Desert Regional Medical Center

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure a resolution letter was issued in response to a grievance (a formal or informal written or verbal complaint which is made to the facility by the patient, or the patient’s representative), for one of 20 sampled patients (Patient 15), in accordance with the facility’s policy and procedure on the grievance process. This failure had the potential to prevent Patient 15 and their representative from receiving timely written notification of the hospital’s investigation and resolution of their grievance. Findings: On July 15, 2026, at 10:12 a.m., a review of Patient 15’s record and concurrent interview were conducted with Clinical Nurse Manager (CNM) 2. A facility document titled, “Admission H&P [History and Physical],” dated March 24, 2026, was reviewed and indicated Patient 15 was admitted to the facility on March 24, 2026, for progressive weakness. A facility document titled, “Complaint/Grievance Intake Form,” dated May 8, 2026, was reviewed. The document indicated, “...Date/Time 05/08/2026 [May 8, 2026]...Caller Name [name of Patient 15’s representative]...Patient Name [Name of Patient 15]...Description...Left voicemail @ [at] 11:42 [a.m.] requesting return telephone call...” During record review, there was no documented evidence the facility returned Patient 15’s representative’s call. On July 15, 2026, at 1:37 p.m., an interview was conducted with CNM 2. CNM 2 stated grievances during the month of May were processed and addressed by the Patient Safety Coordinator (PSC, a healthcare professional who leads and supports initiatives to prevent harm to patients, reduce medical errors, and promote a culture of safety) but the position has been eliminated and the PSC is no longer working in the facility. CNM 2 stated the facility’s grievances are now being processed by the Director of Quality (DQ). On July 15, 2026, at 2 p.m. an interview was conducted with the DQ. The DQ stated the PSC was the person who logged all the incoming grievances for the facility. The DQ stated the facility eliminated several positions and the PSC was one of them. The DQ stated the Quality Department (the internal team responsible for monitoring patient care, enforcing safety standards, and leading process improvements) did not have access to the PSC’s computer files. The DQ stated there was no documentation the facility contacted or mailed a letter in response to Patient 15’s representative’s grievance. The DQ stated the facility’s grievance process was to try and resolve the grievance as soon as possible. The DQ stated if the grievance could not be resolved, the facility was to mail out a letter to the person who filed the grievance within seven days explaining the facility would need more time, which is usually 30 days, to investigate the patient or patient’s representative grievance. The DQ stated there was no documentation the facility resolved Patient 15’s representative’s grievance nor mailed out a letter to Patient 15’s representative addressing his grievance and the facility should have done so. A review of the policy and procedure titled, “...MANAGEMENT OF PATIENT COMPLAINTS/GRIEVANCES,” dated November 21, 2024, was conducted. The policy indicated, “...The patient shall have the ability to file a complaint or grievance as part of the patient rights process...The seriousness of the grievance should drive the response time. Grievances should be resolved and the patient notified of the response within 7 [seven] days...If the resolution of the grievance is determined to take longer than seven days, Patient Safety will send a response to the patient informing him/her that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days (a “Deferral Letter”)...Each grievance will be resolved with a written notice of decision...within 30 days...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 42512 Based on observation, interview, and record review, the hospital failed to ensure a physician’s order for the use of non-violent soft restraints (physical, mechanical, or chemical methods used to limit a patient’s free movement or access to their own body) was renewed in accordance with the facility’s policy and procedure (P&P), for one of 20 sampled patients (Patient 11). This failure had the potential to result in unnecessary use of restraints on Patient 11 and a violation of Patient 11’s rights to be free of restraints. Findings: On July 13, 2026, at 9:38 a.m., a tour of Unit A was conducted with the Clinical Educator of Intensive Care Unit (CEICU) and the Clinical Manager of Intensive Care Unit (CMICU). On July 13, 2026, at 9:42 a.m., an observation of Patient 11, in his room, and concurrent interview were conducted with the CEICU and the CMICU. Patient 11 was observed to have bilateral (both sides) soft wrist restraints (padded cloth devices used in hospitals to limit a patient’s hand and wrist movement). The CMICU stated soft wrist restraints were placed on Patient 11 for safety so Patient 11 could not pull on his endotracheal tube (a tube inserted through the mouth or nose into the trachea (windpipe) to help a patient breathe). On July 14, 2026, at 10:42 a.m., a review of Patient 11’s record and concurrent interview were conducted with Clinical Nurse Manager (CNM) 2. A facility document titled, “Admission H&P (History and Physical),” dated July 7, 2026, was reviewed. The document indicated Patient 11 was admitted to the facility on July 6, 2026, for stroke (a sudden interruption of blood flow to the brain which can lead to brain damage). The document further indicated Patient 11 was placed on non-violent restraints (devices used to support medical healing by preventing confused or sedated patients from interfering with medical treatments, which may include soft wrist restraints). A review of a facility document titled, “Restraint Patient Assessment,” dated July 7, 2026, through July 13, 2026, was conducted. The document indicated Patient 11 was assessed to have two-point wrist restraints (padded or cloth devices applied to a patient’s wrists, ankles, or hands to limit movement safely and prevent self-harm or interference with medical treatment) from July 7, 2026, through July 10, 2026. A review of the physician’s orders for Patient 11 was conducted. There was no documented evidence a physician ordered restraints to be placed on Patient 11 on July 10, 2026. CNM 2 stated there must be an order from a physician to place a patient in restraints. CNM 2 further stated the order for restraints must be renewed every 24 hours. CNM 2 stated Patient 11’s order for restraints was not renewed on July 10, 2026, and it should have been. A review of the policy and procedure (P&P) titled, “...RESTRAINT & SECLUSION [an involuntary confinement of a person in a room or area from which they are physically prevented from leaving],” dated July 18, 2024, was conducted. The document indicated, “...Restraint and Seclusion require an order from a physician or other authorized Licensed Practitioner [person who has been officially authorized by a state to provide health care services] responsible for the care of the patient...Non-violent/Medical Behavior Orders for Restraints [formal instructions from a qualified healthcare provider that allow the use of physical or mechanical methods to limit a patient’s movement when their behavior poses an immediate danger to themselves or others] based on medical needs/behaviors must be renewed daily...””

“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: 47071 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P’s) were implemented, for seven of 20 sampled patients (Patients 1, 2, 3, 13, 14, 15, and 18), when: 1. For Patients 1, 2 , 3, 13, 14, and 15, oral care (oral hygiene, the cleaning of the teeth, gums and tongue) was not provided in accordance with the facility’s policy and procedure (P&P); 2. For Patients 1, 3, and 18 perineal care (peri care, the gentle cleaning of the genital and anal areas) was not provided once a day and as needed (pro re nata, PRN); These failures had the potential to impact the quality of care provided to Patients 1, 2, 3, 13, 14, 15, and 18, decrease their level of personal comfort, increase their risk for infection, may prolong their hospitalization, and may contribute to the worsening of their medical conditions. Findings: 1a. On July 14, 2026, at 10:41 a.m., Patient 1’s record was reviewed with the Quality Coordinator (QC). A facility document titled, “Admission H&P [History and Physical],” dated June 9, 2026, at 10:57 p.m., was reviewed. The document indicated Patient 1 was admitted to the facility on June 9, 2026, with obstructive uropathy (a condition which is characterized by a blockage that prevents urine from flowing naturally through the urinary system) requiring Interventional Radiology (IR, a medical specialty which uses minimally invasive, image-guided techniques to diagnose and treat a wide range of conditions without the need for open surgery) nephrostomy (a medical procedure which creates an opening from the kidney to the outside of the body to allow urine drainage) tube placement (a flexible tube inserted through the skin directly into the kidney to drain urine). The document indicated Patient 1 had a urinary tract infection (bacterial infection in the bladder, urethra, or kidneys) with complaints of right flank pain (discomfort on the side between the lower ribs and the hips). A facility document titled, “Adult ADL’s [activities of daily living, essential self-care tasks that individuals perform on a daily basis to maintain their physical needs and independence],” dated June 10, 2026, through June 15, 2026, was reviewed. There was no documented evidence oral care was provided to Patient 1 on the following dates: - On June 10, 2026; - On June 11, 2026; - On June 12, 2026; - On June 14, 2026; and - On June 15, 2026. During a concurrent interview conducted with the QC, the QC stated oral care should be provided to patients twice daily or more often if the patient is sedated or intubated. The QC stated there is no documentation Patient 1 refused oral care. b. On July 14, 2026, at 10:41 a.m., Patient 2’s record was reviewed with the QC. A facility document titled, “Admission H&P,” dated May 3, 2026, at 3:19 p.m., was reviewed. The document indicated Patient 2 was admitted to the facility on May 5, 2026, for pain in the right ankle after twisting it at home. A facility document titled, “Adult ADL’s,” dated May 22, 2026, through June 1, 2026, was reviewed. The document indicated oral care was not completed on the following dates and shifts (day shift is from 7a.m. to 7p.m., and night shift is from 7p.m. to 7a.m.): - On May 22, 2026, night shift; - On May 23, 2026, day and night shifts; - On May 24, 2026, night shift; - On May 25, 2026, day and night shifts; - On May 26, 2026, day and night shifts; - On May 27, 2026, day and night shifts; - On May 28, 2026, day and night shifts; - On May 29, 2026, day and night shifts; - On May 30, 2026, night shift; - On May 31, 2026, day and night shifts; and - On June 1, 2026, night shift. On June 15, 2026, at 10:20 a.m., an interview was conducted with the QC. The QC stated Patient 2 should have been offered oral care each shift and as needed. The QC stated, upon review of Patient 2’s record, there was no documentation Patient 2 refused oral care. The QC further stated Patient 2 did not receive oral care per the facility policy. c. On July 15, 2026, at 11:10 a.m., Patient 3’s record was reviewed with the QC. A facility document titled, “H&P [History and Physical],” dated July 14, 2026, at 10:19 a.m., was conducted. The document indicated Patient 3 was admitted to the facility on July 14, at 10:19 a.m., for abdominal pain and bright red rectal bleeding. A facility document titled, “Adult ADL’s [activities of daily living, essential self-care tasks that individuals perform on a daily basis to maintain their physical needs and independence],” dated July 1, 2026, through July 12, 2026, was reviewed. The document indicated oral care was not completed on the following dates and shifts (day shift [7a.m. to 7p.m.] or night shift [7p.m. to 7a.m.]: - On July 1, 2026, day and night shifts; - On July 2, 2026, day and night shifts; - On July 4, 2026, day shift; - On July 5, 2026, night shift; - On July 6, 2026, day shift; - On July 8, 2026, day and night shifts; - On July 9, 2026, day and night shifts; - On July 10, 2026, night shift; - On July 11, 2026, night shift; and - On July 12, 2026, night shift. On June 15, 2026, at 11:15 a.m., an interview was conducted with the QC. The QC stated Patient 3 should have been offered oral care each shift and as needed. The QC stated, upon review of Patient 3’s record, there is no documentation Patient 3 refused oral care. The QC further stated Patient 3 did not receive oral care in accordance with the facility’s policy. d. On July 14, 2026, at 1:15 p.m., a review of Patient 13’s record and concurrent interview were conducted with Clinical Nurse Manager (CNM) 2. A facility document titled, “Admission H&P,” dated July 1, 2026, was reviewed and indicated Patient 13 was admitted to the facility on July 1, 2026, for a code stroke (an emergency alert which means a patient is showing signs of a stroke [a sudden interruption of blood flow to the brain]). A facility document titled, “Adult ADL’s ,” dated July 10, 2026, through July 12, 2026, was reviewed. The document indicated oral care was not completed for Patient 13 on July 10, 2026, and July 12, 2026. CNM 2 stated oral care should be provided to patients twice daily or more often if the patient is sedated or intubated. She stated facility staff did not document oral care for Patient 13 on July 10, 2026, and July 12, 2026. CNM 2 stated if the performance of oral care was not documented, then oral care was not provided. e. On July 14, 2026, at 1:43 p.m., a review of Patient 14’s record and concurrent interview were conducted with CNM 2. A facility document titled, “Admission H&P,” dated April 28, 2026, was reviewed and indicated Patient 14 was admitted to the facility on April 28, 2026, for abdominal pain, vomiting, non-bloody diarrhea, and progressive weakness starting at her legs. The document further indicated she was intubated (when a breathing tube is inserted into the windpipe to help a patient breathe). A facility document titled, “Adult ADL’s,” dated July 9, 2026, through July 10, 2026, was reviewed. The document indicated oral care was not completed on the following dates and times: - On July 9, 2026, at 2 p.m.; - On July 9, 2026, at 4 p.m.; - On July 10, 2026, at 8 a.m.; - On July 10, 2026, at 10 a.m.; - On July 10, 2026, at 12 p.m.; and - On July 10, 2026, at 2 p.m. CNM 2 stated oral care should be provided to patients twice daily or more often if the patient is sedated or intubated. She stated facility staff did not document oral care every two hours for Patient 14 on July 9, 2026, and July 10, 2026. CNM 2 stated if the performance of oral care was not documented, then oral care was not provided. f. On July 15, 2026, at 10:12 a.m., a review of Patient 15’s record and concurrent interview were conducted with CNM 2. A facility document titled, “Admission H&P,” dated March 24, 2026, was reviewed and indicated Patient 15 was admitted to the facility on March 24, 2026, for progressive weakness. A facility document titled, “Adult ADL’s,” dated May 2, 2026, through May 11, 2026, was reviewed. The document indicated oral care was not completed for Patient 15 on the following dates: - On May 2, 2026; - On May 5, 2026, through May 8, 2026; and - On May 10, 2026. CNM 2 stated oral care should be provided to patients twice daily or more often if the patient is sedated or intubated. She stated facility staff did not document oral care for Patient 15 on May 2, 2026, May 5, 2026, through May 8, 2026, and on May 10, 2026. CNM 2 stated if the performance of oral care was not documented, then oral care was not provided. 2a. On July 14, 2026, at 10:41 a.m., Patient 1’s record was reviewed with the QC. A facility document titled, “Admission H&P,” dated June 9, 2026, at 10:57 p.m., was reviewed. The document indicated Patient 1 was admitted on June 9, 2026, with obstructive uropathy requiring Interventional Radiology (IR) nephrostomy tube placement. Patient 1 had a urinary tract infection with complaints of right flank pain. A facility document titled, “Adult ADL’s,” dated June 10, 2026, through June 15, 2026, was reviewed. There was no documented evidence peri care was provided for Patient 1 from June 10, 2026, through June 15, 2026. On July 15, 2026, at 11:08 a.m., an interview was conducted with the QC. The QC stated peri care should have been completed once a day and as needed for Patient 1. The QC further stated there was no documentation peri care was provided once a day for Patient 1 from June 10, 2026, to June 15, 2026. b. On July 15, 2026, at 11: 45 a.m., Patient 3’s record was reviewed with the QC. A facility document titled, “H&P,” dated July 14, 2026, at 10:19 a.m., was conducted. The document indicated Patient 3 was admitted to the facility on July 14, at 10:19 a.m., for abdominal pain and bright red rectal bleeding. A facility document titled, “Adult ADL’s,” dated July 1, 2026, through July 12, 2026, was reviewed. The document indicated peri care was not provided one time each day to Patient 3 on the following dates: - On July 1, 2026; - On July 2, 2026; - On July 8, 2026; - On July 9, 2026; and - On July 12, 2026. On June 15, 2026, at 11:55 a.m., an interview was conducted with the QC. The QC stated peri care should have been completed once a day and as needed for Patient 3. The QC further stated Patient 3 did not receive peri care in accordance with the facility’s policy. c. On July 15, 2026, at 2:22 p.m., a review of Patient 18’s record and concurrent interview were conducted with CNM 2. A facility document titled, “Admission H&P,” dated July 7, 2026, was reviewed and indicated Patient 18 was admitted to the facility on July 7, 2026, for cardiac arrest (the abrupt loss of heart function, when the heart stops beating). The document further indicated Patient 18 was intubated. A facility document titled, “Adult ADL’s,” dated July 11, 2026, through July 13, 2026, was reviewed. The document indicated there was no documented evidence peri care was provided to Patient 18 on July 11, 2026, and July 14, 2026. CNM 2 stated the facility did not need an order to provide peri care on patients. CNM 2 stated peri care needed to be provided or offered to each patient at a minimum, daily or as needed. CNM 2 stated Patient 18 should have been provided peri care daily and she was not. A facility policy and procedure titled, “...STANDARDS OF CARE: ASSESSMENT, REASSESSMENT, AND CARE PLANS,” dated March 20, 2025, was reviewed. The facility policy and procedure indicated, “...Pericare will be done at least daily and with each bowel movement...Pericare is completed at least once per shift in patient’s with indwelling urinary catheters. Oral hygiene will be provided at least 2 [two] times daily and more frequently in the comatose/less responsive patient...””

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 50122 Based on interview and record review, the facility failed to ensure patient rights were implemented, for one of 30 sampled patients (Patient 3), when the patient or her family was not notified of the patient’s change of condition. This failure resulted in Patient 3 and her family to not be informed of the change in Patient 3’s condition and had potential for Patient 3 and/or her family to not be able to participate in decision making regarding the patient’s plan of care. Findings: On November 17, 2025, at 2:30 p.m., a review of Patient 3’s record was conducted with the Stroke Program Coordinator (SPC). A facility document titled, “Admission H&P [History and Physical]...,” dated March 15, 2025, was reviewed. The document indicated Patient 3 had a medical history of cerebral vascular accident (stroke, loss of blood flow to a part of the brain), atrial fibrillation (a rapid, irregular heartbeat caused by a problem with the heart’s electrical signals), peripheral artery disease (condition where arteries which supply blood to the legs and feet become narrowed or blocked), and hypertension (high blood pressure, normal is 120/80). The document indicated Patient 3 was admitted to the facility on March 15, 2025, for a fall, and pelvic and hip fracture (a break in the bones). On November 17, 2025, at 2:45 p.m., a facility document titled, “Case Management Reassessment,” dated March 17, 2025, at 5:23 p.m., authored by Social Worker (SW) 1 was reviewed. The document indicated, “...Emergency contact is her [family member, FM] [Name of FM]...[FM] acts as her surrogate agent...” On November 17, 2025, at 3 p.m., a facility document titled, “Progress Note- Nursing...Result Detail...,” dated March 23, 2025, at 11:43 a.m., authored by registered nurse (RN) 1 was reviewed. The document indicated, “...Physician communication....Patient [Patient 3] condition...MD [physician] notified pt [Patient 3] having [sic] difficulty coming in with her words, and has R [right] upper and lower extremity [arms and legs] jitterness [sic] and weakness. Per MD he will order CT [computerized tomography, an imaging procedure] of the head...” On November 17, 2025, at 3:02 p.m., a facility document titled, “Order Sheet,” dated March 23, 2025, at 11:43 a.m., authored by MD 1 was reviewed. The document indicated, “...CT Head or Brain W/O [without] Contrast [a substance used to improve the visibility of internal body structures]...Reason For Exam...upper extremity [arms] tremor [shaking]...” On November 17, 2025, at 3:05 p.m., a facility document titled, “Final Report,” dated March 23, 2025, at 1:32 p.m., authored by Radiology Technician (RT) 1 was reviewed. The document indicated, “...Small amount of intraventricular hemorrhage [IVH, bleeding which occurs inside or around the brain’s ventricles (which are C-shaped fluid-filled spaces in the brain)] within the right lateral ventricle [one of two ventricles in the brain], new since previous exam...” On November 17, 2025, at 3:10 p.m., a facility document titled, “Progress Note...,” dated March 23, 2025, at 1:42 p.m., was reviewed. The document indicated, “...consulted neurosurgeon on-call [name of MD] who recommended neuro ICU [intensive care unit, a unit for critically ill patients] admission with frequent neuro checks [a series of tests to assess the brain’s condition], seizure [convulsions] prophylaxis [the use of medication to prevent seizures in individuals at high risk], keep blood pressure less than 140 at all times and repeat CT head in AM [morning]. Consulted intensivist [a physician who specialized in treating critically ill patients]...Discussed with nursing...” There was no documented evidence Patient 3 or her family was notified about the change in Patient 3’s condition. On November 19, 2025, at 10 a.m., an interview and concurrent review of Patient 3’s record were conducted with the Chief Medical Officer (CMO). The CMO stated there was no documentation Patient 3’s change of condition was discussed with Patient 3 or her family. On November 19, 2025, at 11 a.m., an interview was conducted with the Director of Telemetry (unit where patients’ heart rates and rhythms are continuously monitored remotely) 3 (D3E)). The D3E stated the patient and/or the patient’s family should be notified of a change in the patient’s condition, depending on the patient’s ability to understand. The D3E stated the primary responsibility of notifying the patient or the patient’s family is with the physician. On November 19, 2025, at 12:13 p.m., an interview was conducted with the Regulatory Manager (RM). The RM stated she was unable to find documentation Patient 3 or her family was notified of Patient 3’s change of condition. The RM stated the facility has no policy and procedure (P&P) for notification of the patient or the patient’s family about a change in the patient’s condition. A review of the P&P titled, “Patient Rights And Responsibilities,” revised September 18, 2025, was conducted. The P&P indicated, “...It is the responsibility of [name of facility] and its staff to protect and promote each patient’s rights...Receive information about your health status, diagnosis [the nature of an illness], prognosis [a forecast of the likely course of a disease], course of treatment, prospects of recovery and outcomes of care (including unanticipated outcomes)...””

“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: 50122 Based on interview and record review, the facility failed to ensure its policy and procedure (P&P) were implemented, for three of 30 sampled patients (Patients 3, 18, and 26), when: 1. For Patient 3, the facility P&P for patient rights was not implemented when a change of condition was not discussed with the patient or family. In addition, coordination of care was not facilitated when Patient 3 and her family requested transportation to transfer Patient 3 to another state where the patient resides; 2. For Patient 18, the required services for a homeless patient were not offered before discharge in accordance with the facility P&P titled,”...Homeless Discharge Planning,” and “...Pre-Discharge Services for Homeless Patient;” and 3. For Patient 26, the pain reassessment did not include a pain scale (a tool used to measure and describe the severity of pain using a numerical rating from 0 [no pain] to 10 [worst possible pain]), to assess the effectiveness of or Patient 26’s response to the pain medication administered, in accordance with the facility’s P&P titled, “Adult Pain Management.” These failures had the potential to cause delays in the provision of care for Patients 3, 18, and 26. Findings: 1a. On November 17, 2025, at 2:30 p.m., a review of Patient 3’s record was conducted with the Stroke Program Coordinator (SPC). A facility document titled, “Admission H&P [History and Physical]...,” dated March 15, 2025, was reviewed. The document indicated Patient 3 had a medical history of cerebral vascular accident (stroke, loss of blood flow to a part of the brain), atrial fibrillation (a rapid, irregular heartbeat caused by a problem with the heart’s electrical signals), peripheral artery disease (condition where arteries which supply blood to the legs and feet become narrowed or blocked), and hypertension (high blood pressure, normal is 120/80). The document indicated Patient 3 was admitted to the facility on March 15, 2025, for a fall, and pelvic and hip fracture (a break in the bones). On November 17, 2025, at 3 p.m., a facility document titled, “Progress Note- Nursing...Result Detail...,” dated March 23, 2025, at 11:43 a.m., authored by registered nurse (RN) 1 was reviewed. The document indicated, “...Physician communication....Patient [Patient 3] condition...MD [physician] notified pt [Patient 3] having [sic] difficulty coming in with her words, and has R [right] upper and lower extremity [arms and legs] jitterness [sic] and weakness. Per MD he will order CT [computerized tomography, an imaging procedure] of the head...” On November 17, 2025, at 3:02 p.m., a facility document titled, “Order Sheet,” dated March 23, 2025, at 11:43 a.m., authored by MD 1 was reviewed. The document indicated, “...CT Head or Brain W/O [without] Contrast [a substance used to improve the visibility of internal body structures]...Reason For Exam...upper extremity [arms] tremor [shaking]...” On November 17, 2025, at 3:05 p.m., a facility document titled, “Final Report,” dated March 23, 2025, at 1:32 p.m., authored by Radiology Technician (RT) 1 was reviewed. The document indicated, “...Small amount of intraventricular hemorrhage [IVH, bleeding which occurs inside or around the brain’s ventricles (which are C-shaped fluid-filled spaces in the brain)] within the right lateral ventricle [one of two ventricles in the brain], new since previous exam...” On November 17, 2025, at 3:10 p.m., a facility document titled, “Progress Note...,” dated March 23, 2025, at 1:42 p.m., was reviewed. The document indicated, “...consulted neurosurgeon on-call [name of MD] who recommended neuro ICU [intensive care unit, a unit for critically ill patients] admission with frequent neuro checks [a series of tests to assess the brain’s condition], seizure [convulsions] prophylaxis [the use of medication to prevent seizures in individuals at high risk], keep blood pressure less than 140 at all times and repeat CT head in AM [morning]. Consulted intensivist [a physician who specialized in treating critically ill patients]...Discussed with nursing...” There was no documented evidence Patient 3 or her family was notified about the change in Patient 3’s condition. On November 19, 2025, at 10 a.m., an interview and concurrent review of Patient 3’s record were conducted with the Chief Medical Officer (CMO). The CMO stated there was no documentation Patient 3’s change of condition was discussed with Patient 3 or her family. On November 19, 2025, at 11 a.m., an interview was conducted with the Director of Telemetry (unit where patients’ heart rates and rhythms are continuously monitored remotely) 3 (D3E)). The D3E stated the patient and/or the patient’s family should be notified of a change in the patient’s condition, depending on the patient’s ability to understand. On November 19, 2025, at 12:13 p.m., an interview was conducted with the Regulatory Manager (RM). The RM stated she was unable to find documentation Patient 3 or her family was notified of Patient 3’s change of condition. The RM stated the facility has no policy and procedure (P&P) for notification of the patient or the patient’s family about a change in the patient’s condition. A review of the P&P titled, “Patient Rights And Responsibilities,” revised September 18, 2025, was conducted. The P&P indicated, “...It is the responsibility of [name of facility] and its staff to protect and promote each patient’s rights...Receive information about your health status, diagnosis [the nature of an illness], prognosis [a forecast of the likely course of a disease], course of treatment, prospects of recovery and outcomes of care (including unanticipated outcomes)...” b. On November 17, 2025, at 2:50 p.m., a facility document titled, “Progress Note,” dated March 16, 2025, at 4:42 p.m., authored by MD 2, was reviewed. The document indicated, “...[family member, FM] is at bedside and they live in [name of a state]...She would like transport [Patient 3] home...have discussed surgical verus [sic, versus, against] nonsurgical options with hip replacement [a surgical procedure where a damaged hip joint is replaced with an artificial implant] in the future. She [Patient 3] is very frail and has severe PAD [peripheral artery disease]. I discussed my concern about performing an ORIF [open reduction internal fixation, a surgical procedure to treat fractures] of the acetabulum [the socket of the hip bone]...She [FM] would like to discuss with social work possible transport home...” On November 17, 2025, at 3:50 p.m., a facility document titled, “Progress Note,” dated March 17, 2025, at 5:08 p.m., authored by MD 3 was reviewed. The document indicated, “...[FM] is at bedside who states goal is to get patient back to [name of a state] as soon as possible...Patient and family requesting to speak with social worker and case management to see if there is any available resources that could help with getting patient back to [name of a state]...Consult case management and social worker...” On November 17, 2025, at 3:55 p.m., a review of the facility document titled, “Case Management Reassessment,” dated March 17, 2025, at 5:23 p.m., authored by Social Worker (SW) 1 was reviewed. The document indicated, “...Consult ordered 3/16/25 [March 16, 2025], DCP [direct care provider] patient’s [FM] [name of FMr] would like options on getting patient back home...Pt [Patient 3] insured through [name of insurance]...[FM] states neither her nor [Patient 3] are able to afford to hire medical transportation...pt expressed feeling stressed and guilty about the situation...SW provided hope her [FM] would figure out a solution...[FM]...stated pt’s PCP [primary care provider] informed her to “get pt to [name of a state] asap [as soon as possible]...SW spoke with [FM] and outlined option, including what insurance will and will not cover. SW explained Medicare only covers a limited number of miles. SW also explained that some...HMOs [health maintenance organization, a type of managed health insurance plan] provide transportation via their [name of insurance] plans and suggested she contact [name of state] [name of insurance] to inquire if they have resources to assist in getting pt back home...[FM] expressed frustration and disappointment...Most options for medical transportation home would require out-of-pocket expense, which was explained to both pt and [FM]. SW provided next day SW with above information and requested she continue to explore options with [FM] and team...” There was no documented evidence insurance discussion or estimates of payment and/or out-of-pocket costs for transportation to another state was discussed with Patient 3 or Patient 3’s FM. On November 18, 2025, at 12:15 p.m., an interview was conducted with the Manager of Social Work (MSW). The MSW stated Care coordination is part of the social worker’s role. The MSW stated she would want to call to arrange for transfer of the patient because “that’s where their support system and established care are, there is familiarity, it is the patient’s preference...” On November 19, 2025, at 12:30 p.m., an interview was conducted with the DCM. The DCM stated she was not able to find documentation of insurance contact or proof of cost of coverage for transportation to another state were discussed with Patient 3 or her FM. The DCM stated what usually happens is for the facility to figure out what agency is needed by the patient and what the contracted services are. The DCM stated the facility would then talk to the patient and the patient’s family and try to get their choice, then they would call the insurance and state family is requesting to go home and the insurance would let them know if the insurance is requesting the patient to go back in-network (within the covered area of the insurance). The DCM stated, if the insurance is not requesting in-network, then the responsibility goes to the patient and the facility would let the patient know what the patient is responsible for and would get a list of quotes to provide to the patient. A review of the facility P&P titled, “Hospital Case Management Transition Planning,” dated June 22, 2023, indicated, “...Transition planning includes coordination of hospital, community providers, and support systems to enable the patient to return home safely or through the referral process, place the patient at the appropriate level of care. The discharge planning process addresses all transitions between levels of care with an emphasis on continuity of care...Case Management will determine and utilize patient/caregiver goals and preferences...Once the Case Management...or Social Worker complete the transition evaluation and plan...make the necessary arrangements required to execute the transition plan including arranging...transportation...Case Management staff will document the...plan...patient choice or preferences...in the patient’s medical record...” 2. On November 17, 2025, at 2:56 p.m., a review of Patient 18’s record was conducted with the Sepsis Program Coordinator (SPC) 2. An ambulance document titled, “Patient Care Report,” dated August 22, 2025, was reviewed. The document indicated, “...14:12 [2:12 p.m.]...identification...[Patient 18’s Name]...home address...Homeless...” A facility document titled, “ED [Emergency Department] Note Physician,” dated August 22, 2025, was reviewed. The document indicated, “...14:52 [2:52 p.m.]...with history of schizophrenia [a mental disorder characterized by a distorted perception of reality], and methamphetamine [a powerful and highly addictive stimulant (a substance which produce effects such as heightened alertness, increased energy, and elevated mood)] abuse brought in by ambulance for heat exhaustion. Patient states he was recently kicked out of a home he should be staying in and is now staying on the streets. He would like to speak with the social worker about getting off the streets...” A facility document titled, “Homeless Patient Identification Form,” dated August 22, 2025, was reviewed. The document indicated, “...Permanent Housing...Questions 1: Do you have a fixed and regular night-time residence...no... if no: The patient is considered “homeless”...under the homeless patient discharge planning law...” A facility document titled, “ED disposition,” dated August 22, 2025, was reviewed. The document indicated, “...1546 [3:46 p.m.] ED discharged...home...” A facility document titled, “ED Note Physician,” dated August 22, 2025, was reviewed. The document indicated Patient 18 was seen again at the ED on August 22, 2025, at 9:47 p.m. The document indicated, “...08/22/25 [August 22, 2025]22:31 [10:31 p.m.]...Chief Complaint...Rash/Itching, felt food poisoning...History of present illness... Patient [Patient 18] was seen her [sic, here] earlier today and discharged...Requesting to see the social worker, however, social worker has gone home for the day...” A facility document titled, “Order Sheet,” dated August 22, 2025, was reviewed. The document indicated, “...Social Service Consult...STAT...08/22/25 [August 22, 2025] 21:48 [9:48 p.m.] ...Homeless...” A review of the facility document titled, “ED Discharge Form,” dated, August 22, 2025, indicated, “...22:54 [10:54 p.m.]PDT...ED Discharged...Home...” There was no documented evidence a consult with a social worker was ordered and the required services for a homeless patient, which included infection disease screening, vaccinations, recommendations for follow up care, clothing, discharge medications, transportation and affordable health coverage, were offered to Patient 18 before Patient 18 was discharged on August 22, 2025, at 3:46 p.m. There was no documented evidence a social worker assessed Patient 18 prior to the patient’s discharge on August 22, 2025, at 10:54 p.m. During a concurrent interview with the SC, the SC stated she was unable to find documentation a social worker assessed Patient 18 before the patient was discharged. The SC stated he was unable to find documentation the required services for a homeless patient were offered to Patient 18 before Patient 18 was discharged. On November 18, 2025, at 12:19 p.m., a concurrent interview and review of Patient 18’s record were conducted with the Social Work Manager (SWM). A facility document titled, “Clinical Resource Management Department Assignment,” dated August 22, 2025, was reviewed. The document indicated, “...Unit...ED...Social Worker...[name of SW] ...” The SWM stated the Social Worker (SW) assigned to the ED that day left at 3:30 p.m. but there was SW coverage until 4:30 pm. The SWM further stated after 4:30 p.m., there was no SW assigned to consult specifically for the homeless patients in the ED and the homeless patient will be seen the following day at 7 a.m., if the patient is still there. A concurrent interview and review of Patient 18’s record were conducted on November 19, 2025, at 1:10 p.m., with the ED Director (EDD) and ED Manager (EDM). The EDD stated there was no documentation the required services for homeless patients, such as shelter, infectious disease screening, vaccinations, clothing, transportation and affordable health coverage, were offered to Patient 18 before Patient 18 was discharged. A concurrent interview and review of the facility’s P&Ps titled, “ ...Homeless Discharge Planning,” and “ ...Pre-Discharge Services for Homeless Patient,” dated February 16, 2023, were conducted on November 18, 2025, at 1:15 p.m., with the EDD and EDM. The EDD stated there was no documentation the facility’s staff offered the required services to Patient 18 before Patient 18 was discharged in accordance with the facility’s P&P. A review of the P&P titled,” “ ...Homeless Discharge Planning,” dated February 16, 2023, was conducted. The P&P indicated,”...Offer services to Homeless Patients Prior to Discharge...Hospital will offer various services to Homeless Patients prior to discharge as outlined ...PRE-DISCHARGE SERVICES FOR HOMELESS PATIENT ...” A review of the P&P titled, “ ...Pre-Discharge Services for Homeless Patient, “ dated February 16, 2025, was conducted. The P&P indicated, “...Infection disease Screening...Hospital staff will offer the homeless patient screening for infectious disease common to the region...Vaccinations...Hospital staff will offer the homeless patient appropriate to their presenting medical condition...Clothing...If the homeless patient does not arrive with weather- appropriate clothing, the Hospital staff will offer weather-appropriate clothing and encourage the patient to change into weather appropriate clothing and encourage to change into weather-appropriate clothing before leaving the hospital...Transportation... Hospital staff will offer the homeless patient transportation after discharge to his or her post discharge destination...Assistance with Affordable Health Coverage...The hospital staff will screen the homeless patient for and offer assistance with enrolling in any affordable health insurance coverage for which he or she is eligible...” 3. On November 18, 2025, at 11:30 a.m., a review of Patient 26’s record was conducted with the RM. A facility document titled, “Admission History & Physical,” dated October 17, 2025, was reviewed. The document indicated Patient 26 was admitted to the facility on October 13, 2025, with a chief complaint of altered level of consciousness (a state when a person is not alert, awake, and/or fully aware of their surroundings) and right sided weakness. The document indicated on October 13, 2025, patient had a surgery to remove a clot on the left side of her brain. A facility document titled, “Order Sheet,” dated October 29, 2025, was reviewed. The document indicated, “...acetaminophen-Hydrocodone (a strong pain medication] 325 mg [milligrams, unit of measurement]- 5 [five] mg tab [tablet] 1 [one] tab...Tube [gastrostomy tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems] Q [every] 4 [four] hr [hours]...Pain Moderate, 6 [six, pain score for a pain scale of one to 10, 10 meaning most severe pain], Routine [administered regularly]...” A facility document titled, “Medication Administration,” dated November 4, 2025, was reviewed. The document indicated acetaminophen-Hydrocodone 325 mg-5mg one tablet was administered on November 4, 2025, at 1:53 p.m., by Registered Nurse (RN) 11. A facility document titled, “PRN [to be administered as needed] Response Form Task,” dated November 4, 2025, at 2:53 p.m., was reviewed. The document indicated, “...Medication Effectiveness & Pain Response Form: Medication Administration Painison[sic]: Medication Effective: No Medication Response: Continue to observe for symptoms...” There was no documented evidence a pain score was assigned for Patient’s 26 response to the administered pain medication. On November 18, 2025, at 2 p.m., a review of Patient 26’s record and concurrent interview was conducted with the Clinical Manager (CM). The CM stated the pain reassessment must be completed by the RN within an hour of administration of the pain medication and must include the reassessment of the pain score. A review of the facility’s P&P titled, “Adult Pain Management,” dated December 19, 2024, was conducted. The P&P indicated, “...Documentation of pain assessment consists of the following...Date and time of assessment...Patient’s comfort goal [acceptable pain intensity]...Location of pain...Appropriate pain scale...Reassessment shall be documented within 60 minutes post intervention, and based on the patient’s condition which includes evaluation of sedation [a state of calmness, relaxation or sleepiness induced by medication] as well as appropriate vital signs...””

“DISCHARGE PLANNING-FREEDOM OF CHOICE CFR(s): The hospital , as part of the discharge planning process, must inform the patient or the patient’s representative of their freedom to choose among participating Medicare providers and suppliers of the post-discharge services and must, when possible, respect the patient’s or the patient’s representative goals of care and treatment preferences, as well as other preferences they express. The hospital must not specify or otherwise limit the qualified providers or suppliers that are available to the patients. This Standard is not met as evidenced by: 50122 Based on interview and record review, the facility failed to ensure the facility’s policy and procedure (P&P) was implemented, for one patient of 30 sampled patients (Patient 3), when coordination of care was not facilitated after Patient 3 and her family requested to return to home residence out of state. This failure had the potential to cause delays in the provision of care to Patient 3. Findings: On November 17, 2025, at 2:30 p.m., a review of Patient 3’s record was conducted with the Stroke Program Coordinator (SPC). A facility document titled, “Admission H&P [History and Physical]...,” dated March 15, 2025, was reviewed. The document indicated Patient 3 had a medical history of cerebral vascular accident (stroke, loss of blood flow to a part of the brain), atrial fibrillation (a rapid, irregular heartbeat caused by a problem with the heart’s electrical signals), peripheral artery disease (condition where arteries which supply blood to the legs and feet become narrowed or blocked), and hypertension (high blood pressure, normal is 120/80). The document indicated Patient 3 was admitted to the facility on March 15, 2025, for a fall, and pelvic and hip fracture (a break in the bones). On November 17, 2025, at 2:45 p.m., a facility document titled, “Case Management Reassessment,” dated March 17, 2025, at 5:23 p.m., authored by Social Worker (SW) 1 was reviewed. The document indicated, “...Emergency contact is her [family member, FM] [Name of FM]...[FM] acts as her surrogate agent...” On November 17, 2025, at 2:50 p.m., a facility document titled, “Progress Note,” dated March 16, 2025, at 4:42 p.m., authored by MD 2, was reviewed. The document indicated, “...[family member, FM] is at bedside and they live in [name of a state]...She would like transport [Patient 3] home...have discussed surgical verus [sic, versus, against] nonsurgical options with hip replacement [a surgical procedure where a damaged hip joint is replaced with an artificial implant] in the future. She [Patient 3] is very frail and has severe PAD [peripheral artery disease]. I discussed my concern about performing an ORIF [open reduction internal fixation, a surgical procedure to treat fractures] of the acetabulum [the socket of the hip bone]...She [FM] would like to discuss with social work possible transport home...” On November 17, 2025, at 3:50 p.m., a facility document titled, “Progress Note,” dated March 17, 2025, at 5:08 p.m., authored by MD 3 was reviewed. The document indicated, “...[FM] is at bedside who states goal is to get patient back to [name of a state] as soon as possible...Patient and family requesting to speak with social worker and case management to see if there is any available resources that could help with getting patient back to [name of a state]...Consult case management and social worker...” On November 17, 2025, at 3:55 p.m., a review of the facility document titled, “Case Management Reassessment,” dated March 17, 2025, at 5:23 p.m., authored by Social Worker (SW) 1 was reviewed. The document indicated, “...Consult ordered 3/16/25 [March 16, 2025], DCP [direct care provider] patient’s [FM] [name of FMr] would like options on getting patient back home...Pt [Patient 3] insured through [name of insurance]...[FM] states neither her nor [Patient 3] are able to afford to hire medical transportation...pt expressed feeling stressed and guilty about the situation...SW provided hope her [FM] would figure out a solution...[FM]...stated pt’s PCP [primary care provider] informed her to “get pt to [name of a state] asap [as soon as possible]...SW spoke with [FM] and outlined option, including what insurance will and will not cover. SW explained Medicare only covers a limited number of miles. SW also explained that some...HMOs [health maintenance organization, a type of managed health insurance plan] provide transportation via their [name of insurance] plans and suggested she contact [name of state] [name of insurance] to inquire if they have resources to assist in getting pt back home...[FM] expressed frustration and disappointment...Most options for medical transportation home would require out-of-pocket expense, which was explained to both pt and [FM]. SW provided next day SW with above information and requested she continue to explore options with [FM] and team...” There was no documented evidence insurance discussion or estimates of payment and/or out-of-pocket costs for transportation to another state was discussed with Patient 3 or Patient 3’s FM. On November 18, 2025, at 12:15 p.m., an interview was conducted with the Manager of Social Work (MSW). The MSW stated Care coordination is part of the social worker’s role. The MSW stated she would want to call to arrange for transfer of the patient because “that’s where their support system and established care are, there is familiarity, it is the patient’s preference...” On November 19, 2025, at 12:30 p.m., an interview was conducted with the DCM. The DCM stated she was not able to find documentation of insurance contact or proof of cost of coverage for transportation to another state were discussed with Patient 3 or her FM. The DCM stated what usually happens is for the facility to figure out what agency is needed by the patient and what the contracted services are. The DCM stated the facility would then talk to the patient and the patient’s family and try to get their choice, then they would call the insurance and state family is requesting to go home and the insurance would let them know if the insurance is requesting the patient to go back in-network (within the covered area of the insurance). The DCM stated, if the insurance is not requesting in-network, then the responsibility goes to the patient and the facility would let the patient know what the patient is responsible for and would get a list of quotes to provide to the patient. A review of the facility P&P titled, “Hospital Case Management Transition Planning,” dated June 22, 2023, indicated, “...Transition planning includes coordination of hospital, community providers, and support systems to enable the patient to return home safely or through the referral process, place the patient at the appropriate level of care. The discharge planning process addresses all transitions between levels of care with an emphasis on continuity of care...Case Management will determine and utilize patient/caregiver goals and preferences...Once the Case Management...or Social Worker complete the transition evaluation and plan...make the necessary arrangements required to execute the transition plan including arranging...transportation...Case Management staff will document the...plan...patient choice or preferences...in the patient’s medical record...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 50122 Based on interview and record review, the facility failed to comply with provisions in 42 CFR §489.20 and §489.24, when it failed to ensure a physician to physician consult was conducted to determine whether the facility was capable and had capacity to accept pediatric transfers for five of 25 patients (Patients 21, 22, 23, 24, and 25). These failures resulted in Patients 21, 22, 23, 24, and 25, transfers to be denied based on the transfer center reference list which indicated “No Pediatric Transfers”, without a physician-to-physician consultation. This failure had the potential to cause a delay in treatment for Patients 21, 22, 23, 24 and 25.”

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 50122 Based on interview, and record review, Facility A failed to ensure transfer forms were completed prior to transfer to a facility for higher level of care (HLOC-care that exceeds the transferring facility’s capacity and capability of services) for two of 25 patients (Patient 9, and 18). This failure had the potential to cause the patients to not be informed of their rights, risks and benefits of transfer, and potential for harm to the patient’s health and well-being. Findings: On August 18, 2025, at 8:30 a.m., an unannounced visit was conducted at Facility A for an Emergency Medical Treatment and Labor Act (EMTALA-a federal law that requires hospitals to provide emergency care to anyone who needs it, regardless of their ability to pay or insurance status) survey. 1. A review of Patient 9’s medical record was conducted on August 18, 2025, at 9:30 a.m., with the Regulatory manager (RM). A review of the facility document titled, “ED [Emergency Department] Note - Physician,” dated July 29, 2025, at 9:55 p.m., and signed by MD (Medical Doctor) 1, was conducted with the Regulatory Manager (RM). The document indicated Patient 9 arrived at Facility A’s emergency department with complaints of right arm numbness (a loss of feeling in a part of the body) and expressive aphasia (partial loss of the ability to produce language). A transfer to a HLOC facility was requested by MD 1 due to the need for pediatric neurology (study of the brain and spinal cord). A review of the facility document titled, “Original Order...Decision to Transfer,” dated July 29, 2025 at 10:02 p.m., indicated a request to transfer the patient to another facility. There was no documented evidence of a transfer form found in Patient 9’s medical record. On August 18, 2025, at 3:30 p.m., an interview was conducted with the RM. The RM stated, “...It is the responsibility of the physician to complete the transfer form...The reason for transfer and risks and benefits of transfer should be discussed with the patient/parents prior to transfer...It is important to get consent for transfer so that the patient and family are aware of where they are going and why, and it is their right as a patient to know the risks and benefits...” On August 19, 2025, at 2 p.m., an interview was conducted with the Emergency Department Manager (EDM) and the Emergency Department Director (EDD). The EDM stated, “...it is the unit secretary’s responsibility to get the signature from the patient/family...the provider signs as well...the yellow copy goes into the HIM [Health information management- medical records] bin...the nurses give report to the facility and are responsible for documenting the report...the secretary, Registered nurse and physician are responsible for completing the transfer form in the emergency department...” 50304 2. A review of Patient 18’s medical record was conducted on August 18, 2025, at 2:55 p.m., with the Quality Analyst Improvement Specialist (QAI). A review of an untitled facility document, dated April 4, 2025, was conducted and indicated,”...[Name of Patient 18]...ADMIT DT [Date] / Time: 04/04/25 [April 4, 2025]...Chief Complaint : 5150 [a hold used when a person, due to a mental health disorder, is deemed a danger to themselves or others, or is gravely disabled]...” A facility document titled, “ED [Emergency Department] Note - Physician,” dated, April 4, 2025, was reviewed with the QAI. The document indicated,”...brought in by PD [Police Department] on a 5150 hold for danger to self...DISPOSITION: Transfer to Psych [Psychiatric- branch of medicine that focuses on the diagnosis, treatment, and prevention of mental health conditions] facility...electronically signed on 04/04/25 [April 4, 2025] 06:09 [6:09 a.m.]...[Name of MD 2]...” There was no documented evidence of a transfer form in Patient 18’s record. On August 18, 2025, at 3:41 p.m., an interview was conducted with the Manager of Social Services (MSS). The MSS stated she was not able to locate the transfer form for Patient 18 in the chart. The MSS stated the transfer forms should have been in the chart. The MSS stated it is important to complete the transfer form to show that the patient was “medically stable [condition is under control or had improved] for the level of care” for the accepting facility. On August 18, 2025, at 3:43 p.m., an interview was conducted with the RM. The RM stated it is important to complete the transfer form “for patient rights.” The RM stated, “...They should know where they are going, why, how, and they have the option to refuse...” A review of the facility policy and procedure titled,”...ACCEPTANCE OF PATIENTS TRANSFERRED TO AND FROM OTHER FACILITIES,” dated January 19, 2023, indicated, “...The hospital shall send (with the patient) to the receiving facility copies of all medical records related to the condition needing continued care. The record must include...patient’s informed written consent to the transfer or if none can be obtained, a physician’s written certification that...all reasonable steps were taken to secure informed consent, and...that the medical benefits outweigh the risks of transfer...””

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 50122 Based on interview and record review, the facility failed to ensure a physician to physician consultation was conducted prior to transfer denial, for five of 25 patients (Patients 21, 22, 23, 24, and 25). This failure resulted in the denial of pediatric patients’ transfers without a physician-to-physician consultation, and the potential to delay the treatment of these patients. Findings: On August 18, 2025, at 8:30 a.m., an unannounced visit was conducted at the facility for an Emergency Medical Treatment and Labor Act (EMTALA-a federal law that requires hospitals to provide emergency care to anyone who needs it, regardless of their ability to pay or insurance status) survey. On August 18, 2025, at 10 a.m., an interview and record review of the facility document titled, “State of California Department of Public Health...License to [Name of Facility A],” with an effective date of November 1, 2024, was conducted with the Regulatory Manager (RM). The document indicated, “...Bed Classifications...14 Pediatrics...” The RM stated that Facility A had 14 beds for pediatric patients. On August 19, 2025, at 9:40 a.m., an interview and review of an untitled facility document was conducted with the RM. The RM stated the document was their transfer log from the transfer center, who is responsible for arranging transfer of patients from other facilities. The document indicated five patients (Patients 21, 22, 23, 24 and 25) were declined transfers for higher level of care (HLOC - care that is of a higher degree of service than the facility is capable). The document indicated: A. “...Patient Name...[Name of Patient 21]...Referring Location Name...[name of Facility B]...Complaint List...unknown...Service Line Requested...PEDIATRICS...Case Status Notes...[Name of RN 1]...Location Decision History...Declined...” B. “...Patient Name...[Name of Patient 22]...Referring Location Name...[name of Facility B]...Complaint List...cardiac complications [complications affecting the heart]...Service Line Requested...PEDIATRICS...Location Decision History...Declined...” C. “...Patient Name...[Name of Patient 23]...Referring Location Name...[name of Facility C]...Complaint List...Pneumonia [lung inflammation caused by bacterial or viral infection], Hypoxia [low oxygen level]...Service Line Requested...PEDIATRICS...Case Status Notes...[Name of RN 3]...Location Decision History...Declined...” D. “...Patient Name...[Name of Patient 24]...Referring Location Name...[name of Facility C]...Complaint List...Respiratory Failure [occurs when the lungs cannot adequately exchange oxygen and carbon dioxide between the blood and the atmosphere]...Service Line Requested...PEDIATRICS...Case Status Notes...[Name of RN 3]...Location Decision History...Declined...” E. “...Patient Name...[Name of Patient 25]...Referring Location Name...[name of Facility C]...Complaint List...Appendicitis [a medical condition in which the appendix becomes inflamed and painful]...Service Line Requested...PEDIATRICS...Case Status Notes...[Name of RN 4]...Location Decision History...Declined...” On August 19, 2025, at 11 a.m., a review of the facility document titled, “Emergency Department snapshot,” dated June 25, 2025, at 6 a.m., and 6 p.m., was conducted with the RM. The document indicated there were no patients located in the Pediatric unit or in the emergency department on June 25, 2025, from 6 a.m., to 6 p.m. On August 19, 2025, at 11:15 a.m., a review of the facility email document, dated February 14, 2025, at 3:43 p.m., was conducted with the RM. The document indicated a subject line titled, “[Name of network] - Transfer Center reference table 2.14.25 [February 14, 2025]...,” sent from the Chief Strategy Officer [CSO] at Facility A to the Director of the Transfer Center [DTC], indicated, “...After much discussion with our team at...[name of facility A]...we have an updated reference table. See attached...” On August 19, 2025, at 11:15 a.m., a review of the attached document was conducted with the RM. The document titled, “On-call by facility...[Name of network] ...2.14.25 [February 14, 2025]...Pediatrics...[name of Facility A]...No transfers accepted...” On August 19, 2025, at 11:40 a.m., an interview was conducted with the Transfer Center Manager (TCM). The TCM stated, “...The transfer center has a reference list developed by [name of facility A] leadership and director for [name of network]...[name of Chief Strategy Officer (CSO)] advised their leadership they are no longer going to take pediatric transfers because the children they were accepting ended up needing a higher level of care [care outside the capacity and capability of the facility]...rather than taking those transfers and then subsequently needing to transfer them to another facility, they would rather decline the patient...The reference list for [name of Facility A] stated...Pediatrics - Services not available at...[name of Facility A]...we are not higher level of care...” The TCM further stated, “...the transfer requests for transfer of [name of Patients 21, 22, 23, 24 and 25] were declined by the Transfer center registered nurses [RN 1, RN2, RN 3, RN 4] who followed the guidance given by the reference list they had received from [name of facility A]...” On August 19, 2025, at 12 p.m., an interview was conducted with the DTC. The DTC stated, “...The leadership at [name of Facility A] made a change that they are no longer accepting pediatric patients at [name of Facility A]...before this change, the sending facility would take the phone call and connect with the ED [emergency department] to facilitate an MD to MD [physician to physician] consult...once they get acceptance...set up transportation...When [name of facility] made the change...they don’t attempt the transfers...it is a service they no longer provide...They cannot determine if the patient was a HLOC without an MD to MD consult...” On August 19, 2025, at 1 p.m., an interview was conducted with the CSO and the CNO. The CSO stated, “They thought the physicians were consulting and speaking to each other and letting the transfer center know if they accepted or declined the transfer. The whole purpose is to not delay care...” The CNO stated, “...They need to clarify the reference notes of no transfer accepted...the expectation is to follow their policy...the transfer center would need to refer to the MD [physician] prior to declination...they were not aware of the declinations of pediatric transfers in June...” A review of the facility policy and procedure titled, “...ACCEPTANCE OF PATIENTS TRANSFERRED TO AND FROM OTHER FACILITIES,” dated January 19, 2023, indicated, “...Medical appropriateness for incoming transfer will be determined by the receiving physician...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50454 Based on interview and record review, the facility failed to ensure patient rights were honored, for two of 20 sampled patients (Patients 1 and 2), in accordance with the facility’s policies and procedures (P&P), when restraint orders were not renewed in a timely manner. These failures resulted in the misuse of restraints and had the potential for patient harm. Findings: 1 a. On July 1, 2025, at 1 p.m., a review of Patient 1’s medical record was conducted with the Stoke Program Coordinator (SPC). A facility document titled, “Admission H&P [History and physical],” dated February 17, 2025, was reviewed and indicated Patient 1 was admitted to the facility on February 17, 2025, and presented to the emergency room by ambulance for left sided chest pain that began two weeks ago. The document indicated, “...Past medical history includes the set of expressive aphasia [a language disorder where individuals have difficulty producing speech]...” The facility document titled, “Restraint Initiation Non Violent,” dated February 17, 2025, at 2:31 p.m., was reviewed and indicated, “...Priority: Routine, Requested start date and time: 2/17/2025 [February 17, 2025] 14:31 [2:31 p.m.] PST [Pacific Standard Time], Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 [two] Point Extremity [a limb of the body, specifically the arms and legs], Restraint location: Bilateral [both sides] Upper Extremity, Frequency: Once scheduled, Continuous: No...” The facility document titled, “Restraint Renewal Non Violent,” dated February 18, 2025, at 5:18 p.m., was reviewed and indicated, “...Priority: ASAP [as soon as possible], Requested start date and time: 2/18/2025 [February 18, 2025] 17:18 [5:18 p.m.] PST, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No...” An untitled facility document, dated February 17, 2025, 1 p.m., through February 21, 2025, 1:59 p.m., was reviewed. The document indicated, on February 18, 2025, at 4 p.m., restraints remained on Patient 1 despite not having an active order on February 18, 2025, from 2:31 p.m. to 5:18 p.m. The facility document titled, “Restraint Renewal Non Violent,” dated March 6, 2025, at 10:54 a.m., was reviewed and indicated, “...Priority: Routine, Requested start date and time: 3/6/2025 [March 6, 2025] 10:54 a.m. PST, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No...” The facility document titled, “Restraint Renewal Non Violent,” dated March 7, 2025, at 6:38 p.m., was reviewed and indicated, “...Priority: Routine, Requested start date and time: 3/07/2025 [March 7, 2025] 18:38 [6:28 p.m.] PST, Reason for Restraints: Disconnects/removes therapeutic devices, Criteria for Release: Behavior no longer warrants restraint, Restraints: Hand mittens, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No...” An untitled facility document, dated February 17, 2025, 1 p.m., through March 8, 2025, 1:59 p.m., was reviewed. The document indicated, from March 6, 2025, at 11 a.m., to March 7, 2025, at 6 p.m., restraints remained on Patient 1 despite not having an active order on March 6, 2025, at 10:54 a.m., to March 7, 2025, at 6:38 p.m. An interview was conducted on July 1, 2025, at 1:15 p.m., with the SPC. The SPC stated restraints should be renewed within 24 hours. Based on documentation on February 18, 2025, the restraints were not removed or discontinued by the nurse while waiting for the renewal order. The SPC stated the nurse should have discontinued the restraints on February 18, 2025, at 2:31 p.m., when the order expired. There was no active restraint order for Patient 1 for approximately two and a half hours. The SPC further stated based on documentation on March 6, 2025, at 10:54 a.m., the restraints were not discontinued by the nurse while waiting for the renewal order. The SPC stated the nurse should have discontinued the restraints on March 6, 2025, at 10:54 a.m., when the order expired. There was no active order for Patient 1 for approximately eight hours. 1 b. On July 1, 2025, at 1:30 p.m., a review of Patient 2’s medical record was conducted with the SPC. A facility document titled, “Admission H&P,” dated June 25, 2025, was reviewed and indicated Patient 2 presented to the emergency room after sustaining a fall in the bathtub. Patient 2 was admitted for the diagnosis of Fournier Gangrene (a rare, but life-threatening infection). The facility document titled, “Restraint Initiation Non Violent,” dated June 25, 2025, at 1:21 p.m., was reviewed and indicated, “...Priority: Routine, Requested start date and time: 06/25/2025 [June 25, 2025] 10:00 PDT [Pacific Daylight Time], Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No...” The facility document titled, “Restraint Renewal Non Violent,” dated June 26, 2025, at 12:32 p.m., was reviewed and indicated, “...Priority: Routine, Requested start date and time: 06/26/2025 [June 26, 2025] 12:32 PDT, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No...” An untitled facility document, dated June 26, 2025, 1:29 a.m., through July 2, 2025, 1:59 p.m., was reviewed. The document indicated, on June 26, 2025, at 10 a.m., restraints remained on Patient 2 despite not having an active order on June 26, 2025, from 10 a.m., to 12:32 p.m. The facility document titled, “Restraint Renewal Non Violent,” dated June 30, 2025, at 11:04 a.m., was reviewed and indicated, “...Priority: Routine, Requested start date and time: 06/30/2025 [June 30, 2025] 11:00 a.m. PDT, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No...” The facility document titled, “Restraint Renewal Non Violent,” dated July 1, 2025, at 3:26 p.m., was reviewed and indicated, “...Priority: Routine, Requested start date and time: 07/01/2025 [July 1, 2025] 15:26 [3:26 p.m.] PDT, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No...” An untitled facility document, dated June 30, 2025, 12:00 a.m. through July 2, 2025, 12:00 a.m., was reviewed. The document indicated, on July 1, 2025, at 11:04 a.m., restraints remained on Patient 2 despite not having an active order on July 1, 2025, from 11:04 a.m., to 3:26 p.m. An interview was conducted on July 1, 2025, at 3:20 p.m., with Registered Nurse (RN) 1. RN 1 stated Patient 2 is currently on the unit and wearing restraints. RN 1 further stated the order expired on July 1, 2025, at 11:04 a.m., and should not have been placed at 11:04 a.m. RN 1 further stated there is currently no active order right and Patient 2 should not be in restraints. An interview was conducted on July 2, 2025, at 1:13 p.m., with the Accreditation and Regulatory Manager (ARM). The ARM stated if the restraint order is not renewed within 24 hours, it is expired and should no longer be on the patient until a new order is placed. Our policy reads order must be renewed “daily”, which means within a 24-hour timeframe. The facility P&P titled, “DES ADM 749 RESTRAINT & SECLUSION,” dated January 18, 2024, was reviewed. The P&P indicated, “...to define [name of facility] approach to the use of Restraints and Seclusion for patients in a way that protects the patient’s health and safety, and preserves their dignity, rights, and well-being...Restraint: any manual method: physical or mechanical device material, or equipment that immobilizes or reduces the patients ability to move...Authorized staff must never write Restraint orders on an “as needed” basis or as PRN orders or standing orders...Non-violent/Medical Behavior order for restraints based on medical needs/behaviors must be renewed daily...” The facility P&P titled, “DES ADM 970 PHYSICIAN NOTIFICATION,” dated December 20, 2019, was reviewed. The P&P indicated, “...It is the policy of [name of facility] to assure timely physician notification and appropriate physician intervention to treat each patient’s needs...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This Standard is not met as evidenced by: 50454 Based on interview and record review, the facility failed to ensure patient rights were honored, for one of 20 sampled patients (Patient 3), in accordance with the facility’s policies and procedures (P&P), when restraint orders were placed on an “as needed” basis. This failure resulted in the misuse of restraints and had the potential for patient harm. Findings: On July 1, 2025, at 1:45 p.m., a review of Patient 3’s medical record was conducted with the Stoke Program Coordinator (SPC). A facility document titled, “Admission H&P [History and Physical],” dated June 15, 2025, was reviewed and indicated Patient 3 was admitted to the facility on June 15, 2025, and presented to the emergency room from a skilled nursing facility with shortness of breath. Admitting diagnosis of acute AKI (acute kidney injury- damage to the kidney causing it to not function properly) and hypokalemia (increased levels of potassium in the blood). The facility document titled, “Restraint Renewal Non Violent,” dated June 16, 2025, at 8:03 a.m., was reviewed and indicated, “...Priority: Routine, Requested start date and time: 06/16/2025 [June 16, 2025] 08:03 a.m. [8:03 a.m.] PDT, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 [two] Point Extremity [a limb of the body, specifically the arms and legs], Restraint location: Bilateral [both sides] Upper Extremity, Frequency: Once scheduled, Continuous: No...” An untitled facility document, dated June 14, 2025, 3:52 a.m. through June 21, 2025, 3:59 p.m., was reviewed. The document indicated, on June 17, 2025, at 7:45 a.m., restraints were discontinued and no longer needed based on RN assessment. The facility document titled, “Restraint Renewal Non Violent,” dated June 18, 2025, at 10:40 a.m., was reviewed and indicated, “...Priority: Routine, Requested start date and time: 06/18/2025 [June 18, 2025] 10:40 a.m. PDT, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No...” The facility document titled, “Restraint Renewal Non Violent,” dated June 19, 2025, at 11:01 a.m., was reviewed and indicated, “...Priority: Routine, Requested start date and time: 06/19/2025 [June 19, 2025] 11:01 a.m. PDT, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No...” The facility document titled, “Restraint Renewal Non Violent,” dated June 21, 2025, at 07:30 [7:30 a.m.], was reviewed and indicated, “...Priority: Routine, Requested start date and time: 06/21/2025 [June 21, 2025] 07:30 a.m. PDT, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No...” An untitled facility document, dated June 14, 2025, 3:52 a.m. through June 21, 2025, 3:59 p.m., was reviewed. The document indicated the restraints were not needed for Patient 3 on June 18, June 19, or June 21. An interview was conducted on July 2, 2025, at 1:20 p.m., with Registered Nurse (RN) 2. RN 2 stated the Resident ordered the restraints. However, on June 17, 2025, at 7:45 am, the restraints were discontinued by the nurse because they were no longer deemed necessary based on nursing assessment. The restraints were “pre-ordered” by the resident on June 18, June 19, and June 21. An interview was conducted on July 2, 2025, at 1:25 p.m., with the ICU Manager (ICU-M). The ICU-M stated sometimes the residents “pre-order” the restraints despite the nurses not needing the order. The ICU-M further stated sometimes the residents think that they can put the order in “just in case” the nurses need them and that is not how it works. An interview was conducted on July 2, 2025, at 1:13 p.m., with the Accreditation Regulatory Manager (ARM). The ARM stated the Resident who placed the restraint orders on June 18, 2025, June 19, 2025, and June 21, 2025, no longer works here and can’t speak to why they were ordered when the patient no longer needed them. The facility P&P titled, “DES ADM 749 RESTRAINT & SECLUSION,” dated January 18, 2024, was reviewed. The P&P indicated, “...to define [name of facility] approach to the use of Restraints and Seclusion for patients in a way that protects the patient’s health and safety, and preserves their dignity, rights, and well-being...Restraint: any manual method: physical or mechanical device material, or equipment that immobilizes or reduces the patients ability to move...Authorized staff must never write Restraint orders on an “as needed” basis or as PRN orders or standing orders...Non-violent/Medical Behavior order for restraints based on medical needs/behaviors must be renewed daily...” The facility P&P titled, “DES ADM 970 PHYSICIAN NOTIFICATION,” dated December 20, 2019, was reviewed. The P&P indicated, “...It is the policy of [name of facility] to assure timely physician notification and appropriate physician intervention to treat each patient’s needs...””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure each patient or patient’s representative were informed of their patient’s rights for one of 30 sample patients (Patient 20),when: 1. The family was not informed the patient was being discharged and transferred to another facility; and 2. The patient or the patient representative was not given the Important Message from Medicare (IMM - notification for right to appeal discharge). This failure resulted in poor communication between the facility and Patient 20 or Patient 20’s representative, and had the potential to interfere with Patient 20’s ability to participate in the discharge planning or appeal to the discharge. Findings: 1. On May 7, 2025, a record review and concurrent interview was conducted with Stroke Program Coordinator (SPC). A facility document titled, “History and Physical” (H&P), dated March 25, 2025, was reviewed. The “H&P” indicated, Patient 20 was admitted to the facility on March 25, 2025, as a transfer from another facility for elevated troponin level and fall. A facility document titled, “Progress Note EMR,” dated April 11, 2025, at 8:56 a.m., was reviewed. The document indicated, “...Stop Trazadone as pt [patient] is drowsy in daytime. Wait one more day to see if mentation clears, then DC to SNF [skilled nursing facility]...Stop IV [intravenous-in the vein] narcotics, if needed RN can call for a reorder, as family is concerned they cause delirium and she is very sensitive...they are still looking for Accepting SNF...” A facility document titled, “Case Management Reassessment,” dated April 12, 2025, at 3:21 p.m., was reviewed. The document indicated, “...Patient is accepted to [Name of SNF] 1...Pick up time 17:00 [5:00 p.m.] today...” A facility untitled document dated April 12, 2025, at 18:47 (6:47 p.m.) was reviewed. The document indicated, “...report given to [name of staff] 1 at [name of facility] 3. A facility document titled, “Patient Transfer,” undated, indicated, “...medically indicated transfer...Transfer Requirements...Transferring Physician...[Name of physician] 2...Accepting Physician...Blank...Receiving Facility Representative...Blank...Date/Time Patient Accepted...Blank...Nurse Receiving Report...Blank...Date/Time Report Received...blank...Details of Transfer...Transporter...” A facility untitled document dated April 12, 2025, at 7:50 p.m., was reviewed. The document indicated, “...RN from [Name of facility] 4 called for report. Infromed [sic] report given to [name of staff] 1 at [name of facility] 3... pt has just arrived [name of facility] 3...” There was no documented evidence that the facility contacted Patient 20’s representative. 2. A facility document titled, “Important Message from Medicare,” indicated, “...Please sign below to indicate you received and understood this notice...I have been notified of my rights as a hospital inpatient and that I may appeal my discharge by contacting my QIO (quality improvement organization)...Signature of Patient or Representative...” The document was not signed by the patient or patient representative per the facility’s policy and procedure. The document indicated, “...Verbal Consent from /son...Date/Time...03/27/2025 2:52 PM...” The document did not indicate a copy was given to the patient or patient representative. A facility document titled, “Important Message from Medicare,” indicated “...Please sign below to indicate you received and understood this notice...I have been notified of my rights as a hospital inpatient and that I may appeal my discharge by contacting my QIO (quality improvement organization)...Signature of Patient or Representative...Date/Time 04/11/2025...” The document was not signed by the patient or the patient’s representative per facility’s policy and procedure. The document indicated “...Signature of Patient or Representative...See notes above...Note: IMM letter obtained from Robert (son) via phone...” The document did not indicate a copy was given to the patient or patient representative. The document did not indicate the name of the witness/staff who obtained the verbal consent. On May 7, 2025, at 1 p.m., an interview was conducted with the Accreditation and Regulatory Manager (ARM). The ARM stated the IMM was given to the patient or patient representative within two days of admission. She further states a follow up IMM was given to the patient or patient representative two days prior to discharge so they could have a choice to appeal the discharge. During a review of the facility’s policy and procedure (P&P) titled “HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE), dated April 20, 2020, indicated “...Important Message from Medicare (IMFM)...is a standardized written notice of beneficiary appeal rights regarding coverage decision made during a hospital stay...Hospital must provide the IMFM to the beneficiary...within two days of admission...and...not more than two calendar days before the day of discharge...Hospital must obtain the signature of the beneficiary (or his/her representative) on a copy of the IMFM and a Follow-up Notices(s) and must retain the signed copies in the beneficiary’s medical record...Hospital must designate individuals who must review the admission IMFM with the beneficiary and have the beneficiary sign and date the admission/initial IMFM to confirm receipt. The beneficiary must be given the original IMFM notice...If the representative agrees during a telephone call, a notice may be e-mailed to the representative. All telephone documentation must be signed, dated and witnessed by two...employees. During a review of the facility’s P&P titled, “DES ADM 335 DISCHARGE PROCESS,” dated January 19, 2023, indicated, “...that inpatient and observation patients, being discharged, are provided adequate discharge instructions prior to leaving facility...Inform patient’s family of the estimated time and date of discharge as soon as it’s known...on the day of discharge, review the patient’s discharge instructions with patient, family or representative...””

“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: 38479 Based on interview and record review, the facility failed to ensure patients received care in a safe setting for three of 30 sampled patients (Patient 6, 19, and 28),when: 1. For Patient 6, Durable Medical Equipment (DME, refers to medical devices and supplies that are designed for repeated use and are typically used at home to help individuals manage a medical condition or disability) was not ordered or provided prior to Patient 6’s discharge; 2. For Patient 19, pain medication was ordered with no indication for use, and no measurement of pain; and 3. For Patient 28, visual limitations were not included on the Care Plan. These failures had the potential to result in poor hospital experience by failing to keep patients safe by implementing services that would mitigate environmental risks upon discharge, accommodate an individual with special needs while hospitalized, and ensure indications for medications were addressed. Findings: 1. On May 5, 2025, at 8:30 a.m., an unannounced visit was conducted at the facility for a complaint validation survey. On May 6, 2025, a review of Patient 6’s medical record was conducted with the Accreditation Regulatory Manager (ARM). A review of the facility document titled, “Admission H&P [History and Physical] EMR [Electronic Medical Record],” dated March 26, 2025, at 10:35 p.m., indicated Patient 6 was admitted to the facility for auto versus pedestrian. Patient 6 had a medical history of general anxiety disorder (nervousness), Bipolar disorder (a psychiatric disorder characterized by both manic and depressive episodes), and developmental delay (a person not meeting age-appropriate milestones in one or more areas of development, including physical, cognitive, communication, social, or emotional development). A review of the facility document titled, “Progress Note EMR No Cosign SOAP [Subjective, Objective, Assessment, and Plan],” dated March 30, 2025, at 5:34 p.m., indicated, “...Assessment/Plan...Ordered...Other Durable Medical Equipment (DME)...” A review of the facility document titled, “PT [Physical Therapy] Initial Evaluation-Text,” dated March 29, 2025, at 2:41 p.m., indicated, “...Discharge Needs...Professional Skilled Services, Anticipated : Physical Therapy...Home Equipment, Anticipated...Gait belt for safety for caregiver (pt requesting)...” A review of the facility document titled, “IP [In patient] Patient Depart Summary,” dated April 1, 2025, at 11:05 a.m., indicated, “...Other Durable Medical Equipment (DME)...3/30/2025 [March 30, 2025] 7:46:00 [7:46 a.m.] PDT [Pacific Daylight Time]...DME (free text): Gait belt...Dx [Diagnosis]: multiple Rib Fractures...” During the review of Patient 6’s medical record with the ARM, there was no documented evidence an order was placed for a gait belt. A review of the facility’s untitled letter dated April 10, 2025, addressed to Patient 6, indicated an investigation was done regarding a complaint/grievance filed on April 4, 2025, regarding Patient 6’s hospital stay from March 26, 2025, to April 1, 2025. The document indicated Patient 6, “...requested...a gait belt...gait belt was not ordered by your doctor. If you would prefer these items, they would be an out of pocket cost to you...” On May 7, 2025, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she discharged Patient 6 on his first visit. RN 1 stated she recalls Patient 6 being upset with the DME he needed. RN 1 stated she remembers Patient 6 saying he would file a grievance, but RN 1 could not recall the reason why. RN 1 stated she could not recall anything about a gait belt prior to discharge home. On May 8, 2025, at 12:45 p.m., an interview was conducted with the Interim [Name of Facility] Director of Case Management (IDCM). The IDCM stated if the physician put an order in for a gait belt, case management (CM) would speak with the patient regarding coverage for the supply. If they were told of a need from a provider (like physical therapy), the CM should have spoken to the physician to obtain an order. The IDCM stated, “...the patient did not get a gait belt, there was never an order...CM relies on orders from the physician, and the person who was notified of the need should have been the one to communicate with the physician for an order. They should have documented that conversation...” A review of the policy and procedure (P&P) titled, “DES ADM 335 DISCHARGE PROCESS,” dated March 20, 2025, indicated, “...It is the policy, of [Name of Facility], that inpatient and observation patients, being discharged, are provided adequate discharge instructions prior to leaving the facility...confirm that all durable medical equipment is ordered or provided to patient...” 2. On May 7, 2025, at 9:37 a.m., a review of Patient 19’s medical record was conducted with the Stroke Program Coordinator (SPC). It indicated Patient 19 was admitted to the facility on December 11, 2024, at 18:51 (6:51 p.m.) for anemia (low level of red blood cells in the blood). A review of the facility document titled, “ED Note-Physician,” dated December 11, 2024, at 20:11 (8:11 p.m.) was reviewed and indicated “...h/o [history of] sickle cell disease and CKD [chronic kidney disease] requiring nightly peritoneal dialysis [method of removing waste and excess fluid from blood when kidneys are not functioning] presenting from outpatient hematologist for Hgb [hemoglobin] 6 [normal range 12-15]...” A review of the facility document titled, “Orders,” dated December 12, 2024, was reviewed. The document indicated, “...Keterolac [Toradol] 15 mg [unit of measurement]=0.5 mL [unit of measurement] Injection, IV Push, Once Scheduled STAT [immediately]...Completed...[name of ordering physician]...” There were no documented indications for the order of the pain medication. A concurrent interview was conducted with the SCRN. The SCRN stated the physician should have noted an indication for the pain medication. A review of the facility document titled, “Medication Administration,” dated December 11, 2024, through December 13, 2024, indicated registered nurse administered pain medication Toradol to Patient 19 on December 12, 2024, at 8:49 a.m. A review of the facility document titled, “Pain Assessment,” dated December 12, 2024, at 8:59 a.m. indicated, “...Pain Present...No Actual Pain...” A concurrent interview was conducted with the SCRN. The SCRN stated the registered nurse should have documented a pain level prior to administering the pain medication. A review of the facility’s P&P titled, “Medication Administration,” dated September 22, 2022, was conducted. The document indicated, “...All medications...shall be prepared and administered in accordance with Federal and State Laws, under the orders of a licensed practitioner, as per accepted standards of practice...All medications shall be administered utilizing appropriate safe administration technique, including the integrated technologies designed to help prevent and or reduce the occurrence of medication-related errors...PRN” or “STAT” medications times are recorded in eMAR by the person who administered the medication. Responses to all “PRN” medications must be noted in the medical record...” A review of the facility’s P&P titled, “DES RX 1121 SAFE ORDER WRITING AND CLARIFCATION OF UNSAFE MEDICATION ORDERS,” dated December 15, 2022, was reviewed. The document indicated, “...To adhere to the Regulatory Standards for safe and appropriate medication order writing...All medication orders processed...shall comply with the following requirements...all prescription orders should include the reason for prescribing...This information may be written with the medication order or be available in the electronic medical record...All as needed (PRN) orders must have a clear indication associated with their intended use...All pain medications will be processed using the following scale...PAIN SCALE...Mild Pain 1-3...Moderate Pain 4-6...Severe Pain 7-10...” 3. On May 6, 2025, at 9:40 a.m., Patient 28’s medical record was reviewed with the Stroke Program Coordinator (SPC). The “Admission H&P” [History and Physical]”, dated January 30, 2025, indicated, “...endorses sickle cell retinopathy [a serious eye condition that can occur in people with sickle cell disease where the shape of their red blood cells changes, leading to blockages in the small blood vessels of the retina. This can result in damage to the retina and vision loss] and is blind in the l [left] eye and is visually impaired in the r [right] eye...” A review of the facility document titled, “daily nursing shift assessment,” dated January 1, 2025, through February 2, 2025, indicated, Patient 28 had been identified with loss of vision in the left eye, and blurred vision to right eye. A review of the facility’s undated document titled, “Care Plans,” was conducted with the SPC. There was no documented evidence Patient 28’s visual losses had been addressed nor interventions made available to accommodate Patient 28’s immediate needs impacted by visual limitations. On May 6, 2025, at 9:40 a.m., an interview with the SPC was conducted. The SPC stated, Patient 28 had no care plans to help address her needs, like call light accessible device such as braille [braille, a tactile system of reading and writing for visually impaired people], provide orientation of room, or how to call for assistance. The SPC stated, there should be a care plan that identifies the patient’s concerns and would provide for consistency of intervention. The SPC further stated, patient’s with disabilities should be provided with accommodation of their needs. A review of the facility policy titled, “DES ADM 111 AUXILIARY AIDS AND SERVICES,” dated September 21, 2023, indicated, “...II PURPOSE: This policy sets forth a plan that accommodates individuals with the special needs defined in Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA) of 1990 which prohibits discrimination on the basis of disability in the delivery of healthcare services. The regulation implementing these Acts requires that sensory impaired individuals, including the blind and the hearing impaired, be provided with...equal opportunity to participate in and benefit from healthcare services. The decision of the method to be used for communication requires the input of the patient and their choice must be given weight. Failure to properly assess and subsequently provide these services is punishable by fine to the provider...” 50122”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 38479 Based on interview and record review, the facility failed to implement their policy for one of 30 sampled patients (Patient 24), when the physician did not conduct a “1-hour face-to-face evaluation” after “Violent/Self-Destructive Restraint” were applied. This failure resulted in Patient 24 to not receive an evaluation to determine the patient’s immediate situation, reaction to the intervention, and the need to continue or terminate the restraints. Findings: A review of Patient 24’s medical record was conducted on May 7, 2025, at 10:31 a.m., with the Peer Review Coordinator (PRC). A review of the facility document titled, “Progress Note,” dated May 6, 2025, indicated, “...brought in by ambulance s/p [status post] auto versus pedestrian...patient was attempting to cross...when he was sideswiped by a vehicle...5/4 [May 4]...Ortho planning for ORIF [bone repair surgery, Open Reduction Internal Fixation]...5/5 [May 5]...Patient had ORIF of left ankle...hit his [family member] yesterday. Telepsychiatry consulted due to history of psychiatric illness...Ortho planning for ORIF right femur tomorrow...” A review of the facility document titled, “Orders” dated 05/06/2025 18:33 [May 6, 2025, 6:33 p.m.] indicated, “...Restraint Initiation Violent Adult Routine, 05/06/25 18:33 [6:33 p.m.] PDT [Pacific Daylight Time], Imminent Risk to Self...Soft limb, Restraint Points: 2 Points, Restraint location: Bilateral Upper Extremity...” A review of the facility document titled, “Orders,” dated, 05/06/2025 18:33 [May 6, 2025, 6:33 p.m.] indicated “...Restraint Monitoring Violent Adult, Routine 05/06/25 18:33 PDT, Q15 Min-int [minute interval], for 4 hr [hour]...” A review of the facility document titled, “Orders,” dated, 05/06/2025 18:33 [May 6, 2025, 6:33 p.m.] indicated, “Contact Physician for Evaluation of Restraint Renewal, Routine, Obtain Renewal Order by: 05/06/25 22:33 [10:33 p.m.] PDT...” Further record review with the PRC indicated no documented evidence a physician conducted a face to face within one hour of the initiation of restraints, to evaluate their use, and if it was clinically indicated. A concurrent interview with the PRC was conducted. The PRC stated, there was no documented evidence of a face to face evaluation, by the physician, within an hour, after restraints were applied, and should have been done. On May 7, 2025, at 11:33 a.m., an interview was conducted with the Nursing Director (ND) 1. ND 1 stated there was no documented evidence a physician evaluated the patient in-person within one hour of the initiation of restraints. A review of the facility’s policy and procedure titled, “DES ADM 749 RESTRAINT AND SECLUSION,” dated January 18, 2024, indicated, “...II. PURPOSE: To define...the use of restraint and Seclusion for patients in a way that protects the patient’s health and safety, and preserves their dignity, rights, and well-being...V. PROCEDURE...Violent/Self-Destructive Restraints: a. For Restraints used to manage Violent or Self-Destructive Behavior, a physician...responsible for the care of the patient must evaluate the patient in-person within one hour of the initiation of Restraint or Seclusion. The in-person evaluation must include...Evaluation of patient’s immediate situation...Patient reaction to the intervention...Patient’s medical and behavioral condition...The need to continue or terminate the Restraint or Seclusion...””

“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: 38479 Based on interview, and record review, the facility failed to follow their policy and procedures (P&P) for five of 30 sampled patients (Patient 1, 2, 4, 9, and 28) when: 1. For Patient 1, there was no documentation of a date, time, or physician signature on the consent for dialysis, prior to Patient 1 receiving dialysis; 2. For Patient 2, a STAT (immediate) order for glucose was not completed per physician order; 3. For Patient’s 4, and 9, there were missing evidence of documentation for daily weights; and 4. For Patient 28, pain was not reassessed within 60 minutes after pain medication was administered. These failures had the potential to jeopardize the health and safety of the patients. Findings: 1. On May 7, 2025, at 9:37 a.m., a review of Patient 1’s record was conducted with the Accreditation Regulatory Manager (ARM). A review of the facility document titled, “History and Physical [H&P],” dated May 2, 2025, at 1:05 p.m., indicated Patient 1 was admitted to the facility for altered mental status on May 2, 2025. Patient 1 had a medical history of anxiety (a feeling of worry), hemodialysis (a machine that filters wastes and fluid from your blood), and end stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer function adequately). A review of the facility document titled, “Dialysis Consult,” dated May 3, 2025, at 10:45 a.m., indicated, “...Priority...Routine...Requested Start Date/Time...5/3/2025 [May 3, 2025] 10:45 PDT [Pacific Daylight Time]...dialysis time: 3 hours...Notify [Name of facility] 1 of acute order...” A review of the facility document titled, “Consent To Surgery/Special Procedures (With Physician Certification),” dated May 4, 2025, at 1:30 p.m., indicated, a consent for “...Hemodialysis...Dr. [Name of Physician]...” During the review of Patient 1’s medical record, there was no documented evidence of a Physician Certification date, time, or Physician Signature present on the consent form or in the Electronic Medical Record (EMR). A review of the facility document titled, “Acute Hemodialysis Flow Sheet,” dated May 4, 2025, at 3:03 p.m., indicated Patient 1 had hemodialysis from 3 p.m. to 6 p.m. with a total of 2300 milliliters (unit of measurement) of fluid removed. On May 7, 2025, at 11:25 a.m., an interview with the ARM was conducted and indicated, “...the physician should have signed the consent, and the dialysis nurse should have escalated to the physician before dialysis if there was no signature on the consent form...” The facility P&P titled, “DES ADM 675 Informed Consent,” dated, December 21, 2023, indicated, “...Physicians must provide patients the information they need to make their decisions...the patient’s physician is responsible for providing the information to the patient and/or surrogate decision maker needs in order to make an informed decision and for obtaining informed consent...the hospitals role in the informed consent process is to verify that the physician obtained the patient’s informed consent before the physician is permitted to perform the procedure...” 2. On May 7, 2025, at 11:30 a.m., a review of Patient 2’s medical record was conducted with the ARM. A review of the facility document titled, “Admission H&P [History and Physical] EMR [Electronic Medical Record] No Cosign,” dated April 11, 2025, at 12 p.m., indicated, Patient 2 was admitted to the facility on April 11, 2025, for nausea and vomiting with abdominal pain. Patient 2 had a medical history of hypertension (high blood pressure), and diabetes (elevated blood glucose which usually occurs when the body either doesn’t produce enough insulin or can’t effectively use the insulin it produces). A review of the facility document titled, “Order Sheet,” dated May 2, 2025, at 6:42 p.m., indicated, “...Blood Glucose by Nursing...Stat [Immediately], 05/02/25 [May 2, 2025]...16:38:00 PDT [4:38 p.m., Pacific Daylight Time]...One Time Unscheduled...” During the review of Patient 2’s medical record with the ARM, there was no documented evidence that a stat blood glucose was performed, as ordered. An interview with the ARM was conducted on May 7, 2025, at 11:40 a.m. The ARM stated, “It is the expectation that all stat orders are completed by nursing prior to one hour.” A review of the facility policy dated, June 22, 2023, indicated, “...All written orders will be transcribed and processed under the direct supervision of a registered nurse within 1 [one] hour. STAT orders will be processed within 15 [fifteen] minutes...” 3a. On May 7, 2025, at 12:30 p.m., a review of Patient 4’s medical record was conducted with the ARM. A review of the facility document titled, “Admission H&P EMR,” dated May 2, 2025, at 12:31 a.m., indicated Patient 4 was admitted to the facility on May 1, 2025, at 11:09 p.m., for auto versus pedestrian, and avulsion to left lower extremity (a fracture where a piece of bone is pulled away from the main bone, often by a ligament or tendon). A review of the facility document titled, “Order Sheet,” dated, May 2, 2025, at 1:39 a.m., indicated, an order for “...Weight...Routine...05/02/25 [May 2, 2025]...1:39 [1:39 p.m]...Daily...” A review of the facility documents titled, “Results Detail,” indicated a daily weight for Patient 4 on the following dates: - May 2, 2025, at 7:54 a.m., - 78.5 kg (kilogram) - May 4, 2025, at 4 a.m., - 79 kg - May 5, 2025, at 4:23 a.m., - 79 kg - May 6, 2025, at 2 a.m., - 79 kg - May 7, 2025, at 5 a.m., - 79.2 kg During the review there was no documented evidence of a daily weight on May 3, 2025. 3b. On May 8, 2025, at 10:30 a.m., a review of Patient 9’s medical record was conducted with the ARM. A review of the facility document titled, “Admission H&P EMR,” dated April 26, 2025, at 12:49 p.m., indicated, Patient 9 was admitted to the facility for low oxygen saturation and recent discharge from the hospital for pneumonia. Patient 9 had a medical history of Subdural hematoma (a collection of blood that forms between the brain and the dura mater) status post hemicraniectomy (a surgical procedure where a portion of the skull is removed on one side to create space for the brain to swell), respiratory failure (a condition where the lungs cannot adequately transfer oxygen into the blood or remove carbon dioxide) status post tracheostomy placement (the surgical creation of an opening in the neck and into the trachea to allow for breathing), diabetes, and on a home ventilator (machine used medically to support the breathing of a person who is ill, injured, or anesthetized). A review of the facility document titled, “Order Sheet,” dated, April 26, 2025, at 9:45 a.m., indicated, an order for “...Weight...Routine...04/26/25 [April 26, 2025]...9:45:00 [9:45 a.m.]...Daily...” A review of the facility documents titled, “Results Detail,” indicated a daily weight for Patient 4 on the following dates: - April 26, 2025, at 6:57 p.m., - 83.3 kg - April 27, 2025, at 5 a.m., - 80.5 kg - April 29, 2025, at 5 a.m., - 85.6 kg - April 30, 2025, at 5 a.m., - 88.1 kg - May 2, 2025, at 5 a.m., - 90.6 kg - May 3, 2025, at 5 a.m., - 88.1 kg - May 4, 2025, at 5 a.m., - 88.4 kg During the review there was no documented evidence of a daily weight on April 28, 2025, and May 1, 2025. An interview was conducted on May 8, 2025, at 10:40 a.m., with the ARM. The ARM stated, “The expectation is to follow the physician orders and complete daily weights.” A review of the facility P&P titled, “DES NAD 1371 WEIGHTS: PATIENTS,” dated September 22, 2022, indicated, “...All patients will be weighed upon admission and per physician order...It will be the responsibility of the patient’s primary nurse to check that the patient weight has been done per physician order...” 4. A review of Patient 28’s medical record was conducted on May 6, 2025, at 10:48 a.m., with the Stroke Program Coordinator (SPC). A review of the facility document titled, “Admission H&P” [History and Physical],” dated January 30, 2025, indicated, “...female...episodes of sickle cell crisis (a painful episode that can occur in people with sickle cell disease when sickled red blood cells (crescent-shaped) block blood flow in small vessels, causing pain and potentially other complications. These blockages lead to reduced oxygen delivery to tissues and organs, triggering pain and inflammation) 2-3x/year, dx (diagnosed) at 4yo (years old)...intense pain for 7 days...” A review of the facility document titled, “All Orders,” dated January 31, 2025, indicated, “...HYDROmorphone [Dilaudid, indicated for the management of pain in patients] 1mg=1mL [milligram/milliliter-unit of measurement], Injection, IV [intravenous] Push, Q [every] 4hr [hour], PRN [as needed], For: Pain Breakthrough Severe. A review of the facility document titled, “MAR [Medication Administration Record] Summary”, indicated: On January 31, 2025, at 4:17 a.m., HYDROmorphone 1 mg, Injection, IV Push, Q 4hr, PRN, For: Pain Breakthrough Severe, was administered; and On January 31, 2025, at 1:35 p.m., HYDROmorphone 1 mg, Injection, IV Push, Q 4hr, PRN, For: Pain Breakthrough Severe, was administered. A review of the facility document titled, “Pain Assessment” indicated, no documented evidence a reassessment was conducted after pain medications were administered on January 31, 2025. On May 6, 2025, at 10:48 a.m., the SPC was interviewed. The SPC stated, there was no documentation of pain reassessment following the administration of pain medication on January 31, 2025, at 4:17 a.m., and 1:35 p.m. The SPC stated pain reassessment should be conducted after pain control medication is administered to better manage the patient’s pain control needs. A review of the facility P&P titled, “DES ADM 889 ADULT PAIN MANAGEMENT,” dated December 19, 2024, indicated, “...II PURPOSE: To assure the adequate assessment, reassessment and treatment of pain for patients throughout the continuum of care...Initial assessment is done by the RN upon admission and documented...All patients are assessed for pain at a minimum of every 12 hours...D. Reassessment shall be documented within 60 minutes post intervention, and based on the patient’s condition which includes evaluation of sedation as well as appropriate vital signs...” 50122”

“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: 42512 Based on observation, interview, and record review, the facility failed to ensure medical records were accurately written, completed, and filed, for one of 30 sampled patients (Patient 14), when the Conditions of Admission (COS) document reflected Patient 14 did not have an advanced directive or a durable power of attorney, after family provided the facility a copy of Patient 14’s advanced directive and power of attorney. This failure had the potential to not accurately reflect the patient’s wishes, delay care and/or cause patient harm. Findings: On May 5, 2025, at 11:05 a.m., an interview was conducted with Patient 14’s family. Patient 14’s family stated he provided the facility with the following documents: Physician Orders for Life-Sustaining Treatment (POLST), Power of Attorney, and Advance Health Care Directive. Family further stated the facility staff added their name to Patient 14’s board with the initials “DPOA,” (durable power of attorney). On May 6, 2025, at 3:45 p.m., Patient 14’s medical record was reviewed with the Catheritzation Lab Clinical Manager (CLCM). It indicated Patient 14 was admitted to the facility on May 2, 2025, at 11:35 p.m., for bradycardia (slow heart rate). A review of the facility document titled, “CONSENT FOR TREATMENT AND CONDITIONS FOR ADMISSION,” was reviewed and indicated “...Patient [Patient 14] has an advanced directive or living will...No...Patient has a Medical Durable Power of Attorney...No...Patient has designated a Health Care Surrogate...No...if yes, copy provided...No...I would like to receive further information about Living Wills and other advanced directives...No...” The document further indicated, “Patient/Parent or Legal Guardian Signature...[Signature name of Patient 14’s son]...Relationship to Patient...DPOA/Son...” On May 7, 2025, at 1:55 p.m., an interview was conducted with the Patient Access Director (PAD). The PAD stated the expectation of patient access staff is to ask the patient or the patient representative if they had a power of attorney (POA) or an advance directive (AD). She stated, if the patient did not have an AD, the patient access staff would then ask if the patient or the patient representative would like more information regarding the AD. She further stated that whatever the family answered to those questions, the answers should be marked accordingly, on the Consent for Treatment and Conditions for Admission (COS) form. The PAD stated for Patient 14, the COS record did not reflect accurate information. She stated the COS indicated Patient 14 did not have a POA or AD, but the record further indicated family had provided the facility with copies of the POA and the AD. A review of the facility’s policy and procedure (P&P) titled, “DES ADM 25 ADVANCED HEALTH CARE DIRECTIVE,” dated September 7, 2023, was conducted. The policy indicated, “...To fully educate patients...regarding their authority over decisions concerning their medical care...As part of the admission process the Registration Department staff must ask the patient or responsible person if the patient has an Advance Health Care Directive...Registration Department staff must fill out the...conditions of service acknowledgement on all adult patients...the patient’s completed Advance Health Care Directive forms are to be placed with the other admission packet forms...Computer system will be checked advance health care directive on file. The Conditions of Service form is to be checked off appropriately by the Registration staff...” A review of the facility’s P&P titled, “REGISTRATION,” dated February 13, 2024, was conducted. The document indicated, “...During the Patient Registration Process, Patient Access Team Members will...Ensure the appropriate individual...signs all required standard and Client facility-specific forms, including...Consent for Treatment and or Conditions of Service...All patients must acknowledge if they have an Advanced Directive by checking yes or no. If yes, request a copy...””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 42512 Based on observation, interview, and record review, the facility failed to ensure equipment was ready for use when a glucometer was not ready for use due to the quality control (QC) not being completed timely. This failure had the potential to delay patient care and services and/or cause patient harm. Findings: A tour of Unit A was conducted on May 5, 2025, at 9:37 a.m., with the Peer Review Coordinator, Emergency Room (ED) Director, and the ED Manager. The glucose monitor device (a machine that is used to measure the sugar in a patient’s blood) was observed docked near the trauma bays. When the glucose monitor device was turned on, the screen read “...QC Due Immediately...” An interview was conducted on May 5, 2025, at 9:51 a.m., with the ED Manager. The ED Manager stated the glucose monitor device needed to be quality controlled (QC’d) every 24 hours. She stated the glucometer was usually QC’d first thing in the morning by the nurses assigned to bays near the device. The ED Manager requested Registered Nurse (RN) 2 to turn on the glucose monitor device. RN 2 turned on the glucose monitor device and stated the device had not been QC’d and it should have. The ED Manager stated it needed to be QC’d in order to use it on a patient needing their blood sugar checked and it was not. A review of the facility’s policy and procedure titled, “DES LAB 665 POINT OF CARE TESTING OVERVIEW,” dated September 22, 2022, was conducted. The policy indicated, “...To define the responsibilities and policies related to the administration and performance of Point of Care Testing...Quality control...and corrective action when quality control is unacceptable...follows manufacturer’s instructions for quality control...Quality control must be performed according to manufacturer’s instructions...Quality control checks are performed at the frequency and number of levels recommended by the manufacturer and as defined by the hospital’s policies...For instrument based waved testing, quality control checks are performed on each instrument used for patient testing per manufacturer’s instructions...” A review of the [Name of glucose device] Operator’s Manual was conducted. The operators manual indicated, “...Glucose Control Testing...The following requirements must be met before you can perform a test...Glucose control tests specified in the configuration must be run and completed successfully before running patient tests...Information whether glucose control tests are necessary is displayed in the Power Up Screen...If a glucose control test is shown as required, patient glucose testing cannot be performed until the controls are run successfully...””

“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: 42512 Based on observation, interview, and record review, the facility failed to ensure infection control methods for preventing and controlling transmission of infections within the hospital were implemented. This failure had the potential to spread infection and/or cause patient harm. Findings: On May 5, 2025, at 9:37 a.m., a tour of Unit A was conducted with the Peer Review Coordinator, Emergency Room (ED) Director, and the ED Manager. On May 5, 2025, at 10:02 a.m., during the tour of Unit A, with the ED Manager, five commodes (portable toilets) were observed in the dirty utility room. Each of the five commodes had a brown cardboard strip wrapped around the toilet seat. A concurrent interview was conducted with the ED Manager. The ED Manager stated the brown cardboard strip around the toilet seat indicated the commodes had been cleaned, disinfected by environmental services (EVS), and were ready for patient use. She further stated after the commodes were used by patients, EVS would clean, disinfect and store the clean commodes in the dirty utility room. On May 8, 2025, at 9:11 a.m., an interview was conducted with EVS Staff 1. EVS Staff 1 stated the brown cardboard band around the toilet seat indicated the commode had been cleaned and disinfected. She stated after cleaning and disinfecting the commodes, EVS staff would then store the commodes in the dirty utility room. She stated this was the process in Unit A. She stated there was limited room in Unit A and the commodes were always stored in the dirty utility room. On May 8, 2025, at 10 a.m., an interview was conducted with the Accreditation Regulatory Manager (ARM). The ARM stated there was no policy for the cleaning and storage of clean equipment such as commodes. A review of the facility’s policy and procedure (P&P) titled, “2024 INFECTION PREVENTION ANNUAL PLAN” dated June 20, 2024, was conducted. The policy indicated, “...Infection Prevention Plan provides a description of the interdisciplinary and systematic approach developed to protect, visitors, employees of [name of facility] from communicable pathogens...Ensure Use of a systematic approach to infection prevention and assess ongoing improvement...Reduce Risk of infections related to procedures, medical equipment and devices...Assure clean and sanitary environment...Reduce potential transmission of organisms to patients, staff and others...” A review of the facility’s P&P titled, “DES IP 359 EQUIPMENT CLEANING,” dated April 18, 2024, was conducted. The policy indicated, “...To provide general guidelines for cleaning hospital patient care equipment...Equipment...commodes...and other equipment used in patient care areas...Equipment will be cleaned before and after each patient use...All equipment disinfectant cleaning will be done by EVS, designated department, or user...All clinical areas must designate separate “clean” and “soiled” utility rooms...””

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to evaluate the discharge needs and make appropriate arrangements for post-hospital care before discharge, for one of 30 sampled patients (Patient 13), who was newly unhoused. This deficient practice had the potential to result in an unsafe discharge when the patient’s post-discharge needs were not addressed, and appropriate arrangements were not made, which could have resulted in adverse events (undesirable clinical outcome such as worsening of health condition). Findings: On May 6, 2025, at 3:15 p.m., an interview and concurrent record review were conducted with the Catheterization Lab Clinical Manger (CLCM). A review of facility document titled, “APPLICATION FOR ASSESSMENT, EVALUATION, AND CRISIS INTERVENTION OR PLACEMENT FOR EVALUATION AND TREATMENT,” dated April 4, 2025, indicated, “...To...[acute psych facility]...Application is hereby made for the assessment and evaluation of [Name of Patient 13]...for up to 72-hour assessment, evaluation, and crisis intervention...[Name of Patient 13] was brought into clinic...for resources. When [Patient 13] came to the clinic he had lost his glasses and cannot see to get around. [Name of Patient 13] has a history of Adjustment Disorder and Unsheltered Homelessness. The APS [Adult Protective Service] report has been filed...[Name of Patient 13] is unable to navigate the streets due to not being able to see without his glasses. He is unable to find shelter or food. He was turned away from The Access Center due to not being able to see. He is in distress and is suffering from anxiety and depression due to his current situation...Gravely disabled adult...” A review of facility document titled, “ED [Emergency Department] Triage Form,” dated April 4, 2025, at 18:15 6:15 p.m., indicated “...Chief Complaint: 5150 [involuntary hold of a patient who is a danger to self, others or gravely disabled], and difficulty seeing. A review of facility document titled, “ED Note-Physician,” dated April 4, 2025, at 6:46 p.m., indicated, “...with history of blindness who presents on a 5150 hold by PD [police department] because he lost his glasses and now cannot see. He is also homeless...Impact of social determinants of health on diagnosis and/or treatment: Housing insecurity...” A review of facility document titled, “ED Triage Form,” dated April 4, 2025, at 6:50 p.m., indicated, “...Document Has Been Revised...Suicide Present Sign Symptom BH Cmplaint [sic]: Yes...Wish to be Dead: Lifetime, yes...In past month, have you actually had thoughts about killing yourself?...Yes...In the past month, have you been thinking about how you might kill yourself?...Yes...In the past month, have you had these thoughts and had some intention of acting on them?...Yes...In the past month have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?...Yes...Have you ever done anything, started to do anything, or prepared to do anything to end your life?...Yes...In the past three months, have you done anything, started to do anything, or prepared to do anything to end your life?...Yes...” A review of facility document titled, “Case Management Reassessment,” dated April 4, 2025, at 7:47 p.m., indicated, “...BIBA [brought in by ambulance] on 5150 for Gravely Disabled [GD]. Pt [Patient] presents as a transfer from [acute psych facility]...Assessment...Pt says he has been at [acute psych facility] 1 since yesterday evening, and staff were talking about sending me to Indio to get help. They were going to get me to the place that will help me get my ID and transitional housing. Pt endorses experiencing homelessness for approximately 1 month. He sold his trailer after being hospitalized and having no money...says I’ll be fine once I get some glasses and some help...Per 5150 hold, [Name of Patient 13] is unable to navigate the streets due to not being able to see without his glasses. Pt says he has been turned away by shelters...due to not being able to see. At this time, patient is unable to adequately access basic needs or navigate unsheltered homelessness...Pt seen over the last few days during a medical admission to [Name of this facility]. Per chart review, APS report was made for self-neglect...Denies contact with family or other social supports...pt currently only has access to about $600 from the sale of his trailer. He says he does not receive SSI [Supplemental Security Income], and has no other means of steady income...At this time, patient appears to continue to meet criteria for 5150 hold for GD. Patient is unable to access basic needs or navigate challenged of being unhoused...SW [social worker] will uphold 5150 for GD as of 04/04/2025 [April 4, 2025] at 13:33 [1:33 p.m.]...” A review of facility document titled, “Case Management Reassessment,” dated April 5, 2025, at 2:39 p.m., indicated, “...Pt...BIBA on a 5150 hold for Gravely Disabled Adult due to losing his glasses and being unable to navigate being unhoused without his glasses...SW and LCSW [licensed clinical social worker] met with Pt...Pt reported that he can still see without his glasses, but is not able to read letters up close...Pt reported that he is able to buy food/water/clothing with his income and has enough money to pay for a hotel room for the next few days until he is able to connect with his worker who is helping him obtain transitional housing. Pt reported that he can schedule an appointment for an eye exam and is able to pay for new glasses...Pt stated that he is aware of homeless resources and has tired to access services at the [Name of center] 1, but was turned away because he was not able to see/read/sign any documents without his glasses...Pt will be discharged to previous living arrangement. Pt requested assistance with transportation as she [sic] does not have any means of transportation at this time. SW completed taxi voucher and coordinated transportation back to Pts previous living arrangement...SW placed a call to APS to notify of Pts discharge. APS agreed to notate update and have assigned SW follow Pt in the community...” A review of facility document titled, “Transportation Voucher,” dated April 5, 2025, at 5:53 p.m., indicated, “...transported to [Name and address of Hotel]...Taxi...Reason for This Level of Transportation...BIBA 5150 (GD) - Interrupted...” A review of facility document titled, “Transportation Voucher, “ dated April 5, 2025, at 5:55 p.m., indicated, “...transported to [acute psych facility] 1...BIBA 5150 on 04/04 [April 4], discharged to motel, came back unable to check in due to lack of ID...” A review of facility document titled, “ED Patient Department Summary,” dated April 5, 2025, at 5:53 p.m., indicated, “...Arrival Time: 04/04/2025, 18:04 [April 4, 2025, 6:04 p.m.]...ED Discharge Time: 04/05/2025 15:53 [April 5, 2025, 3:53 p.m.]...presenting complaint: 5150...Discharge Location: (blank)...Immunizations: (blank)...Discharged To: Home...” There was no documentation where Patient 13 was discharged to, as he was homeless and there was no documented evidence Patient 13 was offered immunizations while at the facility. On March 8, 2025, at 7:59 a.m., an interview was conducted with APS worker (APSW). The APSW stated he did not receive a phone call from the facility regarding Patient 13’s discharge on April 5, 2025. APSW stated Patient 13 did not have social security income. APSW stated that on Monday when he returned to work, he was informed that Patient 13 arrived at Acute Psych Facility 1 crying. APSW was able to intervene and helped Patient 13 find temporary hotel lodging until he could obtain an ID and glasses. APSW stated Patient 13 had severe vision impairment and the facility should have helped him with that. On March 8, 2025, at 2:19 p.m., an interview was conducted with Manager of Social Services (MSS) and Licensed Clinical Social Worker (LCSW) 1. MSS stated Patient 13’s funds of $600 dollars would not be enough to secure food, water and shelter if he didn’t have an income. MSS stated the note did indicate that Patient 13 did not receive social security but that didn’t mean he doesn’t pan handle. MSS stated the social worker note on April 5, 2025, did not indicate who at APS was notified of Patient 13’s discharge and that the expectation would have been for the social worker to document who they spoke to, what number was called, and the case number. LCSW 1 stated it was a normal process to document the screeners’ name, badge number and reference number. MSS stated Patient 13 had indicated he can still see without his glasses but is not able to read letters up close. MSS stated in the ED, staff would not facilitate helping a patient make an optometry appointment unless they had Inland Empire Health Plan (IEHP) insurance. LCSW 1 stated Patient was discharged to a hotel but then couldn’t get a room because he didn’t have an ID. LCSW 1 stated Patient 13 was then given a voucher for a taxi to go back to Acute Psych Facility 1. A review of the facility’s Policy and Procedures (P&P) titled “DES CM 168 CALIFORNIA HOMELESS DISCHARGE PLANNING,” dated February 16, 2024, indicated, “...To ensure Transitional Management and discharge planning for the homes patient is conducted with dignity, respect, and compassion...will provide individualized discharge planning for individuals who are homeless upon presenting to the facility...Offer Services to Homeless Patients Prior to Discharge...Hospital will offer various services to Homeless Patients prior to discharge...” A review of the facility’s (P&P) titled “DES CM 168 PR.02 PRE-DISCHARGE SERVICES FOR HOMELESS PATIENTS,” dated February 16, 2023, indicated, “...Vaccinations...Hospital staff will offer homeless patients’ vaccinations appropriate to their presenting medical condition. The patient may refuse the vaccination. If so, hospital staff should obtain an informed refusal...” A review of the facility’s (P&P) titled “DES CM 168 PR.03 COMMUNITY SERVICES,” dated February 16, 2023, indicated, “Referral to Shelter...will offer to assist a homeless patient who requests shelter, connection with an existing case manager or referral to the Los Angeles County Housing for Health Access Referral and Engagement Team. The post-discharge referral process should consider that placement at a shelter or other similar limited stay or temporary residence facility is not considered “ideal” and should only be considered after all reasonable efforts have been made to place the homeless patient in long term or supportive housing, or structured living facilities...Non-shelter options will be discussed with the patient and the patient will be encouraged to accept alternative placement to a shelter, if any exist...Social Services or designated trained staff will process a patient’s request for shelter placement...If a homeless patient...Does not indicate A principal place of dwelling or a fixed and regular nighttime residence...The hospital may need to contact adult Protective Services or the office of the account conservator/guardian...””

“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: 34933 Based on interview and record review, the facility failed to implement their policies and procedures (P&P) for six of 30 sampled patients (Patient 1, 2, 11, 14, 19, and 28) when: 1. For Patient 1, the nurse did not notify the physician and primary nurse of vital information to determine if Patient 1 was a danger to self; (Refer to A-398) 2. For Patients 2, and 11, pain was not reassessed within 60 minutes after administration of pain medication; (Refer to A-398) 3. For Patient 11, the nurse changed the standard alarm limits (50-120) to 40 on the cardiac monitoring machine without a physician order; (Refer to A-398) 4. For Patient 14, the nurse did not notify the physician when Patient 14’s heart rate parameter fell below the standard alarm limit of 50 on the cardiac rhythm strips; (Refer to A-398) 5. For Patients 14 and 28, the primary nurse did not verify, validate and sign the cardiac rhythm strips; (Refer to A398) 6. For Patient 19, pain medications were not administered for pain rated eight out of 10 (pain level, describes severity of pain, zero meaning no pain and 10 meaning the worst pain possible); (Refer to A-398) 7. For Patient 28, there was no care plan to address restraints; and (Refer to A-398) 8. For Patient 28, the nurse did not document vital signs (a measurement which shows how well your body is working and includes, heart rate, temperature, blood pressure, and respiration) in a timely manner. (Refer to A-398) The cumulative effects of these systemic failures had the potential to impact the health, safety, and treatment of the patients, poor pain management and may cause delays in the provision of patient care and/or death.”

“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: 34933 Based on interview and record review, the facility failed to prevent one patient (Patient 2) from being misgendered and not addressed by her preferred pronoun by multiple staff members. This failure had the potential to impact the health, treatment of patients, and cause emotional harm to other patients and may cause delays in the provision of patient care. Findings: On March 3, 2025, an unannounced visit was conducted at the facility for a complaint validation survey. A review of Patient 2’s medical record was conduct with the Chest Pain Coordinator (CPC) on March 4, 2025. A review of the facility document titled, “ED [emergency department] Note-Physician,” dated February 18, 2025, indicated, Patient 2 was a Transgender female, with pronouns of she/her, past medical history multiple gender affirming surgeries, on hormone replacement therapy, brought in by ambulance due to pain around surgical drain. Patient recently had “tummy tuck” and was scheduled for drain removal today but she awoke this morning with sudden onset sharp pain around the right surgical drain. An interview was conducted with the Nursing House Supervisor (NHS) on March 4, 2025, at 3:43 p.m. The NHS indicated, Patient 2 was called by the wrong pronoun by staff and the Director of Emergency Department (DED) and Clinical Nurse Manager (CNM) had spoke with Patient 2 regarding the incident. Patient 2 was called the wrong pronoun again by different staff during the same shift, at which time Patient 2 requested to speak with the NHS. The NHS stated she apologized to Patient 2 for multiple staff using the wrong pronouns. The NHS further stated Patient 2 indicated, Registered Nurse 2 (RN 2) used a tone and said the wrong pronoun on purpose because she did not like her. An interview was conducted with the DED on March 4, 2025, at 4:05 p.m. The DED stated RN 2’s comments to Patient 2 were not appropriate, and the nursing staff were coached to use the patient’s preferred pronouns. A review of the facility P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES,” dated May 19, 2022, indicated, “...You have the right to: Considerate and respectful care, and to be made comfortable. You have the right to respect for your cultural, psychosocial, spiritual, and personal values, beliefs and preferences...””

“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: 34933 Based on interview and record review, the facility failed to implement their policies and procedures (P&P) for six of 30 sampled patients (Patient 1, 2, 11, 14, 19, and 28) when: 1. For Patient 1, the nurse did not notify the physician and primary nurse of vital information to determine if Patient 1 was a danger to self; 2. For Patients 2, and 11, pain was not reassessed within 60 minutes after administration of pain medication; 3. For Patient 11, the nurse changed the standard alarm limits (50-120 bpm) to 40 on the cardiac monitoring machine without a physician order; 4. For Patient 14, the nurse did not notify the physician when Patient 14’s heart rate parameter fell below the standard alarm limit of 50 bpm on the cardiac rhythm strips; 5. For Patients 14 and 28, the primary nurse did not verify, validate and sign the cardiac rhythm strips; 6. For Patient 19, pain medications were not administered for pain rated eight out of 10 (pain level, describes severity of pain, zero meaning no pain and 10 meaning the worst pain possible); 7. For Patient 28, there was no care plan to address restraints; and 8. For Patient 28, the nurse did not document vital signs (a measurement which shows how well your body is working and includes, heart rate, temperature, blood pressure, and respiration) in a timely manner. These failures had the potential to compromise patient safety, resulting in poor pain management, and delays in medical care and/or death. Findings: 1. A review of the facility document titled, “Incident Report,” dated October 12, 2024, at 3:20 p.m., indicated, “...I USO [unit security officer, Name of Security Guard] observed siblings [Patient 1 and family member (FM)] check into the ER [emergency room] lobby with the Registered Nurse [RN]. Patient [Patient 1] had a bandage wrapped around her arm, and I overheard her telling the RN she had accidentally cut herself while wood carving. The FM immediately disputed that, and claimed the wound was self-inflicted, which caused patient [Patient 1] to begin shouting. Patient [Patient 1] yelled at the FM to leave the facility and called him a liar, which prompted me to intervene and ask the FM to step outside at 1522 [3:22 p.m.] hours. The FM informed me that the patient [Patient 1] cut herself with a razor about an hour prior to their arrival, and the FM showed me several photos on his phone confirming this. Patient [Patient 1] reportedly has a history of mental health issues and has been placed on legal holds in the past...The FM provided his phone number...and requested that I [Security Guard] inform the nursing staff about the situation. I [Name of Security Guard] went back inside to the ER nurse’s station and informed the Clinical Nurse Manager [CNM] about the incident, and I [Security Guard] provided the CNM with the FM’s contact number...Patient [Patient 1] returned to the lobby shortly afterward, and the FM drove off property...” A review of Patient 1’s medical record and a concurrent interview was conducted with the Manager of Emergency Department (MED) on March 5, 2025, at 10:22 a.m. The MED stated, Patient 1 was a triage level 3 (urgent, indicates a patient condition that is not life-threatening but requires prompt attention) and was asked all the suicidal ideation (SI) questions and answered no. If the SI questions were answered yes, report would be given to the back hall nurse who the behavioral health nurse is. The MED stated, there was no documentation in the medical record Patient 1 was brought into the ER by her FM and was suicidal. A review of the facility document titled, “History and Physical (H&P),” dated February 26, 2020, indicated, “...61 YO [year old] F [Female] with hx [history] of depression and bipolar disorder presents with generalized body pain, worst in chest that began this morning after waking up. Patient 1 reports she was in a head on collision yesterday at 1500 [3 p.m.] on the freeway while driving, she ran into a large truck on the freeway...Documented Medications Effexor [medication to treat depression] XR [extended release] 75 mg [milligrams, unit of measure] oral capsule, extended release ...Clonazepam [medication to reduce anxiety] 1 mg oral tablet: BID [twice a day]...” A review of the facility document titled, “Case Management Reassessment,” dated February 28, 2020, indicated, “ ...presenting issue- SWKR [Social Worker] consult for depression/anxiety, suicide attempt ...Patient does have a hx of making suicidal statements on 08/09/2013 [August 9, 2013] ...” A review of the facility document titled, “ED Triage Form,” dated October 12, 2024, at 3:34 p.m. indicated, “...Chief Complaint: LT [left] arm laceration from cutting wood per pt [patient] ...” A review of the facility document titled, “ED Triage Form,” dated October 12, 2024, at 4:32 p.m. indicated, “...CSSRS Pre-Screener [Columbia Suicide Severity Rating Scale, screening tool for patients requiring a suicide risk screening]...Suicide Present Sign Symptom BH [Behavioral Health] Cmplaint [sic]: No...” Review of the facility document titled, “ED Note-Physician,” dated October 12, 2024, dated 6:05 p.m., indicated, “...65-year-old female with history of depression and anxiety presents to ED for left forearm laceration that occurred PTA [prior to admission]. Patient states that she is recently started woodcarving as a hobby. Patient 1 was using a blade and accidentally cut her arm. Patient 1 was able to wrap it and control the bleeding.” An interview was conducted with Provider 1 on March 5, 2025, at 10:30 a.m. Provider 1 indicated, Patient 1 stated she took up a new hobby woodworking and cut her arm. The patient (Patient 1) said that’s what happened, so he believed her. He was not told about the FM being outside or that she had SI. The plan for Patient 1’s care would have been different had he known it was a suicide attempt. An interview was conducted with the CNM on March 5, 2025, at 2 p.m. The CNM stated, “I don’t remember this incident or being told about it. The process for a SI patient is they will get checked in by the pivot nurse and if they need to go back immediately, they call me, and I go talk to the Provider. If the FM says that to the pivot nurse, then the patient would go to the back and a consult for Social Worker would be done. I usually call for a 1:1 [one to one observation, one competent Constant Observer to one patient within line of sight] if it’s a 5150 [involuntary hold of an adult when they are a danger to self or others]. We are supposed to triage these problems, but the patient is in charge of their care. If a family member told me a different story than the patient, then I would call the Social Worker to intervene and try to get the stories straight.” An interview was conducted with the Director of Emergency Department (DED) on March 6, 2025, at 9:20 a.m. The DED stated, if there was a suicide attempt, the nurse is supposed to notify the physician right away if the nurses were made aware, then the physician will initiate the Social Worker consult. The DED further stated, “We get all kinds of patients with cuts and injuries, but it will be up to the physician if they want to investigate it as self-harm.” A review of the facility policy and procedure titled, “STANDARDS OF CARE: ASSESSMENT, REASSESSMENT, AND CARE PLANS,” dated March 3, 2025, indicated, “...The completed patient assessment establishes the foundation for the diagnosing/analyzing of patient problems, formulating a plan of care and determining appropriate referrals and reassessments...The patient is assessed/reassessed based on the following circumstances...Whenever there is a significant change in the patient’s condition or diagnosis...Based on reassessment, the healthcare provider will modify/revise the patient’s plan of care and education plan as appropriate...The medical provider will be notified of any significant changes in patient condition...” 2a. A review of Patient 2’s medical record was conducted on March 4, 2025, at 3 p.m., with the Chest Pain Coordinator (CPC). A review of the facility’s document titled, “ED (emergency department) Note-Physician,” indicated, Patient 2 arrived at the ED for a post op (operative, after surgery) surgical evaluation with sudden onset sharp pain around the right surgical drain. A review of the facility’s document titled, “Order Sheet,” dated February 18, 2025, at 10:44 a.m. indicated, Acetaminophen (pain medication) 325 mg tablet, take 2 tablets orally stat (right away). A review of the facility document titled, “MAR (medication administration record),” indicated, “...acetaminophen 325 mg [mg, unit of measurement] 2 tablets...orally...given on February 18, 2025...12:47 p.m...” A review of the facility’s document titled, “Pain Assessment,” dated February 18, 2025, at 12:47 p.m. indicated Patient 2 did not have documentation of a pain level or reassessment. On March 4, 2025, at 3 p.m. and interview and record review were conducted with the CPC. The CPC stated there was no documentation Patient 2’s pain level were assessed and pain levels should be obtained prior to administration and reassessed 60 minutes after administration. 2b. A review of Patient 11’s medical record was conducted on March 4, 2025, at 11:25 a.m., with the ARM. A review of the facility’s document titled, “H&P,” indicated, Patient 11 was admitted to the facility on March 3, 2025, for diabetic ketoacidosis (acids build up in the blood to levels that can be life-threatening). A review of the facility’s document titled, “Pain Assessment,” dated March 3, 2025, at 7:29 a.m., indicated patient 11 rated her pain 10 out of 10. A review of the facility’s document titled, “Medication Details,” indicated, “...morphine 4 mg [milligram, unit of measurement] 1 ml [milliliter, unit of measurements]...IV push [Intravenous]...Given on March 3, 2025...08:04 a.m...” A review of Patient 11’s MAR indicated, there was no documented evidence a pain reassessment (checking patient’s pain level to see if pain medication was affective). On March 3, 2025, at 11:25 a.m., an interview and record review were conducted with the ARM. The ARM stated the nurse did not reassess pain 60 minutes after administering pain medication per policy. The ARM further stated there was no documented evidence the nurse reassessed pain in the Electronic Medical Record (EMR). A review of the facility’s P&P titled, “ADULT PAIN MANAGEMENT,” dated December 19, 2024, indicated, “...To assure the adequate assessment, reassessment and treatment of pain for patients throughout the continuum of care...Reassessment of pain post [after] intervention is documented within 60 minutes after intervention...” 3. On March 3, 2025, at 9:35 a.m., a facility tour was conducted with the ARM, the MED, and the DED, the following was observed: “I walked into room A after obtaining permission from the patient. I observed Patient 11 connected to a cardiac monitor; the heart rate was between 47 to 55 beats per minute. The audible alarm did not sound when the heart rate dropped as low as 47. I asked the MED if the alarms had been silenced, she checked the settings and stated, “it looks like the heart rate parameters was set at 40.” On March 3, 2025, at 10:03 a.m., an interview was conducted with the Emergency Department Registered Nurse 1 (ED RN 1). ED RN 1 stated, “I do not know who set the parameters, I did not, it must have been the night nurse.” ED RN 1 further stated, “I did not see an order for the parameter to be changed to 40, I did not check it when I hooked the patient up this morning when she arrived. I did not notice that the machine was not sounding when falling below parameters.” On March 3, 2025, at 10:11 a.m. an interview and record review were conducted with the MED. The MED stated the parameters should have not be set at 40 without a physician order and further stated “ I verified and there is no order for that setting.” The MED further stated the nurse should have checked the parameters when hooking up the patient to the monitor, that is part of the assessment at the beginning of the shift. The MED stated ED RN 1 did not follow the policy, there is no order to change the parameter to 40 and there is no documentation that the physician was notified. On March 3, 2025, at 10:14 a.m. an interview was conducted with the DED. The DED stated the nurse should not change the parameters without a physician order. The DED further stated the parameters should be set at 50-120. A review of Patient 11’s medical record was conducted on March 4, 2025, at 11:25 a.m., with the ARM. A review of the facility’s untitled document, dated March 3, 2025, at 7:36 a.m. was reviewed, the document indicated, “...Vent rate 46 BPM [Beat Per Minute]...PR interval [a measurement on an electrocardiogram] 166...QRS interval [the time it takes for the electrical impulse to spread through the ventricles]...Sinus bradycardia [a condition where the heart rate is slower than 60 beats per minute]...Abnormal ECG [Electrocardiogram, a test that records the electrical activity of the heart]...” A review of the facility’s P&P titled, “PATIENT CLINICAL ALARMS,” dated August 18, 2021, indicated, “...The Registered Nurse (RN) must ensure that all alarms are set to activate at appropriate settings for each patient and are sufficiently audible with respect to distances and competing noise within the unit...” A review of the facility’s P&P titled, “DYSRHYTHMIA MONITORING,” dated June 19, 2024, indicated, “...When notification parameters are not ordered and the patient’s heart rate exceeds or is below the standard alarm limits (50-120), the physician must be notified...At the beginning of each shift, the RN will verify placement, proper functioning of the monitoring/transmitter, and check the battery indicator, if available. Assessment will be documented in the EMR...” 4. A review of Patient 14’s medical record was conducted on March 4, 2025, at 3:04 p.m., with the ARM. A review of the facility’s document titled, “H&P,” indicated, Patient 14 was admitted to the facility on February 28, 2025, for altered mental status (confusion) and pneumonia (infection in the lungs). A review of the facility’s document titled, “Vital Signs,” dated March 1, 2025, at 10 p.m., indicated, “...Heart Rate...March 1, 2025, at 22:00 [10 p.m.] 41...Sinus Bra...” There was no documented evidence in the EMR that the primary nurse notified the physician of the heart rate of 41, which fell below the order parameters. On March 4, 2025, at 3:40 p.m. an interview and record review were conducted with the ARM. The ARM stated the nurse did not notify the physician when the heart rate went out of parameters. The ARM further stated there was no documented evidence found in the EMR that the nurse called the physician and received any new orders, the nurse did not follow the policy when reporting...” A review of the facility’s P&P titled, “DYSRHYTHMIA MONITORING,” dated June 19, 2024, indicated, “...this policy is to facilitate appropriate, timely, and accurate electrocardiographic monitoring for those meetings the criteria specific to the nursing unit/department and/or physician direction...the patient’s heart rate exceeds or is below the standard alarm limits (50-120), the physician must be notified...” 5a. A review of Patient 14’s medical record was conducted on March 4, 2025, at 3:04 p.m., with the ARM. A review of the facility’s document titled, “H&P,” indicated, Patient 14 was admitted to the facility on February 28, 2025, for altered mental status and pneumonia. Admit to ICU (Intensive Care Unit). A review of the facility’s document titled, “Vital Signs,” dated March 1, 2025, at 10 p.m., indicated, “...Heart Rate...March 1, 2025, at 22:00 [10 p.m.] 41...Sinus Bra...” There was no documented evidence the strip was printed, evaluated, signed and placed in the physical chart for the sinus bradycardia episode of 41. On March 4, 2025, at 3:44 p.m. an interview and record review were conducted with the ARM. The ARM stated the nurse did not print, evaluate, sign and place the change in rhythm in the chart. The ARM further stated the nurse did not follow the policy. 5b. On March 5, 2025, at 11:15 a.m., a concurrent interview and record review of Patient 28’s medical record were conducted with the Quality Analyst (QA). The facility document titled, “Admission H&P, “ dated March 2, 2025 at 12:57 p.m., indicated Patient 28 was admitted to the facility on March 2, 2025, with diagnoses of intracranial hemorrhage (bleeding inside the skull that can put pressure on the brain), polycythemia vera (rare blood condition where the body makes too many red blood cells and can increase the risk of blood clots), Myocardial Infarction (heart attack, occurs when blood flow to part of the heart is blocked causing damage to the heart). The facility document titled, “Alarm Review Report,” dated March 3, 2025, at 8:56 p.m., was not signed by the RN. The QA stated, this report should be signed by the RN to acknowledge the patient’s rate, rhythm and interpretation of the monitor strip. The facility document titled, “Code Blue (a medical emergency where a patient is experiencing cardiac arrest, or another life-threatening condition that requires immediate resuscitation) Record,” dated March 4, 2025, indicated, “...Time event Recognized: 0224 [2:24 a.m.]...Status when need for compression identified: Pulseless...First Rhythm Requiring Compressions: PEA [Pulseless Electrical Activity, medical condition where the heart’s electrical system is working, but the heart is not pumping blood effectively]...Time Chest Compressions Started: 0224 [2:24 a.m.]...” The facility document titled, “INFORMATION OF DECEASED,” indicated, “Date of Death: March 4, 2025...Time of Death: 0243 [2:43 a.m.]...” The facility document titled, “Discharge Summary...Death Discharge Note,” dated March 4, 2025, at 10:57 a.m., indicated “...CAUSE OF DEATH- INTRACEREBRAL HEMORRHAGE...” On March 6, 2025, at 11:30 a.m., an interview was conducted with the Clinical Manager of ICU (CM). The CM stated the rhythm stripe on March 3, 2025, at 8:56 p.m., was not verified, validated and signed by the RN and the policy was not followed. A review of the P&P titled, “DYSRHYTHMIA MONITORING,” dated June 19, 2024, was conducted. The P&P indicated, “...this policy is to facilitate appropriate, timely, and accurate electrocardiographic monitoring for those meeting the criteria specific to the nursing unit/department and/or physician direction...ASSESSMENT ON INPATIENT UNITS...The Monitor Technician will obtain, evaluate, and print a rhythm strip for each patient record. The RN will then verify, validate, and co-sign all printed strips... with any dysrhythmia that is new, symptomatic or reflective of a change from a previous rhythm, or that requires immediate intervention...” 6. A review of Patient 19’s medical record was conducted on March 5, 2025, at 3:40 p.m., with the ARM. A review of the facility’s document titled, “H&P,” indicated, Patient 19 was admitted to the facility on January 9, 2025, for pituitary mass (growths that develop in the pituitary gland) and headache. A review of the facility’s document titled, “Pain Assessment,” dated January 10, 2025, at 8:26 a.m., indicated patient 19 rated his pain 8 out of 10, and the patient was not given pain medication. A review of the facility’s untitled document, undated, indicated, “...morphine [pain medication used for moderate to severe pain] 2 mg / [per] ml injection; 1 ml...2 mg 1 ml Push, Q [every] 4 hr [hours]...PRN [as needed], Pain Breakthrough Severe...” A review of Patient 19’s MAR indicated, there was no documented evidence the prescribed PRN pain medication for severe pain was given. There was no documented evidence in the EMR that Patient 19’s pain was addressed. On March 5, 2025, at 4:05 p.m. an interview and record review were conducted with the ARM. The ARM stated there was pain medication ordered for the patient and the expectation would be for the nurse to administer the pain medication and reassess in an hour. The nurse did not follow the facility policy for pain management. The ARM further stated there was no evidence in the EMR that the pain was addressed. A review of the facility’s P&P titled, “ADULT PAIN MANAGEMENT,” dated December 19, 2024, indicated, “...To assure the adequate assessment, reassessment and treatment of pain for patients throughout the continuum of care...Documentation of pain assessment consist of the following...Intervention done to relieve pain...” 7. On March 3, 2024, at 12:30 p.m., an observation was made in the Intensive Care Unit (ICU, unit where seriously ill patients receive close monitoring and specialized medical care). Patient 28 was observed to have bilateral wrist restraints. On March 5, 2025, at 11:15 a.m., a concurrent interview and record review of Patient 28’s medical record were conducted with the QA. The facility document titled, “Admission H&P,” dated March 2, 2025, at 12:57 p.m., indicated Patient 28 was admitted to the facility on March 2, 2025, with diagnoses of intracranial hemorrhage, polycythemia vera and Myocardial Infarction. The facility document titled, “All Orders,” dated March 2, 2025, 5:48 p.m., indicated, “...Restraint Initiation Non-Violent...Interferes with Medical device...Soft limb...2 [two] Point Restraint, Restraint location: Bilateral Upper Extremity...” The facility document titled, “Plan of Care,” indicated there was not a care plan (an outline that details a patient’s health needs and the steps healthcare providers will take to help meet those needs) to address the restraints. The QA stated a care plan to address restraints including remaining free from injury, skin integrity and positioning should have been in place for Patient 28. On March 6, 2025, at 11:30 a.m., an interview was conducted with the CM. The CM stated that all patients in restraints should have a care plan in place to address the restraints and this was not done. A review of the P&P titled, “STANDARDS OF CARE: ASSESSMENT, REASSESSMENT, AND CARE PLANS,” dated March 3, 2025, was conducted. The P&P indicated, “...The patient’s plan of care is initiated on admission and reviewed a minimum of every shift based on the patient’s response to their specific assessed need for care and treatment...Patient care goals, needs, interventions, and response to care are reviewed (an updated as needed) and documented every shift...” A review of the P&P titled, “RESTRAINT & [and] SECLUSION,” dated January 18, 2024, was conducted. The P&P indicated, “...Monitoring and Reassessment...When Restraint or Seclusion is used, there must be documentation in the patient’s medical record of the following...A description of the patient’s behavior and the intervention used...Alternatives or other less restrictive interventions attempted...The patient’s condition or symptom(s) that warranted the use of the Restraint or Seclusion...The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention...Individual patient assessments and reassessments...Use of Restraint or Seclusion in the Plan of Care...” 8. On March 5, 2025, at 11:15 a.m., a concurrent interview and record review of Patient 28’s medical record were conducted with the QA. The facility document titled, “Admission H&P,” dated March 2, 2025, at 12:57 p.m., indicated Patient 28 was admitted to the facility on March 2, 2025, with diagnoses of intracranial hemorrhage, polycythemia vera and Myocardial Infarction. The facility document titled, “Vital signs,” dated March 3, 2025, 6 p.m. through March 4, 2025, at 2:15 a.m., indicated the following: -On March 3, 2024, at 6 p.m., heart rate 100 sinus tachycardia (occurs when heart beats faster than normal), respiratory rate 22, blood pressure 122/60; -On March 3, 2024, at 7 p.m., heart rate 103 sinus tachycardia, respiratory rate 17, blood pressure 118/61; -On March 3, 2024, at 8 p.m., heart rate 103 sinus tachycardia, respiratory rate 20, blood pressure 123/51; -On March 3, 2024, at 9 p.m., heart rate 113 sinus tachycardia, respiratory rate 25, blood pressure 115/87; -On March 3, 2024, at 10 p.m., heart rate 117 sinus tachycardia, respiratory rate 24, blood pressure 129/71; -On March 3, 2024, at 11 p.m., sinus tachycardia; -On March 3, 2024, at 11:15 p.m., heart rate 139, respiratory rate 33, blood pressure 123/69; -On March 3, 2024, at 11:30 p.m., heart rate 124, respiratory rate 36, blood pressure 147/84; -On March 3, 2024, at 11:45 p.m., heart rate 110, respiratory rate 36, blood pressure 147/84; -On March 4, 2024, at 12:00 a.m., sinus tachycardia; -On March 4, 2024, at 12:45 a.m., heart rate 128, respiratory rate 39, blood pressure 134/71; -On March 4, 2024, at 1 a.m., heart rate 130 sinus tachycardia, respiratory rate 39, blood pressure 121/84; -On March 4, 2024, at 2 a.m., heart rate 89 normal sinus rhythm (normal heartbeat), respiratory rate 28, blood pressure 100/63; and -On March 3, 2024, at 2:15 a.m., heart rate 76 sinus tachycardia, respiratory rate 24, blood pressure 53/39. Continued review of Patient 28’s record indicated that all vital signs were documented on March 4, 2025, at 6:32 a.m. by the primary RN. The QA stated vital signs should be documented in real time and this was not done. The facility document titled, “Code Blue Record,” dated March 4, 2025, indicated, “...Time event Recognized: 0224...Status when need for compression identified: Pulseless...First Rhythm Requiring Compressions: PEA...Time Chest Compressions Started: 0224...” The facility document titled, “INFORMATION OF DECEASED,” indicated, “Date of Death: March 4, 2025...Time of Death: 0243...” The facility document titled, “Discharge Summary...Death Discharge Note,” dated March 4, 2025, at 10:57 a.m., indicated “...CAUSE OF DEATH- INTRACEREBRAL HEMORRHAGE...” On March 6, 2025, at 11:30 a.m., an interview was conducted with the CM. The CM stated all vital signs for Patient 28 were documented late and the expectation is for the RN to document them as close to real time as possible. The CM further stated it is not acceptable to document all the hourly vital signs at once. A review of the P&P titled, “CRITICAL CARE PLAN FOR PROVISION OF CARE AND SCOPE OF SERVICE,” dated December 19, 2024, was conducted. The P&P indicated, “...Monitoring Documentation...Heart rhythm and rate...Every 1 [one] hour...Monitor strip interpretation...Every 12 hours with any change in rhythm...Blood pressure...Every 1 hour...Respiratory rate...Every 2 hours...Plan of Care...Every 12 hours...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45431 Based on interview and record review, the facility failed to ensure patient rights were maintained for two of 34 patients (Patients 7, and 26) when: 1. For Patient 26, was not continuously monitored while on cardiac telemetry (see A- 144). 2. For Patient 7, a physician’s order for restraints (devices or methods that restrict a patient’s movement) was not obtained prior to Patient 7 being placed in restraints (see A- 168). 3. For Patient 7, while in restraints, Patient 7 was not was monitored and reassessed every 15 minutes as ordered (see A-175). The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients and may cause delays in the provision of patient care.”

“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: 45431 Based on interview and record review, the facility failed to follow their policy and procedures for four of 34 sample patients (Patients 2, and 26), when: 1. For Patient 2, consent was not obtained before sending a specimen for drug screen (see A-398). 2. For Patient 26, was not continuously monitored while on cardiac telemetry (see A-398). The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients and may cause delays in the provision of patient care.”

“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: 44871 Based on interview and record review, the facility failed to ensure patients received care in a safe setting for one of 34 sample patients (Patient 26), when Patient 26 was not continuously monitored while on cardiac telemetry (method to monitor a patient’s heart activity and other vital signs remotely). This failure resulted in a delay of treatment for Patient 26, and could have contributed to Patient 26’s death. Findings: On January 7, 2025, at 9:30 a.m., a concurrent interview and record review were conducted with the Accreditation and Regulatory Manager (ARM). The facility document titled, “History and Physical,” dated November 5, 2023, at 4:13 p.m., indicated Patient 26 was admitted to the facility on November 5, 2023, with diagnoses of acute chronic heart failure (weakening of the heart that limits its function), pulmonary edema (a condition that is caused by excess fluid in the lungs), and Atrial fibrillation with rapid ventricular response (A fib with RVR, an irregular heart rhythm that causes the ventricles to beat too quickly). The facility document titled, “Emergency Department Note-Physician,” dated November 5, 2023, indicated, “...There is 1+ edema [swelling] to the bilateral lower extremities that extends to the knees. EKG [electrocardiogram, a test that measures electrical activity of the heart] shows atrial fibrillation with RVR [rapid ventricular response, an irregular heart rhythm that occurs when the heart beats too fast], ventricular rate [the rate at which the heart’s lower chambers, or ventricles beat] of 154. Patient’s rate treated with Diltiazem [medication to treat irregular heart rate] 20 mg [milligrams, a unit of measurement] here in the emergency department which dropped heart rate to 120. Thus patient was started on a Diltiazem drip...MEDICTIONS ORDERED...Continuous...Diltiazem iv [intravenous] additive 125 mg [5 mg/hr.] (per hour) + ns [normal saline] 0.9% [percentage] Premix Diluent 125 ml [milliliters- unit of measurements...IV, 5 ml/hr...” The facility document titled, “ORDER SHEET,” dated November 5, 2023, 6:14 p.m., indicated, “...Routine Vital Signs...Q [every] 4 hr [four hours]...Telemetry Class...Acute Congestive Heart Failure, Maintain telemetry when patient off unit...” An undated facility document titled, “Encounter Location History,” indicated, Patient 26 was admitted to the Telemetry Unit on November 5, 2025 at 5:44 p.m. The facility document titled, “Vital Signs,” dated November 5, 2023 at 5:21 PM through November 6, 2023 at 5 a.m., indicated the following; -On November 5, 2023, at 5:21 p.m., heart rate 130 (a fib), respiratory rate 22, blood pressure 126/76, 02 saturation [the percentage of hemoglobin in your blood that is carrying oxygen] 96%; -On November 5, 2023, at 6 p.m., heart rate 85 (a fib), respiratory rate 18, blood pressure 103/52, 02 saturation 95%; -On November 5, 2023, at 7:48 p.m., heart rate 96 (a fib), respiration rate 18, blood pressure 100/58, 02 saturation 94%; -On November 5, 2023, at 8:05 p.m., 02 saturation 99% on 3 liters of oxygen; -On November 5, 2023, at 8:16 p.m., blood pressure 100/58; -On November 5, 2023, at 10 p.m., heart rate 78 (a fib), respiration rate 20, blood pressure 102/63, 02 saturation 99% on 3 liters oxygen per nasal cannula [medical device that provides supplemental oxygen to patients through their nose]; -On November 5, 2023, at 11:20 p.m., 02 saturation 99% on 4 liters oxygen per nasal cannula; -On November 6, 2023, at 12:31 a.m., heart rate 72 (a fib), respiration rate 18, blood pressure 144/101, 02 saturation 94%, temperature 36.6 degrees celsius; and -On November 6, 2023, at 5 a.m., heart rate 88 (a fib), respiratory rate 20, blood pressure 99/65, 02 saturation 94% on 3 liters nasal cannula. A facility document titled, “Central Monitor Telemetry Log,” dated November 5, (no year), 7 a.m.- 7 p.m., indicated, “...[Patient’s last name] expired 5:35 a.m...Comments...pt [patient] keep taking off leads 3:48 a.m. until 4 a.m...” The facility untitled document, dated November 5, 2023, at 10:46 p.m., indicated, “...Physician Communication Notified of : Medication, Patient condition, other: pt is c/o [complaining of] sob [shortness of breath], nausea. chest pain ekg done, (afib) , sic 3l [liters] o2 [oxygen] nc [nasal canula]...” The facility document titled, “Code Blue Record,” dated November 6, 2023, time event recognized 5:13a.m., indicated, “...5:13 a.m...PEA [pulseless electrical activity, condition where the heart stops beating, but the heart’s electric activity is still present]...5:17 a.m...asystole [the heart’s electrical and mechanical activity stops completely]...5:19 a.m...asystole...5:21 a.m...asystole...5:23 a.m...PEA...5:25 a.m...PEA...5:27 a.m...PEA...5:29 a.m...PEA...5:31 a.m...asystole...5:33 a.m...asystole...5:35 a.m...Time Resuscitation Event Ended...5:35 a.m...Status...Deceased...” The facility document titled, “Discharge Summary...Death Summary,” dated November 6, 2023, at 4:37 p.m., indicated, “...Patient was anxious and taking off monitor lines and NC [Nasal Cannula]...given morphine [a narcotic drug which relieves pain] and Benadryl [a medication that can treat pain or assist with sleep] at night time, he was still restless and was given 0.5mg ativan [a medication that relieves anxiety] at midnight, at 2:30 am pt [patient] was still restless per nurse documentation, pt redirected and no medication given...At 05:13AM, pt was found in asystole, code blue called, ACLS [advanced cardiac life support, a set of procedures and techniques used to treat life-threatening condition] started and lasted until 5:15AM, given epinephrine/calcium/sodium bicarb/magnesium [medications used during a code blue], bagged during the code, no shockable rhythm per code team, pt pronounced expired at 5:15AM...” During further review of Patient 26’s medical record with the ARM, there was no documented evidence of the following: -That Patient 26 received continuous cardiac monitoring leading up to the code blue; -That the Monitor Technician (MT) completed an event log for November 5, 2023, through November 6, 2023, night shift for Patient 26; -That the MT notified the Primary Nurse (PN) to inform her Patient 26’s heart rate fell below 50 bpm (beats per minute); -That the MT notified the PN to inform her Patient 26 was taking his cardiac telemetry leads off; -That the MT notified the PN of Patient 26’s cardiac rhythm which was PEA; Continued review of Patient 26’s record indicated that there was no documentation that the PN had received a call from the MT to inform her of Patient 26’s heart rate of 50 bpm, or that Patient 26 was removing his cardiac telemetry leads. -Additionally, there was no documentation in Patient 26’s record to indicate that the Charge Nurse (CN) had received a call from the MT to inform her Patient 26’s heart rate fell below 50 bpm or what led the CN to go into Patient 26’s room and thus finding Patient 26 unresponsive necessitating a call for code blue response. Review of Patient 26’s record indicated that there were no printed telemetry strips for changes in heart rate or telemetry strips that were obtained during the code blue response nor documentation regarding Patient 26’s cardiac status after 5 a.m. on November 6, 2023, until 5:13 a.m. when the code blue was called. On January 8, 2025, at 9:11 a.m., an interview was conducted with the Primary Nurse (PN). The PN stated the patient was taking off the monitor leads, 02 tubing, and was very anxious. The PN stated the patient was placed on continuous monitoring and needed reinforcement to keep leads on, and the MT did not call about any problems. The PN further stated, “I do not remember if I documented if the patient (Patient 26) was taking the leads off.” On January 8, 2025, at 1:08 p.m., an interview was conducted with the MT. The MT stated there was no event log at that time, if there was a problem, we would call the nurse. The MT further stated, “I did not fill out an event log at the time.” The MT further stated, “I do not remember calling the nurse about this patient (Patient 26).” On January 9, 2025, at 9:57 a.m., an interview was conducted with the Director of Progressive Care Unit/Telemetry and Monitor Technicians (D 1). D 1 stated, “I cannot find the event log or any telemetry strip changes, or telemetry strips during the code for this patient (Patient 26).” D 1 further stated the nurses are expected to document their findings in the Electronic Medical Record (EMR). On January 9, 2025, at 10:05 a.m., an interview was conducted with the ARM. The ARM stated there was no event log for this shift found, or telemetry strips, per the facility policy. She further stated there is no documentation of the event from the monitor technician and the charge nurse per policy. A review of the P&P titled, “DYSRHYTHMIA MONITORING,” dated November 22, 2023, was conducted. The P&P indicated, “...Documentation...Monitor Techs will document any arrhythmias on the Event Log and notify the RN [registered nurse]. The RN will document actions in the EMR [electronic Medical Record]...When notification parameters are not ordered and the patient’s heart rate exceeds or below the standard alarm limits (50-120), the physician must be notified. The Monitor Technician will notify the patient’s nurse for reportable rhythm changes, no waveforms, and/or sustained artifact. The MT will document in the event log and notify the Clinal Manager/Charge Nurse if necessary to obtain timely and necessary response ...The Monitor Technician will obtain, evaluate, and print a rhythm strip for each patient record. The RN will verify, validate, and co-sign all printed strips...with any dysrhythmia that is new, symptomatic or reflective of a change from a previous rhythm, or that requires immediate interventions...MT will document all events on the Event Log and the RN will document events in the EMR...” A review of the P&P titled, “CODE BLUE,” dated August 18, 2021, was conducted. The P&P indicated, “...If a patient on a monitor is found to be in a lethal rhythm (Red Alarm), the monitor tech will call a Code Blue and notify the operator of the patient room location...Interprets the monitored cardiac rhythm and assesses the patient’s hemodynamic status...Completes documentation...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45431 Based on interview and record review the facility failed to ensure a physician’s order for soft wrist restraints (a device designed to limit the movement of wrists) was obtained prior to the patient being placed in restraints, for one of 34 sample patients (Patient 7). This failure had the potential to cause physical or psychological harm and injury to Patient 7. Findings: A review of Patient 7’s medical record was conducted on January 8, 2025, at 10:18 a.m., with the Quality Assistant (QA) 1. A review of the facility document titled, “History and Physical,” dated November 14, 2024, indicated “...ASSESSMENT/PLAN...hypertension Emergency [high blood pressure]...Mental health disorder...endorses suicidal ideation [thoughts of hurting oneself]...” A review of the facility document titled, “IView / I&O [Intake and Output],” dated November 20, 2024, indicated, “...Restraint Placement/Monitoring...11/20/2024 [November 20,2024] 20:00 [8 p.m.]...Behavior Requiring Restraint...Interference with medical device...Nonviolent Restraints....2 point...soft limb...” During a review of Patient 7’s medical record with the QA 1, there was no documented evidence a physician’s order was obtained on November 20, 2024, for the use of soft wrist restraints on Patient 7. During a concurrent interview with the QA 1, the QA 1 stated there was no documentation an order for the restraints was given by the physician for the use of soft wrist restraints on Patient 7 on November 20, 2024. The QA 1 further stated a physician’s order is needed for restraints per the facility policy. An interview was conducted on January 8, 2025, at 2:56 p.m., with the Clinical Manager (CM) 2. The CM 2 stated based on her record review, there was no documented evidence a physician’s order was obtained for Patient 7’s restraints on November 20, 2024. A review of the facility’s P & P titled, “DES ADM 749 Restraints & Seclusion,” dated January 18, 2024, was conducted. The P&P indicated, “...Restraints and Seclusion require an order from a physician or other authorized Licensed Practitioner responsible for the care of the patient...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 45431 Based on interview and record review the facility failed to ensure patients were monitored and reassessed every 15 minutes as ordered while in restraints, for one of 34 sampled patients (Patient 7). This failure had the potential to cause harm, injury, and/or death to Patient 7. Findings: A review of Patient 7’s medical record was conducted on January 8, 2025, at 10:18 a.m., with the Quality Assistant (QA) 1. A review of the facility document titled, “History and Physical,” dated November 14, 2024, indicated “...ASSESSMENT/PLAN...hypertension Emergency [high blood pressure]..Mental health disorder...endorses suicidal ideation [thoughts of harming self]...” A review of facility document titled, “Order,”, dated November 29, 2024, indicated,” ...Restraint Initiation Violent Adult...Details...Reason for Restraints...Imminent risk to self...Criteria for Release...No longer Imminent risk to self ...Restraints...Soft Limb...Points of Restraints ..2 Point Restraints...Restraint Location...Bilateral Upper Extremity...” A review of the facility document titled, “ Order,” dated November 29, 2024, indicated,”...Restraint Monitoring Violent Adult...Details...Frequency Q[every]15 min [minutes]-int...Special Instructions...for 4 hours...” A facility document titled, “IView/I&O [Intake & Output]” dated, November 20, 2024, through November 30, 2024, was reviewed. There was no documentation to show that Patient 7 was monitored or re-assessed every 15 minutes as ordered. During a concurrent interview with QA 1 at the time of the record review, QA 1 stated there was no documented evidence Patient 7 was re-assessed or monitored every 15 minutes as ordered, from November 29, 2024, at 10 p.m., through November 30, 2024, at 6 a.m. An interview was conducted with the Clinical Manager (CM) 1, on January 8, 2025, at 2:19 p.m. The CM 1 stated there was no documented evidence Patient 7 was monitored every 15 minutes because the restraint order was entered wrong. The CM 1 stated the physician ordered the wrong restraint order because behavioral restraints are not used in the Intensive Care Unit (ICU). The CM1 further stated the policy was not followed because the restraint order was wrong and should have been changed from Behavioral to Non-Behavioral restraints. A review of the facility’s policy and procedure (P&P), titled, “DES ADM 749 RESTRAINTS & SECLUSION,” dated January 18, 2024, indicated, “...Monitoring and Reassessment...Appropriate interval for re-assessment is based on patient’s needs, condition, and type of restrained used...When Restraints or Seclusion is used there must be documentation in the patient’s medical record of the following...A description of the patient’s behavior and the interventions used...Alternative or other less restrictive interventions attempted...The patient’s condition or symptom(s) that warranted the use of the Restraint...The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention...Individual patient assessment and re-assessment...””

“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: 45431 Based on interview and record review, the facility failed to implement their policies and procedures (P&P) for two of 34 sample patients (Patients 2, and 26) when: 1. For Patient 2, consent was not obtained before sending a specimen for drug screen; 2. For Patient 26, was not continuously monitored while on cardiac telemetry. These failures had the potential to compromise patient safety and cause delays in medical care, and may have contributed to patients death. Findings: 1. A review of Patient 2’s medical record was conducted on January 7, 2025, at 10 a.m., with the Quality Analyst (QA) 1. A review of the facility’s document titled, “History and Physical,” dated July 5, 2024, indicated, Patient 2 was admitted to the facility on July 5, 2024, due to eminent delivery of a baby. A review of the facility document titled, “ Order,” dated July 5, 2024, indicated, “...Drug Screen Urine...Status Change 07/05/2024 [July 5, 2024]...02:22 PDT (Pacific daylight time)...Department status..In La...” A review of the facility document titled, “CONSENT TO SURGERY/SPECIAL PROCEDURES (WITH PHYCISIAN CERTIFICATION,” dated July 5, 2024, indicated, “...Your physician has recommended the following operation or procedure...vaginal delivery with possibility of episiotomy and/or repair, blood analysis, urine for toxicology...date 07/05/2024 [July 5, 2024]...time 2:35 a.m...signature...” An interview was conducted on January 8, 2025, at 10:14 a.m., with the Perinatal Services Clinical Manager (PSCM). The PSCM stated the facility did not follow the process based on the policy when the urine specimen was sent to the lab for testing before consent was obtained from Patient 2. A review of the facility’s policy and procedure (P&P), titled, “DES PNS 643 PERINATAL DRUG SCREEN,” dated December 15, 2023, indicated, “...It is the policy of Perinatal Services to obtain specimen for drug toxicology on all women admitted to the Perinatal unit. Consents must be signed before the specimen may be sent...” 2. On January 7, 2025, at 9:30 a.m., a concurrent interview and record review were conducted with the Accreditation and Regulatory Manager (ARM). The facility document titled, “History and Physical,” dated November 5, 2023, at 4:13 p.m., indicated Patient 26 was admitted to the facility on November 5, 2023, with diagnoses of acute chronic heart failure (weakening of the heart that limits its function), pulmonary edema (a condition that is caused by excess fluid in the lungs), and Atrial fibrillation with rapid ventricular response (A fib with RVR, an irregular heart rhythm that causes the ventricles to beat too quickly). The facility document titled, “Emergency Department Note-Physician,” dated November 5, 2023, indicated, “...There is 1+ edema [swelling] to the bilateral lower extremities that extends to the knees. EKG [electrocardiogram, a test that measures electrical activity of the heart] shows atrial fibrillation with RVR [rapid ventricular response, an irregular heart rhythm that occurs when the heart beats too fast], ventricular rate [the rate at which the heart’s lower chambers, or ventricles beat] of 154. Patient’s rate treated with Diltiazem [medication to treat irregular heart rate] 20 mg [milligrams, a unit of measurement] here in the emergency department which dropped heart rate to 120. Thus patient was started on a Diltiazem drip...MEDICTIONS ORDERED...Continuous...Diltiazem iv [intravenous] additive 125 mg [5 mg/hr.] (per hour) + ns [normal saline] 0.9% [percentage] Premix Diluent 125 ml [milliliters- unit of measurements...IV, 5 ml/hr...” The facility document titled, “ORDER SHEET,” dated November 5, 2023, 6:14 p.m., indicated, “...Routine Vital Signs...Q [every] 4 hr [four hours]...Telemetry Class...Acute Congestive Heart Failure, Maintain telemetry when patient off unit...” An undated facility document titled, “Encounter Location History,” indicated, Patient 26 was admitted to the Telemetry Unit on November 5, 2025 at 5:44 p.m. The facility document titled, “Vital Signs,” dated November 5, 2023 at 5:21 PM through November 6, 2023 at 5 a.m., indicated the following; -On November 5, 2023, at 5:21 p.m., heart rate 130 (a fib), respiratory rate 22, blood pressure 126/76, 02 saturation [the percentage of hemoglobin in your blood that is carrying oxygen] 96%; -On November 5, 2023, at 6 p.m., heart rate 85 (a fib), respiratory rate 18, blood pressure 103/52, 02 saturation 95%; -On November 5, 2023, at 7:48 p.m., heart rate 96 (a fib), respiration rate 18, blood pressure 100/58, 02 saturation 94%; -On November 5, 2023, at 8:05 p.m., 02 saturation 99% on 3 liters of oxygen; -On November 5, 2023, at 8:16 p.m., blood pressure 100/58; -On November 5, 2023, at 10 p.m., heart rate 78 (a fib), respiration rate 20, blood pressure 102/63, 02 saturation 99% on 3 liters oxygen per nasal cannula [medical device that provides supplemental oxygen to patients through their nose]; -On November 5, 2023, at 11:20 p.m., 02 saturation 99% on 4 liters oxygen per nasal cannula; -On November 6, 2023, at 12:31 a.m., heart rate 72 (a fib), respiration rate 18, blood pressure 144/101, 02 saturation 94%, temperature 36.6 degrees celsius; and -On November 6, 2023, at 5 a.m., heart rate 88 (a fib), respiratory rate 20, blood pressure 99/65, 02 saturation 94% on 3 liters nasal cannula. A facility document titled, “Central Monitor Telemetry Log,” dated November 5, (no year), 7 a.m.- 7 p.m., indicated, “...[Patient’s last name] expired 5:35 a.m...Comments...pt [patient] keep taking off leads 3:48 a.m. until 4 a.m...” The facility untitled document, dated November 5, 2023, at 10:46 p.m., indicated, “...Physician Communication Notified of : Medication, Patient condition, other: pt is c/o [complaining of] sob [shortness of breath], nausea. chest pain ekg done, (afib) , sic 3l [liters] o2 [oxygen] nc [nasal canula]...” The facility document titled, “Code Blue Record,” dated November 6, 2023, time event recognized 5:13a.m., indicated, “...5:13 a.m...PEA [pulseless electrical activity, condition where the heart stops beating, but the heart’s electric activity is still present]...5:17 a.m...asystole [the heart’s electrical and mechanical activity stops completely]...5:19 a.m...asystole...5:21 a.m...asystole...5:23 a.m...PEA...5:25 a.m...PEA...5:27 a.m...PEA...5:29 a.m...PEA...5:31 a.m...asystole...5:33 a.m...asystole...5:35 a.m...Time Resuscitation Event Ended...5:35 a.m...Status...Deceased...” The facility document titled, “Discharge Summary...Death Summary,” dated November 6, 2023, at 4:37 p.m., indicated, “...Patient was anxious and taking off monitor lines and NC [Nasal Cannula]...given morphine [a narcotic drug which relieves pain] and Benadryl [a medication that can treat pain or assist with sleep] at night time, he was still restless and was given 0.5mg ativan [a medication that relieves anxiety] at midnight, at 2:30 am pt [patient] was still restless per nurse documentation, pt redirected and no medication given...At 05:13AM, pt was found in asystole, code blue called, ACLS [advanced cardiac life support, a set of procedures and techniques used to treat life-threatening condition] started and lasted until 5:15AM, given epinephrine/calcium/sodium bicarb/magnesium [medications used during a code blue], bagged during the code, no shockable rhythm per code team, pt pronounced expired at 5:15AM...” During further review of Patient 26’s medical record with the ARM, there was no documented evidence of the following: -That Patient 26 received continuous cardiac monitoring leading up to the code blue; -That the Monitor Technician (MT) completed an event log for November 5, 2023, through November 6, 2023, night shift for Patient 26; -That the MT notified the Primary Nurse (PN) to inform her Patient 26’s heart rate fell below 50 bpm (beats per minute); -That the MT notified the PN to inform her Patient 26 was taking his cardiac telemetry leads off; -That the MT notified the PN of Patient 26’s cardiac rhythm which was PEA; Continued review of Patient 26’s record indicated that there was no documentation that the PN had received a call from the MT to inform her of Patient 26’s heart rate of 50 bpm, or that Patient 26 was removing his cardiac telemetry leads. -Additionally, there was no documentation in Patient 26’s record to indicate that the Charge Nurse (CN) had received a call from the MT to inform her Patient 26’s heart rate fell below 50 bpm or what led the CN to go into Patient 26’s room and thus finding Patient 26 unresponsive necessitating a call for code blue response. Review of Patient 26’s record indicated that there were no printed telemetry strips for changes in heart rate or telemetry strips that were obtained during the code blue response nor documentation regarding Patient 26’s cardiac status after 5 a.m. on November 6, 2023, until 5:13 a.m. when the code blue was called. On January 8, 2025, at 9:11 a.m., an interview was conducted with the Primary Nurse (PN). The PN stated the patient was taking off the monitor leads, 02 tubing, and was very anxious. The PN stated the patient was placed on continuous monitoring and needed reinforcement to keep leads on, and the MT did not call about any problems. The PN further stated, “I do not remember if I documented if the patient (Patient 26) was taking the leads off.” On January 8, 2025, at 1:08 p.m., an interview was conducted with the MT. The MT stated there was no event log at that time, if there was a problem, we would call the nurse. The MT further stated, “I did not fill out an event log at the time.” The MT further stated, “I do not remember calling the nurse about this patient (Patient 26).” On January 9, 2025, at 9:57 a.m., an interview was conducted with the Director of Progressive Care Unit/Telemetry and Monitor Technicians (D 1). D 1 stated, “I cannot find the event log or any telemetry strip changes, or telemetry strips during the code for this patient (Patient 26).” D 1 further stated the nurses are expected to document their findings in the Electronic Medical Record (EMR). On January 9, 2025, at 10:05 a.m., an interview was conducted with the ARM. The ARM stated there was no event log for this shift found, or telemetry strips, per the facility policy. She further stated there is no documentation of the event from the monitor technician and the charge nurse per policy. A review of the P&P titled, “DYSRHYTHMIA MONITORING,” dated November 22, 2023, was conducted. The P&P indicated, “...Documentation...Monitor Techs will document any arrhythmias on the Event Log and notify the RN [registered nurse]. The RN will document actions in the EMR [electronic Medical Record]...When notification parameters are not ordered and the patient’s heart rate exceeds or below the standard alarm limits (50-120), the physician must be notified. The Monitor Technician will notify the patient’s nurse for reportable rhythm changes, no waveforms, and/or sustained artifact. The MT will document in the event log and notify the Clinal Manager/Charge Nurse if necessary to obtain timely and necessary response ...The Monitor Technician will obtain, evaluate, and print a rhythm strip for each patient record. The RN will verify, validate, and co-sign all printed strips...with any dysrhythmia that is new, symptomatic or reflective of a change from a previous rhythm, or that requires immediate interventions...MT will document all events on the Event Log and the RN will document events in the EMR...” A review of the P&P titled, “CODE BLUE,” dated August 18, 2021, was conducted. The P&P indicated, “...If a patient on a monitor is found to be in a lethal rhythm (Red Alarm), the monitor tech will call a Code Blue and notify the operator of the patient room location...Interprets the monitored cardiac rhythm and assesses the patient’s hemodynamic status...Completes documentation...””

“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: 49214 Based on interview and record review, the facility failed to ensure their Pain Reassessment, Medication Administration, and Pressure Injury Assessment, Prevention, Treatment & Management, policies and procedures (P&P) were implemented for six of 30 patients (Patients 2, 4, 6, 10, 22, and 29, when: 1. Patients 2, 4, 6, 22, and 29’s pain levels were not reassessed within 60 minutes after administration of pain medications (Refer to A-0398); 2. For Patient 10, who was unable to manage pressure relief independently, was not turned and repositioned every two hours resulting in a deep tissue injury (Refer to A-0398); and 3. For Patient 22, pain medication refusal was not reported to the physician, nor was there documentation of subsequent attempts to administer the medication (Refer to A-0398). These cumulative failures had the potential to compromise patient safety, result in inadequate pain management, and increase risk for pressure injuries.”

“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: 49214 Based on interview and record review, the facility failed to ensure their Pain Reassessment, Medication Administration, and Pressure Injury Assessment, Prevention, Treatment & Management, policies and procedures (P&P) were implemented for six of 30 patients (Patients 2, 4, 6, 10, 22, and 29, when: 1. Patients 2, 4, 6, 22, and 29’s, pain was not reassessed within 60 minutes after administration of pain medication; 2. Patient 10, who was unable to manage pressure relief independently, was not turned and repositioned every two hours, resulting in a deep tissue injury (a serious bruise under the skin that occurs when pressure is on one part of the body too long like sitting or lying in the same position); and 3. Patient 22’s medication refusal was neither documented nor reported to the doctor, and there was no evidence of a subsequent attempt to administer the medication. These failures had the potential to compromise patient safety, resulting in poor pain management, increase risk of pressure injuries, and delays in medical care. Findings: 1 a. A review of Patient 2’s medical record was conducted on October 1, 2024, at 1:30 p.m., with the Stroke Program Coordinator (SPC). A review of the facility’s document titled, “History and Physical (H&P),” indicated, Patient 2 was admitted to the facility on September 24, 2024, for acute renal failure (kidneys stop working) and diarrhea. A review of Patient 2’s medication administration record (MAR) indicated, there was no documented evidence a pain reassessment (checking patient’s pain if increased or decreased) was done on the following dates and times: -On September 28, 2024, at 2:18 p.m., Morphine (MS, pain medication indicated for severe pain) 2 milligrams (mg, unit to measure how much medication to take) intravenous (IV, medicine or fluid given directly into a vein) was given for a pain level of eight out of 10 (pain level, describes severity of pain, zero meaning no pain and 10 meaning the worst pain possible); -On September 29, 2024, at 5:18 a.m., MS 2 mg IV was given to Patient 2 for a pain level of 10 out of 10; and -On September 30, 2024, at 2:18 p.m., MS 2 mg IV was given to Patient 2 for a pain level of eight out of 10. An interview was conducted on October 1, 2024, with the SPC. The SPC stated the staff did not perform pain reassessments within 60 minutes after interventions on the above dates listed for Patient 2, which was not in accordance with the facility’s policy. 1 b. A review of Patient 4’s medical record was conducted on October 2, 2024, at 9:30 a.m., with the Cardiac Care Coordinator (CCC). A review of the facility’s document titled, “H&P,” indicated, Patient 4 was admitted to the facility on September 24, 2024, for pancreatic mass (abnormal growth in the pancreas). A review of Patient 4’s MAR indicated on October 2, 2024, at 9:33 a.m., Dilaudid (pain medication, indicated for breakthrough severe pain) 1 mg IV was given to Patient 4 for a pain level of nine out of 10. An interview was conducted on October 2, 2024, at 9:55 a.m., with the CCC. The CCC stated the staff did not perform a pain reassessment within 60 minutes after interventions for Patient 4, which was not in accordance with the facility’s policy. 1 c. A review of Patient 6’s medical record was conducted on October 2, 2024, at 10 a.m., with the Cardiac Care Coordinator (CCC). A review of the facility’s document titled, “H&P,” indicated, Patient 6 was admitted on July 2, 2024, for acute cerebral vascular accident (CVA, blood flow to part of brain is blocked). A review of Patient 6’s MAR indicated there was no documented evidence pain reassessments was done on the following dates and times: -On July 3, 2024, at 2:25 a.m., MS 2 mg IV was given to Patient 6 for a pain level of eight out of 10; and -On July 5, 2024, at 6:25 a.m., MS 2 mg IV was given to Patient 6 for a pain level of eight out of 10. An interview was conducted on October 3, 2024, at 10:30 a.m., with the CCC. The CCC stated the staff did not perform pain reassessments within 60 minutes after interventions for Patient 6, which was not in accordance with the facility’s policy. 1 d. A review of Patient 22’s medical record was conducted on October 2, 2024, at 9:00 a.m., with the Stroke Program Coordinator (SPC). A review of the facility’s document titled, “H&P,” indicated, Patient 22 was admitted to the facility on August 13, 2024, for bilateral (affecting both legs) leg swelling and liver cirrhosis (liver disease). A review of Patient 22’s MAR indicated, there were no documented evidence pain reassessments were done on the following dates and times: - On August 14, 2024, at 5:04 p.m., Ibuprofen (pain medication, indicated for mild pain) 400 mg was given with no documented pain level prior to administration; - On August 14, 2024, at 9:16 p. m., Ibuprofen 400 mg was given with no documented pain level prior to administration; - On August 18, 2024, at 11:28 a.m., Tylenol (pain medication, indicated for mild pain) 650 mg was given for a pain level of six out of 10; - On August 18, 2024, at 2:27 p.m., Tylenol 325 mg was given for a pain level of seven out of 10; - On August 18, 2024, at 4:36 p.m., Tylenol 650 mg was given for a pain level of four out of 10; - On August 21, 2024, at 6:28 a.m., Tylenol-Hydrocodone (pain medication, indicate for severe pain) 325 mg-5 mg was given for a pain level of 10; - On September 1, 2024, at 5:59 p.m., Tylenol 650 mg was given with no documented pain level prior to administration; - On September 4, 2024, at 8:30 a.m., Tylenol 650 mg was given with no documented pain level prior to administration.; - On September 6, 2024, at 8:32 a.m., Tylenol 650 mg was given with no documented pain level prior to administration; and - On September 7, 2024, at 12:33 a.m. Tylenol 650 mg was given with no documented pain level prior to administration. An interview was conducted on October 2, 2024, at 2:00 p.m., with the SPC. The SPC stated pain reassessments should be done 60 minutes after medication administration. The SC further stated pain levels should be assessed prior to pain medication administration and documented in the medical record. 1 e. A review of Patient 29’s medical record was conducted on October 3, 2024, at 10:40 a.m., with the Stroke Program Coordinator (SPC). A review of the facility’s document titled, “History & Physical,” indicated, Patient 29 was admitted to the facility on August 12, 2024, for sepsis (serious illness when the body has a strong reaction to an infection). A review of Patient 29’s MAR indicated there was no documented evidence pain reassessments were done on the following dates and times: - On August 14, 2024, at 11:11 a.m., Norco (pain medication, indicated for severe pain) 325/10 mg tablet was administered for a pain level of nine out of 10; - On August 14, 2024 at 6:30 p.m., MS 1 mg IV was administered for pain level of six out of 10. An interview was conducted on October 3, 2024, at 11:00 a.m., with the SPC. The SPC stated the staff did not perform pain reassessments within 60 minutes after interventions for the dates listed above for Patient 29, which was not in accordance with the facility’s policy. A review of the facility’s P&P titled, “Adult Pain Management,” dated August 8, 2021, indicated, “...To assure the adequate assessment, reassessment and treatment of pain for patients throughout the continuum of care...Reassessment of pain post [after] intervention is documented within 60 minutes after intervention...” 2 a. A review of Patient 10’s medical record was conducted on October 2, 2024, at 10:30 a.m., with the Cardiac Care Coordinator (CCC). A review of the facility’s document titled, “History and Physical,” indicated, Patient 10 was admitted to the facility on April 24, 2023, for acute right MCA (middle cerebral [brain] artery [blood vessel that carries oxygen away from the heart]) stroke. A review of the facility’s document titled, “Nursing Admission Assessment,” dated April 24, 2023, indicated Patient 10’s Braden score was 12 (a scoring system to identify if a patient was at risk of developing pressure injury, with a score of 10-12 indicating high risk). A review of Patient 10’s repositioning schedule was conducted. There was no documented evidence Patient 10 was repositioned on the following dates and times: - On May 14, 2023, from 10 p.m., until May 15, 2023, at 1:50 a.m. (3 hours and 50 minutes); - On May 15, 2023, from 1:50 a.m., until 5 a.m. (3 hours and 10 minutes); - On May 15, 2023, from 12 noon until 7:30 p.m. (7 hours and 30 minutes); - On May 16, 2023, from 1 a.m., until 5:17 a.m. (4 hours and 17 minutes); and - On May 20, 2023, from 4 p.m., until 8 p.m. (4 hours). A review of the facility’s document titled, “Wound Care Notes,” dated April 27, 2023, indicated, “...Wound Care Nurse recommendations...Turn and reposition patient every two hours, off load heel and sacrum and nutritional support...” A review of the facility document titled, “Wound Care Notes,” dated May 15 2023, at 11:59 a.m., indicated, “...Turn and reposition patient every two hours...” A review of the Wound Care Notes,” dated May 18, 2023, at 2:01 p.m., indicated, “...sacral wound hospital acquired, deep tissue injury that had opened...wound started as a blister...” On October 2, 2024, at 11:15 a.m., an interview was conducted with the CCC. The CCC stated, Patient 10 was not turned and repositioned every two hours on the above dates. The CCC stated the staff did not follow the wound care nurse’s recommendations or the facility policy. The CCC further stated the wound could have been prevented if Patient 10 had been turned every 2 hours on all shifts. A review of the facility’s policy and procedure (P&P) titled, “Pressure Injury Assessment, Prevention, Treatment & Management,” dated September 22, 2022, indicated, “...To establish a consistent, evidence based approach to pressure injury prevention and management...Repositioning...For patients who are bed-bound and do not interact with the environment, turn every 2 hours or more frequently as needed...” 3 a. A review of Patient 22’s medical record was conducted on October 2, 2024, at 9:00 a.m., with the Stroke Program Coordinator (SPC). A review of the facility document titled, “History and Physical,” indicated, Patient 22 was admitted to the facility on August 13, 2024, for bilateral leg swelling and liver cirrhosis (liver disease). A review of the Medication Administration Record (MAR) indicated, Lactulose (medication for Liver Cirrhosis) 22.5 ml (milliliters, unit of measure) was to be given orally every eight hours. Further review of the MAR indicated three doses of Lactulose that were not given because Patient 22 refused medications on the following dates and times: - On August 21, 2024, at 11:00 p.m., Lactulose 22.5 ml was not given as ordered; - On August 22, 2024, at 8:00 a.m., Lactulose 22.5 ml was not given as ordered; and - On August 22, 2024, at 3:00 p.m., Lactulose 22.5 ml was not given as ordered. An interview was conducted on October 2, 2024, at 9:00 a.m., with the SPC. The SPC stated if a medication was not given the nurse should document the reason and notify the physician. The SPC stated there was no documented evidence why Patient 22 refused the medication, which was not in accordance to facility’s policy. An interview was conducted on October 2, 2024, at 1:42 p.m., with Registered Nurse (RN) 1. RN 1 stated when the patients refuse medications, the policy is to check if the patient is alert and then educate the patient on why they are taking the medication. RN 1 stated Patient 22 refused the Lactulose because it made him go to the bathroom too much. RN 1 further stated she did not document education on importance of medication and she also did not notify the physician. A review of the facility’s P&P titled, “Medication Administration,” dated September 22, 2022, indicated, “...If the patient still refuses a medication, the health care professional will document education and efforts and patient refusal, chart...If the patient refuses more than two (2) sequential doses of a scheduled medication...the physician shall be notified for evaluation and further orders...Pharmacy may be consulted for education and evaluation...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44871 Based on interview and record review, the facility failed to ensure a patients (Patient 10) Do Not Resuscitate (DNR, medical order that instructs healthcare providers to not perform life saving measures) wishes were carried out during his hospitalization when; 1. Patient 10 received Cardiopulmonary Resuscitation (CPR, life saving measures performed when the heart stops beating to pump blood to the brain and vital organs) after coding (cardiac or respiratory arrest). (Refer to A-0132). This failure resulted in Patient 10 being in the Intensive Care Unit (ICU- hospital unit that provides critical care and life support to patients who are very ill) on a ventilator (life support machine that helps people breathe when they are unable to do so on their own), after receiving Cardiopulmonary Resuscitation (CPR). This failure also resulted in Patient 10’s patients’ rights to be violated by not being able to make informed decisions about his care.”

“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: 44871 Based on interview and record review, the facility failed to ensure a patients (Patient 10) Do Not Resuscitate (DNR, medical order that instructs healthcare providers to not perform life saving measures) wishes were carried out during his hospitalization. This failure resulted in Patient 10 being in the Intensive Care Unit (ICU- hospital unit that provides critical care and life support to patients who are very ill) on a ventilator (life support machine that helps people breathe when they are unable to do so on their own), after receiving Cardiopulmonary Resuscitation (CPR, life saving measures performed when the heart stops beating to pump blood to the brain and vital organs). This failure also resulted in Patient 10’s patients’ rights being violated by the facility not honoring his informed decisions about his care. Findings: A review of Patient 10’s medical record was conducted on August 7, 2024, at 9:20 a.m., with the Accreditation Regulatory Manager (ARM). A facility document titled, “ED [Emergency Department] Note-Physician,” dated August 4, 2023, at 9:26 p.m., authored by Physician 1 was reviewed. The document indicated, “...history of myasthenia gravis [autoimmune disease that impacts the neuromuscular system] is presenting with fever, cough, fatigue. The patient did have a trip and fall onto his left knee which had abrasions which she [sic] was seen at urgent care...” There was no documented evidence of code status on this physician note. A facility document titled, “ED Screenings/History Adult,” dated August 4, 2023, at 6:04 p.m., was reviewed. The document indicated, “...Advanced Directive [a legal document that outlines a persons preferences for medical care if they are unable to communicate their wishes]: No...Advanced Directive Additional Information: Information given...[Name of Registered Nurse 1, (RN 1)], August 4, 2023, at 6:03 p.m...” A facility document titled, “Order Entry,” dated August 6, 2023, at 6:57 a.m., was reviewed. The document indicated, “...Resuscitation Status...Routine, August 4, 2023, at 10:15 p.m.,...Full Resuscitation [the process of trying to restart someone’s heart and lungs after they stop working]...” A facility document titled, “History and Physical (H&P),” dated August 5, 2023, at 12:51 a.m., authored by Physician 2 was reviewed. The document indicated, “...Male who presents with acute complaints of fever, chills, fatigue, cough and has a chronic medical problems including myasthenia gravis, hypertension [high blood pressure], hyperlipidemia [excess fat in the blood], history of UTI [urinary tract infection]...Full code [if a patients heart or breathing stops, the medical team will try everything possible to save their life]...” A facility document titled, “Med/Surge Frequent assessment,” dated August 4, 2023, at 5:59 p.m., until 11:33 p.m., authored by RN 2, was reviewed. The document indicated, “...Code Status: Unknown...” There was no documented evidence RN 2 discussed in the handoff to the admitting nurse that Patient 10 was a DNR status. A facility document titled, “Physician Orders for Life-Sustaining Treatment (POLST),” dated August 18, 2019, was reviewed. The document indicated, “...CARDIOPULMONARY RESUSCITATION [CPR]...Do Not Attempt Resuscitation/DNR [Allow Natural Death]...MEDICAL INTERVENTIONS...Comfort-Focused Treatment- primary goal of maximizing comfort...ARTIFICIALLY ADMINISTERED NUTRITION...No artificial means of nutrition, including feeding tubes...” This document was signed and dated by Patient 10 on August 19, 2019, and electronically signed by Patient 10’s physician on September 4, 2019, at 6:26 p.m. This document was faxed in the hospital EHR (Electronic Health Record), on October 5, 2019, at 12:29 (unknown a.m. or p.m.). A facility document titled, “California Advanced Health Care Directive,” dated February 19, 2024, was reviewed. The document indicated, “...INSTRUCTIONS FOR HEALTH CARE ...END-OF-LIFE DECISIONS...[Patient 10’s initials] Choice Not To Prolong Life I do not want my life to be prolonged...RELIEF FROM PAIN...COMFORT MEASURES...” A facility document titled, “California Power of Attorney for Health Care and Health Care Instruction Form,” dated September 26, 2011, was reviewed. The document indicated, “...I make the following instructions to my agent...I do not want effects made to prolong my life and I do not want life-sustaining treatment to be provided or continued...If I am in an irreversible coma [a state where person is unresponsive] or persistent vegetative state [a chromic state of brain dysfunction in which a person shows no sign of awareness]; or if I am terminally ill [a medical term that refers to someone who has a disease that is incurable and will eventually lead to death] and the provision of life sustaining procedures would serve to artificially delay the moment of my death; then, I make the following instructions, by placing my signature in front of my request...I authorize the treatment needed to provide me with food, water, and pain control, and to keep me comfortable, but otherwise do not authorize active treatment of my medical conditions...” A facility document titled, “CODE BLUE RECORD,” dated August 5, 2023, at 11:54 p.m., was reviewed. The document indicated, “...Time of First Assisted Ventilation: 11:55 p.m., ...Invasive Airway: Inserted...Insertion Time : 12:03 a.m...Time Chest Compressions Started: 11:54 p.m...Defibrillator Pads On: Yes...Time Resuscitation Event Ended: 12:03 a.m...Status: Alive...” A facility document titled, “Progress Note,” authored by Physician 3, dated August 6, 2023, at 11:28 a.m., was reviewed. The document indicated, “...Patient’s CODE STATUS is noted to be DNR in this case of repeat cardiac arrest, however at this time we will continue medical treatment and reassess goals of care with the patient’s family in the next 48 hours...” A facility document titled, “PATIENT RIGHTS & RESPONSIBILITIES,” dated April 21, 2018, was reviewed. The document indicated, “...Formulate advanced directive. This includes designating a decision maker if you become incapable of understanding a proposed treatment or become unable to communicate your wishes regarding care. Hospital staff and practitioner who provide care in the hospital shall comply with theses directives. All patients’ rights apply to the person who has legal responsibility to make decisions regarding medical care on your behalf...” A document letter from the facility, addressed to Patient 10’s family member, dated August 17, 2023, was reviewed. The document indicated, “...When you arrived at the ED, you gave his nurse his California Advanced Health Care Directive (DNR) and proceeded to talk to the ED doctors about his care...the nurse called a Code Blue...It appears that this was the likely breakdown in the communication as to your father’s Code status...On August 6, 2023, the physician in ICU [Intensive Care Unit] made her notes and documented your father’s code status was noted to be DNR...We understand your concerns and truly hope your family had a different experience. We apologize for the misinterpretation/misunderstanding made...” During the record review the Demographic bar in Patient 10’s Electronic Health Record (EHR), indicated the code status was unknown and there was no documented evidence a purple DNR band was placed on Patient 10. An interview and record review were conducted with the Clinical Emergency Department Manager (CEDM) on August 7, 2024, at 10:55 a.m. The CEDM stated if the family hands the nurse the DNR the expectation is for the nurse to document he/she received the forms, place a DNR band (purple) on the patient, and a call to social services should be made to verify the forms. The CEDM further stated Advanced Directive is also asked on triage and the nurses are expected to answer appropriately, The CEDM further stated, the expectation would be for the ED nurse to communicate to the admitting floor nurse the patients DNR status. She further stated it does not look like this happened in this case. An interview was conducted with Patient 10’s family member on August 8, 2024, at 9:47 a.m., who stated the DNR paperwork was handed to the male nurse, who walked away to make copies, and returned and stated it is already in the system. The family member further stated, “the facility was given the DNR paperwork several times in the past and I can not believe that they stuck a tube in my 90-year-old dad against his wishes, we were very upset and could not believe this happened.” An interview and record review were conducted with the ARM on August 8, 2024, at 11:01 a.m. The ARM stated there were many issues with this case. The triage nurse documented no advanced directive, the ED physician did not document code status, the admitting physician documented incorrect code status, the physician placed a full resuscitation order, there was no documentation of a handoff report from the ED nurse to the admitting nurse of the code status, and the demographic bar had code as unknown. The ARM further stated the policies and procedure were not followed. A review of the facility’s policy and procedure (P&P) titled, “EMERGENCY DEPARTMENT PROCESS OF CARE,” dated January 19, 2023, was reviewed. The document indicated, “...All patients presenting to the Emergency Department requesting care (or on whose behalf care is requested) shall be entered into the hospitals electronic medical record...Data collected by Emergency Department personnel is guided by the relevant electronic or paper form. Information asked for by the forms shall be collected to the extent relevant and consistent with the operation or clinical concern...” A review of the facility’s P&P titled, “ADVANCED HEALTH CARE DIRECTIVE,” dated September 7, 2023 was conducted. The document indicated, “...MANDATED REQUIREMENTS FOR ALL HOSPITALS: Both the federal and state law attempt to improve utilization of advanced health care directives as follows...All adult inpatients...To ask patient about the existence of and advanced health care directive. To record responses to the above questions. To provide patients without such a document with information regarding their right to establish one. To provide a mechanism for the Hospital to follow-up with the patients during their hospitalization regarding a health care directive...A complete and signed advanced health care directive take effect immediately...””

“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: 45431 Based on observation, interview and record review, the facility failed to ensure the facility’s infection control program was maintained and methods to prevent the transmission of infections were implemented, and failed to ensure a clean and sanitary environment when: a. Regular trash was found in biohazard bins and sharp containers in multiple patient care areas. b. Corrugated boxes were found stored in a cabinet in the recovery area Unit E. c. The ultrasound probe was not appropriately stored after performing a high - level disinfection. d. Patients were not provided a Chlorhexidine Gluconate bath (CHG, bathing product that kills germs and reduces the spread of infection in hospitals), in accordance with the facility’s policy and procedure (P&P), for seven of 32 sampled patients (Patient 2, 14, 17, 20, 22, 24, and 31). This failure had the potential to result in the transmission and spreads of pathogens (bacteria, virus, or other microorganisms) which could cause disease/s to the patients receiving care in this facility. (Refer to A - 0749) ; and e. Professional standards for food service safety were not followed in Kitchen A. f. Food and personal items were found in the nurse’s station in Unit G. g. Food service safety were not followed in the nutrition areas in Units C and D. h. Patient rooms in Unit C (rooms #1 and 2) and D (rooms #3, #4 and#5) had grime and accumulated debris on the floors and dirt on the base boards. These failures had the potential to expose immunocompromised patients to foodborne illnesses (illness caused by ingestion of contaminated food or beverages) due to cross contamination (the transfer of harmful substances or disease- causing microorganisms to food), creating harborage conditions attracting pests, transmit and spread pathogens (bacteria, virus, or microorganism) which could cause disease. (Refer to A - 0750) The cumulative effect of these systemic problems resulted in the facility’s inability to ensure the provision of quality health care, in compliance with the Condition of Participation for Infection Prevention/Control/Abx Stewardship Program.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 45431 Based on observation, interview, and record review the hospital failed to ensure medications were properly secured when: 1. Two crash carts in the Emergency Department (ED) had secure tags that did not match the daily crash cart logs; 2. Medications used for emergency resuscitation was left on top of the crash cart unsecured; and 3. Anesthesia medications (medicines to prevent pain during surgery and other procedures) were found in an unlocked anesthesia cart in one of the operating rooms. These failures had the potential for unauthorized access and diversion or misuse to controlled anesthesia medications. Findings: 1. During a tour of the ED on February 29, 2024, at 1:30 p.m., crash carts two and three had contradicting lock numbers with the crash cart and defibrillator monitoring logs. An interview was conducted on February 29, 2024, at 1:39 p.m., with the Emergency Department Director (EDD). The EDD stated the expectation would be that the locks for the crash cart supplies and emergency medications should match the daily crash carts logs when checked and signed off. The EDD further stated the locks for crash carts two and three did not match the log. An interview was conducted on February 29, 2024, at 1:44 p.m., with the ED Charge Nurse (EDCN). The EDCN stated the lock numbers did not match for both carts (two and three). The EDCN further stated the nurse checking the crash carts must check the actual number on the locks for the supplies and the emergency medications and make sure the numbers match the log, then sign off. A review of facility document titled, “[Name of facility] Crash Cart and Defibrillator Monitor Log,” Dated February 2024, for crash carts two and three were reviewed. The document indicated for crash cart two, “...Cart Lock # 85010186...Drug Lock # 0490962 ...DATE February 29, 2024, SHIFT NOC [7 p.m. to 7 a.m.]...” The actual Cart Lock Number (blue) 0492757 and the Drug Lock number (red) was 8484015. A review of the facility’s Policy and Procedure (P&P) titled, “[Name of the facility] RX 394 Crash Cart Monitoring Exchange,” dated February 22, 2024, indicated, “...Once daily all patient care areas with crash carts will complete and document the crash cart integrity check. A registered nurse, Emergency Department technician, or by a designated person in the ancillary departments shall complete the check. The cart will be checked for the following...1. The front of the cart is locked with a blue numbered lock. This lock number is to be recorded on the monitoring form. 2. The top of the crash cart containing pharmaceuticals is locked with a red numbered lock. This lock number is to be recorded on the monitoring form...If a crash cart is replaced, document the new red and blue lock numbers on the Crash Cart Log to the right of previous number AND document the new crash cart number in the appropriate daily box...” 2. A tour of Unit A was conducted on February 29, 2024, at 3:05 p.m., with the Director of Unit A (DUA). During the tour, crash cart one was observed in the hallway with unsecured medications on top: One vial of Etomidate (a short- acting anesthetic) 20 mg iv (intravenous), and two Rocuronium 50 mg iv (intermediate-acting nondepolarizing neuromuscular blocker). The emergency medication drawer was observed unsecured after the cart was used for a rapid response. An interview was conducted on February 29, 2024, at 3:15 p.m., with the DUA. The DUA stated the medications should have been secured, brought back to the nurse’s station, and not left unattended in the hallway. The DUA stated the used medications should have been placed in a bag and placed in the locked refrigerator for the pharmacy to collect. The DUA further stated the nurse should have secured the emergency medication drawer of the crash cart with orange locks, however, the nurse did not do it. An interview was conducted on February 29, 2024, at 3:29 p.m., with the Rapid Response Nurse (RRN). The RRN stated the medications taken out should have been secured in a bag and place in the unit refrigerator. The emergency medication drawer of the crash cart should have been secured with an orange lock, and then notify the central supply to replace the cart. The RRN further stated, “I did not do this, I assumed the other nurse would secure the cart and medications.” A review of the facility’s Policy and Procedure (P&P) titled, “[Name of the facility] RX 394 Crash Cart Monitoring Exchange,” dated February 22, 2024, was reviewed. The P&P indicated, “...Unused/partially used medications for Rapid Sequence Intubation should be placed in the sleeve/container that it came in and placed back into the unit’s locked medication refrigerator in the “Used” medication bin by a Registered Nurse from the unit where the kit was opened. The unit clinical manager is responsible to ensure all medications are returned timely and properly...Pharmacy will pick up the used medication kit when they round...In the event the crash cart is opened for any reason...A. First, re-secure the crash cart’s medication section of the crash cart with an orange lock, thus notifying subsequent health-care providers, that this cart has been accessed and requires replenishment...Then notify Central Supply for a secured replacement cart.” A review of the facility’s P&P titled, “[Name of facility] RX Storage and Security of Pharmaceuticals,” dated March 24, 2024, indicated, “...Medications shall remain in control of a licensed health care practitioner (HCP) at all times; unless otherwise stored in a secured medication room, cabinet, nursing cart, ADC, locked kit, or a similar secure location...” 3. A tour of the Post Anesthesia Care Unit (PACU) was conducted on March 4, 2024, at 10:45 am, with the Post Anesthesia Care Unit Manager (PACUM). During the tour, two bottles of anesthesia medications: Forane (a general anesthetic) 100 ml (milliliters- unit of measurement) and Sevoflurane (a volatile anesthetic that provides hypnosis, amnesia, analgesia, akinesia, and autonomic blockade during surgical and procedural interventions) 250 ml’s, were found in an unlocked anesthesia cart in operating room A. A concurrent interview was conducted with the PACUM on March 4, 2024, at 10:45 a.m. The PACUM stated the medications should not be left in the cart unsecured. The PACUM further stated there is a dedicated room in the pre-op area for anesthesia supplies including medications. An interview was conducted on March 4, 2024, at 11:25 a.m. with the Anesthesia Tech (AT). The AT stated he oversees the anesthesia carts and the two anesthesia medications found in the bottom drawer of the anesthesia cart should not be there and should be locked. A review of the facility’s P&P titled, “[Name of the facility] RX Storage and Security of Pharmaceuticals,” dated March 24, 2024, indicated, “...Medications shall remain in control of a licensed health care practitioner (HCP) at all times; unless otherwise stored in a secured medication room, cabinet, nursing cart, ADC, locked kit, or a similar secure location...””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 45431 Based on observation, interview, and record review the hospital failed to ensure that all available supplies and equipment are ready for use when: 1. Door handle of heated food cabinet in Kitchen A was loose; 2. Hinge for Refrigerator #2 in Kitchen A was broken; 3. Dishwasher in Kitchen A was not meeting appropriate temperature of 180 F; 4. Patient blanket warmer in the Emergency Department (ED), door was not closing properly; 5. Expired vacutainers and venous blood tubes were found in a supply cabinet on Unit B; 6. Patient blanket warmer in the Post Anesthesia Care Unit (PACU) was broken; and 7. Expired supplies were found in a Malignant Hyperthermia (MH) cart in the Operating Room (O.R.). These failures had the potential to delay patient care and services or cause patient harm. Findings: 1. A tour of Kitchen A was conducted on February 29, 2024, at 9:50 a.m., with the Dietary Supervisor (DS). During the tour the door handle for the heated food cabinet was observed to be loose, making it difficult to open the cabinet. The DS stated he submitted a work order for it to be repaired, but it has not been done yet. There was no documented evidence a work order was submitted for this equipment. A review of the FDA (Food and Drug Administration) Federal Food Code 2022, 4-501.11 titled, “Good Repair and Proper Adjustment”, indicated, “...Proper maintenance of equipment to manufacturer’s specification helps ensure that it will continue to operate as designed...Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk...” 2. A tour of Kitchen A was conducted on February 29, 2024, at 9:50 a.m., with the Dietary Supervisor (DS). During the tour the door hinge of refrigerator #2 was observed to be broken. The DS stated the hinge was broken and he will submit a work order to repair it. A review of the facility’s policy and procedure (P&P) titled, “Policy #G005: Safety and Equipment Maintenance” dated January 2023, was conducted. It indicated, “...Proper maintenance of the physical plan and all equipment in the Department is the responsibility of the Director in cooperation with the Maintenance Department...” A review of the FDA (Food and Drug Administration) Federal Food Code 2022, 4-501.11 titled, “Good Repair and Proper Adjustment”, indicated, “Proper maintenance of equipment to manufacturer’s specification helps ensure that it will continue to operate as designed...Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk...” 3. During a tour of Kitchen A, on February 29, 2024, at 10:09 a.m., the DS performed a wash cycle on the dishwasher. The DS used a thermometer to test the hot water sanitation temperature. The thermometer result indicated the temperature was 174F (degrees Fahrenheit). The DS ran another wash cycle and used a red testing strip attached to a colored container. The test strip indicated the hot sanitation temperature of 180F was not achieved, similarly the thermometer indicated a temperature of 169F. The DS stated that the dishwasher did not reach the required hot sanitation temperature. A review of the facility document titled, “Test Strip Log”, dated February 2024, was conducted with the DS. The log indicated, the dishwasher temperature did not meet the required temperature for February 2024 except on February 8, 19 and 20, 2024. A review of the Food Code of 2022, indicated, “...4-5 Maintenance and Operation 4-501 Equipment...4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures...in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90C (194F) ... For all other machines, 82C (180F) ...” A review of the FDA (Food and Drug Administration) Federal Food Code 2022, 4-501.11 titled, “Good Repair and Proper Adjustment”, indicated, “...Proper maintenance of equipment to manufacturer’s specification helps ensure that it will continue to operate as designed...Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk...” 4. A tour of the Emergency Department (ED) was conducted on February 29, 2024, at 1:44 p.m., with the Emergency Department Director (EDD). The blanket warmer door was observed to not close appropriately. The EDD stated it was broken and he will request a repair work order. A review of the facility’s document titled, “[Name of Facility] Corrective Maintenance/ Repairs Work Order”, dated March 1, 2024, was conducted. The work order indicated, “WO History...WO#287519...Problem: ED...by Trauma Room...Blanket warmer door hinge gets stuck causing door to stay slightly open, needs new door handle too...date 11/2/2023 [November 2, 2023]...Action...Called vendor for parts & [and] part number, vendor told me the blanket warmer is obsolete...” There was no documented evidence that a follow up for this work order occurred since November 2, 2023, or a manufacturer instruction for use manual was available for review. 5. A tour of Unit B was conducted on February 29, 2024, at 2:24 p.m., with the Director of Unit B (DUB). In a supply cabinet there were 37 expired green tube vacutainers (venous blood tubes) with an expiration date of September 30, 2023. The DUB verified the vacutainers were expired and stated, “This should have been found in the Leader EOC [Environmental of Care] weekly rounding. There is a check list for checking for expired care supplies and discarding are included.” The DUB further stated the expectation would be for the Night Clinical Manager (NCM) to carefully check the supplies and discard any expired patient care supplies. A review of the facility’s document titled, “The Leader EOC [Environment of Care] Rounds” dated February 18, 2024, through February 25, 2024, was conducted. It indicated, “...Expired patient care supplies discarded, Unit B...100% compliance...” A review of the facility’s P&P titled, “Procurement and Supply Chain Management ,” dated June 21, 2023, was conducted. It indicated, “ ...All supply items are to be stored so as to ensure that the oldest items are used first...2. All supply items should be reviewed weekly and upon issuance in respect to expiration dates.3. All expired items will be immediately removed from the storage location and placed in a holding area until proper disposition can be made...” 6. A tour of the Post Anesthesia Care Unit (PACU) was conducted on March 4, 2024, at 9:31 a.m., with the Post Anesthesia Care Unit Manager (PACUM). The patient’s blanket warmer cabinet was observed to have silk tape attached to the side and holding a white hard plastic band attached to the blanket warmer door. The PACUM stated the “contraption” was used to hold the door because it does not close correctly. The PACUM stated that, currently this blanket warmer is not being used because it is broken as, it is not heating the blankets, and he had requested the blanket warmer be fixed eight months ago, however it is still broken. A review of the facility’s document titled, “Warmers Upper & Lower Temperature Record Log”, for the PACU, was conducted. It indicated the blanket warmer was “broken” on the following dates: a. July 20, 21, 22, 27 and 28, 2023; b. August 21 and 25, 2023; and c. January 2, 2023 A review of the facility’s document titled, “[Name of Facility] Corrective Maintenance/ Repairs Work Order”, dated March 4, 2024, was conducted. It indicated the last work order completed was July 7, 2023, and no documented evidence that a work order for the blanket warmer was submitted after that date. An interview was conducted on March 6, 2024, at 1:30 p.m., with the PACUM. The PACUM stated he is unable to find the Manufacturer Instruction for Use (MIFU) for the blanket warmer as it is old. He further stated that he is not sure if the temperature indicated in the logs are still accurate or outdated. 7. A tour of the Operating Room (OR) was conducted on March 4, 2024, at 10:15 a.m., with the Operating Room Charge Nurse (ORCN). During the tour the following expired supplies in the Malignant Hyperthermia (MH) cart were found: a. One Anesthesia Breathing Circuit - Expired April 27, 2022; b. One Anesthesia Breathing Circuit - Expired November 20, 2022; c. Four 20G [gauge] X 1” [one inch] Hypothermic Needle - Expired March 12, 2023; d. Three [Brand] dressing - Expired October 31, 2023; e. Two 22G X 1” Intravenous [IV] Catheter - Expired June 1, 2023; f. One 24G X ¾” IV Catheter - Expired May 1, 2023; g. One 18G X 1 ¼ “IV Catheter - Expired March 1, 2023; h. One 18G X 1 ¼ “IV Catheter - Expired January 1, 2023; i. One Non-Conductive Connecting Tubing- 10” length, 3/16” Diameter, Tubing with two Female Connector - Expired February 1, 2024; j. One [Brand] 14 F [French] Intermittent Catheter - Expired January 31, 2024; Two [Brand] 16 F Intermittent Catheter - Expired April 30, 2023; l. One [ Brand] 24 F Intermittent Catheter Expired June 30, 2023; m. Three 18G” Spinal Needle - Expired September 30, 2021; n. Four 3ml [milliliters] Blood Sample Syringe - Expired October 2, 2022; o. Two Gravity Infusion set -Expired May 5, 2023; and p. One Gravity Infusion set -Expired March 20, 2023. A concurrent interview with the ORCN was conducted on March 4, 2024, at 10:15 AM. The ORCN stated the nurses are responsible for the integrity of the lock but do not stock or check for supply expirations. An interview was conducted on March 4, 2024, at 10:18 a.m., with the Pharmacy Technician (PT). The PT stated, the Pharmacy is only in charge of the medications in the MH cart, not the supplies. An interview was conducted on March 4, 2024, at 10:25 a.m., with the Material Management Director (MMD). The MMD stated they provide supplies for the OR’s but do not supply or oversee the MH cart. A review of the facility’s policy and procedure (P&P) titled, “Malignant Hyperthermia (MH),” dated October 4, 2020, was conducted. It indicated, “...Pharmacy will restock the Malignant Hyperthermia kit and Crash Cart supplies...””

“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: 45431 Based on observation, interview and record review, the facility failed to ensure the facility’s infection control program was maintained and methods to prevent the transmission of infections were implemented within the facility when: 1. Regular trash was found in biohazard bins and sharp containers in multiple patient care areas. 2. Corrugated boxes were found stored in a cabinet in the recovery area Unit E. 3. The ultrasound probe was not appropriately stored after performing a high - level disinfection. 4. Patients were not provided a Chlorhexidine Gluconate bath (CHG, bathing product that kills germs and reduces the spread of infection in hospitals), in accordance with the facility’s policy and procedure (P&P), for seven of 32 sampled patients (Patient 2, 14, 17, 20, 22, 24, and 31). This failure had the potential to result in the transmission and spread of pathogens (bacteria, virus, or other microorganisms) which could cause disease/s to the patients receiving care in the facility. Findings: 1. A tour of the Emergency Department (ED) was conducted on February 29, 2024, at 1:50 p.m., with the Emergency Department Director (EDD). Regular tape and gloves were observed inside the sharps container. The EDD stated, “It should not be there.” The EDD further stated there are no regular trash bins in the ED. During a concurrent observation and interview on March 1, 2024, at 9:15 a.m., with the Public Safety Officer (PSO), in Unit C, room 1, the sharps container and biohazard bin contained gloves, used gauze, and silver dressing package. The PSO stated the items found in the sharps container and biohazard bin should not be there. During a concurrent observation and interview on March 1, 2024, at 9:35 a.m., with the PSO, in Unit D, room 1, the biohazard bin contained gloves and paper packaging. The PSO stated the items found in the sharps container should not be there. During a concurrent observation and interview on March 1, 2024, at 9:37 a.m., with the PSO, in Unit D, room 2, the biohazard bin was observed to contain gloves and an irrigation syringe. The PSO stated the items found in the sharp container should not be there. During a concurrent observation and interview on March 1, 2024, at 9:46 a.m., with the PSO, in Unit D, room 3, the biohazard bin contained unsoiled gloves, IV tubing, syringe cover, and a paper cup. The PSO stated the items found should not be there. During an observation on March 1, 2024, at 1:32 p.m., in Unit H room 1, unsoiled gloves, and tape was observed inside the sharp container. During an observation on March 1, 2024, at 1:50 p.m., in Unit I room 1, unsoiled gloves, were in the biohazard bin. During an observation on March 1, 2024, at 2:05 p.m., in Unit I room 2, unsoiled gloves, were in the biohazard bin. During an observation on March 1, 2024, at 2:11 p.m., in Unit J room 1, unsoiled gloves were observed inside the sharp container. During an observation on March 1, 2024, at 2:13 p.m., in Unit J room 2, unsoiled gloves, and paper medicine cups were observed in the biohazard bin. During an observation on March 1, 2024, at 2:25 p.m., in Unit K room 1, unsoiled gloves, paper, and tissue were observed in the biohazard bin. During an observation on March 1, 2024, at 3:02 p.m., in Unit L room 1, unsoiled gloves and tissue were observed in the biohazard bin. During an observation on March 1, 2024, at 3:05 p.m., in Unit L nurse’s station, unsoiled gloves and tissue were observed in the biohazard bin. During an observation on March 1, 2024, at 3:10 p.m., in Unit M room 1, unsoiled gloves, paper, needle covers, including an unused nasogastric (NG) tubing were observed in the biohazard bin. An interview was conducted on March 1, 2024, at 11:00 a.m., with the Chief Administration Officer (CAO). The CAO stated trash should be in the trash bin and items soaked heavily with bodily fluids should be in the biohazard bin. During a concurrent observation and interview on March 4, 2024, at 9:32 a.m., with RN 7, in Unit N, gloves, a styrofoam tray and plates, paper, and plastic spoons were observed in the biohazard bin. RN 7 stated the items should not be in the biohazard bin but in regular trash. During a review of the facility’s P & P titled, “Hazardous Waste management Plan”, dated December 21, 2023, indicated, “...Type of Waste Generated...Regular Nonregulated waste is nonhazardous that is disposed of through traditional trash cans with clear bags...this includes food, cups styrofoam, disposable personal protective equipment (PPE) such as...gloves...Medical waste is categorized either BIOHAZARDOUS, (including sharps)...Biohazardous waste consists of the flowing waste that is red bagged or in red tubs/bins or sharp containers...Red Bag waste: includes anything contaminated with blood or other potentially infectious materials (OPIM) such as: Suction canister liners, blood collection devices, dressings with blood, blood tubing’s with visible blood or OPIM, PPE soiled in blood...Sharps Waste: includes syringes(with or without needles), needles, broken glass...staples, scissors, lancets...” 2. A tour of Unit E was conducted on March 5, 2024, at 3:30 p.m., with the Patient Risk Officer (PSO), Unit E Manager (UEM), and Unit E Director (UED). During a concurrent observation and interview on March 5, 2024, at 3:46 p.m., corrugated boxes in the supply cabinet located across the recovery bays were observed. The UED stated the boxes are stored as found after being delivered by materials management. An interview was conducted on March 5, 2024, at 4:00 p.m., with the Accreditation and Regulatory Manager (ARM). The ARM stated, the facility does not have a policy regarding corrugated boxes. A review of ANSI/AAMI ST79, dated 2017 (American National Standards/Association for the Advancement of Medical Instrument, standards development organizations) Comprehensive Guide to Steam Sterilization and Sterility Assurance in Healthcare Facilities, indicated, “...3.3.6.5...web-edged (corrugated) boxes can collect dust, debris, and insects during shipment and can carry contaminants into the area.” 3. A tour of Unit F was conducted on March 5, 2024, at 10: 39 a.m., with the Patient Risk Officer (PSO) and the Unit F Manager (UFM). During an observation on March 5, 2024, at 10:40 a.m., in Unit F, a [Brand Name] probe was stored without a cover in an open cylindrical container mounted on the wall. An interview was conducted on March 5, 2024, at 10:45 a.m., with the Ultrasound Manager (USM). The USM stated the probe is stored uncovered in the cylindrical container after the high-level disinfection was performed. During a concurrent interview and record review, was conducted on March 7, 2024, at 8:35 a.m., with the UFM, USM, and the Radiology Director (RD). The [Brand Name] User Manual, undated was reviewed. The [Brand Name] User Manual indicated, “The [Brand Name] is designed to provide high level disinfection (HLD) of validated ultrasound probes...Removing the probe...After completion of a successful HLD cycle...do not compromise the probe’s high level disinfected surface...The probe is now ready for use or storage in a [Brand Name] Clean Ultrasound Probe Cover.” The USM and RD stated they do not use the cover as stated in the user manual. During a review of the facility’s policy and procedure (P&P) titled, “[Facility Name] 360 High Level Disinfection”, dated December 21, 2023, indicated, “...Definition: High-Level Disinfection (HLD): High-Level Disinfection is the complete elimination of all microorganisms in or on an instrument, except for small number of bacterial spores... Procedure...The HLD process follows manufacturers and regulatory standards and recommendation for use.” 4. The following records were reviewed with the Accreditation Regulatory Manager (ARM) on March 6, 2024, at 9:30 a.m. a. Patient 2’s face sheet and History and Physical (H&P), indicated Patient 2 was admitted to the facility on February 8, 2024 for a pelvic fracture and is currently inpatient. There was no documented evidence Patient 2 was allergic to Chlorhexidine Gluconate (CHG, bathing product that kills germs and reduces the spread of infection in hospitals). A review of Patient 2’s Activity of daily living (ADL) flow sheet, dated February 28, 2024, to March 6, 2024, indicated no documented evidence that Patient 2 was provided a CHG bath on March 3, 2024. b. Patient 14’s face sheet and H&P indicated Patient 14 was admitted to the facility on February 28, 2024, currently inpatient, and was admitted for right knee infection. There was no documented evidence Patient 14 was allergic to CHG. A review of Patient 14’s ADL flow sheet, dated February 28, 2024, to March 6, 2024, indicated no documented evidence Patient 14 was provided a CHG bath on February 29, 2024. c. Patient 17’s face sheet and H&P indicated Patient 17 was admitted to the facility on February 10, 2024, currently inpatient, and was admitted for a left femur fracture. There was no documented evidence Patient 17 was allergic to CHG. A review of Patient 17’s ADL flow sheet, dated February 11, 2024, to March 6, 2024, indicated no documented evidence Patient 17 was provided a CHG bath on February 23, 2024, February 25, 2024, and February 29, 2024. d. Patient 20’s face sheet and H&P indicated Patient 20 was admitted to the facility on February 25, 2024, for shortness of breath for four days however, patient expired on February 29, 2024. There was no documented evidence Patient 20 was allergic to CHG. A review of Patient 20’s ADL flow sheet, dated February 26, 2024, to February 29, 2024, indicated no documented evidence Patient 20 was provided a CHG bath on February 25, 2024, and February 28, 2024. e. Patient 22’s face sheet and H&P indicates Patient 22 was admitted to the facility on March 4, 2024, currently inpatient, and was admitted for elective surgery right ovary removal. There was no documented evidence Patient 22 was allergic to CHG. A review of Patient 22’s ADL flow sheet, dated March 4, 2024, and March 5, 2024, indicated no documented evidence Patient 22 was provided a CHG bath. f. Patient 24’s face sheet and H&P indicates Patient 24 was admitted to the facility on February 19, 2024, currently inpatient, was admitted for a subarachnoid hemorrhage (bleeding between the brain and tissue). There was no documented evidence Patient 24 was allergic to CHG. A review of Patient 24’s ADL flow sheet, dated February 20, 2024, to March 6, 2024, indicated no documented evidence Patient 24 was provided a CHG bath on February 20, 2024, February 21, 2024, February 25, 2024, February 26, 2024, and February 27, 2024. g. Patient 31’s face sheet and H&P indicates Patient 31 was admitted to the facility on February 26, 2024, currently inpatient, was admitted due to multiple falls at home. There was no documented evidence Patient 31 was allergic to CHG. A review of Patient 31’s ADL flow sheet, dated February 27, 2024, to March 6, 2024, indicated no documented evidence Patient 31 was provided a CHG bath on March 3, 2024, and March 4, 2024. During an interview with the ARM on March 6, 2024, at 1:30 p.m., the ARM stated there was no documentation that CHG baths were provided to Patients 2, 14, 17, 20, 22, 24, and 31 on the dates mentioned above. The ARM further stated the facility’s policy was not implemented. A review of the facility’s policy and procedure (P&P) titled, “DES IP 914 Patient Daily Bathing with 4% Chlorhexidine Gluconate Solution”, dated September 10, 2021, indicated, “...This policy applies to all inpatient areas of [Name of facility], excluding the Neonatal Intensive Care (NICU)...All patients are bathed daily with 4% CHG solution...””

“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: 45431 Based on observations, interviews, and record reviews, the facility failed to ensure a clean and sanitary environment when: 1. Professional standards for food service safety were not followed in Kitchen A. 2. Food and personal items were found in the nurse’s station in Unit G. 3. Food service safety were not followed in the nutrition areas in Units C and D. 4. Patient rooms in Unit C (rooms #1 and #2) and D (rooms #3, #4 and #5) had grime and accumulated debris on the floors and dirt on the base boards. These failures had the potential to expose immunocompromised patients to foodborne illnesses (illness caused by ingestion of contaminated food or beverages) due to cross contamination (the transfer of harmful substances or disease- causing microorganisms to food), creating harborage conditions attracting pests, transmit and spread pathogens (bacteria, virus, or microorganism) which could cause disease. Findings: 1. A tour of Kitchen A was conducted on February 29, 2024, at 9:29 a.m., with the Dietary Supervisor (DS). During a concurrent observation and interview on February 29, 2024, at 9:29 a.m., with the DS, in Kitchen A, Refrigerator # 1, containing prepared food, had dried food residue on the bottom compartment, and dust particles in between the grooves of the refrigerator door seal. The DS stated the expectation is for this equipment to be cleaned every day after meal preparation. During a concurrent observation and interview on February 29, 2024, at 9:39 a.m., with the DS, in Kitchen A, there were food crumbs, black grime build-up and trash observed under the sink. The DS stated this area is cleaned daily and should include the area under the sink. During a concurrent observation and interview on February 29, 2024, at 9:50 a.m., with the DS, in Kitchen A, a male staff was observed not wearing a beard cover. The DS stated the expectation is a beard cover should be worn while in the kitchen. During a concurrent observation and interview on February 29, 2024, at 9:53 a.m., with the DS, in Kitchen A, the inside of the [Brand Name] heated food cabinet, were food crumbs on the side walls, and dust on the bottom compartment with food crumbs, grime build up, and dust at the back and side of the cabinet. The DS stated the area should be cleaned thoroughly daily. During a concurrent observation and interview on February 29, 2024, at 9:57 a.m., with the DS, in Kitchen A, the floor under the Refrigerator # 5, was observed to have grime build up, food crumbs, dust, and dirt. The DS stated this area should be included in the daily cleaning. During a concurrent observation and interview on February 29, 2024, at 9:59 a.m., with the DS, in Kitchen A, the bottom corners of Refrigerator # 2, located behind the food preparation table had dirt and grime buildup. The DS stated this area should be cleaned thoroughly daily. During a concurrent observation and interview on February 29, 2024, at 10:00 a.m., with the DS, in Kitchen A, under the metal supply shelf small dead bugs and dust was observed. The DS stated it needs to be cleaned. During a concurrent observation and interview on February 29, 2024, at 10:01 a.m., with the DS, in Kitchen A, the floor drain by the supply shelf was observed to have a hole approximately three inches by three inches, where pests can enter. The DS stated the hole needs to be repaired. During a concurrent observation and interview on February 29, 2024, at 10:02 a.m., with the DS, in Kitchen A, Refrigerator #3 was observed to have food debris and grime build up on the left side of the refrigerator. The DS stated it needs to be cleaned. During a concurrent observation and interview on February 29, 2024, at 10:04 a.m., with the DS, in Kitchen A, the top of the dishwasher had thick dust and grime build up, which has the potential to contaminate sanitized utensils. The DS stated dusting and wiping the equipment should be done daily. During a concurrent observation and interview on February 29, 2024, at 10:09 a.m., with the DS, in Kitchen A, there was a large size brown stain on the ceiling above the sink by the dishwasher. The DS stated it needs to be repaired. During an observation on February 29, 2024, at 10:16 a.m., the metal wall covering inside the cleaning material closet was unhinged. This had the potential to harbor pests. During an observation on February 29, 2024, at 10:17 a.m., there were dirt and trash under the vending machines, that can provide an environment for attraction of pests. During a concurrent observation and interview on February 29, 2024, at 10:20 a.m., with the DS, in Kitchen A, there were food crumbs, black grime, and trash build-up under the stove range and deep fryer. The DS stated it needs to be cleaned. During a review of the facility’s policy and procedure (P&P) titled, “Policy#E006...Uniform Dress Code”, dated January 2023, indicated, “... Procedures... Associates Working with Food...Restrain facial hair with net/restraints.” During a review of the facility’s P&P titled, “Policy#F014...Area and Equipment Cleaning”, dated January 2024, indicated, “Policies...Written procedures are available, detailing daily and weekly (as needed) cleaning for all areas and equipment in the department.” There was no documented evidence that daily, and weekly cleaning of all areas and equipment for Kitchen A was available for review. A review of the FDA (Food and Drug Administration) Federal Food Code 2022, 4-601.11 titled “Equipment, Food-Contact Surfaces, Nonfood- Contact Surfaces and Utensils,” indicated, “...(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris.” In addition, 4-602.13, indicates “The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.” A review of the FDA (Food and Drug Administration) Federal Food Code 2022, 4-402.12 titled, “Fixed Equipment, Elevation or Sealing,” indicated, “The inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic microorganisms that are transmissible through food.” 2. A tour of the Emergency Department was conducted on February 29, 2024, at 1:30 p.m., with the Patient Safety Officer (PSO), Emergency Department Director (EDD) and Charge Nurse Emergency Department (CNED). During a concurrent observation and interview on February 29, 2024, at 1:35 p.m., with the EDD and CNED, in the ED Nurse’s station, personal food items were observed on top of a computer, which consisted of water bottles, a bottled water with no cover, and a [brand name] coffee cup. There were opened and half eaten biscuits observed by the computer below a wide screen monitor, drinking canisters and a boiled egg in a small plastic storage bag by the radio room. The CNED stated personal food and beverages are not allowed in the nurse’s station. The EDD stated personal food and beverages are not allowed in the nurse’s station however, the items found are from the physicians. During a review of the facility’s P & P titled, “[Name of Facility] IP 126 Bloodborne Pathogen Exposure Control Plan”, dated January 18, 2024, indicated, “...IV...Plan...Personal Miscellaneous...A...Eating and drinking...are not allowed in work areas where there is a reasonable likelihood of occupational hazard...B...Staff food and drink will not be kept in...countertops, workstations on wheels (WOW)...” 3. A tour of Unit C and D was conducted on March 1, 2024, at 9:08 a.m., with the Clinical Manager Intensive Care Unit (CMICU), the Accreditation Regulatory Manager (ARM), and the Director covering for ICU (DCICU). During an observation on March 2, 2024, at 9:32 a.m., in Unit C’s nutrition area, the microwave had food crumbs at the oven cavity, a clear sticky substance on the rotating glass, and a large brown dried sticky substance on the inside door. The outside surface of the microwave was dusty and had accumulated dust, debris, and rust on its base. During an observation on March 1, 2024, at 9:35 a.m., in Unit C’s nutrition area, the coffee maker’s brewing heads were crusted with white, light brown, greenish residue buildup, while the surrounding area contained scattered brown to black dried liquid residue. The drip tray had dried crusted residue discoloration throughout. When the coffee maker was moved, a large brown dried sticky substance was observed. During an observation on March 1, 2024, at 9:40 a.m., in Unit C’s nutrition area, rust, debris, and dust behind the ice machine was observed. There was also white patchy discoloration found on the countertop. During an observation on March 1, 2024, at 9:45 a.m., in Unit C’s nutrition area, the drawer that holds the plastic utensils had yellow and orange discoloration and warping at the base. The succeeding drawers had debris, food crumbs, and dust inside. During an observation on March 1, 2024, at 9:50 a.m., in Unit D’s nutrition area, a large dried sticky liquid was observed under the refrigerator, behind was a large brown dried liquid stain, debris, and dust and on the wall to the left was a dried brown stain. During an observation on March 1, 2024, at 9:53 a.m., in Unit D’s nutrition area, the counter behind the microwave had debris, food crumbs, and dust. An interview was conducted on March 1, 2024, at 9: 55 a.m., with the CMICU. The CMICU acknowledged the findings and stated, “The nurses will wipe things down daily as we come in and out of this nutrition room, but we do not wipe behind appliances.” The CMICU further stated EVS (Environmental Services) oversees the terminal cleaning. An interview was conducted on March 1, 2024, at 9:56 a.m., with the ARM. The ARM acknowledged the findings and stated, “It looks like this room needs to be cleaned”. An interview was conducted on March 1, 2024, at 9:57 a.m., with the Director of EVS (DEVS)/ Food and Nutrition Services Director (FANSD). The DEVS/ FANSD stated, “All staff who uses the nutrition rooms are responsible to ensure that the rooms remain clean, if there is an issue with debris or a large spill, they can call EVS, and we will take care of it.” The DEVS/FANSD further stated under and behind the refrigerator will be cleaned monthly or as needed. An interview was conducted on March 13, 2024, at 2:54 p.m., with the Chief Quality Officer (CQO). The CQO stated there was no prior policy for Patient Nutrition Rooms. The CQO further stated the policy was created on site on March 4, 2024. 4. A tour of Unit C was conducted on March 1, 2024, at 9:08 a.m., with the Patient Risk Officer (PSO). During a concurrent observation and interview on March 1, 2024, at 9:08 a.m., with the PSO, in Unit C room 1, the floor had grime and accumulated dust under the wall mounted cabinet, and the floorboards had grime build up. The PSO stated the floor and floorboards are not clean. During a concurrent observation and interview on March 1, 2024, at 9:08 a.m., with the PSO and Environmental Services Operations Manager (EVSOM) in Unit C room 2, there was black dirt buildup on the floor, floorboards, and under the mounted shelf. The EVSOM stated, Unit C and D has two dedicated EVS staff. The EVSOM stated the room is deep cleaned after a patient is discharge and as needed. Cleaning includes the floor, floorboards and under the mounted shelf. The EVSOM further stated the floor and floorboards in this room needs to be cleaned. A tour of Unit D was conducted on March 1, 2024, at 9:33 a.m., with the Patient Risk Officer (PSO). During a concurrent observation and interview on March 1, 2024, at 9:35 a.m., with the PSO, in Unit D room 3, the floor had black, sticky grime on the floor and dust build up under the wall mounted shelf. The PSO stated the floors needed to be cleaned. During a concurrent observation and interview on March 1, 2024, at 9:36 a.m., with the PSO and EVSOM, in Unit D room 4, the floor had dust and black dirt build up, dust under the wall mounted shelf, and the floorboards had dust and white residue. The EVSOM stated the floor including under the mounted shelf needs to be cleaned. During a concurrent observation and interview on March 1, 2024, at 9:46 a.m., with the PSO in Unit D room 5, the floor had trash, black stain, and dirt build up including under the mounted shelf, and the floorboards had dust and dirt build up. The PSO stated the floors needed to be cleaned. An interview was conducted on March 1, 2024, at 10:59 a.m., with the DEVS/ FANSD. The DEVS/ FANSD stated, the rooms in Unit C and D should be terminally cleaned daily, including the floor and the floorboards. The DEVS/FANSD stated nursing should contact EVS when rooms need to be cleaned. There was no documented evidence a terminal clean had been conducted on rooms 1, 2, 3, 4 and 5. A review of the facility’s policy and procedure titled, “High Profile Room Cleaning” dated October 1, 2023, was conducted. It indicated, “Purpose: to ensure the complete and systematic daily cleaning and disinfection of each patient/resident room...Procedure...High dust horizontal surfaces...Disinfect vertical surfaces including stains and spots from walls, light switches, door knob and other vertical surfaces...Dust mop the room beginning with corners and edges, moving from side of the room towards door...Dust under the bed furniture and behind the door...Damp mop hard surface floors beginning with corners and edges moving from the far side of the room towards the door...””