Uci Health-Orange

“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: 38660 Based on interview and record review, the hospital failed to ensure the nursing staff provided the necessary care and services to one of three sampled patients (Patient C) when the nursing staff failed to notify the physician of the patient’s elevated blood pressure as ordered. This failure posed the increased risk of substandard health outcomes for the patients. Findings: Review of the hospital’s P&P titled Medication Orders dated 11/2025, showed at the time of prescribing or ordering, the prescriber, pharmacist, and clinical staff shall receive or have readily available important information pertinent to the patient’s medical condition and current drug regimen to: facilitate continuity of care, create an accurate medication history and current list of medications, supplement monitoring of medication adverse events, and help provide safe prescribing or ordering, dispensing, administration, and monitoring of medications. An interview and concurrent review for Patient C’s closed medical record was conducted on 8/11/26 at 1010 hours, with the Regulatory Specialist. The medical record showed Patient C was admitted to the hospital on 11/2/25. Review of the physician’s order dated 11/2/25 at 2003 hours, showed to infuse epinephrine (a medication used to treat low blood pressure) at 2mcg/minute, titrate by 2 mcg/minute every 10 - 15 minutes to keep SBP greater than 90 mmHg, maximum dose 20 mcg/ minute, and concentration 16 mcg/ml; notify the physician and hold drip if heart rate more than 120 bpm. Review of the physician’s order dated 11/2/26 at 1323 hours, showed to infuse vasopressin (medication used to raise BP) at 0.04 unit/ minute with no titration, concentration 0.4 unit/ minutes; notify the provider and hold drip if SBP more than 150 mmHg. Review of the NP’s Progress Note dated 11/2/25 at 1837 hours, showed on 11/2/26, Patient C’s BP dropped significantly with repositioning. Patient C received Levophed (norepinephrine, medication used to raise and maintain BP), vasopressin, and epinephrine to maintain SBP greater 90 mmHg. Review of Patient C’s Vital Signs dated 11/3/26, showed Patient C’s BPs were as follows: - At 0430 hours - BP 115/45 mmHg - At 0445 hours - BP 165/96 mmHg - At 0500 hours - BP 181/77 mmHg - At 0505 hours - BP 207/90 mmHg - At 0510 hours - BP 219/69 mmHg - At 0515 hours - BP 227/76 mmHg - At 0530 hours - BP 245/136 mmHg - At 0535 hours - BP 65/40 mmHg - At 0540 hours - BP 73/40 mmHg. Review of Patient C’s eMAR dated 11/3/26, showed Patient C received norepinephrine at 37.5 ml /hour at 0445 hours, the medication was titrated gradually to 23.44 ml/ hour at 0530 hours and increased to 28.13 ml/hour as the BP dropped to 65/40 mmHg at 0535 hours. Patient C also received vasopressin at 0.04 unit/minute. Further review of Patient C’s medical record showed no documented evidence showing Patient C’s high BP was notified the physician as ordered. On 8/17/26 at 1210 hours, the findings were shared with the Regulatory Specialist.”

“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: 38660 Based on interview and record review, the hospital failed to ensure one of three sampled patients (Patient C) plan of care was developed to reflect the patient care and condition during their hospitalization as evidenced by: * The nursing staff did not develop a care plan for Patient C who has experienced no bowel movement for multiple days. * The nursing staff did not develop a care plan for Patient C’s unstable blood pressure. These failures created a risk of not providing the necessary care and services to meet the patient’s needs. Findings: Review of the hospital’s P&P titled Planning of Care date 3/2025, showed the following are considered nursing plans of care: nursing diagnosis based care plans, ... , nursing notes that reference planning, without regard to their placement in the medical record. An interdisciplinary plan of care is otherwise not required. However, care should be provided on an interdisciplinary basis. Each discipline should coordinate its care with the others by reviewing relevant assessments, notes and care/ treatment plans. An Interdisciplinary Plan of Care is available in the electronic health record to include disciplines such as but not limited to nursing, social work, nutrition, skin, RT, PT, OT speech as appropriate. 1. An interview and concurrent review for Patient C’s closed medical record was conducted on 8/17/26 at 1021 hours with the Regulatory Specialist. The medical record showed Patient C was admitted to the hospital on 7/27/25. Review of the Intake and Output Flowsheet showed Patient C did not have bowel movement from admission on 7/27/25 to 8/4/26. Review of the eMAR showed Patient C started receiving senna (a medication used to treat constipation) 8.6 mg tablet two times a day on 7/29/25. Patient C’s medical record failed to show that a nursing care plan had been developed to address Patient C not having bowel movement in multiple days. 2. An interview and concurrent review for Patient C’s closed medical record was conducted on 8/11/26 at 1110 hours with the Regulatory Specialist. The medical record showed Patient C was admitted to the hospital on 11/2/25. Patient C received medications for the patient’s BP during the hospitalization. Cross reference to A395. Patient C’s medical record failed to show that a nursing care plan had been developed to address the Patient C’s unstable blood pressure. On 8/17/26 at 1210 hours, the above findings were shared with the Regulatory Specialist.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to ensure vital signs were taken and documented when blood transfusion was completed for one of three sampled patients (Patient C) as per hospital P&P. This failure created a risk of not providing the necessary care and services to meet the patient’s needs Findings: Review of the hospital’s P&P titled Blood/ Blood Component Transfusion revised 9/2024, showed patients will be monitored for transfusion reactions. Vital signs will be taken at the end of transfusion. On 8/13/26 at 1311 hours, Patient C’s closed medical record was reviewed with the Regulatory Specialist and the Associate Manager of Regulatory Affairs. Patient C’s medical record showed the patient was admitted to the hospital on 11/2/25. Review of the physician’s order dated 11/2/25 at 0533 hours, showed a physician ordered the transfusion of one unit of red blood cells. Further review of Patient C’s medical record showed the transfusion started at 0533 hours and completed at 0613 hours. However, upon reviewing the vital signs documentation, it was noted that there was no record of vital signs at 0614 hours or when the transfusion was completed. The Associate Manager of Regulatory Affairs confirmed these findings.”

“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: 38660 Based on interview and record review, the hospital failed to ensure the nursing staff conducted pain assessment and reassessment within approximately one hour after the administration of pain medication for one of five sampled patients (Patient 1) as per the hospital’s P&P. These failures posed the increased risk of substandard health outcomes for the patients. Findings: Review of the hospital’s P&P titled Pain: Adult and Pediatric dated January 2026 showed the following: * Policy: The healthcare team conducts a comprehensive pain assessment that is consistent with the scope of care, treatment, and services and the patient’s condition. The healthcare team uses methods to assess pain that are consistent with the patient’s age, condition, cultural background, and ability to understand. The healthcare team reassesses and responds to the patient’s pain, based on its reassessment criteria. * Definitions: - The Numeric Rating: (NRS) measures the pain on a 0 to 10 scale, with zero indicating no pain and 10 indicating a severe amount of pain. * Assessment/ Reassessment: - Screen for the presence of pain upon admission or with first contact with the patient. A complaint of pain equal or greater than four, or a complaint of pain greater than usual for the patient or ineffective pain management, requires a more in-depth assessment or self-report to be completed. - A comprehensive pain assessment/ reassessment is conducted as appropriate to the patient’s condition; scope of care; treatment and services provided; and methods are appropriate to the patient’s age and/ or ability. - Assess for location, intensity (pain scores), duration, character or quality (burning, cramping, etc.), and aggravating or alleviating factors. - Reassessment should be completed in a timely manner, within approximately one hour, to determine if the intervention is working or if the patient is experiencing adverse effects. * For the purpose of medication orders, mild pain will be defined as 1-3, moderate pain as 4-6, and severe pain as 7-10 on the 0-10 or 0-8 pain scale. * Documentation: Document all pain assessments, reassessments and interventions in the appropriate section of the EHR. Include pain scales used. An interview and concurrent review for Patient 1’s medical record was conducted on 7/29/26 at 1400 hours, with the Regulatory Specialist and the Health Policy Coordinator. The medical record showed Patient 1 was admitted to the hospital on 2/21/26. Review of the Vascular Surgery/ History and Physical Note dated 2/21/26 at 1455 hours, showed Patient 1 was admitted to the hospital with a brachial artery (the main blood vessel of the upper arm) injury during left upper extremity contracture release on 2/21/26. Review of the physician’s Acute Pain Progress Note date 4/15/26 at 1127 hours, showed Patient 1 had an acute on chronic left upper extremity pain, including chronic left shoulder pain and a new diffuse arm pain following recent vascular and soft tissue surgery. Review of Patient 1’s eMAR and the Pain Assessment and Reassessment flowsheet dated 4/14, 4/16, 4/19/26, showed the following: - The Pain Assessment flow sheet dated 4/14/26 at 1702 hours, showed a pain score of 5, the pain orientation as “Left”, and the medication administered. The pain location, duration, character, quality, and aggravating or alleviating factors were not documented. - The Pain Assessment flow sheet dated 4/14/26 at 2156 hours, showed Patient 1 had an acute pain in the left arm with a pain score of 8, pain described as a spasm, and the medication was administered. - The Pain Assessment flow sheet dated 4/16/26 at 1753 hours, showed Patient 1 had pain in the left arm with a pain score of 10. The pain description, duration, character, quality, and aggravating or alleviating factors were not documented. - The Pain Assessment flow sheet dated 4/19/26 at 1314 hours, showed Patient 1 had pain in the left arm with a pain score of 5, pain described as aching, and the medication was administered. At 1717 hours, Patient 1 had pain in the left shoulder surgical pain with a pain score of 5, pain described as aching, and the medication was administered. The MAR showed Patient 1 received hydrocodone acetaminophen (pain relief) 5-325 mg one tablet on 4/14/26 at 1702 and 2156 hours, 4/16/26 at 1753 hours, and 4/19/26 at 1314 and 1717 hours, as ordered by the physician. However, the pain reassessment was not performed within approximately one hour after medication administration, as per the hospital’s P&P. The findings were shared with the Regulatory Specialist.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure the nursing staff performed and documented the required hourly assessments for one of four sampled patients (Patient 4) while the patient was in behavioral restraints, in accordance with the hospital’s P&P. This failure had the potential to result in unrecognized restraint-related complications, including impaired circulation and skin injury. Findings: Review of the hospital’s P&P titled “Restraint & Seclusion,” dated 2/2026, showed that for behavioral (violent or self-destructive behavior) restraints, staff are required to assess skin integrity and circulatory status at least hourly. On 7/1/26 at 1009 hours, a concurrent interview and record review for Patient 4 was initiated with the CNO, Assistant Director of Regulatory Affairs, and the ED Director. Patient 4’s medical record showed the patient arrived in the ED on 1/23/26 at 1631 hours. Review of Patient 4’s Patient Care Timeline showed the patient was placed in bilateral wrist and bilateral ankle restraints due to violent or self-destructive behavior on 1/23/26 at 1645 hours. The restraints remained in place until they were discontinued at 1945 hours. Review of Patient 4’s medical record failed to show documentation that nursing staff assessed and documented skin integrity and circulatory status at least hourly while Patient 4 remained in behavioral restraints, as required by the hospital’s P&P. On 7/1/26, during the concurrent interview and record review, the CNO, Assistant Director of Regulatory Affairs, and the ED Director verified the findings.”

“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: 29558 Based on interview and record review, the hospital failed to ensure that the nursing staff followed the physician’s order related to medication administration for one of two sampled patients (Patient A) as required by the hospital’s P&P. This failure created the risk of poor health outcomes for the patient. Findings: Review of the hospital’s P&P titled Medication Administration, Administration Time, Monitoring and Documentation dated 03/2025 showed: * Purpose: - To delineate acceptable standards for the medication administration, medication administration time, monitoring, and documentation per physician orders in keeping with applicable safety recommendations and regulatory requirements. * Policy: - Care providers administering medications, regardless of the setting, shall: - Verify the medication against the medication order. - Verify that the dose and route correspond with the practitioner’s order. - Review and follow any special instructions for medication being administered. On 5/14/26 at 0943 hours, an interview with concurrent review of Patient A’s medical record was conducted with the Quality Director and the ICU/CCU Clinical Nurse Educator. Review of Patient A’s physician’s order dated 5/12/26 for the medication norepinephrine (a medication used to treat low blood pressure) showed the following: - Order dose: 0-50 - Route: Intravenous - Frequency: Continuous at 0-187.5 ml/hr. - Duration: One day - Admin dose: 0-50 mcg/min - Initial rate: 1 mcg/min - Increase/decrease by: One mcg/min every 3-15 minutes to specified titration goal (Max rate: 14 mcg/min via a peripheral IV and 80 mcg/min via a central line) - Titration goal: MAP more than 65 mmHg or SBP less than 90 mmHg. Review of the nursing documentation showed the medication administration was initiated on 5/12/26 at 1900 hours, with the initial rate of 3 mcg/min, Patient A’s blood pressure reading showed 74/34 mmHg. However, the order showed the initial rate at 1 mcg/min. Review of the provider’s order for the medication vasopressin (a medication used to treat low blood pressure) showed the following: - Order date 5/12/26 at 1915 hours: Vasopressin 0.04u/min - Goal: MAP 65-85 mmHg - SBP greater than 160 mmHg, call the provider However, review of the nursing documentation showed the vasopressin was initiated on 5/12/26 at 1924 hours, at the rate of 0.03u/min, with the blood pressure reading at 51/31 mmHg. On 5/13/26 at 0339 hours, the vasopressin rate was increased to 0.04u/min. On 5/14/26 at 1405 hours, the CCU/ICU Nurse Educator verified the findings.”

“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: 38660 Based on interview and record review, the hospital failed to ensure that nursing staff provided necessary care and services to one of four sampled patients (Patients 1) when the nursing staff did not reassess Patient 1, monitor their blood pressure, or notify the physician when the patient’s blood pressure dropped to 80/59 mmHg as per the hospital’s P&P. This failure posed an increased risk of poor health outcomes to the patient. Findings: During a review of the hospital’s P&P titled Adult Core Nursing Standard of Care dated July 2025, the hospital’s P&P showed the patient needs will be identified from assessment data, validated throughout the nursing interactions with the patient, and reflected in the patient’s plan of care. - The plan of care for the patient is individualized and begins on admission. - Patient needs will be reviewed every shift and PRN (as needed) to evaluate relevance to the plan of care and treatment plan. - Interventions are reviewed and revised every shift and PRN to reflect the current patient condition based on expected outcomes. The nurse will collaborate with the patient, family and other healthcare providers in providing patient care in a healing, humane, and care environment by adhering to the following standards: - Notify Provider of any change in patient condition or critical results with documentation of the following: time, provider name, communication and provider response/ recommendation. During a concurrent interview and review of Patient 1’s medical record on 4/16/26 at 0900 hours, with the Assistant Manager Regulatory Affairs and the Senior Risk and Regulatory Affairs, the medical record showed Patient 1 was admitted to the hospital on 9/29/25. During a review of the H&P dated 9/30/25 at 1020 hours, the H&P showed Patient 1 presented with shortness of breath, left leg pain and new onset of atrial fibrillation. During a review of the Cardiology’s Progress Note dated 10/5/025 at 1217 hours, the Cardiology’s Progress Note showed Patient 1 was diagnosed with heart failure, atrial fibrillation, left ventricular thrombus, and total occlusion of the left popliteal artery at the level of the knee. Review of Patient 1’s Vital Signs on 10/5/25, showed as follows: * At 1958 hours, the BP was 80/59 mmHg, MAP 65 mmHg. * At 2000 hours, the BP was 80/59 mmHg, MAP 63 mmHg. There was no documentation showing that nursing staff rechecked the patient’s blood pressure, reassessed the patient, or notified the physician when the patient’s blood pressure dropped to 80/59 mmHg. On 4/20/26 at 1030 hours, during a telephone interview with RN 1 in the presence of the Assistant Manager Regulatory Affairs and the Senior Risk and Regulatory Affairs, RN 1 stated that for Patient 1’s BP of 80/59 mmHg, he monitored the mean arterial pressure (MAP). RN stated that with a MAP above 65 mmHg and no symptoms, RN 1 would not notify the physician. RN 1 stated there was no protocol for rechecking the blood pressure unless medications were given. On 4/20/26 at 1520 hours, an interview and medical record review was conducted with the Manager of Cardiovascular Surgery, the Assistant Manager Regulatory Affairs and the Senior Risk and Regulatory Affairs about Patient 1’s low BP and MAP. The Manager of Cardiovascular Surgery stated patient care should rely on clinical assessment, focusing on MAP, patient’s symptoms, and overall condition rather than just numbers. The MAP was based on the physician’s order on how they assessed the patient. For Patient 1 with a BP 80/59 mmHg, the nurse should have contacted the physician. The Manager of Cardiovascular Surgery verified the RN 1 did not recheck the BP and did not notify the physician. There was no MAP order in place for Patient 1.”

“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: 39199 Based on interview and record review, the hospital failed to ensure the nursing staff followed the hospital’s P&P for cardiac monitoring, including documentation of cardiac rhythm at least every four hours and completion of required nursing reassessments for one of three sampled patients (Patient 1). This failure had the potential to delay recognition of changes in patient condition. Findings: Review of the hospital’s P&P titled “Assessment/Reassessment of Patients” dated 11/2025, showed assessment is the systematic collection and review of patient data. All assessment data from the multi-disciplinary team is utilized to determine and prioritize the care needs of the patient. Reassessment across disciplines is ongoing and occurs at designated intervals during the patient’s treatment to determine the response to and effectiveness of the care and interventions. Reassessment provides ongoing data about the patient’s biophysical, psychological, spiritual and social needs. A complete assessment must be completed and documented by the RN, minimally at the beginning of each shift. Focused reassessments will be done and documented according to the following: abnormal findings from previous assessments, per specialty/population specific standards of care, pertinent procedures, and legal regulatory requirements. On 4/21/26, medical record review for Patient 1 was initiated with the Nurse Manager, Risk Manager, and VP of Operations. Medical record review for Patient 1 showed the patient was admitted to the hospital on 1/23/26. Review of Patient 1’s ED Provider Notes dated 1/23/26 at 1246 hours, showed the patient presented with chest pain and was placed on continuous cardiopulmonary monitoring and pulse oximetry. Patient 1 was diagnosed with pneumonia of both lower lobes (infection in the lower parts of the lungs). Review of Patient 1’s History and Physical examination dated 1/23/26 at 1636 hours, showed Patient 1’s diagnoses included pneumonia of both lower lobes, hypertension (high blood pressure), acute on chronic systolic (congestive) heart failure (sudden worsening of ongoing inability of the heart to pump blood effectively), acute respiratory failure with hypoxia (sudden inability of the lungs to provide enough oxygen), hyperlipidemia (high levels of fat in the blood), and permanent atrial fibrillation (ongoing irregular heartbeat). a. Review of Patient 1’s nursing reassessment dated 1/27/26 at 0900 hours, showed the patient was disoriented to place, time, and situation, and respirations were shallow. Despite the patient’s diagnosis of permanent atrial fibrillation, the cardiac reassessment was documented as within defined limits. Review of Patient 1’s nursing reassessment dated 1/27/26 at 2040 hours, failed to show neurological, cardiac, and respiratory assessments were conducted despite the patient’s admission diagnoses and abnormal findings from prior assessments. The Nurse Manager verified the findings during the record review for Patient 1. b. Review of the hospital’s P&P titled “Centralized Cardiac Telemetry Monitoring” dated 8/2023, showed cardiac rhythm must be documented on admission and every four hours. Review of Patient 1’s medical record failed to show documentation of cardiac rhythm every four hours from 01/27/26 at 0800 hours until 01/28/26 at 0800 hours. During the record review, the Nurse Manager verified the findings and stated the nurses were responsible for assessing and documenting the patient’s cardiac rhythm every four hours.”

“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: 39199 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff followed the provider’s medication administration orders for one of three sampled patients (Patient 3). This failure posed a risk of adverse health outcomes to the patient. Findings: On 4/22/26 at 0841 hours, an observation of the medication administration for Patient 3 conducted by RN 5 was initiated. RN 5 pulled the following medications from the automated medication dispensing cabinet: - Aspirin 81 mg, one tablet (prevention of heart attack or stroke) - Protonix 40 mg, IV (treatment of acid reflux or gastrointestinal bleeding) - Zofran 4mg, IV (prevention or treatment of nausea and vomiting) During the observation, RN 5 was observed administering the Zofran 4 mg via IV push over approximately 30 seconds. Following the medication administration, RN 5 reviewed the patient’s medication order and the MAR and acknowledged the order required Zofran 4 mg to be administered via slow IV push over two minutes, which had not been followed. On 4/22/26 at 0930 hours, an interview and concurrent record review was conducted with the Nurse Manager, who verified that Zofran was ordered to be administered over two minutes via IV push.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 29798 Based on observation, interview and record review the hospital failed to maintain a clean and sanitary environment necessary to prevent the transmission of infection to patients, visitors, and staff when: 1. A dead rodent was found in the surgical pre-op area. 2. The staff failed to adhere to the hospital’s Infection Prevention and Control Program, including required surveillance, prevention practices, and corrective actions to maintain a sanitary environment and address infection control issues identified by public health authorities. This failure created a risk of infection transmission, cross-contamination, and increased potential for healthcare-associated infections affecting patients, visitors, and staff. Findings: Review of the hospital’s Policy & Procedure titled Quality, Patient Safety and Transformation Plan last revised 06/2025 showed: * Purpose and Scope: The Quality, Patient Safety and transformation vision at the hospital is to provide the safest, most equitable high-value care to our patients and families by becoming a high-reliability organization (HRO). The aim of an HRO is to create an environment where patient care is consistently delivered without preventable harm. The Quality, Patient Safety and Transformation Plan (Quality Plan) complies with Federal CMS conditions of participation, all California State and Federal regulations, and the Joint Commission (TJC) accreditation standards. * Objectives: - To provide a culture that promotes a culture of safety and risk reduction strategies to prevent adverse outcomes to patients. - To ensure compliance with licensing and accreditation agencies. * High Reliability Approach: The hospital actively pursues zero preventable harm and high reliability by: - Culture of safety and accountability - Provide training on high-reliability leadership and universal skills to instill evidence-based skills to improve safety. * Quality Governance and Committees: The Governing Body has the ultimate authority and responsibility for the care, and services the hospital provides to its patients for the approval and implementation of the Quality Plan. * Quality and Safety Oversight Committee (QSOC):...Promotes patient safety and monitors progress towards targets related to improve safety, quality, and experience. Review of the hospital’s document titled Epidemiology and Infection Prevention (EIP) Program Plan and Goals FY26 (July 1, 2025 - June 30, 2026) showed the following: - Scope of Service:...The EIP services include, but are not limited to - Assessment of the Environment of Care for infection prevention. - Infection Preventionist: The Infection Preventionist (IPs) are responsible for participating in activities as described in the Scope of Service. IPS have knowledge and experience in areas of patient care practices...risk assessment and performance improvement. Review of the hospital’s document titled Environment of Care Master Plan dated 2026 showed in part:...The Plan provides performance standards and indicators to measure and assess the hospital’s performance in maintaining and improving the EOC (Environment of Care). The EOC committee at the hospital is a multidisciplinary focus group and continuous process improvement team that consist of select representative from service and support departments with primary and collaborative responsibility for providing safe, secure, and comfortable environment to facilitate patient care, as well as representatives from the hospital care areas. * Improvement Opportunities and Action Plans: The continual evaluation of the EOC identifies opportunities for improvement that are selected by the EOC Committee as performance improvement projects for the EOC. Review of the Surgical and Procedural Services Environment of Care Rounds dated 3/19/26, showed the hospital’s IP noted “possible pest control issue noted in OR area with mouse/rat trap by OR A”. During a concurrent interview and record review on 4/15/26 at 1025 hours, the IP stated they were not aware of the issue involving a rat observed in the outpatient surgical hallway in February 2026. The IP further stated that they became aware of the issue on 3/19/26, after observing a mouse trap in the outpatient surgical area while conducting EOC rounds. The IP was asked what steps were taken to prevent recurrence of the issue, and stated that no further actions were necessary because EVS had already addressed the situation. During a concurrent interview and record review on 4/15/26 at 1046 hours, the OR Nurse Manager stated the OR Nurse Manager became aware of the rodent issue the next day when the mouse traps were observed in the out-patient surgical area. During a phone interview on 4/15/26 at 1105 hours, the Director of Infection Control stated that the incident involving a rat sighting in the outpatient surgical hallway was handled by environmental services (EVS) after being notified by the OR staff. The Director of Infection Control further stated that the Infection Control Department did not believe escalation was necessary because the issue had been addressed, and added that a rodent issue should only be reported if it became a recurring problem. On 4/15/26 at 1145 hours, the EVS Director provided the pest control visit report dated 2/19/26, which documented a dead mouse. The EVS Director stated they had been informed of a rodent issue in the surgical pre-op area in 2024 and again in 2026 in the outpatient surgical area. The EVS Director reported that doors previously allowing entry of critters had been repaired, though rodents could still enter through other areas of the hospital. The EVS Director further stated that EVS became aware of the most recent rodent issue through a phone call from the OR staff, which was typically followed by an email; however, no follow-up email was received in this case. The EVS Director added that mouse traps had been placed in the area and that Infection Prevention would be notified if the issue became recurring On 4/16/26 at 1650 hours, the above findings were shared with the Program Manager of Regulatory Affairs.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 29558 Based on interview and record review, hospital failed to ensure the staff documented the patient teaching regarding the purpose of violent restraints and the criteria for release for one of four sampled patients (Patient 3), increasing the risk of the patient not being aware of their plan of care. Findings: Review of the hospital’s P&P titled Restraints and Seclusion EPIC Attachment for Patients in Restraints or Seclusion: Inpatient, ARU, and Emergency Department dated 2/26, showed patient and family teaching will be provided for the purpose of the restraint and the criteria for releasing the restraint. On 1/4/26, a closed record review of Patient 4 was conducted with the ED Director and RN 5. Patient 3 presented to the ED on 4/3/26 at 1401 hours and was discharged at 2108 hours. A physician order dated 4/3/26 at 1439 hours, authorized violent/self-destructive restraints to all extremities due to aggressive behavior and imminent danger. Restraints were ordered to begin at 1438 hours, and discontinued at 1830 hours. The Restraint/Seclusion Flow Sheet dated 4/3/26 documented application of four-point restraints at 1445 hours. The record lacked documentation to show staff educated the patient on the purpose of the restraints or the criteria for release. On 4/15/26 at 1115 hours, the above concern was shared and verified with the ED Director and RN.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 29558 Based on interview and record review, the hospital failed to ensure three RNs (RNs 1, 2, and 3) had the required certifications to perform their duties as cardiovascular lab nurses. Additionally, the hospital failed to ensure RN 1’s competency validation was complete. These failures increased the risk of substandard outcomes for the patients receiving care in the cardiac catheterization lab and interventional radiology. Findings: On 3/6/26, a review of hospital documents related to the Cath Lab (cardiac catheterization lab) and IR (Interventional Radiology) was initiated in the presence of the Director of Cath Lab and IR, and the Accreditation and Regulatory Manager. 1. Review of the Job Description for Cardiovascular RN for the Cardiovascular Lab showed a mandatory requirement to perform the functions of the Cath Lab and IR RN was NIHSS (National Institutes of Health Stroke Scale) Certification. The following RNs failed to have current NIHSS Certification: - RN 1’s file showed RN 1 was hired on 10/21/25 and the RN’s first NIHSS certification was granted on 3/6/26. - RN 2’s files showed RN 2’s 2025 Annual Training was completed on 10/2/25. However, the RN’s NIHSS certification was granted on 3/7/26. - RN 3’s filed showed RN3’s 2025 Annual Training was completed on 10/2/25. However, RN 3’s NIHSS certification was granted on 3/6/26. 2. Review of RN 1’s New Hire Initial Assessment and Competency Validation for Cath Lab/IR/Holding Room RN dated 10/21/25, showed RN 4 was the validator for all the skills required. The “Validation Method Key” showed to include: - A = Direct Observation - B = Simulation - C = Document Review - D = Written Test - E = Verbal Response - O = Other, indicate However, the competency validation tool was incomplete as the area to show how the skills were validated was left blank for all the sections by RN 4. On 3/9/26 at 1530 hours, the above findings were shared and acknowledged by the Accreditation and Regulatory Manager, the Quality Director, the COO and the CNO.”

“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: 36703 Based on observation, interview and record review, the hospital failed to ensure RN 7 followed the physician’s order for the administration of a medication for one of eight sampled patients (Patient 3). This failure increased the risk for substandard outcomes for the patient. Findings: Review of the hospital’s P&P titled Medication Administration, Administration Time, Monitoring and Documentation dated 3/25, showed discrepancies or questions will be resolved before the medication is administered. On 3/9/26 at 0923 hours, an observation of a medication administration was conducted in Patient 3’s room with RN 7. RN 7 was observed providing Patient 3 with an oral pill, Norco 5-325 mg (pain medication) for the indication of pain 3/10 (on a 0 - 10 pain scale, zero indicates the patient has no pain and 10 indicates the patient has the worst pain) on the pain scale. Review of the physician’s order dated 3/7/26 at 1221 hours, showed to administer Norco 5-325 mg tablet every four hours as needed for mild pain (score 1-3). Further review showed to give Norco 5-325 mg if pain was not improved with Tylenol (pain medication). However, review of Patient 3’s medical record failed to show Tylenol was given prior to administering Norco 5-325 mg. On 3/9/25 at 1100 hours, an interview was conducted with the Accreditation and Regulatory Manager. The Accreditation and Regulatory Manager stated Patient 3 shared with RN 7 the preference to take Norco instead of Tylenol. However, there was no documentation in Patient 3’s medical record to support clarifying the order with the physician in the event the patient preferred not to take Tylenol. On 3/9/26 at 1530 hours, the above findings were shared and acknowledged by the Accreditation and Regulatory Manager, the Quality Director, the COO, and the CNO.”

“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: 39199 Based on observation, interview, and record review, the hospital failed to ensure patients received care in a safe setting and in accordance with the approved conditions of Program Flexibility FLEX-12858 for the use of Emergency Department (ED) hallway patient care spaces as evidenced by: The hospital caring for patients in ED hallway locations who did not meet the approved inclusion and exclusion criteria, including one Emergency Severity Index (ESI) level 2 psychiatric patient who had not been medically cleared and two patients who were ED boarders with inpatient admission orders. This failure had the potential to place patients at risk for receiving care in an environment not approved for their clinical condition or level of care. Findings: Review of the Approval of Program Flexibility FLEX-12858 issued to the hospital, dated 9/29/25, for alternative ED hallway patient care spaces showed the approval included specific conditions for the use of hallway gurneys and chairs when patient census exceeded licensed capacity. The approval allowed the hospital to use designated ED hallway gurney spaces (ED1-H1, ED1-H2, ED1-H3) and chair spaces (ED1-C1, ED1-C2, ED1-C3, ED1-C4) for up to seven patients during periods when the patient census exceeded licensed capacity and acceptable mechanisms for relief were exhausted. The flexibility approval specified inclusion criteria for patients placed in the ED hallway areas, which included triaged ESI level 3, 4, or 5 patients, and ESI level 2 psychiatric patients only after they had been medically cleared and were pending psychiatric evaluation. The flexibility approval also specified exclusion criteria, which included patients requiring inpatient admission. The approval stated ED boarders with inpatient admission orders were not permitted to receive care in the ED hallway locations. On 3/5/26 at 0915 hours, a tour of the ED was conducted with the Director of Clinical Quality Improvement and the ED Director. During the tour, Patient 4 was observed lying on a gurney connected to a cardiac monitor in hallway location ED1-H1. Patient 5 was observed lying on a gurney in hallway location ED1-H2. A gurney with soiled linen and patient belongings was observed in the location designated for chair spaces. The ED Director stated that Patient 6, who had initially been placed in a chair space, reported discomfort and exhibited behavioral concerns, which resulted in the patient being relocated to a gurney positioned within the chair designated area. a. On 3/4/26 at 1348 hours, an interview and concurrent record review for Patient 4 was conducted with the ED Director. Review of Patient 4’s Patient Care Timeline showed the patient arrived in the ED on 3/3/26 at 0933 hours. On 3/4/26 at 0142 hours, an inpatient admission order was placed for Patient 4. b. On 3/4/26 at 1520 hours, an interview and concurrent record review for Patient 5 was conducted with the ED Director. Review of Patient 5’s Patient Care Timeline showed the patient arrived to the ED on 3/3/26 at 0909 hours. A provider’s note dated 3/3/26 at 1336, showed a plan to admit Patient 5 for intravenous antibiotic therapy and continued hydration. An inpatient admission order for Patient 5 was placed on 3/3/26 at 1416 hours. c. On 3/4/26 at 1530 hours, an interview and concurrent record review for Patient 6 was conducted with the ED Director. Review of Patient 6’s Patient Care Timeline showed the patient arrived in the ED on 3/3/26 at 1203 hours, with a complaint of suicidal ideation. The patient was triaged as ESI level 2. The Patient Care Timeline showed Patient 6 was placed in chair space ED1-C2 on 3/3/26 at 1312 hours. However, review of Patient 6’s ED Provider Notes showed the patient had not been medically cleared and was pending medical clearance as of 3/3/26 at 1400 hours. On 3/4/26, the ED Director verified the findings for Patients 4, 5, and 6. These findings showed Patients 4 and 5 had inpatient admission orders while receiving care in ED hallway locations, and Patient 6 was an ESI level 2 psychiatric patient who had not been medically cleared prior to placement in a designated ED hallway chair space.”

“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: 37663 Based on interview and record review, the hospital failed to ensure the nursing staff provided the necessary care and services to one of eight sampled patients (Patients 1) as evidenced by the following: - The nursing staff did not conduct a comprehensive pain assessment for the patient. - The nursing staff used the FACES pain scale for a patient who was cognitively intact, which was inconsistent with the hospital’s P&P. - The nursing staff failed to conduct pain assessment and reassessment within approximately one hour after the administration of pain medication, as per the hospital’s P&P. These failures posed the increased risk of substandard health outcomes for the patients. Findings: Review of the hospital’s P&P titled Pain: Adult and Pediatric dated January 2026 showed the following: * Policy: The healthcare team conducts a comprehensive pain assessment that is consistent with the scope of care, treatment, and services and the patient’s condition. The healthcare team uses methods to assess pain that are consistent with the patient’s age, condition, cultural background, and ability to understand. The healthcare team reassess and responds to the pain, based on its reassessment criteria * Definitions: - The numeric Rating: (NRS) measures the pain on a 0 to 10 scale, with zero indicating no pain and 10 indicating a severe amount of pain. - Wong-Baker Faces Scale( FACES) employs visual pictures of faces, from happy to sad which the patient points to in order to communicate the amount of pain they are in. Scale was developed for children 3 and above of age and can be used for cognitively impaired adults. * Assessment or Reassessment: - Screen for the presence of pain upon admission or with first contact with the patient. A complaint of 4 or more than 4, or a complaint greater than usual for the patient or ineffective pain management requires a more in depth assessment of self-report to be completed. - A comprehensive pain assessment /reassessment is conducted as appropriate to the patient’s condition, scope of care, treatment and services provided; and methods are appropriate to the patient’s age and or ability. - Upon admission, assess patient’s history of pain experience including understanding of pain management techniques, and cultural beliefs regarding pain as indicated. - Assess for location, intensity (pain scores), duration, character or quality (burning, cramping etc.) and aggravating or alleviating factors. - Determine pain scores using appropriate pain assessment tools to include 0-10 verbal scale.... FACES. - Reassessment should be completed in timely manner, within approximately one hour, to determine if the intervention is working or if the patient is experiencing adverse effects. * Interventions: - For the purpose of medication orders, mild pain will be defined as 1-3, moderate pain as 4-6, and severe pain as 7-10 on the 0-10 or 0-8 pain scale. * Documentation: Document all pain assessments, reassessments and interventions in the appropriate section of the EHR. Include pain scales used. An interview and concurrent review for Patient 1’s medical record was conducted on 3/4/26 at 1500 hours with the Director of Clinical Quality Improvement. The record showed Patient 1 was admitted to the hospital’s telemetry unit on 11/29/25 at 2344 hours. The H&P dated 11/30/25 at 1342 hours, showed Patient 1 presented to the hospital with worsening weakness for 5 days, along with neck and shoulder pain. Patient 1’s Pain Assessment flow sheet dated 11/29/25 at 1837 hours, showed the following documentation: - Presence of pain - The numeric rating pain scale 10 was the worst pain - The Numeric pain rating of pain was 10 There was no documentation on the pain location, duration, character or quality and aggravating or alleviating factors. Patient 1’s Pain Assessment flow sheet dated 11/30/25 at 0059 hours showed the following: - Generalized pain location - Aching - Discomfort for the quality of pain - Pain was present - Preferred pain tool was numeric - Pain rating was 3 - Acceptable pain intensity scale was 6. During the review of Patient 1’s neurological assessment dated 12/1 to 12/2/25, the documentation showed the patient was alert and oriented. However, the RNs assessed Patient 1’s pain level using the FACES pain scale instead of the numeric pain scale, which the patient preferred. During the review of the physician’s order dated 12/1/25 at 2347 hours, the order showed to administer morphine (a pain medication) 4 mg IV every 6 hours PRN for severe pain. During the review of Patient 1’s eMAR and the Pain Assessment and Reassessment flowsheet dated 12/1 to 12/3/25, showed the following: - On 12/1/25 at 2225 hours, the documentation showed the RN used the FACES pain scale to assess the patient’s pain level, and the pain score was documented as 8 (severe pain). Patient 1 was medicated with morphine 4mg IV as ordered by the physician. - On 12/2/25 at 0800 hours, the documentation showed the RN used the FACES pain scale, and the pain score was documented as 8. At 0824 hours, the RN administered morphine 4 mg IV. A pain reassessment was performed on 12/2/25 at 0900 hours using the FACES pain scale, and the pain level was documented as 0. - On 12/2/25 2200 hours, the documentation showed the RN used the FACES pain scale, and the pain score was documented as 8. At 2212 hours, the RN administered morphine 4 mg IV. A pain reassessment was performed on 12/3/25 at 0000 hours using the FACES pain scale, and the pain level was documented as 0. However, the pain reassessment was not performed within approximately one hour after medication administration, as per the hospital’s P&P. The findings were shared with the Director of Clinical Quality Improvement.”

“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: 37663 Based on interview and record review, the hospital failed to ensure the nursing staff developed a care plan related to hypotension and respiratory conditions for one of eight sampled patients (Patient 1). This failure posed an increased risk of substandard health outcomes to the patient. Findings: An interview and concurrent review of Patient 1’s medical record was conducted on 3/4/26 at 1010 hours with the Director of Clinical Quality Improvement. The medical record showed Patient 1 was admitted to the hospital’s telemetry unit on 11/29/25 at 2344 hours. During the review of Patient 1’s H&P dated 11/30/25 at 1342 hours, the documentation showed Patient 1 had history of comorbidities and presented to the hospital with worsening weakness for 5 days, along with neck and shoulder pain. Patient 1 was transferred to SDU on 12/1/25 at 2241 hours, for airway concerns as documented by the physician. Patient 1 was transferred to the ICU on 12/3/25 due to desaturation and hypotension and again transferred to the ICU on 12/13/25 due to hypotension. The patient was receiving a Precedex (a medication used to maintain sedation for a patient) drip while on BiPAP and later received a Levophed (a medication used to treat low blood pressure) drip to treat the hypotension. During the review of the Plan of Care on 3/5/26 at 1452 hours, a care plan for pain was noted. The Director of Clinical Quality Improvement was asked about the plan of care when the patient’s condition changed on 12/3/25 and 12/12/25 due to hypotension and respiratory failure/desaturation, and when the patient was placed on the BiPAP on 12/3/25 for impaired gas exchange. The Director of Clinical Quality and Improvement stated that a care plan for ineffective airway clearance was developed in 12/2025, and confirmed there was no care plan developed for hypotension.”

“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: 37663 Based on interview and record review, the hospital failed to ensure that the nursing staff implemented the hospital’s P&P for performing a focused assessment for one of eight sampled patients (Patient 1) when the patient experienced a change in condition. This failure posed an increased risk of substandard health outcomes to the patient. Findings: Review of the hospital’s P&P titled Assessment and Reassessment dated 11/2025 showed: * Reassessment: a complete assessment must be completed and documented by the RN at the beginning of the shift. Focused reassessments will be done and documented when there is a significant change in the patient’s status and or diagnosis or condition.... Abnormal findings from previous assessment. During an interview and concurrent review of Patient 1’s medical record on 3/5/26 at 1325 hours with the Director of Clinical Quality Improvement, Patient 1’s eMAR dated 12/12/25 was reviewed. The eMAR showed the dexmedetomidine (same as Precedex) drip dose was documented as 0.6 mcg/kg/hr at 2100 hours and 0 mcg/kg/hr at 2200 hours. During the review of the Physician Communication Comments dated 12/25/25 at 2232 hours, showed start Levophed, transfer to ICU, stat ABG, and chest X-ray. During the review of Patient 1’s vital signs flow sheet dated 12/12/25, the following were documented: - 2000 hours: BP 147/91 mmHg, HR 82/min, RR 16/min - 2100 hours: BP 157/90 mmHg, HR 75/min, RR 20/min - 2200 hours: BP 169/89 mmHg, HR 81/min, RR 20/min - 2207 hours: BP 66/47 mmHg, HR 71/min, RR 14/min - 2230 hours: HR 58/min RR 18/min - 2232 hours: BP 62/44 mmHg, HR 57/min, RR 18/min - 2233 hours: BP 51/21 mmHg, HR 58/min RR 18/min During the review of the RN’s physical assessment documentation dated 12/12/25 at 2000 hours, a complete head-to-toe assessment was documented. The Director of Clinical Quality Improvement was asked for the RN’s reassessment of Patient 1 during the change in condition when the BP suddenly dropped to 66/47 mmHg at 2207 hours. The Director of Clinical Quality Improvement stated the RN’s reassessment documentation at 2207 hours, showed diminished breath sounds. The Director of Clinical Quality Improvement was asked if a hand-off was completed between the Step Down Unit RN and the ICU nurse to identify the patient’s condition at the time of hypotension. The Director of Clinical Quality Improvement stated that the SDU RN and the ICU RN hand-off should have been documented in the patient’s EHR. However, there was no documentation of a hand-off. Cross reference 0405”

“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: 37663 Based on interview and record review, the hospital failed to ensure the nursing staff implemented the dexmedetomidine IV infusion P&P and failed to follow the physician’s order for one of eight sampled patient (Patient 1) as evidence by: * The nursing staff failed to conduct the required RASS assessments. * The nursing staff failed to document the dose of dexmedetomidine administered, resulting in missing dose documentation. * The nursing staff failed to adjust the infusion dose in accordance with the hospital’s P&P and the physician’s order. This failure created an increased risk of substandard health outcomes for the patient. Findings: Review of the hospital’s P&P titled IV Drug Legend revised date 11/2025, showed: Dexmedetomidine: Special Considerations/Information: IV infusion; Refer to IV infusion Titration Protocol. Start infusion at 0.2 mcg/kg/hr. Titrate by 0.1 mcg/kg/hr every 5 mins for RASS of -2. Maximum dose = 1.2 mcg/kg/hr. SDU: Titrate and document hourly. An interview and concurrent review of Patient 1’s medical record was conducted on 3/4/26 at 1500 hours, with the Director of Clinical Quality Improvement. The medical record showed Patient 1 was admitted to the hospital’s telemetry unit on 11/29/25 at 2344 hours. Patient 1 was transferred to SDU on 12/1/25 at 2241 hours, for airway concerns as documented by the physician. Patient 1 was transferred to the ICU on 12/3/25 due to desaturation and hypotension and again transferred to the ICU on 12/13/25 due to hypotension. Review of the physician’s order dated 12/3/25 at 2305 hours, showed an order for dexmedetomidine IV (additive 400 mcg 0.2 mcg/kg/hr) in NS 0.9% (Normal Saline, saltwater solution) 100 ml diluents, to start at 0.2 mcg/kg/hr, titrate by 0.1 mcg/kg/hr, every 15 minutes for goal of RASS -1 maximum dose of 1.2 mcg/kg/hr. Concentration 4 mcg/ml. For SDU: titrate and document hourly. An interview and concurrent review of Patient 1’s medical record was conducted on 3/5/26 at 1124 hours, with the Director of Clinical Quality Improvement. The RASS monitoring and dexmedetomidine IV infusion documentation for Patient 1 was reviewed for the period from 12/6/25 at 0844 hours through 12/13/25 at 2200 hours. The Director of Clinical Quality Improvement was asked for Patient 1’s RASS monitoring and the titration of the dexmedetomidine IV infusion administered from 12/6 through 12/13/25. The Director of Clinical Quality Improvement stated there was no documentation of RASS assessments for Patient 1 from 12/7/25 at 2315 hours through 12/9/25 while the patient was receiving dexmedetomidine. The Director of Clinical Quality Improvement stated the RNs started documenting RASS scores on 12/10/25. During the review of Patient 1’s eMAR on 3/5/26 at 1326 hours, the eMAR showed that from 12/6/25 at 0844 hours to 12/13/25 at 2100 hours, the patient received dexmedetomidine IV infusion as follows: a. On 12/6/25 at 0844 hours, the dexmedetomidine was running at 0.2 mcg/kg/hr, with a RASS of -2. At 0935 hours, the dose was increased to 0.3 mcg/kg/hr for RASS of +1. At 1000 hours, the dose remained at 0.3 mcg/kg/hr with a RASS of -1. The IV infusion was turned off at 1030 hours, with the RASS score remaining at -1. Subsequent RASS assessments at 1200 and 1300 hours were both documented as 0. b. On 12/7/25 at 2315 hours, a new 100 mL bag of dexmedetomidine was started at a rate of 0.2 mcg/kg/hr. There was no documentation of the patient’s RASS assessment at that time, and no documentation indicating whether or when the infusion was discontinued or turned off. c. The next entry on the MAR showed that from 0000 to 0200 hours on 12/8/25, the dexmedetomidine IV infusion was running at 0.2 mcg/kg/hr. From 0300 to 0400 hours, the dose was increased to 0.3 mcg/kg/hr. From 0442 to 0500 hours, the infusion rate was 0.4 mcg/kg/hr, and at 0600 hours the dose was decreased back to 0.3 mcg/kg/hr. The Director of Clinical Quality Improvement verified that the physician’s titration order was not followed. The documentation showed that the dexmedetomidine IV infusion was continued from 0700 to 1200 hours at a rate of 0.2 mcg/kg/hr, and from1300 to 1500 hours, the infusion was turned off. From 1600 to 1800 hours, the dexmedetomidine infusion continued at 0.2 mcg/kg/hr. However, there was no documentation indicating how much of the dose the patient received at 1900 hours. The infusion then continued at 0.2 mcg/kg/hr through 2300 hours. d. On 12/9/25 at 0000 hours, the dexmedetomidine infusion rate was increased to 0.3 mcg/kg/hr. From 0100 to 0500 hours, the dose was further increased to 0.4 mcg/kg/hr. At 0600 hours, the rate was decreased to 0.3 mcg/kg/hr, and from 0624 to 0700 hours, the dose was increased again to 0.4 mcg/kg/hr. The Director of Clinical Quality Improvement verified that the physician’s titration order was not followed, as the dexmedetomidine infusion was titrated at intervals of less than one hour. At 0800 hours, the dose administered to the patient was not documented. From 0900 to 1300 hours, the dose was maintained at 0.3 mcg/kg/hr. From 1400 to 1600 hours, the dose was decreased to 0.2 mcg/kg/hr. From 1700 to 1900 hours, there was no documentation showing the dose the patient received. The Director of Clinical Quality and Improvement verified the physician’s order was not followed. e. On 12/10/25 at 0000 to 1500 hours, the patient received dexmedetomidine IV at 0.4 mcg/kg/hr. There was no documented RASS score from 0000 hours to 0600 hours. The RASS scores from 0700 to 1000 hours were documented as -1. At 1100 hours, the RASS score was + 1. From 1200 to 1800 hours, the RASS scores returned to -1. At 1556 hours, the dexmedetomidine dose was decreased to 0.3 mcg/kg/hr and maintained at that rate until 1800 hours However, at 1900 hours, there was no documentation showing the dose the patient received. At 2000 hours, the RASS score was +1, and the dexmedetomidine infusion was increased to 0.4 mcg/kg/hr. The infusion was maintained at this rate until 2300 hours, during which the RASS score was documented as 0. f. On 12/11/25 at 0000 to 0200 hours, the dexmedetomidine infusion was running at 0.4 mcg/kg/hr. Between, 0223 to 0400 hours, the RASS score was +1. The dose was increased to 0.5 mcg/kg/hr until 0300 hours. From 0400 to 0800 hours, the dexmedetomidine infusion was increased to 0.6 mcg/kg/hr. At 0900 hours, the dose was increased to 0.7 mcg/kg/hr with a RASS score of +1. At 1000 hours, the RASS was +1, and the dexmedetomidine infusion was increased to 0.8 mcg/kg/hr from 1000 to 1100 hours. At 1100 hours, the RASS score was -1, and at 1138 hours the dose was decreased to 0.7 mcg/kg/hr. At 1200 hours, the dose was increased to 0.8 mcg/kg/hr with a RASS score of +1. The Director of Clinical Quality Improvement verified that the physician’s titration order was not followed. At 1300 hours, the RASS score was +1, and the dexmedetomidine infusion was increased at 0.9 mcg/kg/hr. Between 1346 to 1400 hours, the RASS score was -1, and the dose was decreased at 0.7 mcg/kg/hr. The Director of Clinical Quality Improvement verified that the physician’s titration order was not followed. At 1500 hours, the RASS score was +1 and the dexmedetomidine infusion was increased to 0.8 mcg/kg/hr. The infusion was maintained at this rate until 1700 hours. From 1600 to 1800 hours, the RASS scores were documented as -1. At 1800 hours, the infusion rate was decreased to 0.4 mcg/kg/hr (a reduction of 0.4 mcg/kg/hr). The Director of Clinical Quality Improvement verified that this adjustment did not follow the physician’s titration order. At 1900 hours, the RASS score was -2. From 2000 to 2100 hours, the dexmedetomidine infusion was increased to 0.5 mcg/kg/hr with RASS score of +1. From 2200 to 2300 hours, the dose was decreased to 0.4 mcg/kg/hr, with RASS scores documented as -1 and 0. g. On 12/12/25, from 0000 to 0300 hours, the infusion was maintained at 0.4 mcg/kg/hr; however, no RASS score was documented at 0300 hours. At 0400 hours, the RASS score was +1, and the dose was increased to 0.5 mcg/kg/hr, which was maintained until 0600 hours for a RASS score of -1. The infusion continued at 0.5 mcg/kg/hr until 0800 hours; however, at 0700 hours, no RASS assessment was documented. The dose remained at 0.5 mcg/kg/hr until 1000 hours for a RASS score of 0. At 1015 hours, the dose was increased to 0.6 mcg/kg/hr, and from 1032 to 1100 hours, the infusion was further increased to 0.7 mcg/kg/hr, with a RASS score of 0. The Director of Clinical Quality Improvement verified that the physician’s titration order was not followed. The dose was increased to 0.8 mcg/kg/hr, with RASS scores of -1 documented from 1200 to 1300 hours. At 1400 hours, the dose was decreased to 0.5 mcg/kg/hr, with a RASS score of 0. At 1500 hours, the dose was increased to 0.8 mcg/kg/hr, with a RASS of -1. At 1523 hours, the dose was decreased to 0.6 mcg/kg/hr, and at 1600 hours, with a RASS of 0, the dose was increased to 0.7 mcg/kg/hr. The Director of Clinical Quality Improvement verified that the physician’s titration order was not followed. The dose was maintained at 0.7 mcg/kg/hr for a RASS of -1. At 1800 hours, the dose was decreased to 0.6 mcg/kg/hr; the RASS score was not documented. At 1900 hours, there was no documentation showing that the patient received a dose. From 2000 to 2100 hours, the dose was 0.6 mcg/kg/hr with a RASS score of 0. At 2200 hours, the dose was documented as 0, along with the RASS entry. On 3/5/26 at 1645 hours, the findings were shared with the CNO and the Director of Clinical Quality Improvement.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure emergency services were provided to four of six sampled patients (Patients 1, 3, 11, and 14) as evidenced by: 1. The hospital failed to provide further medical examination and treatment necessary to stabilize an identified emergency medical condition for Patient 1 prior to discharge in the ED. 2. Transfer forms were incomplete for Patient 11 and Patient 14 prior to the patients transferring to other facilities. 3. Patient 3 were placed in the ED hallway, not according to the conditions of the flex approval granted. These failures increased the risk for substandard outcomes for these patients. Findings: 1. Review of the hospital’s Medical Staff Rules and Regulations dated 11/15/25, showed EMTALA requires for all patients who present to the ED must, at a minimum, provide for an appropriate medical screening examination within the capability of the hospital’s ED, including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition exists. Review of the hospital’s P&P titled Admission/Discharge/Transfer dated November 2025 showed all patients arrive in the ED will be screened for an emergency medical condition (EMC)and compliance with EMTALA requirements. For transfer or discharge criteria, EMC has been cleared/stabilized, and the patient is discharged/transferred and given a referral for follow up care; EMTALA conditions have been met for transfer to another facility; and patient’s condition has been stabilized and admitted to the acute care hospital or psychiatric services for further treatment and evaluation. On 01/22/26, Patient 1’s medical record was reviewed in the presence of the Director of Risk and Regulatory Affairs, Vice President of Nursing, Assistant Manager of Regulatory Affairs, Regulatory Specialist, and ED Educator. Patient 1’s medical record showed Patient 1 was transported by ambulance and presented to the ED on 10/04/25, as a critical trauma following a ground-level fall. Patient 1 was discharged home from the ED on 10/05/25, and was subsequently contacted by the hospital and advised to return to the ED due to concerning finalized imaging findings requiring admission and close monitoring. Review of the Trauma History and Physical dated 10/04/25 at 1900 hours, identified possible diagnoses including central nervous system injury and spinal injury for Patient 1. The documented plan included obtaining an MRI of the acute spinal cord and spine, with consultant evaluation pending. Review of the ED Provider Notes dated 10/04/25 at 1901 hours, showed MD 2 reviewed initial imaging and documented CT scans were negative for intracranial hemorrhage, acute cervical spine fracture, and chest trauma. MD 2 documented trauma services and consultants recommended an MRI and Patient 1’s persistent upper-extremity numbness needed continued diagnostic workup in the Clinical Decision Unit (CDU). Review of physician orders showed an order placed on 10/04/25 at 2111 hours, for an MRI Acute Cord Spinal Survey without contrast for Patient 1. Review of Patient 1’s MRI Acute Cord Spinal Survey without contrast, finalized on 10/05/25 at 0810 hours, showed the following significant findings: - Edema about the C5 spinous process suspicious for a non-displaced fracture and interspinous edema at C4-C5 and C5-C6 suspicious for ligamentous injury. - Edema involving the C5-C6 disc space and anterior C5-C6 vertebral bodies, concerning a nondisplaced anterior osteophyte fracture. - Suspected posterior epidural hematoma extending from C3-C4 through C5-C6 measuring up to approximately 3 mm. - Severe spinal canal stenosis at C4-C5 and C5-C6 with spinal cord impingement and slightly increased cord signal at the C5 level, suggestive of edema versus myelomalacia. - Moderate cervical prevertebral edema. Further review of the radiology report showed that the interpreting radiologist communicated these findings to the NP on 10/05/25 at 0810 hours. Review of the CDU Progress Note dated 10/05/25 at 0700 hours, showed MD 5 documented Patient 1 remained pending Trauma and Orthopedic recommendations. However, documentation reflected that MD 5 recommended discharge of the patient from the CDU. Documentation within the CDU Progress Note showed NP handoff and decision-making with the following: - On 10/04/25 at 2200 hours, a plan to discharge Patient 1 following orthopedic spine intervention for acute cord issues, despite the MRI not yet being finalized. - On 10/05/25 at 0820 hours, NP 1 received handoff from NP 2 and documented notification of finalized MRI results and intent to consult Orthopedics. - On 10/05/25 at 1220 hours, NP 1 documented orthopedic Resident 1 evaluated Patient 1. - On 10/05/25 at 1754 hours, NP 1 documented Orthopedic Spine recommendations included weight bearing as tolerated to all four extremities, cervical collar for comfort, and outpatient orthopedic follow-up. - On 10/05/25 at 1809 hours, NP 1 documented discussion with trauma Resident 2, who stated Patient 1 could discharge once cleared by spine. - On 10/05/25 at 1841 hours, NP 1 documented Patient 1 had a steady gait, declined physical therapy evaluation, and was discharged home. Review of the orthopaedic surgery consult note dated 10/05/25 at 0837 hours, authored by orthopedic Resident 1, showed documentation of Patient 1’s chief complaint of bilateral upper extremities paresthesia. The consult notes included MRI findings of suspicious cervical ligamentous injury, spinal cord stenosis, and epidural hematoma. The documented plan included weight bearing as tolerated to all extremities, cervical collar for comfort, neurologic checks every four hours while inpatient, and instructions to return to the Emergency Department for symptom changes. However, further review of the orthopaedic surgery consult note showed the attestation signed by MD 1 on 10/07/25 at 1839 hours, showed MD 1 documented a recommendation against discharge. MD 1 had not personally examined Patient 1. The attestation documented concern for a fracture line through the disc and an epidural hematoma causing severe central canal stenosis and spinal cord signal change. Review showed Patient 1 had already been discharged from the Emergency Department to home prior to this attestation. Review of the Patient Care Timeline dated 10/5/25 at 1850 hours, showed NP 1 entered an order for “Patient Ready to Go”. Further review showed Patient 1 was discharged from the ED at 2010 hours. Review of the Trauma Surgery Event Update Note dated 10/05/25 at 2010 hours, showed trauma Resident 2 contacted Patient 1 soon after discharge to discuss the finalized MRI findings. Documentation showed Patient 1 had already been discharged and was at home. Due to the MRI findings, the resident instructed Patient 1 to return to the hospital for admission and observation related to cervical spine injury and epidural hematoma. Further review of Patient 1’s medical record showed Patient 1 returned to the Emergency Department on 10/05/25 at 2204 hours Review of the Patient Care Timeline showed Patient 1 arrived to the Emergency Department on 10/05/25 at 2204 hours. At 2207 hours, documentation reflected the chief complaint as being instructed by a physician to return due to concerning MRI findings. At 2217 hours, Emergency Department status changed to Observation. Review of the Trauma Surgery H&P Note dated 10/05/25 at 2216 hours, showed MD 4 documented cervical spine ligamentous injury and epidural hematoma. The note further documented Patient 1 had been discharged earlier without physical therapy evaluation to assess discharge safety and without a documented anticoagulation management plan in the presence of epidural hematoma. Review of the Orthopaedic Spine Surgery Inpatient Consult dated 10/06/25 at 0036 hours, showed an attestation by MD 1 dated 10/07/25 at 1843 hours, documenting a diagnosis of cervical spine fracture with concern for spinal cord injury. Documentation showed discussion of operative management and Patient 1 agreement to proceed with C3-T1 posterior spinal instrumentation and fusion and C3-C7 laminectomy. Review of the Consent for Operation/Procedures or Rendering of Other Medical Services dated 10/06/25 at 1342 hours, showed Patient 1 consented for MD 1 to perform C3-T1 posterior spinal instrumentation and fusion and C3-C7 laminectomy. Review of the Discharge Summary dated 10/07/25 at 0037 hours, and attested by MD 1 at 0927 hours, showed Patient 1 left against medical advice. Documentation showed MD 1 discussed risks of progressive neurologic decline, paralysis, and quadriplegia related to cervical spine injury and epidural hematoma, particularly in the context of anticoagulant use. Documentation showed Patient 1 verbalized understanding of risks and insisted on leaving AMA. On 1/23/25 at 1001 hours, an interview was conducted with the Medical Director of Trauma and Resident 2 in the presence of the Director of Risk and Regulatory Affairs, Assistant Manager of Regulatory Affairs, Regulatory Specialist, and the Trauma Coordinator. Resident 2 stated Patient 1 had initially been placed in Emergency Department observation status. Trauma Resident 2 stated discharge occurred following a repeat neurologic examination and discussion with the orthopedic spine resident, who recommended outpatient follow-up. Trauma Resident 2 stated finalized MRI findings were not available at the time of discharge and did not initially identify the epidural hematoma. The Medical Director of Trauma stated decision-making without finalized imaging reports may occur depending on timing and study type. However, the discrepancy between preliminary and final MRI interpretation was unusual. The Medical Director of Trauma stated the hospital identified a breakdown in communication between the orthopedic resident and the orthopedic attending physician. On 01/23/25 at 1230 hours, interview with MD 1 was conducted. MD 1 stated the attending orthopedic surgeon was in the operating room between approximately 1200 hours and 1900 hours and instructed the resident to retain Patient 1 until personal evaluation could occur. MD 1 stated discovery of Patient 1’s discharge occurred upon his arrival to the Emergency Department for assessment, and the patient was not assessed by MD 1. Upon Patient 1’s return to the ED on 10/5/25, MD 1 stated the clinical presentation was atypical for Patient 1, with minimal pain and preserved movement, except for left hand weakness graded at four out of five. However, MD 1 stated identification of injury severity required specialized spine examination skills. MD 1 stated discharge would not have been recommended, and immobilization and bedrest would have been required pending surgical intervention. MD 1 stated subsequent education was provided to the orthopedic residents emphasizing the requirement to contact the attending physician prior to discharge in similar circumstances. On 01/26/25 at 1402 hours, hospital leadership, including the Director of Risk and Regulatory Affairs, Assistant Manager of Regulatory Affairs, the CNE, and the CMO, were notified of the above findings and concerns. 2. Review of the hospital’s P&P titled Admission/Discharge/Transfer dated November 2025 showed all patients arrive in the ED will be screened for an emergency medical condition (EMC) and compliance with EMTALA requirements. For transfer or discharge criteria, EMC has been cleared/stabilized and the patient is discharged/transferred and given a referral for follow up care; EMTALA conditions have been met for transfer to another facility; and patient’s condition has been stabilized and admitted to the acute care hospital or psychiatric services for further treatment and evaluation. a. Patient 11’s medical record review was initiated on 1/26/26. Patient 1 was brought in by ambulance from another hospital to the ED on 8/26/25, for a chief complaint of facial droop and determination of acute stroke intervention. Patient 11 was transferred back to the sending hospital on 8/27/25. Review of the Patient Care Timeline dated 8/27/25 at 0541 hours, showed NP 3 entered an order for “ED Disposition set to Transfer to Long-Term Acute Care Facility”. Review of the Patient Transfer form dated 8/27/25 at 0605 hours, showed NP 3 signed for Patient 11 to transfer to an appropriate bed available at the receiving hospital. However, the area to show the “Patient Condition” as “Satisfactory”, “Fair”, “Serious” or “Critical” was left blank. Review of the Patient Care Timeline dated 8/27/25 at 0811 hours, showed Patient 11 was discharged from the hospital. On 1/26/26 at 1031 hours, an interview and concurrent review of Patient 11’s medical record was conducted with the Director of ED. The Director of ED acknowledged the above finding. 35310 b. On 1/23/26, Patient 14’s medical record was reviewed. Patient 14’s medical record showed Patient 14 arrived to the ED on 12/3/25 at 1638 hours and left the ED to another facility on 12/5/26 at 0451 hours. Review of the Patient Transfer dated 12/5/25 at 0346 hours, showed the areas to check off patient’s condition: satisfactory, fair, serious, or critical were left empty. During an interview and concurrent medical record review with the ED Nurse Manager on 1/23/26 at 0900 hours, the ED Nurse Manager verified the incomplete transfer form for Patient 14. 3. Review of the CDPH’s letter for Approval of Program Flexibility dated 9/5/25, showed the request for program flexibility of T22 DIV5 CH1 ART8-70805 was approved under the following conditions: ....4. Corridor gurney spaces for medically screen stable ED patients who have a treatment plan. The activation or use of these gurney spaces is based on operational need that is triaged when >75 total patients are in treatment or 20 or greater patients are in the waiting room. Placement is based on clinical judgment of the Triage Care Coordinator and Patient Care Coordinator. Exclusion criteria will include, but not limited to unstable vital signs, isolation precautions, cannot wear a mask, .....Emergency Severity Index (ESI) level 1,2, unstable 3.... During an ED tour on 1/22/26 at 1020 hours, with the ED Educator and Sr. Ambulatory Risk & Regulatory Professional, Patient 3 was observed placing on ED hallway. The ED Educator stated Patient 3 was triaged as level 2. When asked, the ED Educator stated RN 8 assigned Patient 3’s bed placement. RN 8’s documented training to place ED patients’ bed assignment was requested. On 1/23/26, Patient 3’s medical record was reviewed. Patient 3’s medical record showed Patient 3 arrived the ED on 1/21/26 at 1537 hours and left the ED on 1/22/26 at 1631 hours. Review of the ED Care Timeline showed the following: * On 1/21/26 at 1646 hours, Patient 3 was assigned as 2 for patient acuity. * On 1/22/26 at 0000 hours, Patient 3 was placed on XLNK 2 (hallway bed). During an interview and concurrent medical record review with the ED Nurse Manager on 1/23/26 at 0900 hours, the ED Nurse Manager verified the above findings. On 1/27/26 at 0900 hours as of the exit conference conducted, the documentation for RN 8’s training to place ED patients was not provided.”

“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: 29798 Based on interview and record review, the hospital failed to ensure the nursing staff implemented the medication reconciliation P&P for one of three sampled patients (Patient 1). This failure had the potential to cause poor patient outcomes due to lack of communication and delayed treatment. Findings: Review of the hospital’s P&P titled Medication Reconciliation last revised 03/2025, showed: * Purpose: To define the medication reconciliation at the hospital. * Definitions: - Medication Reconciliation: A process for identifying the most accurate list of all medications the patient is taking, including name, dosage, frequency and route by comparing to home medication list in the electronic health record to the medication list obtained from the patient, or other provide(s), or other organization(s) or sources such as prescription claim database and resolving any discrepancies found. - Medication: Medications include prescription drugs/products, non-prescription drugs/products, herbal, and/or dietary supplements, homeopathic products, and home remedies. - Staff: Medical Assistant, Licensed Vocational Nurse, Registered Nurse, Pharmacy Technician, or Pharmacist, etc. - Provider: Physician or physician extender * Policy: The home medication list will contain the following elements: medication name, dose, route, frequency, and for “as needed” medications, the indication. * Procedures: A. When patient is admitted to inpatient or seen in a non-24-hour setting, staff will obtain a list of current medications the patient is taking prior to admission or prior to the visit, as described by the patient or his/her designee and verify whether the patient is taking the medications as prescribed or instructed. B. The staff will compare the home medication list with what was recorded in the electronic health record as the patient’s home medication list and update the list. C. For Inpatient: 1. A provider from the admitting service will review the home medication list and order the medications are to be continued as inpatient, determines which ones are to be held and which ones are to be discontinued based on the patient’s clinical condition. On 12/11/25 Patient 1’s closed medical record was reviewed with the Associate Administrator and the Risk Manager. Patient 1’s medical record showed the patient was admitted to the hospital on 10/5/25. Review of the ED Note-Physician dated 10/5/25 at 2256 hours, showed Patient 1’s home medications. The general assessment section showed no “edema.” Patient 1’s list of home medications contained torsemide (diuretic medication) 20 mg oral tablet, 2 tablets daily. Review of the Admission H&P dated 10/6/25 at 1255 hours, showed “No edema”. The list of medications ordered did not include a diuretic as per Patient 1’s home medications list. Further review of Patient 1’s medical record showed that on 10/6/25, the patient was evaluated by the infectious disease (ID) physician. The ID provider notes showed the following: * On 10/6/25 at 1430 hours, the ID provider documentation showed “BLE edema.” * On 10/7/25 at 1850 hours, the ID provider note showed “edema both legs.” * On 10/8/25 at 2020 hours, the ID provider documented “edema both legs.” * On 10/9/25 at 1330 hours, the ID provider follow up visit note showed “edema both legs.” Review of the nursing documentation dated 10/5, 10/6, 10/7, 10/8, and 10/9/25, failed to show an ongoing accurate assessment and evaluation of Patient 1’s lower extremity edema or evidence that the physician was notified of the patient’s condition. Review of Patient 1’s Medication Administration Record showed a one-time order for “40 mg Lasix (a diuretic medication), IVP.” dated 10/9/25 at 1100 hours. The medication was administered on 10/9/25 at 1116 hours, prior to the patient’s transfer to a higher level of care. The above finding was verified by the Associate Administrator.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 35310 Based on observation, interview, and record review, the hospital failed to ensure two of eight sampled patients (Patients 2 and 5) who were restrained, were monitored as evidenced by: 1. Documentation for medical restraint monitoring/assessment did not accurately reflect the nursing care for Patient 2. 2. There was no documented skin integrity and circulatory status every fifteen minutes for Patient 5 while the patient was on behavioral restraint as per the hospital’s P&P. These failures posed a risk of substandard outcomes for the patient. Findings: Review of the hospital’s P&P titled Restraint & Seclusion revised dated March 2025, showed the following: * Attachment B, Medical vs. Behavioral Restraint Comparison Table Inpatient Medical, ARU, and Emergency Department showed for medical (non-violent), the monitoring and assessment shall occur during intentional rounding: every one hours during the day and every two hours at night or more frequently based on needs; for behavioral (violent or self-destructive behavior), direct continuous observation (i.e., sitter) with every fifteen minutes documentation of skin integrity and circulatory status distal to restraint. * Attachment D, Patients Restraint or Seclusion: Inpatient, ARU and Emergency Department showed for Medical (non-Violent) Restraints, the monitoring and assessments shall occur during intentional rounding and patient care activities. Intentional rounding is completed to address safety issues and ensure basic needs are met: hydration/nutrition, hygiene/elimination/comfort, turning/mobility/ROM, and safety/respiratory/circulatory status/skin/level or distress. 1. During a tour of the unit on 9/3/25 at 0910 hours, with the Assistant Director of Risk and Regulatory and Nurse Manager 1, Patient 2 was observed in two-point soft restraints to the upper extremities. On 9/3/25 at 1013 hours, an interview and concurrent medical record for Patient 2 was conducted with the ED Educator. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 8/20/25. Review of the Restraint dated 8/22/25 at 0200 hours, showed the non-violent medical restraint was initiated. Random dates were selected to review the monitoring and assessment of the restraint. Review of the Restraint dated 8/22/25 at 0200, 0800, 1711, and 2000 hours; and 8/23/25 at 0730 and 2000 hours, showed the monitoring/assessment for restraint was performed. On 9/4/25 at 0818 hours, the Clinical Nurse Specialist was interviewed in the presence of the Assistant Director of Risk and Regulatory. The Clinical Nurse Specialist stated the monitoring/assessment for restraint was to be performed during intentional rounding (every hour during day shift and every two hours during night shift). The Clinical Nurse Specialist also stated nursing staff attested that they performed the monitoring/assessment at the end of their shift but not required to document every time the monitoring/assessment was performed. On 9/4/25 at 1445 hours, the Assistant Director of Risk and Regulatory verified the nursing documentation for medical restraint monitoring/assessment did not accurately reflect nursing care for Patient 2. 2. On 9/4/25 at 0910 hours, an interview and concurrent medical record for Patient 5 was conducted with the ED Educator. Patient 5’s medical record showed Patient 5 arrived to the ED on 9/1/25. Review of the ED Provider Notes under Workup Summary dated 9/1/25 at 1117 hours, showed Patient 5 was placed in four-point restraints due to violent/aggressive behavior towards self, imminent danger and violent/aggressive behavior towards others, imminent danger. During an interview and concurrent medical record for Patient 5 with the ED Educator, the ED Educator stated Patient 5 was on behavioral restraint from 9/1/25 at 1120 hours to 9/2/25 at 1200 hours. Review of the Restraint Assessment showed skin integrity and respiratory/circulatory status were performed every hour during Patient 5 was on behavioral restraint. Further medical record failed to show the skin integrity and circulatory status distal to restraint were performed every 15 minutes as per the hospital’s P&P. On 9/4/25 at 1400 hours, the Assistant Director of Risk and Regulatory verified the above findings.”

“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: 35310 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff performed consistently NG tube feeding placement verification per the hospital’s P&P for one of eight sampled patients (Patient 3). This failure had the potential for unsafe care to the patient. Findings: Review of the hospital’s P&P titled Adult Core Nursing Standards of Care dated July 2025 showed if feeding tube present, placement of feeding tubes will be assessed every four hours for continuous feedings and as needed prior to intermittent feedings or medication administration. During a tour of the unit on 9/3/25 at 0846 hours, with the Assistant Director of Risk and Regulatory and Nurse Manager 1, Patient 3 was observed receiving enteral tube feeding via NG tube. On 9/3/25 at 1245 hours, an interview and concurrent medical record for Patient 3 was conducted with Clinical Nurse Educator 1 in the presence of the Regulatory Program Manager. Patient 3’s medical record showed Patient 3 was admitted to the hospital on 8/15/25. Clinical Nurse Educator 1 stated the hospital followed Lippincott as the nursing guidelines for enteral tube. Review of Lippincott’s guideline titled Enteral Tube Feeding, Gastric dated 11/17/24, showed to verify enteral tube placement using at least two of the following methods: * Observe for a change in the external tube length or the incremental marking on the enteral tube where it exits the patient’s nose or mouth to detect tube migration. * Observe for a change in the volume of aspirate from the enteral feeding tube because a persistent inability to withdraw fluid (or only a few drops of fluid) from the tube may signal the upward displacement of a gastric tube into the esophagus. * Review routine chest and abdominal X-ray reports. * Aspirate the enteral tube contents with an enteral syringe and inspect the visual characteristics of the tube aspirate. Fasting gastric secretions often appear grassy green, brown, or clear and colorless. * Measure the pH of aspirate from the enteral tube. Fasting gastric pH usually is five or less, even in patients receiving gastric acid inhibitors. Random dates were selected to review NG tube placement verification. Review of NG Tube- Nasogastric Right Nostril showed the following: * On 9/2/25 at 1600 hours, air auscultation and gastric contents for placement verification. * On 9/3/25 at 0800 hours, X-ray (per MD report) for placement verification. However, there was no documentation of another method to verify the placement. Further review of Patient 3’s medical record failed to show the enteral tube placement was consistently performed every four hours as per the hospital’s P&P. Clinical Nurse Educator 1 verified the above findings.”

“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: 35310 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff administered medications as per the nursing guidelines that the hospital followed for one of eight sampled patients (Patient 3). This failure created the risk of medication errors and poor health outcomes to the patients. Findings: Review of Lippincott’s guideline titled Enteral Tube Drug Instillation, Long-Term Care dated 11/17/24, showed not to mix different medications intended for administration together through the enteral tube because the risks of physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses. During a tour of the unit on 9/3/25 at 0846 hours, with the Assistant Director of Risk and Regulatory and Nurse Manager 1, RN 1 was administering medication via NG tube to Patient 3. RN 3 was observed mixed crushed medications in the medication cup with the water and administered the mixed medication all together to Patient 3 via NG tube. During an interview with RN 1 stated the crushed medications were urea (medication for low level of sodium in the blood), amiodarone (antiarrhythmic medication), and potassium chloride (medication for low levels of potassium in the blood). Review of the physician’s order showed the following: * On 8/28/25 at 1749 hours, the order was to administer urea packet 15 g via NG tube two times daily. * On 8/28/25 at 1749 hours, the order was to administer amiodarone tablet 100 mg via NG tube daily. * On 9/3/25 at 0724 hours, the order was to administer potassium chloride packet40 mEq via NG tube once. On 9/3/25 at 1245 hours, an interview and concurrent medical record for Patient 3 was conducted with Clinical Nurse Educator 1 in the presence of the Regulatory Program Manager. Patient 3’s medical record showed Patient 3 was admitted to the hospital on 8/15/25. Clinical Nurse Educator 1 stated the hospital followed Lippincott as the nursing guidelines for medication administration via enteral tube feeding. During an interview and concurrent medical record review with Clinical Nurse Educator 1, Clinical Nurse Educator 1 stated RN 1 should have administered each medication separately via NG tube to Patient 3.”

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to ensure the discharge planning evaluation was completed for one of two sampled patients (Patient 1) as per the hospital’s P&P when discharged the patient on 7/14/25 at 1319 hours as evidenced by: * Patient 1’s discharge instruction was missing self-care and home care information for the nephrostomy tube. * Patient 1’s feelings of being unsafe and anxious about going home were not adequately addressed or documented. NP 1 did not document or communicate Patient 1’s concerns about sepsis and nephrostomy tube care to the attending provider prior to discharge the patient. * The hospital’s case management staff failed to conduct an initial assessment and properly evaluate Patient 1’s medical and psychosocial needs before discharged Patient 1. These failures had the potential to result in an unsafe discharge of the patient. Findings: Review of the hospital’s P&P titled Interdisciplinary Discharge Planning dated March 2025 showed the hospital will discharge or transfer patients to an appropriate level of care/setting based on the patient’s individual needs. Discharge planning assessments include, but are not limited to, the likelihood of a patient ’ s capacity for self-care at time of discharge, patient returning to previous living environment, patient’s needs for psychosocial or physical care at time of discharge and/or patient’s need for post-hospital care/ treatment/ services. Discharge planning activities also include ongoing communication and collaboration with the patient and family to incorporate patient’s treatment goals and to validate patient’s agreement with proposed discharge plan. A copy of the discharge summary/after visit summary will be provided to the patient or designated caregiver at the time of discharge. Discharge instructions will include self-care, information regarding home care. Review of the hospital’s Case Management Roles and Expectations dated September 2024 showed the key roles and responsibilities for CM are to coordinate patient care and discharge planning, communicate with patient/families and to ensure the documentation was accurate and timely. The Case Manager Expectations section showed to attend daily team rounds and maintain active communication with Clinical Management Assistants, conduct in-person or phone-based initial meetings with patients/family, and complete an initial assessment within 48 hours of patient admission. On 7/24/25 at 1043 hours, Patient 1’s medical record was reviewed with the Sr. Risk & Regulatory Professional and the Assistant Director of Risk and Regulatory. Patient 1’s medical record showed Patient 1 came to the hospital ED on 7/12/25 at 1950 hours and discharged on 7/14/25 at 1319 hours. The patient returned to the hospital ED on 7/14/25 at 1654 hours and discharged on 7/14/25 at 2004 hours. Review of the ED Provider Notes dated 7/12/25 at 1950 hours, showed Patient 1 came to the ED for a urinary catheter problem (left nephrostomy tube with decreased output, strong odor, and cloudy for two days, with the pain level of 8 out of 10 [10 being the worst pain, 0 being no pain]). The patient presented changes in her urine output and associated pain to the nephrostomy tube. The urine volume in the nephrostomy bag had significantly decreased, with only small drops by morning. The patient did not flush the tube due to lack of instruction. The ED attending physician documented on 7/12/25 at 2217 hours, the ED provider attempted to flush the tube with 50 ml with unsuccessful return. The medical record showed that after the ED staying, Patient 1 was admitted to hospital observation on 7/13/25 at 0204 hours and was discharged on 7/14/25 at 1319 hours. The patient was sent to the hospitality lounge (the discharge lounge, which aids in patient flow by assisting in the discharge process and resolving patient discharge barriers) after being discharged from the observation unit to wait for a ride. Review of Patient Care Timeline from 7/12/25 1950 hours to 7/14/25 1319 hours, showed the following: * On 7/12/25 at 1950 hours, Patient 1 arrived in the ED. * On 7/13/25 at 0134 hours, DC planning of Living arrangements on admission discussed with family members. * On 7/13/25 at 0415 hours, the patient’s head-to-toe assessment showed the patient had a need for emotional. * On 7/13/25 at 0723 hours, the assessment for left nephrostomy showed the site was clean, dry, and reddened (redness/moist at puncture site). * On 7/13/25 at 0728 hours, NP 1 was assigned as a team member for Patient 1’s for 1st call services. * On 7/13/25 at 1716 hours, NP 1 documented in Discharge throughout: the patient was ready for discharge, there were no barriers. * On 7/13/25 at 1900 hours, NP 1 signed out the duty to be the 1st call. * On 7/14/25 at 0704 hours, the DC Prep Milestones was completed. * On 7/14/25 at 0718 hours, NP 1 was assigned as a team member for Patient 1’s 1st call services. * On 7/14/25 at 1221 hours, NP 1 documented DC prep milestones completed, remove peripheral IV lines prior DC, reviewed and printed the Discharge Patient-Review & Print form. * On 7/14/25 at 1238 hours, the RN spoke with the DC lounge staff, the patient would be waiting for family ride at the DC lounge. Patient needed instruction. Review of the After Visit Summary showed Patient 1’s signature and time was 7/14/25 at 1345 hours, the time the patient was presenting at the DC lounge. The form did not include self-care nor information regarding home care of the patient’s nephrostomy tube. Review of RN 1’s Interdisciplinary note dated 7/14/25 at 1319 hours, showed Patient 1 did not feel safe to go home, NP 1 was notified. The patient was advised to go to the ED if any sign and symptoms recurred. On 7/24/25 1335 hours, an interview with RN 1 was conducted. RN 1 stated the Discharge Lounge is a hospitality lounge. The patients came after they were discharged, and no longer as hospital patients. RN 1 stated Patient 1 complained about the weakness in hospitality lounge and stated she was not safe to go home. RN 1 stated Patient 1 was evaluated for orthostatic blood pressure and findings were negative. RN 1 stated NP 1 communicated with Patient 1 and family. RN 1 stated Patient 1 was discharged home, and if the patient felt it needed to be further evaluated, they could go the ED. On 7/25/25 1205 hours, an interview was conducted with NP 1. NP 1 stated Patient 1 told her regarding feeling anxious for possible occurrence of sepsis, the problems with the nephrostomy tube and care. NP 1 stated she did not document this communication in the record nor communicate with the attending provider. NP 1 was asked about the discharge planning process including psychosocial and physical needs. NP 1 stated NP 1 provided the care as the patient medical needs. NP 1 stated Patient 1 and family showed up on the ED after leaving the hospitality lounge. On 7/24/25 at 1519 and 7/25/25 at 0938 hours, an interview with a concurrent review of Patient 1’s medical record was conducted with the Manager of Case Management. The Manager of Case Management reviewed Patient 1’s medical record and stated Patient 1’s ED visit was on a weekend, and the patient was discharged on Monday. The Manager of Case Management was not able to locate a Case Management initial assessment documented in the record. The Manager of Case Management stated that Case Management was not fully staffed over the weekends and would not be able to assess all the patients. On Monday, the Case Managers reviewed the patient list to evaluate the patients who were identified for referral or discharge facilities. Patient 1 was not evaluated by the Case Manager before discharge. The Manager of Case Management stated if the patient felt unsafe and felt anxious during hospitalization, the patient should have been assessed for psychosocial needs. Further review of Patient 1’s medical record showed the Patient Care Timeline from 7/14/25 at 1654 hours to 7/14/25 at 2004 hours, showing Patient 1 arrived in the ED on 7/14/25 at 1645 hours. On 7/14/25 at 2004 hours, the patient was discharged. Review of the ED Provider Notes dated 7/14/25 at 1654 hours, showed Patient 1 presented to the ED two days ago (7/12/25) and was evaluated for dysfunction of the nephrostomy tube. During the hospital course, Patient 1 had a urine culture growing Klebsiella and was discharged on nitrofurantoin (an antibiotic used to treat urinary tract infection). The patient was clinically appropriate for discharge home. However, the patient returned reporting weakness and was unable to ambulate more than a few steps without becoming weak as well as persistent decreased urinary output via the nephrostomy tube. Upon further discussion, the patient noted fear of not being able to care for herself at home and the patient’s family member noted fear of the risk of sepsis with the nephrostomy tube remaining without replacement. The ED provider had an extensive discussion with Patient 1 and the patient’s family member, addressing their significant fear about sepsis. The Workup Summary section dated 7/14/25 at 1945 hours, showed the case manager was contacted regarding home health options, and the patient was eligible for home health but needed to go through the patient’s primary care provider.”

“PATIENT RIGHTS: REVIEW OF 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.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the patient representative’s grievances were addressed as per the hospital’s P&P for one of eight sampled patients (Patient 3), creating the risk of unaddressed grievances and ongoing substandard practices for the patients. Findings: Review of the hospital’s P&P titled Patient Relations: Complaints and Grievances, Formal dated June 2022 showed the following: * Any staff or physician in any area or department can receive inquires, suggestions for improvement, and feedback by telephone, in-person, or correspondence. * Staff or physicians receiving the inquiry, suggestions for improvement or feedback may contact a member of the Office of the Patient Experience for assistance via phone or email. * If it requires investigation and/or further actions to resolve, the concerns become grievances. * The office of the Patient Experience will follow the standard grievance workflow process determined by the department. On 1/29/25, Patient 3’s closed medical record was reviewed with the Clinical Nurse Educator. Review of Patient 3’s closed medical record showed Patient 3 was admitted to the hospital on 12/11/24, and discharged on 12/15/24. Review of the Current Summary Patient/Client Flow Event dated 12/14/24, showed Patient 3’s representative voiced concerns including unacknowledged pain and unresponsive call button for 90 minutes. On 1/29/25 at 1344 hours, an interview was conducted with the Manager of Patient Relations in the presence of the Assistant Director of Risk and Regulatory. When asked, the Manager of Patient Relations stated the concerns seemed like grievances. However, the Department of Patient Relations was not aware of the above concerns. When asked, the Assistant Director of Risk and Regulatory stated the author of the event did not task for the Patient Relations. The Assistant Director of Risk and Regulatory verified the above findings.”

“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: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff supervised and evaluated the nursing care for three of eight sampled patients (Patients 3 and 4) as evidenced by: 1. The nursing staff failed to conduct the pain reassessment and management for Patient 3’s as per the hospital’s P&P. 2. The nursing staff failed to conduct the IV site assessments for Patient 3 as per the hospital’s P&P. 3. The nursing staff failed to complete documentation of a blood transfusion for Patient 4 as per the hospital’s P&P. These failures had the potential for unsafe care to the patients. Findings: 1. Review of the hospital’s P&P titled Pain: Adult & Pediatric dated December 2023 showed reassessment should be completed in a timely manner, within approximately one hour, to determine if the intervention is working or if the patient is experiencing adverse effects. On 1/29/25, Patient 3’s closed medical record was reviewed with the Clinical Nurse Educator. Review of Patient 3’s closed medical record showed Patient 3 was admitted to the hospital on 12/11/24, and discharged on 12/15/24. Review of the flowsheets for the pain scores and medication administration records showed the following: * On 12/12/24 at 0015 hours, Patient 3 complained of pain eight out of 10 (on a 0 to 10 pain scale, 0 being no pain and 10 being the worst pain). Patient 3 received Dilaudid (a pain medication) 0.2 mg IVP at 0015 hours. However, there was no pain reassessment for the patient until at 0308 hours. * On 12/12/24 at 0312 hours, Patient 3 complained of pain 10 out of 10. Patient 3 received Dilaudid 0.5 mg IVP at 0312 hours. However, there was no pain assessment for the patient until 0813 hours. * On 12/12/24 at 2104 hours, Patient 3 complained of pain 10 out of 10. Patient 3 received Oxycodone (a pain medication) 10 mg by mouth at 2105 hours. However, there was no pain assessment until 12/13/24 at 0158 hours. * On 12/13/24 at 0158 hours, Patient 3 complained of pain 8 out of 10. Patient 3 received Dilaudid 0.3 mg IVP 0158 hours. However, there was no pain assessment until 12/13/24 at 0513 hours. 2. Review of the hospital’s P&P titled Adult Core Nursing Standards of Care dated March 2024 showed the peripheral IV site and dressing should be assessed every four hours. On 1/29/25, Patient 3’s closed medical record was reviewed with the Clinical Nurse Educator. Review of Patient 3’s closed medical record showed Patient 3 was admitted to the hospital on 12/11/24, and discharged on 12/15/24. Review of the Peripheral IV to right hand flowsheet showed the infusing IV site was assessed on 12/11/24 at 1947 and 2218 hours; and 12/12/24 at 0813 hours. However, further review of Patient 3’s closed medical record failed to show the IV site was assessed between 12/11/24 at 2218 hours and 12/12/24 at 0813 hours (for eight hours and 55 minutes), as per the hospital’s P&P. 3. Review of the hospital’s P&P titled Blood/Blood Component Transfusion dated September 2024 showed the following: * Patients will be monitored for transfusion reaction. Vital signs will be taken within 30 minutes prior to starting the transfusion, 15 minutes after the start the transfusion, and at the end of the transfusion. * If the transfusion duration is more than 2 hours, vital signs are taken hourly. Review of the Attachment A: Blood Transfusion Guidelines showed to slow the rate of infusion during the first 15 minutes (1-2 ml/min) and observe for adverse effects. On 1/29/25, Patient 4’s medical record was reviewed with the Clinical Nurse Educator. Review of Patient 4’s medical record showed Patient 4 was admitted to the hospital on 1/20/25. Review of the physician’s order dated 1/28/25 at 1154 hours, showed to transfuse one pack of RBC for two hours. Review of the transfuse flowsheet dated 1/28/25, showed the RBC was transfused at 1156 hours at the rate of 200 ml/hr. Further review of Patient 4’s medical record failed to show the completion time of the transfusion and total amount of the blood transfused. In addition, there was no documented evidence of slowing rate of infusion during first 15 minutes. On 1/29/25 at 1315 hours, the Clinical Nurse Educator verified the above findings.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to develop a standardized acuity tool for the infusion center to accurately reflect clinical patient characteristics and workload ensuring appropriate care levels are staffed according to the patient’s needs. This failure increased the risk for substandard outcomes to the patients receiving care at the infusion center. Findings: a. On 1/30/25 at 1153 hours, an interview with the Director of Oncology Services and the Interim Manager for Infusion Center was conducted. The Director of Oncology Services stated establishing a standardized acuity system in the outpatient infusion clinic was a challenge. Accordingly, current academic studies did not have adequate data to support one method over another in acuity and staffing ratios for outpatient infusion clinic; therefore, the hospital was still receiving input and making changes from the nursing staff and leadership in focus groups through the live environment. The Director of Oncology Services stated the current acuity system integrated an EMR-based scheduling program with a separate acuity tool derived from similar research studies. However, the process remained manual, requiring nurses to update both the acuity tool and EMR scheduling system in real time for patients who failed to meet predefined criteria. When asked, the Interim Manager for Infusion Center stated there was no P&P for the acuity tool at the infusion center, but the hospital was actively trying to develop a standardized method to utilize the acuity tool. When asked how long the current acuity system was trialing, the Director of Oncology Services stated it was an ongoing project since November 2024. b. Review of the acuity tool reference the infusion clinic was using showed the following levels of acuity: - Level 1 (Green): one IV drug with or without PO pre-medications, hydration and/or electrolyte replacement. - Level 2 (Yellow): two IV drugs, one drug with IV pre-medication, CADD pump hook up, one to two units of blood product alone, level one acuity and isolation, single agent immunotherapy, single agent chemotherapy. - Level 3 (Pink): three or more drugs, two drugs with pre and post hydration, CADD pump with two or more IV drugs, drug requiring three or more titrations, IV push vesicant therapy, CD1D1 newly diagnosed patient with one to two drugs, clinical trial not meeting level 4, three or more blood products, one to two blood products with IV drug, Level 2 acuity with isolation, procedures, an auto-increase to level 3 is needing full assistance with mobility, add on for infectious work up, coordination of unplanned admission, or infusion reaction. - Level 4 (Orange): C1D1 (cycle 1, day 1) clinical trial with three or more ECG/PK/vital sign, any cycle of clinical trial with eight or more ECG/PK/vital signs, C1D1 newly diagnosed/standard of care with three or more drugs, Level 3 acuity an isolation, C1D1 level 3 acuity clinical trial and SW. On 1/30/25 at 0920 hours, Patient 8’s closed medical record review was conducted with the Infusion Supervisor, Director of Oncology Services, and Professional of Risk and Regulatory. Patient 8’s closed medical record showed the patient came to the infusion clinic on 1/28/25. Patient 8 was designated as a research patient. Review of Patient 8’s physician’s order showed the patient would receive a clinical trial of chemotherapy INV MER-XMT-1660 D1/8 every 28 days. Further review of the physician’s order showed there was no additional chemotherapy, testing or close monitoring required for this clinical trial. Review of the staffing assignment showed Patient 8 was scored an acuity of “2”. Further review of the acuity reference tool showed level 2 failed to identify any level of clinical trial patients, although there was mention of single-agent chemotherapy. When asked, the Infusion Supervisor stated that although the patient was on a clinical trial, the acuity was downgraded to a level 2 instead of 3 as the chemotherapy was a one-dose treatment with no further work-up or close monitoring required. On 1/30/25 at 1020 ours, the above findings were shared and acknowledged by the Director of Oncology Services and Professional of Risk and Regulatory.”

“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: 36703 Based on interview and record review, the hospital failed to ensure the medication was administered to one of eight sampled patients (Patient 8) as ordered. This failure had the potential for unsafe care to the patient. Findings: On 1/29/25 at 1428 hours, Patient 8’s closed medical record was reviewed with the Interim Manager for Infusion Center, Director of Oncology Services, and Infusion Supervisor. Review of Patient 8’s closed medical record showed Patient 8 was treated at the hospital’s infusion clinic on 1/18/25. Review of the physician’s order dated 1/18/25 at 1032 hours, showed to administer a test dose of iron dextran (a medication used to treat iron deficiencies) 25 mg in sodium chloride 0.9% (an IV solution) 50 ml IVPB one time over 10 minutes. Review of the physician’s order dated 1/18/25 at 1032 hours, showed to administer 975 mg iron dextran in sodium chloride 0.9% 500 ml IVPB if there was no adverse reaction within 60 minutes of administering the test dose. Review of the MAR Scheduling History showed the iron dextran 975 mg IVPB was edited and administered on 1/18/25 at 1212 hours. The infusion was stopped by RN 7 at 1721 hours. The Infusion Supervisor stated the pharmacy overfilled the iron dextran IVPB. However, the infusion was discontinued after five hours rather than upon complete administration of the overfilled IVPB and the patient did not receive the full dose of 975 mg of iron dextran as ordered. The above findings were acknowledged by the Director of Oncology Services, and Infusion Supervisor.”

“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: 39199 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff followed the hospital’s P&P on verifying the OG tube placement prior to the medication administration for one of three sampled patients (Patient 2). This failure posed the risk of adverse health outcomes to the patient. Findings: Review of the hospital’s P&P titled Administration of Oral Medications (NICU and Perinatal) dated 7/2023 showed for NG/OG tube administration, verify tube placement prior to medication administration. Patient 2’s medical record showed the patient was admitted to the hospital on 11/13/24. On 12/2/24 at 1050 hours, an observation of medication administration for Patient 2 by RN 2 was conducted, with the NICU Clinical Nurse Educator present. RN 2 was observed administering 0.5 ml of Poly-Vi-Sol (multivitamin) via the OG tube without verifying the tube’s placement beforehand. Both RN 2 and the NICU Clinical Nurse Educator acknowledged the findings. RN 2 and the NICU Clinical Nurse Educator stated the OG tube placement was verified by aspirating the tube to check for stomach contents, and if no stomach contents were aspirated, the staff was to auscultate the stomach.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure the nursing staff followed the hospital’s P&P for Blood Product Administration in the NICU for one of three sampled patients (Patient 1) to assess and document the vital signs during the blood transfusion. This failure posed the risk for potential complications, including undetected changes in the patient’s condition, delayed interventions, and overall compromised patient safety during the blood transfusion process. Findings: Review of the hospital’s P&P titled Blood Product Administration in the NICU dated 10/2024 showed vital signs (temperature, blood pressure, heart rate, respiratory rate) must be taken within 30 minutes prior to starting the transfusion, then 15 minutes after the infusion has started, 1 hour after the start of the transfusion, every hour during administration, at the end of the infusion, and 1 hour after the end of the transfusion. Ensure all vital signs are entered into the electronic health record. On 12/3/24 at 0923 hours, review of Patient 1’s medical record was conducted with the NICU Clinical Nurse Specialist and Assistant Manager of Regulatory Affairs. Patient 1’s medical record showed the patient was admitted to the hospital on 5/18/24. Review of the physician’s order dated 6/4/24, showed to transfuse 17 ml of Neonatal FFP-Aliquot (fresh frozen plasma) over two hours, stat. Review of Patient 1’s medical record showed the fresh frozen plasma transfusion was started on 6/4/24 at 1224 hours and stopped at 1425 hours. However, there was no documented evidence the nurse had taken the patient’s vital signs 15 minutes after the infusion was started. On 12/3/24, during the record review, the NICU Clinical Nurse Specialist and Assistant Manager of Regulatory Affairs verified the findings.”

“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: 35310 Based on interview and record review, the hospital failed to ensure one of nine sampled patients (Patient 1) received care in the safe setting as evidenced by: 1. Patient 1’s suspected ADR was not reported to the incident report system. 2. Patient 1’s pain was not consistently managed as per the hospital’s P&P. These failures had the potential to result in the unsafe care and poor clinical outcomes to the patient. Findings: On 10/7/24, Patient 1’s medical record was reviewed with Assistant Nurse Manager 2 in the presence of the Assistant Director, Regulatory Affairs and Assistant Manager, Regulatory Affairs. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 9/10/24. 1. Review of the hospital’s P&P titled Adverse Drug Reaction dated April 2024 showed to complete the Incident Report for each suspected ADR detected during the course of practice. Review of the Progress Note dated 9/12/24 at 2032 hours, showed to vaccinate Patient 1 for encapsulated bacteria prior to starting the treatment. Review of the physician’s order dated 9/13/24 at 1559 hours, showed to administer haemophilus B (a vaccine can help to protect against heamophilus influenzae type b infection) and meningococcal A & B (a vaccine can help to protect against meningococcal disease which could lead to meningitis or other serious infection) Review of the MAR showed the following vaccinations and medications were administered to the patient by RN 2: * The vaccination for meningococcal A was administered on 9/13/24 at 2000 hours. * The vaccination for meningococcal B was administered on 9/13/24 at 2003 hours. * The vaccination for haemophilus influenzae type b was administered on 9/13/24 at 2028 hours. * Benadryl (an antihistamine) 25 mg IV was administered on 9/13/24 at 2107 hours. * Benadryl 25 mg PO was administered on 9/14/24 at 0314 hours. Review of the Provider Notification showed the following: * On 9/13/24 at 2107 hours, Patient 1 complained of blurred vision, flashes on right eyes, and vomiting episodes. The Provider Response was that the MD came to check the patient to order IV Benadryl. * On 9/14/24 at 0252 hours, Patient 1 just woke up with more rashes, complaints of pain in throat, and itching everywhere. The Provider Response was that the MD came to check patient and ordered Benadryl PO. * On 9/14/24 at 0642 hours, Patient 1 had rashes up to her neck now. On 10/7/24 at 1225 hours, Assistant Nurse Manager 2 was interviewed. When asked, Assistant Nurse Manager 2 stated the nursing staff should inform the physician right away if there was any suspected ADR and report the event to the incident report system right away or at least within 24 hours. On 10/8/24 at 0935 hours, RN 2 was interviewed. RN 2 stated she notified the physician Patient 1’s symptoms after the vaccination and received Benadryl order. When asked, RN 2 stated she considered it as suspected ADR. When asked, RN 2 stated she did not file the event to the Incident Report system. 2. Review of the hospital’s P&P titled Pain Adult & Pediatric dated December 2023 showed the following: * A comprehensive pain assessment/reassessment is conducted as appropriate to the patient’s condition; scope of care; treatment and services provided; and methods are appropriate to the patient’s age and/or ability. * Upon admission, assess patient’s history of pain experience including understanding of pain management techniques, and cultural beliefs regarding pain, as indicated. * Assess for location, intensity (pain scores), duration, character or quality (burning, cramping, etc.), and aggravating or alleviating factors. * Reassessment should be completed in a timely manner, within approximately one hour, to determine if the intervention is working or if the patient is experiencing adverse effects. * If using verbal scale (0-10: 0 is being no pain, 10 is being the worst pain) or FACES and patient is sleeping when pain assessment/reassessment is due, observe and document normal or abnormal sleeping. - Normal sleeping is defined as lying quietly, normal position, no facial grimacing, no distress (derived from FLACC), and respiratory rate within normal range to assess for ADR. * If patient meets normal sleeping criteria, no further assessment is needed and document patient as sleeping. * If patient does not meet normal sleeping criteria as described above, wake the patient up and obtain pain score. On 10/7/24 at 1225 hours, Patient 1’s medical record was reviewed with Assistant Nurse Manager 2 and Assistant Director, Regulatory Affairs and Assistant Manager, Regulatory Affairs. Review of the H&P examination dated 9/10/24 at 1820 hours, showed Patient 1 presented to the hospital with whole-body pain in upper and lower extremities, headache, and chest pain, Review of the Pain Assessment showed the following: * On 9/14/24 at 0652 hours, Patient 1 complained of pain but refused pain medication. However, further medical record review failed to show the patient was assessed for pain location, intensity (pain scores), duration, character or quality (burning, cramping, etc.), and aggravating or alleviating factors as per the hospital’s P&P. * On 9/14/24 at 0838 hours, Patient 1 complained of generalized pain and received pain medication. * On 9/14/24 at 0938 hours, Patient 1 was sleeping, and respiratory assessment was done. However, further medical record review failed to show the documented respiratory assessment including respiratory rate. * On 9/15/24 at 1732 hours, Patient 1 complained of pain level 6 out of 10. However, further medical record review failed to show the patient was assessed pain location, duration, character or quality (burning, cramping, etc.), and aggravating or alleviating factors as per the hospital’s P&P. On 10/9/24 at 0901 hours, the Assistant Director, Regulatory Affairs and Assistant Manager, Regulatory Affairs verified the above findings.”