Saint John’s Health Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45774 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Patient Rights as evidenced by: 1. The facility failed to come to a resolution (decision) of a grievance (complaint that cannot be resolved in a short period of time) initiated (started) for one of 30 sampled patients (Patient 13) with notifications of receipt within 7 days and completion within 30 days in accordance with facility ’ s policy and procedure (P&P) on patient grievances. This deficient practice had the potential for patients not receiving responses and resolutions to their requests to investigate problems encountered during their stays at the facility. (Refer to A-0118) 2. The facility failed to provide care in a safe setting for one of 30 sampled patients (Patient 1) when the emergency department (ED) triage nurse (Registered Nurse [RN] 1, a RN who acts as the first clinical contact in emergency or urgent care settings, assessing patients’ symptoms to prioritize care based on the severity of their condition) failed to recognize urgency of Patient 1 ’ s request to be admitted on a 5150 hold (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves]) in accordance with the facility ’ s policy and procedure on triaging, which led to a failure to identify elopement (escaping) risk. This deficient practice resulted in Patient 1 eloping without the facility ’ s knowledge and action, and Patient 1 was later discovered deceased, hanging from one of the trees on the hospital grounds. (Refer to A-0144) 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: 45774 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 ensure for one of 30 sampled patients (Patient 18), an individualized nursing care plan (an electronic document that helps a patient ’ s care team communicate and organize patient care among health care providers) for Peripheral Inserted Central Catheter (PICC, a catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous [in the vein] treatment that is required over a long period) was initiated in accordance with facility ’ s policy and procedure (P&P) on nursing care plans. This deficient practice had the potential to result in delayed provision of care to the patients by not identifying Patients 18 ’ s needs and risks. (Refer to A-396). 2. The facility failed to ensure: A. Three of 30 sample patients (Patient 13, Patient 17, and Patient 19) pain assessment (pain assessment includes a pain scale uses numbers from 0 to 10, with 0 representing no pain and 10 representing the worst pain possible, location of pain, character of pain, and duration of pain) was not completed prior to medication administration and after pain medication administration to determine if treatment was effective, were implemented in accordance with the facility ’ s policy and procedures for pain management. This deficient practice had the potential for Patient 13, Patient 17, and Patient 19 ’ s pain not to be managed adequately. (Refer to A-398). B. One of 30 sampled patients (Patient 17) , Lactated Ringers (a solution used to restore fluids and electrolytes in the body) intravenous (IV-in the vein) solution bag the tubing was not labeled to include the date and time tubing is to be changed. This deficient practice may have resulted in increased risk for intravascular catheter related infections. (Refer to A-398). C. One of 30 sampled patients (Patient 18), Peripheral Inserted Central Catheter (PICC, a catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous [in the vein] treatment that is required over a long period) dressing was changed every seven days in accordance with the facility ’ s policy and procedure (P & P). This deficient practice had the potential to result in complications such as a central line bloodstream infection (CLABSI, occurs when bacteria or other germs enter the patient ’ s central line and then enter their bloodstream) that may lead to the patient ’ s deterioration of medical condition and prolonged hospital stay. (Refer to A-398). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 45774 Based on interview and record review, the facility failed to come to a resolution (decision) of a grievance (complaint that cannot be resolved in a short period of time) initiated (started) for one of 30 sampled patients (Patient 13) with notifications of receipt within 7 days and completion within 30 days in accordance with facility ’ s policy and procedure (P&P) on patient grievances. This deficient practice had the potential for patients not receiving responses and resolutions to their requests to investigate problems encountered during their stays at the facility. Findings: During an interview on 12/11/2025 at 1:42 p.m. with the Risk Management Analyst (RMA), RMA stated the facility acknowledged Patient 13 voiced a grievance regarding the quality of care during her Emergency Department (ED) visit on 4/18/2025. The RMA stated Patient 13 filed a grievance that alleged Patient 13 was not acknowledged in any way regarding her (Patient 13 ’ s) physician ’ s call or the nature of the physician ’ s referral and the triage nurse was dismissive and unprofessional. The RMA stated Patient 13 ’ s grievance also alleged the Physician Assistant (PA) who attended her (Patient 13) lacked any bedside manner, was rushed, and her (Patient 13 ’ s) concerns were not met. In the same interview, the RMA stated that Patient 13 ’ s grievance was received via email originally on 4/21/25 by the Performance Improvement Coordinator. The RMA stated she received the formal grievance on 4/28/25. The RMA subsequently (next) stated, after reviewing risk management documentation, the response to Patient 13 ’ s grievance took longer than 30 days as per the hospital’s grievance policy. During a review of an email from Performance Improvement Coordinator (PIC) to Service Needs (a group of facility staff that included the RMA) dated 4/21/2025, PIC wrote “we received the below complaint. Forwarding for your review.” The PIC ’ s email included Patient 13 ’ s complaint regarding “Type of complaint: Quality of care/staff/ Provider.” The email indicated that Patient 13 was concerned that she (Patient 13) was not acknowledged in any way regarding her (Patient 13 ’ s) physician ’ s call or the nature of her referral, and the triage nurse was dismissive and unprofessional. In the same email, Patient 13 ’ s grievance also alleged the Physician Assistant (PA) who attended her (Patient 13) lacked any bedside manner, was rushed, and her (Patient 13) pain concerns were not met. Patient 13 ’ s grievance requested a thorough review of this alleged incident. During a review of a grievance resolution letter addressed to Patient 13 via email between the Risk Management Analyst (RMA) and Patient 13, dated 6/5/25 (45 days after initial receipt of the grievance letter from Patient 13), the letter indicated the RMA informed Patient 13, “After a thorough review of the circumstances of your care it was concluded that the treatment provided was appropriate given your clinical presentation at the time ...” In the same interview, RMA stated it is important to resolve grievances promptly within 30 days to make sure the concerns are taken seriously and make changes or to take actions regarding the grievances. During a review of the facility ’ s policy and procedure (P&P) titled, “Patient Complaints and Grievances,” revised on 8/2025, the P&P indicated, “Review, investigate, and resolve grievances promptly, with notifications of receipt within 7 days and completion within 30 days ...””

“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: 45774 Based on interview and record review, the facility failed to provide care in a safe setting for one of 30 sampled patients (Patient 1) when the emergency department (ED) triage nurse (Registered Nurse [RN] 1, a RN who acts as the first clinical contact in emergency or urgent care settings, assessing patients’ symptoms to prioritize care based on the severity of their condition) failed to recognize urgency of Patient 1 ’ s request to be admitted on a 5150 hold (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves]) in accordance with the facility ’ s policy and procedure on triaging, which led to a failure to identify elopement (escaping) risk. This deficient practice resulted in Patient 1 eloping without the facility ’ s knowledge and action, and Patient 1 was later discovered deceased, hanging from one of the trees on the hospital grounds. Findings: During a concurrent interview and record review, Patient care timeline on 12/8/25 at 10:59 a.m. with Accreditation and Regulatory Program Manager (ARPM), ARPM stated that Patient 1 was a walk-in the Emergency Department (ED) on 10/13/25 at 7:38 p.m. Patient 1 informed registration staff (staff responsible for registering patients at a healthcare facility) that Patient 1 arrival complaint was 5150 (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves]). Patient 1 was then sent to triage (preliminary assessment of patients) at 7:39 p.m.. In triage, it was noted by the triage nurse (RN 1) that Patient 1 was refusing to answer RN 1 ’ s questions and walked out at the beginning of triage. At 7:50 p.m., Patient 1 was noted to have eloped (leave without permission). At 10:37 p.m., security was doing a patrol of hospital perimeter and found Patient 1 dead, hanging from a tree within facility premises. The police department was called, and officers arrived immediately as they were on-duty in the ED with another patient. During a concurrent interview and record review, Patient care timeline on 12/8/25 at 10:53 a.m. with Educator (EDE 1), Patient 1 presented himself to the facility ED on 10/13/24 at 7:38 p.m. and told the registrar, “I want 5150 hold.” On 10/13/24 at 7:50 p.m., Registered Nurse (RN) 1 documented that Patient 1 refused to answer triage questions and walked out at the beginning of triage process. Patient 1 left the ED triage area and went toward the ED door. EDE 1 stated that RN 1 also mentioned that Patient 1 requested Seroquel (an antipsychotic medication) during the triage process. EDE 1 also stated that the registration information was documented in EPIC (the facility ’ s electronic medical record system) during the registration process that Patient 1 was a 5150 patient. However, EDE 1 stated that RN 1 mentioned that she was not aware of Patient 1 ’ s chief complaint as a 5150 hold and did not review the registration part of EPIC for Patient 1. During an interview on 12/10/25 at 10:19 a.m. with RN 1, RN 1 stated that she did not review the registration information that Patient 1 ’ s chief complaint is 5150 in EPIC. RN 1 stated she went straight to triage portion of EPIC for triage process. During a review of Patient 1 ’ s “Patient Care Timeline,” dated 10/13/25, the “Timeline” indicated that Patient 1 ’ s name was called out at 7:39 p.m. and then Patient 1 eloped at 7:50 pm. During an interview on 12/8/25 at 11:03 a.m. with Patient Access Supervisor (PAS), the PAS stated that the registrar inputs a patient ’ s chief complaint in the “Registration” tab in EPIC during the registration process. During an interview on 12/8/25 at 11:12 a.m. with the Emergency Department Educator (EDE), EDE stated that RN 1 was not aware Patient 1 walked into ED and told the registrar he (Patient 1) wanted to be placed on a 5150 hold as the reason for his ED visit; registration staff did not relay this information to RN 1. However, that information was available and viewable to RN 1 from the ED narrative flowsheet. During an interview on 12/8/25 at 11:22 a.m. with the Director of the Emergency Department (DED), DED stated that “5150s” were patients identified to be either gravely disabled, danger to self, and/or danger to others. Patient 1 was a 5150 patient. DED further stated that staff were expected to call code green (a hospital-wide call for help when a patient elopes) for a 5150 patient who eloped. During an interview on 12/8/25 at 11:56 a.m. with Accreditation and Regulatory Program Manager (ARPM), ARPM stated that RN 1 identified patient to have eloped at 7:50 PM. APRM stated staff did not call law enforcement or a code green at the time when Patient 1 eloped. During a review of the facility ’ s policy and procedure (P&P) titled, “Triage”, revised 07/2021, the P&P indicated, “Patients presenting to the ED will have as assessment that will include, but not limited to review of the chief complaint and associated symptoms ...” During a review of the facility ’ s P&P titled, “Suicide Risk Assessment and Prevention”, revised 10/2020, the P&P indicated that if patient is unable to participate in the suicide risk screening process, staff must observe patient for suicidal/ self-harm behaviors and complete screening once patient is able to participate. During a review of the facility ’ s P&P titled, “Code Green Patient Elopement”, revised 6/2018, the P&P indicated, “Upon the discovery of an elope patient ...together, the house supervisor, security and charge nurse will determine if the situation warrants Code green announcement ...if the house supervisor deems that the patient is missing from a patient care area, and does not meet the high-risk/elopement criteria, security will assist with retrieving the patient.” During a review of the facility ’ s P&P titled, “Patients Leaving Prior to being Discharged”, dated 10/2024, indicated, “Elopement ...When the ED nurses becomes aware that the patient has left, the appropriate law enforcement agency is notified, if indicated. i.e., for a psychiatric patient .... Documentation of the incident in the medical record should include, why the patient is leaving, the patients physical and emotional condition prior to leaving the ED, and any pertinent statement(s) made by the patient or family to the ED staff.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 45774 Based on interview and record review, the facility failed to ensure for one of 30 sampled patients (Patient 18), an individualized nursing care plan (an electronic document that helps a patient ’ s care team communicate and organize patient care among health care providers) for Peripheral Inserted Central Catheter (PICC, a catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava (large vein that carry blood from the upper right body and return it to the heart), and used for intravenous [in the vein] treatment that is required over a long period) was initiated in accordance with facility ’ s policy and procedure (P&P) on nursing care plans. This deficient practice had the potential to result in delayed provision (services) of care to the patients by not identifying Patients 18 ’ s needs and risks. Findings: During a review of Patient 18 ’ s “Face Sheet (a document containing a patient ’ s medical and demographic information),” (undated), indicated Patient 18 admitting diagnosis was spinal epidural abscess (SEA, a serious, rare infection causing a pus collection in the space between the spinal bones and the spinal cord ’ s protective lining (dura mater), leading to severe back pain, fever, and neurological issues [affecting the brain, spinal cord and nerves]). During a review of Patient 18 ’ s “Insert Peripheral Central Catheter (PICC, a catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava (large vein that carry blood from the upper right body and return it to the heart), and used for intravenous [in the vein] treatment that is required over a long period) line” dated 11/19/2025, the procedure order indicated Patient 18 to be inserted a PICC line on 11/19/2025. During a concurrent interview and record review on 12/11/2025 at 3:35 p.m., with Ortho Manager (OM), OM verified Patient 18 ’ s “LDA Avatar (Lines, Drains, Airways, electronic health record system used by nurses to document)” indicated, Patient 18 ’ s PICC line reason for use indicated “Long term infusion therapy or antibiotics.” OM stated Patient 18 ’ s nursing care plan for Central line was initiated on 11/30/2025 (11 days after the day it should have been initiated). OM stated the nurses should have initiated the Central Line Care plan on 11/19/25 within the shift to monitor Patient 18 ’ s progress, and the nurses would communicate to care for the Patient 18. During a review of the facility ’ s policy and procedures (P&P) titled, “Plan of Care,” revised in 06/2022, indicated, “3. Ongoing management of the plan of care (POC)-The RN is responsible to update the POC as needed to reflect the patient ’ s current, active needs. As a patient ’ s needs change (e.g.: new diagnosis or procedure, resolved problem, recognition of changing goals or strategies, etc.) the POC should be revised to reflect those changes ...During the shift of care, document assessments, interventions, and education performed to prevent and manage complications in the appropriate screens and flowsheet ...””

“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 Based on observation, interview, and record review the facility failed to ensure: 1.Three of 30 sample patients (Patient 13, Patient 17, and Patient 19) pain assessment (pain assessment includes a pain scale uses numbers from 0 to 10, with 0 representing no pain and 10 representing the worst pain possible, location of pain, character of pain, and duration of pain) was not completed prior to medication administration and after pain medication administration to determine if treatment was effective, were implemented in accordance with the facility ’ s policy and procedures for pain management. This deficient practice had the potential for Patient 13, Patient 17, and Patient 19 ’ s pain not to be managed adequately. 2.One of 30 sampled patients (Patient 17) , Lactated Ringers (a solution used to restore fluids and electrolytes in the body) intravenous (IV-in the vein) solution bag the tubing was not labeled to include the date and time tubing is to be changed. This deficient practice may have resulted in increased risk for intravascular catheter related infections. 3.One of 30 sampled patients (Patient 18), Peripheral Inserted Central Catheter (PICC, a catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous [in the vein] treatment that is required over a long period) dressing was changed every seven days in accordance with the facility ’ s policy and procedure (P & P). This deficient practice had the potential to result in complications such as a central line bloodstream infection (CLABSI, occurs when bacteria or other germs enter the patient ’ s central line and then enter their bloodstream) that may lead to the patient ’ s deterioration of medical condition and prolonged hospital stay. Findings: 1.A. During a review of Patient 13 ’ s “Emergency Provider (ED) Provider Note,” dated 4/18/2025, the ED Provider Note indicated Patient 13 was admitted to the facility with a diagnosis of left ovarian cyst (a fluid filled sac that forms on or within an ovary (female reproductive gland that produces eggs)). During a review of Patient 13 ’ s “Medication Administration Report (MAR)” dated 4/18/2025, the MAR indicated a physician ’ s order for Patient 13 to receive the following: - Toradol (pain medication) 15 milligram (mg -a unit of measurement) intravenous (IV-in the vein) once with a start date of 4/18/25. During a concurrent interview and record review, on 12/10/2025 at 3:17 p.m., with Emergency Department Manager (EDM), EDM verified Patient 13 ’ s MAR indicated on 4/18/25 at 11:46 a.m., Patient 13 was given Toradol 15 mg IV. The corresponding pain assessment indicated Patient 13 ’ s pain score was 7 (severe pain) before medication administration. During a concurrent interview and record review on 12/10/2025 at 03:25 p.m., with EDM, the EDM verified there was no documentation of Patient 13 ’ s pain reassessment after pain medication was administered on 4/18/25 at 11:46 a.m. The EDM stated nurses should reassess the patient ’ s pain within 30 minutes after administration of IV pain medication to know if the medication was working. During a review of the document title, “Addendum A: [Name of the Facility] Assessment and Documentation Guidelines for Nursing,” undated, provided by the facility indicated “Pain assessment: Pain rating with prior to administering pain medication. Following administration of pain medication to assess effect ...” During a review of the facility ’ s policy and procedure (P&P) titled, “Medication Range Orders,” dated 5/2024, the P&P indicated, “A. for pain medications: assessment, monitoring and objective measures will be done as per ministry- specific pain management policy ...1. After at least 30 minutes for IV administration (if ordered frequency is less than 30 minutes, RN will perform reassessment prior to giving the next dose.) ...D. Re-assessment is completed and documented according to patient condition and expected response to intervention. Evaluation of plan is recommended if expected response does not occur ....” B. During a review of Patient 17 ’ s “History & (and) Physical (H&P),” dated 12/3/2025, the H&P indicated Patient 17 was admitted to the facility with a diagnosis of Chronic Bilateral L 5 (fifth lumbar vertebra in the spine) Pars Defects (long standing stress fractures on both sides of the small bone bridge connecting the L5 vertebra, often causing persistent low back pain, stiffness, especially with extension/ twisting, and potentially radiating leg symptoms). During a review of Patient 17 ’ s “Medication Administration Report (MAR-document patient medication administration)” dated 12/9/2025, the MAR indicated a physician ’ s order for Patient 17 to receive the following: - Oxycodone (pain medication) 5-10 milligram (mg-a unit of measurement) tablet oral (by mouth) every 3 hours as needed (PRN) for moderate pain (pain score of 4-7 is moderate pain), severe pain (pain score of 8-10 is severe pain), “Administration Instructions: Moderate pain (4-7): Give if pain is not controlled with acetaminophen and NSAID or if not ordered. Severe pain (8-10): Give with Acetaminophen and NSAID as ordered. If dose range is ordered. Initial dose must be the lowest dose. If ineffective upon reassessment, repeat lowest dose after at least 60 mins. For future doses, administer last effective dose with acceptable Pasero Sedation Scale (is a valid, reliable tool used to assess sedation when administering opioid [pain medication] medications to manage pain) at the next allowable time unless patient prefers the lowest dose.” During a concurrent interview and record review, on 12/10/2025 at 4:04 p.m., with Ortho Manager (OM), OM verified Patient 17 ’ s corresponding pain assessment in the medication record (MR- document patient medication administration) titled, “Flowsheets-Pain/Comfort,” was not completed. OM verified Patient 17 ’ s MAR indicated the following medication administration: -On 12/9/2025 at 12:42 p.m. Patient 17 was administered Oxycodone 10 mg tablet; the pain assessment was not completed. The corresponding pain assessment did not indicate the pain score, location of pain, and pain quality. - -On 12/10/2025 at 5:45 a.m. Patient 17 was administered Oxycodone 10 mg tablet; the pain assessment was not completed. The corresponding pain assessment did not indicate the pain score, location of pain, and pain quality. During a concurrent interview and record review on 12/10/2025 at 04:20 p.m., with OM, the OM stated a complete pain assessment includes the pain score, location of pain, and pain quality. OM stated a complete pain assessment was not performed by nursing care and the expectation is to document the full pain assessment prior to medication administration for Patient 17. During a review of the document title, “Addendum A: [Name of the Facility] Assessment and Documentation Guidelines for Nursing,” undated, provided by the facility indicated “Pain assessment: Pain rating with prior to administering pain medication. Following administration of pain medication to assess effect ...” During a review of the facility ’ s policy and procedure (P&P) titled, “Medication Range Orders,” dated 5/2024, the P&P indicated, “A. for pain medications: assessment, monitoring and objective measures will be done as per ministry- specific pain management policy ...1. After at least 30 minutes for IV administration (if ordered frequency is less than 30 minutes, RN will perform reassessment prior to giving the next dose.) ...D. Re-assessment is completed and documented according to patient condition and expected response to intervention. Evaluation of plan is recommended if expected response does not occur ....” C. During a review of Patient 19 ’ s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 6/24/2024, indicated, Patient 19 was admitted to the facility for a relapse(worsening)in acute myeloid leukemia (AML, a type of cancer that starts in the blood cells of the bone). During a record review of the “Medication Orders” dated 07/13/2024, indicated Hydromorphone (Dilaudid) (pain medication) 0.2 milligrams (mg-unit for mass) intravenous (IV-medication given through a small tube into a vein) was ordered every two hours as needed (PRN) for pain. During record review on 12/10/2025 at 2:30p.m.. with the Oncology Manager (OMRN). Patient 19 ’ s “Medication Administration Record” (MAR- medical record showing what time and who administered medications) was reviewed. The MAR indicated Dilaudid 0.2 mg IV was given to Patient 19 at 5:03p.m. and 5:35p.m. During an interview on 12/10/2024 at 2:43p.m. with OMRN, OMRN stated “ I do not see a pain assessment done initially or reassessment documented. The last pain assessment is at 1:56p.m. The pain assessment and reassessment are necessary to determine if the pain medication given has been effective. The expectation is that the Registered Nurse (RN) documents pain assessment initially and reassess pain 30 minutes after if it was given by IV. The consequences of not documenting pain assessments are that the RN will not know if the pain medication has been effective.” During a concurrent interview and record review on 12/11/2025 at 10:17a.m. with the Stroke Program Manager (SPMRN), Patient 19 ’ s MAR was reviewed. The MAR indicated Dilaudid 0.2 mg IV was given to Patient 19 at 5:03p.m. and 5:35p.m. SPMRN stated “I do not see a pain medication assessment, the last one was documented at 1:56PM. The pain assessment determines current level of pain, and if an opportunity arises to help decrease pain, then the nursing staff can help by administering pain medication and documenting if pain medication is being tolerated by patients. The expectations of nurses documenting pain medications is that the RN will document pain medication per policy based on route given” During a review of the facility ’ s Policy and Procedure (P&P) titled, “Medical Administration”, dated 07/2024, indicated Medical Documentation .... D. Pre and post administration assessment of symptoms are recorded for PRN (as needed) medications. During a review of the facility ’ s Policy and Procedure (P&P) titled, “Medication Range Orders”, dated 5/2024, indicated Range Orders- Assessment and Monitoring ...C. Reassess the patient when drug approximately reaches peak effect if needed per provider order or ministry-specific policy: After at least 30minutes for IV administration (if ordered frequency is less than 30 minutes, RN will perform reassessment prior to giving the next dose.) 2.During a concurrent observation and interview, on 12/10/2025 at 11:45 a.m., with Registered Nurse (RN) 2, inside Patient 17 ’ s room, Patient 17 ’ s Lactated Ringers (a solution used to restore fluids and electrolytes in the body) IV solution bag tubing was observed not labeled to include the date and time tubing is to be changed. RN 2 stated the Patient 17 ’ s IV tubing was missing a label with date and time to be changed. RN 2 further stated the importance of labeling the IV tubing was to inform other staff regarding the date and time tubing is to be changed. During a review of Patient 17 ’ s “History and Physical (H&P),” dated 12/3/2025, indicated Patient 17 was admitted to the facility with a diagnosis of Chronic Bilateral L 5 (fifth lumbar vertebra in the spine) Pars Defects (long standing stress fractures on both sides of the small bone bridge connecting the L5 vertebra, often causing persistent low back pain, stiffness, especially with extension/ twisting, and potentially radiating leg symptoms). During a review of the facility ’ s policy and procedure (P&P) titled, “Comprehensive Vascular Access Management,” revised in 5/2023, indicated, “7. Label IV tubing with the date and time tubing is to be changed.” : 3.During an observation and interview, on 12/10/24 at 2:13 p.m., with Registered Nurse 3 (RN 3), Patient 18 was observed in bed, awake and oriented. Patient 18 had a PICC line (a catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous [in the vein] treatment that is required over a long period line on the right arm) was covered with a transparent dressing, the PICC dressing was labeled with a faded date. RN 3, who was Patient 18 ’ s assigned RN, verified the PICC line dressing labeled had a faded date (unable to read the date of last dressing changed). RN 3 stated Patient 18 ’ s PICC line had stopped functioning overnight. During a review of Patient 18 ’ s “Face Sheet (a document containing a patient ’ s medical and demographic information),” (undated), the indicated, Patient 18 admitting diagnosis was Spinal epidural abscess (SEA, a serious, rare infection causing a pus collection in the space between the spinal bones and the spinal cord ’ s protective lining (dura mater), leading to severe back pain, fever, and neurological issues [affecting the brain, spinal cord and nerves]). During a review of Patient 18 ’ s “Insert PICC line” dated 11/19/2025, the procedure order indicated Patient 18 to be inserted a PICC line on 11/19/2025. During a concurrent interview and record review, on 12/11/25 at 11:58 a.m., with Stroke Program Manager (SPRM), SPRM verified Patient 18 ’ s “flowsheets: PICC line 11/19/25 7:07p.m., Single Lumen Basilic Vein (medial side of arm), Right,” dated 12/8/2025, the flowsheet indicated Patient 18 ’ s PICC dressing was last changed on 12 /1/25 and it was not changed on 12/8/25 (the PICC dressing changed was due for changed). SPRM verified there was no other documentation that indicated the PICC line dressing change was completed on 12/8/25. SPRM stated Patient 18 ’ s PICC line dressing should be changed every seven (7) days to prevent risk of infection, securement of the PICC device, and complications such as a central line bloodstream infection. During a review of the facility ’ s policy and procedures (P&P) titled, “Comprehensive Vascular Access Management,” revised in 5/2023, indicated “5. A transparent, semipermeable membrane dressing is changed every seven (7) days or when the dressing integrity is compromised (damp, loosed, or visibly soiled), if moisture, drainage, or blood is present under the dressing, or for further assessment.””

“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: 42937 Based on interview and record review, the facility’s Governing Body failed to assume full legal responsibility for implementing, and monitoring policies governing the facility’s process of suicide screen by use of the Columbia Suicide Severity Rating Scale screener tool. The facility’s Governing Body failed to provide oversight for quality health care in a safe environment. The facility did not meet the condition for coverage in governing body and management by failing to: 1. Ensure staff adhere to the process on assessing patients for suicide and implement safety measures in accordance with the facility’s policy and procedure. This deficient practice resulted in Patient 1 not being properly assessed and no safety measures in-place. Patient 1 eloped from the Emergency Department (ED) and was found dead 1 mile away from the facility by the police department. (Refer to A-144) 2. Ensure that QAPI (Quality Assessment & Performance Improvement) Committee implemented an effective plan of correction that ensured staff adherence to the facility’s policy and procedure (P&P) titled “Suicide Risk Assessment and Prevention” after the incident of Patient 1’s elopement on 6/15/22. This deficient practice can lead to the reoccurrence of failing to implement suicide safety measures on patient who are unable to participate in the CSSRS screening process or is providing any answer other than “yes” or “no”. (Refer to A-273 and A-286) The cumulative effect of these systemic practices resulted in the facility’s inability to ensure the governing body had oversight and accountability for all the facility’s activities and total operations.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42937 Based on interview and record review, the facility to: Ensure staff adhere to the process on assessing patients for suicide and implement safety measures in accordance with the facility’s policy and procedure. This deficient practice resulted in Patient 1 not being properly assessed and no safety measures in-place. Patient 1 eloped from the Emergency Department (ED) and was found dead 1 mile away from the facility by the police department. (Refer to A-144)”

“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: 45774 Based on interview and record review the facility failed to ensure the Condition of Participation for Quality Assurance Performance Improvement (QAPI) was met as evidenced by: 1. The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI, a process used to ensure services are meeting quality standards and assuring care reaches a certain level) department analyze and provide measurable data to track emergency department nursing staffs perform accuracy of answering Columbia Suicide Severity Rating Scales [(C-SSRS) screener tool for suicidal assessment] upon admission at Emergency Department (ED). This deficient practice resulted in the facility’s inability to assess and monitor its staff performance including accuracy of answering C-SSRS for a patient with suicidal ideation which led to Patient 1’s elopement and found dead outside the facility (Refer to A- 0273). 2. The facility failed to perform a root cause analysis (RCA, a structured, facilitated team process to identify the root cause of an event that resulted in an undesired outcome) for accuracy of answering C-SSRS by staff and led to Patient 1’s e elopement from the ED and death outside of the facility. This deficient practice resulted in the facility’s inability to identify potential system or process changes that could improve performance or patient safety and prevent any undesired outcome such as Patient 1’s death or prevent harm and/or death to other patients who are admitted to the ED. (Refer to A- 0286) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment and potentially placing patients at risk of unable to identify patient has risk for suicide, thus compromising patient safety.”

“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: 39503 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. One of four sampled patients (Patient 30), Patient 30’s Pasero Opiod-Induced Sedation Scale (POSS - a tool use to assess the sedation level of patients receiving opiod medications) was completed with each dose of Dilaudid (an opiod, pain medication) as ordered by the physician. This deficient practice had the potential to cause adverse health outcomes which could negatively affect Patient 30’s health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death of the patient. (Refer to A-0395) 2. One of four sampled patients (Patient 30) had a comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) developed upon admission to address Patient 30’s speech deficit as a result from his (Patient 30) surgery. This deficient practice had the potential to result in the delayed provision of care to the patient (Patient 30) by not identifying Patient 30’s needs and risks. (Refer to A-0396) 3. One of six sampled patients (Patient 28), the facility’s policy and procedure (P&P) for Transmission-based Precautions (are additional precaution used for patients with suspected or known transmissible infection to help prevent the spread of infection) was implemented when, Certified Nursing Assistant (CNA) 1 was observed inside Patient 28’s room, who was on contact isolation, not wearing proper personal protective equipment (PPE, equipment worn to minimize exposure to illness, includes gown, gloves, mask, face shield) while taking care of Patient 28. This deficient practice had the potential for the introduction of pathogens (a microorganisms such as bacteria or virus that can cause a disease process) from CNA 1 not wearing proper PPE and the potential for risk of transmission of microorganism to other patients in the same unit or hospital setting. (Refer to A-0398) 4. One of 30 sampled patients (Patients 28), Zosyn (antibiotic medication) was administered as ordered by the physician. This deficient practice resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect Patients 28 and 30’s health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death. (Refer to A-405) 5. One of 30 sampled patients (Patient 30), Dilaudid (narcotic pain medication) was administered as ordered by the physician. This deficient practice resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect Patients 28 and 30’s health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death. (Refer to A-405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 42937 Based on interview and record review, the facility’s Governing Body failed to ensure nursing services provide a safety and guiding standard of care for nurses to screen and assess patients risk of self harm or suicide and implementing steps to protect the patient in accordance with the facility’s policy and procedure (P&P). These deficient practices resulted in nursing staff failing to establish a safe process to screen and properly assessed Patient 1, who eloped from the Emergency Department (ED) and was found dead 1 mile away from the facility by the police department. In addition, these deficient practices had the potential for other patients who come in the ED with risk of suicidal ideation to not be assessed appropriately and for appropriate safety intervention to not be implemented. Findings: During a concurrent record review of Patient 1 electronic medical record (EMR) and interview with the Quality RN (QRN) on 5/6/24 at 2:05 p.m., the QRN stated that patient arrive to the ED on 6/15/2022 at 15:03 p.m. by ambulance. Patient with chief complaint of overdose with an unknown substance. Patient noted to refuse to answer suicide ideation question. there was no documentation of Patient 1 being on a 5150 hold, medical hold or a sitter during this ED admission. During a concurrent record review of Patient 1 electronic medical record (EMR) and interview with Social Worker 1 (SW1) on 5/6/2024 at 2:41 p.m., the SW 1 stated she was made aware of Patient 1 who came in the ED on 6/15/2022 with a chief complaint of accidental overdose. Patient eloped before a SW 1 assessment was completed. During a concurrent record review of Patient 1 electronic medical record (EMR) and interview with the Director of Emergency Department (DED) on 5/7/24 at 11:00 a.m., the DED stated Patient 1’s Columbia Suicide Severity Rating Scale (C-SSRS) screening on 6/15/22 at 1508, by the Triage Nurse, the C-SSRS question, “In the past month, have you wished you were dead or wished you could go to sleep and not wake up?” Patient 1’s answer was “no (unsure).” The DED stated the answer “unsure” of Patient 1 should be considered as a “yes” and Patient 1 should be positive for C-SSRS. The DED stated if a patient was screened positive for C-SSRS, the triage nurse will admit the patient in the ED and the assigned ED nurse should do a C-SSRS reassessment, behavior health assessment of the patient and the patient will have a 1:1 sitter for safety monitoring. During a concurrent record review of the facility’s course outline titled, “Suicide Prevention and Mitigation Plan - Suicide Risk Assessment” and interview with Emergency Department Educator (EDE) on 5/7/24 at 11:40 a.m., EDE concurred the course outline for nursing on suicide risk assessment does not include scenario if a patient is unable to participate in the screening process, or a nurse cannot get an answer of Yes or No from the patient when completing the C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide). During an interview on 5/9/24 at 4:50 p.m., with the Executive Director of Quality (EDQ). EDQ stated there was no Root Cause Analysis (RCA - is a structured facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions) done involving Patient 1’s elopement. There was a critical event review led by the previous EDQ, but that review did not identify any gaps in suicide screening process. Patient 1’s elopement incident deemed to not meet criteria for it to be escalated for an RCA review, there was no concern identified on its initial review; therefore, no action plan was implemented. There was a focus by the facility on reviewing with the security team about elopement, the facility’s P&P and its expectation, but the Facility did not identify there was a gap in the nursing suicide screening process sooner.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 39503 Based on observation, interview, and record review, the facility failed to ensure for one of three sampled patients (Patient 30), the Important Message from Medicare (IMM - a notice given to the patient with Medicare benefits indicating the patient’s rights to a hospital discharge appeal) letter was provided to Patient 30 upon admission to the facility. This deficient practice resulted in Patient 30 to not be informed of his (Patient 30) rights as a patient, which may also result in Patient 30’s inability to effectively make decisions regarding his care or treatment. Findings: During a record review of Patient 30’s record, the “Speech and Language Pathologist Initial Evaluation,” dated 5/7/24, the evaluation indicated Patient 30 was admitted to the facility on 5/6/2024, status post laryngectomy (surgical removal of the larynx [voice box]) right neck dissection left anterolateral thigh free flap (reconstructive surgery technique that involves transfer of skin from one body area to another). During an interview on 5/8/24 at 11:20 a.m., with the Director of Case Manager (DCM), the DCM stated the patient with Medicare (health insurance program) would be issued the IMM letter upon admission and 48-hours prior to the patient discharge from the facility. The DCM stated the initial IMM letter will be issued by the Admitting Department when the patient was admitted, and the IMM letter would be provided to the patient again within 48 hours prior to the patient’s discharge by the case manager. In the same interview, the DCM stated Patient 30’s record did not indicate Patient 30 was given the IMM letter since admission (5/6/24). During an interview on 5/8/24 at 11:29 a.m., with the Patient Access Manager (PAM), the PAM stated the Admitting Department would be responsible in providing the IMM letter to the patient upon admission. The PAM stated Patient 30’s record did not indicate Patient 30 was given the IMM letter on admission. During a review of the facility’s policy and procedure (P&P) titled, “Important Message from Medicare,” revised in 1/2023, the P&P indicated, “The Important message must be provided to all inpatients within two days of their hospital admission.””

“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 interview and record review, the facility failed to ensure for one of six sampled patients (Patients 29), Patient 29 and/or Patient 29’s family member (FM) was provided and signed a consent form for blood transfusion and a consent form for right external ventricular catheter placement (EVD - a temporary method of draining cerebrospinal fluid from the ventricles in the brain) in the preferred written language as indicated in Patient 29’s record. This deficient practice resulted in Patient 29 and Patient 29’s FM to not able to exercise the right to make informed decisions regarding her (Patients 29) care. Findings: During a record review of Patient 29’s record, the “Intensive Care Unit Consultation Note,” dated 5/5/24, the note indicated Patient 29 was admitted to the facility for subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain). A review of Patient 29’s document titled, “Condition of Admission, “ the document was written in Spanish and was signed by Patient 29’s FM on 5/5/24. A review of Patient 29’s “Blood Transfusion Consent,” the consent was written in English and was signed by Patient 29’s FM on 5/5/24. A review of Patient 29’s “Authorization For And Consent to Surgery Special Diagnostic or Therapeutic Procedures,” the consent, for right EVD placement, was written in English and was signed by Patient 29’s FM on 5/5/24. During a concurrent interview and record review on 5/8/24 at 11:29 a.m., with the Patient Access Manager (PAM), the PAM verified Patient 29’s record indicated, “Language: English (spoken), Spanish (written).” The PAM stated the preferred language for spoken and written language in Patient 29’s record should be followed. During an interview on 5/8/24 at 11:35 a.m., with Registered Nurse (RN) 2 and Registered Nurse (RN) 3, RN 2 stated she was the assigned RN for Patient 29. RN 2 stated she speaks English to Patient 29 and Patient 29’s FM. RN 2 and RN 3 stated they were not aware Patient 29’s record had a different preferred language for spoken and written. In the same interview, RN 2 and RN 3 verified in Patient 29’s record that the preferred written language was in Spanish. RN 3 stated the preferred written language in Patient 29 should have been followed. Patient 29 should have been provided documents written in Spanish. During a review of the facility’s policy and procedure (P&P) titled, “Consents,” revised in 7/2018, the P&P indicated, “The consent form must either be in a language the patient can read and understand or be translated into the patient’s preferred language for the patient by an approved translator...””

“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: 42937 Based on interview and record review, the facility’s failed to ensure nursing services provide a safety and guiding standard of care for nurses to screen and assess patients risk of self harm or suicide and implementing steps to protect the patient in accordance with the facility’s policy and procedure (P&P). These deficient practices resulted in nursing staff failing to establish a safe process to screen and properly assessed Patient 1, who eloped from the Emergency Department (ED) and was found dead 1 mile away from the facility by the police department. In addition, these deficient practices had the potential for other patients who come in the ED with risk of suicidal ideation to not be assessed appropriately and for appropriate safety intervention to not be implemented. Findings: During a concurrent interview and record review on 5/6/24 at 2:05 p.m. with Quality RN (QRN), the QRN statedPatient 1 arrived to the ED on 6/15/2022 at 15:03 p.m. by ambulance. Patient 1 with chief complaint of overdose with an unknown substance. Patient 1 noted to refuse to answer suicide ideation question, and there was no documentation of Patient 1 being on a 5150 hold, medical hold or a sitter during this ED admission. During a record review of Patient 1 electronic medical record (EMR) and interview with Social Worker 1 (SW1) on 5/6/2024 at 2:41 p.m., the SW 1 stated she was made aware of Patient 1 who came in the ED on 6/15/2022 with a chief complaint of accidental overdose. Patient eloped before a SW 1 assessment was completed. During a concurrent interview and record review on 5/7/24 at 11 a.m. with the Director of Emergency Department (DED). Patient 1’s Columbia Suicide Severity Rating Scale (C-SSRS) screening on 6/15/22 at 1508, by the Triage Nurse, the C-SSRS question, “In the past month, have you wished you were dead or wished you could go to sleep and not wake up?” Patient 1’s answer was “no (unsure).” The DED stated that the answer “unsure” of Patient 1 should be consider as a “yes” and Patient 1 should be positive for C-SSRS. The DED stated if a patient was screened positive for C-SSRS, the triage nurse will admit the patient in the ED and the assigned ED nurse should do a C-SSRS reassessment, behavior health assessment of the patient and the patient will have a 1:1 sitter for safety monitoring. During a concurrent record review of the facility’s course outline titled, “Suicide Prevention and Mitigation Plan - Suicide Risk Assessment” and interview with Emergency Department Educator (EDE) on 5/7/24 at 11:40 a.m., EDE concur that the course outline for nursing on suicide risk assessment does not include scenario if a patient is unable to participate in the screening process, or a nurse cannot get an answer of Yes or No from the patient when completing the C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide).”

“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: 45774 1. The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI, a process used to ensure services are meeting quality standards and assuring care reaches a certain level) department analyze and provide measurable data to track emergency department nursing staffs perform accuracy of answering Columbia Suicide Severity Rating Scales [(C-SSRS) screener tool for suicidal assessment] upon admission at the ED. This deficient practice resulted in the facility’s inability to assess and monitor its staff performance including accuracy of answering C-SSRS for patient with suicidal ideation, which led to Patient 1’s elopement and death outside of the facility (Refer to A- 0273). Findings: During a review of Patient 1’s History of Present illness (HPI) in ED provider note dated 6/15/22 at 3:07 p.m., the note indicated Patient 1 was brought in by medics from Patient 1’s home, with chief complaint of overdose (accidental). There were several psychiatric medications found at Patient 1’s home. Initially, Patient 1 was given intranasal Narcan, and then medics gave Patient 1 additional doses of IV Narcan in order to regain Patient 1’s mental status and respiration. The medics reported Patient 1 made some statements concerning for possible intentional intent for overdose (OD). Patient 1 denies any drug use, but is evasive in his answering of questions. During a review of Patient’s 1 ED Triage note dated 6/15/22 at 3:06 p.m., Registered Nurse (RN 4) indicated the following: Patient 1 was brought in by Santa Monica Engine 5 for overdose (OD) on unknown substance. Patient 1 refusing to answer suicidal ideation questions. Unknown if ingested or injected. Patient 1 was given Narcan x 3 doses (one intranasal and two IV). Patient 1 was awake and responsive but still denies question. During a review of Patient 1’s Patient Care timeline in ED; dated 6/15/22 at 3:08 p.m., indicated that C-SSRS screening tool was performed by RN 4; C-SSRS number 1 question, “ In the past month, have you wished you were dead or wished you could go to sleep and not wake up?”. RN 4 answered “No (unsure)”. During an interview on 5/7/2024 at 10:00 a.m., with Director of Emergency Department (DED); stated that if patient did not answer C-SSRS or answer (unsure) or answer is not a definitely “No”; staff should treat the patient as positive for suicide ideation. Staff should immediately establish continuous visual observation with a contact observer per facility policy, observe patient for suicidal/self-harm behaviors and complete screening once patient is able to participate. During a review of Patient 1’s social worker (SW) note dated 6/15/22 at 5:53 p.m., indicated there is concern that Patient 1 did intentionally try to OD even though he stated otherwise. Patient 1 kept requiring Narcan while in the ED. Patient 1 would not communicate with staff. Patient 1 bolted from the ED smashing through the doors in the ambulatory bay and was seen running down 22nd street towards Wilshire. Santa Monica Police Department (PD) were called. SW spoke with the Patient 1’s mother by phone. Patient 1’s mother said she will try to convince the patient to return to the ED, but does not want to do anything that will hurt their relationship. SW expressed concern that Patient 1 may be suicidal and he needs to return to the ED. During a review of Patient 1’s Patient Care timeline in ED; dated 6/15/22 at 5:44 p.m., indicated Patient 1 was absent without leave (AWOL) around 5:40 p.m. with IV still in Patient’s body. PD was notified. During an interview on 5/9/2024 at 3:30 p.m. with the Director of Quality (DQ), stated she did not know Patient 1’s eloped and death case until Patient 1’s mother lawyer contact Providence attorney regarding the lawsuit. Patient 1’s case was not escalated to perform a RCA. Suicidal screening is never brought up to QAPI meeting by ED manager. During an interview on 5/9/2024 at 3:50 p.m. with Risk Management (RM), RM stated a verbal debrief about Patient 1’s case; was reported everything was done correctly and no action plan required. RM clarified with security regarding the elopement, and there was no fall out in the process. Patient 1’s death was presented in a leadership meeting hospital consult meeting. The risk management revisited the case in 2023 due to the hospital management received an intent to sue; however, no second RCA was performed to determine Patient 1’s C- SSRS was not screened correctly by ED staff and no further safety precaution was implemented. Patient 1 eloped and died a mile away from the hospital. During an interview on 5/9/2024 at 5:55 p.m., with DED, stated she was not aware there was any issue with ED staff conducting suicidal screenings until an onsite complaint validation survey. The ED staff suicidal screening topic was never brought to QAPI for discussion. During an interview on 5/7/24 at 11:57 a.m., with Emergency Room Nurse (ERN); surveyor asked ERN if a patient is not able to answer the C- SSRS screening, what intervention should be done prior to patient being able to answer the question. ERN stated he did not know the answer to the question. During a record review, there were 6 out of 24 patients (6, 7, 14, 15, 22 & 23) did not have C-SSRS completed during the ED visit. During a concurrent review with sepsis coordinator (SC) of Patient 6’s Patient Care timeline in ED on 5/8/24 1:50 p.m., indicated Patient 6 brought in by ambulance at 1:18 pm; found in car unresponsive by police; given Narcan intranasal 1 time; patient awoke. ED provider saw patient 6 at 1:22 p.m. ED provider indicated patient was eloped from emergency room prior to re-evaluation at 2:38 p.m. No C-RRSR screening tool was performed by ED nurse during the visit. During a concurrent review with sepsis coordinator (SC) of Patient 7’s Patient Care timeline in ED on 5/8/24 1:50 p.m, indicated Patient 7 brought in by ambulance at 1:18 pm; sent in for evaluation after mechanical fall on sidewalk, no loss of conscious or trauma; patient awoke. ED provider saw patient 7 at 4:03 p.m. ED provider indicated patient refused all treatment and declined x-ray for his lower back, patient 7 eloped ED at 5:11 p.m. No C-RRSR screening tool was performed by ED nurse during the visit. During a concurrent record review of Patient 14’s EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 10:30 a.m., the EDE stated Patient 14 was seen in the ED (Emergency Department) on 2/4/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for patient 14. EDE stated that all patient with a chief complaint or diagnosis of OD should have a C-SSRS Screener Tool completed by a nurse. During a concurrent record review of Patient 15’s EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 10:30 a.m., the EDE stated Patient 15 was seen in the ED (Emergency Department) on 2/2/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for Patient 15. During a concurrent record review of Patient 22’s EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 1:54 p.m., the EDE stated Patient 22 was seen in the ED (Emergency Department) on 3/11/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for Patient 22. During a concurrent record review of Patient 22’s EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 1:54 p.m., the EDE stated that Patient 23 was seen in the ED (Emergency Department) on 4/12/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for Patient 23. During a record review of the facility’s policy and procedure (P&P) titled, “Suicide Risk Assessment and Prevention,” approved 10/2020; indicated C-SSRS Risk assessment tool is completed by ministry designated personnel. If the patient is unable to participate in the screening process, observe patient for suicidal/self-harm behaviors and complete screening once patient is able to participate. If the C-SSRS Screener tool is positive or the patient tis expressing suicidal thoughts or exhibits self-harm behaviors, take the following initial steps: a) Immediately establish continuous visual observation with a constant observer per Constance Observer ...d) Ministry designated caregiver completes he C-SSRS risk assessment tool. Interventions maybe modified/implemented based on risk stratification level ..... During a record review of the facility’s Quality Assurance & Performance Improvement (QAPI) and Patient Safety Plan 2021 - 2026, indicated, “An important aspect of improving organization performance and patient safety is to effectively implement evidence-based practice and reducing variation and non-value-added processes that contribute to unanticipated adverse patient safety events and/or outcomes. To accomplish this, Providence has committed to becoming a High Reliability Organization (HRO) through the adoption of its Our Caring Way program’s evidence-based practices, behaviors, and utilization of the continuous process improvement model to ensure processes are designed for safety.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 45774 The facility failed to perform a root cause analysis (RCA, a structured, facilitated team process to identify the root cause of an event that resulted in an undesired outcome) that accuracy of answering C-SSRS by staff and led to Patient 1’s elopement from the ED and f death outside of the facility. This deficient practice resulted in the facility’s inability to identify potential system or process changes that could improve performance or patient safety and prevent any undesired outcome such as Patient 1’s death or prevent harm and/or death to other patients who are admitted to the ED. (Refer to A- 0286) Findings: During a review of Patient 1’s History of Present illness (HPI) in ED provider note dated 6/15/22 at 3:07 p.m., the note indicated Patient 1 was brought in by medics from Patient 1’s home, with chief complaint of overdose (accidental). There were several psychiatric medications found at Patient 1’s home. Initially, Patient 1 was given intranasal Narcan, and then medics gave Patient 1 additional doses of IV Narcan in order to regain Patient 1’s mental status and respiration. The medics reported Patient 1 made some statements concerning for possible intentional intent for overdose (OD). Patient 1 denies any drug use, but is evasive in his answering of questions. During a review of Patient’s 1 ED Triage note dated 6/15/22 at 3:06 p.m., Registered Nurse (RN 4) indicated the following: Patient 1 was brought in by Santa Monica Engine 5 for overdose (OD) on unknown substance. Patient 1 refusing to answer suicidal ideation questions. Unknown if ingested or injected. Patient 1 was given Narcan x 3 doses (one intranasal and two IV). Patient 1 was awake and responsive but still denies question. During a review of Patient 1’s Patient Care timeline in ED; dated 6/15/22 at 3:08 p.m., indicated that C-SSRS screening tool was performed by RN 4; C-SSRS number 1 question, “ In the past month, have you wished you were dead or wished you could go to sleep and not wake up?”. RN 4 answered “No (unsure)”. During an interview on 5/7/2024 at 10:00 a.m., with Director of Emergency Department (DED); stated that if patient did not answer C-SSRS or answer (unsure) or answer is not a definitely “No”; staff should treat the patient as positive for suicide ideation. Staff should immediately establish continuous visual observation with a contact observer per facility policy, observe patient for suicidal/self-harm behaviors and complete screening once patient is able to participate. During a review of Patient 1’s social worker (SW) note dated 6/15/22 at 5:53 p.m., indicated there is concern that Patient 1 did intentionally try to OD even though he stated otherwise. Patient 1 kept requiring Narcan while in the ED. Patient 1 would not communicate with staff. Patient 1 bolted from the ED smashing through the doors in the ambulatory bay and was seen running down 22nd street towards Wilshire. Santa Monica Police Department (PD) were called. SW spoke with the Patient 1’s mother by phone. Patient 1’s mother said she will try to convince the patient to return to the ED, but does not want to do anything that will hurt their relationship. SW expressed concern that Patient 1 may be suicidal and he needs to return to the ED. During a review of Patient 1’s Patient Care timeline in ED; dated 6/15/22 at 5:44 p.m., indicated Patient 1 was absent without leave (AWOL) around 5:40 p.m. with IV still in Patient’s body. PD was notified. During an interview on 5/9/2024 at 3:30 p.m. with the Director of Quality (DQ), stated she did not know Patient 1’s eloped and death case until Patient 1’s mother lawyer contact Providence attorney regarding the lawsuit. Patient 1’s case was not escalated to perform a RCA. Suicidal screening is never brought up to QAPI meeting by ED manager. During an interview on 5/9/2024 at 3:50 p.m. with Risk Management (RM), RM stated a verbal debrief about Patient 1’s case; was reported everything was done correctly and no action plan required. RM clarified with security regarding the elopement, and there was no fall out in the process. Patient 1’s death was presented in a leadership meeting hospital consult meeting. The risk management revisited the case in 2023 due to the hospital management received an intent to sue; however, no second RCA was performed to determine Patient 1’s C- SSRS was not screened correctly by ED staff and no further safety precaution was implemented. Patient 1 eloped and died a mile away from the hospital. During an interview on 5/9/2024 at 5:55 p.m., with DED, stated she was not aware there was any issue with ED staff conducting suicidal screenings until an onsite complaint validation survey. The ED staff suicidal screening topic was never brought to QAPI for discussion. During an interview on 5/7/24 at 11:57 a.m., with Emergency Room Nurse (ERN); surveyor asked ERN if a patient is not able to answer the C- SSRS screening, what intervention should be done prior to patient being able to answer the question. ERN stated he did not know the answer to the question. During a record review, there were 6 out of 24 patients (6, 7, 14, 15, 22 & 23) did not have C-SSRS completed during the ED visit. During a concurrent review with sepsis coordinator (SC) of Patient 6’s Patient Care timeline in ED on 5/8/24 1:50 p.m., indicated Patient 6 brought in by ambulance at 1:18 pm; found in car unresponsive by police; given Narcan intranasal 1 time; patient awoke. ED provider saw patient 6 at 1:22 p.m. ED provider indicated patient was eloped from emergency room prior to re-evaluation at 2:38 p.m. No C-RRSR screening tool was performed by ED nurse during the visit. During a concurrent review with sepsis coordinator (SC) of Patient 7’s Patient Care timeline in ED on 5/8/24 1:50 p.m, indicated Patient 7 brought in by ambulance at 1:18 pm; sent in for evaluation after mechanical fall on sidewalk, no loss of conscious or trauma; patient awoke. ED provider saw patient 7 at 4:03 p.m. ED provider indicated patient refused all treatment and declined x-ray for his lower back, patient 7 eloped ED at 5:11 p.m. No C-RRSR screening tool was performed by ED nurse during the visit. During a concurrent record review of Patient 14’s EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 10:30 a.m., the EDE stated Patient 14 was seen in the ED (Emergency Department) on 2/4/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for patient 14. EDE stated that all patient with a chief complaint or diagnosis of OD should have a C-SSRS Screener Tool completed by a nurse. During a concurrent record review of Patient 15’s EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 10:30 a.m., the EDE stated Patient 15 was seen in the ED (Emergency Department) on 2/2/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for Patient 15. During a concurrent record review of Patient 22’s EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 1:54 p.m., the EDE stated Patient 22 was seen in the ED (Emergency Department) on 3/11/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for Patient 22. During a concurrent record review of Patient 22’s EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 1:54 p.m., the EDE stated that Patient 23 was seen in the ED (Emergency Department) on 4/12/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for Patient 23. During a record review of the facility’s policy and procedure (P&P) titled, “Suicide Risk Assessment and Prevention,” approved 10/2020; indicated C-SSRS Risk assessment tool is completed by ministry designated personnel. If the patient is unable to participate in the screening process, observe patient for suicidal/self-harm behaviors and complete screening once patient is able to participate. If the C-SSRS Screener tool is positive or the patient tis expressing suicidal thoughts or exhibits self-harm behaviors, take the following initial steps: a) Immediately establish continuous visual observation with a constant observer per Constance Observer ...d) Ministry designated caregiver completes he C-SSRS risk assessment tool. Interventions maybe modified/implemented based on risk stratification level .... During a record review of the facility’s Quality Assurance & Performance Improvement (QAPI) and Patient Safety Plan 2021 - 2026, indicated, “An important aspect of improving organization performance and patient safety is to effectively implement evidence-based practice and reducing variation and non-value-added processes that contribute to unanticipated adverse patient safety events and/or outcomes. To accomplish this, Providence has committed to becoming a High Reliability Organization (HRO) through the adoption of its Our Caring Way program’s evidence-based practices, behaviors, and utilization of the continuous process improvement model to ensure processes are designed for safety.”

“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 interview and record review, the facility failed to ensure for one of four sampled patients (Patient 30), Patient 30’s Pasero Opiod-Induced Sedation Scale (POSS - a tool use to assess the sedation level of patients receiving opiod medications) was completed with each dose of Dilaudid (an opiod, pain medication) as ordered by the physician. This deficient practice had the potential to cause adverse health outcomes which could negatively affect Patient 30’s health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death of the patient. Findings: During a record review of Patient 30’s record, the “Speech and Language Pathologist Initial Evaluation,” dated 5/7/24, the evaluation indicated Patient 30 was admitted to the facility on 5/6/2024, status post laryngectomy (surgical removal of the larynx [voice box]) right neck dissection left anterolateral thigh free flap (reconstructive surgery technique that involves transfer of skin from one body area to another). During a review of Patient 30’s “Medication Order,” dated 5/6/24, the order indicated to administer Dilaudid 0.2 to 0.4 milligram (mg) intravenous (IV - through the vein) every 2 hours as needed (PRN) for pain. The order further indicated, “If dose range is ordered, then first dose must be the lowest dose. Titrate to effective dose by repeat of lowest dose every 30 minutes PRN pain...Use Pasero Sedation Scale (POSS)...” During a review of Patient 1’s “Medication Administration Record (MAR)” the MAR indicated Patient 1 was administered Dilaudid IV on the following dates and times: - On 5/6/24 at 10:59 p.m., Dilaudid 0.2 mg IV was given; - On 5/6/24 at 11:47 p.m., Dilaudid 0.2 mg IV was given; - On 5/7/24 at 2:24 a.m., Dilaudid 0.2 mg IV was given; - On 5/7/24 at 6:27 a.m., Dilaudid 0.2 mg IV was given; - On 5/7/24 at 7:31 a.m., Dilaudid 0.2 mg IV was given; - On 5/7/24 at 10:12 a.m., Dilaudid 0.4 mg IV was given; - On 5/7/24 at 12:56 p.m., Dilaudid 0.4 mg IV was given; - On 5/7/24 at 5:46 p.m., Dilaudid 0.4 mg IV was given; - On 5/7/24 at 10:48 p.m., Dilaudid 0.4 mg IV was given; - On 5/8/24 at 2:57 a.m., Dilaudid 0.4 mg IV was given; - On 5/8/24 at 6:53 a.m., Dilaudid 0.4 mg IV was given; - On 5/8/24 at 1:20 p.m., Dilaudid 0.4 mg IV was given; and, - On 5/8/24 at 7:14 p.m., Dilaudid 0.4 mg IV was given. There was no documented evidence Patient 1’s POSS was completed with each dose of Dilaudid. These lack of documentation was verified by the Medication Safety Officer (MSO). During an interview on 5/9/24 at 11:43 a.m., with the MSO, the MSO stated when a patient received opiod medication, it is important to do the POSS with each dose to assess the patient’s sedation level. The MSO stated the patient’s POSS assessment would help ensure medication safety on the effect of the opiod to the patient and if dose adjustment or discontinuation of the opiod medication is needed. In the same interview, the MSO stated Patient 1 should have a POSS completed with each dose of Dilaudid, as indicated in the physician’s order, to monitor Patient 1’s sedation level from the use of the opiod medication. During a review of the facility’s policy and procedure (P&P) titled, “Pasero Opiod-induced Sedation Scale,” revised in 4/2021, the P&P indicated the following: - The Pasero Opiod-induced Sedation Scale (POSS) may be used to assess opiod related sedation and guide care. - The nurse interacts with the patient and determines the level of sedation based on the scale’s descriptions of patient arousal. - Associated with each level are suggested nursing measures for the ongoing care of the patient. - Document the POSS score and any interventions required in the electronic medical record.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 39503 Based on observation, interview, and record review, the facility failed to ensure for one of four sampled patients (Patient 30) had a comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) developed upon admission to address Patient 30’s speech deficit as a result from his (Patient 30) surgery. This deficient practice had the potential to result in the delayed provision of care to the patient (Patient 30) by not identifying Patient 30’s needs and risks. Findings: During an observation on 5/8/24 at 11 a.m., Patient 30 was observed in his room, lying in bed, alert and awake. Patient 30 had a tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea from the outside of the neck). The Registered Nurse (RN) at the bedside stated Patient 30 was not able to speak and communicate through writing on the white board or by gesture. Patient 30 made a sign with his hand indicating he did not want to participate and subsequently left the patient’s room. From outside Patient 30’s room, Patient 30 was observed to be gesturing a sign to the RN while the RN was trying to guess what Patient 30 wanted. During a record review of Patient 30’s record, the “Speech and Language Pathologist (SLP) Initial Evaluation,” dated 5/7/24, the SLP evaluation indicated Patient 30 was admitted to the facility on 5/6/2024, status post laryngectomy (surgical removal of the larynx [voice box]) right neck dissection left anterolateral thigh free flap (reconstructive surgery technique that involves transfer of skin from one body area to another). The SLP evaluation further indicated Patient 30’s current communication was via writing and gestures. There was no documented evidence a care plan for Patient 30’s speech deficit and communication needs were developed. This lack of documentation was verified by Quality Registered Nurse (QRN) 2. During an interview on 5/9/24 at 11:24 a.m., with QRN 2, QRN 2 stated it is important to developed a care plan for Patient 30 addressing the patient’s speech deficit and communication needs. The care plan would ensure continuation of quality care and the staff would be consistent in addressing Patient 30’s needs. During a review of the facility’s policy and procedure (P&P) titled, “Plan of Care,” revised in 7/2021, the P&P indicated the following: - The Registered Nurse (RN) is accountable to assure the development of a patient-centric, interprofessional individualized plan of care. - Developing the Patient’s Plan of Care...Determine specific patient goals, preferences and care needs that require intervention (including, but not limited to language, communication, cultural practices, health beliefs and/or spiritual practices).”

“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 failed to ensure for one of six sampled patients (Patient 28), the facility’s policy and procedure (P&P) for Transmission-based Precautions (are additional precaution used for patients with suspected or known transmissible infection to help prevent the spread of infection) was implemented when, Certified Nursing Assistant (CNA) 1 was observed inside Patient 28’s room, who was on contact isolation, not wearing proper personal protective equipment (PPE, equipment worn to minimize exposure to illness, includes gown, gloves, mask, face shield) while taking care of Patient 28. This deficient practice had the potential for the introduction of pathogens (a microorganisms such as bacteria or virus that can cause a disease process) from CNA 1 not wearing proper PPE and the potential for risk of transmission of microorganism to other patients in the same unit or hospital setting. Findings: During a concurrent observation and interview on 5/6/2 at 1:37 p.m., with Nurse Manager (NM) 1, Patient 28’s room was observed to have an isolation sign at the patient’s (Patient 28) door and an isolation cart outside the patient’s room. NM 1 stated Patient 28 was on contact isolation. Subsequently, CNA 1 was observed to entered Patient 28’s room, wearing a face mask and closed the patient’s door. CNA 1 was not observed donning (putting on) proper PPE before entering Patient 28’s room. In the same observation and interview, NM 1 asked CNA 1 to step out of Patient 28’s room. CNA 1 stated she was aware Patient 28 was on contact isolation. CNA 1 stated she was aware that she needed to don proper PPE (gown and gloves) before entering Patient 28’s room. CNA 1 stated she rushed going inside the patient’s room to assist Patient 28 and she did not have time to wear her PPE. During an interview on 5/6/24 at 1:40 p.m., with Registered Nurse (RN) 1, RN 1 stated she was the assigned RN for Patient 28. RN 1 stated Patient 28 was on contact isolation for Methicillin-resistant Staphylococcus aureus (MRSA - a type of bacterial infection) of the sputum. RN 1 stated it is important to wear proper PPE before entering the patient’s room, on isolation, to help protect from the infection and prevent the spread of infection to the other patients in the unit. In the same interview, RN 1 stated part of PPE when entering Patient 28’s room was to wear a face shield because Patient 28 was confused and had an incident of spitting on the staff. During a follow-up observation on 5/6/24 at 1:42 p.m., NM 1 asked CNA 1, who was inside Patient 28’s room, where was her (CNA 1) face shield. CNA 1 told NM 1 that it was hanging at the isolation cart outside Patient 28’s room. NM 1 observed to picked up a face shield with CNA 1’s name written on it and hand it to CNA 1, CNA 1 wore the face shield. During a review of Patient 28’s “Hospitalist History and Physical (H&P),” dated 4/24/24, the H&P indicated Patient 28 was admitted to the facility with a chief complaint of weakness. . During a review of physician’s order, dated 5/4/24, the order indicated Patient 28 was on contact isolation for Acinetobacter calcoacaticus-baumannii (type of infection) in the sputum. During a review of Patient 28’s “Progress Notes,” dated 5/2/24 at 5:12 p.m., authored by the chaplain, the note indicated the sitter reported that Patient 28 spit on her (sitter). During a review of Patient 28’s nursing notes, dated 5/2/24 at 6:48 p.m., the note indicated Patient 28 was uncooperative with care, refusing medication and spit on the sitter. During a review of the facility’s P&P titled, “Standard Precautions & (and) Transmission-Based Precautions,” revised in 12/2022, the P&P indicated the following: - Use Contact Precaution...For patients known or suspected to be infected or colonized with epidemiologically important/significant microorganisms that can be transmitted by direct/indirect contact with the patient or with environmental surfaces or patient care items in the patient’s environment. - Caregiver Protection and Personal Protective Equipment (PPE). In addition to Standard Precautions, wear gloves and gown with 360-degree coverage when there is a risk of self or clothing having direct contact with the patient, potentially contaminated environmental surfaces or items. - Don PPE when entering a patient’s room based on the anticipated interaction with the patient or their environment.”

“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 interview and record review, the facility failed to ensure for two of 30 sampled patients (Patients 28 and 30) the following: 1. Patient 28’s Zosyn (antibiotic medication) was administered as ordered by the physician; and 2. Patient 30’s Dilaudid (narcotic pain medication) was administered as ordered by the physician. These deficient practices resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect Patients 28 and 30’s health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death. Findings: 1. During a review of Patient 28’s “Hospitalist History and Physical (H&P),” dated 4/24/24, the H&P indicated Patient 28 was admitted to the facility with a chief complaint of weakness and was assessed to have severe sepsis (a life threatening complication of an infection) and suspected pneumonia (infection of the lungs). During a review of Patient 28’s “Medication Order,” dated 4/24/24, the order indicated Zosyn 3.375 gram (g) to be given intravenous (IV - through the veins) every 8 hours at the rate of 25 milliliter / hour (ml/hr) over 4 hours. The Zosyn order further indicated Patient 28 was administered Zosyn 3.375 g IV on the following dates and times: - On 4/24/24 at 5:53 p.m., the next dose was on 4/25/24 at 3:26 a.m. (9 hours and 30 minutes from the last dose); - On 4/28/24 at 12:04 a.m., the next dose was on 4/28/24 at 10:17 a.m. (10 hours from the last dose); - On 4/29/24 at 11:59 p.m., the next dose was on 4/30/29 at 9:29 a.m. (9 hours and 30 minutes from the last dose); - On 4/30/24 at 11:30 p.m., the next dose was on 5/1/24 at 9 a.m. (9 hours and 30 minutes from the last dose); - On 5/4/24 at 8:07 a.m., the next dose was on 5/4/24 at 6:04 p.m. (10 hours from the last dose). During an interview on 5/8/24 at 2:30 p.m., with the Quality Registered Nurse (QRN) 2, QRN 2 stated Patient 28’s record review was accurate. In the same interview, QRN 2 stated Patient 28’s Zosyn 3.375 g IV every 8 hours was not given as ordered by the physician. QRN 2 stated antibiotics should be given on time for effective treatment of the patient’s infection. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” revised in 7/2023, the P&P indicated, “Time Critical - Medications are to be administered within 30 minutes before or after the scheduled time: antibiotics...” 2. During a record review of Patient 30’s record, the “Speech and Language Pathologist Initial Evaluation,” dated 5/7/24, the evaluation indicated Patient 30 was admitted to the facility on 5/6/2024, status post laryngectomy (surgical removal of the larynx [voice box]) right neck dissection left anterolateral thigh free flap (reconstructive surgery technique that involves transfer of skin from one body area to another). During a review of Patient 30’s “Medication Order,” dated 5/6/24, the order indicated to administer Dilaudid 0.2 to 0.4 milligram (mg) intravenous (IV - through the vein) every 2 hours as needed (PRN) for pain. The order further indicated, “If dose range is ordered, then first dose must be the lowest dose. Titrate to effective dose by repeat of lowest dose every 30 minutes PRN pain...Use Pasero Sedation Scale (POSS)...” During a review of Patient 1’s “Medication Administration Record (MAR)” the MAR indicated Patient 1 was administered Dilaudid IV on the following dates and times: - On 5/7/24 at 2:24 a.m., Dilaudid 0.2 mg IV was given. Patient 30’s corresponding pain assessment on 5/7/24 at 2 a.m., indicated a pain score of 0 (0, means no pain) and on 5/7/24 at 2:54 a.m., indicated Patient 30 was “sleeping;” and, - On 5/7/24 at 6:27 a.m., Dilaudid 0.2 mg IV was given. There was no documented evidence Patient 30’s pain was assessed when Dilaudid was given on 5/7/24 at 6:27 a.m. This lack of documentation was verified by the Medication Safety Officer (MSO). During an interview on 5/9/24 at 2 p.m., with the MSO, the MSO stated Patient 30’s record review was accurate. The MSO stated Patient 30 should have not given Dilaudid on 5/7/24 at 2 a.m., since the patient’s (Patient 30) pain score was 0 and does not warrant a Dilaudid dose. During an interview on 5/9/24 at 2 p.m., with QRN 2, QRN 2 stated Patient 30 did not have a pain assessment when Dilaudid was given on 5/7/24 at 6:27 a.m. QRN 2 stated the patient pain should be assessed prior to administering pain medication to ensure the patient received the correct dose of pain medication. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” revised in 7/2023, the P&P indicated, “Medication Administration Requirements - General...Verifying patient identification and medication to be administered is accomplished by the following...Administer the medication as directed...””