Redlands Community Hospital

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 47360 Based on interview and record review, the facility failed to ensure the Governing Body (GB) provided adequate oversight to ensure safe and effective patient care with the contracted emergency service medical staff for two of 34 sampled patients (Patient 30 and 33), when 1. For one patient (Patient 30), intravenous (IV - given through a tube directly into the blood stream) medications and a computed tomography angiogram (CTA- an imaging test that uses X-rays and contrast dye to create detailed images of the blood vessels) of the head and neck were ordered and administrated to Patient 30, without indication and intended for the other patient. (Refer to A-0084) 2. For one patient (Patient 33), a critical radiology value (a result with an immediate health risk requiring immediate action) was not communicated in a timely manner to the emergency department (ED) nursing staff. (Refer to A-0084) The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 51269 Based on interview and record review, the facility failed to maintain an effective and ongoing hospital wide, Quality Assessment and Performance Improvement (QAPI) program for a universe of 34 sampled patients, when the QAPI failed to monitor, collect and analyze quality data regarding patients’ assessment and reassessment, timely report and intervention of critical radiology values (a result with an immediate health risk requiring immediate action), and improper medication administration. (Refer to A-0273) The cumulative effects of these systemic problems resulted in the hospital’s inability to identify problem prone areas and ensure the provision of quality health care and nursing services in a safe environment and had the potential to cause adverse health outcomes (undesirable and harmful effects on someone’s health) which could interfere with the patients’ medical care and may jeopardize the health and safety of other patients.”

“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: 51269 Based on interview and record review, the hospital failed to maintain effective and organized nursing services for nine of 35 sampled patients (Patient 1, 5, 6, 9, 12,14, 16, 30 and 33) as evidenced by: 1. For one patient (Patient 33), the nursing staff did not ensure the computed tomography (CT-a test that uses x rays to create images of the body) angiogram (dye that is injected directly into the blood stream to visualize blood vessels) for Head and Neck was appropriately ordered and completed for the correct and intended patient. (Refer to A-0395) 2. For one patient (Patient 1), the nursing staff did not document vital signs (VS-basic body measurements including temperature (temp-with normal range of 36.5 Celsius (C - unit of measurement) to 37.2 C), blood pressure (bp - the force of blood moving through the arteries), pulse (heart rate), respiration (breathing) rate, oxygenation saturation (SPO2 - amount of oxygen in blood) before discharged. (Refer to A-0398) 3. For one patient (Patient 1), the nursing staff did not complete wound assessment appropriately. (Refer to A-0398) 4. For six patients (Patient 5, 6, 9,12,14, and 16), the nursing staff did not document patients’ temperature every two hours as required with every set of VS assessments. (Refer to A-0398) 5. For two patients (Patient 30 and 33), patient reassessments and VS were not conducted per the emergency department’s policy and procedures. (Refer to A-0398). 6. For one patient (Patient 1), the nursing staff did not reassess Patient 1’s BP after amlodipine (medication to treat blood pressure) administration. (Refer to A-0405) 7. For one patient (Patient 9), the nursing staff did not assess Patient 9 before and/or after Hydromorphone (medication to treat pain) administration. (Refer to A-0405) 8. For one patient (Patient 30), intravenous (IV-given through a tube directly into the blood stream) medications were ordered and administered without documented indication or supporting clinical justification. (Refer to A-0405) The cumulative effects of these systemic problems resulted in the hospital’s inability to provide consistent and adequate nursing services in a safe environment and potentially resulted in delayed supervision, monitoring, evaluation, and treatment which jeopardized the health and safety of the patients.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 47360 Based on interview and record review, the facility failed to ensure the contracted emergency service medical staff provided care in a safe and effective manner for two of 34 sampled patients (Patient 30 and 33) when: 1. For one patient (Patient 30), intravenous (IV - given through a tube directly into the blood stream) medications and a computed tomography angiogram (CTA- an imaging test that uses X-rays and contrast dye to create detailed images of the blood vessels) of the head and neck were ordered and administrated to Patient 30, without indication and intended for another patient. 2. For one patient (Patient 33), a critical radiology value (a result with an immediate health risk requiring immediate action) was not communicated in a timely manner to the emergency department (ED) nursing staff. These failures resulted in inappropriate medical treatment and diagnostics when the wrong patient (Patient 30) received medications and testing intended for another patient and delay in treatment and diagnostic results for Patient 33, which had the potential for drug interactions, organ damage, medical complications, further delay in treatment, and death. Findings: 1. During a review of Patient 30’s “Emergency Department Note” dated August 6, 2025, at 10:19 AM, the “Emergency Department Note” indicated, Patient 30 presented to the emergency department with symptoms including chest tightness, difficulty in breathing and anxiety. During a review of Patient 30’s “eMAR [electronic Medicine Administration Record] Administration Report” (eMAR), dated August 6, 2025, the “eMAR” indicated Prochlorperazine (medication used to treat nausea and vomiting, migraine and multiple mental health issues) 10 milligrams (mg - unit of measurement) IV was administered at 11:08 AM as ordered. There was no indication noted on the physician order. During a review of Patient 30’s “eMAR,” dated August 6, 2025, the “eMAR” indicated, Hydromorphone (fast-acting, powerful, narcotic pain medication) 0.5 mg IV was administered to Patient 30 at 12:35 PM. There was no indication noted on the physician order. During a review of Patient 30’s “Orders,” dated August 6, 2025, a CTA for Head and Neck was ordered and completed. The “Orders” included an indication as “[evaluation] subarachnoid hemorrhage” (bleeding in the brain). There were no symptoms noted in Patient 30’s “Emergency Department Note” consistent with bleeding in the brain. During a concurrent interview and record review on September 23, 2025, at 9:15 AM, with the Quality Coordinator (QC) and the Assistant Chief Nursing Officer (ACNO), Patient 30’s “Emergency Department Note: Addendum,” dated August 10, 2025, was reviewed. The “Emergency Department Note: Addendum” indicated, “ ...please note that the CT of the head and neck were accidentally ordered in error on this patient and this was communicated to the patient and her husband. Also the [hydromorphone] and [prochlorperazine] ordered for this patient were also an error. All of these orders were intended to be placed on another patient I had just seen with a severe headache ...” The ACNO stated that leadership were notified Medical Doctor 1 (MD 1) ordered the wrong medication and imaging for Patient 30, intended for another patient. MD 1 was not available to be interviewed. 2. During a review of Patient 33’s “Emergency Department Note,” dated Augst 6, 2025, at 10:10 AM, the “Emergency Department Note” indicated, Patient 33 presented to the emergency department with complaints including headache, dizziness and blurred vision and was currently taking prescription warfarin (a medication ‘blood thinner’ used to treat clots, but increase the risk for bleeding). During a concurrent interview and record review on September 24, 2025, at 11:00 AM, with the Emergency Department Observation Manager (EDOM), Patient 33’s “Imaging Report” and “Patient Audit Trail,” dated August 6, 2025, were reviewed. The “Imaging Report” indicated, “ [computerized tomography] (CT - a medical imaging procedure that uses X-rays to create detailed, cross-sectional images of the body’s internal structures) head/brain [without contrast] (intravenous dye to visualize blood vessels) ...Impression ...subdural hematoma with herniation (a life-threatening condition where a brain hemorrhage causes a blood clot to form under the brain’s outer membrane, leading to excessive pressure that forces brain tissue to shift into an abnormal position).” The “Imaging Report” also indicated, Medical Doctor 1 (MD 1) was notified by the radiologist of this critical finding on August 6, 2025, at 11:32 AM. A continuous concurrent interview and record review with the EDOM, the “Patient Audit Trail” indicated, Patient 33 was in a waiting area until an emergency room nurse assumed care at 12:47 PM (1 hour and 15 minutes after critical finding received), then Patient 33 was moved to a monitored bed. The EDOM stated, there was no documented evidence of communication between the physician and nursing regarding Patient 33’s subdural hematoma and escalation of services after MD 1 received notification of Patient 33’s critical finding from the radiologist. The EDOM further stated, there was also no documentation of interventions implemented or monitoring of Patient 33 for over one hour after the critical finding was communicated by radiology to MD 1. During an interview on September 24, 2025, at 11:10 AM, with Medical Doctor 2 (MD 2), MD 2 stated, all critical imaging results would be called directly to the provider, for example a brain bleed would be communicated to the doctor caring for the patient from the radiologist. MD 2 stated, once a critical result, such as a brain bleed is noted, the provider is expected to notify the charge nurse immediately so that the patient can be continuously monitored, neurosurgery can be consulted and interventions can be implemented, as a patient with a brain bleed can decompensate quickly. During a concurrent interview and record review, on September 24, 2025, at 11:45 AM, with the QC, the facility’s policy and procedure (P&P) titled, “Critical Results, Reporting of Critical Test/Procedure Results”, dated January 2023, was reviewed. The “P&P” indicated, “ ...Critical results are defined as a result that would constitute an immediate health risk to the individual or require immediate action ...3. Outpatient: The provider, CLS [Clinical Laboratory Science], nurse, or other individual receiving the critical result notifies the provider via direct verbal communication ... 4. Documentation: Written or electronic documentation by the reporting individual of the call date and time, content of the critical result report, names of both the reporting person and the recipient of the critical result(s), and completion of read-back, are completed at the time the notification is made ...” The QC stated, this is the only policy related to critical results and there was not a policy related to radiology specifically or the expectation of communication with the emergency department nurse regarding critical results received directly by the physician. During an interview on September 24, 2025, at 2:58 PM, with the Governing Board (GB), the complaint validation survey findings were reviewed. GB Member 1 (GBM 1) stated, the GB meets monthly as a whole and each committee including the Patient Safety Committee (PSC), and Medical Executive Committee (MEC) also meet monthly with a representative that reports to the GB. GBM 1 stated, recent process improvement focusses on the emergency department (ED) has been centered on patient throughput (the length of stay in the ED at which patients move through each stage of care, from arrival to discharge or transfer). GBM 1 further stated, the findings of this survey had not been issues identified prior and had not been presented to the GB during past meetings. GBM 2 stated that the quality of patient care and patient safety was the responsibility of GB. GBM 2 further stated, the GB needs to hold the PSC and the MEC accountable and provide continued oversight to ensure patient safety in the ED. During a review of the facility’s document titled, “Quality and Patient Safety Plan,” dated June 2025, the “Quality and Patient Safety Plan” indicated, “ ...The [Name of Hospital] Board of Directors: Ultimate authority for the Patient Safety program rests with the Board of Directors. It is the duty of the Board to assure patient care is safely delivered within the guidelines established by the medical staff and hospital leadership while meeting all standards and regulations. The Board may delegate responsibilities to other committees. The board prioritizes patient safety and responsibility for oversight of a system wide assessment on safety and execution of patient safety initiatives and operations with specific improvement plans and metrics ...””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 51269 Based on interview and record review, the Quality Assessment and Performance Improvement (QAPI) program failed to monitor, collect and analyze quality data for a universe of sampled 34 patients, when the QAPI failed to monitor, collect and analyze quality data regarding patients’ assessment and reassessment, timely report and intervention of critical radiology values (a result with an immediate health risk requiring immediate action), and improper medication administration. These failures across multiple patients and services demonstrate that the facility did not effectively track or analyze patient care processes, limiting its ability to detect patterns, correct deficiencies, and implement performance improvement measures. Findings: During an interview on September 24, 2025, at 2:14 PM, in the conference room with the QAPI team that consists of the Director of Quality and Medical Services (QMSS), Director of Emergency department (ED)/observation (DED), Emergency Department Observation Manager (EDOM), Pharmacy Clinical Coordinator (PCC), Associate Chief Nurse Officer (ACNO), Chief Nursing Officer (CNO), and Quality Coordinator (QC). The QMSS stated, issues found get escalated to the QAPI with the department vice president, then the data would go to the board of directors. A continuous interview on September 24, 2025, at 2:20 PM, with the QAPI team, the DED stated that the focus in the ED was to improve the flow. The DED implemented a flow coordinator because the department would get congested at the front of the ED. During a concurrent interview and record review on September 24, 2025, at 2:25 PM, with the QAPI team the “Quality and patient safety council meeting,” dated July 10, 2025, and September 11, 2025, was reviewed. The “Quality and patient safety council meeting” indicated the meeting minutes and the quality measures discussed with data collected from department directors. The survey team brought up some issues identified during survey including missing or incomplete vital signs (VS-basic body measurements including temperature (temp-with normal range of 36.5 Celsius (C - unit of measurement) to 37.2 C), blood pressure (bp - the force of blood moving through the arteries), pulse (heart rate), respiration (breathing) rate, oxygenation saturation (SPO2 - amount of oxygen in blood)) documentation prior to discharge, before and/or after medication administration; lack of required wound assessments; failure to record temperatures with vital signs every two hours; incomplete patient reassessments, untimely communication of critical radiology values, and improper administration of intravenous medications without clinical justification in the ED. The DED was unable to provide quality measures regarding action plans, trends, interventions, and evaluations regarding the survey team’s findings. The DED stated that the issues had not been identified or escalated to QAPI. During a review of the facility’s policy and procedure (P&P) titled “Quality and Patient Safety Plan” dated June 2025, the P&P indicated, “The Quality and Patient Safety Council ....13) collect and analyze safety metrics, use external benchmarks to monitor performance, evaluate care processes for opportunities to reduce risk of preventable harm and initiate improvement activities and patient events ...””

“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: 47360 Based on interview and record review, the facility failed to ensure the nursing staff supervised and evaluated the nursing care for one of 34 sampled patients (Patient 30) when the nursing staff did not ensure the computed tomography (CT-a test that uses x rays to create images of the body) angiogram (dye that is injected directly into the blood stream to visualize blood vessels) for head and neck was appropriately ordered and completed for the correct and intended patient. This failure had resulted in inappropriate test completed on Patient 30 which had the potential to cause unnecessary exposure to dye that could damage Patient 30’s organ, created stress, and loss of trust from patient and family with the healthcare team which could jeopardize Patient 30’s overall health condition and prolong hospitalization. Findings: During a review of Patient 30’s “Emergency Department Note,” dated August 6, 2025, at 10:19 AM, the “Emergency Department Note” indicated, Patient 30 presented to the emergency department with symptoms including chest tightness, difficulty in breathing and anxiety. During a concurrent interview and record review, on September 23, 2025, at 9:12 AM, with the Quality Coordinator (QC), Patient 30’s “Orders,” dated August 6, 2025, a CT angiogram Head and Neck was ordered and completed. The “Orders” included an indication as “[evaluation] subarachnoid hemorrhage” (bleeding in the brain). There were no symptoms noted in Patient 30’s “Emergency Department Note” consistent with bleeding in the brain. The QC confirmed Patient 30’s “Emergency Department Note” indicated patient presented to the ED with chest pain, difficulty breathing and anxiety. During a concurrent interview and record review on September 23, 2025, at 9:15 AM with the QC and the Assistant Chief Nursing Officer (CNO), Patient 30’s “Emergency Department Note: Addendum,” dated August 10, 2025, was reviewed. The “Emergency Department Note: Addendum” indicated, “ ...please note that the CT of the head and neck were accidentally ordered in error on this patient and this was communicated to the patient and her husband ... orders were intended to be placed on another patient I had just seen with a severe headache ...” The ACNO stated that leadership were notified Medical Doctor 1 (MD 1) ordered the wrong imaging that was intended for another patient. During an interview on September 23, 2025, at 4:45 PM, with Registered Nurse 2 (RN 2), RN 2 stated, he did not recall reviewing the order for CT angiogram of the head and neck. RN 2 further stated, the fast-track area (a waiting area with chairs where treatments and medication can be administered and patients monitored) is usually staffed with two nurses and patients rotate through the chairs quickly. RN 2 stated, there are times orders that may not be reviewed by nursing and verified as appropriate for the patient because it gets busy and there is not enough time to check. During a concurrent interview and record review, on September 24, 2025, at 10:45 AM, with RN 3, the policy and procedure (P&P) titled, “Medication Administration and Documentation in the Electronic Medication Record (eMAR),” dated September 2024, was reviewed. The P&P indicated, “ ...2. Order Acknowledgement/Administration ...b. Practitioner administering medication will know: i. why the patient is receiving medication, ii. what effects to expect, iii. What unusual effects may develop ...” RN 3 stated, safe practices to medication administration include the five rights (right patient, right drug, right dose, right route and right time) and include understanding what symptoms the patient had presented with and any current diagnoses. RN 3 stated, when orders did not match the patients’ presentation, then the ordering provider needed to be notified to confirm the indication for the order or if the order was meant for another patient. RN 3 stated, medications and diagnostic testing that includes contrast (dye injected directly into the blood stream during an angiogram) could cause worsening of a patient’s medical condition if given to the wrong patient. During a review of the facility’s job description (JD) titled, “Registered Nurse: Emergency Department,” dated March 20, 2025, the JD indicated, “ ...Promotes culture of safety for patients and employees through proper identification, reporting, documentation, and prevention ...Demonstrates the ability to formulate questions that address clinical issues ...Utilizes clinical reasoning and knowledge based on evidence-based practice outcomes and research studies as the basis for decision making and comprehensive care ...Implements care in a knowledgeable, skillful, consistent manner that is individualized to the patient’s unique ...Administers medication in a safe manner using knowledge of drug/substance and recognizes potential side effects or adverse reactions ...Collaborates with physicians and the healthcare team by providing appropriate data related to the medical condition of patient and clarifying issues related to medical treatment plan...” 51269”

“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: 51269 Based on interview and record review, the facility failed to ensure all licensed nurses adhered to hospital policies and procedures (P&P), provide adequate supervision and evaluation for nine of 34 sampled patients (Patient 1, 5, 6, 9, 12,14, 16, 30 and 33) when: 1. For one patient (Patient 1), the nursing staff did not document vital signs (VS-basic body measurements including temperature (temp-with normal range of 36.5 Celsius (C - unit of measurement) to 37.2 C), blood pressure (bp - the force of blood moving through the arteries), pulse (heart rate), respiration (breathing) rate, oxygenation saturation (SPO2 - amount of oxygen in blood) before discharged. 2. For one patient (Patient 1), the nursing staff did not complete wound assessment appropriately. 3. For six patients (Patient 5, 6, 9,12,14, and 16), the nursing staff did not document patients’ temperature every two hours as required with every set of VS assessments. 4. For two patients (Patient 30 and 33), the nursing staff did not reassess patients and complete vital signs every two hours per the emergency department (ED)’s policy and procedures. These failures resulted in the hospital’s inability to provide consistent and adequate nursing services in a safe environment and potentially resulted in delayed evaluation, treatment, deterioration of patient conditions, and unsafe patient care. Findings: 1. During a review of Patient 1’s “History and Physical” (H&P- a document containing demographic information), dated April 17, 2025, at 9:03 PM, the H&P indicated, Patient 1 was admitted on April 17, 2025, at 8:00 PM, for gastrostomy tube (G-tube-small soft tube that goes through the stomach to give foods, fluids, and medicine directly into the stomach) displacement. Patient 1 had medical history including chronic obstructive pulmonary disease (COPD- long term disease that makes it hard to breath because the air way sacs are damaged, typically requiring oxygen), congestive heart failure (CHF-heart is not pumping blood as well as it should causing blood and fluids to go back up into the lungs and other body parts), and respiratory failure (a condition where the respiratory system can’t adequately oxygenate the blood or remove carbon dioxide) status post (s/p- a term used to indicate that a patient has previously undergone a specific procedure, event, or treatment) tracheostomy (trach- A tracheostomy allows air to pass into the windpipe to help with breathing). A review of Patient 1’s “ED Discharge Assessment,” dated April 18, 2025, at 10:01 AM, indicated the patient left the facility at 10:01 AM. During an interview on September 24, 2025, at 8:45 AM, with Registered Nurse (RN 1), RN 1 stated patients in the ED should be getting reassessed at least every two hours or sooner and at least within one hour of discharge. RN 1 further stated that in the reassessment there should always be a set of VS. RN1 stated that the VS consists of Temperature, HR, BP, SPO2, RR and pain. During a concurrent interview and record review on September 24, 2025, at 9:18 AM, with RN 1, Patient 1’s “Vital Signs,” dated April 17, 2025, through April 18, 2025, were reviewed. The “Vital Sign” indicated, the last set of VS documented were on April 18, 2025, at 6:28 AM. RN 1 verified and confirmed the last set of VS. A follow-up interview and record review on September 24, 2025, at 9:20 AM, with RN 1, Patient 1’s “ED Discharge Assessment,” dated April 18, 2025, was reviewed. RN 1 verified and confirmed, Patient 1 was discharged from the facility on April 18, 2025, at 10:01 AM. RN 1 stated that there should have been at least two more sets of VS prior to Patient 1 being discharged. During a concurrent interview and record review on September 24, 2025, at 9:50 AM, with the ED Observation Night Shift Manager (EDOM) and Pre-Hospital Coordinator (PHC), Patient 1’s “Vital Signs,” dated April 17, 2025, through April 18, 2025, were reviewed. The “Vital Sign” indicated, the last set of VS documented on April 18, 2025, at 6:28 AM. The EDOM stated the expectation was that the nurses are documenting discharge VS at least one hour prior to the patient leaving the facility. The EDOM was unable to provide any documented evidence to show that the nursing staff completed Patient 1’s VS after April 18, 2025, at 6:28 AM. During a concurrent interview and record review on September 24, 2025, at 9:51AM, with the EDOM and PHC, the facility’s P&P titled, “Discharge of Patients from the Emergency Department,” dated March 2025, was reviewed. The P&P indicated, “ ...Vital signs must be taken within one hour of discharge or post [after] any medication administration ...” The EDOM and PHC both stated that the policy was not followed and should have been. The PHC stated it is important to obtain VS prior to discharge to make sure the patient is stable and ultimately for patient safety. 2. A review of Patient 1’s H&P, dated April 17, 2025, at 9:03 PM, indicated, Patient 1 was admitted on April 17, 2025, at 8:00 PM, for gastrostomy tube displacement. Patient 1 had medical history including COPD, CHF, and respiratory failure s/p trach. A review of Patient 1’s “ED Head to Toe,” dated April 17, 2025, at 8:36 PM, indicated “skin assessment ...skin color appropriate for race, warm, and dry. No wound or pressure ulcer [areas of skin damage that develop when pressure is applied to the same spot for an extended period] present ...” During an interview on September 24, 2025, at 8:55 AM, with RN 1, RN 1 stated when skin breakdown is noted on a patient the nursing staff are required to assess the skin or wound, take a picture of the wound, and document the assessment of the wound in the EHR (electronic health record- patients electronic medical record). During a concurrent interview and record review on September 24, 2025, at 9:15 AM, with RN 1, Patient 1’s “Skin photo documentation,” dated April 17, 2025, at 11:47 PM, and “ED notes,” dated April 17, 2025, through April 18, 2025, were reviewed. The “Skin photo documentation” indicated, “wound location: Perianal [area around the anus (opening at the end of the rectum)] / buttock. The “ED notes” did not indicate any wound to perianal area. RN 1 verified and confirmed that there was no documented evidence of wound to perianal area. RN 1 stated that a picture was not sufficient documentation of skin breakdown, and the nursing staff should document description of the skin or wound. During a concurrent interview and record review on September 24, 2025, at 9:48 AM, with the EDOM and PHC, the “skin photo documentation,” dated April 17, 2025, at 11:47 PM, was reviewed. The “Skin photo documentation” indicated, “wound location: Perianal/ buttock. The EDOM and PHC stated that the expectation was for nursing staff to also document the skin or wound assessment in the EHR. The EDOM was unable to provide any documented evidence to show that the nursing staff completed Patient 1’s skin assessment or nursing note with a description of the skin breakdown. During a concurrent interview and record review on September 24, 2025, at 9:49 AM, with the EDOM and PHC, the facility’s P&P titled, “Initial Wound Care treatment,” dated January 2025, was reviewed. The P&P “ ...3. Essential steps ...a. assess the wound ... vi. Complete wound assessment in the electronic record ...” The EDOM and PHC stated the policy was not followed because Patient 1’s EHR did not have additional documentation in relation to the picture that was obtained. The EDOM stated it is important for the nursing staff to document when the nursing staff notice a change to the skin to have a baseline and help track if the skin is progressing to help prevent Hospital Acquired Pressure Injuries (HAPIs- a pressure injury (PI- a sore that develops on the skin when there is too much pressure on one area for a long time) obtained in the hospital). 3a. A review of Patient 5’s H&P, dated September 14, 2025, indicated Patient 5 was admitted on September 14, 2025, for a motor vehicle accident (MVA- car accident), with a history of CHF. Patient 5 was found to have an acetabulum fracture (break in the socket of the hip bone where the thigh bone fits), fracture of superior pubic ramus (break in the front part of the pelvic bone near groin area), and sacral fracture (break in the sacrum, the triangle bone at the bottom of the spine). During a concurrent interview and record review on September 23, 2025, at 8:50 AM, with the Telemetry (Tele-patients with cardiac or heart monitoring) Manager (TM), Patient 5’s H&P, dated September 14, 2025, was reviewed. The H&P indicated, Patient 5 was admitted on September 14, 2025. The TM stated the date on the H&P was the day Patient 5 got admitted to the medical surgical unit (MS-patients with general health conditions or those with recent surgery) and that the date Patient 5 arrived at the facility was on September 12, 2025, at 8:44 PM. During an interview on September 24, 2025, at 8:45 AM, with RN 1, RN 1 stated patients in the ED should be getting reassessed at least every two hours or sooner and at least within one hour of discharge. RN 1 stated that in the reassessment there should always be a set of VS. RN1 stated that the VS consists of Temp, HR, BP, SPO2, RR and pain. During a concurrent interview and record review on September 24, 2025, at 9:00 AM, with RN 1, Patient 5’s “Vital Signs,” dated September 12, 2025, through September 14, 2025, were reviewed. The “Vital Signs” for Temp was not completed every two hours as follows: --September 12, 2025, at 8:50 PM, Temp: 36.5 C --September 13, 2025, at 6:21 AM, Temp: 36.5 C (9 hours and 29 minutes from previous) --September 13, 2025, at 9:41 AM, Temp: 36.5 C (3 hours and 20 minutes from previous) --September 14, 2025, at 8:18 PM, Temp: 36.8 C (34 hours and 37 minutes from previous) RN 1 verified and confirmed, the nursing staff did not document Temp as part of the VS at least every two hours and should have. RN 1stated, it is important for nursing staff to reassess patients and take a set of VS every two hours because that way the nursing staff can detect if there is a change in condition. 3b. A review of Patient 6’s H&P, dated September 19, 2025, indicated Patient 6 was admitted on September 19, 2025, for a fall in the shower. Patient 6 had a history of hypertension (high bp) and was found to have a fracture of the femur (broken thigh bone). During an interview on September 24, 2025, at 8:45 AM, with RN 1, RN 1 stated patients in the ED should be getting reassessed at least every two hours or sooner and at least within one hour of discharge. RN 1 stated that in the reassessment there should always be a set of VS. RN1 stated that the VS consists of Temp, HR, BP, SPO2, RR and pain. During a concurrent interview and record review on September 24, 2025, at 9:02 AM, with RN 1 Patient 6’s “Vital Signs,” dated September 19, 2025, through September 21, 2025, were reviewed. The “Vital Signs” for Temp was not completed every two hours as follows: --September 19, 2025, at 1:21 PM, Temp: 36.7 C --September 20, 2025, at 12:05 AM, Temp: 36.9 C (10 hours and 44 minutes from previous) --September 20, 2025, at 3:57 AM, Temp: 37 C (3 hours and 52 minutes from previous) --September 20, 2025, at 8:30 AM, Temp: 37.3 C (4 hours and 33 minutes from previous) RN 1 verified and confirmed, the nursing staff did not document Temp as part of the VS at least every two hours and should have. RN 1 stated, it is important for nursing staff to reassess the patients and take a set of VS every two hours because that way the nursing staff can detect if there is a change in condition. 3c. A review of Patient 9’s H&P, dated September 19, 2025, indicated Patient 9 was admitted on September 19, 2025, for chest pain. Patient 9 had a history of myocardial infarctions (Heart attacks). During a concurrent interview and record review on September 23, 2025, at 8:53 AM, with the TM, Patient 9’s H&P, dated September 19, 2025, was reviewed. The H&P indicated, Patient 9 was admitted on September 19, 2025. The TM stated the date on the H&P was the day Patient 9 got admitted to the MS unit and that the date Patient 9 arrived at the facility was on September 18, 2025, at 11:25 PM. During an interview on September 24, 2025, at 8:45 AM, with RN 1, RN 1 stated patients in the ED should be getting reassessed at least every two hours or sooner and at least within one hour of discharge. RN 1 stated that in the reassessment there should always be a set of VS. RN1 stated that the VS consists of Temp, HR, BP, SPO2, RR and pain. During a concurrent interview and record review on September 24, 2025, at 9:04 AM, with RN 1, Patient 9’s “Vital Signs,” dated September 18, 2025, through September 21, 2025, were reviewed. The “Vital Signs” for Temp was not completed every two hours as follows: --September 18, 2025, at 11:27 PM, Temp: 36.7 C --September 19, 2025, at 12:15 PM, Temp: 36.4 C (12 hours and 48 minutes from previous) --September 19, 2025, at 3:50 PM, Temp: 36.8 C (3 hours and 45 minutes from previous) --September 20, 2025, at 12:00 AM, Temp: 36.8 C (8 hours and 10 minutes from previous) RN 1 verified and confirmed, the nursing staff did not document Temp as part of the VS at least every two hours and should have. RN 1 stated, it is important for nursing staff to reassess the patients and take a set of VS every two hours because that way the nursing staff can detect if there is a change in condition. 3d. A review of Patient 12’s H&P, dated September 22, 2025, indicated Patient 12 was admitted on September 22, 2025, for face swelling. Patient 12 had medical history including hypertension, diabetes (high blood sugar), rheumatoid arthritis (a disease where your body starts attacking your own joints causing pain, swelling, stiffness), and neuropathy (nerve damage). During an interview on September 24, 2025, at 8:45 AM, with RN 1, RN 1 stated patients in the ED should be getting reassessed at least every two hours or sooner and at least within one hour of discharge. RN 1 stated that in the reassessment there should always be a set of VS. RN1 stated that the VS consists of Temp, HR, BP, SPO2, RR and pain. During a concurrent interview and record review on September 24, 2025, at 9:08 AM with RN 1, Patient 12’s “Vital Signs,” dated September 22, 2025, were reviewed. The “Vital Signs” for Temp was not completed every two hours as follows: --September 22, 2025, at 8:41 AM, Temp: 37.0 C --September 22, 2025, at 2:56 PM, Temp: 37.3 C (6 hours and 15 minutes from previous) RN 1 verified and confirmed, the nursing staff did not document Temp as part of the VS at least every two hours and should have. RN 1stated, it is important for nursing staff to reassess the patients and take a set of VS every two hours because that way the nursing staff can detect if there is a change in condition. 3e. A review of patient 14’s H&P, dated September 22, 2025, indicated Patient 14 was admitted on September 22, 2025, for weakness. Patient 14 has a history of diabetes, and cholecystectomy (surgical removal of the gallbladder (a small pouch under your liver that stroke fluid that helps digest fat)). During an interview on September 24, 2025, at 8:45 AM, with RN 1, RN 1 stated patients in the ED should be getting reassessed at least every two hours or sooner and at least within one hour of discharge. RN 1 stated that in the reassessment there should always be a set of VS. RN1 stated that the VS consists of Temp, HR, BP, SPO2, RR and pain. During a concurrent interview and record review on September 24, 2025, at 9:10 AM with RN 1, Patient 14’s “Vital Signs,” dated September 22, 2025, were reviewed. The “Vital Signs” for Temp was not completed every two hours as follows: --September 22, 2025, at 11:48 AM, Temp: 37.2 C --September 22, 2025, at 7:14 PM, no Temp documented (7 hour 26 minutes from previous) RN 1 verified and confirmed, the nursing staff did not document Temp as part of the VS at least every two hours and should have. RN 1stated that it is important for nursing staff to reassess the patients and take a set of VS every two hours because that way the nursing staff can detect if there is a change in condition. 3f. A review of patient 16’s H&P, dated September 3, 2025, indicated Patient 16 was admitted on April 3, 2025, for right knee pain. Patient 16 had medical history including atrial fibrillation (irregular heartbeat), CHF, hypertension, and prostate cancer (cells in the prostate (below the bladder that helps make fluid for semen), start growing out of control). Patient 16 was found to have tibial plateau fracture (broken top part of the shinbone) During an interview on September 24, 2025, at 8:45 AM, with RN 1, RN 1 stated patients in the ED should be getting reassessed at least every two hours or sooner and at least within one hour of discharge. RN 1 stated that in the reassessment there should always be a set of VS. RN1 stated that the VS consists of Temp, HR, BP, SPO2, RR and pain. During a concurrent interview and record review on September 24, 2025, at 9:10 AM, with RN 1, Patient 16’s “Vital Signs,” dated April 3, 2025, through April 5, 2025, were reviewed. The “Vital Signs” for Temp was not completed every two hours as follows: --April 3, 2025, at 4:53 PM, Temp: 36.8 C --April 5, 2025, at 1:51 PM, no Temp documented (44 hours and 58 minutes from previous) RN 1 verified and confirmed, the nursing staff did not document Temp as part of the VS at least every two hours and should have. RN 1 stated, it is important for nursing staff to reassess the patients and take a set of VS every two hours because that way the nursing staff can detect if there is a change in condition. During a concurrent interview and record review on September 24, 2025, at 9:55 AM, with the EDOM and PHC, the facility’s P&P titled, “triage guidelines,” dated February 2025, was reviewed. The P&P indicated, “ ...h. any patient who is triaged and remains in the Emergency Department’s waiting room due to department saturation or lack of bed capacity will be re-evaluated every 2 hours or as necessary for detection of deterioration of condition. The EDOM and PHC confirmed and verified that there was no documented evidence to show Temp was completed every two hours for Patient 5, 6, 9, 12,14, and 16. The EDOM stated the nursing staff did not follow the policy and should have because it is important to see changes in conditions and for patient safety. 47360 4a. During a review of Patient 30’s “Emergency Department Note,” dated August 6, 2025, at 10:19 AM, the “Emergency Department Note” indicated, Patient 30 presented to the emergency department with symptoms including chest tightness, difficulty breathing and anxiety. During a review of Patient 30’s “Care Assessments,” dated August 6, 2025, the “Care Assessments” indicated, Patient 30 was triaged (a rapid assessment in the emergency department to sort patients by the urgency of their condition, ensuring those with life-threatening problems get seen first and those with less severe issues can wait) with complaints of anxiety and chest pain, and vital signs were conducted, upon arrival to the emergency department at 10:14 AM. During a concurrent interview and record review, on September 23, 2025, at 3:41 PM, with the Registered Nurse Clinical Educator (RNCE), Patient 30’s “Patient Audit Trail” (timeline of events during ED visit), dated August 6, 2025, was reviewed. The “Patient Audit Trail” indicated, Patient 30 received prochlorperazine (medication used to treat nausea and vomiting, migraine and multiple mental health issues) 10 milligrams (mg - unit of measurement) intravenous push (IV- through a tube directly into a patient blood stream) at 11:08 AM, and hydromorphone (fast-acting, powerful, narcotic pain medication) 0.5 mg IV at 12:35 PM. There was no documented evidence of reassessment of Patient 30’s symptoms, pain or vital signs for approximately five hours, until patient was discharged home at 3:12 PM. The RNCE stated that the nurse should have been triggered to assess pain before and after the administration of hydromorphone, and vital signs should have been monitored. The RNCE stated, the prochlorperazine does not have a trigger for symptoms or charting prior to administration because there are multiple indications (specific reason for which a doctor orders a particular medication, test or treatment). The RNCE stated, all patients presenting to the ED are to be reassessed every two hours or more frequently as necessary. During a concurrent interview and record review, on September 23, 2025, at 4:42 PM, with RN 2, Patient 30’s “Patient Audit Trail,” dated August 6, 2025, was review. The “Patient Audit Trail” indicated, Patient 30 was medicated with prochlorperazine and hydromorphone, but there was no evidence of assessment or reassessment. RN 2 stated, Patient 30 was in fast track (a waiting area with chairs where treatments and medication can be administered and patients monitored), which was fast moving chairs and did not have specific ratio or patient assignment. RN 2 stated, the patient had already received prochlorperazine from a previous nurse and recalls he administered hydromorphone per order. RN 2 stated, he failed to document pain assessment. RN 2 stated, Patient 30 should have been assessed before and after receiving the prochlorperazine and hydromorphone and Patient 30’s vital signs should have been monitored because both medications can cause drowsiness. During a review of the facility’s P&P titled, “Medication Ordering, Administration, and Monitoring,” dated September 2024, the P&P indicated, “ ...B. Administration ...2. Before administration, the individual administering the medication will discuss any unresolved concerns about the medication with the patient’s licensed independent practitioner, prescriber (if different from the licensed independent practitioner), and/or staff involved with the patient’s care, treatment, and services ...C. Verification and Monitoring 1. Ongoing monitoring of medication effects on the patient will be based on patient perceptions, and practitioner’s assessments of changes in patient condition ...3. Administering practitioners will reassess the patient for therapeutic responses, adverse drug events or side effects to the mediation. This will be documented in the medical record ...” 4b. During a review of Patient 33’s “Emergency Department Note,” dated Augst 6, 2025, at 10:10 AM, the “Emergency Department Note” indicated, Patient 33 presented to the emergency department with complaints including headache, dizziness and blurred vision and was currently taking prescription warfarin (a medication ‘blood thinner’ used to treat clots, but increase the risk for bleeding). During a review of Patient 33’s “Care Assessments,” dated August 6, 2025, at 10:06 AM, the “Care Assessments” indicated, Patient 33 was triaged by nursing, vital signs were obtained and pain level assessed. During a concurrent interview and record review on September 23, 2025, at 9:20 AM, with the Quality Coordinator (QC), Patient 33’s “Patient Audit Trail,” dated August 6, 2025, at 1:58 PM, was reviewed. The “Patient Audit Trail” indicated, there was no documented evidence Patient 33 was reassessed related to symptoms or vital signs monitored during her wait in the emergency room for nearly four hours, until Patient 33’s admission to the Intensive Care Unit (ICU a hospital section for patients with critical, life-threatening conditions who need constant medical attention, specialized equipment, and life-support machines to monitor and maintain their vital bodily functions) at 2:06 PM with a diagnosis of subdural hemorrhage (a collection of blood that forms between the brain and its outer protective layer). The QC stated there was no documented evidence of vital signs or reassessment during that time in the emergency department. During a concurrent interview and record review, on September 23, 2025, at 3:41 PM, with the RNCE, the facility’s P&P titled, “Triage Policy,” dated June 2024, was reviewed. The “P&P” indicated, “ ...H. Any patient who is triaged and remains in the Emergency Department’s waiting room due to department saturation or lack of bed capacity will be re-evaluated every 2 hours or as necessary for detection of deterioration of condition ...” The RNCE stated Patient 33 should have been reassessed at least every two hours, or more frequently if needed. The RNCE stated there was no guideline for which patients required more frequent reassessments, or for patients that are being treated in a waiting room area, as that would be specific to the nurse caring for the patient.”

“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: 51269 Based on interview and record review, the facility failed to ensure that medications were administered in accordance with physician orders and accepted standards of practice for three of 34 sampled patients (Patient 1, 9, and 30) when: 1. For Patient 1, the nursing staff did not reassess Patient 1’s blood pressure (BP-the force of blood moving through the arteries with adult normal range being 120/80) after Amlodipine (medication to treat high blood pressure) administration. 2. For Patient 9, the nursing staff did not assess Patient 9 before and/or after Hydromorphone (medication to treat pain) administration. These failures placed patients at risk for ineffective treatment, and undetected adverse reactions which could negatively affect patients’ health. 3. For Patient 30, intravenous (IV-given through a tube directly into the blood stream) medications were ordered and administered without documented indication or supporting clinical justification. This failure resulted in inappropriate medical treatment given to Patient 30, who received medications intended for another patient, which could cause adverse health outcomes that negatively damage Patient 30’s organ, delay in treatment, and lead to actual harm or death. Findings: 1. A review of Patient 1’s “History and Physical” (H&P- a document containing demographic information), dated April 17, 2025, at 9:03 PM, the H&P indicated, Patient 1 was admitted on April 17, 2025, at 8:00 PM, for gastrostomy tube (G-tube-small soft tube that goes through the stomach to give foods, fluids, and medicine directly into the stomach) displacement. Patient 1 had medical history including chronic obstructive pulmonary disease (COPD- long term disease that makes it hard to breath because the air way sacs are damaged, typically requiring oxygen), congestive heart failure (CHF-heart is not pumping blood as well as it should causing blood and fluids to go back up into the lungs and other body parts), and respiratory failure (a condition where the respiratory system can’t adequately oxygenate the blood or remove carbon dioxide) status post (s/p- a term used to indicate that a patient has previously undergone a specific procedure, event, or treatment) tracheostomy (trach- A tracheostomy allows air to pass into the windpipe to help with breathing). During an interview on September 24, 2025, at 8:45 AM, with Registered Nurse (RN 1), RN 1 stated patients in the Emergency Department (ED) should be getting reassessed at least every two hours or sooner and at least within one hour of discharge. RN 1 further stated that in the reassessment there should always be a set of vital signs (VS-basic body measurements including temperature (temp-with normal range of 36.5 Celsius (C - unit of measurement) to 37.2 C), bp, pulse (heart rate), respiration (breathing) rate, oxygenation saturation (SPO2 - amount of oxygen in blood)). RN1 stated that the VS consists of Temp, HR, BP, SPO2, RR and pain. During a concurrent interview and record review on September 24, 2025, at 9:18 AM, with RN 1, Patient 1’s “Vital Signs” (VS), dated April 17, 2025, through April 18, 2025, and “Medication Administration Summary” (MAS), dated April 18, 2025, were reviewed. The VS indicated, the last set of VS documented were on April 18, 2025, at 6:28 AM, with a BP of 173/72 (high blood pressure). The MAS indicated, “AmLODIPine 10 mg [milligram-unit of measurement] tablet” was administered on April 18, 2025, at 6:28 AM. RN 1 verified and confirmed that the last set of VS was on April 18, 2025, at 6:28 AM, with a BP of 173/72 (high blood pressure) prior to the Amlodipine administration. A follow-up interview and record review on September 24, 2025, at 9:20 AM, with RN 1, Patient 1’s “ED Discharge Assessment,” dated April 18, 2025, was reviewed. The “ED Discharge Assessment” indicated, Patient 1 discharged from the facility on April 18, 2025, at 10:01 AM. RN 1 stated, the primary nurse should have reassessed Patient 1’s BP at least within an hour of the Amlodipine administration to evaluate the effectiveness of the blood pressure medication. RN 1 was unable to provide any documented evidence to show Patient 1’s BP was rechecked after Amlodipine was given. During a concurrent interview and record review on September 24, 2025, at 9:50 AM, with the ED Observation Night Shift Manager (EDOM) and Pre-Hospital Coordinator (PHC), Patient 1’s VS, dated April 17, 2025, through April 18, 2025, were reviewed. The VS indicated, the last set of VS documented on April 18, 2025, at 6:28 AM. The EDOM verified and stated, she was unable to provide any documented evidence to show that the nursing staff completed Patient 1’s VS after April 18, 2025, at 6:28 AM. During a concurrent interview and record review on September 24, 2025, at 9:52 AM, with the EDOM and PHC, the facility’s policy and procedure (P&P) titled, “Discharge of Patients after Medication Administration,” dated March 2025, was reviewed. The P&P indicated, “ ...Vital signs must be obtained prior to discharge after medication administration ...b. Repeat vital signs prior to patient discharge after any medication administration ...” The EDOM and PHC both stated that the policy was not followed and should have been. The PHC stated it is important to obtain VS prior to discharge to make sure the patient is stable, to know the efficacy of the medication and ultimately for patient safety. The PHC stated the nursing staff should reassess the blood pressure after administration of bp medications and if it did not drop the high blood pressure the physician should have been notified. 2. A review of Patient 9’s H&P, dated September 19, 2025, indicated Patient 9 was admitted on September 19, 2025, for chest pain. Patient 9 had a history of myocardial infarctions (heart attacks). During a concurrent interview and record review on September 23, 2025, at 8:53 AM, with the Telemetry (the area where patients received continuous heart monitoring) Manager (TM), Patient 9’s H&P, dated September 19, 2025, was reviewed. The H&P indicated, Patient 9 was admitted on September 19, 2025. The TM stated the date on the H&P was the day Patient 9 got admitted to the Medical Surgical unit (MS-patients with general health conditions or those with recent surgery) and that the date Patient 9 arrived at the facility was on September 18, 2025, at 11:25 PM. During an interview on September 24, 2025, at 9:06 AM, with RN 1, RN1 stated the nursing staff should assess patients’ pain at least 60 minutes before pain medication administration. RN 1 further stated, the nursing staff must reassess patients’ pain no more than 60 minutes after pain medication administration. A review of Patient 9’s “ED Pain Assessment [a scale from zero to 10, zero meaning patient does not have any pain, 10 meaning it is the worst pain possible],” dated September 18, 2025, at 11:34 PM, indicated Patient 9 reported “chest -pain level 9”. During a concurrent interview and record review on September 24, 2025, at 9:28 AM, with RN 1, Patient 9’s “MAR [medication administration record] DOCS [documents],” for Hydromorphone, dated September 19, 2025, were reviewed. The “MAR DOCS” indicated Hydromorphone 0.5 mg was administered with pain assessment as follows: September 18, 2025, at 11:34 PM pain level nine September 19, 2025, at 12:06 AM, given Hydromorphone (no pain assessment after) September 19, 2025, at 1:51 AM, given Hydromorphone (no pain assessment prior to administration) September 19, 2025, at 2:37 AM, pain level 10 September 19, 2025, at 4:17 AM, given Hydromorphone (no pain assessment before and after administration) September 19, 2025, at 7:45 AM, pain level 10 September 19, 2025, at 7:48 AM, given Hydromorphone RN 1 verified and confirmed that the nursing staff did not assess Patient 9’s pain before and/or after with every pain medication administration. RN 1 stated, it is important to document pain assessments to verify the effectiveness of the medication. Without reassessments the nursing staff would not know if the medication was working for the patients. During an interview on September 24, 2025, at 9:57 AM, with the EDOM and PHC, the PCH stated pain should be assessed with every VS. Typically, if the nurses are going to give a pain medication, the nurse should check pain level right before and after administration. The EDOM stated if it is an oral (by mouth) medication, the effectiveness should be assessed 45 to 60 minutes after medication administration. The EDOM further stated, if it is IV, the pain assessment should be completed within 15 to 30 minutes after medication administration. During a concurrent interview and record review on September 24, 2025, at 9:58 AM, with the EDOM and PHC, the facility’s P&P titled, “Pain Assessment and Management” dated March 2022 was reviewed. The P&P Indicated, “ ...c) a focused pain assessment is conducted before and after any pain treatment per standards of care ...4. Reassessment of pain treatment is a cornerstone of effective and safe pain management that evaluates the effectiveness and side effects of pain treatment (such as unwanted sedation). The timing for reassessment is dependent on the intervention and is timed around the peak effect of the treatment...” The EDOM and PHC verified and confirmed that the policy was not followed because the nursing staff did not assess pain prior and after the administration of the pain medication. The EDOM stated the facility did not have additional documentation regarding the missing assessments. The PHC stated it is important for the nursing staff to follow the policy to know the efficacy of the medications being provided and making sure the nursing staff are not over/[or] under medicating patients. 47360 3. During a review of Patient 30’s “Emergency Department Note,” dated August 6, 2025, at 10:19 AM, the “Emergency Department Note” indicated, Patient 30 presented to the ED with symptoms including chest tightness, difficulty breathing and anxiety. During a review of Patient 30’s “eMAR [electronic Medicine Administration Record],” dated August 6, 2025, the “eMAR” indicated Prochlorperazine (medication used to treat nausea and vomiting, migraine and multiple mental health issues) 10 mg IV was administered at 11:08 AM. There was no indication provided in the physician’s order for giving Prochlorperazine to Patient 30. During a review of Patient 30’s “eMAR,” dated August 6, 2025, the “eMAR” indicated, Hydromorphone 0.5 mg IV was administered to Patient 30 at 12:35 PM. There was no indication noted on the physician order for given Hydromorphone. During a concurrent interview and record review on September 23, 2025, at 9:15 AM, with the Quality Coordinator (QC) and Assistant Chief Nursing Officer (ACNO), Patient 30’s “Emergency Department Note: Addendum,” dated August 10, 2025, was reviewed. The “Emergency Department Note: Addendum” indicated, “ ...please note that ... the [hydromorphone] and [prochlorperazine] ordered for this patient were also an error. All of these orders were intended to be placed on another patient I had just seen with a severe headache ...” The ACNO stated that leadership was notified Medical Doctor 1 (MD 1) ordered the wrong medication, intended for another patient, to Patient 30. MD 1 was not available for the interview. During a concurrent interview and record review on September 23, 2025, at 4:45 PM, with RN 2, Patient 30’s “eMAR,” dated August 6, 2025, was reviewed. The “eMAR” indicated, Hydromorphone and Prochloperazine were administered, but there was no indication noted on the order and no assessment or reassessment of the patient regarding reason for giving the medication or response once medication was received. RN 2 stated, Patient 30 did have pain because he asked her, he just did not document Patient 30’s pain assessment. RN 2 stated, he could not speak as to why Patient 30 received the Prochloperazine as he was not the nurse giving that medication. RN 2 further stated, there should be a reason to give Prochloperazine though because it has many uses, and have many side effects including drowsiness, anxiety and dizziness. During a concurrent interview and record review, on September 24, 2025, at 10:45 AM, with RN 3, the facility’s P&P titled, “Medication Administration and Documentation in the Electronic Medication Record (eMAR),” dated September 2024, was reviewed. The P&P indicated, “ ...2. Order Acknowledgement/Administration ...b. Practitioner administering medication will know: i. why the patient is receiving medication, ii. what effects to expect, iii. What unusual effects may develop ...” RN 3 stated, safe practices to medication administration include the five rights (right patient, right drug, right dose, right route and right time) and include understanding what symptoms the patient had presented with and any current diagnoses. RN 3 stated, when orders did not match the patients’ presentation, then the ordering provider needed to be notified to confirm the indication for the order or if the order was meant for another patient. RN 3 stated, medications could cause worsening of a patient’s medical condition if given to the wrong patient. During a review of the facility’s job description (JD) titled, “Registered Nurse: Emergency Department,” dated March 20, 2025, the JD indicated, “ ...Promotes culture of safety for patients and employees through proper identification, reporting, documentation, and prevention ...Demonstrates the ability to formulate questions that address clinical issues ...Utilizes clinical reasoning and knowledge based on evidence-based practice outcomes and research studies as the basis for decision making and comprehensive care ...Implements care in a knowledgeable, skillful, consistent manner that is individualized to the patient’s unique ...Administers medication in a safe manner using knowledge of drug/substance and recognizes potential side effects or adverse reactions ...Collaborates with physicians and the healthcare team by providing appropriate data related to the medical condition of patient and clarifying issues related to medical treatment plan ...”.”