Dominican Hospital

“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: 49345 Based on interview and record review, the hospital failed to comply with Conditions of Participation for Nursing Services as evidenced by: Failure to follow its Policy and procedure (P&P) entitled “Foley Removal Process” when nursing staff did not ensure foley catheter (a device that drains urine from the urinary bladder into a collection bag outside of the body, held by a fluid-filled balloon inside the urinary bladder) tip was intact after traumatic removal by Patient 6. (Refer to A-0395) The cumulative effect of this deficient practice resulted in the facility’s inability to ensure the provision of quality health care. Patient 6 was discharged with an incomplete foley catheter in the body.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 49345 Based on interview and record review, the hospital failed to comply with Conditions of Participation for Emergency Services as evidenced by: Failure to follow its Policy and Procedure (P&P) titled “Discharge and Follow Up from the Emergency Department” when the Emergency Physician did not check the CT Scan (Computed Tomography, an imaging study) Final Report prior to discharge (Refer to A-1104). The cumulative effect of this deficient practice resulted in inability to ensure the provision of quality health care. Patient 6 was discharged with a retained severed foley catheter inside the urinary bladder.”

“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: 49345 Based on interview and record review, the hospital failed to ensure a Registered Nurse (RN) followed its Policy and procedure (P&P) entitled “Foley Removal Process” for one (Patient 6) out of 30 sampled patients when the RN did not properly assess Patient 6 after a traumatic removal of an indwelling foley catheter (a device that drains urine from the urinary bladder into a collection bag outside of the body, held by a fluid-filled balloon inside the urinary bladder). This failure resulted in Patient 6 being discharged with an incomplete foley catheter in the body and subsequent visit to the hospital and urinary tract infection (UTI, an infection in any part of the urinary system). Findings: A review of Patient 6’s medical records indicated an admission date of 5/28/25 and discharge date of 6/5/25. Patient 6 underwent spinal fusion and instrumentation surgery (a surgical procedure used to correct problems with the small bones in the spine) on 5/28/25. A review Patient 6’s Surgical Documents on 1/28/26 at 3 p.m. with the Director of Patient Safety (DPS) indicated, foley catheter (a soft, flexible, indwelling tube inserted through the urethra [tube through which urine leaves the body] into the bladder to continuously drain urine into a collection bag, it is held inside the bladder by a balloon filled with water) was inserted on 5/28/25 at 8:30 a.m. with 10 ml (milliliter, a unit of measurement) sterile water for balloon inflation by RN B. Review of Patient 6 Nurses Notes dated 5/29/25 indicated, “ ...Pt [patient] pulled out foley and IV [intravenous line] at 1400 with restraints on..” During an interview with the Director of Nursing (DON) on 1/26/26 at 1:17 p.m., the DON reviewed the above Nurses Notes and verified there was no documentation that foley catheter tip was intact after removal. The DON also verified there was no documentation if there was a trauma on the site after Patient 6 pulled out his foley catheter. The DON stated the nurse should have looked at the tip of the foley catheter after removal to ensure all parts were intact. The DON verified there was no documentation of other foley catheter insertion order or reinsertion attempts after Patient 6 removed his catheter. The DON also verified, Patient 6 was discharged to a Skilled Nursing Facility (SNF) on 6/5/25 and stated Patient 6 did not get a foley catheter insertion during his stay in the SNF. During an interview on 1/28/26 at 1:43 p.m. with RN A, RN A stated she was on her break when Patient 6 pulled out his foley catheter on 5/29/25 and another nurse was with Patient 6. RN A also stated she could not remember if she checked or saw the foley catheter after removal. RN A stated it should be documented if the foley catheter was intact after removal. RN A stated there was approximately 10 ml of fluid inside the catheter balloon and there would be bleeding and trauma on the site if all components of the foley catheter were forcefully removed by a patient. RN A stated she could not recall if Patient 6 had complaints after the incident. RN A verified she did not see and document any trauma on Patient 6’s male genitalia after forceful removal of the foley catheter. During an interview with the Director of Patient Safety (DPS) on 1/30/26 at 9:25 a.m., the DPS stated, Patient 6’s surgeon reported on 12/1/25 that a Urologist (a doctor who specializes in urinary and male reproductive system) discovered and removed a severed foley catheter from Patient 6. A review of Patient 6’s ED (Emergency Department) Physician Notes indicated, Patient 6 was admitted to ED on 7/13/25 at 2:17 a.m. with chief complaint of rectal pain. A CT scan of Abdomen and Pelvis was done for Patient 6 in ED on 7/13/25 and the final report indicated, “ ...Pelvic Organs: Mild fat stranding and thickening of the bladder wall [ bladder muscle is not thin and smooth as it should be, but rather swollen]. Foley catheter is in appropriate position, and terminates within the bladder lumen [the empty, hollow, inside space of the bladder where urine collects and sits] ...” Patient 6 was observed without external foley catheter during this ED visit and was discharged home with a diagnosis of UTI and was prescribed antibiotics. No foley catheter was removed from Patient 6 in ED on 7/13/25. A report sent by the hospital to the Department on 12/5/25 indicated, “ ...the patient’s surgeon was informed that the patient’s Urologist [a doctor who specializes in urinary and male reproductive system] discovered and removed a severed Foley Catheter ...On 12/1/25 the surgeon reported the event to Quality ...” Review of the UpToDate (an online medical reference) article “Placement and management of urinary catheters in adults” updated 12/4/24 indicated, “ ...Accidental or traumatic removal- If an indwelling urinary catheter is accidentally removed (often by the patient), it can be gently replaced if there is no blood at the meatus. However, if there is blood at the meatus or if there is resistance upon reinserting the catheter, the reinsertion attempt should be aborted and urologic consultation requested ...” A review of hospital’s Staff RN II Job Description dated 6/16/25 indicated, “ ...RN is responsible for supporting efforts to improve clinical and service excellence of patient care provided ...” A review of hospital’s undated Policy and Procedure (P&P) entitled “Foley Removal Process”, the P&P indicated, “ ...9. Catheter removal: ...b. Pull catheter out smoothly and slowly. Examine it to ensure that it is whole and that tip is intact ...Rationale A nonwhole (not intact) catheter means that pieces of catheter may still be in the bladder. Notify health care provider immediately ...””

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 49345 Based on interview and record review, the hospital failed to ensure that medical staff had continuing assessment of the medical care provided in the emergency department when one (Patient 6) out of 30 sampled patients was discharged with a retained foreign object inside the body. This failure had the potential to put Patient 6 at risk for severe infection, injury to the body organs, and physiological distress. Findings: A review of Patient 6’s ED (Emergency Department) Physician Notes dated 7/13/25 and verified by Emergency Department Doctor (ERMD) on 7/14/25 at 1:29 p.m. indicated, Patient 6 was admitted to ED on 7/13/25 at 2:17 a.m. with chief complaint of rectal pain. A CT Scan of Abdomen and Pelvis was done on 7/13/25. A review of Patient 6’s Final Report of CT scan (Computed Tomography, an imaging study) of Abdomen and Pelvis dated 7/13/25 indicated, “Pelvic Organs: Mild fat stranding and thickening of the bladder wall [ bladder muscle is not thin and smooth as it should be, but rather swollen]. Foley catheter is in appropriate position, and terminates within the bladder lumen [the empty, hollow, inside space of the bladder where urine collects and sits]..” Further review of the final report of the CT scan did not indicate the foley catheter in the “Impression [findings].” During an interview with the Chief Medical Officer (CMO) on 1/26/26 at 2:43 p.m., the CMO verified the ERMD was the physician who admitted and discharged Patient 6 in the ED on 7/13/25. The CMO also verified that the ERMD did physical assessment/exam for Patient 6 on 7/13/25 and there was no documentation of a foley catheter externally noted on Patient 6. The CMO also verified, the CT scan Final Report was available prior to Patient 6’s discharge. The CMO stated the ERMD should have read the whole Final Report of the CT scan prior to discharging Patient 6 and noticed the presence of the foley catheter in the bladder when Patient 6 had no external foley catheter during physical exam. The CMO verified Patient 6 was discharged from the ED by the ERMD on 7/13/25 at 6:30 a.m. with an incomplete foley catheter inside the body, a diagnosis of Urinary Tract Infection (an infection in any part of the urinary system) and was sent home with a prescription of cephalexin (an antibiotic used to treat various bacterial infections). During an interview with the Director of Patient Safety (DPS) on 1/30/26 at 9:25 a.m., the DPS stated, Patient 6’s surgeon reported on 12/1/25 that a Urologist (a doctor who specializes in urinary and male reproductive system) discovered and removed a severed foley catheter from Patient 6. The Department received a report from the provider on 12/5/25. The report indicated Patient 6 was admitted to the hospital on 5/28//25 and a foley catheter was inserted peri-operatively. On 5/29/25 Patient 6 “pulled out” his own foley catheter. The report further indicated that on 7/13/25 Patient 6 went to the ED and CT scan was performed identifying a Foley Catheter was in place while Patient 6 not having a Foley catheter. A severed Foley catheter was discovered and removed by Patient 6’s Urologist. A review of hospital’s policy and procedure (P&P) entitled, “Bladder Management” effective 11/22/21, the P&P indicated, “ ...3. Indwelling urinary catheters [IUC] shall be inserted only when less-invasive methods are ineffective and removed as soon as possible to prevent catheter -associated urinary tract infections (CAUTIs) ...4. The IUC must be removed when the patient no longer has an appropriate indication ...” A review of hospital’s policy and procedure (P&P) entitled, “Discharge and Follow Up from the Emergency Department” dated 12/28/26, the P&P indicated, “Purpose to ensure that all patients discharged will have appropriate follow-up care reviewed/discussed with them prior to discharge ...Every patient seen in the Emergency Department (ED) must have a plan for follow-up care as needed ...Procedure When possible, both the ED Provider, and the RN [Registered Nurse] are responsible for the patient and should both be present with the patient, and conduct the discharge together. 1. Obtain competent patient record with follow-up plan indicated on chart 2. Verify all orders have been carried out and signed off ...6. Provide Radiology contact telephone number (####) for patient to obtain copies of Radiology studies if applicable ...At the discretion of the ED physician, occasional patients will be provided an electronic copy of Radiology studies ...””

“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: 44733 Based on interview and record review, the hospital failed to comply with the Condition of Participation for Nursing Services as evidenced by: Failure to follow its Policy and procedure (P&P) titled “Bladder Management Protocol” when: (1) nursing staff did not remove the betadine sponge swab after the indwelling urethral catheterization (IUC, known as a foley catheter, a flexible tube inserted into the bladder to drain urine) and (2) there was no physician order for the IUC (Refer to A-398). The cumulative effect of these deficient practices resulted in the facility’s inability to ensure the provision of quality health care. Patient 7 had retained a betadine sponge swab after the indwelling urethral catheterization.”

“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: 44733 Based on interview and record review, the hospital failed to ensure a Registered Nurse (RN) followed its policy and procedure (P&P) titled, “Bladder Management Protocol” for one of 31 sampled patients (Patient 7), when the RN assigned to insert an indwelling urethral catheter (IUC, known as a foley catheter, a flexible tube inserted into the bladder to drain urine) to Patient 7 failed to follow the urethral catheterization procedure per policy, and there was no physician order for the insertion of the IUC. These failures resulted in Patient 7 having a retained betadine sponge swab inside the female private area after an indwelling urethral catheterization. FINDINGS: Review of Patient 7’s History and Physical (H&P), dated 3/28/25, the H&P indicated, “Chief Complaint: chest pain. History of Present Illness: 67 year old women with history of obesity (a disorder that involves having too much body fat), TIAs (transient ischemic attack, known as mini stroke), migraines (a headache of varying intensity), HTN (hypertension, high blood pressure), hypercalcemia (high calcium level in the blood), HDL (high density lipoprotein, a good cholesterol), OA (osteoarthritis, a common joint disorder).” The H&P indicated, “Assessment/Plan: 1. NSTEMI (non-ST-segment elevation myocardial infarction, a type of heart attack), admit to cardiac tele, cardiology consultation pending.” Review of Patient 7’s Intensive Care Unit (ICU) flowsheets, it indicated, “Urethral indwelling catheter: insert new” on 3/30/25. Review of Patient 7’s physician orders, there was no physician order for the indwelling urethral catheter insertion. During an interview with the ICU Assistant Manager (AM) on 6/18/25 at 11:08 a.m., she stated RN A inserted a foley catheter on 3/30/25 as preparation for the scheduled surgery, and the betadine sponge swab was found in Patient 7’s vaginal opening at the OR (operating room) on 3/31/25. The ICU AM stated RN A stated during her interview that she used the betadine sponge swab to mark the area for the Foley catheter insertion and forgot to remove it after the foley catheter insertion. The ICU AM acknowledged the betadine sponge swab should be used to clean the area prior to insert Foley catheter and be removed and discarded after use. Review of Patient 7’s Nursing Progress Note by the ICU AM dated 4/3/25, the note indicated, “I disclosed to her the inadvertent retention of a foreign body discovered and removed Monday 3/31. I explained the process, rational and intentions for exchanging her Foley catheter on Sunday 3/30 and that the nurse accidentally left a prep swab in her vaginal opening that was then discovered Monday morning when she went to surgery.” Review of Patient 7’s Operative Report dated 3/ 3I /25, the report indicated, “Procedures performed: Coronary artery bypass grafting (CABG, a surgical procedure used to improve blood flow to the heart) x5.” During an interview and record review with the Chief Nursing Officer (CNO) on 6/19/25 at 12:40 p.m., the CNO confirmed there was no physician order to insert the IUC for Patient 7. The CNO stated there should be a physician order for the insertion of the IUC. During an interview with OR RN B on 6/19/25 at 2:47 p.m., she stated Patient 7 was at the OR for CABG procedure on 3/31/25. RN B stated she observed a protruded stick from Patient 7’s vaginal opening when Patient 7 was placed in a frog leg position for the CABG procedure. RN B stated she removed the stick which was a betadine sponge swab and assessed Patient 7 for injury. During an interview with the ICU manager on 6/23/25 at 10:44 a.m. at ICU, she stated the Foley catheter tray contained three betadine sponge swabs to clean the area prior the catheter insertion. The ICU manager acknowledged that the betadine sponge swab should not be used to mark an area for catheterization. During a telephone interview with RN A on 6/25/25 at 11:08 a.m., she stated she inserted the Foley catheter for Patient 7 on 3/30/25. RN A stated she used the betadine sponge swab to hold some tissues for visualization of the area during the Foley catheterization and forgot to remove the swab. RN A stated she should not have used the betadine sponge swab to hold the tissues. RN A acknowledged that there should be a physician order for the Foley catheterization. During a review of the hospitals P&P titled, “Bladder Management Protocol” revised 1/19/23 (in effect on incident date), the P&P indicated, “An order from a physician is required for the insertion of an IUC.” The P&P included “Indwelling (Foley) Catheter Care” which indicated, “Procedure: Figure 6. Following exposure of the urethral meatus, use an antiseptic solution soaked into cotton balls or oversized cotton-tipped applicators to clean the exposed meatus and surrounding tissues.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46939 Based on observation, interview and record review, the hospital failed to comply with the Condition of Participation (CoP) for Patient Rights as evidenced by: The hospital failed to provide safe patient care to one of 30 sampled patients (Patient 24), when the hospital failed to ensure a gurney was used according to manufacturer recommendations. This failure resulted in Patient 24 sustaining multiple injuries as a result of a fall from the gurney onto the floor during transportation to a mobile MRI (Magnetic Resonance Imaging) trailer (refer to A-0144). The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment.”

“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: 46939 Based on observation, interview and record review the hospital failed to provide safe patient care to one of 30 sampled patients (Patient 24), when the hospital failed to ensure a gurney was used according to manufacturer recommendations. This failure resulted in Patient 24 sustaining multiple injuries as a result of a fall from the gurney onto the floor during transportation to a mobile MRI (Magnetic Resonance Imaging) trailer. Findings: During an interview on 1/13/25, at 9:40 a.m., with Imaging Director (ID) ID stated, he was notified of a fall that occurred on 12/28/24 in the MRI trailer located at the facility’s ambulance bay. ID stated, Patient 24 was transported from his unit in the facility to the MRI trailer by Patient Transporter A (PT A). ID stated, when Patient 24 arrived to the MRI trailer, MRI Technician B (MT B) helped transfer the patient from his hospital bed gurney to the MRI safe gurney located outside the MRI trailer. ID stated, according to the rapid response nurse notes, the patient fell onto the floor of the lift (that takes the patient up the to level of the MRI trailer) from the gurney, as the MT B was attempting to bring the gurney inside the trailer from the lift. During a review of Patient 24’s “Orders,” dated 12/26/24, the orders indicated an order for MRI Brain... Reason for exam: worsened arousal and mental status, recent CVA (stroke, cerebral vascular accident) and gliosarcoma (brain cancer). During a review of a “RRT [Rapid Response Team] Activation and Response” document for Patient 24, dated 12/28/24, it indicated, Patient 24, “sustained fall from MRI gurney to floor of MRI trailer. It was reported that patient fell on front of his body... Abrasions to nose, bilateral arms, knees and toes. Patient is on blood thinner. ER staff initially assisted patient and staff... Stat CT head completed”. During a review of Patient 24’s “CT [computerized x-ray imaging procedure] Maxillofacial Final Report,” dated 12/29/24, it indicated, “Reason for exam fall,. . . Impression: 1. Bilateral nasal bone fractures with mild displacement. 2. Nasal Spine fracture”. During an interview on 1/13/25, at 2 p.m., with PT A, PT A stated, she was the transporter who brought Patient 24 from his unit in the facility to the MRI trailer located outside the facility in the ambulance bay on 12/28/24. PT A stated she used the patient’s hospital gurney to transport the patient outside the facility to the MRI trailer, then MT B assisted her in transferring the patient to the MRI safe gurney. PT A stated she and MT B placed the MRI safe gurney with the patient laying on his back onto the lifting platform to bring the patient from the ground level to the height of the MRI trailer. PT A stated MT B operated the lift with the patient, while she walked up the stairs to remove her metal objects before entering the MRI trailer scan area. PT A stated, while assisting MT B with moving the gurney off the lift platform and onto the MRI trailer there is a little bump, and when she was trying to help move the gurney into the trailer, the patient moved, “he kind of put his weight on one side of the bed and it was too small, the rails on the bed, he flipped and fell”. PT A stated after the fall she called the emergency department staff and they responded immediately. During an interview on 1/14/25, at 10:05 a.m., with MT B, MT B stated, he was the MRI Technician working at the MRI trailer on 12/28/24. MT B stated, he saw PT A arrive with Patient 24 to the MRI trailer, together they transferred Patient 24 from his bed gurney to the MRI safe gurney because the MRI trailer was higher than the ground, they had to use the lift platform to lift the patient to the same level as the trailer. MT B stated, “the gurney has a left and right side rail which were lifted up, but they are very low, they will not reach the height of the patients [Patient 24’s] belly. There was an unanticipated motion from the patient so he was turning to his right side and because he turned, he toppled over the hand rail, because the hand rail is so low and he fell face down onto the stage [lift platform]”. MT B stated, he informed his supervisor one month before this fall he was concerned the gurney didn’t have any straps to hold the patients in place. MT B stated, “I expressed my concern about the gurney not having straps”. During an observation on 1/14/25 at 12:20 p.m., the hospital’s MRI safe gurney was observed. MRI safe gurney indicated, it was manufactured by Ferno, with a model named Model 35x PROFlexx. During a review of “User’s Manual” for Ferno Model 35x Series PROFlexx gurney, undated, it indicated, “Warning... Improper use of the cot [gurney] can cause injury. Use the cot only for the purpose described in this manual... An unrestrained patient can fall off the cot and be injured. Use restraints to secure the patient to the cot... Included with purchase... set of 3 restraints... Standard features All cots are built with the following features... Restraints (set of 3)... Restraints, Mattress and Accessories... Before placing the cot in service assign appropriate personnel to install the mattress, restraints”. During a review of Patient 24’s “History & Physical [H&P],” dated 12/28/24, it indicated, Patient 24 was transferred to the Intensive Care Unit after his fall at the MRI trailer. It indicated, “Chief Complaint Closed head injury after accidental fall... Problem List: A Left-sided soft tissue injury secondary to fall... Unfortunately before patient [Patient 24] was able to enter scanner [MRI], because of complications moving him into the portable unit, apparently fell to ground level from the gurney, falling face first, sustaining some soft tissue trauma... the patient was transferred to the medicine service with admission to the intensive care unit for further neurological checks”. During an interview on 1/15/25, at 12:30 p.m., with Staffing Manager (SM) C, SM C stated, he is the manager for staffing employees who work in the MRI trailer. SM C stated, the company he works for provided the MRI safe gurney to the facility for use in the MRI trailer, and the gurney was delivered brand new to the MRI trailer some time in the middle of 2024. SM C stated, he was informed about the fall that occurred on 12/28/24 by ID. SM C stated, he made a visit to the MRI trailer on either 12/29/24 or 12/30/24. SM C stated, straps were installed onto the gurney on one of those dates. SM C stated, he was unsure why the straps/restraints were not installed prior to first use of the gurney.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 48590 Based on interview and record review, the hospital failed to provide written evidence a patient has the right to formulate an advance directive (a written instruction for health care) for one of 30 sampled patient (Patient 30). This failure had the potential for patient to not have their healthcare rights and wishes known and honored. Findings: Patient 30 was admitted to the hospital on 12/2/24 for status epilepticus (a seizure that lasts more than five minute, or two or more seizures without regaining consciousness between them). During a concurrent interview and record review on 12/5/24 at 9:57 a.m., with the Clinical Informatics Program Manager (CIPM), the CIPM reviewed Patient 30’s medical record and she confirmed there was no advance directive on file and had no indication the hospital inquired or provided the patient or patient’s representative with information regarding advance directive. The CIPM confirmed there was no documentation in the medical record that Patient 30 was offered an advance directive. During a review of the hospital’s policy and procedure (P&P), titled “Healthcare Individual Instructions and Advance Directives/PSDA/POLST”, date approved 4/19/22, indicated “Provide to each individual, at the time of admission as an inpatient or outpatient ...written information regarding an individual’s rights ... and to formulate advance directives. Document in the individual’s medical record whether or not the individual has been offered or has executed an Advance Directive.””

“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: 48590 Based on interview and record review, the hospital failed to ensure the registered nurse evaluated the nursing care for eight of 30 sampled patients (Patient 4, 5, 9, 12, 13, 15, 16, and 19) when pain reassessment was not done. This failure had the potential for patients to have continued pain. Findings: Patient 4 was admitted to the hospital on 11/30/24 for right femur fracture (a type of hip fracture that occurs in the upper part of the thigh bone). During a concurrent interview and record review, on 12/4/24 at 10:29 a.m., with the Clinical Informatics Program Manager (CIPM), Patient 4’s pain was assessed and rated at 7 of 10 on 12/4/24 at 7:54 a.m., and Oxycodone 10 milligrams (mg, unit of measurement) tablet was administered. The CIPM confirmed pain reassessment documentation performed at 10:17 a.m. Patient 5 was admitted to the hospital on 11/24/24 for acute abdominal pain (a sudden and severe pain in the abdomen). During a concurrent interview and record review, on 12/4/24 at 10:48 a.m., with the CIPM, Patient 5’s pain was assessed prior to administration of hydromorphone (Dilaudid, used to treat severe pain) on 11/24/24 at 8:12 p.m., 11/25/24 at 8:40 a.m., 11/25/24 at 11:58 a.m., 11/26/24 at 6:20 a.m., 11/27/24 at 8:25 a.m., 11/27/24 at 11;53 a.m., 11/27/24 at 2:50 p.m., 11/229/24 at 7:21 a.m., 11/29/24 at 1:22 p.m., 11/30/24 at 8:50 a.m., 11/30/24 at 11:03 a.m., 11/30/24 at 1:58 p.m., 12/1/24 at 7:58 a.m., 12/1/24 at 1:28 p.m., 12/2/24 at 7:53 a.m., 12/2/24 at 9:31 p.m., and 12/3/24 at 7:25 a.m. The CIPM confirmed there was no pain reassessment done. Patient 9 was admitted to the hospital on 12/3/24 for femoral neck fracture (a break in the thighbone that occurs one to two inches from the hip joint). During a concurrent interview and record review, on 12/4/24 at 12:55 p.m., with the CIPM, Patient 9’s pain was assessed and rated at 7 of 10 and morphine (used to treat moderate to severe pain) 6 milligrams (mg, unit of measurement) intravenous push (IVP, a process of introducing a medication directly into the bloodstream) was administered. The CIPM confirmed no pain reassessment was done. Patient 12 was admitted to the hospital on 11/30/24 for right femur fracture (a type of hip fracture that occurs in the upper part of the thigh bone). During a concurrent interview and record review, on 12/4/24 at 1:55 p.m., with the CIPM, Patient 12’s pain was assessed on 12/1/24 at 8:14 a.m., and 12/1/24 at 2:26 p.m. and acetaminophen-hydrocodone (Norco, used to treat for pain) 5-325 mg tablet was administered. The CIPM confirmed there was no pain reassessment done. Patient 13 was admitted to the hospital on 12/3/24 for cervical myelopathy (compression of the spinal cord in the neck). During a concurrent interview and record review on 12/4/24 at 2:25 p.m., with the CIPM, Patient 13’s pain was assessed on 12/3/24 at 5:23 p.m., and 12/3/24 at 9:20 p.m. prior to administration of acetaminophen-oxycodone (Percocet, used to treat moderate to severely moderate pain) 325/5 mg tablet. The CIPM confirmed there was no pain reassessment done. Patient 15 was admitted to the hospital on 12/3/24 for sacral abscess (an infection that occurs at the base of the spine) During a concurrent interview and record review, on 12/4/24 at 2:50 p.m., with the CIPM, Patient 15’s pain was assessed on 12/3/24 at 1:10 p.m. and rated at 8 of 10 prior to administration of acetaminophen-hydrocodone tablet. The CIPM confirmed no pain reassessment was done. Patient 16 was admitted to the hospital on 12/1/24 for femur fracture. During a concurrent interview and record review, on 12/4/24 at 2:45 p.m., with the CIPM, Patient 16’s pain was assessed on 12/1/24 at 2:14 p.m., 12/1/24 at 4:16 p.m., 12/2/24 at 7:53 a.m., 12/2/24 at 12:21 p.m., 12/2/24 at 2:00 p.m., 12/3/24 at 10:58 a.m., and 12/3/24 at 3:55 p.m. prior to administration of Fentanyl (a narcotic used to treat severe pain) injection, hydromorphone, and oxycodone tablet. The CIPM confirmed no pain reassessment was done. Patient 19 was admitted to the hospital on 11/9/24 for discitis (infection of the spinal discs). During a concurrent interview and record review, on 12/4/24 at 3;24 p.m., with the CIPM, Patient 19’s pain was assessed on 11/17/24 at 12:17 a.m., 11/17/24 at 2:24 p.m., 11/19/24 at 8:43 a.m., 11/19/24 at 2:45 p.m., 11/19/24 at 8:57 p.m., 11/24/24 at 10:15 p.m., 11/25/24 at 6:11 p.m., 11/27/24 at 5:46 p.m., 11/27/24 at 11:44 p.m., 11/28/24 at 12:01 p.m., 11/28/24 at 8:47 p.m., 11/29/24 at 8:20 p.m., and 12/4/24 at 6:27 p.m. prior to administration of acetaminophen-hydrocodone tablet and hydromorphone 2 mg tablet. The CIPM confirmed no pain reassessment was done. During the review of the hospital’s policy and procedure (P&P), titled “Core Nursing standards of Practice for Med/Surg, TCU, Oncology, and Acute Rehab”, date approved 8/12/21, indicated “pain reassessment within 30 minutes for all PO medications or within 15 minutes for IV medication administered for pain.””

“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: 48590 Based on interview and record review, the hospital failed to ensure nursing staff developed individualized and updated care plans (a tool used to provide nursing care to patients) related to pain for three of 30 sampled patients (Patient 12, 13 and 15). This failure had the potential to result in lack of, or delay in appropriate care and monitoring of these patients. Findings: Patient 12 was admitted to the hospital on 11/30/24 for right intertrochanteric femur fracture (a type of hip fracture that occurs in the upper part of the thigh bone) status post intermedullary rodding (a patient has recently undergone surgery where a metal rod was inserted in the bone to stabilize a fracture). During a concurrent interview and record review, on 12/4/24 at 1:55 p.m., with the Clinical Informatics Program Manager (CIPM), the CIPM confirmed Patient 12’s care plan was not initiated upon admission and after pain assessment and administration of Acetaminophen-Hydrocodone (Norco, used to relieve moderate to severe pain). During a concurrent interview and record review, on 12/4/24 at 2:10 p.m., with Chief Nursing Officer (CNO), the CNO confirmed Patient 12’s care plan was not initiated upon admission. Patient 13 was admitted to the hospital on 12/3/24 for cervical myelopathy (compression of the spinal cord in the neck). During a concurrent interview and record review, on 12/4/24 at 2:25 p.m., with the CIPM, the CIPM confirmed Patient 13’s care plan was not initiated on admission and after pain assessment and administration of Acetaminophen-Oxycodone (Percocet, used to relieve moderate to severe pain). Patient 15 was admitted to the hospital on 12/3/24 for sacral abscess (an infection at the base of the spine). During a concurrent interview and record review, on 12/4/24 at 2:50 p.m., with the CIPM, the CIPM confirmed Patient 15’s care plan for pain was not initiated after pain assessment and administration of Acetaminophen-Hydrocodone (Norco, used to relieve moderate to severe pain). During a review of the hospital’s policy and procedure (P&P), titled “Core Nursing Standards of Practice for Med/Surg, TCU, Oncology, and Acute Rehab”, date approved 8/12/21, indicated “Standard 1: Nursing Process 4. Plan of Care - The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes. The registered nurse: h. Document implementation, modifications, and evaluation of goals; including changes or omissions, of the identified plan. i. The plan of care is reviewed and updated at a minimum of every shift and PRN.” During a review of the hospital’s policy and procedure (P&P), titled “Core Nursing Standards of Practice for Med/Surg, TCU, Oncology, and Acute Rehab”, date approved 8/12/21, indicated “Appendix A: Standard of Practice: Assessment & Charting for Med/Surg minimum frequency of nursing interventions and documentation: Plan of Care - upon admission.””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48590 Based on observation, interview, and record review, the hospital failed to implement infection prevention and control measures when a Certified Nursing Assistant (CNA) was observed entering patient rooms without removing, cleaning and/or disinfecting the face shield. This failure had the potential to result in transmission and spread of infectious diseases to staff, patients , and visitors. Findings: During an observation on 12/5/24 at 10:31 a.m., in a Medical-Surgical unit, a CNA was observed wearing a face shield entering patient rooms without removing, cleaning, and/or disinfecting the face shield. During a concurrent observation and interview, on 12/5/24 at 10:35 a.m., with Infection Prevention Director (IPD), the ICD stated face shield should be cleaned before and after entering a patient room. During a review of the hospital’s policy and procedure (P&P), titled “Personal Protective Equipment (PPE), date approved 9/21/22, indicated “Personal Protective Equipment (PPE) is worn to protect healthcare workers from exposure to potentially infectious microorganisms. The outside of goggles or face shield is considered contaminated. Remove PPE at doorway before leaving patient room and discard inside room.””