Arrowhead Regional Medical Center

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 47394 Based on interview and record review, the Governing Body (GB- a group of people responsible for the overall direction and management of an organization) failed to provide adequate oversight to ensure a safe and effective quality of care for one of 31 sampled patients (Patient 31) when the GB did not ensure an effective quality preventive measurement program on labeling of blood products (substance from human blood) prepared for blood transfusion (a procedure where donated blood is delivered into patients’ body) (Refer to A0049). The cumulative effects of this failure resulted in the hospital’s inability to ensure effective oversight for Patient 31 who suffered a hemolytic reaction (a condition when blood cells are prematurely destroyed, often caused by triggered blood type mismatch and cell damage) that contributed to acute kidney injury (AKI-a condition where sudden loss of kidney function occur) and jeopardize Patient 31’s health, safety and well-being and had the potential to negatively affect any patient receiving a blood transfusion.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 47394 Based on interview and record review, the facility failed to maintain an effective and ongoing Quality Assessment and Performance Improvement (QAPI-identify, analyzes, addresses performance issues in the facility) program for one of 31 sampled patients (Patient 31) when the QAPI Program did not utilize monitor, track or analyze data-driven quality assessments to identify opportunities to prevent the mislabeling of blood products (substance from human blood) prepared for blood transfusion (a procedure where donated blood is delivered into patients’ body) (Refer to A0286). The cumulative effects of this failure resulted in the hospital’s inability to early identify that a blood product was mislabled which contributed to Patient 31 suffered a hemolytic reaction (a condition when blood cells are prematurely destroyed, often caused by triggered blood type mismatch and cell damage) that caused acute kidney injury (AKI-a condition where sudden loss of kidney function occur) and jeopardize Patient 31’s health, safety and well-being and had the potential to negatively affect any patient receiving a blood transfusion.”

“LABORATORY SERVICES CFR(s): 482.27 The hospital must maintain, or have available, adequate laboratory services to meet the needs of its patients. The hospital must ensure that all laboratory services provided to its patients are performed in a facility certified in accordance with Part 493 of this chapter. This Condition is not met as evidenced by: 47394 Based on interview and record review, the facility failed to maintain laboratory services to meet the needs for one of 31 sampled patients (Patient 31) when one unit of Packed Red Blood Cells (PRBC- a type of blood product) was mislabeled by the Clinical Laboratory Scientist (CLS - a technician who works in blood bank for processing of blood) and transfused (give) to Patient 31. (Refer to A 0582). This failure resulted in the hospital’s inability to ensure safe and effective laboratory services which caused adverse health outcomes (undesirable outcomes from provided care) for Patient 31 who suffered a hemolytic transfusion (a condition when blood cells are prematurely destroyed, often caused by triggered blood type mismatch and cell damage) reaction that contributed to acute kidney injury (AKI-a condition where sudden loss of kidney function occurs) and jeopardized Patient 31’s health, safety and well-being and had the potential to negatively affect any patient receiving a blood transfusion.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 47394 Based on interview and record review, the Governing Body (GB- a group of people responsible for the overall direction and management of an organization) failed to provide adequate oversight to ensure a safe and effective quality of care for one of 31 sampled patients (Patient 31), when the clinical laboratory scientist (CLS- a technician who works in blood bank for processing of blood products) mislabeled a blood product (substance from human blood) for Patient 31. This failure resulted in Patient 31 suffering a transfusion reaction (unexpected event happened after blood transfusion) which caused a hemolytic reaction (a condition when blood cells are prematurely destroyed, often caused by triggered blood type mismatch and cell damage) that contributed to acute kidney injury (AKI-a condition where sudden loss of kidney function occur) and jeopardized Patient 31’s health and well-being. Findings: During a review of Patient 31’s “History and Physical” (H&P), dated January 26, 2026, the H&P indicated, Patient 31 was admitted to the facility with the complaint of fall and had a medical history of hematemesis (vomiting of blood) and hematochezia (passing of blood from rectum). During a review of Patient 31’s “Emergency Department Provider Note” (ED Note), dated January 26, 2026, the ED Note indicated, Patient 31 was ordered three units of Packed Red Blood Cells (PRBC- a type of blood product) for transfusion (give). During an interview on June 30, 2026, at 8:30 AM, with CLS 1, CLS 1 stated, she was the person who processed Patient 31’s three units of PRBC. CLS 1 acknowledged she mislabeled one unit of PRBC as negative for the Kell antigen (a condition that patient’s red blood cells have components that attack Kell positive blood which poses significant risk for blood transfusion that could result in death), but Patient 31 was positive for the Kell antigen. CLS 1 further stated, she thinks she was multitasking at the time of preparing the PRBC units, which led to the mislabeling of Patient 31’s PRBC unit. During an interview on July 1, 2026, at 9:40 AM, with the Blood Bank Supervisor (BB S), the BB S stated the facility did not require a two-person verification process when cross matching labeling blood products. The BB S further stated it was the responsibility of the laboratory staff to ensure the cross matching and labeling of blood products are completed accurately. During an interview on July 2, 2026, at 11:30 AM, with the Laboratory Manager (LM), the LM stated, the blood bank does not have a process for double checking or verifying the labeling of blood products. The LM further stated, the blood bank does not track, monitor or collect data related to the cross matching or labeling of blood products. During an interview on July 2, 2026, at 1:40 PM, with the Chief Complaint Officer (CCO), the CCO stated there was no double verification process in place prior to this mislabeling incident. The CCO acknowledged the mislabeling resulted in the blood transfusion reaction (unexpected event happened after blood transfusion). The CCO stated it was very important to correctly cross matches and label blood products transfusion of an incorrectly labeled blood product can result in serious health problems and could even result in death. During a concurrent interview and record review on July 2, 2026, at 2:00 PM, with the CCO, the facility’s document titled, “[Facility’s name] Medical Staff Bylaws”, dated June 27, 2023, was reviewed. The “[ Facility’s name] Medical Staff Bylaws”, indicated, “ ...The Governing body recognized that the medical staff is required to be self-governing with respect to the professional work performed at the facility that it exercises self-governance rights and responsibilities derived from the statute, and it is the responsible to the governing body for the adequacy and quality of care rendered to patients ...2.1 ...B. To ensure that all patients admitted to or treated in any of the facilities, departments or services of the medical center receive care which is at a level of quality and efficiency consistent with generally accepted standards and attainable within the Medical Center’s means and circumstances”. The CCO stated that the governing body was responsible for all facilities operations, and it was unfortunate that the mislabeled blood product was administered to Patient 31.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 47394 Based on interview and record review, the facility failed to ensure an effective and ongoing hospital wide Quality Assessment and Performance Improvement (QAPI-identify, analyzes, and addresses performance issues identified in the facility) program for one of 31 sampled patients (Patient 31) when, the QAPI Program did not utilize monitor, track or analyze data-driven quality assessments to identify opportunities to prevent the mislabeling of blood products (substance from human blood) prepared for blood transfusion (a procedure when donated blood is delivered into patients’ body). This failure resulted in Patient 31 suffering a hemolytic reaction (a condition when blood cells are prematurely destroyed, often caused by triggered blood type mismatch and cell damage) that contributed to acute kidney injury (AKI-a condition where sudden loss of kidney function occur) and jeopardized Patient 31’s health, safety and well-being. Findings: During a review of Patient 31’s “History and Physical” (H&P), dated January 26, 2026, the H&P indicated, Patient 31 was admitted to the facility with the complaint of a fall and had history of hematemesis (vomiting of blood) and hematochezia (passing of blood from rectum). During a review of Patient 31’s “Emergency Department Provider Note” (ED Note), dated January 26, 2026, the ED Note indicated, Patient 31 was ordered three units of Packed Red Blood Cells (PRBC- type of blood product) for transfusion (give). During an interview on July 1, 2026, at 9:40 AM, with the Blood Bank Supervisor (BB S), the BB S stated that the facility did not require a two-person verification process for cross matching and labeling blood components. The BB S further stated it was the responsibility of the laboratory staff to ensure the cross matching and labeling of blood products are completed accurately. During an interview on July 2, 2026, at 11:30 AM, with the Laboratory Manager (LM), the LM stated, the blood bank does not have a process for double checking or verifying the labeling of blood products. The LM further stated, the blood bank does not track, monitor or collect data related to the cross matching or labeling of blood products. During a concurrent interview and record review on July 2, 2026, at 1:35 PM, with the LM, the facility’s document titled, “QAPI meeting minutes for Laboratory department”, dated from June 2025, through May 2026, was reviewed. The “QAPI meeting minutes for Laboratory department” had no documented evidence to indicate product cross matching and labeling was being tracked. The LM verified and confirmed, there are no auditing tools or data collection regarding the labeling of blood products. During an interview on July 2, 2026, at 1:40 PM, with the Chief Complaint Officer (CCO), the CCO stated there was no double verification process in place prior to this mislabeling incident. The CCO acknowledged the mislabeling resulted in the blood transfusion reaction (unexpected event happened after blood transfusion). The CCO stated it was very important to correctly cross matches and label blood products transfusion of an incorrectly labeled blood product can result in serious health problems and could even result in death. During a concurrent interview and record review on July 2, 2026, at 1:45 PM, with the CCO, the facility’s document titled, “Organizational Performance Improvement Plan 2026” (OPI), dated May 27, 2026, was reviewed. The OPI indicated, “Purpose: organizational performance improvement plan is an ongoing program that demonstrates measurable improvement in indicators for which there is evidence that they will improve patient outcomes and identify and reduce medical errors. Patient safety program is defined component of the OPI plan and focuses on the identification, reporting, analysis, and prevention of the patient safety events ...1. Safe Avoiding injuries to patient from the care that is intended to help them by; recognizing and acknowledging risk and unanticipated adverse events; focusing on process and systems with minimization of individual blame are retribution for involvement in a medical/healthcare error with implementation of just culture.” The CCO verified and acknowledged that the QAPI program was responsible for patient safety, and it was an opportunity that was not identified because the mislabeling of a blood product occurred.”

“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: 47394 Based on interview and record review, the facility failed to ensure the nursing staff adhered to the policy and procedure (P&P) for two of 31 sampled patients (Patient 27 and Patient 31) when: 1. For Patient 27, the nursing staff did not document the reason Acetaminophen (Tylenol-a medication used to treat pain and fever) was administered. 2. For Patient 31, the nursing staff did not complete a pain assessment before and after hydromorphone (Dilaudid-a medication used to treat pain) was administered. These failures had the potential for ineffective fever and pain management and increased risk for medication errors, which may compromise the health, safety and wellbeing of patients. Findings: 1. During a review of Patient 27’s “History and Physical” (H&P), dated June 9, 2026, the H&P indicated, Patient 27 had a history of acute respiratory failure (a condition in which lungs are not working to get oxygen into the blood or remove carbon dioxide) and came was admitted for a scheduled colonoscopy (a procedure of visualization of the colon). During a review of Patient 27’s “Physician Order”, dated June 29, 2026, the “Physician Order” indicated, Tylenol 650 milligrams (mg-a unit of measurement) was ordered every 6 six hours as needed for fever (normal temperature range between 97 degrees Fahrenheit to 99 degrees). The “Physician’s Order” did not specify a temperature range for when the Tylenol was appropriate to administer. During a concurrent interview and record review on July 1, 2026, at 1:30 PM, with Quality Management team member (QM), Patient 27’s “Electronic Health Record Flowsheet” (EHR F- an electronic document about the patient care and vital information), dated July 1, 2026, was reviewed. The EHR F indicated, Patient 27 received Tylenol on July 1, 2026, at 5:50 AM. QM confirmed Patient 27 received Tylenol, but could not provide the reason Tylenol was administered. QM stated, the physician’s order did not specify a temperature range to indicate when Tylenol should be administered, and the nurse did not document the patient the reason Tylenol was given. QM further stated, when there was no specific range for temperature ordered, the nursing staff should call the physician to verify the order or document the reason the medication was administered. QM acknowledged that there was no documented evidence regarding the reason Tylenol’s was administered. During an interview on July 2, 2026, at 10:45 AM, with the Quality Director (QD), the QD stated, if a physician’s order does not specify a temperature range for fever medication, the nursing staff is expected to follow the unit protocol which defines fever as a temperature above 100.4 degrees Fahrenheit. The QD further stated, staff should have written a note about the reason for administering Tylenol. During a concurrent interview and record review on July 2, 2026, at 10:50 AM, with the QD, the facility’s P&P titled, “Medication Administration”, dated March 18, 2024, was reviewed. The P&P indicated, “ ... Procedures: ...V.A. Appropriate timing of medication administration must take into account the complex nature and variability among medications, the indication for which they are prescribed; the clinical situation in which they are administered; and the need of the patient receiving them ...” The QD stated, the facility’s policy was not followed. 2. During a review of Patient 31’s H&P, dated January 26, 2026, the H&P indicated, Patient 31 was admitted to the facility with the complaint of fall and had a medical history of hematemesis (vomiting of blood) and hematochezia (passing of blood from rectum). During a record review of Patient 31’s “Physician Order”, dated January 26, 2026, the “Physician Order” indicated, Dilaudid 2 mg for severe pain (a scale to measure patient’s pain intensity with 0 being no pain and 10 is the worst possible pain) of 7-10 every 4 hours. During a concurrent interview and record review on July 2, 2026, at 8:45 AM, with QM, Patient 31’s “EHR F”, dated January 30, 2026, was reviewed. The “EHR F” indicated that Patient 31 was given a Dilaudid 2 mg oral tablets on January 30, 2026, at 2:24 PM. There was no documented evidence of a pain assessment before or reassessment after administration of the Dilaudid. QM verified and confirmed there was no pain assessment and reassessment documentation. QM stated, the nursing staff are expected to do a pain assessment and reassessment with every pain medication administration. During a concurrent interview and record review on July 2, 2026, at 11:00 AM, with the QD, the facility’s P&P titled, “Pain assessment and management”, dated November 20, 2024, was reviewed. The P&P indicated, “Policy: Pain Assessment ...D. Pain data is collected, assessed and reassessed ... 5. With each report of new pain. 6. 30 to 60 minutes after pain relieving intervention ... 8. Comprehensive pain assessment is completed upon admission, every shift, and with each report of new pain. Comprehensive pain assessment includes but is not limited to: a. pain assessment b. pain score ...” The QD stated, the P&P was not followed.”

“ADEQUACY OF LABORATORY SERVICES CFR(s): 482.27(a) The hospital must have laboratory services available, either directly or through a contractual agreement with a certified laboratory that meets the requirements of part 493 of this chapter. This Standard is not met as evidenced by: 47394 Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for blood typing (a test to verify patient’s specific blood group) and labeling for one of 31 sample patients (Patient 31) when the clinical laboratory scientist (CLS- a technician who works in blood bank for processing of blood products) mislabeled blood product (substance from human blood) for Patient 31. This failure resulted in Patient 31 suffering a transfusion reaction (unexpected event happened after blood transfusion) which caused a hemolytic reaction (a condition when blood cells are prematurely destroyed, often caused by triggered blood type mismatch and cell damage) that contributed to acute kidney injury (AKI-a condition where sudden loss of kidney function occur) and jeopardize Patient 31’s health and well-being. Findings: During a review of Patient 31’s “History and Physical” (H&P), dated January 26, 2026, the H&P indicated, Patient 31 was admitted to the facility with the complaint of fall. Patient 31 had history of hematemesis (vomiting of blood) and hematochezia (passing of blood from rectum). During a review of Patient 31’s “Emergency Department Provider Note” (ED Note), dated January 26, 2026, the ED Note indicated, Patient 31 was ordered three units of Packed Red Blood Cells (PRBC- a type of blood product). During an interview on June 30, 2026, at 8:30 AM, with CLS 1, CLS 1 stated, she was the person who processed Patient 31’s three units of PRBC. CLS 1 acknowledged she mislabeled one unit of PRBC as negative for the Kell antigen (a condition that patient’s red blood cells have components that attack Kell positive blood which poses significant risk for blood transfusion that could result in death), but Patient 31 was positive for the Kell antigen. CLS 1 further stated, she thinks she was multitasking at the time of preparing the PRBC units, which led to the mislabeling of Patient 31’s PRBC unit. During a concurrent interview and record review on July 1, 2026, at 9:10 AM, with Nephrologist Physician (N MD 1 - a doctor specializing in the care of kidney diseases), Patient 31’s “Inpatient Nephrology Consultation Notes” (Consult Note), dated January 28, 2026, was reviewed. The Consult Note indicated, Patient 31 was consulted for a febrile hemolytic (a reaction occurs when the immune system rapidly destroys transfused red blood cells due to blood type mismatch) transfusion reaction that resulted in AKI related to thrombotic microangiopathy (a severe condition in which tiny blood clots form in small blood vessels leading to organ damage). N MD 1 stated, the Consult Note indicated, Patient 31’s AKI resulted from the blood transfusion reaction. N MD 1 further stated the blood transfusion reaction can cause a high chance of permanent kidney damage. During a concurrent interview and record review on July 1, 2026, at 9:30 AM, with the Blood Bank Supervisor (BB S), the facility’s “Job Description for Clinical Laboratory Scientist II” (JD CLS II), dated August 2022, was reviewed. The JD CLS II indicated, “ ... Clinical laboratory scientist II who performs a wide variety of complex laboratory procedures and analysis. Position Duties and responsibilities ... 2. Group, type, and crossmatch blood and determine antibodies and blood count”. The BB S verified and confirmed the JD CLS II was not followed and resulted in the mislabeling of one PRBC unit administered to Patient 31. The BB S stated that CLS staff are trained in cross matching and labeling blood products and are expected to complete the labeling correctly. The BB S further stated, if the antigen (any substance usually a protein, sugar or lipid that body recognized as a foreign and fight to get rid of it) is not correctly identified and a patient receives the wrong blood type; it would negatively affect patients’ health, causing severe reaction and could even result in death. During a concurrent interview and record review on July 1, 2026, at 10:30 AM, with the BB S, the facility’s P&P titled, “RBC Phenotyping [observable physical traits of a person such as eye color or height]”, dated January 27,1994, was reviewed. The P&P indicated, “Purpose: Identifying antigens on red cell surfaces allow selection of compatible units even when unexpected antibodies are detected...” The BB S stated, the facility does not have a specific P&P for labeling blood products. The BB S further stated that it was very important for CLS staff to correctly label blood products since the antigen needs to be identified to prevent any unexpected blood transfusion reaction During an interview on July 2, 2026, at 11:30 AM, with the Laboratory Manager (LM), the LM stated that the blood bank does not have any kind of double checking or verification process for labeling. The LM further stated that CLS staff are responsible for the processing of blood products.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 47360 Based on interview and record review, the Facility 1 failed to ensure their “Patient Rights” policy and procedure (P&P ) was implemented for one of 32 sampled patients (Patient 9) when, Patient 9’s “After Visit Summary” (AVS - a document summarizing your visit, including the reason you were there, what the doctor found, any new medicines or changes, test orders, and clear instructions for follow-up) did not include a patient-specific summary of what care was provided, follow-up instructions, plan for continued care or when to seek emergency medical care if needed. This failed practice resulted in ineffective communication and documentation upon Patient 9’s discharge from the Behavior Health Unit Emergency Department (BHED) and may have contributed to Patient 9’s parents misunderstanding of aftercare instructions and to seek emergency medical evaluation at Facility 2 shortly after discharge from the BHED. Findings: During a review of Patient 9’s “History and Physical” (H&P - contains medical history, current medical needs and plan for care), dated November 27, 2025 indicated, Patient 9 had a history of frontal lobe epilepsy (seizures in the front part of your brain which affects your personality, movement and your ability to plan actions), non-verbal (unable to speak) autism (when a person’s brain works differently, affecting how they see the world, interact with people, communicate, and handle sensory input, creating unique strengths and challenges). The “H&P” further indicated, Patient 9 was brought to the Behavioral Health Unit Emergency Department (BHED) by his parents for increased aggression which led to physical violence at home. During a concurrent interview and record review on January 6, 2025, at 10:30 AM with the Behavioral Health Unit Manager (BHM), Patient 9’s “AVS” and the “AVS Signature Page” (signature confirmation the “AVS” was received and the outcome of the visit and the instructions for follow-up care were understood), dated November 27, 2025, was reviewed. The “AVS” included the reason for Patient 9’s visit, but did not include a summary of Patient 9’s visit, or instructions for follow-up after the BHED visit. The “AVS Signature Page” was left blank without signature of Patient 9’s parents. The BHM stated, he was uncertain as to the process for discharging patients from the Behavioral Health Emergency Department (BHED) and was not certain what they would receive as a plan of care moving forward upon discharge from the BHED. During an interview on January 6, 2025, at 2:00 PM, with the Quality Administrator (QA), the QA stated, the main emergency department had a policy and procedure (P&P) for discharging patients from their department, but the facility did not have a “P&P” for discharging patients from the BHED. During a concurrent interview and record review on December 7, 2025, at 9:39 AM, with Psychiatrist (mental health physician) 1, Patient 9’s “AVS” dated November 27, 2025, was reviewed. The “AVS” indicated, Patient 9’s reason for visit was a psychiatric evaluation for aggression in a pediatric autistic patient. The “AVS” did not include a summary of Patient 9’s visit or aftercare or follow-up instructions after discharge from the BHED. Psychiatrist 1 stated, she verbally spoke to Patient 9’s parents about community resources, an upcoming psychiatrist appointment, and to return if Patient 9’s behavior begins to escalate again. Psychiatrist 1 stated, she could not remember the specific date for Patient 9’s follow-up appointment or the name of the provider. Psychiatrist 1 stated, a discharge plan of care is provided to patients admitted to the Behavioral Health Unit (BHU), but not part of the “AVS” when discharged directly from the BHED. Psychiatrist 1 stated, patients who are not admitted to BHU are generally given verbal instructions prior to release from the BHED triage unit. During an interview on January 7, 2025, at 10:19 AM, with the Behavioral Health Clinical Director (BHCD ), the BHCD stated, there should have been an “AVS” for Patient 9, that included specific after care instructions and follow-up information for Patient 9’s parents to review and reference. The BHCD stated, there was no “P&P” specific to the BHED, outlining the discharge process and what should be included in the “AVS” or patient process for acknowledgement and understanding of discharge instructions. The BHCD stated, the importance of the patient receiving an “AVS” is the transition of care from the emergency medical concern to discharge. The BHCD stated, the BHED staff need to ensure the patient has a plan and can follow-up so that their symptoms do not worsen after they leave the hospital, this is the reason patient’s seek help at the Behavioral Health Unit. The BHCD further stated, all patients discharged from the unit should receive discharge instructions with plan to follow-up specific to their medical needs. During a review of the facility’s P&P titled , “Patient Rights” dated April 26, 2023, the P&P indicated, “ ...A. Every patient, whether inpatient or out patient, is made aware of their rights ...C. Patients or his/her representative have the right to ...30. Be informed of continuing health requirements following discharge from the hospital and the means for meeting them ...36. Considerate and respectful care. 37. Receive information about illness, the course of treatment and prospects for recovery in terms that he patient can understand. 38. Have all patients’ rights apply to the person who may have legal responsibility to make decisions regarding medical care on behalf of the patient ...”.”

“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: 47394 Based on observation, interview and record review the facility failed to ensure the policy and procedure (P&P) for providing care in a safe setting was maintained and implemented when: 1. Emergency Department (ED- a unit in the hospital where the patients come for immediate care) call signal system was not functioning and readily available for patient care area for 43 of 43 licensed beds. 2. Environmental service (a department meant for cleaning and sanitation to ensure safe and hygienic environment) was unable to provide cleaning log for ED rooms from October 12, 2025 till October 15, 2025. 3. Patient 24’s room was visibly soiled and found with used /soiled chuck and syringe on the countertop. These failures had the potential to compromise patient safety by leaving them unable to signal for help in case of medical emergency, unwanted exposure to infections which will increase the risk for infection, prolonged hospitalizations and have negative impact on the health and wellbeing of patients. Findings: 1a. During a concurrent observation and interview on November 17, 2025, at 9:50 AM, in ED, with Patient 26, Patient 26 was lying in her bed connected to intravenous fluids (IV - liquid infused to a patient’s body through vein), Patient 26 stated, she came to the facility on November 16, 2025, at 7:45 PM, and there was no call signal system. Patient 26 further stated, if she needs help, she will get out of bed and call loud for nurses. During a review of Patient 26’s “Admission Record” (demographic record), the “Admission record” indicated patient 26 was admitted to the facility on November 16, 2025, at 7:45 PM, with the diagnosis of Gastrointestinal problems. b. During a concurrent observation and interview on November 17, 2025, at 10:00 AM, in ED, with patient 27, Patient 27 was lying in his bed with no call signal system at bedside. Patient 27 stated, he does not have a call light or a bell to call the staff since he came to the ED room on November 16, 2025. Patient 27 further stated, he was concerned about falling when he did not have a call light. During a review of Patient 27’s “Admission Record”, the “Admission Record” indicated, Patient 27 was admitted to the facility on November 16, 2025, at 9:31 AM, with the chief complaint of blood in urine. c. During a concurrent observation and interview on November 17,2025, at 10:05 AM, in ED, with patient 28, Patient 28 was lying in his bed with no call signal system at bedside. Patient 28 stated, he came to the ED since November 16, 2025 and had no call light. Patient 28 further stated, he usually calls the staff loudly so they could come and help. During a review of the facility’s document titled “admission record”, the “admission Record” indicated, Patient 28 was admitted to the facility on November 16,2025, at 8:48 AM with the complaints of shortness of breath. d. During a concurrent observation and interview on November 17, 2025, at 10:30 AM, in ED, with patient 29, Patient 29 was lying in her bed, able to answer questions and family was at bedside, with no call signal system at bedside. Patient 29 stated, she came to the ED on November 16, 2025, because of her high blood glucose level. Patient 28 further stated, nobody gave her a call light or a bell to call the staff. Patient 28 further stated, she usually calls out loud for help or assistance. During a review of the Patient 29’s “admission record”, the “admission Record” indicated, Patient 29 was admitted to the facility on November 16, 2025, at 7:51 AM, with the complaints of altered mental status brought in by ambulance. During a review of Patient 29’s “history and physical”, dated November 16, 2025, at 11:32 AM, the “history and physical” indicated, Patient 29 had the past medical history of type 2 diabetes mellitus( a condition in which the blood sugar is high) on insulin( a medication used to treat high blood sugar) and hypertension (a condition in which patient has high blood) presenting due to altered mental status starting this morning. Glasgow Coma Scale (GCS - a tool used to evaluate the level of consciousness on scale of 3-8 as severe ,9-12 as moderate and 13-15 as mild ,3 - considered as deep coma and 15 fully alert) on arrival was 11. During a concurrent observation and interview on November 17, 2025, at 9:55 AM, with ED Assistant Manager (ED AM), in ED, the ED AM stated, that the call signal system was not functional for more than two to three years and small portable bell was an alternative for call lights. The ED AM further stated that it was the primary nurse’s responsibility to provide a bell to each patient and ensure that the bell is easily available to reach. The ED AM acknowledged that patients 26, 27,28 and 29 did not have a bell or a call light within reach. During an interview on November 19, 2025,at 8:44 AM, with Registered Nurse 5 (RN5),RN5 stated, the call signal system was not working for years and the primary RN should be responsible in giving a bell for the patients.RN5 further stated, it is important to give call bell so that patient can reach out to the nurses in case of emergency. During an interview on November 19,2025, at 9:41 AM, with ED Director (ED D), the ED D stated that the call signal system was not functioning for more than four years. The ED D further stated it was expected to give bells for all patients who are in an ED room to call the nurses. The ED D verified that all 43 rooms in ED does not have a call signal system. During a concurrent interview and record review on November 19, 2025, at 10:00 AM, with the ED D, the facility’s policy and procedures (P&P) titled, “system failure”, dated July 11, 2025, was reviewed. The P&P indicated, “ .... ix. Failure of: Nurse call system .... C. Responsibilities of nursing, bedside clinician and users, Bells supplies by engineering services until repairs are complete. The ED D stated, the policy was not followed. During a concurrent interview and record review on November 19, 2025, at 10:05 AM, with the ED D, the facility’s policy and procedures (P&P) titled “Patient Rights”, dated April 26, 2023, was reviewed. The P&P indicated, “ .... Procedure: ...C ...6. Receive care in a safe setting.” The ED D stated, we did not follow the policy. The ED D acknowledged that the policy was not followed as there was no bell easily available for patients in ED. During a concurrent interview and record review on November 19, 2025, at 5:00 PM, with Assistant Chief Nursing Officer ED (ACNO ED), the facility’s document titled “ Job description for ED Registered Nurse” (JD), dated September ,2025, was reviewed. The document indicated, “ ...Position duties and Responsibilities Duties may include, but are not limited to, the following: ... ...5. practice safety measures in all activities associated with patient care”. The ACNO ED stated, the nurse should have given the bell to each patient when they come into the ED rooms. During a concurrent interview and record review on November 19, 2025, at 5:15 PM, with ACNO ED, the facility’s P&P titled “Fall Program”, dated November 7,2022, was reviewed. The P&P indicated, “ .... Procedures.. iii. Implement standard fall prevention interventions for patients scoring 0-44. A. Safe environment (I. e. Bed in low position, call light within reach ...” The ACNO ED stated, that it is right that the call light should be within reach. The ACNO ED further stated, we will take this as an opportunity to improve call lights. 2. During an interview on November 19, 2025, at 9:15 AM, with the Manager of Environmental Services (EVSM- a person who is responsible for cleaning and environmental protection), the EVSM stated, the ED cleaning log was not fully electronic as they are transitioning the paper documents and the ED has 43 beds and waiting areas. The EVSM further stated, the supervisors have the documentation for the cleaning. During a review of the facility’s document titled “EVS staff assignment” for October 12, 2025 till October 15,2025, the “EVS staff assignment” indicated only staff’s name assigned to ED unit. Document did not have information indicating whether each room was soiled or cleaned as per the assignment. During a review of the facility’s document titled “Environmental services Supervisor’s checklist”, dated October 12,2025 through October 18,2025, the “Environmental services Supervisor’s checklist” indicated, that the supervisor has the generalized daily checklist which included about the staff call off, daily environmental concerns in each areas. The document did not indicate a specific section for the supervisor or the staff would check each room for cleanliness. During an interview on November 20, 2025, at 9:05 AM, with EVSM, the EVSM stated, there was no cleaning log for the ED rooms. The EVSM further stated, the only document the facility had was the supervisor check list which includes daily rounding. During a concurrent Interview and record review on November20, 2025, at 9:15 AM, with EVSM, the facility’s document titled “position description Hospital Environmental services Supervisor -Environmental Service (EVS)”, dated April ,2022, was reviewed. The “position description Hospital Environmental services Supervisor -Environmental Service (EVS)” indicated, “ .... Position duties and responsibilities 1. Supervise the day-to-day activities of the environmental services department.2. Evaluate environmental services being performed by department staff, maintain, and monitor cleanliness, safety, and quality of work, ensure proper staffing at all times.3. Plan, assign, review and evaluate the work of supervising custodians and other support staff, council staff regarding performance, conduct, attendance, and other related matters, handle or participate in disciplinary or hiring actions”. The EVSM stated, there was no other document specifically to indicate each ED room cleanliness other than the supervisor’s checklist to indicate the cleanliness of the rooms. During a concurrent interview and record review on November 20, 2025, at 9:20 AM, with EVSM, the facility’s policy and procedure (P&P) titled “Patient Rights”, dated April 26, 2023 was reviewed. The P&P indicated, “ ....6. Receive care in a safe setting”. The EVSM stated, that the policy was not followed. The EVSM further stated, that there should be an EVS cleaning log for ED. 49001 3. During a review of Patient 24’s “Demographics” (a summary document in a medical record that provides a quick overview of a patient’s key information), indicated, Patient 24 was admitted to the facility on November 10, 2025. During a review of Patient’s 24’s “History and Physical” (H&P), dated November 10, 2025, the H&P indicated, the Chief complaint, was “Motor Vehicle Crash” ... During a concurrent observation and interview on November 17, 2025, at 10:28 AM, in Patient 24’s room, with the Unit Manager, the floor was noted with used alcohol pad, used white paper, wrinkled clear plastic, clear plastic tip, countertop with multi stained colors, a visibly soiled chuck with brown stuff on the countertop, and the soap dispenser was backing with old brown stained. The family member in the room stated that “I think this is from last night.” The Unit Manager stated she was unsure whether the room was cleaned. Unit manager further stated her expectation of the rooms to be kept cleaned. During an interview and concurrent record review on November 19, 2025, at 9:45 AM, with the Administrator of Operation (AO) and Manager of Environmental and linens services (EVSM), the facility’s policy and procedures (P&P), titled “Cleaning Patient Room-Occupied”, dated March 30, 1999, was reviewed. The P&P indicated, “All patient rooms will be cleaned daily.” EVSM stated his expectation was the room to be cleaned every day. EVSM stated that all areas of assignment would be auto populated at 7:00AM to the assigned staff. The EVSM stated first thing in the morning staff takes out trash, soiled linens and staff mop and clean the whole room. The EVSM further stated, the staff should have done their job. During a joined interview on November 19, 2025, at 2:10 PM, with Custodian Environmental services (CEVS), and EVSM, the EVSM stated, she picked up trash, moped the floor, cleaned the sink, countertop and dust. CEVS stated, first, she removes the dust, takes out trash, biohazard bag, and dirty linens. CEVS stated, after her breaks she moped the floor, wiped the sink, countertop and furniture. She stated she follows cleaning process. CEVS further stated, she did not work on Monday. During a second observation and concurrent interview on November 19, 2025, at 3:05 PM, in Patient 24’s room with AO, CEVS, Unit Manager, Registered Nurse, (RN) escort, and Epidemiology RN (IP), observed countertop with multi stained colors, soiled chuck laying on a countertop with large dirty syringe. Soap dispenser backing with brown old stained and the base of the faucet and sink with brown stuff. CEVS, stated he was not sure where the stained-on countertop comes from and how long it has been there. The unit manager stated she does not know what it was and does not remember how long the multicolored stain has been on the countertop. The IP stated it was not acceptable to have a dirty countertop in patient room. IP expectation wass countertop and room to be cleaned. During an interview and concurrent record review on November 20, 2025, at 9:20 AM, with EVSM, the facility’s procedures, titled “EVS-7 Step Cleaning Process” dated November 15, 2017, was reviewed. The P&P indicated, Patient Room Daily Cleaning, 3 ..., “then proceed to disinfecting everything in the room with Germicidal solution. This includes B, Furniture, Trash, and Bio, closets, Linen containers and wall fixtures ...ed,” EVSM stated, facility did not follow the procedures when the room was visibly soiled. EVSM further stated, the supervisor uses check list to go around visually inspect the room. There was no document provided for Patient 24’s room inspection.”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d) Patient Rights: Confidentiality of Records This Standard is not met as evidenced by: 49001 Based on observation, interview and record review, the facility failed to protect the private health information for one of 32 sampled patients (Patient 32), when Patient 32’s specimen label was found on the floor in a shared room that was accessible to the public. This failure had the potential for Patient 32’s private information to be disclosed without authorization which could lead to Health Insurance Portability and Accountability Act (to protect medical records and other personal information) violations. Findings: During a review of Patient 32’s “Demographics” (a summary document in a medical record that provides a quick overview of a patient’s key information), indicated, Patient’s 32 was admitted on November 16, 2025. During a review of Patient’s 32 History and Physical (H&P), dated November 16, 2025, the H&P indicated, Chief complaint, was “Patient presents with knee pain ... During a concurrent observation and interview on November 17, 2025, at 11:51 AM, with Clinical Director II (CD) in Patient 32’s room. Patient 32 was asleep. A specimen label was observed on the floor. Clinical Director II (CD) picked up the specimen label from the floor. The CD stated, it was a urine specimen label. The CD verified and acknowledged that the specimen label belonged to Patient 32 and the label had patient name, Medical Record Number and date of birth. The CD further stated this should not have happened. During an interview on November 19, 2025, at 9:05 AM with CD, the CD stated facility must always protect patient information. The CD further stated the extra label from urine collection should have been shredded. During an interview and concurrent record review on November 19, 2025, at 10:50 AM, with the Administrator, Quality & Accreditation and Chief Compliance Officer (QA&CCO), the facility’s policy and procedures (P&P), Titled “Patient Privacy Protections” dated March 25, 2021, was reviewed. The P&P, indicated ... “I. Written Information, A. When possible, patient names shall be kept out of public view ...VI, Expectations and Best Practice Guidelines. A. “Shred all paper containing confidential health information or place in closed locked shred receptacles ...” A continued review with the QA&CCO on November 19, 2025, at 10:55AM, the facility’s P&P titled “Patient’s Rights” dated May 26, 2005, was reviewed. The P&P indicated, ...8. “The confidentiality of his/her clinical records pertaining to patient’s care and stay in the hospital.” The QA&CCO stated, the facility did not follow the policy. The QA&CCO further stated, the patient has the right to have their information protected. During an interview on November 19, 2025, at 11:35 AM, with Registered Nurse (RN1), RN 1 stated, when he had extra specimen label, he would place it inside the specimen bag and send it to the laboratory, or he would shred it. RN 1 further stated he would not leave it in the room.”

“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: 51099 Based on observation, interview, and record review, the facility failed to ensure nursing staff adhered to the facility’s policies and procedures (P&P) for three of 32 sampled patients (Patient 3 ,27 and 31) when: 1. Seizure (sudden burst of abnormal electrical activity in the brain that causes changes in behavior, movement, feeling, or awareness) precautions were not consistently implemented for Patient 3 who had a history of seizures and known seizure risk. 2. For Patient 27, appropriate isolation precautions were not used and crash cart (a cart on wheels with all essential medications and equipment for a life treating emergency) was left inside the patient room, who was on contact isolation precautions (a set of precautions like wearing personal protective including gown, gloves before entering to the room). 3. For Patient 31, inter department transfer and communication was not documented as per the facility P&P. 4. For Patient 31, intake (the amount of food or fluids consumed by a patient) and output (the quality of excretion) was incomplete. These failures had the potential to result in patient harm, including falls, aspiration, head injury, or other complications, due to the lack of appropriate safety interventions and increase the risk of cross contamination (spreading of infection from person to another), unclear about the nutritional status of patients which would affect the psychosocial and wellbeing of patients. Findings: 1. During a review of Patient 3’s face sheet (contains demographic and medical information), the face sheet indicated, Patient 3 was admitted to the facility on November 12, 2025, with diagnoses, such as toxic encephalopathy (brain dysfunction caused by exposure to toxins [chemicals, drugs that can mess with brain function]) and hepatitis C (virus that infects the liver and causes inflammation and long-term damage over time). A review of Patient 3’s “History and Physical” (H&P) dated November 13, 2025, the H&P indicated a history of seizure activity in the past. A review of Patient 3’s “Physician Progress Note” dated November 13, 2025, indicated, “ ...wife noticed patient exhibiting seizure-like activity ...ED [Emergency Department] Course: ...Received 2L (liter) LR (lactated ringer’s- sterile IV fluid to replace fluid and electrolytes in the body), Aspirin (pain reliever, fever reducer, anti-inflammatory) 324mg (milligram), and 1000mg Keppra (medication used to prevent and control seizures) x1 (one time) @2:15 [AM] in ED ...” A further review of the H&P document showed Patient 3 had a past medical history of seizures. A review of Patient 3’s “Medication Administration Record” (MAR) dated November 13, 2025, the MAR indicated Patient 3 was administered Keppra (anti-seizure medication) 1000mg during the admission in the Emergency Department (ED). A review of Patient 3’s “Inpatient Consult to Neurology,” dated November 13, 20 25, indicated, “ ...Reason for consult? Seizure like activity ...Summary: ...Given this patient’s history of alcohol abuse, seizures due to alcohol withdrawal are suspected ...” During an observation on November 17, 2025, at 10:04 AM, Patient 3 was observed resting in bed, with side-rails up and no padding strapped to the rails. No other seizure precautions, such as suction set up, were visible despite Patient 3’s identified seizure risk. During a concurrent interview and record review on November 17, 2025, at 3:50 PM, with Registered Nurse Educator (RNE), Patient 3’s nursing flowsheet titled, “Precautions,” dated November 14, 2025-November 17, 2025, was reviewed. “Precautions,” was documented with the following: - November 14, 2025: “fall; seizure” - November 15, 2025: “fall” - November 16, 2025: “fall” - November 17, 2025: none No seizure precautions were documented throughout November 15, 2025-November 17, 2025. RNE confirmed Patient 3 met the criteria for seizure precautions and there were none documented in Patient 3’s medical chart from November 15, 2025-November 17, 2025. During an interview on November 19, 2025, at 2:56 PM, with Registered Nurse 1 (RN 1), RN 1 stated when a patient admits to the facility with a history of seizure or active seizure activity, it would be a nursing judgement and per facility protocol to implement seizure precautions. RN 1 further stated, the precautions would need to be documented per shift in the patient’s chart. During a concurrent interview and record review on November 19, 2025, at 4:35 PM, with Unit Manager 1 (UM 1), the facility’s policy and procedure (P&P) titled “Patient Care References”, policy no. 413.00 Issue 6, with no revision date, was reviewed. The P&P specified, “ ...Seizure precautions prevent patients from incurring injury from a fall or seizure ...Implementation: ...For patient with history of seizures, keep bed in lowest position with side rails up ...Pad rails if patient is at risk for head injury and, as an option, offer protective headgear. Have oral suction and oxygen equipment ready for use ...” UM 1 stated Patient 3 would fall under the category of needing seizure precautions, but the facility did not follow P&P for Patient 3. 47394 2. During a review of the facility’s document titled “admission record” (demographic data), indicated, Patient 27 was admitted to the facility on November 16,2025, at 9:31 AM, with the chief complaint of blood in urine. During a review of the facility’s document titled “initiate contact isolation”, dated November 16,2025, the “initiate contact isolation” indicated patient 27 should be on contact isolation by physician 1 (P1). The document also indicated that the patient should be on contact isolation for every admission. During an observation on November 17,2025, at 10:00 AM, in Emergency department (ED- a unit in the hospital where the patients come for immediate care) Patient 27 was lying in Bed C in Rapid POD ( an area where patients are responded as rapid) and the crash cart was observed to be in the corner of the room. Patient 27 did not have any contact isolation signage posted and was placed on standard precautions (a set of basic infection control practices used for all patients in health care to prevent the spread of infection). During a concurrent interview and record review on November 17,2025, at 3:30 PM, with Registered Nurse 4 (RN 4), the facility’s “electronic heath record for isolation status” (EHR- an electronic documentation of patient care) was reviewed. The EHR indicated ,Patient 27 should be on contact isolation precautions from November 16,2025,at 7:26 PM for infected with ESBL( Extended spectrum Beta Lactamase- a bacteria),Acinetobacter -MDR (a bacteria which is resistant to multi drug),CRE (carbapenem resistant enterobacterial- a bacteria which is resistant to carbapenem drug),Candida auris rule out ( a multi drug resistant fungal infection),Carbapenem resistant pseudomonas aeruginosa (CRPA- a bacteria which is resistant for carbapenems).RN 4 acknowledged and stated that Patient 27 was a patient who should be in contact precaution. During an interview on November 17,2025, at 4:03 PM, with the Infection Control Nurse (IC N), the IC N stated, crash cart should not be left inside an isolation patient’s room. IC N further stated, Patient 27 should be on isolation precautions as soon as the laboratory results came positive for infection. During an interview on November 17,2025, at 4:05 PM, with ED Assistant Manager (ED AM), the ED AM stated, the crash cart is usually kept in the corner of Bed C in Rapid POD and usually isolation patients are not placed in that room. The ED AM further stated, that Patient 27 should be in contact isolation and the crash cart should have moved out of the room. During a concurrent interview and record review on November 19,2025, at 10:00 AM, with the ED Director (ED D) the facility’s policy and procedure(P&P) titled 1) “Crash Carts”, dated September 28,2022, was reviewed. The P&P indicted, “ ... Procedure B. Crash carts are not brought inside the room of patients in isolation precautions.” The ED D stated, the policy was not followed. During a concurrent interview and record review on November 19,2025, at 10:05 AM, with ED D, the facility’s P&P titled “Standard and Isolation Precautions”, dated February 2022, was reviewed. The P&P indicated, “ ...A. General Principles 1. Transmission -based precautions are the second tier of basic infection control and are to be used in addition to standard precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission ...6. a sign indicating the type of precautions required is posted on the outside of the patient room door until isolation precautions are discontinued or the patient is discharged or transferred ...7. An isolation cart is required for isolation patients who are not in a room with an anteroom. a. Sterile processing department (SPD) provides isolation carts. b. Place the cart outside the patient room.c.do not use isolation cart to store other patient care supplies, meal trays or other items...D. Contact Isolation Precautions 1. In Addition to standard precaution, use contact isolation precautions, for patients with non all suspected infections that represent an increased risk for contact transmission.2. Use of PPE a. Wear clean exam gloves add a disposable isolation gown whenever in patient’s room, even if not intending to have direct contact with patient or with any item/surface in the patients room. Ensure that the gown is secured at the neck and waist. b. Remove and discard PPE before exiting the patients room or area.3. Patient placement a. Place the patient in a private room. b. When a private room is not available, place the patient in a room with a patient who has active infection or colonization with the same microorganism but with no other infection (cohorting- a group of people sharing the same characteristic). When A private room is not available and cohorting it’s not achievable, consider the epidemiology off the microorganism and the patient population when determining patient placement. The ED D acknowledged that the policy was not followed. The ED D stated, it was not acceptable to keep the crash cart in an isolation precaution room. 3. During a review of Patient 31’s “Admission record” dated October 12,2025, the “Admission record “ indicated, Patient 31 was admitted to the facility on October 12,2025, at 10:52 PM, with the diagnosis of melena( a condition in which patient has black ,tarry stools caused by bleeding in the upper gastrointestinal tract). During a concurrent interview and record review on November 18,2025, at 10:30 AM, with Registered Nurse 4 (RN 4), Patient 31’s “flowsheet” (electronic document where the patient data is charted), dated October 12,2025 through October 15,2025, was reviewed. The “flowsheet” indicated, Patient 31 was transferred from ED to telemetry floor (an area where the patient is connected to a cardiac monitor [ a heart rhythm monitoring equipment]) to a single room on October 14,2025 at 4:03 PM. Patient 31 was transferred from telemetry floor to medical surgical floor (an area where patient is admitted due to a medical or a surgical condition) on October 15,2025, at 12:12 AM, and Patient 31 was discharged on October 15,2025 at 10:00 AM. RN 4 acknowledged that Patient 31 was transferred from telemetry floor to medical surgical floor without any documentation of inter transfer and patient communication with patient or emergency contact person. RN 4 stated, nurses are expected to document the transfer and communication to the patient. During an interview on November 19,2025, at 3:10 PM, with RN 1, RN 1 stated, that when the patients are transferred from one unit to another it is expected to document about the transfer and notification to family regarding the transfer. RN 1 further stated, nurses can document about the transfer in the “flowsheet” or as a free nurse’s note in patient record. During a concurrent interview and record review on November 19,2025, at 4:01 PM, with Clinical Director (CD), the facility’s document titled “position description Registered Nurse Medical Surgical Unit”, dated July ,2025, was reviewed. The “position description Registered Nurse Medical Surgical Unit” indicated, “ ... Position duties and responsibilities ....2. Document patient care from admission through discharge incorporating the nursing process.4. Practice safety measures in all activities associated with patient care.9. Serve as patient advocate”. The CD stated, nurses should have documented Patient 31’s transfer from one unit to another. During a concurrent interview and record review on November 19,2025, at 4:05 PM, with CD, the facility’s P&P titled “Patient Transfer in house and interagency”, dated July 14,2025, was reviewed. The P&P indicated, “ .....PROCEDURE ...2..e. A transfer note is written by the sending nurse to include patient status at the time of transfer, date and time of transfer, mechanism of transportation, who accompanied the patient, where patient was transferred from, where patient is being transferred to ...g. A note is written by the receiving nurse, to include date and time, where patient comes from, name of the receiving unit, mechanism of transportation, who accompanied the patient and an assessment of the patient”. The CD stated, the policy was not followed as the nurse did not document regarding the transfer. During a concurrent interview and record review on November 19,2025, at 4:10 PM, with CD, the facility’s P&P titled “Patient Rights”, dated April 26,2023, was reviewed. The P&P indicated, “ ....PROCEDURE ...16. Know the reason for his/her transfer either within or outside the hospital”. The CD stated, the policy was not followed as there was no documentation. 4. . During a review of Patient 31’s “Admission record” (demographic data), dated October 12,2025, the “Admission record “ indicated, Patient 31 was admitted to the facility on October 12,2025, at 10:52 PM with the diagnosis of melena (a condition in which patient has black tarry stools caused by bleeding in the upper gastrointestinal tract). During a review of Patient 31’s “Patient care TimeLine”, dated October 12,2025, through October 14,2025, the “patient care timeline” indicated the following: October 13,2025, at 12:41 AM: Patient 31’s diet order was on nothing per mouth (NPO-patient is not allowed to take any food or liquid by mouth) status. On October 13,2025, at 8:27 AM: Patient 31’s diet order was modified to NPO except sips of water for medications. On October 13,2025, at 3:30 PM: Patient 31’s diet was ordered as adult clear liquid diet (patient will be allowed to have liquid diet). On October 13,2025, at 10:45 PM: Patient 31’s Clear liquid diet was discontinued. On October 14,2025, at 12:01 AM: Patient 31 was placed on NPO status On October 14,2025, at 11:35 PM: Patient 31’s diet order was modified to NPO except sips of water. On October 14,2025, at 4:57 PM: Patient 31 diet was modified to regular diet. During a concurrent interview and record review on November 18,2025, at 11:00 AM, with RN 4, facility’s EHR titled “flowsheet for intake and output”, dated October 12,2025 through October 15,2025, was reviewed. The “flowsheet for intake and output” indicated, Patient 31’s “intake and output” was incomplete, and there was no intake a nd output of 250 ml(milli liter- a unit of measurement) was documented for the day of October 13,2025 and October14, 20 25. RN 4 stated, the nurses are expected to complete the intake and output chart on every shift. RN 4 further stated, Patient 31 was taking the Go Lytle (a medication used in preparation for gastrointestinal procedures) and it should be included in the intake. During an interview on November 19,2025, at 3:15 PM, with RN1, RN1 stated, that the nursing team is responsible for documenting the intake and output of the patient.RN1 further stated, the intake and output should include the amount of fluid and the food intake and should be updated in timely manner. During a concurrent interview and record review on November 19,2025, at 5:10 PM, with Assistant Chief Nursing Officer ED (ACNO ED), the facility’s P&P titled “Documentation, Nursing”, dated July 11,2025, was reviewed. The P&P indicated, “ ...PROCEDURE ...V. 24 hour intake and output A. 24 hour I&O totals cover the period from 00:00 to 23:59 the following day. B. The 24 hour I&O totals are calculated within the electronic health record (EHR)...VI. REAL TIME DOCUMENTATION A. Documentation is completed in “real time”, at the time the intervention or assessment is performed, as often as possible”. The ACNO ED stated, the policy was not followed as nurses did not update the intake and output chart.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 47360 Based on interview and record review, the facility failed to ensure the patient’s right to receive an appropriate assessment and management of pain, and the facility policies and procedures (P&P) were followed for three of 30 sampled patients (Patient 3, 24 and Patient 26) seeking emergency care when: 1. Patient 26 presented to the emergency department (ED) with a burn to left leg and pain was not assessed during triage (a process used to assess patients’ injuries or illnesses and determine the priority of care), or at any time during his ED visit. 2. Patient 24 presented to the ED for a headache and pain was not assessed during triage. 3. Patient 3 presented to the ED with palpitations (the sensation of feeling your heartbeat in an irregular, rapid, fluttering, or pounding way) and a headache and her pain was not assessed during triage. These failures resulted in inconsiderate care and ineffective pain management of patient’s presenting to the ED with self-reported pain, and the potential for avoidable patient suffering and negative consequences for patient health outcomes. Findings: 1. During a review of Patient 26’s, “History of Present Illness” (HPI - a document containing patient history and current medical issues), dated May 20, 2025, the “HPI” indicated, “ ...Patient reports that a towel had caught fire on his left leg 2 days ago which caused the burn on his left shin ...He continues to have pain on the left leg. Now it is red and warm. He is concerned that it may be infected ...”. During a concurrent interview and record review on July 8, 2025, at 9:50 AM with the Emergency Department Educator (EDE), Patient 26’s “ED Triage Vitals [Vital Signs- measurement of the body’s most basic function including temperature, pulse, respiration rate, blood pressure, oxygen saturation and pain]”, dated May 20, 2025, were reviewed. The “ED Triage Vitals” did not include a pain assessment (rating of how bad the pain is 0 to 10, where 0 is no pain and 10 is the worst pain imaginable, location of pain, type of pain, duration of pain, and what makes the pain better or worse). The EDE stated, there was no documented pain assessment by the triage nurse. Upon further review of Patient 26’s “ED Vitals”, the EDE stated, Patient 24’s chart had no documented pain assessment during his visit to the ED. The EDE further stated, pain assessments are to be done by the triage nurse, with each set of vital signs, as needed and then documented in the patient’s chart. 2. During a review of Patient 24’s “HPI”, dated June 10, 2025, the “HPI” indicated, Patient 24 presented to the ED on June 10, 2025, with complaints of headache and right sided abdominal pain and was and was admitted to the hospital with a diagnosis of diabetic ketoacidosis (DKA - a life-threatening complication of diabetes [a condition where your body has trouble managing sugar levels in your blood] that happens when your body doesn’t have enough of a hormone called insulin (allows the body to use sugar as energy). During a concurrent interview and record review on July 8, 2025, at 10:00 AM with the EDE, Patient 24’s “Vitals Signs” , dated June 10, 2025, at 11:31 AM, were reviewed. The “Vital Signs”, that were measured upon triage of Patient 24, did not include a pain assessment. The EDE stated, there was no documented pain assessment by the triage nurse. The EDE stated, the pain assessment is part of the triage and should be assessed and documented during the patient’s triage assessment. 3. During a review of Patient 3’s Face sheet (FS-a document that provides a summary of Patient’s key information), the FS indicated, Patient 3 was brought to the facility on May 20, 2025, at 7:05 PM. During a review of Patient 3’s “HPI”, dated May 20, 2025 at 8:10 PM , the “HPI” indicated, Patient 3 was brought into the facility from a dialysis (a medical procedure to remove waste and excess fluid from the blood when the kidneys are no longer filtering the blood) clinic, because Patient 3 began experiencing Palpitations (the sensation of feeling your heart beat in an irregular, rapid, fluttering, or pounding way) and Head Ache. Patient 3 was found to be in Supraventricular Tachycardia (a heart rhythm disorder causing a rapid heartbeat, typically originating in the upper chambers of the heart). During a concurrent interview and record review on July 7, 2025, at 2:34 PM with the EDE, the “Vital Signs” were reviewed. The initial vital signs taken on May 20, 2025, at 7:08 PM, indicated no pain assessment was done. The first pain assessment done by nursing staff was until May 20, 2025, at 9:00 PM. The EDE stated the nurses are supposed to do a pain assessment when the patient first comes in or during triage. During an interview with Registered Nurse (RN1) on July 8, 2025, at 9:40 AM, RN 1 stated, the nursing staff was expected to do a pain assessment when patients first come in or during the triage process. RN 1 stated, that a patient is seen by a provider and the patient is medicated, the nursing staff have 1 hour to document a reassessment of pain. During an interview with the Director of Emergency Department (DED) on July 8, 2025, at 2:11 PM, the DED stated, it is expected for the nurses to assess pain level with the vital signs and during triage, even if the patient cannot verbally state their pain, the nursing staff can use the FLACC [Face, legs, Activity, Cry, and Consolability - used to assess pain in patients’ who cannot express their pain in words) Pain Scale, Critical Care Pain Observation Tool (CPOT - used to assess pain in critically ill patients who cannot communicate pain), Wong Baker Face (uses pictures showing facial expressions from smiling and happy to a crying, sad face). The DED, further stated pain assessment is highly important because it can affect the patient’s overall condition and vital signs. During a concurrent interview and record review with the DED on July 8, 2025, at 2:25 PM of the facility’s policy and procedure (P&P) titled “Pain Assessment and Management” dated July 3, 2019, was reviewed. The P&P indicated, “ ...D. Pain is collected, assessed and reassessed: 1. On admission to the hospital or clinic 2. With each set of routine vital signs, pain is assessed as the 5th vital sign ...” The DED stated, the P&P was not followed, and nursing staff are expected to perform pain assessment with the vital signs. During a concurrent interview and record review with the DED on July 8, 2025, at 2:26 PM of the facility’s P&P titled “Patient rights” dated May 26, 2014, was reviewed. The P&P indicated, “... 21. Be informed of the right to have pain treated as effectively as possible ...25. Receive appropriate assessment of pain and optimum management of pain ...”. The DED stated, the Patient Rights “P&P” was not followed and should have been. The DED stated, ED triage assessments need to be focused on the patient’s chief complaint, and pain was an important piece of the assessment, especially when the patient has presented to the ED with a complaint of pain. The DED further stated the patients’ pain assessment was highly important because pain can affect a patient’s physical health during an emergency and the patient’s overall wellbeing.”