, “Fall Post Event Summary,” dated 2/2/25, was reviewed. The Fall Post Event Summary indicated Patient 6 had an unwitnessed fall while in the ICU. Patient 6 was found sitting on the floor with a urinal (a container used by patients who are unable to get out of bed to collect their urine). During an interview on 2/21/2025 at 12:33 p.m. with the Co-Chair of the Falls Performance Improvement (PI) Team (RM), RM stated the Falls PI team communicates directly with QAPI (Quality Assurance Performance Improvement- a data driven and proactive approach to quality improvement) and was responsible for fall prevention measures, system assessment, collaboration with other department leaders. RM was unaware of Patient 1’s falls and Patient 6’s fall until the day of the interview (2/21/2025), stating, “I did not review this case (Patient 1’s fall on 11/28/2024) unit this morning.” During an interview on 2/21/2025 at 2:00 p.m. with the Director of ICU (DIR) 2, DIR 2 stated that after a patient fall, a post-fall huddle was conducted, but nursing staff were not included in these discussions. Instead, one leader from the unit where the fall occurred, such as the charge nurse, unit manager, or unit representative, will attend. DIR 2 also stated that they did not participate in the post-fall huddle for Patient 1’s fall on 11/28/2024. During an interview on 2/21/2025 at 9:20 p.m. with the Chief Executive Officer (CEO), the CEO stated Governing Body relies heavily on the QAPI department to report on current issues and outline action plan taken in response. CEO emphasized that ultimately, the Governing Body holds the responsibility for overseeing all services in the facility, and ensuring oversight of an ongoing quality improvement plan focused on patient safety, quality of care, organization-wide quality assessment. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement “ dated 12/1/2024, the P&P indicated, “The quality assessment and performance improvement plan (QAPI) is a proactive, interdisciplinary, systematic approach to designing or redesigning patient centered systems to improve quality of care and patient safety in alignment with regulatory standards... As part of performance Improvement, leaders (including governing body) will: 1. Set priorities (le high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines 2. Identify frequency of data collection for performance improvement 3. Prioritize performance improvement in response to changes within the internal and external environment 4. Proactively identify processes needing improvement to prevent medical errors 5. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performance of process improvement/deficiencies, and monitoring/sustaining processes... Structure and Accountability: 1. The Community Board (GB) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectations for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective AHGL committees/teams ...” During a review of the facility’s policy and procedure (P&P) titled, “Performance Improvement Team Charter: 2025 Falls PI Team, “ dated 1/10/2012, the P&P indicated, “Define the Issues: Non-compliant behaviors (e.g., patient/family turning off bed alarm, don’t call/wait for assistance).Inconsistencies with bed alarms and zone settings activation (e.g., staff do not set bed in moderate sensitivity setting, do not activate the bed alarm after turning off). Falls from chairs (including commode, wheelchair) because of inconsistencies with using chair alarms. Inconsistent yellow gown and gait belt usage. Reinforce bedside charting, especially for high fall risk patients. Goals of the Process Improvement: Analyze monthly falls and initiate immediate corrective actions to improve performance and compliance with designated interventions. Lead processes that support full compliance with Fall Prevention Policy. Strategize fall prevention measures specific to patient needs and continue to evaluate and modify strategies as appropriate ... How Does This Process Support the Hospital’s Overall Strategic Plan? By working to reduce the number and rate of falls we are focusing on patient safety, patient satisfaction, and prevention of hospital acquired conditions.” During a review of the facility’s policy and procedure (P&P) titled, “Utilization of Safety Attendants for Patients” dated 6/10/2022, the P&P indicated, “The purpose of this policy is to provide guidelines for safety attendant placement for patients with high risk behaviors, high fall risk, or other behaviors that place the patient at risk for injury... Safety attendant will accompany the patient at all times.” 2. During an interview on 2/18/2025 at 2:32 p.m. with the Sterile Processing Technician - Lead (LSPT), LSPT stated that the ultrasonic machine (a cleaning device that uses high frequency sound waves to remove contaminants from surgical instruments) must be tested daily (a test solution that is inserted inside the machine to assess for color changes in the solution after the test and to ensure that the ultrasonic cleaning process effectively utilizes cavitation [powerful cleaning effect, helping to dislodge dirt, debris, and contaminants from surfaces] to decontaminate and clean instruments properly by examining the changes in dosimeters [testing solution] after a cleaning cycle, operators can gauge the effectiveness of the cavitation process]) by the graveyard shift (the overnight work shift), but the log was nowhere to be found. During an interview on 2/18/2025 at 2:32 p.m. with the following staff: Sterile Processing Technician -Lead (LSPT) and Sterile Processing Technician (SPT 1), in the decontamination room (a specific section or designated space where contaminated or soiled items are received, sorted, and prepared for the decontamination process), the staff (LSPT and SPT 1) were not able to answer questions about the ultrasonic machine, including how it worked, what the daily tests were for, and where the log for the daily testing was located. During a concurrent observation and interview on 2/18/2025 at 4:38 p.m. with the Director of Operative Services (Dir 1), Dir 1 was observed using an alcohol pad to wipe the brown marks present on the sterile surgical instruments (the Narrow Deaver [retractor 1, a surgical retractor used to hold back tissue and provide access to deeper surgical sites], and the Sweetheart retractor [retractor 2, a surgical instrument used to hold back tissues and provide stability in the surgical field]). Brown staining of the alcohol pad was noted after Dir 1 wiped down the instruments (retractor 1 and 2). Dir 1 then stated that these instruments should not be used for patients in the operating rooms and should be sent back for reprocessing (a special process or treatment in preparation for reuse) due to the presence of brown stains. During a concurrent observation and interview on 2/19/2025 at 10:27 a.m. with the Administrative Director (AD 1) and the Sterile Processing Technician-Lead (LSPT), in the Assemble Room (a designated area where surgical instruments and supplies are organized, assembled, and prepared for sterilization [the process of eliminating all living microorganisms from an object or surface] and subsequent use in surgical procedures), surgical tray preparation for sterilization, was observed. Multiple trays were observed to contain green towels (a type of fabric used to cover and wrap surgical instruments and trays to provide protection and maintain sterility during surgical procedures) covering the trays with surgical instruments on top. AD 1 stated that trays that lack a liner (a protective material or insert, such as sterile wrap, intended to create a barrier between the instruments and the tray, ensuring proper sterilization and preventing contamination) must be wrapped with green towels to protect the instruments. Both AD 1 and LSPT stated that they were not aware if this practice (using green towels to cover trays) was in accordance with the facility’s policy and procedures. During a concurrent observation and interview on 2/19/2025 at 11:11 a.m. with the Sterile Processing Technician-Lead (LSPT), LSPT demonstrated a cart (a cart with enclosed compartments and secure doors that transports surgical instruments and supplies) that would typically be used for the transport of dirty instruments from the Operating Room (OR) to the decontamination room (a specific section or designated space where contaminated or soiled items are received, sorted, and prepared for the decontamination process). LSPT also demonstrated how the biohazard sign (a biological material or substance that can cause disease or illness in humans) on top of the cart can be switched to a clean cart sign whenever necessary. LSPT stated that the same cart(s) was(were) used for the transport of clean/sterile instruments ; the cart would have to be cleaned with [Brand] enzymatic solution (a cleaning product that contains enzymes to break down stains and soils) before re-use and then the sign would be changed to “clean cart” on top, allowing the cart to be used for the transport of clean and sterile instruments. During the same interview on 2/19/2025 at 10:27 a.m. with the Sterile Processing Technician-Lead (LSPT), LSPT was not able to provide information regarding the enzymatic [Brand] wipes used for cleaning carts. During an interview on 2/19/2025 at 3:00 p.m. with the Manager of the Operating Room (MOR), MOR stated that the facility’s policy regarding stored sterile packages (sealed containers that contain surgical instruments or supplies used in sterile procedures, designed to maintain the sterility of their contents until they are opened for use, ensuring safety and minimizing the risk of infection) indicated that sterile packages shelf life was indefinite if the temperature and humidity were maintained within range and sterile items had no tear in the package, then it should be okay to continue storing sterile packages. The MOR also stated there were no routine inspections conducted to inspect the integrity of sterile packages in sterile supply room and there was no log. During a concurrent observation and interview on 2/19/2025 at 3:22 p.m. with the Director of Operative Services (Dir 1) in the central supply room in the Surgical Department, a Gelpi retractor (a surgical instrument used for holding back tissue in a surgical procedure) was observed with brown-colored deposits like rust after instrument was removed from a sterile total hip tray (a collection of instruments specifically prepared and sterilized for use during total hip replacement surgeries). Dir 1 stated the following: “The brown deposit in the middle section of the Gelpi retractor could be rust. The water exposure could lead to damage of the instrument. When we identify issues like this one, the instrument gets treated by the contracted company that would either polish the instrument or replace it.” During an interview on 2/21/2025 at 9:30 a.m. with the Sterile Processing Technician (SPT 4), SPT 4 stated the following: “I am from registry (temporarily hired employee), and I have been working at this place since November 2024. I have been doing this job for a very long time, and I am very familiar with the processes. In this hospital, the setup is different, the sinks are much smaller and do not allow submergence of bigger surgical instruments and trays. We only recently received brushes. And before that, I did not have the brushes to clean the scopes (a medical instrument used for viewing or performing procedures). I also have never really been oriented to any of the policies here. I only had general orientation when I was shown where everything is. There are no visual guidelines regarding what to do with instruments and how to clean them. Staff can look up the manufacturer guidelines by logging into a portal, called oneSOURCE (a leading healthcare management solution that enables facilities to stay in compliance 24/7 through its robust online platform equipped with the world’s most updated IFUs (instructions for use) and PM (preventative maintenance) Service Manuals), but I am registry, and I don’t have access to oneSOURCE. We do get a lot of rusty instruments which I send back to decontamination room. As to the tape on instruments, I never received instructions that instruments with tape should not be used.” During an interview on 2/21/2025 at 3:11 p.m. with the Infection Prevention Manager (IPM), IPM stated that carts used for transport of dirty and clean/sterile instruments could be reused once they were cleaned with bleach (disinfectant that kills germs) in between use. The IPM then stated that questions regarding cleaning carts should be addressed with the SPD (Special Processing Department, the area in a hospital where cleaning and sterilization of devices used in medical procedures takes place) manager or director. During a concurrent interview and record review on 2/21/2025 at 5:35 p.m. with the Director of Education (DE) and Manager of Education (MED), three employee files (Special Processing Technician (SPT 1, SPT 4, and Surgical Scrub technicians [SST 1]) were reviewed for professional competencies (the specific requirements and knowledge required to perform job functions effectively and safely). All competencies provided for the three employees for the years 2023 and 2024 contained missing signatures that were required to be signed by the verifier of competencies upon evaluation. The DE was not able to provide a list of required items by the facility annual educational requirements and competencies for Special Processing Department (SPD, a hospital department that cleans, disinfects [clean and safe for use], and sterilizes [free of germs] medical instruments and devices) employees and Surgical Scrub Technicians working in the Surgical Department (the area in a hospital where surgical procedures are performed, and where procedural staff must be properly trained and competent in their roles). During the same record review on 2/21/2025 at 5:35 p.m., the Facility did not provide any pertinent documents regarding the employees’ required annual competencies and annual educational requirements (HealthStream assignments, educational and training modules or courses assigned to healthcare employees such as continuing education, compliance training, competency assessments that are essential for enhancing staff knowledge, skills and performance in their role) specific to the department of employment, including copies of employee competency records, and relevant policies. During a concurrent interview and record review on 2/21/2025 at 5:35 p.m. with the Director of Education (DE) and the Manager of Education (MED), the Sterile Processing Technician’s (SPT 4) employee file, was reviewed. SPT 4’s employee file contained no documented orientation with introduction to the facility’s policies, procedures, and specific job responsibilities. SPT 4’s file also contained no documented granted access to oneSOURCE upon the start date of 11/27/2024. During an interview on 2/21/2025 at 6:24 p.m. with the Director of Quality (DQ), DQ stated the facility conducted internal self-reassessment for the sterile processing department (SPD) on 10/7/2024 and identified problems including but not limited to ripped sterile packs in the central supply room and SPD staff being unable to speak to the process of cleaning. DQ stated there was an action plan in place including reprocessing problem items, training SPD staff and validating their competencies in response to the problems identified in SPD. During an interview on 2/21/2025 at 9:27 p.m. with the Chief Executive Officer (CEO), CEO stated the following: governing body oversee the overall quality and safety of the facility. The issues in sterile processing department were escalated to quality committee to ensure there was action taken. The governing body delegated to subcommittee and quality committee to oversee all quality and safety activities for patients. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI),” dated 3/2024, the P&P indicated, “Scope: As part of performance improvement, leaders (including governing body) will: 1. Set priorities (ie high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines. 2. Identify frequency of dada collection for performance improvement. 3. Prioritize performance improvement in response to changes within the internal and external environment. 4. Proactively identify processes needing improvement to prevent medical errors. 5. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performances of process improvement/deficiencies, and monitoring/sustaining processes ... Structure and Accountability ... 1. The Community Board (governing body [GB]) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectation for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective [the facility’s] committees/ teams.” During a review of the facility’s policy and procedure (P&P) titled, “Infection Control Guidelines for Sterile Processing Department,” dated 9/2023, the P&P indicated the following: The sterile Processing Department (SPD) is recognized as a high risk for infection prevention. To protect patients and other personnel from unnecessary exposure to potentially pathogenic organisms, Sterile Processing employees will be expected to abide by the following: Basic training in aseptic technique for all new sterile processing employees much be presented and documented. Personnel are expected to have general orientation to the hospital infection prevention program and periodic in-service of infection prevention policies and procedures. During a review of the facility’s policy and procedure (P&P) titled, “Wrapped Packaging,” dated 12/6/2024, the policy indicated that the facility recognizes the important role of sterility... During a review of the facility’s policy and procedure (P&P) titled, “Sterilization of Equipment Supplies,” dated 9/27/2021, the policy indicated that sterile items must be received, stored, and distributed in a manner which ensure sterility and integrity. During a review of the Association for the Advancement of Medical Instrumentation (AAMI, is a nonprofit organization that develops standards and guidelines doe the safe and effective use of medical devices and equipment, advocating for best practices in healthcare and medical technology) guidelines titled, “Standards of Sterilization,” dated 2021, the guidelines indicated that steam sterilization cannot be assured unless proper cleaning of the device and reduced bioburden (define) and soil was achieved. Verification and documentation of automated cleaning processes through objective means is an important aspect of quality control. Cleaning encompasses the removal of organic residue and microorganisms from the patient, from handling, or from water exposure during reprocessing. Inspection using enhanced visualization tools such as lighted magnification and video borescopes might identify residues not observable by the unaided eye. During a review of the facility’s policy and procedure (P&P) titled, “Event-Related Sterile Package Shelf Life,” the P&P indicated the following: 6. Trays/supplies [in the central supply room] should be rotated with the “first in/first out” rule ( is a management principle commonly used in inventory control that dictates that the first items placed in storage should be the first ones to be used, to ensure that items are used in the order they were received or processed). 9. Inspect all stored items quarterly to monitor compliance with this policy regarding storage and condition of the sterile product. This inspection will ne performed by the Qualified Special Processing technician. All packing that looks worn or handled will be discarded if disposable or returned to SPD for reprocessing if re-usable. 10. Document all the findings of the inspection on each departmental Environmental Rounds Report. Send a copy to SP who will report findings through their Quality Assurance (QA) quarterly report and to Infection Prevention who will report the findings at their meetings. 11. Evaluate all items found at inspection time to exceed 12 months of inactivity with the department head as to the need to maintain sterile. 14. Training will be interdisciplinary for persons responsible for handling storage, cleaning, and inspecting of sterile supplies. The training will be documented. During a review of the facility’s policy and procedure (P&P) titled, “Sterilization of Equipment Supplies,” dated 9/2021, the P&P indicated that 1. Sterile items must be received, stored, and distributed in a manner which ensures sterility and integrity. 2.An orderly system of rotation of supplies must be used so items stored first are used first. During a review of the facility’s policy and procedure (P&P) titled, “Manual Cleaning Process,” dated 9/2023, the P&P indicated that instrument tape and plastic dipping material, when used properly, are ways of identifying specific instruments. These types of marking products wear out over time and staff need to inspect them each time the instrument is processed and should be checked for wear according to the IFU of the product used. During a review of the facility’s policy and procedure (P&P) titled, “Manual Cleaning Process: Inspection and Non-Submergible Items,” dated 9/2023, the P&P indicated the following: A. Sterile processing and Operating Services staff are to follow manufacturer recommendation to properly decontaminate contaminated non-submersible items (any object that cannot be fully submerged in water during the cleaning process). 3.Clean luminated items with a brush of the recommended type, size, material, cleaning solution. 9. Change the solution after every use. During a review of the Association for the Advancement of Medical Instrumentation (AAMI, is a nonprofit organization that develops standards and guidelines doe the safe and effective use of medical devices and equipment, advocating for best practices in healthcare and medical technology) guidelines, titled, “Standards of Sterilization,” dated 2021, the guidelines indicated that 7.4.1.c. To begin decontamination process as soon as possible after the items have been used. 7.4.1.h. The importance of using a cleaning solution compatible with the device and following manufacturer’s cleaning guidelines for proper dilution, concentration, and contact time. 7.4.1.i. Before manual cleaning, the cleaning solution should be ensured to be clean and changed when appears soiled, which could be after one use. 7.6.4.2.i. Monitor the water temperature as required in the manufacturer’s written IFUs; Change the solution after every use (a use should be defined in the health care facility’s policies and procedure). During a review of the facility’s policy and procedure (P&P) titled, “Manual Cleaning Process: Inspection and Washing of Submersible Instrumentation,” dated 9/2023, the P&P indicated the following: A. 2nd sink: all items that are deemed submersible by manufacturer’s written instructions should be submerged in 2nd sink with enzyme solution. Follow manufacturer written instructions for use (IFU) which indicate the amount of contact time required between the submersible instruments in the 2nd sink with enzyme solution. IV. 1. Instruments with dried blood, bone pieces and debris should be presoaked in 1st sink with enzymatic solution following IFUs. During a review of the Association for the Advancement of Medical Instrumentation (AAMI, is a nonprofit organization that develops standards and guidelines doe the safe and effective use of medical devices and equipment, advocating for best practices in healthcare and medical technology) guidelines, titled, “Standards of Sterilization,” dated 2021, the guidelines indicated that the healthcare organization should establish policies and procedures for all methods of cleaning and decontamination of reusable items. Process audits to monitor compliance with the various policies and procedures should be performed on a scheduled basis, with appropriate follow-up to address problems. Additionally, the device manufacturer’s current written instructions for Use (IFUs) should be accessible, reviewed, and followed. During a review of the facility’s policy and procedure (P&P) titled, “Instruments, Scopes, and Equipment Processing, dated 10/2021, the P&P indicated the following regarding A. Handling of sterile instruments and supplies: all wrapped sterile instrument trays and supplies processed in Special Processing Department (SPD) will be transported to the OR in a covered cart after the sterilization process is completed and the packages are dry and properly labeled. Covered carts will be used for transport and ONLY sterile items will be placed and transported on these carts. Never any soiled or dirty items. B. Handling of used instruments: Operating Room (OR) case carts will be used to transport contaminated instruments to the decontamination room in the Operating Room. The cart will be wiped down with germicidal solution [a substance that kills germs, like bacteria and viruses, that can cause disease] after it is unloaded in the instrument room and before being re-used. During a review of the facility policy and procedure (P&P) titled, “Instruments, Scopes, and Equipment Processing,” dated 10/26/2021, the policy indicated that all trays will be prepared and placed directly in the wire basket provided with the Sterile Container System. No TOWELS or foam will be used in the bottom of the tray. Instrument room personal will sign and date the bottom of the menu sheet before placing it on the tray. During a review of the Association for the Advancement of Medical Instrumentation (AAMI, is a nonprofit organization that develops standards and guidelines doe the safe and effective use of medical devices and equipment, advocating for best practices in healthcare and medical technology) guidelines, titled, “Standards of Sterilization,” dated 2021, the guidelines indicated that 7.6.4.4.1.Ultrasonic cleaning equipment should be cleaned every day that it is used, according to the manufacturer’s written IFUs. b. Cavitation testing daily should be done whenever the equipment is in use. 7.6.4.5. Mechanical cleaning equipment performance should be tested each day it is used, and all results should be recorded.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility’s governing body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to: 1. Ensure its contracted service staff adhered to infection control and prevention practice to disinfect (killing germs and bacteria) one of three sampled hemodialysis (HD, the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) machine (HDM 2) with heat or bleach at the end of day use, after hemodialysis, was completed for one of 30 sampled patients (Patient 16), in accordance with the contracted service’s policy and procedure and hemodialysis machine operator manual. This deficient practice had the potential to result in bacterial contamination within the hemodialysis machine and had the potential to introduce bacteria to other patients’ bloodstream who may use the same machine (HDM 2) thus causing infection to patients from hemodialysis treatment. 2. Ensure that contracted dialysis services adhered to the facility’s “Dialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) Services,” policy and procedure when one of one sampled dialysis machine (HDM 1) was left unattended in a public area, containing intravenous (IV, administered into the vein) fluids, chemical reagents (solutions, typically containing electrolytes used to create the “dialysate” fluid which is circulated through a dialysis machine to filter waste products from a patient’s blood), and patient-identifiable information. This deficient practice had the potential to result in unauthorized access to medical records (the HDM 1 contained patient-identifiable information), contamination, and breaches of patient confidentiality, etc. Findings: 1. During a review of Patient 16’s “(H&P, a formal and complete assessment of the patient and the problem),” dated 2/11/2025, Patient 16 was admitted to the facility with diagnoses including but not limited to acute renal failure (the sudden and rapid loss of kidney’s ability to filter waste and balance fluid in blood), acute (new onset) exacerbation (worsening of a disease or an increase in its symptoms) of congestive heart failure (CHF, a chronic condition in which a weakness of the heart leads to a buildup of fluid in the lungs), and electrolyte (minerals in the blood) abnormality. During an interview on 2/20/2025 at 2:59 p.m. with the Chief Executive Officer (HDD) of the facility’s hemodialysis contracted service (HDC), HDD stated hemodialysis nurses were responsible to use either heat or bleach at the end of day use to disinfect the hemodialysis machine to prevent infection and keep the machine clean per manufacturer’s guideline. During a concurrent interview and record review on 2/20/2025 at 3:15 p.m. with HDD, Patient 16’s hemodialysis record titled, “Dialysis Nurses Notes (HD note),” dated 2/14/2025, was reviewed. The HD note indicated Patient 16 received hemodialysis on 2/14/2025 from 1:35 p.m. to 4:35 p.m. using HD machine (HDM 2). The HD note also indicated Hemodialysis Nurse (HDN 3) rinsed HDM 2 after hemodialysis was completed. HDD stated HDN 3 did not disinfect HDM 2 with heat or bleach at the end of hemodialysis treatment. During a concurrent interview and record review on 2/20/2025 at 3:20 p.m. with HDD, hemodialysis machine (HDM 2)’s “Equipment Log Sheet (HD log),” dated from 2/12/2025 to 2/16/2025, was reviewed. The HD log indicated, Patient 16’s hemodialysis treatment was the last treatment for day (2/14/2025). The HD log also indicated next HD treatment was on 2/16/2025. HDD stated HDN 3 should have disinfected HDM 2 after completing hemodialysis for Patient 16 with heat or bleach. HDN 3 did not disinfect HDM 2 at the end of the day (2/14/2025). During an interview on 2/21/2025 at 9:27 p.m. with the Chief Executive Officer (CEO), CEO stated the facility’s governing body was responsible to oversee the quality and safety of the facility. CEO stated the contracted service was required to follow policy and procedure to make sure services provided meet requirement to provide quality care to patients. During a review of the facility’s policy and procedure (P&P) titled, “Dialysis Service,” dated 2/2020, the P&P indicated, “Each contracted dialysis service is responsible for serving, maintaining, and upgrading the equipment, including safety checks.” During a review of the facility’s hemodialysis contracted service (HDC)’s policy and procedure (P&P) titled, “Single Pass Dialysis Machine - Cleaning & Disinfection and Documentation,” dated 12/2024, the P&P indicated, “It is the policy of [the contracted service] to follow the cleaning and disinfectant procedures outlined below per manufacturer’s guidelines ... The single pass dialysis machine is to be heat or bleach disinfected at the end of each day (end of day per individual nurse assignment) when machine is used for treatment. Document cleaning and/or disinfection for every treatment in provided machine logbook.” During a review of the hemodialysis machine (HDM 2) manufacturer’s guidelines titled, “[brand] Hemodialysis Machine Operator’s Manual Rev P,” undated, the manufacturer’s guidelines indicated, “Heat Disinfect or Chemical/Rinse is recommended daily when the machine is used for treatment.” During a review of the facility’s contract agreement with the HDC titled, “Dialysis Services Agreement (HD contract),” dated 11/20/2023, the HD contract indicated, “1.5 Nursing Services ...Dialysis Company shall ensure ... said nursing personnel shall perform the following nursing services pursuant to this Agreement ... demonstrate responsible handling of waste, sterilization and disinfection of equipment.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI),” dated 3/2024, the P&P indicated, “Structure and Accountability ... 1. The Community Board (governing body [GB]) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectation for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective [the facility’s] committees/ teams.” During a review of the facility’s GB bylaws (legal guidelines for an organization) titled, “Bylaws of [the facility],” dated 5/ 2023, the GB bylaws indicated, “The Community Boar bylaws shall specify the exact functions of the Community Board, consistent with these bylaws. Subject to the Board’s ultimate oversight and authority to take action, the Board delegates the following responsibilities to the Community Board... (b) determining that the Corporation’s hospital, its employees, and the appointees of the medical staff will conduct their activities so as to conform with the requirements and principles of all applicable laws and regulations... (d) establishing and approving policies and procedures for those functions of the Corporation’s hospital that have been delegated to the Community Board... (e) assuring a safe environment within the Corporation’s hospital for employees, medical staff, patients, and visitors...” 2. During a concurrent observation and interview on 2/18/2025 at 3:15 p.m. with Infection Control Manager (IPM) on the East Tower ground floor in front of the elevator, the dialysis machine (HDM 1) was observed to be left unattended. IPM stated, “The dialysis machine should never be left unattended. The machine should be stored in the storage area in the basement.” The machine contained: -Two normal saline (is a solution of 0.9% sodium chloride [salt] in water) intravenous (IV,) fluid bags hanging - Four bottles of reagent (chemical solutions used in dialysis treatment) -A bottle of vinegar -A binder containing patient medical records numbers (MRN, unique identifier used to tack patient medical records). During an interview on 2/18/2025 at 3:20 p.m. with Hemodialysis Nurse (HDN) 1, HDN1 stated, “I usually leave the dialysis machine there (referring to the location at the East Tower ground floor in front of the elevator) to go for lunch.” During an interview on 2/21/2025 at 3:20 p.m. with Chair Executive Officer (HDD) of the Dialysis contracted services. HDD stated, “Leaving the dialysis machine unattended is unacceptable and not safe practice.” HDD confirmed that unattended dialysis machine poses a risk of cross-contamination (the transfer of harmful bacteria [a tiny living thing that can cause infection and illness], viruses [a tiny germ that can cause illness], chemicals, or other contaminations from one person, object, or surface to another), as unauthorized individuals may tamper with the machine. HDD further stated, “Dialysis nurses have keys to the storage room and are required to store the dialysis machine in the designated storage area before taking breaks. During an interview on 2/21/2025 at 9:27 p.m. with the Chief Executive Officer (CEO), CEO stated the facility’s governing body was responsible to oversee the quality and safety of the facility. CEO stated the contracted service was required to follow policy and procedure to make sure services provided meet requirement to provide quality care to patients. During a review of the facility’s policy and procedure (P&P) titled, “Dialysis Services,” dated 6/16/2023, the P&P indicated, “The purpose of this policy is to define the process of the provision of dialysis services to patients. Patient’s dialysis needs will be met through the utilization of competent contracted services ... Rooms are available for storage of dialysis equipment and supplies. Dialysis equipment is to be placed in storage rooms whenever not in use. The dialysis company(s) assigned to the storage room is responsible for maintaining it in orderly fashion. The dialysis nurse will notify the Nursing Resource Office before leaving if housekeeping is needed for cleaning the room. Note: If the storage room key is not returned to the Nursing Resource Office in a timely manner, the dialysis company will be billed for the lock being re-keyed or replacement. No copies are to be made of the keys ...Dialysis equipment is not to be left unattended in any area. There are no exceptions. If the patient is on isolation, the equipment must be wiped down with an appropriate disinfectant and stored in the assigned locked storage area after each treatment.” During a review of the facility’s policy and procedure (P&P) titled, “Infection Prevention and Control Plan,” dated 4/9/2024, the P&P indicated, “Infection Prevention and Control (IPC) program assists patient care by reducing the risk of infection in patients, visitors, associates and others through education, surveillance, prevention, control, and continuous review and evaluation of infection prevention practices. The scope of service includes surveillance, prevention, and control of infections in patients, healthcare workers, volunteers, and visitors...Responsibilities: Oversees the organization-wide Infection Prevention and Control Program... The Infection Control committee - Standard and transmission-based precautions monitoring through active rounding by IP...” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibility,” dated 9/9/2024, the P&P indicated, “Have personal privacy respected ... Confidential treatment of all communications and records pertaining to your care and stay in the hospital. You will receive a separate “Notice of Privacy Practices· that explains your privacy rights in detail and how we may use and disclose your protected health information.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI),” dated 3/2024, the P&P indicated, “Structure and Accountability ... 1. The Community Board (governing body [GB]) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectation for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective [the facility’s] committees/teams.” During a review of the facility’s GB bylaws (legal guidelines for an organization) titled, “Bylaws of [the facility],” dated 5/ 2023, the GB bylaws indicated, “The Community Boar bylaws shall specify the exact functions of the Community Board, consistent with these bylaws. Subject to the Board’s ultimate oversight and authority to take action, the Board delegates the following responsibilities to the Community Board... (b) determining that the Corporation’s hospital, its employees, and the appointees of the medical staff will conduct their activities so as to conform with the requirements and principles of all applicable laws and regulations... (d) establishing and approving policies and procedures for those functions of the Corporation’s hospital that have been delegated to the Community Board... (e) assuring a safe environment within the Corporation’s hospital for employees, medical staff, patients, and visitors...””

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility’s governing body (is a group of people who are legally responsible for the hospital’s operations. This group is also responsible for ensuring the hospital’s compliance with regulations and the provision of high-quality care) failed to ensure that contracted dialysis services adhered to safe practices and the facility’s policy and procedure regarding safe handling and storage protocols for dialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) machines, when one of one sampled dialysis machine (HDM 1) was left unattended in a public area, containing intravenous (IV, administered into the vein) fluids, chemical reagents (solutions, typically containing electrolytes used to create the “dialysate” fluid which is circulated through a dialysis machine to filter waste products from a patient’s blood), and patient-identifiable information. This deficient practice had the potential to result in unauthorized access to medical records (the HDM 1 contained patient-identifiable information), contamination, and breaches of patient confidentiality, etc. Findings: During a concurrent observation and interview on 2/18/2025 at 3:15 p.m. with the Infection Control Manager (IPM) on the East Tower ground floor in front of the elevator, the dialysis machine (HDM 1) was observed to be left unattended. IPM stated, “The dialysis machine should never be left unattended. The machine should be stored in the storage area in the basement.” The machine contained: -Two normal saline (is a solution of 0.9% sodium chloride [salt] in water) intravenous (IV, a method of delivering fluids or medicine directly into a vein) fluid bags hanging - Four bottles of reagent (chemical solutions used in dialysis treatment) -A bottle of vinegar -A binder containing patient medical records numbers (MRN, unique identifier used to tack patient medical records). During an interview on 2/18/2025 at 3:20 p.m. with Hemodialysis Nurse (HDN) 1, HDN1 stated, “I usually leave the dialysis machine there (referring to the location at the East Tower ground floor in front of the elevator) to go for lunch.” During an interview on 2/21/2025 at 3:20 p.m. with the Chair Executive Officer (HDD) of the Dialysis contracted services, HDD stated, “Leaving the dialysis machine unattended is unacceptable and not safe practice.” HDD confirmed that unattended dialysis machine poses a risk of cross-contamination (the transfer of harmful bacteria [a tiny living thing that can cause infection and illness], viruses [a tiny germ that can cause illness], chemicals, or other contaminations from one person, object, or surface to another), as unauthorized individuals may tamper with the machine. HDD further stated, “Dialysis nurses have keys to the storage room and are required to store the dialysis machine in the designated storage area before taking breaks. During an interview on 2/21/2025 at 9:27 p.m. with the Chief Executive Officer (CEO), CEO stated the facility’s governing body was responsible to oversee the quality and safety of the facility. CEO stated the contracted service was required to follow policy and procedure to make sure services provided meet requirement to provide quality care to patients. During a review of the facility’s policy and procedure (P&P) titled, “Dialysis Services,” dated 6/16/2023, the P&P indicated, “The purpose of this policy is to define the process of the provision of dialysis services to patients. Patient’s dialysis needs will be met through the utilization of competent contracted services ... Rooms are available for storage of dialysis equipment and supplies. Dialysis equipment is to be placed in storage rooms whenever not in use. The dialysis company(s) assigned to the storage room is responsible for maintaining it in orderly fashion. The dialysis nurse will notify the Nursing Resource Office before leaving if housekeeping is needed for cleaning the room. Note: If the storage room key is not returned to the Nursing Resource Office in a timely manner, the dialysis company will be billed for the lock being re-keyed or replacement. No copies are to be made of the keys ...Dialysis equipment is not to be left unattended in any area. There are no exceptions. If the patient is on isolation, the equipment must be wiped down with an appropriate disinfectant and stored in the assigned locked storage area after each treatment. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement “ dated 12/1/2024, the P&P indicated, “The Community Board (GB) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectations for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective AHGL committees/teams ...” During a review of the facility’s policy and procedure (P&P) titled, “Infection Prevention and Control Plan,” dated 4/9/2024, the P&P indicated, “Infection Prevention and Control (IPC) program assists patient care by reducing the risk of infection in patients, visitors, associates and others through education, surveillance, prevention, control, and continuous review and evaluation of infection prevention practices. The scope of service includes surveillance, prevention, and control of infections in patients, healthcare workers, volunteers, and visitors...Responsibilities: Oversees the organization-wide Infection Prevention and Control Program... The Infection Control committee - Standard and transmission-based precautions monitoring through active rounding by IP...” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibility,” dated 9/9/2024, the P&P indicated, “Have personal privacy respected ... Confidential treatment of all communications and records pertaining to your care and stay in the hospital. You will receive a separate “Notice of Privacy Practices· that explains your privacy rights in detail and how we may use and disclose your protected health information.””

“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: 31993 Based on interview and record review the facility failed to ensure that one of 30 sampled patients (Patient 25) was properly provided adequate information regarding refusal of blood product transfusion as well as be provided with alternative options to blood transfusion (a medical procedure where blood or blood components from a donor are transferred into the bloodstream of a recipient), as part of the informed consent process (a process that involves discussing treatment options with the patient, including risks and benefits, and getting their agreement to proceed), in accordance with the facility’s policy and procedure regarding informed consent. This deficient practice resulted in Patient 25 receiving three (3) units of packed red blood cells (PRBC- used to increase the oxygen-carrying capacity of the blood in patients with anemia [when the body does not have enough health red blood cells], blood loss, or other conditions that cause a low red blood cell count) during a surgical procedure emergency, which violated Patient 25’s rights regarding informed consent. Findings: During a record review on 2/19/2025 at 11:00 a.m. with the Information Technology Manager (ITM), the Risk Management Specialist (RMS) and the Director of Risk Management (DRM), Patient 25’s history and physical (H&P, a complete and formal assessment of the patient and the problem), dated 7/31/2024, at 11:20 a.m., was reviewed. The H&P indicated Patient 25 was admitted for Bradycardia (heartbeat less than 60 beats per minute) and difficulty breathing. During further record review on 2/19/2025, Patient 25’s cardiology (a branch of medicine that focuses on the diagnosis, treatment, and prevention of heart and blood vessel diseases) consultation note, dated 7/31/2024, at 11:06 p.m., completed by MD (Medical Doctor) 7, was reviewed. In the same cardiology consultation note, MD 7 documented recommendation of a pacemaker device system (a small device that prevents the heart from beating slow) and documented indications for the procedure and that the risks and the benefits regarding the pacemaker placement were explained to Patient 25 and family member. However, there was no documentation that Blood Transfusion refusal or other alternative options to blood transfusion, was discussed with Patient 25 and/or family member. Likewise, a record review of Patient 25’s Advance directive (a legal document that lets you specify your medical care wishes if you are unable to make decisions for yourself) indicated “No Blood.” These lack of documentation, in the MD notes, regarding MD discussion about blood transfusion and/or alternatives to blood transfusion were confirmed by the ITM and the RMS during an interview. During a review of Patient 25’s record of Consent to Surgery/Special Procedure, dated 8/1/2024, signed by Registered Nurse (RN) 10 and the second RN witness (RN 11), the Consent to Surgery/Special Procedure form, indicated Patient 25’s refusal to permit Blood and Blood Products. However, Patient 25’s Main EP (Electro Physiology- a report that contains details of the results of a test used to assess the electrical activity of the heart) Report indicated Patient 25 received three units of blood despite a documented refusal by Patient 25 to receive blood and blood products. During a review of Patient 25’s medical record titled, pre-anesthesia (a medical intervention that temporarily blocks pain and sensation during surgical procedures and other medical treatments) evaluation informed consent (a process that involves discussing treatment options with the patient, including risks and benefits, and getting their agreement to proceed), the record indicated “Consent (referring to consent for blood transfusion) not obtained due to emergency circumstances.” During a review of Patient 25’s Operative report, dated 8/1/2024, documented by MD 7, the Operative Report indicated MD 7 had several conversations with Patient 25’s family members regarding Patient 25’s status during surgery. However, there was no documentation in the Operative report regarding Patient 25’s Family member’s notification pertaining to Patient 25 having received three units of blood. During a concurrent interview and record review on 2/20/2025 at 1:50 p.m. with the Catheterization Surgical Laboratory (area that uses technology to diagnose and treat heart conditions) Director (CSLD) and the ITM, Patient 25’s Procedure note, dated 8/1/2024, and the Main EP Report, dated 8/1/2024, were reviewed. CSLD was asked if there was documentation of discussion or plan for Patient 25’s refusal of Blood Products in the OR record time out (a brief pause before a surgical procedure where the entire surgical team verbally confirms critical patient details like their identity, the intended procedure, and the surgical site, ensuring everyone is on the same page and minimizing the risk of errors before making an incision; it’s a crucial patient safety check considered a standard practice in modern surgery) and in the Operative report. Both the ITM and the CSLD confirmed there was no plan, or any alternatives to blood transfusion presented and discussed with Patient 25, when Patient 25 refused blood transfusion nor was there any communication documented addressing Patient 25’s refusal of Blood Products in preparation for the procedure (pacemaker placement). CSLD stated MD 7 was in communication with the Family member during the procedure. However, there was no documentation to indicate that alternative options to Blood transfusion were discussed with Patient 25’s family member during the procedure (Pacemaker placement). During an interview on 2/20/2025 at 9 :35 a.m. with the Risk Management Specialist (RMS) and the Director of Risk Management (DRM), the RMS and the DRM stated that the event involving Patient 25’s documented refusal of Blood transfusion which was reflected in the consent form, and yet during surgery, received three (3) units of blood (PRBC, Packed Red Blood Cells- used to increase the oxygen-carrying capacity of the blood in patients with anemia, blood loss, or other conditions that cause a low red blood cell count), was reviewed by the facility. The review was completed on 9/16/2024 and included a need for communication with MD when a patient verbalizes Blood transfusion refusal including a need for patient informed consents to be reviewed during Operation room time outs. In addition, the Medical Staff Director (MSD) stated the Department chair, and a designated medical staff member were also reviewing the case and their review will be completed in March 2025. During a review of the facility’s Policy and Procedure (P&P) titled, “Informed Consent,” dated 12/4/2024, the P&P indicated “the physician will document the information specified in the following procedures and the patient medical record whenever the following diagnostic and therapeutic interventions are to be performed which included blood transfusion.” During a review of the facility’s document titled, “Massive Transfusion Protocol,” dated 2/2/2022, the protocol indicated “physician to obtain consent for blood product transfusion from patient or patient surrogate ...” The protocol also indicated “provider must document the medical determination that an emergency exists.””

“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: 46333 Based on interview and record review, the facility failed to follow the physician’s order for one of 30 sampled patients (Patient 1) to provide a bedside sitter (a trained individual, often a healthcare worker or sitter, assigned to provide continuous, one-on-one supervision of a patient to ensure their safety, especially if the patient is at risk of falls, disorientation, or self-harm) for constant supervision to monitor Patient 1’s safety, when: 1. On 11/28/2024, in the Intensive Care Unit (ICU, ward that provides the critical care and life support for acutely ill and injured patients), Registered Nurse (RN 1) left Patient 1 unattended while retrieving medications from the medication room resulting in Patient 1 falling to the floor. This deficient practice resulted in Patient 1 experiencing a fall (an unexpected, unintentional descent of a patient to the ground or another lower surface) in the ICU on 11/28/2024. This deficient practice also had the potential to result in complications such as fracture (break in the bone), etc. 2. On 12/6/2024, a sitter was not assigned to Patient 1 when Patient 1 was transferred to the Step-Down Unit (SDU, an intermediate care unit for patients who no longer require intensive care but still need close monitoring). From 12/6/2024 through 12/11/2024, Patient 1 remained without a sitter. On 12/11/2024, Patient 1 was found disconnected from the Bilevel Positive Airway Pressure (BIPAP, a non-invasive ventilator that assist patients with breathing difficulties) machine and suffered cardiac arrest (when the heart suddenly stops beating) in the SDU. This deficient practice resulted in a cardiac arrest in the SDU on 12/11/2024 due to Patient 1’s disconnection from the BiPAP machine. In addition, this deficient practice had the potential to place other patients with physician-ordered bedside sitters at risk for similar sentinel event (a patient safety event that results in death, permanent harm, or severe temporary harm) due to inadequate supervision. On 2/21/2025 at 4:44 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Executive Officer (CEO), System Chief Medical Officer (SCMO), Chief Nursing Officer (CNO), Chief Operating Officer (COO), Director of Quality (DQ), Senior Director for Risk Management (DRM), System Director for Accreditation and Licensing (SDAL), and Regulatory Specialist (RS). The facility failed to follow physician order to provide a bedside sitter (a trained individual, often a healthcare worker, assigned to provide continuous, one-to-one supervision of a patient to ensure their safety, especially if the patient is at risk for falls [an unexpected, unintentional descent of a patient to the ground or another lower surface], disorientation [the condition of having lost one’s sense of direction], or self-harm) for constant supervision to monitor Patient 1’s safety thus resulting in Patient 1 having an unwitnessed fall in the Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill). Subsequently, Patient 1 was found having disconnected self from a BIPAP (bilevel positive airway pressure, provide pressurized air to patient’s airway to assist with breathing) machine which led to a cardiac arrest (when the heart stops beating) in the Step Down Unit (specialist hospital wards that serve as a transition point for patients who are no longer critically ill enough to remain in ICU but still require more intensive monitoring and care than a general ward can provide). Patient 1 was brought to the facility’s emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) for tachycardia (high heart rate) and generalized weakness on 11/24/2024. On 11/26/2024, there was a physician order to have a sitter for Patient 1. On 11/28/2024 at 12:10 a.m., Patient 1 was found on the floor in the Intensive Care Unit (ICU) when Registered Nurse (RN 1) left Patient 1 to get medications. Patient 1 was then transferred to the facility’s Step Down Unit on 12/6/2024. There was no sitter in place from 12/6/2024 to 12/11/2024 despite an existing order which was never discontinued by the physician. On 12/11/2024, Patient 1 pulled out BIPAP machine which led to cardiac arrest. Code Blue (hospital emergency code use to summon help when a patient is in need of resuscitation [to revive a patient]) was called. Patient 1 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and sent back to ICU. On 2/21/2025 at 9:20 p.m., the IJ was removed in the presence of the Chief Executive Officer (CEO), System Chief Medical Officer (SCMO), Chief Nursing Officer (CNO), Director of Quality (DQ), Senior Director for Risk Management (DRM), System Director for Accreditation and Licensing (SDAL), and Regulatory Specialist (RS). The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed through observation, interview and record review. The IJ Removal Plan indicated that for immediate action taken by the facility, on 2/21/2025, nursing leaders conducted facility-wide validations to ensure that every high fall-risk patient with a sitter order had a sitter present and that 15-minute observation were properly documented. Education began with nursing staff that were on duty on 2/21/2025 and covered the following: nurses must follow physician orders for a sitter when a patient is identified as high risk for falls, patients must be observed if a sitter order is in place regardless of patient’s sedation status, nurse must call charge nurse or lead nurse to provide constant observation, uninterrupted observation must be documented every 15 minutes and there must be hand-off communication between unit to unit and sitter to sitter. The IJ Removal Plan also included nursing leaders or designated staff would conduct observations and record review to confirm sitter order and compliance of sitter implementation and documentation. Findings: 1. During a review of Patient 1’s “History and Physical (H&P, a documented comprehensive formal assessment by a healthcare provider who examines the patient and their presenting problem),” dated 11/25/2025, the “H&P” indicated, Patient 1 was brought in by ambulance from home and presented with tachycardia (an abnormally fast heart rate exceeding 100 beats per minutes). The H&P also indicated that Patient 1 had a history of dementia (a disorder causing memory loss and confusion) and atrial fibrillation (a-fib, an irregular and often rapid heart rhythm that increases the risk of stroke [blood clot in the brain], heart failure [a condition where the heart muscle is weakened or stiff, making it unable to pump blood effectively], and other complications). Neurological (relating to the nervous system, which includes the brain, spinal cord, and nerves) assessment indicated: “Unable to assess mental status, patient unable to follow commands.” During a concurrent interview and record review on 2/19/2025 at 3:00 p.m. with the Director of Medical Surgical unit (DIR) 3, Patient 1’s “Nursing Documentation-Flowsheet (a form that records a patient’s clinical observations over time),” dated 11/28/2024, was reviewed. The flowsheet indicated, at 12:11 a.m., Patient 1 was “found on the floor, lying flat.” DIR 3 stated that the cause of the fall (an unexpected, unintentional descent of a patient to the ground or another lower surface) remained unknown. During a concurrent interview and record review on 2/20/2025 at 10:00 a.m. with the Nurse Manager (NM) 3 of the Surgical Treatment Unit (STU, a hospital area where surgeries are performed and patients are cared for before and after) Patient 1’s Medication Administration Record (MAR), from 11/26/2024 through 11/28/2024, was reviewed. The MAR indicated, Patient 1 was administered continuous infusion of Precedex (dexmedetomidine, a sedation used to reduce anxiety [an emotion that can feel like fear, or uneasiness] and agitation [feeling extremely restless, tense, or irritated] without suppressing breathing) on 11/26/2024 at 11:59 p.m., which continued until 12/11/2024, when Patient 1’s BiPAP (Bilevel Positive Airway Pressure machine, a non-invasive ventilator that assist patients with breathing difficulties) machine was accidentally disconnected. During an interview on 2/21/2025 at 1:00 p.m. with ICU Registered Nurse (RN) 1, RN 1 confirmed that Patient 1 was receiving continuous sedation with Precedex and was being monitored using the Richmond Agitation-Sedation Scale (RASS, a 10-point scale used to assess a patient’s level of sedation [a state of relaxation or drowsiness] or agitation, ranging from +4 [combative] to -5 [unarousable]), with a target RASS score of 0 to -2. RN 1 stated Patient 1 was at -1 (drowsy, a state of sleepiness and wakeness) on 11/28/2024. RN 1 stated Patient 1 was high risk for falls and was left sleeping while RN 1 retrieved medications from the medication room. Upon returning, RN 1 found Patient 1 on the floor with other staff present. The fall was unwitnessed, and the reason for the fall was unknown. During a concurrent interview and record review on 2/21/2025 at 2:30 p.m. with Registered Nurse (RN) 2, Patient 1’s electronic medical record (EMR, a digital version of a patient’s paper chart that contains their medical history) document titled, “Order” report, dated 11/26/2024, was reviewed. The physician (MD 5) ordered bedside sitter for Patient 1 from11/26/2024 at 12:59 p.m. to 12/17/2024 at 1:02 a.m. RN 2 confirmed that there was no documented evidence that a sitter (a trained individual, often a healthcare worker, assigned to provide continuous, one-to-one supervision of a patient to ensure their safety, especially if the patient is at risk for falls [an unexpected, unintentional descent of a patient to the ground or another lower surface], disorientation [the condition of having lost one’s sense of direction], or self-harm) was monitoring Patient 1 on 11/28/2024 (when Patient 1 fell in the ICU). RN 2 further stated, “As long as there is an order from the physician for a sitter, they need to have a sitter for constant observation. If they do not have a sitter, it can lead to fall, or accidental extubation (removal of the tube from the patient’s throat that helps them breathe).” During a review of the facility’s policy and procedure (P&P) titled, “Utilization of Safety Attendants for Patients” dated 6/10/2022, the P&P indicated, “The purpose of this policy is to provide guidelines for safety attendant placement for patients with high risk behaviors, high fall risk, or other behaviors that place the patient at risk for injury... Safety attendant will accompany the patient at all times.” During a review of the facility’s policy and procedure (P&P) titled, “Fall Prevention Program,” dated 6/30/2022, the P&P indicated, “Assessment may only be conducted by a licensed clinical individual. When a patient has been identified as being at risk for falling, interventions implemented to reduce falls are specific to the patient’s assessed needs and risk level.” 2. During a concurrent interview and record review on 2/20/2025 at 10:00 a.m. with the Nurse Manager (MN) 3 of the Step-Down Unit (SDU, a hospital unit that provides intermediate care for patients who are not ready for general ward care but don’t need intensive care), Patient 1’s “transfer Summary,” dated 12/6/2024, was reviewed. The summary indicated Patient 1 was transferred to the SDU on 12/6/2024. MN 3 confirmed that Patient 1 was transferred to SDU without a sitter. During a concurrent interview and record review on 2/20/2025 at 10:30 a.m. with Nurse Manager (MN) 3, Patient 1’s “Clinical Note Nursing,” was reviewed. The note indicated on 12/11/2024 at 1:30 a.m. the Telemetry Monitor Technician (MT, a healthcare worker who monitors a patient’s heart rate remotely) observed that Patient 1’s heart rate was at 30s and notified any RN to check on Patient 1. RN 9 found that Patient 1 had pulled out the BiPAP’s tubing resulting in a cardiac arrest (heart stop). Code Blue (a hospital emergency response for a patient in a cardiac arrest or respiratory arrest [when a person stops breathing or breathes inadequately]) was called, and Patient 1 was intubated (a medical procedure where a tube is inserted into the airway to assist with breathing) before being sent back to the ICU. During a concurrent interview and record review on 2/21/2025 at 2:30 p.m. with Registered Nurse (RN) 2, Patient 1’s electronic medical record (EMR, a digital version of a patient’s paper chart that contains their medical history) document titled, “Order Summary,” report dated 11/26/2024, was reviewed. The physician (MD 5) ordered bedside sitter for Patient 1 from 11/26/2024 at 12:59 p.m. to 12/17/2024 at 1:02 a.m. RN 2 confirmed that there was no documented evidence that a sitter was monitoring Patient 1 on 12/11/2024. During a review of the facility’s policy and procedure (P&P) titled, “Utilization of Safety Attendants for Patients” dated 6/10/2022, the P&P indicated, “The purpose of this policy is to provide guidelines for safety attendant placement for patients with high risk behaviors, high fall risk, or other behaviors that place the patient at risk for injury... Safety attendant will accompany the patient at all times.” During a review of the facility’s policy and procedure (P&P) titled, “Fall Prevention Program,” dated 6/30/2022, the P&P indicated, “Assessment may only be conducted by a licensed clinical individual. When a patient has been identified as being at risk for falling, interventions implemented to reduce falls are specific to the patient’s assessed needs and risk level.””

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d)(1) The patient has the right to the confidentiality of his or her clinical records. This Standard is not met as evidenced by: 46333 Based on observation, interviews, and record review the facility failed to protect the confidentiality of information, in accordance with the facility’s policy and procedure regarding Patient Rights (a subset of human rights) and Responsibility, for twenty of twenty sampled patients (who were receiving dialysis for the month of February 2025), when a binder containing medical record numbers (MRNs) was left unattended on a dialysis machine (HDM 1) in a public area (on the East Tower ground floor in front of the elevator). This deficient practice violated patient confidentiality and compromised compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA, is a federal law that protects patients’ health information) regulations. This deficient practice also increased the risk of unauthorized access to protected health information (PHI, any individually identifiable health information about a patient that is held by a covered entity, like a healthcare provider or health plan, and is subject to privacy regulations under the Health Insurance Portability and Accountability Act [HIPAA]), failing to uphold patients’ rights to privacy and confidentiality of their clinical records. Findings: During a concurrent observation and interview on 2/18/2025 at 3:15 p.m. with the Infection Control Manager (IPM) on the East Tower ground floor in front of the elevator, the dialysis machine (HDM 1) was observed to be left unattended. IPM stated, “The dialysis machine should never be left unattended. The machine should be stored in the storage area in the basement.” The machine contained: -Two normal saline (a solution of 0.9% sodium chloride [salt] in water) intravenous (IV, a method of delivering fluids or medicine directly into a vein) fluid bags hanging - Four bottles of reagent (chemical solutions used in dialysis treatment) -A bottle of vinegar -A binder containing patient medical records numbers (MRN, unique identifier used to tack patient medical records). During an interview on 2/18/2025 at 3:20 p.m. with Hemodialysis Nurse (HDN) 1, HDN 1 stated, “I usually leave the dialysis machine there (referring to the location East Tower ground floor in front of the elevator) to go for lunch.” During an interview on 2/21/2025 at 3:20 p.m. with the Chair Executive Officer (HDD) of the Dialysis contracted services. HDD stated, “Leaving the dialysis machine unattended is unacceptable and not safe practice.” HDD further stated, “Dialysis nurses have keys to the storage room and must take the dialysis machine to the storage room prior to taking breaks.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibility,” dated 9/9/2024, the P&P indicated, “Have personal privacy respected ... Confidential treatment of all communications and records pertaining to your care and stay in the hospital. You will receive a separate “Notice of Privacy Practices· that explains your privacy rights in detail and how we may use and disclose your protected health information. During a review of the facility’s policy and procedure (P&P) titled, “Dialysis Services,” dated 6/16/2023, the P&P indicated, “The purpose of this policy is to define the process of the provision of dialysis services to patients. Patient’s dialysis needs will be met through the utilization of competent contracted services ... Rooms are available for storage of dialysis equipment and supplies. Dialysis equipment is to be placed in storage rooms whenever not in use. The dialysis company(s) assigned to the storage room is responsible for maintaining it in orderly fashion. The dialysis nurse will notify the Nursing Resource Office before leaving if housekeeping is needed for cleaning the room. Note: If the storage room key is not returned to the Nursing Resource Office in a timely manner, the dialysis company will be billed for the lock being re-keyed or replacement. No copies are to be made of the keys ...Dialysis equipment is not to be left unattended in any area. There are no exceptions. If the patient is on isolation, the equipment must be wiped down with an appropriate disinfectant and stored in the assigned locked storage area after each treatment.””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to identify, analyze, and address deficiencies in ICU (Intensive Care Unit- ward that provides the critical care and life support for acutely ill and injured patients) equipment availability through its Quality Assessment and Performance Improvement (QAPI, a systematic approach to improving the quality of care and safety in a healthcare setting. QAPI combines Quality Assurance [QA] and Performance Improvement [PI] to create a comprehensive, data-driven program) program, resulting in inadequate monitoring for four of 30 sampled Patients (Patient 5, Patient 7, Patient 8, and Patient 9), with an arterial line (A-line, a catheter placed in an artery to monitor blood pressure and obtain blood samples) to ensure they each have a leveler (a device used to ensure proper positioning of the A-line relative to the patient’s photostatic axis [atomical reference point at the 4th intercostal space, mid-axillary line]) at the bedside, to use each time the patient was repositioned to ensure accurate reading of the patient’s blood pressure (the force of blood against artery walls as the heart pumps blood throughout the body), in accordance with the facility’s policy and procedure regarding Monitoring Arterial Blood using a Pressure Transducer (a device that converts the pressure fluctuations of blood within the artery into an electrical signal) System and the policy regarding QAPI. This deficient practice resulted in delays in recalibration of the A-line, and had the potential for inaccurate blood pressure readings which may lead to delays in the implementation of timely interventions, thus compromising patient safety due to complications of unidentified elevated, uncontrolled blood pressure such as stroke (a clot in the brain), damage to vital organs such as kidneys, etc. Findings: 1. During a review of Patient 5’s “ED (emergency department, hospital department that treats patients in need of immediate care upon arrival to the hospital) Physician Notes,” dated 2/17/2025, the note indicated, Patient 5 “presents to the emergency department by ambulance from home for sudden and significant change in mental function, nausea (the urge to throw-up), vomiting and diarrhea (loose stools), profuse diarrhea tonight and family stated she (Patient 5) has been more confused than usual, low oxygen saturation (the amount of oxygen in the blood).” Diagnostic studies indicated Patient 5 had an acute (sudden and severe onset) intracranial hemorrhage (a brain bleed). During a concurrent observation and interview on 2/19/2025 at 12:05 p.m. with the charge nurse (CN 3, charge nurse responsible for overseeing ICU nursing staff) in the intensive care unit (ICU, ward that provides the critical care and life support for acutely ill and injured patients) in room ABC on 2/19/2025 at 12:05 p.m., Patient 5 was observed with an A-Line in the left wrist. There was no A-line leveler (a device used to ensure the A-line is correctly positioned for accurate blood pressure readings. If the transducer [a device that converts the pressure fluctuations of blood within the artery into an electrical signal], is too high, it underestimates blood pressure, if the transducer is too low, it overestimates blood pressure. The leveler helps maintain correct alignment to prevents errors) in the room. CN 3 stated that the ICU only had two levelers available for all ICU patients. CN 3 said that each time a patient was repositioned (for bathing, hygiene care, wound care, transfer to chair or off the unit, and scheduled repositioning every two hours), the nurse must leave the room to retrieve the leveler from the medication room, causing a delay in care. CN3 confirmed that the lack of sufficient levelers could result in potential delays in patient care and monitoring. During a review of Patient 5’s “Arterial Line Group,” flowsheet (document used to track clinical observations for Patients over time), dated 2/18/2025, the flowsheet indicated, an Arterial line was inserted for Patient 5 on 2/18/2025 at 7:53 a.m. and remained current. During an interview on 2/21/2025 at 7:30 p.m. with the Director of ICU (DIR) 2, DIR 2 confirmed that the ICU had only two levelers stored in the medication room and stated there should be one leveler per patient room. DIR 2, a member of the QAPI subcommittee, stated that QAPI team and ICU leadership discussed this issue (regarding inadequate number of available levelers) earlier that morning and were in the process of ordering a leveler for each ICU room. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI),” dated 3/13/2024, the P&P indicated, “The quality assessment and performance improvement plan (QAPI) is a proactive, interdisciplinary, systematic approach to designing or redesigning patient¿-centered systems to improve quality of care and patient safety in alignment with regulatory standards...As part of performance Improvement, leaders (including governing body) will: Set priorities (le high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines...Prioritize performance improvement in response to changes within the internal and external environment. Proactively identify processes needing improvement to prevent medical errors. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performance of process improvement/deficiencies, and monitoring/sustaining processes ... Performance Improvement Committee Functions: Patient Safety Program (Refer to Patient Safety Program Plan): Patient safety integrates with all quality assessment and performance Improvement activities. Proactive Risk Assessments, such as FMEA (Failure Mode Effect Analysis), will be utilized to assess actual and potential risk, failure, points of vulnerability, and prioritized areas for improvement based on impact to patient care outcomes ...” During a review of the facility’s policy and procedure (P&P) titled, “Monitoring Arterial Blood using a Pressure Transducer System, dated 2025, the P&P indicated: -“Level transducer (a pressure sensor that converts pressure into electrical signals) with the patient’s phlebostatic axis (an anatomical reference point at the fourth intercostal space at the mid-axillary line (an imaginary line that runs vertically down the torso from the armpit), used for accurate readings.” -“Level Transducer to the patient’s phlebostatic axis and zero transducers to atmospheric pressure (calibrating the transducer to eliminate the effects of ambient air pressure) each time the patient is repositioned to ensure accuracy and consistency of arterial BP (blood pressure) measurements.” 2. During a review of Patient 7’s “Face sheet (a document within a patient’s medical chart that summarizes key information),” dated 2/12/2025, the face sheet indicated, Patient 7 was admitted for symptomatic bradycardia (a slow heart rate that causes symptoms like dizziness, fatigue [a feeling of extreme tiredness], or shortness of breath. A normal heart rate for adults is faster than 60 beats per minute), hyperkalemia (a higher-than-normal level of potassium [an essential mineral for nerve and muscle function] in the bloodstream), and acute renal failure (a condition characterized by a sudden and significant decline in kidney function). During a review of Patient 7’s “Operation/Procedure Report,” dated 2/13/2025, the note indicated, Patient 7 had a procedure to insert an Arterial line into the femoral artery (a large blood vessel located in the upper thigh) at 10:25 a.m. on 2/13/2025. During an interview on 2/19/2025 at 12:05 p.m. with the Charge Nurse (CN) 3 in the ICU, CN 3 stated that the ICU only had two levelers available for all ICU patients. CN3 stated that each time a patient was repositioned (for bathing, hygiene care, wound care, transfer to chair or off the unit, and scheduled repositioning every two hours), the nurse must leave the room to retrieve the leveler from the medication room, causing a delay in care. CN 3 confirmed that the lack of sufficient levelers could result in potential delays in patient care and monitoring. During an interview on 2/21/2025 at 7:30 p.m. with the Director of ICU (DIR) 2, DIR 2 confirmed that the ICU had only two levelers stored in the medication room and stated there should be one leveler per patient room. DIR 2, a member of the QAPI subcommittee, stated that QAPI team and ICU leadership discussed this issue earlier that morning and are in the process of ordering a leveler for each ICU room. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI),” dated 3/13/2024, the P&P indicated, “The quality assessment and performance improvement plan (QAPI) is a proactive, interdisciplinary, systematic approach to designing or redesigning patient ¿centered systems to improve quality of care and patient safety in alignment with regulatory standards...As part of performance Improvement, leaders (including governing body) will: Set priorities (le high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines...Prioritize performance improvement in response to changes within the internal and external environment. Proactively identify processes needing improvement to prevent medical errors. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performance of process improvement/deficiencies, and monitoring/sustaining processes ... Performance Improvement Committee Functions: Patient Safety Program (Refer to Patient Safety Program Plan): Patient safety integrates with all quality assessment and performance Improvement activities. Proactive Risk Assessments, such as FMEA (Failure Mode Effect Analysis), will be utilized to assess actual and potential risk, failure, points of vulnerability, and prioritized areas for improvement based on impact to patient care outcomes ...” During a review of the facility’s policy and procedure (P&P) titled, “Monitoring Arterial Blood using a Pressure Transducer System, dated 2025, the P&P indicated: -“Level transducer (a pressure sensor that converts pressure into electrical signals) with the patient’s phlebostatic axis (an anatomical reference point at the fourth intercostal space at the mid-axillary line (an imaginary line that runs vertically down the torso from the armpit), used for accurate readings.” -“Level Transducer to the patient’s phlebostatic axis and zero transducers to atmospheric pressure (calibrating the transducer to eliminate the effects of ambient air pressure) each time the patient is repositioned to ensure accuracy and consistency of arterial BP (blood pressure) measurements.” 3. During a review of Patient 8’s “Operation/Procedure Report, dated 2/17/2025, the Report indicated, Patient 8 was scheduled for a mitral valve (one of four valves in your heart that regulates blood flow) replacement. The Operation/Procedure Report also indicated Patient 8 “past medical history include endocarditis (an inflammation of the inner lining of the heart chambers and heart valves) ...Patient (Patient 8) did undergo cardiology (the branch of medicine that deals with diseases and abnormalities of the heart) evaluation including an echocardiogram (a test of the action of the heart), which demonstrated evidence of severe mitral regurgitation (a valve in the heart, called the mitral valve, doesn’t close properly, allowing blood to leak backwards instead of flowing smoothly forward) with a flail posterior mitral valve leaflet (is a flap of tissue in the heart valve that opens and closes to allow blood to flow through the heart).” The report also indicated an A-line was inserted to the wrist of Patient 8. During an interview on 2/19/2025 at 12:05 p.m. with the Charge Nurse (CN) 3 in the ICU, CN 3 stated that the ICU only had two levelers available for all ICU patients. CN 3 stated that each time a patient was repositioned (for bathing, hygiene care, wound care, transfer to chair or off the unit, and scheduled repositioning every two hours), the nurse must leave the room to retrieve the leveler from the medication room, causing a delay in care. CN 3 confirmed that the lack of sufficient levelers could result in potential delays in patient care and monitoring. During an interview on 2/21/2025 at 7:30 p.m. with the Director of ICU (DIR) 2, DIR 2 confirmed that the ICU had only two levelers stored in the medication room and stated there should be one leveler per patient room. DIR 2, a member of the QAPI subcommittee, stated that QAPI team and ICU leadership discussed this issue earlier that morning and are in the process of ordering a leveler for each ICU room. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI),” dated 3/13/2024, the P&P indicated, “The quality assessment and performance improvement plan (QAPI) is a proactive, interdisciplinary, systematic approach to designing or redesigning patient ¿centered systems to improve quality of care and patient safety in alignment with regulatory standards...As part of performance Improvement, leaders (including governing body) will: Set priorities (le high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines...Prioritize performance improvement in response to changes within the internal and external environment. Proactively identify processes needing improvement to prevent medical errors. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performance of process improvement/deficiencies, and monitoring/sustaining processes ... Performance Improvement Committee Functions: Patient Safety Program (Refer to Patient Safety Program Plan): Patient safety integrates with all quality assessment and performance Improvement activities. Proactive Risk Assessments, such as FMEA (Failure Mode Effect Analysis), will be utilized to assess actual and potential risk, failure, points of vulnerability, and prioritized areas for improvement based on impact to patient care outcomes ...” During a review of the facility’s policy and procedure (P&P) titled, “Monitoring Arterial Blood using a Pressure Transducer System, dated 2025, the P&P indicated: -“Level transducer (a pressure sensor that converts pressure into electrical signals) with the patient’s phlebostatic axis (an anatomical reference point at the fourth intercostal space at the mid-axillary line (an imaginary line that runs vertically down the torso from the armpit), used for accurate readings.” -“Level Transducer to the patient’s phlebostatic axis and zero transducers to atmospheric pressure (calibrating the transducer to eliminate the effects of ambient air pressure) each time the patient is repositioned to ensure accuracy and consistency of arterial BP (blood pressure) measurements.” 4. During a review of Patient 9’s “Face sheet,” dated 2/12/2025, the face sheet indicated, Patient 9 was admitted to the facility for gastrointestinal (GI, bleeding is bleeding in the digestive tract [is a long, continuous tube-like pathway through which food travels from the mouth to the anus, where it is broken down, absorbed for nutrients, and ultimately expelled as waste]). During a record review of Patient 9’s “Operative/Procedure Report,” dated 2/13/2025, the Report indicated Patient 9 had a procedure to insert a A-line to the left wrist. During an interview on 2/19/2025 at 12:05 p.m. with the Charge Nurse (CN) 3 in the ICU, CN 3 stated that the ICU only had two levelers available for all ICU patients. CN 3 stated that each time a patient was repositioned (for bathing, hygiene care, wound care, transfer to chair or off the unit, and scheduled repositioning every two hours), the nurse must leave the room to retrieve the leveler from the medication room, causing a delay in care. CN3 confirmed that the lack of sufficient levelers could result in potential delays in patient care and monitoring. During an interview on 2/21/2025 at 7:30 p.m. with the Director of ICU (DIR) 2, DIR 2 confirmed that the ICU had only two levelers stored in the medication room and stated there should be one leveler per patient room. DIR 2, a member of the QAPI subcommittee, stated that QAPI team and ICU leadership discussed this issue earlier that morning and are in the process of ordering a leveler for each ICU room. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI),” dated 3/13/2024, the P&P indicated, “The quality assessment and performance improvement plan (QAPI) is a proactive, interdisciplinary, systematic approach to designing or redesigning patient ¿centered systems to improve quality of care and patient safety in alignment with regulatory standards...As part of performance Improvement, leaders (including governing body) will: Set priorities (le high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines...Prioritize performance improvement in response to changes within the internal and external environment. Proactively identify processes needing improvement to prevent medical errors. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performance of process improvement/deficiencies, and monitoring/sustaining processes ... Performance Improvement Committee Functions: Patient Safety Program (Refer to Patient Safety Program Plan): Patient safety integrates with all quality assessment and performance Improvement activities. Proactive Risk Assessments, such as FMEA (Failure Mode Effect Analysis), will be utilized to assess actual and potential risk, failure, points of vulnerability, and prioritized areas for improvement based on impact to patient care outcomes ...” During a review of the facility’s policy and procedure (P&P) titled, “Monitoring Arterial Blood using a Pressure Transducer System, dated 2025, the P&P indicated: -“Level transducer (a pressure sensor that converts pressure into electrical signals) with the patient’s phlebostatic axis (an anatomical reference point at the fourth intercostal space at the mid-axillary line (an imaginary line that runs vertically down the torso from the armpit), used for accurate readings.” -“Level Transducer to the patient’s phlebostatic axis and zero transducers to atmospheric pressure (calibrating the transducer to eliminate the effects of ambient air pressure) each time the patient is repositioned to ensure accuracy and consistency of arterial BP (blood pressure) measurements.””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to track, analyze, and implement preventive actions for adverse patient events (a negative or harmful result experienced by a patient as a consequence of medical care), specifically recurrent patient falls (an unexpected, unintentional descent of a patient to the ground or another lower surface) in the Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill). The Quality Assessment and Performance Improvement (QAPI, a systematic approach to improving the quality of care and safety in a healthcare setting. QAPI combines Quality Assurance [QA] and Performance Improvement [PI] to create a comprehensive, data-driven program) program team did not conduct a Root Cause Analysis (RCA, a systematic process used to identify and analyze the underlying causes of a medical error or adverse event, with the goal of preventing similar incidents from happening again by addressing the root issues rather than just the symptoms; it typically involves a multidisciplinary team to thoroughly investigate the event and develop corrective actions) or established an effective action plan to prevent falls among high-risk patients, in accordance with the facility’s policy and procedure regarding QAPI. This deficient practice resulted in repeated falls in the ICU, including: -Patient 1, who fell on 11/28/2024 unwitnessed while sedated, and was identified as a high fall risk. -Patient 6, who had an unwitnessed fall on 2/2/2025 after heart surgery. The failure to implement an effective fall prevention strategy placed patients at risk for serious harm and compromised patient safety. Findings: 1. During a review of Patient 1’s “History and Physical (H&P, a documented comprehensive formal assessment by a healthcare provider who examines the patient and their presenting problem),” dated 11/25/2025, the “H&P” indicated, Patient 1 was brought in by ambulance from home and presented with tachycardia (an abnormally fast heart rate exceeding 100 beats per minutes). The H&P also indicated that Patient 1 had a history of dementia (a disorder causing memory loss and confusion) and atrial fibrillation (a-fib, an irregular and often rapid heart rhythm that increases the risk of stroke [blood clot in the brain], heart failure [a condition where the heart muscle is weakened or stiff, making it unable to pump blood effectively], and other complications). Neurological (relating to the nervous system, which includes the brain, spinal cord, and nerves) assessment indicated: “Unable to assess mental status, patient unable to follow commands.” During a concurrent interview and record review on 2/19/2025 at 3:00 p.m. with the Director of Medical Surgical unit (DIR) 3, Patient 1’s electronic medical record (EMR, a digital version of a patient’s paper chart that contains their medical history), was reviewed. The document titled “Nursing Documentation-Flowsheet (a form that records a patient’s clinical observations over time),” dated 11/28/2024, was reviewed. The flowsheet indicated, on 11/28/2024 at 12:11 a.m., Patient 1 was “found on the floor, lying flat.” DIR 3 confirmed that Patient 1 had been identified as high fall (an unexpected, unintentional descent of a patient to the ground or another lower surface) risk and stated that the cause of the fall remained unknown. During an interview on 2/21/2025 at 1:00 p.m. with ICU Registered Nurse (RN)1, RN 1 confirmed that Patient 1 was receiving continuous sedation with Precedex (dexmedetomidine, a sedation used to reduce anxiety [an emotion that can feel like fear, or uneasiness] and agitation [feeling extremely restless, tense, or irritated] without suppressing breathing) and was being monitored using the Richmond Agitation-Sedation Scale (RASS, is a 10-point scale used to assess a patient’s level of sedation or agitation, ranging from +4 [combative] to -5 [unarousable]), with a target RASS score of 0 to -2. RN 1 stated Patient 1 was at -1 (drowsy, a state of sleepiness and wakeness) on 11/28/2024. RN 1 stated Patient 1 was high risk for falls and was left sleeping while RN 1 retrieved medications from the medication room. Upon returning, RN 1 found Patient 1 on the floor with other staff present. The fall was unwitnessed, and the reason for the fall was unknown. During a concurrent interview and record review on 2/21/2025 at 2:30 p.m. with Registered Nurse (RN) 2, Patient 1’s electronic medical record (EMR, a digital version of a patient’s paper chart that contains their medical history) document titled, “Order” report, dated 11/26/2024, was reviewed. The physician (MD 5) ordered bedside sitter for Patient 1 from 11/26/2024 at 12:59 p.m. to 12/17/2024 at 1:02 a.m. RN 2 confirmed that there was no documented evidence that a sitter was monitoring Patient 1 on 11/28/2024. During an interview on 2/21/2025 at 12:33 p.m. with the Co-Chair of the Falls Performance Improvement (PI) Team (RM), RM stated the Falls PI team communicates directly with QAPI (Quality Assurance Performance Improvement- a systematic approach to improving the quality of care and safety in a healthcare setting. QAPI combines Quality Assurance [QA] and Performance Improvement [PI] to create a comprehensive, data-driven program) and was responsible for fall prevention measures, system assessment, collaboration with other department leaders. RM was unaware of Patient 1’s fall until the day of the interview (2/21/2025), stating, “I did not review this case (Patient 1’s fall on 11/28/2024) until this morning.” During an interview on 2/21/2025 at 2:00 p.m. with the Director of ICU (DIR) 2, DIR 2 stated that after a patient fall, a post-fall huddle was conducted, but nursing staff were not included in these discussions. Instead, one leader from the unit where the fall occurred, such as the charge nurse, unit manager, or unit representative, would attend. DIR 2 also stated that they did not participate in the post-fall huddle for Patient 1’s fall on 11/28/2024. During an interview on 2/21/2025 at 9:20 p.m. with the Chief Executive Officer (CEO), the CEO stated Governing Body relies heavily on the QAPI department to report on current issues and outline action plan taken in response. CEO emphasized that ultimately, the Governing Body holds the responsibility for ensuring oversight of an ongoing quality improvement plan focused on patient safety, quality of care, organization-wide quality assessment. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement,” dated 12/1/2024, the P&P indicated, “The quality assessment and performance improvement plan (QAPI) is a proactive, interdisciplinary, systematic approach to designing or redesigning patient centered systems to improve quality of care and patient safety in alignment with regulatory standards...As part of performance Improvement, leaders (including governing body) will: Set priorities (high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines...Prioritize performance improvement in response to changes within the internal and external environment. Proactively identify processes needing improvement to prevent medical errors. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performance of process improvement/deficiencies, and monitoring/sustaining processes... Structure and Accountability: The Community Board (GB) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectations for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective AHGL committees/teams ...” During a review of the facility’s policy and procedure (P&P) titled, “Performance Improvement Team Charter: 2025 Falls PI Team, “ dated 1/10/2012, the P&P indicated, “Define the Issues: Non-compliant behaviors (e.g., patient/family turning off bed alarm, don’t call/wait for assistance).Inconsistencies with bed alarms and zone settings activation (e.g., staff do not set bed in moderate sensitivity setting, do not activate the bed alarm after turning off). Falls from chairs (including commode, wheelchair) because of inconsistencies with using chair alarms. Inconsistent yellow gown and gait belt usage. Reinforce bedside charting, especially for high fall risk patients. Goals of the Process Improvement: Analyze monthly falls and initiate immediate corrective actions to improve performance and compliance with designated interventions. Lead processes that support full compliance with Fall Prevention Policy. Strategize fall prevention measures specific to patient needs and continue to evaluate and modify strategies as appropriate ... How Does This Process Support the Hospital’s Overall Strategic Plan? By working to reduce the number and rate of falls we are focusing on patient safety, patient satisfaction, and prevention of hospital acquired conditions.” During a review of the facility’s policy and procedure (P&P) titled, “Utilization of Safety Attendants for Patients,” dated 6/10/2022, the P&P indicated, “The purpose of this policy is to provide guidelines for safety attendant placement for patients with high risk behaviors, high fall risk, or other behaviors that place the patient at risk for injury... Safety attendant will accompany the patient at all times.” 2. During a review of Patient 6’s “Progress Notes (a documented comprehensive formal assessment by a healthcare provider who examines the patient and their presenting problem),” dated 2/3/2025, the note indicated, Patient 6 “The patient (Patient 6) presented to the emergency room following the acute (sudden and severe in onset) onset of severe abdominal and chest pain. He (Patient 6) was complaining that he (Patient 6) could not move his right leg. The patient (Patient 6) underwent a CT angiogram (computed tomography angiography [CTA], is a medical imaging test that uses X-rays to create pictures of blood vessels and blood flow) which demonstrated evidence of a type A thoracic aortic dissection (a tear in the inner layer of the aorta, the main artery that carries oxygenated blood from the heart to the body).” The Progress Notes also indicated Patient 6 had undergone emergency heart surgery. During a concurrent interview and record review on 2/21/2025 at 11:30 a.m. with the Nurse Manager (MN) 3 of the Step-Down Unit (SDU, a hospital unit that provides intermediate care for patients who are not ready for general ward care but don’t need intensive care), Patient 6’s electronic medical record (EMR, a digital version of a patient’s paper chart that contains their medical history) document titled, “Fall Post Event Summary,” dated 2/2/25, was reviewed. The Fall Post Event Summary indicated Patient 6 had an unwitnessed fall while in the ICU. Patient 6 was found sitting on the floor with a urinal (a container used by patients who are unable to get out of bed to collect their urine). During an interview on 2/21/2025 at 12:33 p.m. with the Co-Chair of the Falls Performance Improvement (PI) Team (RM), RM stated the Falls PI team communicates directly with QAPI and was responsible for fall prevention measures, system assessment, and collaboration with other department leaders. RM was unaware of Patient 1’s falls and Patient 6’s fall until the day of the interview (2/21/2025), stating, “I did not review this case (Patient 1’s fall on 11/28/2024) until this morning.” During an interview on 2/21/2025 at 2:00 p.m. with the Director of ICU (DIR) 2, DIR 2 stated that after a patient fall, a post-fall huddle (a meeting held after a patient falls to determine the cause and prevent future falls) was conducted, but nursing staff were not included in these discussions. Instead, one leader from the unit where the fall occurred, such as the charge nurse, unit manager, or unit representative, would attend. DIR 2 also stated that they did not participate in the post-fall huddle for Patient 1’s fall on 11/28/2024. During an interview on 2/21/2025 at 9:20 p.m. with the Chief Executive Officer (CEO), the CEO stated Governing Body relies heavily on the QAPI department to report on current issues and outline action plan taken in response. CEO emphasized that ultimately, the Governing Body holds the responsibility for ensuring oversight of an ongoing quality improvement plan focused on patient safety, quality of care, organization-wide quality assessment. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement “ dated 12/1/2024, the P&P indicated, “The quality assessment and performance improvement plan (QAPI) is a proactive, interdisciplinary, systematic approach to designing or redesigning patient centered systems to improve quality of care and patient safety in alignment with regulatory standards ... As part of performance Improvement, leaders (including governing body) will: Set priorities (le high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines ...Prioritize performance improvement in response to changes within the internal and external environment. Proactively identify processes needing improvement to prevent medical errors. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performance of process improvement/deficiencies, and monitoring/sustaining processes... Structure and Accountability: The Community Board (GB) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectations for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective AHGL committees/teams ...” During a review of the facility’s policy and procedure (P&P) titled, “Performance Improvement Team Charter: 2025 Falls PI Team, “ dated 1/10/2012, the P&P indicated, “Define the Issues: Non-compliant behaviors (e.g., patient/family turning off bed alarm, don’t call/wait for assistance).Inconsistencies with bed alarms and zone settings activation (e.g., staff do not set bed in moderate sensitivity setting, do not activate the bed alarm after turning off). Falls from chairs (including commode, wheelchair) because of inconsistencies with using chair alarms. Inconsistent yellow gown and gait belt usage. Reinforce bedside charting, especially for high fall risk patients. Goals of the Process Improvement: Analyze monthly falls and initiate immediate corrective actions to improve performance and compliance with designated interventions. Lead processes that support full compliance with Fall Prevention Policy. Strategize fall prevention measures specific to patient needs and continue to evaluate and modify strategies as appropriate ... How Does This Process Support the Hospital’s Overall Strategic Plan? By working to reduce the number and rate of falls we are focusing on patient safety, patient satisfaction, and prevention of hospital acquired conditions.” During a review of the facility’s policy and procedure (P&P) titled, “Utilization of Safety Attendants for Patients” dated 6/10/2022, the P&P indicated, “The purpose of this policy is to provide guidelines for safety attendant placement for patients with high risk behaviors, high fall risk, or other behaviors that place the patient at risk for injury... Safety attendant will accompany the patient at all times.””

“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: 46333 Based on observation, interview, and record review, the facility failed to ensure that four of 30 sampled Patients (Patient 5, Patient 7, Patient 8, and Patient 9), with an arterial line (A-line, a thin, flexible tube that’s inserted into an artery to measure blood pressure and to collect blood samples) had a leveler (a device used to ensure proper positioning of the A-line relative to the patient’s photostatic axis [atomical reference point at the 4th intercostal space, mid-axillary line]) at the bedside to use each time the patients (Patients 5, 7, 8, and 9) were repositioned, to ensure accurate reading of the patient’s blood pressure (the force of blood against artery walls as the heart pumps blood throughout the body), in accordance with the facility’s policy and procedure regarding Monitoring Arterial Blood using a Pressure Transducer (a device that converts the pressure fluctuations of blood within the artery into an electrical signal) System. This deficient practice resulted in delays in recalibration of the A-line, and had the potential for inaccurate blood pressure readings which may lead to delays in the implementation of timely interventions, thus compromising patient safety due to complications of unidentified elevated, uncontrolled blood pressure such as stroke (a clot in the brain), damage to vital organs such as kidneys, etc. Findings: 1. During a review of Patient 5’s “ED (emergency department, hospital department that provides services to patients whose condition requires immediate care) Physician Notes,” dated 2/17/2025, the note indicated, Patient 5 “presents to the emergency department by ambulance from home for sudden and significant change in mental function, nausea (the urge to throw-up, vomiting and diarrhea (loose stools), profuse diarrhea tonight and family stated she (Patient 5) has been more confused than usual, low oxygen saturation (amount of oxygen in the blood).” Diagnostic studies indicated Patient 5 had an acute (sudden and severe in onset) intracranial hemorrhage (a brain bleed). During a concurrent observation and interview on 2/19/2025 at 12:05 p.m. with the charge nurse (CN 3, charge nurse responsible for overseeing ICU nursing staff) in the intensive care unit (ICU, ward that provides the critical care and life support for acutely ill and injured patients), in room ABC, on 2/19/2025 at 12:05 p.m., Patient 5 was observed with an Arterial Line (A-line, a catheter placed in an artery to monitor blood pressure and obtain blood samples) in the left wrist. There was no A-line leveler (a device used to ensure the A-line is correctly positioned for accurate blood pressure readings) in the room. CN 3 explained that the ICU only had two levelers available for all ICU patients. CN3 said that each time a patient was repositioned (for bathing, hygiene care, wound care, transfer to chair or off the unit, and scheduled repositioning every two hours), the nurse must leave the room to retrieve the leveler from the medication room, causing a delay in care. CN 3 confirmed that the lack of sufficient levelers could result in potential delays in patient care and monitoring. During an interview on 2/21/2025 at 7:30 p.m. with the Director of ICU (DIR) 2, DIR 2 confirmed that the ICU had only two levelers stored in the medication room and stated there should be one leveler per patient room. DIR 2 stated they were in the process of ordering more. During a review of Patient 5’s “Arterial Line Group,” flowsheet (document used to track clinical observations for Patients over time), dated 2/18/2025, the flowsheet indicated, an Arterial line was inserted for Patient 5 on 2/18/2025 at 7:53 a.m. and remained current. During a review of the facility’s policy and procedure (P&P) titled, “Monitoring Arterial Blood using a Pressure Transducer System, dated 2025, the P&P indicated: -“Level transducer (a pressure sensor that converts pressure into electrical signals) with the patient’s phlebostatic axis (an anatomical reference point at the fourth intercostal space at the mid-axillary line (an imaginary line that runs vertically down the torso from the armpit), used for accurate readings.” -“Level Transducer to the patient’s phlebostatic axis and zero transducers to atmospheric pressure (calibrating the transducer to eliminate the effects of ambient air pressure) each time the patient is repositioned to ensure accuracy and consistency of arterial BP (blood pressure) measurements.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI),” dated 3/22/2022, the P&P indicated, “The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually.” During a review of the facility’s policy and procedure (P&P) titled, “Standard of Nursing Practice,” dated 3/22/2022, the P&P indicated, “The Standards of Nursing Practice provide guidelines to our Registered Nurses (RN) and establish the framework for the evaluation of our practice. Standards are written in measurable terms and describe the responsibilities for which nurses are accountable. The American Nurse’s Association (ANA) has two distinct categories: Standards of Practice and Standards of Professional Performance ... The Standards of Practice describe a competent level of nursing care according to the critical thinking model known as the nursing process ...The standards of Professional Performance describe a competent level of behavior in the professional role that includes the following: Resource Utilization: The RN utilizes appropriate resources to plan, provide, and sustain evidence-based services that are safe, effective, and fiscally responsible.” 2. During a review of Patient 7’s “Face sheet (a hospital is a document within a patient’s medical chart that summarizes key information),” dated 2/12/2025, the face sheet indicated, Patient 7 was admitted for symptomatic bradycardia (a slow heart rate that causes symptoms like dizziness, fatigue [a feeling of extreme tiredness], or shortness of breath. A normal heart rate for adults is faster than 60 beats per minute), hyperkalemia (a higher-than-normal level of potassium [an essential mineral for nerve and muscle function] in the bloodstream), and acute renal failure (a condition characterized by a sudden and significant decline in kidney function). During a review of Patient 7’s “Operation/Procedure Report,” dated 2/13/2025, the note indicated, Patient 7 had a procedure to insert an Arterial line into the femoral artery (a large blood vessel located in the upper thigh) at 10:25 a.m. on 2/13/2025. During a concurrent observation and interview on 2/19/2025 at 12:05 p.m. with the Charge Nurse (CN 3, charge nurse responsible for overseeing ICU nursing staff) in the intensive care unit (ICU, ward that provides the critical care and life support for acutely ill and injured patients), in room ABC, on 2/19/2025 at 12:05 p.m., Patient 5 was observed with an Arterial Line (A-line, a catheter placed in an artery to monitor blood pressure and obtain blood samples) in the left wrist. There was no A-line leveler (a device used to ensure the A-line is correctly positioned for accurate blood pressure readings) in the room. CN 3 explained that the ICU only had two levelers available for all ICU patients. CN 3 said that each time a patient was repositioned (for bathing, hygiene care, wound care, transfer to chair or off the unit, and scheduled repositioning every two hours), the nurse must leave the room to retrieve the leveler from the medication room, causing a delay in care. CN 3 confirmed that the lack of sufficient levelers could result in potential delays in patient care and monitoring. During a review of Patient 7’s “Arterial Line Group,” flowsheet (document used to track clinical observations for Patients over time), dated 2/18/2025, the flowsheet indicated, an Arterial line was inserted for Patient 7 on 2/18/2025 at 7:53 a.m. and remained current. During a review of the facility’s policy and procedure (P&P) titled, “Monitoring Arterial Blood using a Pressure Transducer System, dated 2025, the P&P indicated: -“Level transducer (a pressure sensor that converts pressure into electrical signals) with the patient’s phlebostatic axis (an anatomical reference point at the fourth intercostal space at the mid-axillary line (an imaginary line that runs vertically down the torso from the armpit), used for accurate readings.” -“Level Transducer to the patient’s phlebostatic axis and zero transducers to atmospheric pressure (calibrating the transducer to eliminate the effects of ambient air pressure) each time the patient is repositioned to ensure accuracy and consistency of arterial BP (blood pressure) measurements.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI),” dated 3/22/2022, the P&P indicated, “The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually.” During a review of the facility’s policy and procedure (P&P) titled, “Standard of Nursing Practice,” dated 3/22/2022, the P&P indicated, “The Standards of Nursing Practice provide guidelines to our Registered Nurses (RN) and establish the framework for the evaluation of our practice. Standards are written in measurable terms and describe the responsibilities for which nurses are accountable. The American Nurse’s Association (ANA) has two distinct categories: Standards of Practice and Standards of Professional Performance ... The Standards of Practice describe a competent level of nursing care according to the critical thinking model known as the nursing process ...The standards of Professional Performance describe a competent level of behavior in the professional role that includes the following: Resource Utilization: The RN utilizes appropriate resources to plan, provide, and sustain evidence-based services that are safe, effective, and fiscally responsible.” 3. During a review of Patient 8’s “Operation/Procedure Report, dated 2/17/2025, the report indicated, Patient 8 was scheduled for a mitral valve (one of four valves in your heart that regulates blood flow) replacement. Patient 8 “past medical history include endocarditis (an inflammation of the inner lining of the heart chambers and heart valves) ...Patient (Patient 8) did undergo cardiology (the branch of medicine that deals with diseases and abnormalities of the heart) evaluation including an echocardiogram (a test of the action of the heart), which demonstrated evidence of severe mitral regurgitation (a valve in the heart, called the mitral valve, doesn’t close properly, allowing blood to leak backwards instead of flowing smoothly forward) with a flail posterior mitral valve leaflet (is a flap of tissue in the heart valve that opens and closes to allow blood to flow through the heart).” The report indicated an A-line was inserted to the wrist. During a concurrent observation and interview on 2/19/2025 at 12:05 p.m. with the Charge Nurse (CN 3, charge nurse responsible for overseeing ICU nursing staff) in the intensive care unit (ICU, ward that provides the critical care and life support for acutely ill and injured patients), in room ABC, on 2/19/2025 at 12:05 p.m., Patient 8 was observed with an Arterial Line (A-line, a catheter placed in an artery to monitor blood pressure and obtain blood samples) in the left wrist. There was no A-line leveler (a device used to ensure the A-line is correctly positioned for accurate blood pressure readings) in the room. CN 3 explained that the ICU only had two levelers available for all ICU patients. CN 3 said that each time a patient was repositioned (for bathing, hygiene care, wound care, transfer to chair or off the unit, and scheduled repositioning every two hours), the nurse must leave the room to retrieve the leveler from the medication room, causing a delay in care. CN3 confirmed that the lack of sufficient levelers could result in potential delays in patient care and monitoring. During an interview on 2/21/2025 at 7:30 p.m. with the Director of ICU (DIR) 2, DIR 2 confirmed that the ICU had only two levelers stored in the medication room and stated there should be one leveler per patient room. DIR 2 stated they were in the process of ordering more. During a review of the facility’s policy and procedure titled, “Monitoring Arterial Blood using a Pressure Transducer System, dated 2025, the P&P indicated: -“Level transducer (a pressure sensor that converts pressure into electrical signals) with the patient’s phlebostatic axis (an anatomical reference point at the fourth intercostal space at the mid-axillary line (an imaginary line that runs vertically down the torso from the armpit), used for accurate readings.” -“Level Transducer to the patient’s phlebostatic axis and zero transducers to atmospheric pressure (calibrating the transducer to eliminate the effects of ambient air pressure) each time the patient is repositioned to ensure accuracy and consistency of arterial BP (blood pressure) measurements.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI),” dated 3/22/2022, the P&P indicated, “The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually.” During a review of the facility’s policy and procedure (P&P) titled, “Standard of Nursing Practice,” dated 3/22/2022, the P&P indicated, “The Standards of Nursing Practice provide guidelines to our Registered Nurses (RN) and establish the framework for the evaluation of our practice. Standards are written in measurable terms and describe the responsibilities for which nurses are accountable. The American Nurse’s Association (ANA) has two distinct categories: Standards of Practice and Standards of Professional Performance ... The Standards of Practice describe a competent level of nursing care according to the critical thinking model known as the nursing process ...The standards of Professional Performance describe a competent level of behavior in the professional role that includes the following: Resource Utilization: The RN utilizes appropriate resources to plan, provide, and sustain evidence-based services that are safe, effective, and fiscally responsible.” 4. During a review of Patient 9’s “Face sheet,” dated 2/12/2025, the face sheet indicated, Patient 9 was admitted to the facility for gastrointestinal (GI, bleeding is bleeding in the digestive tract [is a long, continuous tube-like pathway through which food travels from the mouth to the anus, where it is broken down, absorbed for nutrients, and ultimately expelled as waste]). During a record review of Patient 9’s “Operative/Procedure Report,” dated 2/13/2025, the report indicated Patient 9 had a procedure to insert an A-line to the left wrist. During a concurrent observation and interview on 2/19/2025 at 12:05 p.m. with the Charge Nurse (CN 3, charge nurse responsible for overseeing ICU nursing staff) in the intensive care unit (ICU, ward that provides the critical care and life support for acutely ill and injured patients), in room ABC, on 2/19/2025 at 12:05 p.m., Patient 9 was observed with an Arterial Line (A-line, a catheter placed in an artery to monitor blood pressure and obtain blood samples) in the left wrist. There was no A-line leveler (a device used to ensure the A-line is correctly positioned for accurate blood pressure readings) in the room. CN 3 explained that the ICU only had two levelers available for all ICU patients. CN 3 said that each time a patient was repositioned (for bathing, hygiene care, wound care, transfer to chair or off the unit, and scheduled repositioning every two hours), the nurse must leave the room to retrieve the leveler from the medication room, causing a delay in care. CN 3 confirmed that the lack of sufficient levelers could result in potential delays in patient care and monitoring. During an interview on 2/21/2025 at 7:30 p.m. with the Director of ICU (DIR) 2, DIR 2 confirmed that the ICU had only two levelers stored in the medication room and stated there should be one leveler per patient room. DIR 2 stated they were in the process of ordering more. During a review of the facility’s policy and procedure (P&P) titled, “Monitoring Arterial Blood using a Pressure Transducer System, dated 2025, the P&P indicated: -“Level transducer (a pressure sensor that converts pressure into electrical signals) with the patient’s phlebostatic axis (an anatomical reference point at the fourth intercostal space at the mid-axillary line (an imaginary line that runs vertically down the torso from the armpit), used for accurate readings.” -“Level Transducer to the patient’s phlebostatic axis and zero transducers to atmospheric pressure (calibrating the transducer to eliminate the effects of ambient air pressure) each time the patient is repositioned to ensure accuracy and consistency of arterial BP (blood pressure) measurements.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment, Performance Improvement Plan (QAPI),” dated 3/22/2022, the P&P indicated, “The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and determine the number of distinct improvement projects annually.” During a review of the facility’s policy and procedure (P&P) titled, “Standard of Nursing Practice,” dated 3/22/2022, the P&P indicated, “The Standards of Nursing Practice provide guidelines to our Registered Nurses (RN) and establish the framework for the evaluation of our practice. Standards are written in measurable terms and describe the responsibilities for which nurses are accountable. The American Nurse’s Association (ANA) has two distinct categories: Standards of Practice and Standards of Professional Performance ... The Standards of Practice describe a competent level of nursing care according to the critical thinking model known as the nursing process ...The standards of Professional Performance describe a competent level of behavior in the professional role that includes the following: Resource Utilization: The RN utilizes appropriate resources to plan, provide, and sustain evidence-based services that are safe, effective, and fiscally responsible.””

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure two of two sampled staff (Registered Nurse [RN] 6 and Charge Nurse [CN] 5) were competent and able to implement hemodialysis (HD, the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency take off (a procedure to quickly disconnect a dialysis patient from the dialysis machine in a critical situation) procedure, in accordance with the facility policy and procedure regarding hemodialysis emergency take off procedure in case of emergency and when a hemodialysis nurse (HD nurse, a Registered Nurse who specialized performing hemodialysis) becomes incapacitated, for one of 30 sampled patients (Patient 13). This deficient practice had the potential to result in Patient 13 being left on hemodialysis machine running with no proper supervision and/or improperly disconnecting Patient 13 from the hemodialysis machine during an emergency, thus causing harm or even death during hemodialysis treatment. Findings: During a review of Patient 13’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/9/2025, the H&P indicated, Patient 13 was admitted to the facility with diagnoses including but not limited to bilateral lower extremities (both legs) cellulitis (an infection of the deeper layers of skin and the underlying tissue), hyperkalemia (a condition where the potassium [an essential mineral for nerve and muscle functions] level in the blood is abnormally high), and end stage renal disease (ESRD, a stage where the kidneys can no longer support the body’s needs for waste removal and fluid balance) on hemodialysis (HD, the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly). During a concurrent observation and interview on 2/19/2025 at 12:29 p.m. with Registered Nurse (RN) 6, in Patient 13’s room, Patient 13 was receiving hemodialysis with hemodialysis nurse (HDN [HD nurse, a Registered Nurse who specialized performing hemodialysis] 3) at bedside. RN 6 stated HDN 3 would stay with Patient 13 during hemodialysis. RN 6 also stated he (RN 6) did not know how to shut off the hemodialysis machine in case of the HD nurse passed out or became incapacitated. During an interview on 2/19/2025 at 12:31 p.m. with Charge Nurse (CN) 5, CN 5 stated nursing staff was not trained how to perform dialysis emergency take off procedure (a procedure to quickly disconnect a dialysis patient from the dialysis machine in a critical situation). CN 5 stated she (CN 5) would not touch the hemodialysis machine. During an interview on 2/19/2024 at 12:34 p.m. with the hemodialysis nurse (HDN 3), HDN 3 stated nursing staff should know how to clamp Patient 13’s dialysis tubing and turn off the hemodialysis machine in case of emergency. During an interview on 2/19/2024 at 12:40 p.m. with the Director (DIR 3) of Medical Surgical Unit (Med-Surg, general patient population hospitalized for various causes such as illness and surgery), DIR 3 stated nursing staff did not receive training with regards to dialysis emergency take off procedure. DIR 3 stated it would be a good opportunity to train the nursing staff. During a review of the facility’s policy and procedure (P&P) titled, “Dialysis Service,” dated 6/2023, the P&P indicated, “In the event of an emergency (power failure, earthquake, or fire) and the patient’s safety is of concern, the staff RN in the absence of the dialysis nurse will clamp the dialysis tubing, both tubes separately, closet to the patient turn off the dialysis unit (machine) and cut the tubing on the side closet to the dialysis unit (machine) beyond the clamps.””

“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: 46333 Based on interview and record review, the facility failed to follow its “Utilization of Safety Attendants for Patients” policy and procedure and the physician’s order to provide a bedside sitter (a trained individual, often a healthcare worker, assigned to provide continuous, one-to-one supervision of a patient to ensure their safety, especially if the patient is at risk for falls [a sudden, unintentional descent of a patient to the ground or another lower surface] , disorientation [the condition of having lost one’s sense of direction], or self-harm) for constant supervision for one of 30 sampled patients (Patient 1). This deficient practice resulted in Patient 1 experiencing a fall in the ICU on 11/28/2024, and a cardiac arrest (a sudden loss of heart function, leading to a lack of blood flow to the brain and vital organs) in the SDU (Step Down Unit, specialist hospital wards that serve as a transition point for patients who are no longer critically ill enough to remain in ICU but still require more intensive monitoring and care than a general ward can provide) on 12/11/2024, due to accidentally being disconnected from the Bilevel Positive Airway Pressure (BIPAP machine, a non-invasive ventilator that assist patients with breathing difficulties) machine. In addition, this deficient practice had the potential to place other patients with physician-ordered bedside sitters at risk for similar sentinel events (a patient safety event that results in death, permanent harm, or severe temporary harm) due to inadequate supervision. Findings: During a review of Patient 1’s “History and Physical (H&P, a documented comprehensive formal assessment by a healthcare provider who examines the patient and their presenting problem),” dated 11/25/2025, the “H&P” indicated, Patient 1 was brought in by ambulance from home and presented with tachycardia (an abnormally fast heart rate exceeding 100 beats per minute). The H&P also indicated that Patient 1 had a history of dementia (a disorder causing memory loss and confusion) and atrial fibrillation (a-fib, an irregular and often rapid heart rhythm that increases the risk of stroke [blood clot in the brain], heart failure [a condition where the heart muscle is weakened or stiff, making it unable to pump blood effectively], and other complications). The physical examination indicated : Neurological (relating to the nervous system, which includes the brain, spinal cord, and nerves): “Unable to assess mental status, patient unable to follow commands.” During a concurrent interview and record review on 2/19/2025 at 3:00 p.m. with the Director of Medical Surgical unit (DIR) 3, Patient 1’s “Nursing Documentation-Flowsheet (a form that records a patient’s clinical observations over time),” dated 11/28/2024, was reviewed. The flowsheet indicated, at 12:11 a.m., Patient 1 was “found on the floor, lying flat.” DIR 3 stated that Patient 1 did not have a sitter (a trained individual, often a healthcare worker, assigned to provide continuous, one-to-one supervision of a patient to ensure their safety, especially if the patient is at risk for falls [a sudden, unintentional descent of a patient to the ground or another lower surface] , disorientation [the condition of having lost one’s sense of direction], or self-harm) at this time (12:11 a.m. on 11/28/2024) and the cause of the fall remained unknown. During a concurrent interview and record review on 2/20/2025 at 10:00 a.m. with the Nurse Manager (MN) 3 of the Surgical Treatment Unit (STU, a hospital area where surgeries are performed and patients are cared for before and after), Patient 1’s Medication Administration Record (MAR), from 11/26/2024 through 11/28/2024, was reviewed. The MAR indicated, Patient 1 was started on continuous infusion of Precedex (dexmedetomidine, a sedation [a state of relaxation or drowsiness] used to reduce anxiety [an emotion that can feel like fear, or uneasiness] and agitation [feeling extremely restless, tense, or irritated] without suppressing breathing) on 11/26/2024 at 11:59 p.m., which continued until 12/11/2024, when Patient 1’s BiPAP (Bilevel Positive Airway Pressure machine, a non-invasive ventilator that assist patients with breathing difficulties) machine was accidentally disconnected. During an interview on 2/21/2025 at 1:00 p.m. with ICU Registered Nurse (RN) 1, RN 1 confirmed that Patient 1 was receiving continuous sedation with Precedex and was being monitored using the Richmond Agitation-Sedation Scale (RASS, is a 10-point scale used to assess a patient’s level of sedation or agitation, ranging from +4 [combative] to -5 [unarousable]), with a target RASS score of 0 to -2. RN 1 stated Patient 1 was at -1 (drowsy, a state of sleepiness and wakeness) on 11/28/2024. RN 1stated Patient 1 was high risk for falls and was left sleeping while RN 1 retrieved medications from the medication room. Upon returning, RN 1 found Patient 1 on the floor with other staff present. The fall was unwitnessed, and the reason for the fall was unknown. During a concurrent interview and record review on 2/20/2025 at 10:00 a.m. with the Nurse Manager (MN) 3, Patient 1’s “transfer Summary,” dated 12/6/2024, was reviewed. The summary indicated Patient 1 was transferred to the SDU (Step Down Unit, specialist hospital wards that serve as a transition point for patients who are no longer critically ill enough to remain in ICU but still require more intensive monitoring and care than a general ward can provide), on 12/6/2024. MN 3 confirmed that Patient 1 was transferred to SDU without a sitter. During a concurrent interview and record review on 2/20/2025 at 10:30 a.m. with the Nurse Manager (MN) 3, Patient 1’s “Clinical Note Nursing, was reviewed. The note indicated on 12/11/2024 at 1:30 a.m., the Telemetry Monitor Technician (MT, a healthcare worker who monitors a patient’s heart rate remotely) observed that Patient 1’s heart rate was at 30s and notified any RN to check on Patient 1. RN 9 found that Patient 1 had pulled out the BiPAP’s tubing resulting in a cardiac arrest (when the heart stops beating). Code Blue (a hospital emergency response for a patient in a cardiac arrest or respiratory arrest [when a person stops breathing or breathes inadequately]) was called, and Patient 1 was intubated (a medical procedure where a tube is inserted into the airway to assist with breathing) before being sent back to the ICU. During a concurrent interview and record review on 2/21/2025 at 2:30 p.m. with Registered Nurse (RN) 2, Patient 1’s electronic medical record (EMR, a digital version of a patient’s paper chart that contains their medical history) document titled, “Order,” report, dated 11/26/2024, was reviewed. The Order indicated the physician (MD 5) had ordered bedside sitter for Patient 1 from 11/26/2024 at 12:59 p.m. until 12/17/2024 at 1:02 a.m. RN 2 confirmed that there was no documented evidence that a sitter was monitoring Patient 1 on 11/28/2024, the date Patient 1 fell, or on 12/11/2024, when Patient 1 was accidentally disconnected from the BiPAP and went into cardiac arrest. During a review of the facility’s policy and procedure (P&P) titled, “Utilization of Safety Attendants for Patients,” dated 6/10/2022, the P&P indicated, “The purpose of this policy is to provide guidelines for safety attendant placement for patients with high risk behaviors, high fall risk, or other behaviors that place the patient at risk for injury... Safety attendant will accompany the patient at all times.””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure staff adhered to infection control and prevention practices when: 1. One of one sampled staff (Patient Access Representative [PAR1, acts as the first point of contact for patients at a healthcare facility, responsible for greeting them, registering them for appointments, verifying insurance information, collecting necessary paperwork, and generally managing the patient check-in process]) did not perform hand hygiene (the practice of cleaning one’s hands to remove dirt and germs by using soap and water or alcohol-based sanitizer) upon entry and exit from a patient’s room for one of 30 sampled patients (Patient 21), in accordance with the facility’s policy and procedure regarding hand hygiene. This deficient practice had the potential to result in the spread of germs and bacteria from Patient 21 to others including other patients, staff and/or visitors. 2. The facility’s one of one sampled contracted service staff (HDN 3) did not disinfect (killing germs and bacteria) one of three sampled hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) machine (HDM 2) with heat or bleach at the end of day use, after hemodialysis was completed for one of 30 sampled patients (Patient 16), in accordance with the contracted service’s policy and procedure and hemodialysis machine operator manual. This deficient practice had the potential to result in bacterial contamination within the hemodialysis machine and introduce bacteria to other patients’ bloodstream, who may end up using the same HD machine (HDM 2), thus causing infection from a hemodialysis treatment. Findings: 1. During a review of Patient 21’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/18/2025, Patient 21 was admitted to the facility with diagnoses including but not limited to urinary tract infection (UTI, an infection in any part of the urinary system), positive blood cultures (suggests a systemic infection requires prompt medical attention), and hypertension (high blood pressure). During a concurrent observation and interview on 2/19/2025 at 11:04 a.m. with the Clinical Educator (CED 2) of the Medical-Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery) Unit, outside Patient 21’s room, the Patient Access Representative (PAR 1- acts as the first point of contact for patients at a healthcare facility, responsible for greeting them, registering them for appointments, verifying insurance information, collecting necessary paperwork, and generally managing the patient check-in process) walked into Patient 21’s room without performing hand hygiene (the practice of cleaning one’s hands to remove dirt and germs by using soap and water or alcohol based sanitizer). PAR 1 later left Patient 21’s room without performing hand hygiene. CED 2 stated all staff were required to perform hand hygiene, “foam in and foam out (using alcohol-based hand sanitizer when entering and exiting of patient room),” upon entry and exit of a patient’s room. During an interview on 2/19/2025 at 11:08 a.m. with Patient Access Representative (PAR 1, acts as the first point of contact for patients at a healthcare facility, responsible for greeting them, registering them for appointments, verifying insurance information, collecting necessary paperwork, and generally managing the patient check-in process), PAR 1 stated she (PAR 1) forgot to “foam in and foam out” at Patient 21’s room. PAR 1 stated, “it was my fault. I forgot.” During an interview on 2/21/2025 at 7:08 p.m. with the Infection Prevention Manager (IPM), IPM stated the following: the facility followed World Health Organization (WHO)’s “5 Moments of Hand Hygiene.” Staff was required to perform hand hygiene upon entry and exit of a patient’s room. It was important to perform hand hygiene so no one would move germs from one patient to people including other patients, staff and/or visitors. During a review of the facility’s policy and procedure (P&P) titled, “Hand Hygiene,” dated 9/2024, the P&P indicated, “[the facility] recognizes that hand hygiene is the single most important measure for preventing and controlling infections. The medical center follows Centers for Disease Control and Prevention (CDC, agency that helps protect the public’s health) and World Health Organization (WHO) guidelines for hand hygiene the risk of infection from potential pathogens on the hands of healthcare workers (HCWs).” During a review of the World Health Organization (WHO) guidelines for hand hygiene titled, “Your 5 Moments for Hand Hygiene,” dated 5/2009, the guidelines indicated, “1. Before touching a patient ... clean your hands before touching a patient when approaching him/her ... 5. After touching patient surroundings ... clean your hands after touching any object or furniture in the patient’s immediate surroundings, when leaving - even if the patient had not been touched.” 2. During a review of Patient 16’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/11/2025, Patient 16 was admitted the facility with diagnoses including but not limited to acute renal failure (the sudden and rapid loss of kidney’s ability to filter waste and balance fluid in blood), acute (new onset) exacerbation (worsening of a disease or an increase in its symptoms) of congestive heart failure (CHF, a chronic condition in which a weakness of the heart leads to a buildup of fluid in the lungs), and electrolyte (minerals in the blood) abnormality. During an interview on 2/20/2025 at 2:59 p.m. with the Chief Executive Officer (HDD) of the Hemodialysis Contracted Service (HDC), HDD stated hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) nurses were responsible to use either heat or bleach at the end of day use to disinfect the hemodialysis machine to prevent infection and keep the machine clean per manufacturer’s guideline. During a concurrent interview and record review on 2/20/2025 at 3:15 p.m. with the Chief Executive Officer (HDD), Patient 16’s hemodialysis record titled, “Dialysis Nurses Notes (HD note),” dated 2/14/2025, was reviewed. The HD note indicated Patient 16 received hemodialysis on 2/14/2025 from 1:35 p.m. to 4:35 p.m. using HD machine (HDM 2). The HD note also indicated Hemodialysis Nurse (HDN 3) rinsed HDM 2 after hemodialysis was completed. HDD stated HDN 3 did not disinfect HDM 2 with heat or bleach at the end of hemodialysis treatment. During a concurrent interview and record review on 2/20/2025 at 3:20 p.m. with the Chief Executive Officer (HDD), hemodialysis machine (HDM 2)’s “Equipment Log Sheet (HD log),” dated from 2/12/2025 to 2/16/2025, was reviewed. The HD log indicated, Patient 16’s hemodialysis treatment was the last treatment for day (2/14/2025). The HD log also indicated next HD treatment was on 2/16/2025. HDD stated HDN 3 should have disinfected HDM 2 after completing hemodialysis for Patient 16 with heat or bleach. HDN 3 did not disinfect HDM 2 at the end of the day (2/14/2025). During a review of the facility’s policy and procedure (P&P) titled, “Dialysis Service,” dated 2/2020, the P&P indicated, “Each contracted dialysis service is responsible for serving, maintaining, and upgrading the equipment, including safety checks.” During a review of the facility’s hemodialysis contracted service (HDC)’s policy and procedure (P&P) titled, “Single Pass Dialysis Machine - Cleaning & Disinfection and Documentation,” dated 12/2024, the P&P indicated, “It is the policy of [the contracted service] to follow the cleaning and disinfectant procedures outlined below per manufacturer’s guidelines ... The single pass dialysis machine is to be heat or bleach disinfected at the end of each day (end of day per individual nurse assignment) when machine is used for treatment. Document cleaning and/or disinfection for every treatment in provided machine logbook.” During a review of the hemodialysis machine (HDM 2) manufacturer’s guidelines titled, “[brand] Hemodialysis Machine Operator’s Manual Rev P,” undated, the manufacturer’s guidelines indicated, “Heat Disinfect or Chemical/Rinse is recommended daily when the machine is used for treatment.” During a review of the facility’s contract agreement with the HDC titled, “Dialysis Services Agreement (HD contract),” dated 11/20/2023, the HD contract indicated, “1.5 Nursing Services ...Dialysis Company shall ensure ... said nursing personnel shall perform the following nursing services pursuant to this Agreement ... demonstrate responsible handling of waste, sterilization and disinfection of equipment.””

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 46238 Based on interview and record review the facility failed to ensure infection control policies and procedures regarding Employee Health Services were implemented when the facility failed to: 1. Ensure that one of two sampled Sterile Processing Technician (SPT 4, responsible for sterilizing and maintaining medical equipment and instruments), had completed a mandatory N-95 (a disposable mask that filters airborne particles) fit test (a procedure used to evaluate how well a respirator fits am individual, ensuring that it effectively filters out airborne particles to provide adequate respiratory protection), in accordance with the facility’s Employee Health Services Infection Prevention Policies and Employee health testing. This deficient practice had the potential to result in increased risk of exposure to airborne pathogens which could lead to infection for both the employee, the patients, and other staff. 2. Ensure that four of six employees (E1, E3, E4, E5) had annual screening for tuberculosis (TB, a chronic bacterial infection that primarily affects the lungs) infection by QuantiFERON laboratory test (a blood test used to detect latent or active tuberculosis infection by measuring the immune response to specific TB antigens), in accordance with the regulatory requirements set by the [State] Department of Public Health (DPH) regarding TB testing (checks to see if someone was infected with tuberculosis). This deficient practice increases the risk of tuberculosis transmission among staff, patients and visitors due to inadequate testing/monitoring. Findings: 1. During an interview on 2/21/2025 at 5:57 p.m. with the Director of Human Resources (DHR), the DHR stated that one personnel file for a Sterile Processing Technician (SPT 4, responsible for sterilizing [free of germs] and maintaining medical equipment and instruments) that was reviewed to ensure compliance with accepted Employee Health Infection Control Policies, had no current completed mandatory annual N-95 (a disposable mask that filters airborne particles) fit test on file (N-95 fit test determines if an N-95 respirator fits a person’s face and provides adequate protection). During the same interview on 2/21/2025 at 5:57 p.m. with the Director of Human Resources (DHR), the DHR stated that N-95 fit test was required for all employees upon hire and annually in accordance with the facility’s policy. During a review of the facility’s policy and procedure (P&P) titled, “Infection Control Guidelines for Sterile Processing Department,” dated 9/2023, the P&P indicated the following: The sterile Processing Department (SPD) is recognized as a high risk for infection prevention. To protect patients and other personnel from unnecessary exposure to potentially pathogenic organisms, Sterile Processing employees will be expected to abide by the following: I. Personnel are expected to comply with accepted Employee Health Services Infection Prevention Policies with particular emphasis to annual physician examination, Rubella immunity, and annual TB skin testing. III. Basic training in aseptic technique for all new sterile processing employees much be presented and documented. Personnel are expected to have general orientation to the hospital infection prevention program and periodic in-service of infection prevention policies and procedures. During a review of the facility’s policy and procedure (P&P) titled, “Pre-Employment Health and Physical Screening,” dated 3/24/2023, the P&P indicated that 12. Complete N-95 fit test and fit test questionnaire in accordance with the facility’s respiratory protection policy as defined by OSHA (Occupational Safety and Health Administration, federal agency that sets and enforces workplace safety standards) for all accepted post-offer candidates ... 2. During a review of the facility’s personnel files, four (4) out of six (6) employee ( E1, E3, E4, E5) health files reviewed had no annual tuberculosis (TB, a chronic bacterial infection that primarily affects the lungs) infection screening by QuantiFERON laboratory (lab) test (a blood test used to detect latent or active tuberculosis infection by measuring the immune response to specific TB antigens), in accordance with the regulatory requirements set by the [State] Department of Public Health (DPH). During a review of the four employee (E1, E3, E4, and E5) health files, the Health Files indicated the following: -E1 had last annual TB infection screening by QuantiFERON lab test done on 7/22/2022 and it was negative. -E3 had last annual TB infection screening by chest X-ray (a test that creates an image of lungs) done on 1/21/2016 and was negative. -E4 had last annual TB infection screening by QuantiFERON lab test done on 2/28/2023 and was negative. -E5 had last annual TB infection screening by QuantiFERON lab test done on 6/8/2021 and was negative. During an interview on 2/21/2025 at 6:20 p.m. with the Director of Human Resources (DHR), the DHR stated that the facility’s current practice was to screen employees for tuberculosis infection only upon hire and every four years thereafter. The DHR also stated that the practice for TB screening for employees with a positive history of TB screening is to verify the presence or absence of active tuberculosis infection by obtaining a chest Xray every 10 years. During an interview on 2/21/2025 at 6:20 p.m. with the Infection Prevention Manager (IPM), the IPM stated that the facility had been using a FLEX (a temporary modification or exemption allowed by the regulatory bodies that permits an alternative approach to standard protocols, in this case, for tuberculosis screening). The IPM then stated that the FLEX has expired, but the facility has applied for a new FLEX. However, it has not been approved yet. During a review of the tuberculosis (TB) testing [State] regulatory requirements, the guidelines for tuberculosis screening require an annual TB test that shall be done on those individuals with a previously documented negative tuberculosis test ... Less frequent testing for tuberculosis, but never less than every four years, may be adopted as hospital policy when documented in writing as approved by the Infection Control Committee, the medical staff and the health officer of the health jurisdiction in which the facility is located.”

“IC PROFESSIONAL TRAINING CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (iv) Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of infection prevention and control guidelines, policies, and procedures. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that personnel training and education on the practical applications of infection prevention and control guidelines, policies and procedures were provided, completed and documented when: 1. Proof of completion of annual competencies (specific set of skills, knowledge, and abilities required to perform job functions effectively and safely within a particular field) verification and completion of skills check for three of six sampled employee records (Sterile Processing Technicians- responsible for sterilizing [free of germs] and maintaining medical equipment and instruments [SPT 1, SPT 4], and Surgical Scrub technicians- assists the surgeon during surgical procedures [SST 1]), were found to be incomplete with missing signatures from a preceptor (provides supervision during training) to indicate/verify staff competency. This deficient practice had the potential to result in improper training which has the potential for patient safety risks due to improperly sterilized instruments, increased infection rates, etc. 2. Proof of completion of orientation (refers to the process of introducing new employees to an organization, including its policies, procedures, culture, and specific job responsibilities) upon hire, and access to oneSOURCE (a platform commonly used in healthcare settings to provide access to essential information, such as manufacturer’s instructions for use [IFUs], policy documents, and compliance-related materials) were not provided for one of one sampled employee (Sterile Processing Technician- responsible for sterilizing [free of germs] and maintaining medical equipment and instruments [SPT 4]). The facility was also not able to provide copies of completed orientation checklist for SPT 4 for surveyor review. This deficient practice had the potential to result in non-compliance with job related requirements due to lack of knowledge from training and inability to access resources which may lead to potential patient safety risks due to errors in cleaning and sterilization processes (free of germs) for surgical instruments. Findings: 1. During a concurrent interview and record review on 2/21/2025 at 5:35 p.m. with the Director of Education (DE) and the Manager of Education (MED), three employee files (Special Processing Technician- responsible for sterilizing [free of germs] and maintaining medical equipment and instruments [SPT 1, SPT 4,] and Surgical Scrub technician [SST 1]), were reviewed for professional competencies (the specific requirements and knowledge required to perform job functions effectively and safely). All competencies provided for the three employees (SPT 1, SPT 4, and SST 1) for the years 2023 and 2024 contained missing signatures that were required to be signed by the verifier of competencies upon evaluation. The DE was not able to provide a list of items required by the facility’s annual educational requirements and competencies for the Special Processing Department’s (SPD, a hospital department that cleans, disinfects [clean and safe for use], and sterilizes [free of germs] medical instruments and devices) employees and Surgical Scrub Technicians working in the Surgical Department (the area in a hospital where surgical procedures are performed, and where procedural staff must be properly trained and competent in their roles). During the same record review on 2/21/2025 at 5:35 p.m. with the Director of Education (DE) and the Manager of Education (MED), the Facility was not able to provide any pertinent documents regarding the employees’ required annual competencies and annual educational requirements (HealthStream assignments, educational and training modules or courses assigned to healthcare employees such as continuing education, compliance training, competency assessments that are essential for enhancing staff knowledge, skills and performance in their role) specific to the department of employment (SPD), including copies of employee competency records, and relevant policies. 2. During an interview on 2/21/2025 at 9:30 a.m. with the Sterile Processing Technician (SPT 4, responsible for sterilizing [free of germs] and maintaining medical equipment and instruments, and stores medical equipment), the SPT 4 stated the following: “I only had general orientation when I started working here (referring to the facility under survey) in November 2024. I was shown where everything is. There are no visual guidelines regarding what to do with instruments and how to clean them. Staff can look up the manufacturer guidelines by logging into a portal, called OneSource (a web-based solution allowing all healthcare departments and staff easy access to Instructions For Use [IFUs], cleaning protocols, service manuals, and Safety Data Sheets [SDS- a detailed document provided by a chemical manufacturer that outlines the properties, hazards, and safety precautions related to any chemicals used in the sterilization process]), but I am registry (staff personnel provided by a placement service on a temporary or on a day -to- day basis), and I don’t have access to OneSource. During a concurrent interview and record review on 2/21/2025 at 5:35 p.m. with the Director of Education (DE) and the Manager of Education (MED), the Sterile Processing Technician’s (SPT 4) employee file, was reviewed. SPT 4’s employee file contained no documented orientation with introduction to the facility’s policies, procedures, and specific job responsibilities. SPT 4’s file also contained no documented granted access to oneSOURCE upon the start work date of 11/27/2024. During a review of the facility’s policy and procedure (P&P), titled “Infection Control Guidelines for Sterile Processing Department,” dated 9/2023, the P&P indicated the following: The sterile Processing Department (SPD) is recognized as a high risk for infection prevention. To protect patients and other personnel from unnecessary exposure to potentially pathogenic organisms, Sterile Processing employees will be expected to abide by the following: Basic training in aseptic technique for all new sterile processing employees much be presented and documented. Personnel are expected to have general orientation to the hospital infection prevention program and periodic in-service of infection prevention policies and procedures.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 46238 Based on observation, interview and record review, the facility failed to ensure that the staff adhered to its policies and procedures regarding the reprocessing (the specific process of cleaning, disinfecting [the process of eliminating or reducing harmful germs on surfaces to a level that does not pose a risk of infection], and sterilizing [the process of completely destroying all forms of germs through methods ensuring that medical instruments and equipment are free from any living microbes (germs) before use] reusable medical equipment to ensure it is safe to reuse between patients) of surgical instruments and infection control (practices and procedures implemented to prevent the spread of infections by minimizing the transmission of germs in a healthcare setting) when: 1.Adhesive tape, placed in the decontamination room (the first stop for instruments that make it to the basement is the decontamination room, where the instruments are soaked and precleaned) in the sink, to measure the water fill amount (serves as an informal guideline for staff), was not replaced when it (adhesive tape) started showing signs of degradation (peeling, edges darkened and curling, and residue on the sink surface). This deficient practice had the potential for the tape residue to accumulate organic matter (biological material derived from living organisms, including blood, tissue, body fluids and can serve as a medium for microbial growth, interfering with the effectiveness of disinfection and sterilization processes) and bacteria (germs that can spread through contaminated surfaces, instruments, and improper infection control practices), which can facilitate the spread of bacteria through surfaces. 2.a. In a Gelpi retractor (a surgical instrument used for holding back tissue in a surgical procedure), the middle part of the instrument between each fork, referred to as the shank (the connecting section between the two pointed tips), it was observed with brown-colored deposits similar to rust (presence of rust on surgical instruments may compromise the integrity of the instrument and its sterility) after instrument was removed from a sterile total hip tray (a collection of instruments specifically prepared and sterilized for use during total hip replacement surgeries). This deficient practice had the potential to compromise the Gelpi retractor’s integrity and sterility, placing patients’ safety during surgical procedures at risk. 2.b. Two sterile instruments: the Narrow Deaver (a surgical retractor used to hold back tissue and provide access to deeper surgical sites), and the Sweetheart retractor (a surgical instrument used to hold back tissues and provide stability in the surgical field), inside a sterile major tray ( a tray containing a collection of essential instruments prepared and sterilized for surgical procedures), were found to have brown spots that left brown staining on the alcohol pad after cleaning. This deficient practice had the potential to result in compromised sterility of the instruments increasing the risk of infection for all the facility’s surgical patients. 3. Sterile packages (sealed containers that contain surgical instruments or supplies or use in sterile procedures, designed to maintain the sterility of their contents until they are opened for use, ensuring safety and minimizing the risk of infection) were not inspected quarterly (the scheduled review process to ensure compliance with established standards), in accordance with the facility’s policy. Additionally, audits of supplies and shelf life (the process of varying the expiration dates and integrity of medical supplies) was not performed and no orderly system of rotation of supplies in place for stored sterilized items was routinely conducted, in accordance with the facility’s policy regarding sterile package shelf-life. This deficient practice had the potential to increase the risk of infection for all patients undergoing surgical procedures when regular audits and inspections were not performed to ensure that all materials used in patient care meet regulatory standards. 4. An enzymatic solution (a cleaning agent specifically designed to break down organic material, such as blood, tissue, or other bodily fluids) in the decontamination process to facilitate the cleaning of surgical instruments, was not used in accordance with the manufacturer’s instructions for use (MIFU). This deficient practice had the potential to diminish the effectiveness in breaking down organic material leading to ineffective cleaning and sterilization of surgical instruments increasing the risk for surgical site infections and other complications with a potential to compromise patient safety and well-being. 5. Carts marked as biohazard (designated carts intended for the transportation of contaminated materials, that are handled in a manner that minimizes the risk of exposure to infectious agents), used for transportation of dirty and contaminated surgical instruments, were wiped down with a multi-enzymatic cleaner (formulated to breakdown organic matter such as blood, tissue, and other biological materials) and subsequently used for the transport of clean and sterile items. This deficient practice has the potential to compromise patient safety, increase surgical site infection and other healthcare associated infections for patients due to a potential for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) of sterile items. 6. A towel was observed to be positioned at the bottom of the tray within the sterile minor surgical tray packaging (minor tray is a sterile, single-use tray of instruments used for minor surgical procedures). This deficient practice had the potential to compromise the sterility of the instruments, (towels can harbor bacteria and may not be sterilized to the same standards), and compromise patient safety and well-being by increasing surgical site infections. 7. Log containing records of daily testing of ultrasonic machine (an ultrasonic cleaning device useful for washing hard-to-reach- areas on a medical device) to ensure that the device was functioning properly and effectively cleaning items by verifying the presence of cavitation (when proper cavitation is occurring, indicating the machine is generating sufficient ultrasonic energy to clean effectively), was not located. This deficient practice had the potential to harm surgical patients as there was no assurance that the ultrasonic machine had been properly maintained or functioning effectively, which could compromise the cleaning process for surgical instruments in the facility leading to increased risk of infections. 8. Updated preventive maintenance (PM) stickers (adhesive labels that indicate when maintenance has been performed on equipment, along with the next scheduled maintenance date) were not available for staff on equipment, such as washers, sterilizers, and other reprocessing equipment, in accordance with the facility’s policy regarding preventive maintenance. This deficient practice had the potential to pose risk to patient safety by using equipment that may not meet safety and performance standards. Findings: 1. During an observation on 2/18/2025 at 2:05 p.m. in the decontamination room (a designated area within the facility where contaminated surgical instruments and equipment are cleaned, disinfected [methods to eliminate or reduce harmful organisms], and prepared for sterilization [the process of eliminating all forms of microbial life, including bacteria, viruses, fungi, spores, from surfaces, instruments, or materials), three (3) sinks numbered (#) 1, 2, and 3 were observed. Sink # 2 was filled with blue colored solution. Adhesive tape was observed in sink # 2, attached to the side [surface] of the sink. The tape was observed showing signs of degradation, including peeling, darkened and curling edges, and residue on the sink surface. During an interview on 2/18/2025 at 2:13 p.m. with the Sterile Processing Technician -Lead (LSPT), the LSPT stated that sink 2 was used for enzymatic soak (a cleaning process involving immersion of surgical instruments in a solution containing enzymes that break down organic material such as blood and tissue to facilitate effective cleaning) with lukewarm water. The LSPT then stated that the tape was the marker for the water line, but it should be replaced as it does not look good and should have been replaced. During an interview on 2/21/2025 2:51 p.m. with the Infection Prevention Manager (IPM), the IPM stated the following regarding the adhesive tape residue in the sink: “The adhesive tape has been already replaced; it was used to define the fill line as a marker for the technicians to know how much water is required.” The IPM also stated that the facility follows the AAMI guidelines (Association for the Advancement of Medical Instrumentation guidelines) which provide standards and best practices for the cleaning, disinfection, and sterilization of medical instruments and then presented printed guidelines for the decontamination process, dated 2017. The IPM also stated they (the IPM) were not certified in Special Processing (systemic procedure of cleaning, disinfecting, sterilizing, and preparing surgical instruments and medical devices for safe use in healthcare setting). During a review of the Association for the Advancement of Medical Instrumentation (AAMI, is a nonprofit organization that develops standards and guidelines for the safe and effective use of medical devices and equipment, advocating for best practices in healthcare and medical technology) guidelines, titled “Standards of Sterilization,” dated 2021, the recommendation was for the sinks to be disinfected after each use. Additionally, AAMI guidelines emphasize that all surfaces should be kept clean and free from contaminants, including residues and materials that can harbor microorganisms. Regular cleaning and disinfection of sinks contribute to effective infection control practices and support sterilization process. 2.a. During an observation on 2/19/2025 at 3:22 p.m. in the central supply room in the Surgical Department a Gelpi retractor (a surgical instrument used for holding back tissue in a surgical procedure) was observed with brown-colored deposits like rust after the instrument was removed from a sterile total hip tray (a collection of instruments specifically prepared and sterilized for use during total hip replacement surgeries). During an interview on 2/19/2025 at 3:22 p.m. with the Director of Operative Services (Dir 1), the Dir 1 stated the following: “The brown deposit in the middle section of the Gelpi retractor could be rust. The water exposure can lead to damage of the instrument. When we identify issues like this one, the instrument gets treated by the contracted company that would either polish the instrument or replace it.” During an interview on 2/19/2025 at 3:26 p.m. with the Director of Operative Services (Dir 1), the Dir 1 stated that the reprocessing process (the systematic procedure of cleaning instruments for safe reuse) should begin with Sterile Processing Department (SPD), and the instruments should be checked by the Special Processing Technicians (SPTs). The last and final check was done in the operating room (OR) by the surgical scrub technician (a specialized technologist who assists the surgeon during procedures by managing instruments and ensuring a sterile environment), who can identify any issues and will tag the instrument and send it back to reprocessing. The Dir 1 then said that that the facility was also contracted with a company that comes every Thursday to inspect surgical instruments and their quality. During a review of the facility’s policy and procedure (P&P) titled, “Wrapped Packaging,” dated 12/6/2024, the policy indicated that the facility recognizes the important role of sterility... During a review of the facility’s policy and procedure (P&P) titled, “Sterilization of Equipment Supplies,” dated 9/27/2021, the policy indicated that sterile items must be received, stored, and distributed in a manner which ensure sterility and integrity. During a review of the Association for the Advancement of Medical Instrumentation (AAMI, is a nonprofit organization that develops standards and guidelines doe the safe and effective use of medical devices and equipment, advocating for best practices in healthcare and medical technology) guidelines titled, “Standards of Sterilization,” dated 2021, the guidelines indicated that steam sterilization cannot be assured unless proper cleaning of the device and reduced bioburden (define) and soil was achieved. Verification and documentation of automated cleaning processes through objective means is an important aspect of quality control. Cleaning encompasses the removal of organic residue and microorganisms from the patient, from handling, or from water exposure during reprocessing. Inspection using enhanced visualization tools such as lighted magnification and video borescopes might identify residues not observable by the unaided eye. 2.b. During an observation on 2/18/2025 at 4:35 p.m., in the Surgery Department, in the main Operating Room (OR), the major tray (a tray containing a collection of essential instruments prepared and sterilized for surgical procedures) was selected to be opened for an inspection of its contents: sterilized surgical instruments. Two sterile surgical instruments (the Narrow Deaver [a surgical retractor used to hold back tissue and provide access to deeper surgical sites], and the Sweetheart retractor [a surgical instrument used to hold back tissues and provide stability in the surgical field]) were inspected and observed with marks on both surgical instruments. During a concurrent observation and interview on 2/18/2025 at 4:38 p.m. with the Director of Operative Services (Dir 1), the Dir 1 was observed using an alcohol pad to wipe the brown marks on the surgical instruments (the Narrow Deaver [a surgical retractor used to hold back tissue and provide access to deeper surgical sites], and the Sweetheart retractor [a surgical instrument used to hold back tissues and provide stability in the surgical field]), were inspected and observed with marks on both surgical instruments. Brown staining of the alcohol pad was noted after Dir 1 cleaned the retractors. Dir 1 then stated that these instruments should not be used for patients in the operating rooms and should be sent back for reprocessing (a special process or treatment in preparation for reuse) due to the presence of brown stains. During an interview on 2/19/2025 at 3:26 p.m. with the Director of Operative Services (Dir 1), the Dir 1 stated that the reprocessing process (the systematic procedure of cleaning instruments for safe reuse) should begin with Sterile Processing Department (SPD), and the instruments should be checked by Special Processing Technicians (SPTs). The last and final check was done in the operating room (OR) by the surgical scrub technician (a specialized technologist who assists the surgeon during procedures by managing instruments and ensuring a sterile environment), who can identify any issues and will tag the instrument and send it back to reprocessing. The Dir 1 then said that that the facility is contracted with a company that comes every Thursday to inspect surgical instruments and their quality. During a review of the facility’s policy and procedure (P&P) titled, “Wrapped Packaging”, dated 12/6/2024, the policy indicated that the facility recognizes the important role of sterility... During a review of the facility’s policy and procedure (P&P) titled, “Sterilization of Equipment Supplies,” dated 9/27/2021, the policy indicated that sterile items must be received, stored, and distributed in a manner which ensure sterility and integrity. During a review of the Association for the Advancement of Medical Instrumentation (AAMI, is a nonprofit organization that develops standards and guidelines for the safe and effective use of medical devices and equipment, advocating for best practices in healthcare and medical technology) guidelines titled, “Standards of Sterilization,” dated 2021, the guidelines indicated that steam sterilization cannot be assured unless proper cleaning of the device and reduced bioburden (define) and soil was achieved. Verification and documentation of automated cleaning processes through objective means is an important aspect of quality control. Cleaning encompasses the removal of organic residue and microorganisms from the patient, from handling, or from water exposure during reprocessing. Inspection using enhanced visualization tools such as lighted magnification and video borescopes (optical devices used for inspection of areas that are otherwise difficult to access) might identify residues not observable by the unaided eye. 3. During an interview on 2/19/2025 at 10:30 am with the Sterile Processing Technician-Lead (LSPT), the LSPT stated that technicians from the Sterile Processing Department (SPD, a hospital department that prepares medical devices and instruments for use in surgical procedures), did not inspect stored sterile supplies and did not routinely conduct rotation of stored sterilized items. During an observation on 2/19/2025 at 2:41 p.m. in the central supply storage room (a designated area with controlled temperature and humidity, where sterile supplies, instruments, and equipment is organized, stored, and maintained), in the OR (Operating Room, the specialized area in the hospital where surgical procedures are performed), a Shunt Passer (a surgical instrument used to facilitate the placement of shunts or catheters), processed on 2/17/2024, was found in a sterile peel pack with a label (attached to the instrument, inside the sterile peel pack) containing printed physician’s name on it, along with another label reading a “Peritoneal Passer(a surgical instrument used to facilitate placement of catheters into the peritoneal [abdominal] cavity) right below the physician name’s sticker. During an interview on 2/19/2025 at 2:45 p.m. with the Nurse Manager for Operating Room (MOR), the MOR looked at the peel pack containing a Shunt Passer and stated the following: “There should not be any labels or tickers inside sterile packing on sterilized instruments.” During a concurrent observation and interview on 2/19/2025 at 2:45 p.m. with the Nurse Manager for Operating Room (MOR), a punctured peel pack (when a peel pack is punctured, it indicates that the sterility of the packing has been compromised, which can lead to potential contamination) containing a Hemlock clip applier (a surgical instrument used to apply clips to tissue during surgical procedures), processed on 1/14/2025, was found in the central supply room. The MOR stated that sharp instruments should have protectors, and perhaps the protector fell off, resulting in the instrument puncturing the peel pack. The MOR also stated that the punctured peel pack compromised the sterility of the instrument (Hemlock clip applier) and was no longer sterile. During a concurrent observation and interview on 2/19/2025 at 2:46 p.m. with the Nurse Manager for Operating Room (MOR), a peel pack containing a clip applier (a surgical instrument used to apply clips to tissue during surgical procedures), processed on 10/22/2018, was observed with red surgical tape and brown residue at the handle. The MOR stated that the tape and residue should have been removed during reprocessing (a special process or treatment in preparation for reuse) before being sterilized on 10/22/2018. During an interview on 2/19/2025 at 3:00 p.m. with the Manager of the Operating Room (MOR), the MOR stated that the facility’s policy regarding stored sterile packages (sealed containers that contain surgical instruments or supplies used in sterile procedures, designed to maintain the sterility of their contents until they are opened for use, ensuring safety and minimizing the risk of infection) indicated that sterile packages’ shelf life was indefinite if the temperature and humidity were maintained within range and sterile items have no tear in the package, then it should be okay to continue storing sterile packages. The MOR also stated there were no routine inspections conducted to inspect the integrity of sterile packages in sterile supply room and there was no log. During an observation on 2/19/2025 at 3:10 p.m. in the sterile supply room in the main OR, a peel pack containing skin hooks tray (a surgical instrument used to hold or retract skin), processed on 12/09/2022, were observed. Two hooks inside the tray contained attached instrument tape. The top of the tray contained blue adhesive tape, and a label with the handwritten name on it. During an interview on 2/19/2025 at 3:15 p.m. with the Director of Surgical Services (Dir 1), the Dir 1 stated that this sterile plastic peel pack containing a tray with skin hooks should not be used because sterility might have been compromised since the tape was not removed during reprocessing. During a review of the facility’s policy and procedure (P&P) titled, “Care and Cleaning of Instruments,” dated 9/2022, the P&P indicated that the guidelines for the care and cleaning of instruments in Sterile Processing require the instrument technician to use tip protectors before placing cutting instruments and knives into appropriate trays and place instruments into appropriate packaging ... During a review of the facility’s policy and procedure (P&P) titled, “Event-Related Sterile Package Shelf Life,” the P&P indicated the following: 6. Trays/supplies (in the central supply room) should be rotated with the “first in/first out” rule (is a management principle commonly used in inventory control that dictates that the first items placed in storage should be the first ones to be used, to ensure that items are used in the order they were received or processed). 9. Inspect all stored items quarterly to monitor compliance with this policy regarding storage and condition of the sterile product. This inspection will ne performed by the Qualified Special Processing technician. All packing that looks worn or handled will be discarded if disposable or returned to SPD for reprocessing if re-usable. 10. Document all the findings of the inspection on each departmental Environmental Rounds Report. Send a copy to SP who will report findings through their Quality Assurance (QA) quarterly report and to Infection Prevention who will report the findings at their meetings. 11. Evaluate all items found at inspection time to exceed 12 months of inactivity with the department head as to the need to maintain sterile. 14. Training will be interdisciplinary for persons responsible for handling storage, cleaning, and inspecting of sterile supplies. The training will be documented. During a review of the facility’s policy and procedure (P&P) titled, “Sterilization of Equipment Supplies,” dated 9/2021, the P&P indicated that 1. Sterile items must be received, stored, and distributed in a manner which ensures sterility and integrity. 2.An orderly system of rotation of supplies must be used so items stored first are used first. During a review of the facility’s policy and procedure (P&P) titled, “Manual Cleaning Process,” dated 9/2023, the P&P indicated that instrument tape and plastic dipping material, when used properly, are ways of identifying specific instruments. These types of marking products wear out over time and staff need to inspect them each time the instrument is processed and should be checked for wear according to the IFU of the product used. 4. During an observation on 2/18/2025 at 2:05 p.m. in the decontamination room (the designated area where soiled medical instruments were initially received, sorted, and cleaned of gross debris before further processing), a sink (sink number [#] two (2), was observed filled with light, blue-colored solution. During an interview on 2/18/2025 at 2:05 p.m. with the Sterile Processing Technician (SPT 1), the SPT 1 stated that the solution (the enzymatic cleaner, removes bioburden- refers to the quantity of live germs present on a surface, medical device, or material before sterilization [free of germs] or disinfection [clean]) was used for cleaning instruments to remove bioburden. The SPT 1 also stated that the SPT 1 would change the solution only when the solution gets dirty. During an interview on 2/21/2025 at 10:02 a.m. with the Sterile Processing Technician (SPT 4), the SPT 4 stated the following: “Sink # 2 is used for soaking and should not typically be used for scrubbing instruments. The point of soaking instruments is to reduce the bioburden or to loosen it up. I change the solution when it starts getting cloudy and drain the sink completely before going to lunch or a break. We don’t have any visual guidelines available for us in the decontamination room. The soaking should be for about 5 minutes. The solution for soaking has been changed twice since I started here, and I never got the guidelines for brushing either. I am registry (temporary hired worker) and I have started working here in November 2024. I have never received access to the facility’s portal where I can access all the manufacturer’s recommendations and instructions for use (IFUs, detailed guidelines provided by manufacturers on how to properly use and maintain medical devices and equipment).” During a review of the facility’s policy and procedure (P&P) titled, “Manual Cleaning Process: Inspection and Non-Submergible Items,” dated 9/2023, the P&P indicated the following: A. Sterile processing and Operating Services staff are to follow manufacturer recommendation to properly decontaminate contaminated non-submersible items (any object that cannot be fully submerged in water during the cleaning process). 3. Clean luminated items with a brush of the recommended type, size, material, cleaning solution. 9. Change the solution after every use. During a review of the Association for the Advancement of Medical Instrumentation (AAMI, is a nonprofit organization that develops standards and guidelines doe the safe and effective use of medical devices and equipment, advocating for best practices in healthcare and medical technology) guidelines titled, “Standards of Sterilization,” dated 2021, the guidelines indicated that 7.4.1.c. To begin decontamination process as soon as possible after the items have been used. 7.4.1.h. The importance of using a cleaning solution compatible with the device and following manufacturer’s cleaning guidelines for proper dilution, concentration, and contact time. 7.4.1.i. Before manual cleaning, the cleaning solution should be ensured to be clean and changed when appears soiled, which could be after one use. 7.6.4.2.i. Monitor the water temperature as required in the manufacturer’s written IFUs; Change the solution after every use (a use should be defined in the health care facility’s policies and procedure). During a review of the facility’s policy and procedure (P&P) titled, “Manual Cleaning Process: Inspection and Washing of Submersible Instrumentation,” dated 9/2023, the P&P indicated the following: A. 2nd sink: all items that are deemed submersible by manufacturer’s written instructions should be submerged in 2nd sink with enzyme solution. Follow manufacturer written instructions for use (IFU) which indicate the amount of contact time required between the submersible instruments in the 2nd sink with enzyme solution. IV. 1. Instruments with dried blood, bone pieces and debris should be presoaked in 1st sink with enzymatic solution following IFUs. During a review of the Association for the Advancement of Medical Instrumentation (AAMI, is a nonprofit organization that develops standards and guidelines doe the safe and effective use of medical devices and equipment, advocating for best practices in healthcare and medical technology) guidelines titled, “Standards of Sterilization,” dated 2021, the guidelines indicated that the healthcare organization should establish policies and procedures for all methods of cleaning and decontamination of reusable items. Process audits to monitor compliance with the various policies and procedures should be performed on a scheduled basis, with appropriate follow-up to address problems. Additionally, the device manufacturer’s current written instructions for Use (IFUs) should be accessible, reviewed, and followed. 5. During an interview on 2/18/2025 at 2:05 p.m. with the Infection Prevention Manager (IPM), the IPM stated the following: “Surgical instruments are transported from OR (Operating Room, area where surgical procedures take place) to decontamination room (a specific section or designated space where contaminated or soiled items are received, sorted, and prepared for the decontamination process). Clean instruments are transported in the same cart that is used for dirty instruments ...Technicians clean the carts with wipes and re-use the same carts for transporting clean instruments and then sterile instruments ...” The IPM then said, “it’s an acceptable practice, there is no facility policy regarding this practice.” During a concurrent observation and interview on 2/19/2025 at 11:11 a.m. with the Sterile Processing Technician-Lead (LSPT), the LSPT demonstrated a cart (a cart with enclosed compartments and secure doors that transports surgical instruments and supplies) that would typically be used for the transport of dirty instruments from the Operating Room (OR) to the decontamination room. The LSPT also demonstrated how the biohazard sign (a biological material or substance that can cause disease or illness in humans) on top of the cart can be switched to a clean cart sign whenever necessary. The LSPT also stated that the same cart(s) is(are) used for the transport of clean/sterile instruments ; the cart will have to be cleaned with [Brand] enzymatic solution (a cleaning product that contains enzymes to break down stains and soils) before re-use and then the sign will be changed to “clean cart” on top, allowing the cart to be used for the transport of clean and sterile instruments. During the same interview on 2/19/2025 at 10:27 a.m. with the Sterile Processing Technician-Lead (LSPT), the LSPT was not able to provide information regarding the enzymatic [Brand] wipes used for cleaning carts. During an interview o 2/20/2025 at 3:11 p.m. with the Infection Prevention Manager (IPM), the IPM stated that carts used for transport of dirty and clean/sterile instruments can be reused once they are cleaned with bleach (disinfectant that kills germs) in between use. The IPM then stated that questions regarding cleaning carts should be addressed to the SPD (Sterile Processing Department, the area in a hospital where cleaning and sterilization of devices used in medical procedures takes place) manager or director. During a review of the facility’s policy and procedure (P&P) titled, “Instruments, Scopes, and Equipment Processing, dated 10/2021, the P&P indicated the following regarding A. Handling of sterile instruments and supplies: all wrapped sterile instrument trays and supplies processed in Special Processing Department (SPD) will be transported to the OR in a covered cart after the sterilization process is completed and the packages are dry and properly labeled. Covered carts will be used for transport and ONLY sterile items will be placed and transported on these carts. Never any soiled or dirty items. B. Handling of used instruments: Operating Room (OR) case carts will be used to transport contaminated instruments to the decontamination room in the Operating Room. The cart will be wiped down with germicidal solution (a substance that kills germs, like bacteria and viruses, that can cause disease) after it is unloaded in the instrument room and before being re-used. During a review of the facility’s policy and procedure (P&P) titled, “Containment and Transport of Soiled Items,” dated 9/15/2023, the P&P indicated that: all container or carts used for containing contaminated items be marked with a biohazard label ...Containers with biohazard labels are to be dedicated for soiled transport and storage. Soiled biohazard labeled containers are never to transport clean equipment. Soiled case carts must be cleaned after each use. Transportation equipment/carts should be disinfected after each use. Decontamination of transportation equipment after each use helps prevent cross-contamination of items transported at a later time. 6. During an observation on 2/18/2025 at 4:25 p.m., a sterile minor surgical tray packaging (minor tray is a sterile, single-use tray of instruments used for minor surgical procedures) was inspected by the Director of Surgical Services (Dir 1). The Dir 1 was observed to open a sterile (free of living microorganisms, viruses, or germs) minor surgical tray, and a green towel was observed at the bottom of the tray with instruments laid on top. During a concurrent observation and interview on 2/19/2025 at 10:27 a.m. with the Administrative Director (AD) and the Sterile Processing Technician-Lead (LSPT), in the Assemble Room (a designated area where surgical instruments and supplies are organized, assembled, and prepared for sterilization [the process of eliminating all living microorganisms from an object or surface] and subsequent use in surgical procedures), surgical tray preparation for sterilization, was observed. Multiple trays were observed to contain green towels (a type of fabric used to cover and wrap surgical instruments and trays to provide protection and maintain sterility during surgical procedures) covering the trays with surgical instruments on top. The AD stated that trays that lack a liner (a protective material or insert, such as sterile wrap, intended to create a barrier between the instruments and the tray, ensuring proper sterilization and preventing contamination) must be wrapped with green towels to protect the instruments. Both the AD and the LSPT said that they were not aware if this practice (using green towels to cover trays) was in accordance with the facility’s policy and procedures. During an interview on 2/19/2025 at 3:42 p.m. with the Director of Surgical Services (Dir 1), the Dir 1 stated that the facility still uses green towels to wrap trays. The Dir 1 also said that the facility was in the process of obtaining more cushioning for instruments (materials designed to provide protective padding around surgical instruments during transportation and sterilization, which helps prevent damage and proper sterilization). During a review of the facility policy and procedure titled, “Instruments, Scopes, and Equipment Processing,” dated 10/26/2021, the policy indicated that all trays will be prepared and placed directly in the wire basket provided with the Sterile Container System. No TOWELS or foam will be used in the bottom of the tray. Instrument room personnel will sign and date the bottom of the menu sheet before placing it on the tray. During a review of the Association for the Advancement of Medical Instrumentation (AAMI, is a nonprofit organization that develops standards and guidelines doe the safe and effective use of medical devices and equipment, advocating for best practices in healthcare and medical technology) guidelines titled, “Standards of Sterilization,” dated 2021, the guidelines indicated that healthcare facilities should follow established protocols for sterilization and instrument preparation, which may include the use of approved materials and methods. 7. During a concurrent observation and interview on 2/18/2025 at 2:24 p.m. in the decontamination room (a designated area within a healthcare facility where contaminated surgical instruments are cleaned and processed for sterilization), with the Sterile Processing Technician (SPT 1), the ultrasonic machine (use powerful sound waves to create cavitation (formation of vapor bubbles) capable of removing residual soils from complex instruments), was observed to finish the cycle, called the Da Vinci Cycle (or also known as Cycle 1, a cleaning cycle designed to run for 30 min and used for specific instruments). SPT 1 stated that the load the machine just finished cleaning had the wrong cycle selected earlier and said the instruments now need to be cleaned on Cycle 4, which is used for general instruments and runs for about 15 min. The SPT 1 then said that the machine had been set for Cycle 1 about a month ago because the machine was down and had to be re-programmed by Biomed (the biomedical engineering department responsible for maintaining and calibrating medical equipment) who oversaw it. During an interview on 2/18/2025 at 2:32 p.m. with the Sterile Processing Technician -Lead (LSPT), the LSPT stated that the ultrasonic machine (a cleaning device that uses high frequency sound waves to remove contaminants from surgical instruments) must be tested daily (a test solution that is inserted inside the machine to assess for color changes in the solution after the test and to ensure that the ultrasonic cleaning process effectively utilizes cavitation [powerful cleaning effect, helping to dislodge dirt, debris, and contaminants from surfaces] to decontaminate and clean instruments properly by examining the changes in dosimeters [testing solution] after a cleaning cycle, operators can gauge the effectiveness of the cavitation process]), by the graveyard shift (the overnight work shift), but the log (to validate that testing was done daily) was nowhere to be found. During an interview on 2/18/2025 at 2:32 p.m. with the following staff: Sterile Processing Technician -Lead (LSPT) and Sterile Processing Technician (SPT 1), in the decontamination room, the staff was not able to answer questions about the ultrasonic machine, including how it worked, what the daily tests were for, and where the log for the daily testing was located. During a review of the Operator Manual for [Brand] Ultrasonic Washer (no date), the manual indicated that all personnel operating or maintaining the Ultrasonic Cleaning Systems are fully trained in equipment operation and safe use. During a review of the Association for the Advancement of Medical Instrumentation (AAMI, is a nonprofit organization that develops standards and guidelines doe the safe and effective use of medical devices and equipment, advocating for best practices in healthcare and medical technology) guidelines titled, “Standards of Sterilization,” dated 2021, the guidelines indicated that 7.6.4.4.1.Ultrasonic cleaning equipment should be cleaned every day that it is used, according to the manufacturer’s written IFUs. b. Cavitation testing daily should be done whenever the equipment is in use. 7.6.4.5. Mechanical cleaning equipment performance should be tested each day it is used, and all results should be recorded. 8. During an observation on 2/18/2025 at 2:24 p.m. in the decontamination room (a designated area within a healthcare facility where contaminated surgical instruments are cleaned and processed for sterilization), the ultrasonic washer (the cleaning system uses ultrasonic energy to thoroughly wash by removing tissue, blood, and other contaminants), was observed. The ultrasonic washer had no Preventive Maintenance (PM) sticker with a date that would indicate when the next scheduled PM was due. During an interview on 2/18/2025 at 2:32 p.m. with the Sterile Processing Technician -Lead (LSPT), the LSPT stated that preventive maintenance of the equipment should be monitored by the company and then stated: “We do not monitor PMs.” During an interview on 2/18/2025 at 2:34 p.m. with the Sterile Processing Technician -Lead (LSPT), the LSPT stated that Clinical Engineering checks on all electrical equipment safety and does maintenance checks. The LSPT then pointed out to the barcode attached to the ultrasonic washer and stated: “These are scannable (barcodes), scan the barcode and it will show when it [PM] was done last.” During a concurrent observation and interview on 2/18/2025 at 2:36 p.m. with the Sterile Processing Technician -Lead (LSPT), the Washer number (#) 1 and Washer #2, were observed in the decontamination room. The PM stickers on both washers (1 and 2) indicated that PMs were due on 5/2024. The LSPT then stated the PMs were done annually for washers and preventive maintenance for both was scheduled this month [February 2025]. During an interview on 2/18/2025 at 2:55 p.m. with the Clinical Engineer (CE), the CE stated that the ultrasonic machine should contain a sticker from the vendor company to indicate when the next preventive maintenance (PM) was due. During a review of the Operator Manual for [Brand] Ultrasonic Washer, (no date), the manual indicated that a thorough t preventive maintenance program was essential for safe and proper unit operation. The manual contained comprehensive instructions for monthly, quarterly, and semi-annual preventive maintenance. During a review of the facility’s policy and procedure (P&P) titled, “Equipment Safety-Maintenance,” dated 3/28/2024, the policy indicated that electrical equipment safety and maintenance checks are conducted by Clinical Engineering; Contracted service for equipment maintenance checks is Facilities. In order to assure equipment safety, all electrical equipment shall be checked and tagged by Clinical Engineering. Nursing will help identify (PM) stickers that have expired and call Clinical Engineering to re-check.”