Ronald Reagan UCLA Medical Center

“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: 45774 Based on interview and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met, as evidenced by: 1.The facility failed to ensure continuous cardiac monitoring (ongoing tracking of a patient ’ s heart rate and rhythm using electronic monitoring equipment) for one of 54 sampled patients (Patient 19), who had symptoms of shortness of breath (the sensation of not being able to get enough air into the lungs or feeling like you ’ re struggling to breathe) and chest pain for three days upon his arrival in the emergency department (ED) on 1/12/26. This deficient practice had the potential to result in the nursing staff ’ s failure to observe, interpret, or respond to Patient 19 ’ s real-time heart data, which could have lead to missed life-threatening events, such as arrhythmias (abnormal heartbeat) or cardiac arrest (sudden loss of heart activity). (Refer to A-0395) 2.The facility failed to assess and/or reassess three of 54 sampled patients (Patient 11, 12, and 23) for pain (assessment or reassessment in medical record) in accordance with the facility ’ s policy and procedure regarding pain management. This deficient practice had the potential to result in ineffective pain management for Patients 11, 12, and 23. (Refer to A-0398) 3.Ensure intravenous (IV, fluids given directly into the blood stream) tubing was labeled with the date, time, and staff initials (date and time of when the IV tubing needs to be changed and initials of the nurse who changed initiated the IV tubing placement) and IV solution bags were labeled with the patient ’ s name, patient ID number, date and time hung, solution type, volume of solution, and the Registered Nurse ’ s initials for two of 54 sampled patients (Patient 49 and Patient 50) in accordance with the facility ’ s policy and procedure regarding care and maintenance of IV tubing. This deficient practice had the potential to place Patient 49 and Patient 50 at risk for infection (invasion and growth of germs in the body) when it was not known when the IV tubing and solution bag needed to be changed. (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 45774 Based on interview and record review, the facility failed to ensure continuous cardiac monitoring (ongoing tracking of a patient ’ s heart rate and rhythm using electronic monitoring equipment) for one of 54 sampled patients (Patient 19), who had symptoms of shortness of breath (the sensation of not being able to get enough air into the lungs or feeling like you ’ re struggling to breathe) and chest pain for three days upon his arrival in the emergency department (ED) on 1/12/26. This deficient practice had the potential to result in the nursing staff ’ s failure to observe, interpret, or respond to Patient 19 ’ s real-time heart data, which could have lead to missed life-threatening events, such as arrhythmias (abnormal heartbeat) or cardiac arrest (sudden loss of heart activity). Findings: During a review of Patient 19 ’ s “ED Provider Notes,” dated 1/12/2026, the “ED Provider Note” indicated that Patient 19 presented to the ED on 1/12/2026 with shortness of breath and chest pain for three days. During a review of Patient 19 ’ s “Manage Order – Order History,” dated 1/13/2026 at 2:20 a.m., the “Order History” indicated Patient 19 had a physician ’ s order to be placed on cardiac monitoring. During a concurrent interview and record review on 5/12/2026 at 11:51 a.m. with Nurse Informaticist (NI2), Patient 19 ’ s “Patient Care Timeline,” dated from 1/12/2026 5:57 p.m. to 1/16/2026 4:54 a.m., was reviewed. The “Timeline” indicated an initial documented cardiac rhythm (the heart ’ s electrical pattern as captured on a monitoring device) reading of normal sinus rhythm (NSR, means the heart is beating in a healthy, regular, and coordinated pattern) was noted on 1/13/26 at 2:24 p.m. NI2 stated that there should have been an earlier capture of patient cardiac rhythm since the order for cardiac monitoring was placed on 1/13/2026 at 2:20 a.m. During a concurrent interview and record review on 5/14/2026 at 3:38 p.m. with Director of Emergency Department - Inpatient (DEDI), Patient 19 ’ s “Patient Care Timeline,” dated from 1/12/2026 5:57 p.m. to 1/16/2026 4:54 a.m., was reviewed. The “Timeline” indicated that on 1/13/2026 at 2:11 a.m., Patient 19 was moved from the South Lobby to the waiting room, and at 3:17 a.m., Patient 19 was again moved from the waiting room to the South Tent outside the ED. DEDI stated that since Patient 19 was in the South Tent, the ED was unable to provide cardiac monitoring for patients who are in the South Tent. DEDI stated Patient 19 should have been moved to a section in the ED with cardiac monitoring capacity, since the patient had an active cardiac monitoring order. DEDI added that Patient 19 also had orders to be admitted to the 7 East Telemetry Unit (a specialized unit for patients who require continuous cardiac monitoring) placed on 1/13/26 at 2:14 a.m. During a review of the facility ’ s policy and procedure (P&P) titled, “7 East - Acute Medicine and Telemetry Unit” (dated 5/2025), the P&P indicated the following: SCOPE OF SERVICE: 7 East is a 26-bed acute care inpatient unit that provides efficient and effective nursing care to complex patients who have a variety of medical diagnoses requiring a high level of care. Our patients consist of a combination of non-monitored and continuous monitored that requires specialized nursing care for those patients who are acutely ill, and are at risk for rapid status change. Further defined, our patient population consists of two levels of care: Continuous Cardiac Monitor (Telemetry): the patients are acutely ill patients in need of continuous non-invasive monitoring and who are at risk for immediate intervention.”

“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: 45774 ased on observation, interview, and record review, the facility failed to: 1. Assess and/or reassess three of 54 sampled patients (Patient 11, Patient 12, and Patient 23) for pain (assessment or reassessment in medical record) in accordance with the facility ’ s policy and procedure regarding pain management. This deficient practice had the potential to result in ineffective pain management for Patients 11, Patient 12, and Patient 23. 2. Ensure intravenous (IV, fluids given directly into the blood stream) tubing was labeled with the date, time, and staff initials (date and time of when the IV tubing needs to be changed and initials of the nurse who changed initiated the IV tubing placement) and IV solution bags were labeled with the patient ’ s name, patient ID number, date and time hung, solution type, volume of solution, and the Registered Nurse ’ s initials for two of 54 sampled patients (Patient 49 and Patient 50) in accordance with the facility ’ s policy and procedure regarding care and maintenance of IV tubing. This deficient practice had the potential to place Patient 49 and Patient 50 at risk for infection (invasion and growth of germs in the body) when it was not known when the IV tubing and solution bag needed to be changed. Findings: A. During a review of Patient 11 ’ s “Face Sheet” (the foundational patient intake document that acts a cover page of a patient ’ s chart, allowing doctors and nurses to quickly review essential information before treating them), dated 3/17/2026, the “Face Sheet” indicated Patient 11 arrived at the emergency department (ED) with complaints of chest pain, at 8:56 PM. During a concurrent interview and record review on 5/12/2026 at 2:38 PM with Registered Nurse (RN) 2, Patient 11 ’ s “ED Physician Note,” dated 3/18/2026, was reviewed. RN 2 confirmed that the “Note” indicated Patient 11 complained of chest pain and difficulty breathing. In the same concurrent interview and record review, Patient 11 ’ s “Triage Nursing Notes,” dated 3/17/2026, was reviewed. RN 2 confirmed the “Triage Nursing Notes” indicated Patient 11 ’ s initial vital signs (critical measurements of a person ’ s basic bodily functions including body temperature, heart rate, respiratory rate, blood pressure, oxygen saturation, and pain level) were taken and indicated a pain score of 10 out of 10 possible (worst pain ever). In the same concurrent interview and record review, Patient 11 ’ s physician orders, dated 3/18/2026, were reviewed. RN 2 confirmed Patient 11 ’ s physician orders indicated there was an order for –four milligrams (mg - a metric unit of measurement used for medication dosage and/or amount) of morphine (a type of strong pain medication) by intravenous (IV – into the vein) push right away (STAT – aka statim; without delay). In the same concurrent interview and record review, Patient 11 ’ s medication administration record (MAR – a clinical document used to track, verify, and document all the medications administered to a patient), dated 3/18/2026, was reviewed. RN 2 confirmed the MAR indicated Patient 11 was given morphine at 2:25 AM. Concurrently, during a review of Patient 11 ’ s vital signs, RN 2 stated that Patient 11 was not assessed for pain prior to administering pain medication on 3/18/2026, at 2:25 AM. RN 2 stated that Patient 11 ’ s previous pain assessment, prior to administering pain medication, was obtained during triage, when Patient 11 arrived in the ED at 9 PM, on 3/17/2026. RN 2 stated that Patient 11 should have been assessed for pain prior to being given pain medication.RN 2 further stated Patient 11 was not assessed for pain within one hour after pain medication of morphine 4 mg IVP was given on 3/18/2026 at 2:25 AM to evaluate the treatment for pain. RN 2 stated Patient 11 was not reassessed for pain until 3/18/2026 at 2 PM – approximately 12 hours after having received pain medication. B. During a review of Patient 12 ’ s “Face Sheet,” dated 3/17/2026, the “Face Sheet” indicated Patient 12 arrived in the ED at 10:03 PM. During a concurrent interview and record review on 5/13/2026 at 10:04 AM with Nurse Informaticist (NI) 1, Patient 12 ’ s ED Timeline, dated 3/18/2026, was reviewed. NI 1 stated the following: Patient 12 ’ s triage vital signs were obtained on 3/17/26, at 10:26 PM, without pain assessment. On 3/17/26, at 11:25 PM, Patient 12 reported pain score of 6 out of 10 (moderate pain in the head). Patient 12 ’ s acceptable pain goal is no pain. On 3/18/26, at 6:36 PM, Patient 12 ’ s last vital signs were obtained without pain assessment. On 3/18/26, at 7:15 PM, Patient 12 was discharged home. During an interview on 5/13/2026, at 10:11 AM, with the Assistant Nurse Manager of ED (RN 3), RN 3 stated in the ED, the vital signs were usually done every two hours with pain assessment. During a review of the facilities policies and procedures (P&P) titled, “Pain Assessment and Management Policy, HS 1341” (dated 8/2023), the policy indicated the following: RE-ASSESSMENT AND MONITORING A. Pain is reassessed with new reports of pain and following procedures or activities that are expected to cause pain. B. Depending on setting, pain is reassessed following pharmacologic and non-pharmacologic interventions with consideration of peak analgesic effect and documented in the medical record. C. Patients will be monitored for potential side effects of pain management interventions including sedation level with consideration of the specific pharmacologic, non-pharmacologic, procedural treatments and potential for interactions with other treatments simultaneously in use. During a review of the facilities policies and procedures (P&P) titled, “Emergency Department RN Documentation Standards” (dated 6/2025), the policy indicated the following: Assessments and Reassessments: Focused assessment based off chief complaint, history of present illness, appearance and significant medical history documented by RN within 45 minutes of arrival to ED treatment room. Focused assessment/reassessment documented every 2 hours and as needed if change in patient condition or assessment. C. During a review of Patient 23 ’ s “ED Provider Notes”, dated 3/25/2026, the “ED Provider Notes” indicated that Patient 23 was seen in the emergency department with complaint of abdominal pain gradually worsening over the last three days. During a concurrent interview and record review on 5/13/2026 at 4:16 PM with the Nurse Informaticist (NI1), Patient 23 ’ s “Patient Care Timeline,” dated from 3/25/2026 8:37 p.m. to 3/26/2026 9:31 p.m., was reviewed. The “Timeline” indicated that Patient 23 ’ s initial pain assessment by use of pain scale (a tool healthcare providers use to measure the intensity of a patient’s pain using the 0-10 Numeric Rating Scale, where 0 means “no pain” and 10 means the “worst possible pain”) was taken on 8/25/26 at 8:43 p.m. with a pain score of 8 out of 10, there was no follow up assessment or re-assessment until the next day on 8/26/26 at 1:00 p.m. The NI1 stated that there was a 15-hour gap between pain assessments; Patient 23 came in with a chief complaint of abdominal pain, there should have been a follow-up or reassessment of Patient 23 ’ s pain level. NI1 added that she was not sure how often emergency department staff should assess patients ’ pain level. During an interview with the Director of Emergency Department (DED) on 5/14/2026 at 3:40 p.m. The DED stated that pain reassessment and monitoring of patients in the emergency department (ED) depended on whether a patient receives a pharmacologic or a non-pharmacologic intervention to address their pain.The DED stated a non-pharmacologic intervention pain reassessment should be done every 2 hours and as needed with new reports of pain. It was noted that Patient 23 declined pain medication and opted for a non-pharmacologic approach of “Prayer” to address his 8/10 pain on 8/25/26 at 8:43 p.m. There was no reassessment done on patient 23. During a review of the facilities policies and procedures (P&P) titled, “Pain Assessment and Management Policy, HS 1341” (dated 8/2023), the policy indicated the following: RE-ASSESSMENT AND MONITORING A. Pain is reassessed with new reports of pain and following procedures or activities that are expected to cause pain. B. Depending on setting, pain is reassessed following pharmacologic and non-pharmacologic interventions with consideration of peak analgesic effect and documented in the medical record. C. Patients will be monitored for potential side effects of pain management interventions including sedation level with consideration of the specific pharmacologic, non-pharmacologic, procedural treatments and potential for interactions with other treatments simultaneously in use. During a review of the facilities policies and procedures (P&P) titled, “Emergency Department RN Documentation Standards” (dated 6/2025), the policy indicated the following: Assessments and Reassessments: Focused assessment based off chief complaint, history of present illness, appearance and significant medical history documented by RN within 45 minutes of arrival to ED treatment room. Focused assessment/reassessment documented every 2 hours and as needed if change in patient condition or assessment. 2. A. During a review of Patient 49 ’ s Emergency Department (ED, a specialized hospital unit that provides immediate care for acute illnesses and severe injuries) “Patient Demographic Sheet (the part of the chart that contains a summary of basic information about the patient),” dated 5/11/2026, the demographic sheet indicated Patient 49 arrived at the ED for a complaint of “Seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), complains of forehead and occipital (the back of the head, skull, or brain) pain ...”. During a review of Patient 49 ’ s ED “Medication Administration Record (MAR),” dated 5/11/2026, the MAR indicated a physician ’ s order for Lactated Ringers [a fluid used to replace water and electrolytes (essential minerals found in the body) in the body] Intravenous (IV, fluids given directly into the blood stream) Solution bolus (a single, relatively large dose of a substance given all at once), 1000 ml (milliliter, a unit of liquid measure), to infuse over one hour. During a concurrent observation and interview on 5/11/2026 at 12:00 p.m. with the ED Assistant Nurse Manager (CN) 1 at Patient 49 ’ s bedside, Patient 49 ’ s IV bag was infusing with attached IV tubing, and neither the IV solution bag nor the IV tubing was labeled with Patient 49 ’ s name, date, time, or initials of Registered Nurse who initiated the infusion. CN 1 stated there was no need to label the IV bag or the IV tubing because, “Not much can happen since in the Emergency Department the IV bag and the tubing aren ’ t in use for long.” During a concurrent interview and record review on 5/14/2026 at 2:00 p.m. with ED Unit Director (Dir ED), the facility ’ s policy and procedure (P&P) titled, “IV Therapy and Parenteral (outside the digestive tract) Nutrition – Adults/Peds/Neonate/Perinatal (Pediatrics: the branch of medicine dealing with individuals from birth through young adulthood, Neonate: the branch of medicine dealing with newborns; Perinatal: the period immediately before and after birth), Nur-HS 116,” revised 09/2025, was reviewed. The P&P indicated: IV Administration sets: “ ....Label tubing with date, time hung, and RN ’ s/LVN ’ s initials.” IV Solution: “ ...Label IV bag with patient name, patient ID (identification number) number, date and time hung, drug name, drug dose, solution type, and volume of solution, and RN ’ s initials.” The Dir ED stated IV solution bags and IV tubing in the ED did not need to be labeled because patients in the ED did not have long-term stays. The Dir ED stated the Emergency Department (ED) used a different P&P for IV therapy and provided the facility ’ s P&P titled, “ED Peripheral (the area near the surface of the body or outer edges) IV Nurse Protocol HS 3170,” revised 2/2026. During a review of the facility ’ s P&P titled, “ED Peripheral IV Nurse Protocol HS 3170,” revised 2/2026, the P&P did not indicate a reference to IV solution bag labeling or IV tubing labeling. However, the P&P indicated, “Applicable Policy: IV Therapy and Parental Nutrition-Adults/Peds/Neonate/Perinatal, Nurse-HS 116.” B. During a review of Patient 50 ’ s Emergency Department “Patient Demographic Sheet,” dated 5/11/2026, the demographic sheet indicated Patient 50 arrived at the ED for a complaint of facial swelling for one hour. During a review of Patient 50 ’ s ED “Medication Administration Record (MAR),” dated 5/11/2026, the MAR indicated a physician ’ s order for Sodium Chloride 0.9% (a compound composed of equal parts sodium and chlorine used for rehydration, wound cleaning and to maintain bodily fluid balance) Intravenous (IV, fluids given directly into the blood stream) Solution bolus (a single, relatively large dose of a substance given all at once), 1000 ml (milliliter, a unit of liquid measure), to infuse over half an hour. During a concurrent observation and interview on 5/11/2026 at 12:06 p.m. with the ED Registered Nurse (RN) 1 at Patient 50 ’ s bedside, Patient 50 ’ s IV bag was infusing with attached IV tubing, and neither the IV solution bag nor the IV tubing was labeled with Patient 50 ’ s name, date, time, or initials of the Registered Nurse who initiated the infusion. RN 1 stated there was no need to label the IV bag or the IV tubing because there were no additional medications added to the IV solution bag and the IV tubing would be discarded. During a concurrent interview and record review on 5/14/2026 at 2:00 p.m. with ED Unit Director (Dir ED), the facility ’ s policy and procedure (P&P) titled, “IV Therapy and Parenteral (outside the digestive tract) Nutrition – Adults/Peds/Neonate/Perinatal (Pediatrics: the branch of medicine dealing with individuals from birth through young adulthood, Neonate: the branch of medicine dealing with newborns; Perinatal: the period immediately before and after birth), Nur-HS 116,” revised 09/2025, was reviewed. The P&P indicated: IV Administration sets: “ ....Label tubing with date, time hung, and RN ’ s/LVN ’ s initials.” IV Solution: “ ...Label IV bag with patient name, patient ID (identification number) number, date and time hung, drug name, drug dose, solution type, and volume of solution, and RN ’ s initials.” The Dir ED stated IV solution bags and IV tubing in the ED did not need to be labeled because patients in the ED did not have long-term stays. The Dir ED stated the Emergency Department (ED) used a different P&P for IV therapy and provided the facility ’ s P&P titled, “ED Peripheral (the area near the surface of the body or outer edges) IV Nurse Protocol HS 3170,” revised 2/2026. During a review of the facility ’ s P&P titled, “ED Peripheral IV Nurse Protocol HS 3170,” revised 2/2026, the P&P did not indicate a reference to IV solution bag labeling or IV tubing labeling. However, the P&P indicated, “Applicable Policy: IV Therapy and Parental Nutrition-Adults/Peds/Neonate/Perinatal, Nurse-HS 116.””

“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: 36329 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by: 1.The facility failed to document one of 30 sampled patient ’ s (Patient 9) behavioral status while he was being physically restrained (a manual or mechanical device restricting a patient ’ s movement, generally used to prevent harm to the patient or others). This deficient practice has the potential for the patient while under restraint may lead to poor blood circulation, depending on the type of restraint, and inability of the patient to maintain hygiene, due to lack of periodic (occurring repeatedly from time to time) monitoring. (Refer to A-0395) 2.The facility failed to assess, reassess, manage and document seven of 30 sample patients (Patient 2, Patient 10, Patient 18, Patient 19, Patient 20, Patient 22 and Patient 30) pain level per facility policies and procedures. These deficient practices resulted in patients ’ needs for pain relief not being met. (Refer to A-0398). 3. The facility failed to ensure one of 30 sample patients (Patient 2) was administered was administered medications from home by an authorized and licensed hospital personnel according to a doctor ’ s order and facility policy and procedure during hospital admission. This deficient practice resulted in Patient 2 receiving home medication from a family member without a physician order and without clearance from pharmacist (a licensed person who give out prescription medication) to verify the identification of the medication while in the facility. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 36329 Based on observation, interview, and record review the facility failed to document and monitor one of 30 sampled patient ’ s (Patient 9) behavioral status while he was being physically restrained (a manual or mechanical device restricting a patient ’ s movement, generally used to prevent harm to the patient or others). This deficient practice has the potential for the patient while under restraint may lead to poor blood circulation, depending on the type of restraint, and inability of the patient to maintain hygiene, due to lack of periodic monitoring Findings: During a tour on 5/29/2025 at 10:40 a.m., accompanied by RN 2, Patient 9 was observed in bed with soft restraints (band placed around a patient ’ s wrist and tethered to the bed to restrict movement) to both wrists. The restraints were secured to the underside of the bed and Patient 9 ’ s arms were spread out and apart from the midline (imaginary line runs down the center of the body, that dividing into left and right halves) of his body. Patient 9 was sleeping at this time. During an interview on 5/29/2025 at 1:40 p.m., RN 2 stated Patient 9 pulled out two IV lines (small tubes placed within veins to infuse fluids) last night (5/28/2025) and was restrained to prevent Patient 9 from pulling out the lines and slowing the delivery of medicine. RN 2 also stated patients with restraints should be monitored to ensure the restraint is not too tight around the wrist and the patient has a chance to use the restroom. RN 2 subsequently stated, after reviewing the ’ Flowsheets ’ for ’ Non-Violent Restraints (Medical Surgical) ’ dated 5/29/2025, there was no documentation of monitoring Patient 9 for restraint tightness or offering toileting from 9:00 AM through 1:00 PM on 5/29/2025. During an interview on 5/29/2025 at 1:15 p.m., the Clinical Director of Regulatory Affairs (CDRA) stated, per the hospital ’ s policy, if a patient is monitored every two hours while on restraints then the details of monitoring should be recorded in the patient ’ s medical record. During a review of the ’ Neurocritical Care Admission Note ’ , patient assessment performed by a neurosurgeon - surgeon specializing in surgery on the nervous system, especially the brain and spinal cord, dated 5/3/2025, indicated Patient 9 presented to the hospital after two generalized tonic-clonic seizure (change of the electrical activity in the brain that exhibits loss of consciousness, stiffening of the body, and jerking movements). The treatment plan of this note indicated frequent neuro-checks (assessments of a patient’s neurological function such as body movement and ability to speak, typically performed by nurses to monitor and detect changes in a patient’s condition) by nursing and antiseizure medications will be administered. A review of the ’ Non-behavioral, non-violent/non-self destructive, restraint order number 780608056, dated 5/29/2025 at 3:26 AM, indicated restraint began on 5/29/2025 at 3:30 a.m., and ended 5/30/2025 at 11:59 p.m. The ’ Comments Section ’ of this order indicated the restraint order must be renewed every calendar day based upon examination of the patient. A review of the ’ Flowsheets ’ for ’ Non-Violent Restraints (Medical Surgical) ’ indicated that restraints were discontinued from Patient 9 at 8:00 a.m. on 5/25/2025. Further review of this ’ Flowsheet ’ for restraint use indicated Patient 9 was on soft restraints beginning 3:30 a.m. on 5/29/2025, per ’ Non-behavioral, non-violent/non-self destructive, restraint order number 7806080556; There was no documentation of monitoring from 9:00 AM through 1:00 PM on 5/29/2025 (a total of 4 hours). During a record review of the facility ’ s policy and procedure titled ’ Restraint, HS 1321 ’ Policy State ID 14535451 approved 11/2023, this document indicated restraints are used so they do not cause unnecessary physical discomfort, harm, or pain and are removable in the event of an emergency. The ’ Observation, Monitoring and Documentation ’ part of this policy indicted patients under non-violent restraint are observed and monitored at least every 2 hours for signs of injury, level of consciousness and circulation, sensory and motor function (ability to perform voluntary motion); These assessments are then documented.”

“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: 36329 Based on interview and record review, the facility failed to assess, reassess, manage and document seven of 30 sample patients (Patient 2, Patient 10, Patient 18, Patient 19, Patient 20, Patient 22 and Patient 30) pain level per facility policies and procedures. These deficient practices resulted in patients ’ needs for pain relief not being met. Findings: 1. During a review of Patient 2 ’ s face sheet (a document summarizing a patient ’ s personal and demographic information), dated 8/31/2024, indicated patient arrived at the ED (Emergency Department, a specialized area within a hospital that provides immediate medical care for patients with serious or emergent conditions) at 5:06p.m. and with diagnosis of vomiting and abdominal pain. During concurrent interview and record review on 5/28/2025, at 12:53 p.m., with Emergency Department Director (ED Dir) 1 of Patient 2 ’ s ED triage (process of sorting patient for treatment based on injury or illness) notes, dated 9/1/2024, ED Dir 1 stated on 8/31/2024, at 5:11 p.m., patient ’ s (Patient 2) family member reported patient had severe pain with a pain score of 8 (intense pain)out of 10 (tool use to measure pain ,with 0 no pain and a score of 10 being the worse possible pain imaginable). During concurrent interview and record review on 5/28/2025 at 12:55p.m., of Patient 2 ’ s Emergency Department (ED) flowsheet with the ED Dir 1. ED Dir 1 stated Patient 2 was not reassessed for pain until 12 hours after initial report of pain, at 9/1/2024 at 5:15 p.m. from the time Patient 2 was admitted in the ED. During interview and record review on 5/28/2025 at 12:58p.m. with the ED Dir 1, Patient 2 ’ s medication administration record (MAR – a legal document that provides a comprehensive and accurate record of all medications administered to a patient), dated 8/31/2024 was reviewed. ED Dir 1 stated there was no medications ordered for Patient 2 ’ s severe (serious) pain and patient did not receive any medication for severe pain reported. ED Dir 1 stated there was no documentation of non-pharmacological interventions for Patient 2 ’ s severe pain of 8 out of 10. Concurrently, during review of facility ’ s ED Pain Protocol, dated 3/2025), indicated Pain will be assessed using an approved pain scale and pain medication will be expeditiously administered to patients who present to the ED triage in pain. Concurrently, during review of facility ’ s Pain Assessment and Management policy, dated 8/2023), indicated pain is always subjective and pain assessment included information from the patient or patient ’ s proxy and pain ratings obtained with a validated pain measurement tool with the patient ’ s developmental and/or cognitive status. 2. During an interview on 5/29/2025 at 1:45 p.m. Registered Nurse (RN 2), RN 2 stated per hospital ’ s policy dictates (rule) how pain is evaluated (to judge something) an assessment (collection of data about an individual ’ s health status) should be documented in the patient ’ s medical record. RN 2 also stated that pain intensity(strength) should be monitored to determine if the pain therapy is effective (successful). Concurrently, during review of facility ’ s Pain Assessment and Management policy, dated 8/2023), indicated patients are screened for pain as part of the patient ’ s initial evaluation and on an ongoing basis. And, pain is reassessed following pharmacologic and nonpharmacologic interventions with consideration of peak analgesic effect and documented in the medical record. During a record review of the ’ Medicine History and Physical ’ (a comprehensive evaluation of a patient ’ s medical history and physical examination) indicated Patient 10 was admitted on 5/26/2025 and presented with acute pain crisis (sudden severe pain that can last few hours, days, or even weeks). It also indicated Patient 10 ’ s past medical history (a comprehensive record of a patient ’ s medical, personal, and family history, encompassing past illnesses, surgeries, injuries, allergies and more) : sickle cell crisis (event when sickle-shaped red blood cells block blood flow, leading to intense pain and other symptom), multiple strokes (sudden disruption of blood flow to the brain, causing brain tissue damage), AVN (Avascular Necrosis, a condition where bone tissue dies due to a lack of blood supply) The ’ Medicine History and Physical ’ indicated part of Patient 10 plan was to alleviate (reduce) pain due to sickle cell crisis included the use of several pain medications including Tylenol (medication usually given for reduction of minor pain) given three times per day. During a review of the ’ Flowsheets ’ showed that on 5/29/2025 at 10:20 a.m., Patient 10 was experiencing pain to the head and that medication was given. This document did not indicate the pain assessment tool used to determine the severity (seriousness) of pain or actual pain experienced by Patient 10. This document did not indicate any follow up assessment of pain after the medication was given. During a review of the Medical Administration Record (MAR) indicated Patient 10 also received a 30 mg dose of ketorolac (medication used for the short-term relief of moderately severe pain) on 5/29/2025 at 10:20 a.m. Patient 10 was also given a 500 mg (milligram-a unit of weight or mass in the metric system) dose of Tylenol (pain medication) on 5/29/2025 at 10:27 AM. During a review of the ’ Pain Assessment and Management Policy, HS 1341 ’ , this policy indicated assessment includes pain level determined by an appropriate tool consistent with the patient ’ s cognition (mind ability to think, learn, and understand). This policy indicated pain assessment will include the following: location, intensity, quality (description), and duration (how long something last). The ’ Pain Assessment and Management policy ’ specified that depending on the setting, pain is reassessed following medication administration considering the peak (highest point) pain reduction affect and documented in the patient ’ s medical record. 3.A review of Patient 18 ’ s face sheet (a document summarizing a patient ’ s personal and demographic information), dated 5/27/2025, indicated patient arrived in the Emergency Department (ED, a specialized area within a hospital that provides immediate medical care for patients with serious or emergent conditions) at 7:42 p.m. with a chief complaint of sepsis (body response to infection). During concurrent interview and record review on 5/29/2025, at 2:17 p.m., with Nurse Informaticist (Nse Info) 1 of Patient 18 ’ s Emergency Department (ED) triage notes, Nse Info 1 stated patient was triaged at 7:45 p.m. and complained of mild pain with a pain score of 3 out of 10, and with an acuity (severity of patient illness) of 3, urgent(patients with this condition that requires multiple resources and/or have a moderate risk of deterioration, such as a broken bone, a severe headache, or abdominal pain). During concurrent interview and record review on 5/29/2025 at 2:20p.m., of Patient 18 ’ s nursing flowsheet, dated 5/28/2025, Nse Info 1 stated patient was not reassessed for pain from 1:53 a.m. to 8:15 a.m. Concurrently, during review of the facility ’ s policy for Pain Assessment and Management, dated 8/2023, indicated pain is reassessed following pharmacological interventions, with consideration of peak analgesic effect and documented in the medical record. 4.A review of Patient 19 ’ s face sheet (a document summarizing a patient ’ s personal and demographic information), dated 5/26/2025, indicated patient was admitted to the facility with a diagnosis of infection in the abdominal wall (a multilayered structure of skin, fascia, and muscles that encloses and protects the abdominal cavity and its organs)On 5/29/2025, at 3:05 p.m., during concurrent interview and record review with Nurse Informaticist (Nse Info) 1, Patient 19 ’ s Clinic visit, dated 5/23/2025 was reviewed. Nse Info 1 stated patient was seen by her primary physician who found an abscess (collection of pus (thick milky-white or yellowish fluid) within the body tissue) in the patient ’ s abdomen that need to be drained. During record review of Patient 19 ’ s history and physical (H&P – a comprehensive assessment of a patient ’ s health, encompassing both a detailed medical history and a physical examination), dated 5/26/2025, indicated the following: Past medical history of cancer with an abscess with a drain placed on 1/4/2025, with dependance on gastrostomy tube (g-tube – a flexible tube inserted into the stomach through an opening in the abdominal wall), with a complaint of increasing abdominal pain and swelling, and development of carbapenem resistant pseudomonal infection (class of antibiotic use to treat bacteria that are resistant to other drugs). During concurrent interview and record review on 5/29/2025 at 3:10p.m., with Nse Info 1, of Patient 19 ’ s nursing flowsheet, dated 5/27/2025, and medication administration record (MAR – document used to track and record all medications administered to a patient), dated 5/27/2025, and physician orders for medications, Nse Info 1 stated the following: At 1:32 p.m., patient complained of moderate pain with a pain score of 4 out of 10 and was given Tylenol (pain medication) 650 milligrams (mg). Patient ’ s pain was not reassessed after one hour from receiving Tylenol 650 mg. From 3:32 p.m. to 5:00 p.m., left the unit for a procedure and pain was not reassessed. At 5:00 p.m., patient returned to the unit and complained of severe pain with a pain score of 8 out of 10. At 5:48 p.m., patient was given oxycodone 10 mg for pain score of 8/10. Patient ’ s pain was not reassessed after one hour from receiving oxycodone 10 mg for severe pain. At 9:42 p.m., patient complained of worsening pain with a pain score of 9/10 and was given oxycodone 20 mg for worsening pain. At 10:42 p.m., patient reported mild pain with a score of 1/10. During review of the facility ’ s Pain Assessment and Management policy, dated 8/2023, indicated pain assessment included pain ratings obtained with a validated pain measurement tool consistent with the patient ’ s developmental and/or cognitive status. Pain is reassessed following pharmacologic and nonpharmacologic interventions and is documented in the medical record. 5.A review of Patient 20 ’ s face sheet (a document summarizing a patient ’ s personal and demographic information), dated 5/28/2025, indicated patient arrived at the ED at 2:28 a.m. with a rash. A review of Patient 20 ’ s ED (Emergency Department, a specialized area within a hospital that provides immediate medical care for patients with serious or emergent conditions) physician note, dated 5/28/2025, indicated patient had an abscess in the mouth, which began a week ago with blisters (pocket of fluid underneath the skin) that worsened with swelling in the right cheek, more blisters inside the mouth, and difficulty swallowing. During concurrent interview and record review of the Emergency Department Time line for Patient ’ s 20 Emergency Department visit, on 5/30/2025, at 8:28 a.m., with Nurse Informaticist (Nse Info) 1, of Patient 20 ’ s ED timeline, dated 5/28/2025. Nse Info 1 stated the following: During triage, patient complained of severe pain, in the mouth with multiple blisters, with a pain score of 10 out of 10 (worst pain ever), at 2:38 a.m. There was no indication of pain management until 4:12a,.m. At 4:12 a.m., physician ordered pain medication, morphine (strong pain medication) 4 mg by vein (IV-intravenous-method of administering fluids or medicine directly in the vein). No reasseement of Patient ’ s 20 pain since triage at 2:38a.m. And prior to administering morphine 4 mg IV for pain at 4:30a.m. Patient was not reassessed for pain within one hour of receiving the second dose of morphine 4 mg IV, to check the effectiveness of the pain medication given. At 7:35 a.m. and at 8:49 a.m., patient complained of severe pain with a pain score of 10/10, and there was no documentation of pain-relieving interventions or pain medication given. At 11:30 a.m., patient complained of severe pain with a score of 10/10 and was given pain medication, hydromorphone (pain medication use to treat severe pain)1 mg IV. Patient was not reassessed for pain within one hour after receiving pain medication hydromorphone, to check the effectiveness of the pain medication given. At 4:27 p.m., patient was not reassessed for pain, prior to being given Tylenol 1000 mg IV and morphine 2 mg IV. Patient was not reassessed for pain within one hour of receiving pain Tylenol and morphine medications, to check the effectiveness of the pain medications given.at 8:24 p.m., patient was admitted to intensive care unit. During review of facility ’ s Pain Assessment and Management policy, dated 8/2023, indicated patient is screened for pain as part of the patient ’ s initial evaluation and on an ongoing basis. And pain is reassessed following pharmacologic interventions and documented in the medical record. 6.A review of Patient 22 ’ s face sheet (a document summarizing a patient ’ s personal and demographic information), dated 5/22/2025, indicated that patient arrived in the ED (Emergency Department, a specialized area within a hospital that provides immediate medical care for patients with serious or emergent conditions) at 12:00 a.m., with breathing difficulties. On 5/30/2025, at 10:49 a.m., during concurrent interview with Nse Info 1 and record review of Patient 22 ’ s nursing flowsheet, dated 5/22/2025, Nse Info 1 stated Patient 22 was not assessed for pain from 12:00 a.m. to 3:45 a.m., in the ED. A review of facility ’ s Pain Assessment and Management policy, dated 8/2023, indicated that patients are screened for pain and on an ongoing basis, using pain measurement tools consistent with the patient ’ s developmental and intellectual capacity. 7.A review of Patient 30 ’ s face sheet (a document summarizing a patient ’ s personal and demographic information), dated 4/23/2025, indicated patient was admitted to the facility with a chief complaint of debility (a state of physical weakness). On 5/29/2025, at 12:05 p.m., uring concurrent interview with Emergency Department (ED - a specialized area within a hospital that provides immediate medical care for patients with serious or emergent conditions) Director (ED Dir) 1 and record review of Patient 30 ’ s Emergency Department triage notes, dated 4/23/2025. ED Dir 1 stated patient complained of severe pain with a pain score of 8 out 10, at 2:54 p.m. During interview on 5/29/2025 at 12:08p.m., with Nurse Informaticist ( a nurse combines their clinical expertise and knowledge of information technology) (Nse Info) 1 stated Patient 30 was reassessed for pain, after two hours, on 4/23/25 at 4:56 p.m., and was given pain medication of Tylenol 1000 mg (milligram-a unit of weight or mass in the metric system) by mouth for pain score of 5/10 – which was moderate pain. Nse Info 1 stated Patient 30 was not reassessed for pain after having received pain medication of Tylenol at 4:56p.m., to check the effectiveness of the pain medication. Nse Info 1 stated patient should have been reassessed for pain within one hour of receiving Tylenol. Nse Info 1 stated there was no documentation that the pain was relieved after receiving Tylenol 1000 mg on 4/23/2025, at 4:56 p.m., per facility ’ s policy and procedure for pain management. Nse Info 1 also stated Patient 30 was only reassessed for pain, since receiving Tylenol, on 4/24/2025, at 3:00 a.m. – more than 12 hours after receiving Tylenol for pain. A review of facility ’ s policy for Pain Assessment and Management, dated 8/2023, indicated the following: Patients have the right to evidence-based pain treatment and supports a multidisciplinary (people from different disciplines working together) approach to pain assessment and management. Pain assessment includes information from the patient or proxy (a person authorized to act for another) about provoking (cause) factors, quality/characteristics, region/radiation(spread), relieving factors associated(related) with symptoms and timing. Pain assessment includes pain ratings obtained with a validated (confirm) pain measurement tool consistent(regularly) with the patient ’ s developmental(growing)and/or cognitive (mental process like thinking, learning and remembering) status. Patients are screened for pain as part of the patient ’ s initial evaluation and on an ongoing basis, for pain scores unacceptable to the patient or proxy. Pain history is obtained when pain in present, upon initial screening or upon the first report of pain, whichever comes first. If initial pain screen was negative, but a later screen is positive and relevant to the visit, the pain assessment/history is to be obtained, at that time. Pain assessment will include location, intensity, quality, and duration. Patients should receive prompt, effective pharmacologic/non-pharmacologic and/or procedural management for their pain, if indicated and relevant to the visit. Pain management plans are individualized and include concerns of the patient, family and/or proxy. Pain is reassessed with new reports of pain and following procedures/activities that are expected to cause pain. Pain is reassessed following pharmacologic (treatment with use of drugs) and non-pharmacologic (treatment with non use of drugs) interventions, with consideration of peak analgesic effect and are documented in the medical record. A review of facility ’ s policy for Emergency Department Pain Protocol, dated 3/2025, indicated the following: The use of evidence-based nurse-initiated pathways to enhance the quality and efficiency (effectiveness)of patient care to expeditiously(fast) administer pain medications to patients who present to the emergency department (ED) triage area in pain. Pain will be assessed using approved pain scale. Patients should receive only one dose of medication based on the protocol for pain. First line goal is acetaminophen (medication use to treat minor pain)650 milligrams (mg) by mouth, for pain, if requested and/or used by patient, before without issue, once. Ibuprofen (use to treat mild to moderate pain) 400 to 600 mg by mouth, for pain, if requested and/or used by patient before without issue, once. Registered Nurse (RN) will document all interventions (treatment) for pain control. Providers will co-sign the order initiated by the RN, per protocol.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 36329 Based on interview and record review, the facility failed to ensure one of 30 sample patients (Patient 2) was administered medications from home by an authorized and licensed hospital personnel according to a doctor ’ s order and facility policy and procedure. This deficient practice resulted in Patient 2 receiving home medication from a family member without a physician order and without clearance from pharmacist (a licensed person who give out prescription medication) to verify the identification of the medication while in the facility. Findings: A review of Patient 2 ’ s face sheet (a document summarizing a patient ’ s personal and demographic information), dated 8/31/2024, indicated patient arrived in the Emergency Department (ED) at 5:06 p.m., with patient ’ s family member who lived with the patient, with a complaint of problems with the gastrostomy tube (G-tube – a flexible tube inserted into the stomach through an opening in the stomach wall to provide nutrition, fluids and/or medications directly into the stomach). On 5/28/2025, at 12:53 p.m., durrng concurrent interview with Emergency Department (ED - a specialized area within a hospital that provides immediate medical care for patients with serious or emergent conditions) Director (ED Dir)1 and record review of Patient 2 ’ s ED nursing notes, dated 9/1/2024 was reviewed. ED Dir 1 stated Registered Nurse (RN) 3 assisted Patient 2 ’ s family member who crushed patient ’ s medications, mixed the medications with warm water, and administered the medications by patient ’ s G-tube.ED Dir 1 stated Patient 2 had no physician orders for patient ’ s family member to administer patient ’ s home medications, in the facility. RN 3 did not send Patient 2 ’ s home medications to the pharmacy for verification of medication ’ s identification, prior to administration, per facility ’ s policy and procedure. RN 3 did not document the two medications levetiracetam (treat seizures) and pantoprazole (treat increase stomach acid) given to Patient 2 by Patient 2 ’ s family member – including the name of the medication, the dose of the medication, and expiration date of the medication. During concurrent interview and record review on 5/28/25 at 1:00p.m., with ED Dir, a review of Patient 2 ’ s medication administration record, dated 9/1/2024 was conducted. ED Dir 1 stated RN 3 did not give two medications, levetiracetam (treat seizures) 500 milligrams and pantoprazole (treat increase stomach acid) 40 milligrams, because Patient 2 ’ s family member already gave the two medications. A review of facility ’ s policy for Medications – Use of Patient ’ s Personal, dated 5/2025, indicated the following: The physician writes an order in the patient ’ s medical record indicating that the patient ’ s personal supply of medical be used. Medications brought in by the patient to the hospital are to be immediately delivered to the pharmacy to make a positive identification of the medication by verifying the product ’ s physical shape, size, color, and manufacturer ’ s imprinted identification number. If the patient ’ s personal supply of medication is used, the pharmacy shall repackage the medication to allow it to be distributed in unit dose form. A review of facility ’ s policy for Medication Administration, dated 11/2024, indicated the following: Before a medication can be administered, an order must be written by a person lawfully authorized to prescribe. Requirements of medication administration include identifying the following critical steps: right patient, right drug, right dose, right route, and right time. Before administration, the individual administering the medication must verify the medication selected hasn ’ t expired. The nurse must observe the patient taking the medication. Medications are not to be administered to personnel or visitors, except for patient ’ s immediate family with approval of the unit director or charge nurse, after an order has been written by the physician on a prescription and dispensed by the pharmacy – this is to be a one-time order only. Non-Formulary – medications brought into the hospital by the patient may be used if the medication was not available from the pharmacy, if the pharmacist made a positive identification of the drug and re-labeled it in the pharmacy department, if the physician wrote an order authorizing use of the patient ’ s personal supply, and the pharmacy department stored the medications brought in from home by the patient, until the patient is discharged.”

“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: 46333 Based on interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to ensure nursing staff provided patient services in accordance with accepted standards of nursing practice and facility policy for three of 30 sampled patients’ (Patient 21, Patient 26, and Patient 28) intravenous (IV - in the vein) access sites (A point of access to the bloodstream, to move fluids and medications into the body) were not labeled to include the date and time of insertion, and the respective staff member’s initials by the staff to identify who inserted the respective IV catheter in the patient. (Refer to A-0398) This deficient practice may have resulted in negative consequences for Patient 21, Patient 26, and Patient 28, increasing their risks for intravascular catheter related infections. 2. The facility failed to ensure nursing staff provided patient services in accordance with accepted standards of nursing practice and facility policy when a physician’s order for IV insertion and/or removal prior to initiating and discontinuing IV therapy (administration of fluids, medication, and nutrients directly into the bloodstream through a vein) was not obtained for two of 30 sampled patients (Patient 21 & Patient 26). (Refer to A-0398) This deficient practice of performing interventions without a physician’s order could have negatively affected Patient 21 and Patient 26’s safety and overall quality of care received in the facility. 3. The facility failed to ensure nursing staff provided patient services in accordance with accepted standards of nursing practice and facility policy for one of 30 sampled patient’s (Patient 22) permacath (a special catheter used for dialysis, a medical procedure that helps remove extra fluid and waste products from your blood) dressing was not changed within seven days for two consecutive dressing change schedules. (Refer to A-0398) This failure may have resulted in negative consequences for Patient 22, increasing the risk of intravascular catheter-related infections. 4. The facility failed to ensure appropriate nursing care was provided according to accepted standards of practice and facility policy, for one of 30 sampled patients (Patient 24), when Patient 24’s pain level assessment before and after pain medication administration was not completed. This failure had the potential to result in delayed treatment provision to address Patient 24’s acute pain, as well as failure to manage Patient 24’s overall pain adequately to their individualized care needs, both of which could have negatively affected Patient 24’s safety and quality of care received. (Refer to A-0395) 5. The facility failed to ensure Registered Nurse (RN) 25’s documentation in the Pediatric Sepsis Screen (systematic screening is used to enable rapid recognition of sepsis [a life-threatening organ dysfunction caused by the body’s response to infection]) tool for one of thirty (30) sampled patients (Patient 1) with a new-onset fever (sudden rise in a body temperature of 101 degrees Fahrenheit [F, a temperature scale, 38.3 degrees Celsius [C, a temperature scale], the average normal body temperature is generally accepted as 98.6°F [37°C]) and failure to document the name of the attending physician or charge nurse being notified of the\ fever. This deficient practice affects the effectiveness of the sepsis screening tool utilized by the facility to alert health care providers that Patient 1 may be identified as being septic, which is likely to cause a delay in emergent assessment and treatment for Patient 1. (Refer to A-0398) The cumulative effect of these systemic practices resulted in the facility’s inability to ensure the condition of participation for nursing service was met.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to: 1. Ensure 1 of the 3 sampled care areas (NL, North Lobby, an emergency department surge area used when a hospital has reached the point of overcapacity, requiring the hospital to implement a unique process to allow for decompression) that provides services for pediatric patients and adult patients has an accessible pediatric’ s emergency crash cart (cart stocked with emergency medical equipment, supplies, and drugs for use during efforts to resuscitate a patient) that contains pediatric emergency supplies and medicine. This deficient practice poses safety risks for pediatric patients, as essential emergency supplies and guidelines such as the Broselow Tape (the tape relates a child’s height as measured by the tape to their weight to provide medical instructions including medication dosages, the size of the equipment that should be used, and the level of energy when using a defibrillator) for managing pediatric emergencies are not readily available when needed, potentially impacting the quality and timeliness of care provided to pediatric patients in critical situations. 2. Ensure one of three sampled (Restroom 1, in the emergency department overflow area, Hallway 12) restroom destinated for patient use is equipped with an emergency pull cord (part of a communication system where, when pulled, a light outside the bathroom flashes, which notifies a nurse or someone who is around to help the person in need. In addition to the flashing light, a buzzer or tone can be heard). This deficient practice is likely to compromise patient safety in an emergency by delaying access to urgent assistance, hindering the patient’s ability to quickly summon help when needed, which could lead to adverse outcomes when immediate intervention is required. Findings: 1. During a concurrent observation and interview on 6/5/24 at 11:32 a.m. with the Director of Emergency Care Unit (DECU) in the overflow area of the emergency department “North Lobby (NL)” area, NL is located outside of the main emergency department in the front lobby entrance, where four beds are destinated for emergency care. There was a red emergency crash cart station straight ahead from the entrance into the NL. DECU stated, “The crash cart is for adults and pediatrics.” The DECU stated the pediatric Broselow tape should be in the first drawer. When the first drawer was opened by the DECU, there was no Broselow tape for pediatrics, and there were no pediatric medications or supplies. The DECU stated she had mistakenly thought the crash cart contained both adult and pediatric supplies. The DECU stated that the pediatric crash cart is inside the main emergency department. A walk with the DECU to the main emergency department where the pediatric crash cart is station is about 120 feet and requires going through two doors. The DECU shows a different path from the North Lobby to the pediatric crash cart located in the main ED, which requires going through one door and is about 100 feet away. During an interview on 6/7/24 at 4:32 p.m. with the Director of Emergency Department (DED), DED confirmed that the North Lobby surge area services pediatric patients and adult patients. The DED stated the emergency department has one pediatric emergency crash cart located in the main ED and seven adult crash carts. As of today, the facility is working on adding pediatric emergency supplies to the North Lobby area crash cart. During a review of the facility’s policy and procedure (P&P) titled “Emergency Department,” dated June 2023, the P&P indicated that “(Name of the facility) a 41-bed Emergency Department and a Comprehensive Emergency Department licensed within the California State Emergency Medical Services system and is designated as a level 1 trauma center, pediatric trauma center (PTC), certified comprehensive stroke center, pediatric medical center (PMC), and STEMI receiving center by the County of Los Angeles. Within those 41 beds are two trauma/resuscitation bays, eight high-acuity examination/treatment areas, eight acute exam/treatment rooms, two psychiatric beds with adjacent toilet facilities, two orthopedic beds, two gynecological exam rooms, one EYE/ENT/dental room, and a 10-bed ECU emergency care unit for boarding in patients. The ECU volume is often greater than 10, so patients flow out into the main ED and thus become a virtual boarding unit. sees a patient population that falls into the following age groups: neonate (up to 1 month), pediatric (ages 1 month to 12 years), adolescent (13 to 17 years), adult (18 to 65 years), and geriatric (65 years and up), with 51% of the population female and 49% male. During a review of the facility’s “Emergency Department Overflow-Surge Response Plan: Surge Management for ED Patients & in-patients boarding in the ED,” dated February 2023, the surge response plan indicated, “The purpose of this plan is to describe key components, roles, and responsibilities involved in the activation and use of additional Emergency Department space in response to an influx of patients and or back log effects of inadequate patient throughput for the volume of patients presenting to the health system ... Location Set-Up Requirements: Equipment to be deployed prior to initiation of patient care in any dedicated surge location includes, but is not limited to: ...Supply Carts (with dedicated patient care equipment and supplies) ...Emergency resuscitation equipment, to include, but not limited to; airway equipment, ambu-bags, Oxygen supplies, crash cart.” 2. During a concurrent observation and interview on 6/5/24 at 10:45 a.m. with Registered Nurse (RN) 14 in “Hallway 12” of the emergency department surge area, beds line this hallway, and in between the two beds that line this hallway is a restroom. Patient (Patient 31) exiting the restroom and walking to her bed located along Hallway 12. Inside the restroom, there is no emergency pull cord. RN 14 stated, “This is a restroom for the patient’s use.” During an interview on 6/7/24 at 5:45 p.m. with the Safety Officer (SO), SO confirmed the restroom in Hallway 12 did not have an emergency pull cord. The SO confirmed that for safety purposes, restrooms used by patients should be equipped with an emergency pull cord. During a review of the facility’s “Emergency Department Overflow-Surge Response Plan: Surge Management for ED Patients & in-patients boarding in the ED,” dated February 2023, the surge response plan indicated, “The purpose of this plan is to describe key components, roles, and responsibilities involved in the activation and use of additional Emergency Department space in response to an influx of patients and or back log effects of inadequate patient throughput for the volume of patients presenting to the health system. Resource deployment activation: Activation is initiated via paging the necessary parties for set-up as part of the activation process. The following table outlines the departments and responsibilities for set-up of the surge areas ...Office of Environmental Health & Safety to assess set-up for any safety risks and approve set-up prior to use.” During a review of the facility’s policy and procedure (P&P) titled, “Health System Facilities, “dated October 2020, the P&P indicated, “Health System Facilities is responsible for ensuring the hospital’s core building utility systems operate dependably while minimizing risks associated with system failures. The department maintains building finishes throughout the areas the Health System occupies and re¿upholsters or replaces furnishings in public areas as needed. The department responds to both urgent and routine calls, performs required testing, inspections, and maintenance of all core building utility systems and equipment ...The department ensures that the hospital is in compliance with all applicable codes, standards and regulatory agencies associated with the utilities and systems under its responsibility. The department maintains all utilities related documentation required regulatory and licensing agencies ... Nurse Call and Public Address Systems - Ensure the reliability of the nurse call and public address system and engage the services of vendor when needed.””

“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: 50521 Based on observation, interview, and record review, the facility staff failed provide adequate care according to facility policy and procedure as evidence by: 1. The facility failed to ensure three of 30 sampled patients’ (Patient 21, Patient 26, and Patient 28) intravenous (IV - in the vein) access sites (A point of access to the bloodstream, to move fluids and medications into the body) were not labeled to include the date and time of insertion, and the respective staff member’s initials by the staff to identify who inserted the respective IV catheter in the patient. This dificient practice may have resulted in negative consequences for Patient 21, Patient 26, Patient 28, and Patient 22, increasing their risks for intravascular catheter related infections. 2. The facility failed to ensure a physician’s order for IV insertion and/or removal prior to initiating and discontinuing IV therapy (administration of fluids, medication, and nutrients directly into the bloodstream through a vein) was not obtained for two of 30 sampled patients (Patient 21 & Patient 26). This deficient practice of performing interventions without a physician’s order could have negatively affected Patient 21 and Patient 26’s safety and overall quality of care received in the facility. 3. The facility failed to ensure one of 30 sampled patient’s (Patient 22) permacath (a special catheter used for dialysis, a medical procedure that helps remove extra fluid and waste products from your blood) dressing was change within seven days for two consecutive dressing change schedules. This failure may have resulted in negative consequences for Patient 22, increasing the risk of intravascular catheter-related infections. 4. The facility failed to ensure Registered nurse (RN) 25’s document in the Pediatric Sepsis Screen (systematic screening is used to enable rapid recognition of sepsis [a life-threatening organ dysfunction caused by a dysregulated host response to infection]) tool for one of thirty (30) sampled patients (Patient 1) with a new-onset fever (sudden rise in a body temperature of 101 degrees Fahrenheit [F, a temperature scale, 38.3 degrees Celsius [C, a temperature scale], the average normal body temperature is generally accepted as 98.6°F [37°C]) and failure to document the name of the attending physician or charge nurse notified. This deficient practice affects the effectiveness of the sepsis screening tool utilized by the facility to alert health care providers that Patient 1 may be identified as being septic, which is likely to cause a delay in emergent assessment and treatment for Patient 1. Findings: 1a. During a review of Patient 21’s “Patient Care Timeline (PCT),” dated 6/7/2024, the “PCT” indicated, that Patient 21 was triaged (the preliminary assessment of patient to determine the urgency of their need for treatment) for abdominal pain. Patient 21 also had a medical history including coronary artery disease (CAD - a condition that affects the heart making it difficult for arteries to supply the heart with enough blood, oxygen and nutrients), gastroesophageal reflux disease (GERD - a condition in which the stomach contents move up into the esophagus, the passage for food), and hypertension (high blood pressure, a harmful condition in which the blood vessels have persistently raised pressure). During a concurrent observation and interview on 6/5/2024 at 12:23 p.m. with Patient 21, in their assigned room accompanied by their spouse, Patient 21 stated, “My IV catheter was inserted about 45 minutes ago, no one explain the need of the IV.” Patient 21’s right antecubital (AC - antecubital vein located on the front of the elbow joint) peripheral intravenous (IV) dressing was not labeled at the IV catheter site. During an interview on 6/7/2024 at 11:08 a.m. with Registered Nurse 19 (RN 19), RN 19 stated the IV kit supplies included a label that he would use to label the date, time, and his initials when inserting an IV into a patient. RN 19 stated, “When I start an IV, I explain to the patient or explain to the mother in cases of pediatric patient. For the procedure, I will explain the plan of care, is expected I document in nursing care, I will write the plan of care.” RN 19 further stated, “To start an IV, I assess the vein, open supplies in kit, then I label time, date, and initial.” During an interview on 6/7/2024 at 2:56 p.m. with the Nursing Director of Emergency Department (DED), the DED stated, “Labeling an IV is an ideal and label it if they need to.” The DED stated, “If medical doctor (MD), is already asking for IV fluids it is already inferred to start an IV.” During an interview on 6/7/2024 at 4:45 p.m. with the DED, the DED stated, “The IV policy and procedure for the emergency department is the same policy for all patients.” During a review of the facility’s policy and procedure (P&P) titled, “Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116,” dated 4/2024, the P&P indicated, “Peripheral IV site care, A. Label dressing with: date, time, and RN’s/LVN’s initials.” 1b. During a review of Patient 26’s “History and Physical (H&P),” dated 6/5/2024, the “H&P” indicated, Patient 26 was admitted to the facility for emesis (throwing up or vomiting). During an observation on 6/5/2024 at 12:18 p.m. within the facility’s Emergency Department (ED), Patient 26 had an IV catheter site to their right antecubital (AC - antecubital vein located on the front of the elbow joint) with transparent dressing. Patient 26’s transparent dressing did not have a label indicating the date, time, and initial of the staff member who inserted the IV. During a concurrent observation and interview on 6/5/2024 at 12:22 p.m. with Registered Nurse 2 (RN 2), within Patient 26’s room in the facility’s ED, Patient 26’s IV catheter site to their right AC with transparent dressing was observed. RN 2 stated, the patient’s IV sites were not normally labeled in the facility’s ED, but they were labeled within the facility’s Medical-Surgical Departments. During a review of the facility’s policy and procedure (P&P) titled, “Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116,” dated 4/2024, the P&P indicated, “Peripheral IV site care, A. Label dressing with: date, time, and RN’s/LVN’s initials.” 1c. During a review of Patient 28’s “History & Physical (H&P),” dated 6/5/2024, the “H&P” indicated, Patient 28 was admitted to the facility for rhabdomyolysis (medical condition involving the painful breakdown of muscle tissue). During an observation on 6/5/2024 at 11:22 a.m. in Patient 28’s room within the facility’s ED, Patient 28 had an IV catheter site to their right hand, with dressing that was without an IV label indicating the date, time, and initial of the staff member who inserted the IV. During a concurrent observation and interview on 6/5/2024 at 11:25 p.m. with Registered Nurse 3 (RN 3), in Patient 28’s ED room, RN 3 observed Patient 28’s IV site dressing. RN 3 stated, there was typically no need to label IV sites in the ED. During a review of the facility’s policy and procedure (P&P) titled, “Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116,” dated April 2024, the P&P indicated, “Peripheral IV site care, A. Label dressing with: date, time, and RN’s/LVN’s initials.” 2a. During a concurrent interview and record review on 6/7/2024 at 10:23 a.m. with Nursing Informaticist 3 (NI 3) and Nursing Informaticist 4 (NI 4), Patient 21’s “Patient Care Timeline,” dated 6/5/2024 was reviewed. The NI 3 reviewed Patient 21’s “Patient Care Timeline” and indicated there was no physician’s order for the IV insertion and IV removal. The NI 3 stated Patient 21’s medical record was accurate. The NI 3 stated Patient 21’s IV insertion order and IV removal order were not found in Patient 21’s clinical record. During a continued concurrent interview and record review on 6/7/2024 at 10:23 a.m., with the NI 3 and the NI 4, the NI 3 stated, the medical record for Patient 21 included the Registered Nurse (RN) placing Patient 21’s peripheral IV to their right AC, placed on 6/5/2024 at 11:45 a.m. The NI 3 stated, no physician order to start an IV was found in Patient 21’s clinical record. The NI 3 stated, a physician placed an order for IV medication on 6/5/24 at 12:56 p.m. for Patient 21. The NI 3 stated, an RN removed Patient 21’s IV on 6/5/24 at 4:58 p.m. without a physician order for IV removal. During a continued concurrent interview and record review on 6/7/2024 at 10:23 a.m., with the NI 3 and the NI 4, Patient 21’s “Medication Administration Record (MAR),” dated for 6/5/2024 was reviewed. The “MAR” indicated, on 6/5/2024, for a 1:00 p.m. start time, Patient 21 had a physician’s order for Dextrose 5%/0.45% NaCl IV solution bolus (intravenous fluid) 1,000 milliliters (mL, a metric unit of measurement). The “MAR” further indicated, Patient 21 was administered, Dextrose 5%/0.45% NaCl IV solution bolus (intravenous fluid) 1,000 mL IV, on 6/5/2024 at 1:49 p.m. The NI 3 stated, Patient 21 did not have a physician order for an IV catheter insertion in their clinical record. During an interview on 6/7/2024 at 4:45 p.m. with the Nursing Director of Emergency Department (DED), the DED stated, “The IV policy and procedure for the emergency department is the same policy for all patients.” During a review of the facility’s policy and procedure (P&P) titled, “Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116” revised on April 2024, the P&P indicated, “An MD/Designee’s order is required to initiate and discontinue intravenous therapy (administration of fluids, medication, and nutrients directly into the bloodstream through a vein).” 2b. During a concurrent interview and record review on 6/6/2024 at 12:04 p.m. with the Nursing Informaticist 2 (NI 2), Patient 26’s “Patient Care Timeline,” respective to the date of 6/5/2024, was reviewed. The “Patient Care Timeline” for Patient 26 indicated the following: - On 6/5/2025 at 8:00 a.m., Registered Nurse 20 (RN 20) inserted an IV to Patient 26’s right antecubital (AC - antecubital vein located on the front of the elbow joint) without a documented physician’s order. - On 6/5/2024 at 8:26 a.m., Patient 26 received Ondansetron (medication for nausea) 4 mg/2 ml (4 mg) dose via peripheral IV to their right AC. - On 6/5/2024 at 1:24 p.m., Registered Nurse 3 (RN 3) removed Patient 26’s peripheral IV from their right AC upon discharge from the facility, without a documented physician’s order. During a review of the facility’s policy and procedure (P&P) titled, “Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116,” revised April 2024, the P&P indicated, “An MD/Designee’s order is required to initiate and discontinue intravenous therapy (administration of fluids, medication, and nutrients directly into the bloodstream through a vein).” 3). During a review of Patient 22’s “Progress Notes,” dated 4/26/2024, the “Progress Notes” indicated, Patient 22 was admitted to the facility on 2/24/2024 for Cirrhosis (Chronic liver damage) and had a medical history including Chronic Kidney Disease (CKD - long-term disease of the kidneys leading to kidney failure). During a concurrent interview and record review on 6/5/2024 at 3:23 p.m. with the Nursing Informaticist 1 (NI 1), Patient 22’s electronic health record (EHR - patient health information in digital format), dated between 2/24/2024 and 6/5/2024, was reviewed. The EHR indicated, Patient 22 had a dialysis catheter (used for moving blood from the body to a hemodialysis machine, which is used to clean the blood for a person whose kidneys don’t work) placed on 4/26/24 and dressing interventions were initiated. The NI 1 reviewed the documentation and stated, Patient 22’s permacath dressings were changed on the following dates: - 5/7/24 - 5/11/24 - 5/17/24 - 5/25/24 - 6/2/24 For the documented dressing change dates of 5/25/24 and 6/2/24 for Patient 22, these documented dates indicated the dressing were changed upon the eighth day, not by the seventh day. The NI 1 reviewed the documentation for Patient 22 and stated the dressing change dates of 5/25/24 and 6/2/24 indicated the dressing were changed on the eighth day for Patient 22, and not by the seventh day. During a review of Patient 22’s “Invasive Device within Specimen Collection,” dated 5/17/24 through 6/2/24, the “Invasive Device within Specimen Collection” documentation indicated the following dressing interventions in Patient 22’s EHR: - On 5/17/24 at 8:00 p.m., the “dressing intervention” indicated, “Changed” - On 5/25/24 at 11:50 a.m., the “dressing intervention” indicated, “Changed” - On 6/2/24 at 1:00 a.m., the “dressing intervention” indicated, “Changed” During a review of Patient 22’s “Summary within the Index,” dated 6/1/2024, the documentation indicated, dressing was change on the 8th day instead of 7 days. During an interview on 6/5/24 at 4:15 p.m. with Registered Nurse 4 (RN 4), RN 4 stated, for permacath dressings, it was expected for the dressings to be changed as needed but must have been within seven days. During an interview on 6/6/24 at 10:34 a.m. with the Clinical Nurse Specialist 1 (CNS 1), the CNS 1 stated the following: - Transparent (clear) dressings that were clean, dry, and intact were good for seven days, and gauze (very thin cloth to cover skin wounds) dressings were good for 48 hours (2 days). - It was important to not to go beyond seven days, per national and CDC guidelines (Center for Disease Control and Prevention, a national authority on infection and disease control) to prevent CLABSI (Central Line Associated Blood Stream Infection - occurs when bacteria or other germs enter the patient’s central line and into the bloodstream, causing a dangerous infection). During a review of the facility’s policy and procedure (P&P) titled, “Central Venous Catheter Care, Nur-HS 104”, revised in January 2024, the P&P indicated, “Dressing change frequency: sterile gauze and tape - change at least every 2 days. Sterile transparent dressing - change at least every 7 days.” 4.During a review of patient 1’s “History and Physical (H&P),” dated 4/9/24, the “H&P” indicated Patient 1 is a four-years-old who presented with mother to the emergency department complaining of a fever associated with diarrhea and vomiting episodes. Patient 1 is receiving care for relapsed Juvenile myelomonocytic leukemia (JMML, a rare cancer of the blood that affects young children). The H&P further indicated Patient 1 is immunosuppression (suppression of the body’s immune system and its ability to fight infections and other diseases). During a concurrent interview and record review on 6/6/24 at 2:28 p.m. with Clinical Nurse specialist (CNS) 3, Patient 1’s flow sheet (electronic health records contain a large volume of data about patient assessments and interventions) dated from 2/3/24 through 2/10/24 was reviewed, the flowsheet indicated Patient 1 did not have an ongoing or sustain fever from 2/3/24 through 2/8/24. On 2/9/24 at 10:00 a.m. Patient 1 started having a fever of 39.1 Celsius (102.38 Fahrenheit) and continues to have fever until 2/10/24. CNS 3 stated there was no documentation of Patient 1 onset of fever was communicated to the physician. During a concurrent interview and record review on 6/6/24 at 3:35 p.m. with CNS 3, Patient 1’s Pediatric Sepsis Screen dated 2/9/24 indicated Patient 1’s meets two criteria indicated in the sepsis screen, which were tachycardia (high heart rate) and a fever of 39.1 Celsius (102.38 Fahrenheit). However, the CNS stated the fever was not entered into the Pediatric Sepsis Screen (systematic screening used to enable rapid recognition of sepsis, a life-threatening organ dysfunction caused by a dysregulated host response to infection), and all other criteria were left blank, such as question number two (2), which indicated, “Does the patient have suspected bacterial infection?” CNS 3 also stated the high temperature should be entered into the sepsis screen as the temperature is one of the criteria that would trigger the sepsis alert. During a concurrent interview and record review on 6/6/24 at 3:40 p.m. with CNS 3, Patient 1’s electronic medical record under physician orders dated 2/9/24 was reviewed, an order was entered at 5:11 p.m., for blood culture (blood collected to test for systemic infection), over seven (7) hours after Patient 1 has a fever of 39.1 Celsius. During a review of the physician note titled, “Significant Event,” dated 2/9/24, the P&P indicated, “Date and Time of Rapid Response: 2/9/2024 at 8:16 PM ...Tonight, RRT (Rapid Response Team, a team deployed to treat a patient when the patient demonstrates signs of imminent clinical deterioration) called for persistent tachycardia (an abnormally fast heartbeat), fever, and new development of hypotension (decrease in blood pressure below accepted low values) Per primary team, patient developed fever today ...” During a review of the facility’s Sepsis/PICU (pediatric intensive care unit): Sepsis, Care Plan, undated, indicated, “Febrile episodes: Send blood, urine, sputum, or wound cultures per MD order and administer cooling measures.” During a review of the facility’s Pediatric Sepsis Screen tool, undated, indicated the following. 1. Two (2) or more new signs of SIRS or organ dysfunction? o Temp greater than 38 or less than 36 Celsius o Tachycardia (Heart Rate greater than 130) o Tachypnea (abnormally rapid breathing) or need for supplemental oxygen (respiratory rate [the number of breaths per minute] greater than 18) o Hypotension (Systolic blood pressure less than 105) o AMS, altered mental status (lethargic [sluggish, having little energy], irritable, confuse) o Delay capillary refill (length of time it takes for the fingernail’s bed to regain its color after pressure has been applied) for less than 2 seconds. o Cool/mottled (skin covered with areas of different colors that do not form a regular pattern) or flushes/ruddy (sudden reddening of the face, neck, or upper chest due to increased blood flow) skin. o None 2. Does the patient have a suspected bacterial infection ... 3. If YES, you must document intervention. 4. Name of Attending or Charge RN (Registered Nurse) During a review of the facility’s adopted policy and procedure (P&P) titled “Pediatric Sepsis: International Guidelines for Management of Septic shock and Sepsis-Associated Organ Dysfunction in children (2020),” dated 10/1/20, the guideline indicated, “Children with sepsis and septic shock require emergent assessment and treatment, with frequent reevaluation of their response to treatment. Institute systematic screening for sepsis, because early recognition leads to prompt treatment and improves outcomes. The guideline does not recommend an optimal screening tool, and instead suggests adapting screening tools to the type of patients, resources, and processes particular to each facility. Obtain blood cultures before initiating antibiotic therapy, provided this will not substantially delay antibiotic administration. The guideline is intended for children (ranging in age from at least 37 weeks’ gestation or greater at birth to 18 years) with septic shock or sepsis-associated organ dysfunction” (Lippincott 2024). During a review of the facility’s policy and procedure (P&P) titled, “Documentation of Patient Care.” dated August 2023, the P&P indicated, “The purpose of this policy is to establish the requirements and responsibilities for the documentation of nursing care in the inpatient medical record in compliance with professional nursing and regulatory standard. All nursing personnel are responsible for documenting patient care provided in the EHR ...The frequency of documentation is driven by physician/designee orders, policies, guidelines, patient condition, level of care, unit standards, and nursing judgment. Documentation of patient care is to be completed on a timely and ongoing basis throughout the shift to ensure patient safety ... Registered Nurses - All CCP and LVN documentation responsibilities in addition to the following ... Nursing interventions and patient progress toward the goals will be reflected in EHR flowsheets, nursing documentation in the Notes, Treatments, End of Shift Summary and other appropriate related Flowsheets.””

“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: 46333 Based on observation, interview, and record review, the facility staff failed provide adequate care according to facility policy and procedure as evidence by: 1. The facility failed to ensure three of 30 sampled patients’ (Patient 21, Patient 26, and Patient 28) intravenous (IV - in the vein) access sites (A point of access to the bloodstream, to move fluids and medications into the body) were not labeled to include the date and time of insertion, and the respective staff member’s initials by the staff to identify who inserted the respective IV catheter in the patient. This dificient practice may have resulted in negative consequences for Patient 21, Patient 26, Patient 28, and Patient 22, increasing their risks for intravascular catheter related infections. 2. The facility failed to ensure a physician’s order for IV insertion and/or removal prior to initiating and discontinuing IV therapy (administration of fluids, medication, and nutrients directly into the bloodstream through a vein) was not obtained for two of 30 sampled patients (Patient 21 & Patient 26). This deficient practice of performing interventions without a physician’s order could have negatively affected Patient 21 and Patient 26’s safety and overall quality of care received in the facility. 3. The facility failed to ensure one of 30 sampled patient’s (Patient 22) permacath (a special catheter used for dialysis, a medical procedure that helps remove extra fluid and waste products from your blood) dressing was change within seven days for two consecutive dressing change schedules. This failure may have resulted in negative consequences for Patient 22, increasing the risk of intravascular catheter-related infections. 4. The facility failed to ensure Registered nurse (RN) 25’s document in the Pediatric Sepsis Screen (systematic screening is used to enable rapid recognition of sepsis [a life-threatening organ dysfunction caused by a dysregulated host response to infection]) tool for one of thirty (30) sampled patients (Patient 1) with a new-onset fever (sudden rise in a body temperature of 101 degrees Fahrenheit [F, a temperature scale, 38.3 degrees Celsius [C, a temperature scale], the average normal body temperature is generally accepted as 98.6°F [37°C]) and failure to document the name of the attending physician or charge nurse notified. This deficient practice affects the effectiveness of the sepsis screening tool utilized by the facility to alert health care providers that Patient 1 may be identified as being septic, which is likely to cause a delay in emergent assessment and treatment for Patient 1. Findings: 1a. During a review of Patient 21’s “Patient Care Timeline (PCT),” dated 6/7/2024, the “PCT” indicated, that Patient 21 was triaged (the preliminary assessment of patient to determine the urgency of their need for treatment) for abdominal pain. Patient 21 also had a medical history including coronary artery disease (CAD - a condition that affects the heart making it difficult for arteries to supply the heart with enough blood, oxygen and nutrients), gastroesophageal reflux disease (GERD - a condition in which the stomach contents move up into the esophagus, the passage for food), and hypertension (high blood pressure, a harmful condition in which the blood vessels have persistently raised pressure). During a concurrent observation and interview on 6/5/2024 at 12:23 p.m. with Patient 21, in their assigned room accompanied by their spouse, Patient 21 stated, “My IV catheter was inserted about 45 minutes ago, no one explain the need of the IV.” Patient 21’s right antecubital (AC - antecubital vein located on the front of the elbow joint) peripheral intravenous (IV) dressing was not labeled at the IV catheter site. During an interview on 6/7/2024 at 11:08 a.m. with Registered Nurse 19 (RN 19), RN 19 stated the IV kit supplies included a label that he would use to label the date, time, and his initials when inserting an IV into a patient. RN 19 stated, “When I start an IV, I explain to the patient or explain to the mother in cases of pediatric patient. For the procedure, I will explain the plan of care, is expected I document in nursing care, I will write the plan of care.” RN 19 further stated, “To start an IV, I assess the vein, open supplies in kit, then I label time, date, and initial.” During an interview on 6/7/2024 at 2:56 p.m. with the Nursing Director of Emergency Department (DED), the DED stated, “Labeling an IV is an ideal and label it if they need to.” The DED stated, “If medical doctor (MD), is already asking for IV fluids it is already inferred to start an IV.” During an interview on 6/7/2024 at 4:45 p.m. with the DED, the DED stated, “The IV policy and procedure for the emergency department is the same policy for all patients.” During a review of the facility’s policy and procedure (P&P) titled, “Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116,” dated 4/2024, the P&P indicated, “Peripheral IV site care, A. Label dressing with: date, time, and RN’s/LVN’s initials.” 1b. During a review of Patient 26’s “History and Physical (H&P),” dated 6/5/2024, the “H&P” indicated, Patient 26 was admitted to the facility for emesis (throwing up or vomiting). During an observation on 6/5/2024 at 12:18 p.m. within the facility’s Emergency Department (ED), Patient 26 had an IV catheter site to their right antecubital (AC - antecubital vein located on the front of the elbow joint) with transparent dressing. Patient 26’s transparent dressing did not have a label indicating the date, time, and initial of the staff member who inserted the IV. During a concurrent observation and interview on 6/5/2024 at 12:22 p.m. with Registered Nurse 2 (RN 2), within Patient 26’s room in the facility’s ED, Patient 26’s IV catheter site to their right AC with transparent dressing was observed. RN 2 stated, the patient’s IV sites were not normally labeled in the facility’s ED, but they were labeled within the facility’s Medical-Surgical Departments. During a review of the facility’s policy and procedure (P&P) titled, “Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116,” dated 4/2024, the P&P indicated, “Peripheral IV site care, A. Label dressing with: date, time, and RN’s/LVN’s initials.” 1c. During a review of Patient 28’s “History & Physical (H&P),” dated 6/5/2024, the “H&P” indicated, Patient 28 was admitted to the facility for rhabdomyolysis (medical condition involving the painful breakdown of muscle tissue). During an observation on 6/5/2024 at 11:22 a.m. in Patient 28’s room within the facility’s ED, Patient 28 had an IV catheter site to their right hand, with dressing that was without an IV label indicating the date, time, and initial of the staff member who inserted the IV. During a concurrent observation and interview on 6/5/2024 at 11:25 p.m. with Registered Nurse 3 (RN 3), in Patient 28’s ED room, RN 3 observed Patient 28’s IV site dressing. RN 3 stated, there was typically no need to label IV sites in the ED. During a review of the facility’s policy and procedure (P&P) titled, “Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116,” dated April 2024, the P&P indicated, “Peripheral IV site care, A. Label dressing with: date, time, and RN’s/LVN’s initials.” 2a. During a concurrent interview and record review on 6/7/2024 at 10:23 a.m. with Nursing Informaticist 3 (NI 3) and Nursing Informaticist 4 (NI 4), Patient 21’s “Patient Care Timeline,” dated 6/5/2024 was reviewed. The NI 3 reviewed Patient 21’s “Patient Care Timeline” and indicated there was no physician’s order for the IV insertion and IV removal. The NI 3 stated Patient 21’s medical record was accurate. The NI 3 stated Patient 21’s IV insertion order and IV removal order were not found in Patient 21’s clinical record. During a continued concurrent interview and record review on 6/7/2024 at 10:23 a.m., with the NI 3 and the NI 4, the NI 3 stated, the medical record for Patient 21 included the Registered Nurse (RN) placing Patient 21’s peripheral IV to their right AC, placed on 6/5/2024 at 11:45 a.m. The NI 3 stated, no physician order to start an IV was found in Patient 21’s clinical record. The NI 3 stated, a physician placed an order for IV medication on 6/5/24 at 12:56 p.m. for Patient 21. The NI 3 stated, an RN removed Patient 21’s IV on 6/5/24 at 4:58 p.m. without a physician order for IV removal. During a continued concurrent interview and record review on 6/7/2024 at 10:23 a.m., with the NI 3 and the NI 4, Patient 21’s “Medication Administration Record (MAR),” dated for 6/5/2024 was reviewed. The “MAR” indicated, on 6/5/2024, for a 1:00 p.m. start time, Patient 21 had a physician’s order for Dextrose 5%/0.45% NaCl IV solution bolus (intravenous fluid) 1,000 milliliters (mL, a metric unit of measurement). The “MAR” further indicated, Patient 21 was administered, Dextrose 5%/0.45% NaCl IV solution bolus (intravenous fluid) 1,000 mL IV, on 6/5/2024 at 1:49 p.m. The NI 3 stated, Patient 21 did not have a physician order for an IV catheter insertion in their clinical record. During an interview on 6/7/2024 at 4:45 p.m. with the Nursing Director of Emergency Department (DED), the DED stated, “The IV policy and procedure for the emergency department is the same policy for all patients.” During a review of the facility’s policy and procedure (P&P) titled, “Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116” revised on April 2024, the P&P indicated, “An MD/Designee’s order is required to initiate and discontinue intravenous therapy (administration of fluids, medication, and nutrients directly into the bloodstream through a vein).” 2b. During a concurrent interview and record review on 6/6/2024 at 12:04 p.m. with the Nursing Informaticist 2 (NI 2), Patient 26’s “Patient Care Timeline,” respective to the date of 6/5/2024, was reviewed. The “Patient Care Timeline” for Patient 26 indicated the following: - On 6/5/2025 at 8:00 a.m., Registered Nurse 20 (RN 20) inserted an IV to Patient 26’s right antecubital (AC - antecubital vein located on the front of the elbow joint) without a documented physician’s order. - On 6/5/2024 at 8:26 a.m., Patient 26 received Ondansetron (medication for nausea) 4 mg/2 ml (4 mg) dose via peripheral IV to their right AC. - On 6/5/2024 at 1:24 p.m., Registered Nurse 3 (RN 3) removed Patient 26’s peripheral IV from their right AC upon discharge from the facility, without a documented physician’s order. During a review of the facility’s policy and procedure (P&P) titled, “Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116,” revised April 2024, the P&P indicated, “An MD/Designee’s order is required to initiate and discontinue intravenous therapy (administration of fluids, medication, and nutrients directly into the bloodstream through a vein).” 3). During a review of Patient 22’s “Progress Notes,” dated 4/26/2024, the “Progress Notes” indicated, Patient 22 was admitted to the facility on 2/24/2024 for Cirrhosis (Chronic liver damage) and had a medical history including Chronic Kidney Disease (CKD - long-term disease of the kidneys leading to kidney failure). During a concurrent interview and record review on 6/5/2024 at 3:23 p.m. with the Nursing Informaticist 1 (NI 1), Patient 22’s electronic health record (EHR - patient health information in digital format), dated between 2/24/2024 and 6/5/2024, was reviewed. The EHR indicated, Patient 22 had a dialysis catheter (used for moving blood from the body to a hemodialysis machine, which is used to clean the blood for a person whose kidneys don’t work) placed on 4/26/24 and dressing interventions were initiated. The NI 1 reviewed the documentation and stated, Patient 22’s permacath dressings were changed on the following dates: - 5/7/24 - 5/11/24 - 5/17/24 - 5/25/24 - 6/2/24 For the documented dressing change dates of 5/25/24 and 6/2/24 for Patient 22, these documented dates indicated the dressing were changed upon the eighth day, not by the seventh day. The NI 1 reviewed the documentation for Patient 22 and stated the dressing change dates of 5/25/24 and 6/2/24 indicated the dressing were changed on the eighth day for Patient 22, and not by the seventh day. During a review of Patient 22’s “Invasive Device within Specimen Collection,” dated 5/17/24 through 6/2/24, the “Invasive Device within Specimen Collection” documentation indicated the following dressing interventions in Patient 22’s EHR: - On 5/17/24 at 8:00 p.m., the “dressing intervention” indicated, “Changed” - On 5/25/24 at 11:50 a.m., the “dressing intervention” indicated, “Changed” - On 6/2/24 at 1:00 a.m., the “dressing intervention” indicated, “Changed” During a review of Patient 22’s “Summary within the Index,” dated 6/1/2024, the documentation indicated, dressing was change on the 8th day instead of 7 days. During an interview on 6/5/24 at 4:15 p.m. with Registered Nurse 4 (RN 4), RN 4 stated, for permacath dressings, it was expected for the dressings to be changed as needed but must have been within seven days. During an interview on 6/6/24 at 10:34 a.m. with the Clinical Nurse Specialist 1 (CNS 1), the CNS 1 stated the following: - Transparent (clear) dressings that were clean, dry, and intact were good for seven days, and gauze (very thin cloth to cover skin wounds) dressings were good for 48 hours (2 days). - It was important to not to go beyond seven days, per national and CDC guidelines (Center for Disease Control and Prevention, a national authority on infection and disease control) to prevent CLABSI (Central Line Associated Blood Stream Infection - occurs when bacteria or other germs enter the patient’s central line and into the bloodstream, causing a dangerous infection). During a review of the facility’s policy and procedure (P&P) titled, “Central Venous Catheter Care, Nur-HS 104”, revised in January 2024, the P&P indicated, “Dressing change frequency: sterile gauze and tape - change at least every 2 days. Sterile transparent dressing - change at least every 7 days.” 4.During a review of patient 1’s “History and Physical (H&P),” dated 4/9/24, the “H&P” indicated Patient 1 is a four-years-old who presented with mother to the emergency department complaining of a fever associated with diarrhea and vomiting episodes. Patient 1 is receiving care for relapsed Juvenile myelomonocytic leukemia (JMML, a rare cancer of the blood that affects young children). The H&P further indicated Patient 1 is immunosuppression (suppression of the body’s immune system and its ability to fight infections and other diseases). During a concurrent interview and record review on 6/6/24 at 2:28 p.m. with Clinical Nurse specialist (CNS) 3, Patient 1’s flow sheet (electronic health records contain a large volume of data about patient assessments and interventions) dated from 2/3/24 through 2/10/24 was reviewed, the flowsheet indicated Patient 1 did not have an ongoing or sustain fever from 2/3/24 through 2/8/24. On 2/9/24 at 10:00 a.m. Patient 1 started having a fever of 39.1 Celsius (102.38 Fahrenheit) and continues to have fever until 2/10/24. CNS 3 stated there was no documentation of Patient 1 onset of fever was communicated to the physician. During a concurrent interview and record review on 6/6/24 at 3:35 p.m. with CNS 3, Patient 1’s Pediatric Sepsis Screen dated 2/9/24 indicated Patient 1’s meets two criteria indicated in the sepsis screen, which were tachycardia (high heart rate) and a fever of 39.1 Celsius (102.38 Fahrenheit). However, the CNS stated the fever was not entered into the Pediatric Sepsis Screen (systematic screening used to enable rapid recognition of sepsis, a life-threatening organ dysfunction caused by a dysregulated host response to infection), and all other criteria were left blank, such as question number two (2), which indicated, “Does the patient have suspected bacterial infection?” CNS 3 also stated the high temperature should be entered into the sepsis screen as the temperature is one of the criteria that would trigger the sepsis alert. During a concurrent interview and record review on 6/6/24 at 3:40 p.m. with CNS 3, Patient 1’s electronic medical record under physician orders dated 2/9/24 was reviewed, an order was entered at 5:11 p.m., for blood culture (blood collected to test for systemic infection), over seven (7) hours after Patient 1 has a fever of 39.1 Celsius. During a review of the physician note titled, “Significant Event,” dated 2/9/24, the P&P indicated, “Date and Time of Rapid Response: 2/9/2024 at 8:16 PM ...Tonight, RRT (Rapid Response Team, a team deployed to treat a patient when the patient demonstrates signs of imminent clinical deterioration) called for persistent tachycardia (an abnormally fast heartbeat), fever, and new development of hypotension (decrease in blood pressure below accepted low values) Per primary team, patient developed fever today ...” During a review of the facility’s Sepsis/PICU (pediatric intensive care unit): Sepsis, Care Plan, undated, indicated, “Febrile episodes: Send blood, urine, sputum, or wound cultures per MD order and administer cooling measures.” During a review of the facility’s Pediatric Sepsis Screen tool, undated, indicated the following. 1. Two (2) or more new signs of SIRS or organ dysfunction? o Temp greater than 38 or less than 36 Celsius o Tachycardia (Heart Rate greater than 130) o Tachypnea (abnormally rapid breathing) or need for supplemental oxygen (respiratory rate [the number of breaths per minute] greater than 18) o Hypotension (Systolic blood pressure less than 105) o AMS, altered mental status (lethargic [sluggish, having little energy], irritable, confuse) o Delay capillary refill (length of time it takes for the fingernail’s bed to regain its color after pressure has been applied) for less than 2 seconds. o Cool/mottled (skin covered with areas of different colors that do not form a regular pattern) or flushes/ruddy (sudden reddening of the face, neck, or upper chest due to increased blood flow) skin. o None 2. Does the patient have a suspected bacterial infection ... 3. If YES, you must document intervention. 4. Name of Attending or Charge RN (Registered Nurse) During a review of the facility’s adopted policy and procedure (P&P) titled “Pediatric Sepsis: International Guidelines for Management of Septic shock and Sepsis-Associated Organ Dysfunction in children (2020),” dated 10/1/20, the guideline indicated, “Children with sepsis and septic shock require emergent assessment and treatment, with frequent reevaluation of their response to treatment. Institute systematic screening for sepsis, because early recognition leads to prompt treatment and improves outcomes. The guideline does not recommend an optimal screening tool, and instead suggests adapting screening tools to the type of patients, resources, and processes particular to each facility. Obtain blood cultures before initiating antibiotic therapy, provided this will not substantially delay antibiotic administration. The guideline is intended for children (ranging in age from at least 37 weeks’ gestation or greater at birth to 18 years) with septic shock or sepsis-associated organ dysfunction” (Lippincott 2024). During a review of the facility’s policy and procedure (P&P) titled, “Documentation of Patient Care.” dated August 2023, the P&P indicated, “The purpose of this policy is to establish the requirements and responsibilities for the documentation of nursing care in the inpatient medical record in compliance with professional nursing and regulatory standard. All nursing personnel are responsible for documenting patient care provided in the EHR ...The frequency of documentation is driven by physician/designee orders, policies, guidelines, patient condition, level of care, unit standards, and nursing judgment. Documentation of patient care is to be completed on a timely and ongoing basis throughout the shift to ensure patient safety ... Registered Nurses - All CCP and LVN documentation responsibilities in addition to the following ... Nursing interventions and patient progress toward the goals will be reflected in EHR flowsheets, nursing documentation in the Notes, Treatments, End of Shift Summary and other appropriate related Flowsheets.””

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 46333 Based on interviews and record reviews, the facility’s medical staff failed to assume responsibility for implementing and monitoring the facility’s medical staff services. The facility’s medical staff failed to provide oversight for the quality health care provided to patients by the hospital. The facility did not meet the conditions for coverage for medical staff and management by failing to: 1. Ensure one of the three sampled physicians (MD 2), who was the cardiologist on-call for Patient 1 on 12/8/24, documented Patient 1s assessment in the medical record.’ This deficient practice of omitting documentation may result in a lack of crucial information for safe discharge, potential miscommunication among healthcare providers, and compromised patient safety. (Refer to A-360.) 2. Ensure one of the three sampled physician credential records (MD 1) had the approved clinical privileges (authorization to a medical staff member to provide medical services granted by a governing authority or according to medical staff bylaws [define the structure and responsibilities of these member organizations]) on file. This deficient practice has the potential to impact patient care and lead to unsafe practices. Without the correct privileges documented, physicians may be allowed to perform procedures or make decisions outside their expertise, increasing the risk of medical errors and misdiagnoses, compromising the quality of care provided, and compromising patient safety. (Refer to A-341.) The cumulative effect of these systemic practices resulted in the facility’s inability to ensure the medical staff had oversight and accountability for the quality of medical care provided to patients by the hospital.”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 46333 Based on the interview and record review, the facility failed to ensure one of the three sampled physician credential records (MD 1) had the approved clinical privileges (authorization to a medical staff member to provide medical services granted by a governing authority or according to medical staff bylaws [define the structure and responsibilities of these member organizations]) on file. This deficient practice has the potential to impact patient care and lead to unsafe practices. Without the correct privileges documented, physicians may be allowed to perform procedures or make decisions outside their expertise, increasing the risk of medical errors and misdiagnoses, compromising the quality of care provided, and compromising patient safety. Findings: During a concurrent interview and record review on 5/2/24 at 9:55 a.m. with the Manager of Medical Staff (MMS), MD 1’s “Delineation of Privileges (the practice of listing specific granted to provide medical and other patient care procedures and services that a provider is allowed to perform within an organization),” provisional appointment (the employment of a person to a vacant position for a specify period of time) dated 7/31/23 through 7/31/25 was reviewed. The Delineation of Privileges form indicated that MD 1 was approved for the following: “Anesthesiology core: A core privilege is granted to physicians who are qualified by training to render patients insensible (lacking sensory perception or ability to react) to pain and stress during surgical, obstetrical (relating to childbirth and the processes associated with it), radiological (a branch of medicine that uses imaging technology to diagnose and treat disease), and certain medical procedures using general anesthesia (medicine that is administered by an anesthesiologist, to eliminate all sensations, accompanied by total loss of consciousness as well as loss of the ability to maintain a functional airway). Category Core privileges include conscious (sedation that the patient stay awake and aware without feeling discomfort) and deep sedation (induced depression of consciousness during which patients cannot be easily aroused but respond purposefully) for anesthesiologists (a physician who evaluates, monitors, and supervises patient care before, during, and after surgery, delivering anesthesia). The Delineation of Privileges form also indicated MD 1 is on proctor (an objective evaluation of a provider’s clinical competence by someone serving as a proctor who represents and is responsible to the medical staff) for the following: Proctor: Pediatric Anesthesia, Ages < 12 Years Proctor, Level I: Healthy greater than or equal to 2 years. of age; complex and critically ill greater than or equal to 6 years of age.” MMS stated, “MD 4 is overseeing MD 1. MD 4 will cosign MD 1’s note (the physician’s note).” During a concurrent interview and record review on 5/2/24 at 12:21 p.m. with the physician anesthesiologist (MD 1), Patient 1’s “Anesthesia Post Procedure Handoff Report (the transfer of information, responsibility, and authority from one provider to another in health care),” dated 12/8/23, was reviewed. The report indicated that on 12/8/23, Patient 1, who was a 7-month-old pediatric patient with a medical history of Tetralogy of Fallot (a congenital heart condition that affects normal blood flow through the heart), was administered general anesthesia by MD 1. MD1 confirmed that on 12/8/23, he was the physician anesthesiologist for Patient 1. The Anesthesia Post-Procedure Handoff Report was not co-signed by MD 4. During a concurrent interview and record review on 5/2/24 at 1:07 p.m. with the MMS, the Anesthesiology Service Privilege Delineation Form” was reviewed. MMS stated MD1 “has a recommendation for pediatric level 3 privilege, but we recorded as level 1; it is a recording error on our part; we had marked the wrong privilege.” MMS stated Level 1 privileging may care for healthy less than or equal to 2 years of age, complex and critically ill older than or equal to 6 years of age. For privilaging at level 3, the physician can care for infants and children of all ages that are healthy, complex and critically ill. MMS stated MD 1 is recommended for level 3 privileges, but he must complete the requirements for proctoring. MMS stated the requirement is to complete five (5) general anesthesia cases and two (2) pediatric anesthesia cases. MMS stated that MD 1 completed the 5 cases but did not complete the 2 cases. MMS stated, “The 2 cases had to be specific cases, to the age group, healthy, complex, and critically ill infants and children of all ages.” During a concurrent interview and record review on 5/2/24 at 2:20 p.m. with the Accreditation Specialist (ACS), the ACS stated MD 1 had completed all 7 cases as required by level 3 privileges. The facility was able to locate the two (2) cases completed, titled “Anesthesiology Pediatric Anesthesia Proctoring Form,” dated 8/30/23 and 8/31/23. The ACS confirmed the two forms were in MD 4 possession; the two forms were not in the medical credential files kept by the Medical Staff Administration. During an interview on 5/2/24 at 4:17 p.m. with the Chief Medical of Anesthesiology (MD) 5, the MD 5 stated that the anesthesiologist in proctorship may perform procedures and does not require the signature of the attending physician for their physician’s note. During a review of the facility’s “Medical Staff Bylaws,” dated 2023, the Medical Staff Bylaws indicated, under section Clinical Privileges, “The Governing Body may grant clinical privileges upon the recommendation of the Medical Staff Executive Committee, the Credentials Committee, and the Service Chief(s) (or Designee(s) in which the practitioner holds appointment. These privileges generally shall be for two years to coincide with the appointment term for the medical staff. Privileges for each Medical Staff member shall be kept on file by Medical Staff Administration and available to the Medical Center by intranet access.””

“MEDICAL STAFF RESPONSIBILITIES - ASSESSMENT CFR(s): An assessment of the patient (in lieu of the requirements of paragraphs (c)(5)(i) and (ii) of this section) be completed and documented after registration, but prior to surgery or a procedure requiring anesthesia services, when the patient is receiving specific outpatient surgical or procedural services and when the medical staff has chosen to develop and maintain a policy that identifies, in accordance with the requirements at paragraph (c)(5)(v) of this section, specific patients as not requiring a comprehensive medical history and physical examination, or any update to it, prior to specific outpatient surgical or procedural services. The assessment must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure one of the three sampled physician (MD 2), who was the cardiologist on-call for Patient 1, documented Patient 1’s assessment in the medical record. This deficient practice of omitting documentation may result in a lack of crucial information for safe discharge, and potential miscommunication among healthcare providers, and compromised patient safety. Findings: During a review of Patient 1’s “Progress Notes,” dated 12/7/24, the “Progress Notes” indicated that Patient 1 “is 7 months old and is being seen in a cardiology (a branch of medicine that specializes in diagnosing and treating diseases of the heart, blood vessels, and circulatory system) clinic after hospital follow-up. History includes T21 (Down syndrome, trisomy 21 is a genetic condition caused by an extra chromosome [a structure found inside the cell]), right cerebellar hypoplasia (condition in which the part of the brain that coordinates movement-is smaller than usual or not completely developed), atrioventricular septal defect (AVSD, a heart defect in which there are holes between the chambers of the right and left sides of the heart, and the valves that control the flow of blood between these chambers may not be formed correctly). Will need a CT (computed tomography, a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) or MRI (A procedure that uses radio waves, a powerful magnet, and a computer to make a series of detailed pictures of areas inside the body) the MRI is scheduled for tomorrow morning. Otherwise, no changes. No change in respiratory status (how well a patient is breathing); no diaphoresis (excessive sweating due to a secondary condition); energy level unchanged ...mom checks saturations (measurement of how much oxygen the blood is carrying as a percentage of the maximum it could carry) at home daily. Saturations remain in the low 80’s on 1 L 02 (one liter of oxygen), decrease off supplemental 02 (oxygen) ...noisy breathing and needs a lot of suctioning, but is consistent with baseline (an initial measurement of a condition that is taken at an early time point and used for comparison over time to look for changes) ...” During a review of Patient 1’s “MR (Magnetic resonance angiography, a powerful magnetic field, radio waves and a computer to specifically evaluate the body’s blood vessels) WO (without) + W (with) contrast (drugs administered to patients to enhance the ability to see blood vessels and organs),” dated 12/8/23, by MD 6, the MR report indicated, “Reason for Exam: 6 month old female patient with history of Tetralogy Fallot (a combination of four heart changes present at birth. There is a hole in the heart) and Blalock shunt (a small, soft tube that lets blood in the body be redirected). Evaluate for pulmonary artery (blood vessels that carry oxygen-poor blood from the right side of your heart to your lungs) anatomy (the identification and description of the structures of living things) and intracardiac (situated or occurring within or introduced or involving entry into the heart) anatomy. The study was performed on a (name of the scanner) MRI scanner at (name of the facility), under uneventful general anesthesia (medicine that is administered by an anesthesiologist, to eliminate all sensations, accompanied by total loss of consciousness as well as loss of the ability to maintain a functional airway). with controlled ventilation (a mode of ventilation in which the respirator delivers the preset volume or pressure regardless of the patient’s own inspiratory efforts) ...” During a concurrent interview and record review on 5/2/24 at 4:26 p.m. with the Anesthesiologist Resident (MD 3), Patient 1’s “Anesthesia Post Procedure Evaluation,” dated 12/8/23, was reviewed. The anesthesia post-procedure evaluation indicated, “Arrived in PACU with frank upper airway obstruction (occlusion or narrowing of the airways leading to compromise in ventilation), mild retractions (a sign that someone is working hard to breathe), placed on an HFNC (high-flow nasal cannula, an oxygen supply system capable of delivering up to 100% humidified and heated oxygen at a flow rate of up to 60 liters per minute). Weaned down to baseline 2LNC (two liters [unit of volume measurement]) nasal cannula [a device that gives additional oxygen through the nose] with SpO2 (a measurement of how much oxygen the blood is carrying as a percentage of the maximum it could carry): 70-80% as assessed by the peds cardiology hospitalist.” MD 3 stated although her notes on 12/8/23 indicated that the cardiologist assessed the patient (Patient 1) the cardiologist “did not put in a note.” During an interview on 5/2/24 at 3:00 p.m. with the Chief Medical of Anesthesiologist (MD) 5, MD 5 stated after the cardiologist examine the patient (Patient 1) there should be documentation of the assessment. During a review of the facility’s Medical Staff Bylaws dated 2023, the Medical Staff Bylaws indicated, “To supervise and ensure compliance with these Bylaws, Rules and Regulations, Medical Staff Policies, and Medical Center policies to carry out its responsibilities for patient safety and the professional work performed in the Hospital, pursuant to the authority delegated by the Governing Body.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46333 Based on observation, interview and record review, the facility failed to ensure that the Condition of Participation for Patient’s Rights was met as evidenced by: 1. The facility failed to ensure one (1) of thirty sampled patients’ (Patient 1’s) parents was notified when Patient 1 was transferred from the NICU (neonatal intensive care unit, an area of the hospital that specializes in the treatment of medically unstable or critically ill newborns) to the pediatric unit. (Refer to A - 130). 2. The facility failed to ensure the patient’s right to make informed decision was implemented according to facility’s policy and procedure for three (3) of 11 sampled patients (Patients 16, 19, and 25) and/or the patients’ next of kin (NOK - a designee to receive information regarding the patient’s medical care) as evidence by: a. For Patient 16, the patient’s NOK signed the surgical consent that is not in a language Patient 16’s NOK understood (in Spanish). (Refer to A - 131). b. For Patient 19, the documentation did not indicate the language used for interpreter for Patient 19’s NOK to obtain Patient 19 consent by telephone (in Spanish). (Refer to A - 131). c. For Patient 25, no documented evidence from Physician 1 regarding obtaining the consent from for Patient 25’s bilateral skin sparing mastectomy and blood transfusion and why consent was obtained via telephone and not signed in person by Patient 25. (Refer to A - 131). The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure that the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to assess patient’s skin irritation (the production of reversible damage to the skin following the application of a substance) at the affected area (underarm and left side of the body) after treatment was rendered and to document if the issue had been resolved for one (1) of 30 sampled patients. (Refer to A 395). 2. The facility failed to assess the pain level of Patient 18 and 22’s pain prior to administering pain medication according to facility policy and procedure. (Refer to A 395). 3 The failed to provide nursing care according to facility’s policy and procedure for three (3) of 30 sampled patients (Patients 1, 29, and 30) as evidence by: a. Patient 1’s medication (Aquaphor, an ointment used to restore, protects, and soothes extremely dry skin, cracked hands and feet, minor cuts and burns) was not scanned during medication administration by nurses. (Refer to A 398). b. Patients 29’s critical laboratory value results (Hemoglobin, protein in the blood responsible for delivery of oxygen to the tissue, Hematocrit, a percentage by volume of red cells in the blood, and potassium (a mineral essential in the body) was not communicated to the physician. (Refer to A 398). c. Patients 30’s critical laboratory value result to check troponin (a protein that is released into the bloodstream during a heart attack) was not communicated to the physician. (Refer to A 398). 4. The facility failed the ensure medications were administered according to physician’s order and facility’s policy and procedure (P&P) for 3 of 30 sampled patients (Patients 18, 22, and 27). (Refer to A - 405). The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care by the nursing staff.”

“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: 46333 Based on interview and record review, the facility failed to ensure one (1) of thirty sampled patients’ (Patient 1’s) parents was notified when Patient 1 was transferred from the NICU (neonatal intensive care unit, an area of the hospital that specializes in the treatment of medically unstable or critically ill newborns) to the pediatric unit. This deficient practice resulted to Patient 1’s parent not being notified of the transfer and had the potential of no being actively included in their Patient 1’s plan of care. Findings: A record review of Patient 1’s “History and Physical (H&P),” dated 6/24/2021, indicated Patient 1 was admitted to the NICU (neonatal intensive care unit, an area of the hospital that specializes in the treatment of medically unstable or critically ill newborns) for prematurity (babies born before 37 weeks of pregnancy)), neonatal respiratory distress syndrome (RDS, a common breathing disorder that affects newborns), and fetal growth restriction (FGR, a condition in which an unborn baby [fetus] is smaller than expected for the number of weeks of pregnancy). During an interview, on 11/8/2023 at 1:07 p.m., the Clinical Nurse Specialist 2 (CNS 2) stated the decision to transfer Patient 1 to the pediatric unit was because the baby (Patient 1) was the most stable patient in the NICU at that time. CNS 2 stated the transfer of Patient 1 also occurred during COVID time when the NICU was at full capacity. CNS 2 stated the NICU will transfer patients to prioritized care as they need beds for critically ill babies. CNS 2 confirmed the parents should have been notified of the transfer, regardless of the reason the baby was being transferred. CNS 2 confirmed that the parents were not notified by the NICU that their baby had been transferred to the pediatric unit. During an interview on 9/11/2023 at 10:40 a.m, the Director of Pediatrics 1 (PD 1) 1 stated, “There should be notification to the parent prior to transferring the baby to another unit.” PD 1 stated the parent of the infant should also be given a tour of the unit to which their child will be relocated. PD 1 stated a tour of the unit ensures the family was oriented to the unit and ensures family involvement in their baby plan of care. PD 1 stated Patient 1’s parents did not receive a tour of the pediatric unit prior to the transfer of their baby (Patient 1). PD 1 also stated that the parent of Patient 1 was not notified of the transfer. During a review of the facility’s policy and procedure (P&P) titled “Neonatal Standard of Care,” effective February 1988, revised March 2023, the P&P indicated the purpose of the policy is “to establish consistent standards of care for all Neonatal Intensive Care Unit (NICU) patients. Each patient in the NICU shall receive quality patient care based on established standards. The following are the minimum standards of care: Patients may be monitored more frequently according to the nurse’s discretion and/or as patient condition warrants. Age-appropriate/developmental care (Lippincott developmental support, neonatal) In planning an infant’s care, the following components shall be considered: Include parents in all aspects of developmental assessment, interventions, and evaluations. Documentation: Families and patients shall be oriented to the unit upon admission, and this orientation shall be documented on the NICU Admission Assessment, Daily Cares flowsheet, and education record. Family/patient educational and cultural needs shall be assessed and documented as applicable ...” During a review of the facility’s policy and procedure (P&P) titled “Patient Rights and Responsibilities,” dated June 20, 2021, the P&P indicated, “As a patient of the facility’s hospital system, you have the right to: receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery, and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in the development and implementation of your plan of care. You have the right to participate in ethical questions that arise in the course of your care, including issues of conflict resolution, withholding resuscitative services, forgoing or withdrawing life-sustaining treatment, or to request an ethics consult ...””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 39503 Based on observation, interview, and record review, the facility failed to ensure the patient’s right to make informed decision was implemented according to facility’s policy and procedure for three (3) of 11 sampled patients (Patients 16, 19, and 25) and/or the patients’ next of kin (NOK - a designee to receive information regarding the patient’s medical care) as evidence by: 1. For Patient 16, the patient’s NOK signed the surgical consent that is not in a language Patient 16’s NOK understood (in Spanish). 2. For Patient 19, the documentation did not indicate the language used for interpreter for Patient 19’s NOK to obtain Patient 19 consent by telephone (in Spanish). 3. For Patient 25, no documented evidence from Physician 1 regarding obtaining the consent from for Patient 25’s bilateral skin sparing mastectomy and blood transfusion and why consent was obtained via telephone and not signed in person by Patient 25. These deficient practices resulted in the patients and the patients’ NOK to not received the comprehensible information needed to make an informed decision regarding the patient’s care. Findings: 1. During an observation on 11/7/2023 at 2 p.m., Patient 16 was observed in the Neonatal Intensive Care Unit (NICU - specialty unit for newborn babies who need intensive medical care) asleep in the crib wrapped in blanket. Patient 16 had a peripherally inserted central catheter (PICC - an intravenous access used to deliver medications and other treatments directly to the large central veins near the heart) line on the left lower extremity. A record review of Patient 16’s Pediatric History and Physical, dated 10/16/2023, indicated Patient 16 was admitted to the facility with a chief complaint of abnormal laboratory result. A record review of Patient 16’s Basic Demograhics (Patient Information) record, dated 10/16/2023, indicated Patient 16 NOK’s preferred language was Spanish. A record review of Patient 16’s physician’s order, dated 10/17/2023, indicated a PICC line placement for Patient 16. A record review Patient 16’s Sedation and Analgesia For Procedures Informed Consent Information, written in English, had a signature under the “Signature of patient, parent or conservator,” on 10/17/2023 at 3:05 p.m. The consent did not indicate the relationship of the person ,who signed the consent for Patient 16. A record review on 11/7/2023, the “PICC Consent To Operation and Other Procedures,” written in English, had a signature under the “signature of patient, parent or conservator” on 10/17/2023 at 3:10 p.m. The consent did not indicate the relationship of the person who signed the consent to Patient 16. During an interview with Charge Nurse 1 (CN1) and concurrent record review of Patient 1’s consents (Sedation and Analgesia For Procedures Informed Consent Information and PICC Consent To Operation and Other Procedures) on 11/7/2023, at 2 p.m., CN 1 stated Patient 16 NOK’s preferred language was Spanish, and the consents signed by Patient 16’s NOK should have been written in Spanish. CN 1 stated the signature on both of Patient 16’s consents were like the signature of Patient 16’s NOK. CN 1 stated Patient 16’s consents were signed other than the patient, and the relationship to Patient 16 should have been indicated. During a concurrent interview with the Director of Language Services (DLS) and record review of Patient 16’s Sedation and Analgesia For Procedures Informed Consent Information, on 11/8/2023 at 11:38 a.m., the DLS stated Patient 16’s Sedation and Analgesia For Procedures Informed Consent Information, dated 10/17/2023, written in English, indicated an interpreter was used for Patient 16’s NOK to sign the consent. The DLS stated the consent did not indicate the method of interpretation used, the name of the language interpreter used, the date, and time of the interpretation. During a concurrent interview with the DLS and record review, on 11/8/2023 at 11:38 a.m., the DLS stated Patient 16’s “PICC Consent To Operation and Other Procedures,” dated 10/17/2023, written in English, indicated an interpreter was used for Patient 16’s NOK to sign the consent. The DLS stated the consent did not indicate the method of interpretation used, the name of the language interpreter used, the date, and time of the interpretation. During an interview, on 11/8/2023, at 11:38 a.m., the DLS stated there were health information documents available to use that were translated and written in other languages. The DLS stated when a health care information document was available in the preferred language of the patient or the patient’s NOK, the documents should be used to provide information. The DLS stated when a document was not available in the preferred language of the patient or the patient’s NOK, a language interpreter should be used, and documentation of the interpretation should be completed in accordance with the facility’s policy and procedure. During a concurrent interview with Nurse Informatics 2 (NI 2) and record review of Patient 16’s Sedation and Analgesia For Procedures Informed Consent Information, on 11/8/2023 at 11:40 a.m., NI 2 stated the facility had a Spanish version of the Sedation and Analgesia For Procedures Informed Consent Information. NI 2 stated the facility’s “PICC Consent To Operation and Other Procedures,” was only written in English. During a review of the P&P titled, “Patient Rights and Responsibilities,” revised in 06/2021, the P&P indicated, “ ...Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcome of care in terms you can understand ...” During a review of the P&P titled, “Consent - Obtaining and Documenting,” revised in 10/2023, the P&P indicated, “ ...Consent forms should be written in a language the patient can understand or translated into such language. Interpreter services is available to translate forms upon request ...” During a review of the P&P titled, “Language Assistance for Patients and Families,” revised in 7/2019, the P&P indicated, “ ...Document the following information in Care Connect (Electronic Health Record) as part of the legal medical record: a. The method of interpretation used (phone, video, in-person). b. The name of the qualified healthcare interpreter who provided language assistance. c. The qualified healthcare interpreter’s identification or badge number who provided language assistance ...” 2. During an observation on 11/7/2023 at 2:20 p.m., with Registered Nurse 7 (RN 7) 7, Patent 19 was observed in the room inside a crib, intubated (a tube inserted through the mouth into the airway to assist patient in breathing) and was receiving multiple intravenous (IV) medications. RN 7 stated Patient 19 was scheduled for a cardiac catheterization (a test or treatment for heart problems using a thin catheter guided through a blood vessel to the heart). A review of Patient 19’s Basic Demographics (Patient information) record, indicated Patient 19 was admitted on 9/23/2023. Patient 19’s preferred language was Spanish. During a concurrent interview with the DLS and record review of Patient 19’s signed consents, on 11/8/2023 at 11:40 a.m., the DLS stated the Patient 19 had the following consents: a. The surgical consent for “Carotid artery (a major blood vessel that provide blood supply to the vein) cut down,” dated 11/6/2023, written in English, indicated an interpreter was used for Patient 19’s NOK to sign the telephone consent. b. The surgical consent for “Cardiac catheterization,” dated 11/6/2023, written in English, indicated an interpreter was used for Patient 19’s NOK to sign the telephone consent. c. The surgical consent for “Insertion of Extracorporeal Membrane Oxygenation (ECMO - is a technique of providing prolonged cardiac and respiratory support to persons whose heart and lungs are unable to provide an adequate amount of gas exchange or perfusion to sustain life),” dated 11/6/2023, written in English, indicated an interpreter was used for Patient 19’s NOK to sign the telephone consent. During a concurrent interview, on 11/8/2023 at 11:40 a.m., the DLS stated all three surgical consents had the language interpreter’s first name only and had no other documentation to verify qualification of the interpreter used in each of Patient 19’s consents. The DLS stated when the facility used an interpreter, the interpreter’s full name and identification number should be documented to ensure verification of a qualified interpreter was used. During a review of the P&P titled, “Language Assistance for Patients and Families,” revised in 7/2019, the P&P indicated, “ ...Document the following information in Care Connect (Electronic Health Record) as part of the legal medical record: a. The method of interpretation used (phone, video, in-person). b. The name of the qualified healthcare interpreter who provided language assistance. c. The qualified healthcare interpreter’s identification or badge number who provided language assistance ...” 3. A record review of Patient 25’s Pre-Op (before surgery) History and Physical, dated 11/7/2023, indicated Patient 25 was admitted to the facility for breast reconstruction surgery. A record review of Patient 25’s Consent For Surgery or Special Diagnostic or Therapeutic Procedure, indicated Patient 25 needed to consent for bilateral skin sparing mastectomy (a surgical procedure where the breast tissue is removed while most of the health breast skin is left) and for blood transfusion. The consent was signed by Physician 1, on 11/6/2023 at 9:11 a.m., and a “Witness signature if consent was obtained by telephone,” was signed by the Nurse Practitioner (NP) on 11/6/2023 at 9:15 a.m. The consent did not include Patient 25’s signature. The consent indicated the following: a. “If not signed by patient, indicate relationship,” was not answered. b. Name of person signing for patient (if applicable),” was not answered; and, c. “Was consent obtained via telephone, email or fax? Yes.” There was no documented evidence from Physician 1, who she spoke to and who she got the consent from for Patient 25’s bilateral skin sparing mastectomy and blood transfusion. There was no documented evidence from Physician 1 the reason why Patient 25’s surgical consent was obtained via telephone and not signed in person by the patient (Patient 25). During an interview on 11/9/2023 at 10:56 a.m. and concurrent record review of Patient 25’s Consent For Surgery or Special Diagnostic or Therapeutic Procedure, RN 8 stated before a patient was brought to the Operating Room (OR) the consent would be verified with the patient which included the patient’s name, the surgical procedure, and the signature on the consent. RN 8 stated the surgical consent was usually signed by the patient and a telephone consent would only be obtained when the patient is a minor or incapacitated and the patient’s guardian was not available to sign the consent in person. RN 8 stated there was no documented evidence from Physician 1, who she spoke to and who she got the consent from for Patient 25’s bilateral skin sparing mastectomy and blood transfusion. RN 8 stated there was no documented evidence from Physician 1 the reason why Patient 25’s surgical consent was obtained via telephone and not signed in person by the patient (Patient 25). During an interview, on 11/9/2023 at 11:31 a.m., RN 9 stated she was assigned in the pre-operating (Pre-op) area. RN 9 stated one of the preparations for the patient going to surgery was to verify, the patient’s surgical consent. RN 9 stated the consent would be verify with the patient which included the patient’s name, the surgical procedure, and the signature on the consent. RN 9 stated she remembered being the pre-op RN for Patient 25. RN 9 stated she did not remember Patient 25’s telephone surgical consent. RN 9 stated she thought she verified Patient 25’s signature on the consent. During a concurrent interview and record review of Patient 25’s Consent For Surgery or Special Diagnostic or Therapeutic Procedure, on 11/9/2023 at 4 p.m., Physician 2 stated he was the Medical Director for Surgical Services. Physician 2 stated the physician would often have the patient sign the consent prior to their schedule surgery date, when the patient had no access to electronic signing of the consent, a telephone consent would be obtained. Physician 2 stated Patient 25’s had a surgical consent for bilateral skin sparing mastectomy and stated the consent has no documentation on the consent regarding who the consent was given to and who signed the telephone consent. Physician 2 stated, if Patient 25 signed the telephone consent, Patient 25’s name should have been written in the consent. During a review of the facility’s P&P titled, “Consent - Obtaining and Documenting,” revised in 10/2023, the P&P indicated the following: a. Obtaining Informed Consent. Generally, it is presumed that an adult patient has the capacity to make health care decisions and provide consent. b. Documenting Informed Consent in the Medical Record. Patient Confirmation. The patient (or his or her legal representative) should sign the consent form(s). c. Verification. California law requires that, prior to non-emergency surgery, the person responsible for administering anesthesia or the surgeon must ascertain that a signed consent form for the contemplated surgical procedure is in the medical record. The signature of the patient or the patient’s legal representative documents that the informed consent discussion has taken place between the physician and the patient. d. Consent by Telephone. Telephone consent for medical or surgical treatment should only be obtained; when the patient or a person with legal capacity to consent for the patient and/or the person obtaining consent are not available to complete consent in person. When consent is granted by telephone the documentation in the medical record must explain why consent was obtained in this manner, should include witnesses, and must indicate that the informed consent discussion occurred in compliance with this policy.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 39503 Based on observation, interview, and record review, the facility failed to ensure appropriate nursing care for pain assessment was provided for three (3) of 30 sampled patients (Patients 1, 18 and 22). 1. The facility failed to assess Patient 1’s skin irritation (the production of reversible damage to the skin following the application of a substance) at the affected area (underarm and left side of the body) after treatment was rendered and to document if the issue had been resolved. This deficient practice placed Patient 1’s health at risk for a potential unidentified underlining infection or allergic reaction that could require specific interventions. 2. The facility failed to assess the pain level of Patient 18 and 22’s pain prior to administering pain medication according to facility policy and procedure. These deficient practices had the potential to result in delay of patient treatment and uncontrolled pain for Patients 18 and 22. Findings: 1. A review of Patient 1’s “History and Physical (H&P),” dated 6/24/2021, indicated that Patient 1 was admitted to the NICU (neonatal intensive care unit, an area of the hospital that specializes in the treatment of medically unstable or critically ill newborns) for prematurity (babies born before 37 weeks of pregnancy), neonatal respiratory distress syndrome (RDS, a common breathing disorder that affects newborns), and fetal growth restriction (FGR, a condition in which an unborn baby [fetus] was smaller than expected for the number of weeks of pregnancy). During a concurrent interview with Clinical Nurse Specialist (CNS) 1, and record review of Patient 1’s “End of Shift Summary,” on 11/8/2023 at 1:07 p.m., CNS reviewed and stated Patient 1’s End of Shift Summary, date of service 7/14/2021 at 6:56 a.m. indicated, “Patient left side of the body underarm irritated from leads (electrodes in the form of sicker pads that are attached from the patient to a battery pack transmitting impulses to the monitor) and Detachol (an adhesive rover solution). Aquaphor ordered per Medical Doctor (MD). CNS 2 stated on 7/13/2021, during a night shift, a care partner (staff that provides support to a licensed nurse in caring for patients in a hospital) used the Detachol to loosen a telemonitor’s lead on a pediatric patient (Patient 1), and as a result, the baby’s skin was reddened. CNS 2 stated, “Aquaphor, an ointment was applied.” During an interview with the Director of Pediatrics (DP) 1, DP 1 stated, “Around 10:00 p.m. during the night shift, a care partner was using Detachol to remove a telemetry lead that was placed on the baby’s chest, and the baby’s skin became red.” During a concurrent interview with the Director of Pediatric (DP 1) and record review of Patient 1’s Nursing Assessment Flow Sheet, on 11/8/2023 at 1:20 p.m. DP 1 stated the nursing assessment flow sheet section, “Skin Integrity,” dated 7/13/2021 at 12:42 a.m. was reviewed and stated the flow sheet indicated, under skin integrity, “Intact.” DP1 stated the record had no documentation describing the location of the affected area. The record indicated the next skin assessment was documented ten hours and forty-eight minutes later, on 7/14/2023, at 11:30 a.m., indicating “Intact.” DP 1 stated that there was no documentation that indicated the patient’s skin irritation to the underarm and left side of the body was effectively treated when Aquaphor had been applied or if the irritation to the skin was resolved. DP1 stated, “There should be documentation that indicates the affected area with redness has been resolved to provide continuity of care.” During an interview, on 9/11/2023 at 10:40 a.m. with the Program Manager of Wound and Ostomy Care (PMCNS) 1, PMCNS stated that if there was an unusual reaction to the skin for documentation, PMCNS 1 stated, “There should be a drop-down under integumentary and selection for description of the wound.” PMCNS stated it is encouraged to create an LDA (section of lines, drains, and airways) if there is treatment ordered. PMCNS stated that the LDA column allows for continuous documentation of those skin issues. PMCNS confirmed that even if the skin problem was not a pressure injury, the document should include a description and status of the affected skin area. During a review of the facility’s policy and procedure (P&P) titled, “Assessment of Patients,” effective date February 1995 and revised date March 2023, the P&P indicated the following. To comprehensively assess and document the initial admission assessment of all patients, and to ensure that each patient’s physical, psychological spiritual, cultural, nutritional, and social status needs are assessed continuously ... Examples of reassessment will include but are not limited to; blood pressure, pulse, respiratory rate, temperature, and pain, if indicated. Additional reassessments will be done and documented according to the following: a. When there ls a significant change in the patient’s condition/ diagnosis b. When there Is a change in the level of care. c. An untoward event places the patient at risk for an adverse outcome. d. To determine the patient’s response to treatment. e. Physician orders f. Based upon the patient or family desire. g. Abnormal findings from previous assessment h. Per specialty/population specific standards of care and pertinent policy and procedures i. Unrelieved pain A review of the facility’s policy and procedure (P&P) titled, “Documentation of Patient Care,” affective date July 1982 and revised date August 2023, indicated, “The purpose of this policy is to establish the requirements and responsibilities for the documentation of nursing care in the inpatient medical record in compliance with professional nursing and regulatory standards. All nursing personnel are responsible for documenting patient care provided in the HER (electronic health record). The frequency of documentation is driven by physician/designee orders, policies, guidelines, patient condition, level of care, unit standards, and nursing judgment ... Documentation of patient care is to be completed on a timely and ongoing basis throughout the shift to ensure patient safety. Nursing interventions and patient progress toward the goals will be reflected in EHR flowsheets, nursing documentation in the Notes, Treatments, End of Shift Summary, and other appropriate related Flowsheets ...” 2. During an observation on 11/7/2023 at 2:15 p.m., Patient 18 was observed in the patient’s room, sitting on the chair, and was watching a movie. Patient 18 had a left chest tube (a surgical drain that is inserted through the chest wall into the lungs to drain unwanted fluid or air). A record review of Patient 18’s Pediatric History and Physical, dated 11/2/2023, indicated Patient 18 was admitted to the facility with a chief complaint of mediastinal mass (lung tumor). A record review of Patient 18’s Chest Tube Flowsheets, indicated Patient 18’s left chest tube was inserted, on 11/3/2023. A record review on 11/8/2023, Patient 18’s Medication Administration Report (MAR) indicated a physician’s order of acetaminophen (pain medication) 690 milligram (mg, unit of measurement) to be given intravenous (IV, into the vein) every 6 hours as needed for mild pain for pain scale of one (1) to three (3) (pain scale level of 1 [mild pain] through 10 [severe or worst pain]). Patient 18’s MAR indicated the following: a. On 11/3/2023 at 5:42 p.m., Patient 18 was administered acetaminophen 690 mg IV. There was no documented evidence Patient 18’s pain was assessed prior to administering acetaminophen on 11/3/2023 at 5:42 p.m. During an interview with Charge Nurse Manager 1 (CNM 1), on 11/8/2023 at 2:22 p.m., CNM 1 stated Patient 18’s pain level should have been assessed prior to administering the acetaminophen on 11/3/2023 at 5:42 p.m., to ensure an appropriate pain medication would be given to manage Patient 18’s pain. During a review of the facility’s P&P titled, “Pain Assessment and Management Policy,” revised in 8/2023, the P&P indicated, “Patients are screened for pain as part of the patient’s initial evaluation and an ongoing basis, if relevant to the visit.” “Patents receive prompt, effective pharmacologic, non-pharmacologic, and/or procedural management for their pain...” 3. During a concurrent observation and interview, on 11/7/23 at 3:10 p.m., Patient 22 was observed in his room, lying in bed, alert and oriented. Patient 22’s right leg was surgically wrapped and elevated in a pillow, and the left thigh was covered with a dressing. Patient 22 stated there was an explosion. Patient 22 stated the explosion injured his legs. Patient 22 stated he had a surgery on the right leg, and they took the bone graft (a surgical procedure that uses transplanted bone to repair and rebuild damaged bones) from his left thigh. Patient 22 stated, “It’s painful not sure why I need to ask frequently for pain meds, why can they give it to me.” A record review of Patient 22’s Trauma Surgery H&P (History and Physical), dated 10/24/2023, indicated Patient 22 was admitted for trauma with open deformity (not in the normal position) to the right lower extremity. During a record review on 11/9/2023, Patient 22’s MAR indicated a physician order of oxycodone (pain medication) 15 milligram (mg, unit of measurement) to be given by mouth (po) every 6 hours as needed for severe pain (pain scale level of 1 [mild pain] through 10 [severe or worst pain]). Patient 22’s MAR indicated the following administration of oxycodone: a. On 10/28/2023 at 7:44 p.m., Patient 22 was administered oxycodone 15 mg po. b. On 10/29/2023 at 2:14 a.m., 7:33 a.m., and 3:32 p.m., Patient 22 was administered oxycodone 15 mg po. There was no documented evidence Patient 22’s pain was assessed prior to administering oxycodone 15 mg on 10/28/2023 at 7:44 p.m. and 10/29/2023 at 2:14 a.m. During an interview with CNM 2, on 11/9/2023 at 9:35 a.m., CNM 2 stated Patient 22’s pain level should have been assessed prior to administering the pain medication to know Patient’s baseline of pain and to ensure an appropriate pain medication would be given to manage Patient 22’s pain. During a review of the facility’s P&P titled, “Pain Assessment and Management Policy,” revised in 8/2023, the P&P indicated, “Patients are screened for pain as part of the patient’s initial evaluation and an ongoing basis, if relevant to the visit.” “Patents receive prompt, effective pharmacologic, non-pharmacologic, and/or procedural management for their pain...””

“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: 39503 Based on observation, interview, and record review, the facility license nurse failed provided care according to the facility’s policy and procedure (P&P) for three (3) of 30 sampled patients (Patients 1, 29, and 30) as evidence by: 1. Patient 1’s medication (Aquaphor, an ointment used to restore, protects, and soothes extremely dry skin, cracked hands and feet, minor cuts and burns) was not scanned during medication administration by nurses. This deficient practice had the potential to result in Patient 1 receiving the wrong medication or dosage and not administered according to physician order. 2. Patients 29’s critical laboratory value results (Hemoglobin, protein in the blood responsible for delivery of oxygen to the tissue, Hematocrit, a percentage by volume of red cells in the blood, and potassium (a mineral essential in the body) was not communicated to the physician. This deficient practice had the potential for the physician to not be informed of abnormal critical lab value result which may result in delay of emergent Patient 29’s care treatments. 3. Patients 30’s critical laboratory value result to check troponin (a protein that is released into the bloodstream during a heart attack) was not communicated to the physician. This deficient practice had the potential for the physician to not be informed of abnormal critical lab value result which may result in delay of emergent patient treatment for Patient 30. Findings: 1. A review of Patient 1’s “History and Physical (H&P),” dated 6/24/2021, indicated that Patient 1 was admitted to the NICU (neonatal intensive care unit, an area of the hospital that specializes in the treatment of medically unstable or critically ill newborns) for prematurity (babies born before 37 weeks of pregnancy), neonatal respiratory distress syndrome (RDS, a common breathing disorder that affects newborns), and fetal growth restriction (FGR, a condition in which an unborn baby [fetus] was smaller than expected for the number of weeks of pregnancy). During a concurrent interview with Clinical Nurse Specialist (CNS) 1, and record review of Patient 1’s “End of Shift Summary,” on 11/8/2023 at 1:07 p.m., CNS reviewed and stated Patient 1’s End of Shift Summary, date of service 7/14/2021 at 6:56 a.m. indicated, “Patient left side of the body underarm irritated from leads (electrodes in the form of sicker pads that are attached from the patient to a battery pack transmitting impulses to the monitor) and Detachol (an adhesive rover solution). Aquaphor ordered per MD (Doctor of Medicine) and administered.” During a concurrent interview with Nurse Informatics 3 (NIF 3), and record review of Patient 1’s “Medication Administration Record (MAR),” on 11/9/2023 at 10:12 a.m. NIF 3 reviewed and stated Patient 1’s MAR, dated 7/13/2023 through 7/15/2023, indicated there was no administration record for Aquaphor. NIF 3 reviewed the “Medication Tracking Information (log for medication administered)” and stated, “No administration record was found for Aquaphor medication,” for Patient 1. The NIF 3 showed and stated the medication tracking system indicated, “Mineral oil-hydrophilic petrolatum (Aquaphor) ointment is scheduled to start on 7/14/23 at 12:51 a.m.” NIF 3 confirmed that the medication tracking information system indicated “no administration records.” During an interview on 11/9/2023 at 10:40 a.m. with Program Manager, Wound Clinical Nurse Specialist (PMCNS) 1, PMCNS 1 stated it (Aquaphor) was a medication that was distribute by pharmacy, so it (Aquaphor) should be scan in during administration. PMCNS 1 stated, “It (Aquaphor administration) should show up in the MAR.” During an interview on 11/9/2023 at 1:05 p.m. with Director of Pediatric (DP) 1, DP 1 stated she did not locate in the Patient 1’s MAR of the administration of Aquaphor. DP 1 stated “Although the registered nurse documents that she had administered the Aquaphor in her end of shift note, it (Aquaphor) was a medication that requires scanning, especially that the ordered indicated it (Aquaphor) was PRN (as needed; as circumstances require) medication.” During a review of the facility’s policy and procedure (P&P) titled “Medication Administration,” effective date, September 1980, and revised date, May 2023, the P&P indicated, “The purpose of this policy is to specify the requirements for safe and accurate preparation, administration, storage, and documentation of medications in accordance with the facility’s system standard.” The P&P indicates the following: a. Medication Administration Flow Chart Requirements of medication administration include identifying the following critical steps: right patient, right drug, right dose, right route, and right time. In areas with barcode medication administration, the nurse shall scan the patient ID band, then scan the medication barcode prior to administration. b. Medication administration records are reviewed prior to shift change to assure all medications have been administered and documented. c. Medication Documentation included drug name, dose, route, (site as necessary), and time are documented in the medical record on the MAR following administration. d. All medication entries in the medical record require initials and/or signature of the individual administering the medication. With the electronic medication administration record, the individual initials will automatically be documented upon administration of the medication. A review of the facility’s medication administration flow chart, titled “Appendix A, Medication Administration Flow Chart,” undated, indicated steps to follow in the medication administration process, which starts with the physician entering the medication order and continues through several checkpoints. The eleventh step within the chart is at the bedside, where the chart indicates, “Scan the patient’s ID band. Verbally validate patient name with patient or family, when possible, scan medication, confirm dose and route are correct, do a final visual check of the medication, open and administer medication, chart the medication given, log out of the system, and monitor patient for adverse reaction and effectiveness.” 2. A record review of Patient 29’s Emergency Department (ED) Provider Notes, dated 11/8/2023, indicated Patient 29 was presented to the ED for abdominal pain and worsening laboratory test results. A record review on 11/9/2023, Patient 29’s laboratory test result indicated on 11/7/2023 at 11:37 p.m., Clinical Laboratory Scientist (CLS) 1 called and notified Registered Nurse 10 (RN 10) of Patient 29’s critical laboratory test result for Hemoglobin of 6.6 (Hgb., protein in the blood responsible for delivery of oxygen to the tissue, normal value was 11.6 gram (g, unit of measurement)/deciliter (dl, unit of measurement)to 15.2 g/dl) and Hematocrit of 17.9 (Hct., percentage by volume of red cells in the blood, normal value was 34.9 percentage [%] to 45.2 %). There was no documented evidence RN 10 notified the physician for Patient 29’s critical laboratory test for Hgb. and Hct. A record review on 11/9/2023, Patient 29’s laboratory test result indicated on 11/7/2023 at 10:54 p.m., CLS 2 called and notified RN 10 of Patient 29’s critical laboratory test result for potassium (electrolyte in the body, with low level of potassium can cause muscle cramp and abnormal heart rhythms) of 2.9 millimoles per liter (mmol/L) (normal value was 3.6 mmol/L to 5.3 mmol/L). During an interview and concurrent record review of Patient 29 laboratory results, on 11/9/2023 at 3:15 p.m., Unit Director 2 (UD 2) stated when a patient had a critical laboratory test result, the CLS would immediately call the unit and report to the RN, then the RN who received the critical laboratory test result would immediately report it (laboratory result) to the physician to address the results and give the orders. UD stated there was not documented evidence that RN 10 notified the physician for Patient 29’s critical laboratory test result for Hgb., Hct., and potassium. UD 2 stated the reporting of the critical laboratory test results from the CLS to the RN to the Physician should be documented in accordance with the facility’s P&P. 3. A record review Patient 30’s ED Service Report, dated 11/7/2023, indicated Patient 30 was presented to the ED with chest pain. A record review on 11/9/2023, Patient 30’s laboratory test result indicated on 11/7/2023 at 4:49 p.m., Clinical Laboratory Scientist (CLS) 3 called and notified RN 11 of Patient 30’s critical laboratory test result for Troponin of 1,980 nanogram (ng)/liter (L) (a protein that is released into the bloodstream during a heart attack, normal values are below 14 ng/L). There was no documented evidence RN 11 notified the physician for Patient 30’s critical laboratory test for Troponin. During an interview on 11/9/2023 at 3:15 p.m., UD 2 stated when a patient had a critical laboratory test result, the CLS would immediately call the unit and report to the RN, then the RN who received the critical laboratory test result would immediately report it to the physician to address the results and give the orders. UD 2 stated there was not documented evidence that RN 11 notified the physician for Patient 30’s critical laboratory test for Troponin. UD 2 stated the reporting of the critical laboratory test results from the CLS to the RN to the Physician should be documented in accordance with the facility’s P&P. During a review of the facility’s P&P titled, “Reporting of Critical Results and Values,” revised in 8/2021, the P&P indicated the following: a. All critical values - are reported within the departmental defined critical value time interval to the responsible licensed caregiver who can act on the results determined by the department. b. The person who provides the telephone report of critical values perform the following: report the critical value, record time and name of the person receiving the report, and record that the critical value was read back and confirmed.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 39503 Based on observation, interview, and record review, the facility failed the ensure medications were administered according to physician’s order and facility’s policy and procedure (P&P) for 3 of 30 sampled patients (Patients 18, 22, and 27). These deficient practices resulted to delay of treatment for Patient 18, 22, and 27. The deficient practices had the potential to cause adverse health outcomes which could negatively affect the patient’s health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death. Findings: 1. During an observation on 11/7/2023 at 2:15 p.m., Patient 18 was observed in the patient’s room, sitting on the chair, and was watching a movie. Patient 18 had a left chest tube (a surgical drain that is inserted through the chest wall into the lungs to drain unwanted fluid or air). A record review of Patient 18’s Pediatric History and Physical, dated 11/2/2023, indicated Patient 18 was admitted to the facility with a chief complaint of mediastinal mass (lung tumor). A record review of Patient 18’s Chest Tube Flowsheets, indicated Patient 18’s left chest tube was inserted, on 11/3/2023. A record review on 11/8/2023, Patient 18’s Medication Administration Report (MAR) indicated a physician’s order of acetaminophen (pain medication) 690 milligram (mg, unit of measurement) to be given intravenous (IV, into the vein) every 6 hours as needed for mild pain for pain scale of one (1) to three (3) (pain scale level of 1 [mild pain] through 10 [severe or worst pain]). Patient 18’s MAR indicated the following: a. On 11/3/2023 at 12:49 a.m., Patient 18 was administered acetaminophen 690 mg IV. The corresponding pain assessment on 11/3/2023 at 12:49 a.m., indicated Patient 18’s “Pain score 10 - worst pain.” b. On 11/3/2023 at 5:42 p.m., Patient 18 was administered acetaminophen 690 mg IV. There was no documented evidence Patient 18’s pain was assessed prior to administering acetaminophen on 11/3/2023 at 5:42 p.m. During an interview with Clinical Nurse Manager 1 (CNM 1), on 11/8/2023 at 2:22 p.m., CNM 1 stated the acetaminophen administered to Patient 18 on 11/3/2023 at 12:49 a.m. was not in accordance with the physician’s order because it was for mild pain. Patient 18’s pain level was severe pain (pain scale of 7 to 10). CNM 1 stated the Registered Nurse (RN) should have called the physician for order of pain medication that would help managed Patient 18’s severe pain. CNM 1 stated Patient 18’s pain level should have been assessed prior to administering the acetaminophen on 11/3/2023 at 5:42 p.m., to ensure an appropriate pain medication would be given to manage Patient 18’s pain. A review of the facility’s P&P titled, “Medication Administration,” revised date 5/2023, the P&P indicated, “...Requirement of medication administration include...right drug, right dose...” “Before administration, the individual administering the medication must...verifies that the medication is being administered...in the prescribed dose...” During a review of the facility’s P&P titled, “Pain Assessment and Management Policy,” revised date 8/2023, the P&P indicated, “Patients are screened for pain as part of the patient’s initial evaluation and an ongoing basis, if relevant to the visit.” “Patents receive prompt, effective pharmacologic, non-pharmacologic, and/or procedural management for their pain...” 2. A record review of Patient 22’s Trauma Surgery H&P (History and Physical), dated 10/24/2023, indicated Patient 22 was admitted for trauma with open deformity (not in the normal position) to the right lower extremity. A record review of Patient 22’s MAR indicated a physician order of Zosyn (piperacillin/tazobactam [antibiotic]) 3.375 grams (g, unit of measurement) to be given intravenous (IV) every 6 hours with a start date of 10/26/2023 at 6:30 p.m. Patient 22’s MAR indicated the following administration of Zosyn: a. On 10/26/2023 at 9:02 p.m., Patient 22 was administered the first dose of Zosyn (2 hours and 30 minutes after the scheduled first dose of Zosyn). b. On 10/27/2023 at 12 midnight, Patient 22’s Zosyn was not given with a reason of “time adjusted.” c. On 10/27/2023 at 5:30 a.m., Patient 22 was administered Zosyn (8 hours and 30 minutes after the last dose of Zosyn administration). d. On 10/27/2023 at 2:40 p.m., Patient 22 was administered Zosyn (9 hours after the last dose of Zosyn administration). e. On 10/27/2023 at 9:15 p.m., Patient 22 was administered Zosyn. f. On 10/28/2023 at 2:33 a.m., Patient 22’s Zosyn was not given with a reason of “time adjusted.” g. On 10/28/2023 at 6:28 a.m., Patient 22 was administered Zosyn (9 hours after the last dose of Zosyn administration). During an interview with Pharmacist 2 and concurrent record review of Patient 22’s MAR, on 11/9/2023 at 9 a.m., Pharmacist 2 stated on review of Patient 22’s MAR, the order for Zosyn 3.375 g was to be given IV every 6 hours with a start date of 10/26/2023 at 6:30 p.m. Pharmacist 2 stated, on 10/26/2023 at 6:04 p.m. Zosyn was available to be administered and the first dose should have been given at 6:30 p.m., as ordered by the physician. Pharmacist 2 stated when a new antibiotic was ordered for the patient, it would be started as soon as the antibiotic was verified and available for administration. Pharmacist 2 stated for the subsequent doses of antibiotic, when there is a change in the schedule administration, the Registered Nurse (RN) should notify the Pharmacist to change the dosing schedule for the patient. During an interview on 11/9/2023 at 9:35 a.m., CNM 2 stated Patient 22’s first dose of Zosyn was delayed. CNM 2 stated Zosyn was available and should have been administered as ordered on 10/26/2023 at 6:30 p.m. CNM 2 stated Patient 22’s subsequent Zosyn doses were delayed and not given in accordance with the physician’s order. CNM 2 stated when there is a need for adjustment of scheduled time administration, the RN should notify the Pharmacist so that it would be adjusted in the MAR and the antibiotic dosing time would be followed as ordered by the physician. During a review of the facility’s P&P titled, “Standard Medication Administration Times,” revised in 6/2020, the P&P indicated the following: a. New IV antibiotics: After an antibiotic order is entered, the first dose will be administered as soon as possible and will not hold for a standard administration time. Subsequent doses should be staggered back the selected standard (routine) administration schedule. b. If a dose is delayed or missed, the nurse will give the next dose as soon as possible and follow the chart title How to Stagger medications to Return to Standard Administration Times to return to standard schedule. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” revised in 5/2023, the P&P indicated, “...Requirement of medication administration include...right drug, right dose, right route and right time...” 3. A record review of Patient 27’s Neurocritical (area regarding intensive care of the brain or nervous system) Care Attending Note, dated 8/31/2023, indicated Patient 27 was admitted to the facility, on 8/30/2023, for status epilepticus (a seizure that lasts longer than 5 minutes, or having more than 1 seizure within 5 minutes period without returning to a normal level of consciousness between episodes). A record review of Patient 27’s physician’s order indicated meropenem (antibiotic) 2 g to be given intravenous (IV) every 8 hours for lower respiratory tract infection. A record review of Patient 27’s medication administration report (MAR) indicated the following: a. On 11/7/2023 at 7:44 a.m., meropenem 2 g IV was administered to Patient 27. b. On 11/7/2023 at 5:25 p.m., meropenem 2 g IV was administered to Patient 27 (9 hours and 30 minutes after the last dose of meropenem). c. On 11/9/2023 at 12:06 a.m., meropenem 2 g IV was administered to Patient 27. d. On 11/9/2023 at 9:43 a.m., meropenem 2 g IV was administered to Patient 27 (9 hours and 45 minutes after the last dose of meropenem). During an interview, on 11/9/2023 at 1:09 p.m., the Unit Director (UD 1) stated per P&P the medication administration times for every 8-hour schedule was 8 a.m., 4 p.m., and 12 a.m. UD 1 stated Patient 27’s meropenem 2 g IV administration was administered late on 11/7/2023 at 5:25 p.m., and on 11/9/2023 at 9:43 a.m. During a review of the facility’s P&P titled, “Medication Administration,” revised in 5/2023, the P&P indicated, “...Requirement of medication administration include...right drug, right dose, right route and right time...” During a review of the facility’s policy and procedure titled, “Standard Medication Administration Times,” revised in 6/2020, the P&P indicated, “...Q8H (every 8 hours) Scheduled Times: 08 - 16 (4 p.m.) - 24 (12 a.m.)...””