Adventist Health White Memorial Montebello

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 36329 Based on interview and record review, the facility failed to acquire consent from 1 of 20 sampled patients before transferring the patient (Patient 3) from this facility’s emergency department to another facility for higher level of care. This deficient practice led to Patient 3 not being able to make an informed decision about the transfer. Findings: During an interview on 7/26/2024 at 10:15 AM, MD 1 stated that he did not specifically recall if Patient 3 was informed of her pending transfer to another facility on 7/6/2024. Subsequently MD 1 said it is the facility’s usual practice to inform the patient or responsible party of the need to transfer the patient; if a responsible party is not available, nursing will sign the consent in that person’s absence. During an interview on 7/26/2024 at 11:05 AM, RN 2 stated, after reviewing Patient 3’s medical record, he was one of the nurses treating Patient 3 on 7/6/2024 but did not remember the details of Patient 3’s discharge. At this time, RN 2 said it is usual practice for nursing to leave 3 telephone messages to the responsible party in the event the patient is unable to verbalize his or her consent to transfer to another facility. RN 2 then confirmed if there is no verified consent by the patient or responsible party then the responsibility of acquiring consent to transfer would be escalated to the treating physician. Lastly, RN 2 said that after all attempts to attain consent for transfer have failed, two nurses can sign in place of consent by the patient or responsible party and the transfer can proceed. During an interview on 7/26/2024 at 12:10 PM, Regulatory Compliance stated he could locate any documentation Patient 3 or an responsibility party had been informed of the risks and benefits or agreed to transfer Patient 3 to another facility. During a review of ‘Emergency Department Reports’ indicated on 7/5/2024 Patient 3 presented to the emergency department with altered mentation (disruption in brain function that may lead to change in behavior), elevated heart rate, and was hot to touch. The ‘Emergency Department Reports’ showed that Patient 3 had a ureteral stone (crystal caught in the tubes that release urine from the kidney to the bladder) that was accompanied by sepsis (infection causing organ damage) and septic shock (the most severe form of infection causing low blood pressure). This document specified the services required to treat Patient 3 were not available at this facility; Patient 3 was stabilized and transferred to another hospital for higher level of care on 7/6/2024. A review of the ‘Patient Transfer Acknowledgement’ indicated Patient 3 was unable to sign the form confirming Patient 3 understood the reasons for transfer to another hospital and agreed to the tranfer; 2 nurses signed this form dated and timed 7-6-2024 at 4:25 AM; the transferring physician confirmed Patient 3 was stable for transfer on 7/6/2024 at 4:25 AM. A review of the document ‘Standard Policy: EMTALA - Patient Transfer’ (policy 20625) indicated the following procedure for those patients stable before transfer: the patient may be transferred to another facility for medical or non-medical reasons; the patient will be transferred according to the facility’s hospital policies, applicable state laws, procedures and forms for the transfer of patients to another hospital or another facility. A review of the document ‘Transfer Check List AHWM Montebello’ indicated if a patient is stable for transfer to another facility, the facility and patient/responsible party are required to sign the ‘Patient Transfer Acknowledgement’. This part of the document stipulated there must be reason for the transfer to another facility, signature of a registered nurse witness to patient consent to transfer, and patient/caregiver signature to consent to transfer.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 36329 Based on interview and record review, the facility failed to acquire consent from 1 of 20 sampled patients before transferring the patient (Patient 3) from this facility’s emergency department to another facility for higher level of care. This deficient practice led to Patient 3 not being able to make an informed decision about the transfer. Findings: During an interview on 7/26/2024 at 10:15 AM, MD 1 stated that he did not specifically recall if Patient 3 was informed of her pending transfer to another facility on 7/6/2024. Subsequently MD 1 said it is the facility’s usual practice to inform the patient or responsible party of the need to transfer the patient; if a responsible party is not available, nursing will sign the consent in that person’s absence. During an interview on 7/26/2024 at 11:05 AM, RN 2 stated, after reviewing Patient 3’s medical record, he was one of the nurses treating Patient 3 on 7/6/2024 but did not remember the details of Patient 3’s discharge. At this time, RN 2 said it is usual practice for nursing to leave 3 telephone messages to the responsible party in the event the patient is unable to verbalize his or her consent to transfer to another facility. RN 2 then confirmed if there is no verified consent by the patient or responsible party then the responsibility of acquiring consent to transfer would be escalated to the treating physician. Lastly, RN 2 said that after all attempts to attain consent for transfer have failed, two nurses can sign in place of consent by the patient or responsible party and the transfer can proceed. During an interview on 7/26/2024 at 12:10 PM, Regulatory Compliance stated he could not locate any documentation Patient 3 or an responsibilite party had been informed of the risks and benefits or agreed to transfer Patient 3 to another facility. A review of ‘Emergency Department Reports’ indicated on 7/5/2024 Patient 3 presented to the emergency department with altered mentation (disruption in brain function that may lead to change in behavior), elevated heart rate, and was hot to touch. The ‘Emergency Department Reports’ showed that Patient 3 had a ureteral stone (crystal caught in the tubes that release urine from the kidney to the bladder) that was accompanied by sepsis (infection causing organ damage) and septic shock (the most severe form of infection causing low blood pressure). This document specified the services required to treat Patient 3 were not available at this facility; Patient 3 was stabilized and transferred to another hospital for higher level of care on 7/6/2024. A review of the ‘Patient Transfer Acknowledgement’ indicated Patient 3 was unable to sign the form confirming Patient 3 understood the reasons for transfer to another hospital and agreed to the tranfer; 2 nurses signed this form dated and timed 7-6-2024 at 4:25 AM; the transferring physician confirmed Patient 3 was stable for transfer on 7/6/2024 at 4:25 AM. A review of the document ‘Standard Policy: EMTALA - Patient Transfer’ (policy 20625) indicated the following procedure for those patients stable before transfer: the patient may be transferred to another facility for medical or non-medical reasons; the patient will be transferred according to the facility’s hospital policies, applicable state laws, procedures and forms for the transfer of patients to another hospital or another facility. A review of the document ‘Transfer Check List AHWM Montebello’ indicated if a patient is stable for transfer to another facility, the facility and patient/responsible party are required to sign the ‘Patient Transfer Acknowledgement’. This part of the document stipulated there must be reason for the transfer to another facility, signature of a registered nurse witness to patient consent to transfer, and patient/caregiver signature to consent to transfer.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 46238 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to assess and reassess one of 30 sampled patient’s pain level (Patient 11) in a timely manner, in accordance with the facility’s policy and procedure regarding pain assessment and management. The nurse did not follow up on Patient 11’s pain level for over two hours, after pain level rating of 9/10 (indicates severe pain) and 6/10 (indicates moderate pain) was obtained and documented by the CNA (Certified Nursing Assistant) in Patient 11’s electronic medical record. This deficient practice had the potential to negatively affect Patient 11’s physiological (normal functioning of the body) and psychological (mental and emotional state) well-being and predispose Patient 11 to prolonged discomfort by not addressing pain in a timely manner. This deficient practice can also result in the delay of treatment of Patient 11’s pain, which can worsen Patient 11’s pain level. (Refer to A-0395) 2. The facility failed to assess one of 30 sampled patient’s (Patient 13) pain level after physical therapy (a type of treatment that can help a patient regain normal movement and ease pain) was performed, in accordance with the facility’s policy and procedure regarding pain assessment and management. Nursing staff did not assess Patient 13’s pain level after physical therapy session and did not document the findings in Patient 13’s medical chart. This deficient practice had the potential to worsen Patient 13’s pain and may prolong recovery from illness. (Refer to A-0395) 3. The facility failed to initiate and implement an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) to address potential problems about infection and high blood pressure for one of 30 sampled patients (Patient 26), in accordance with the facility’s policy and procedure regarding care planning. This deficient practice had the potential for Patient 26’s needs and risks to not be addressed which may result in patient harm and or death resulting from infection or uncontrolled high blood pressure. (Refer to A-0396) 4. The facility failed to notify the physician about a change in condition (a deterioration in health) for one of 30 sampled patients (Patient 2) when Patient 2’s respiratory (breathing) rate significantly increased, in accordance with the facility’s policy and procedure regarding physician notification. This deficient practice had the potential to compromise health and safety of Patient 2 when nursing did not address change in respiratory status of Patient 2 and did not notify and document physician notification, which may result in worsening of Patient 2’s respiratory condition that may lead to respiratory arrest (absence of breathing) and or death. (Refer to A-0398) 5. The facility failed to label three multi dose insulin vials (vials of liquid medication intended for parenteral administration [injection or infusion] that contains more than one dose of medication) after opening to indicate the expiration date. This deficient practice had the potential to compromise safety and well being of the facility ’ s patients if outdated insulin (a hormone medication that helps the body use glucose (sugar) for energy and regulate blood sugar levels) was administered to patients for managing blood sugar levels. Expired medications may be less effective and will not be able to control the patients’ blood sugar levels, which can result in diabetic coma (a life-threatening disorder that causes unconsciousness) and or death. (Refer to A-0398) 6. The facility failed to follow the facility’s policy regarding IV (intravenous insertion where a small tube is inserted into a vein to supply fluids or medicine) dressing site labeling for two of 30 sampled patients (Patient 23 and Patient 24). This deficient practice had the potential to result in inflammation (swelling, which is the body’s natural reaction to injury and infection) and infection developing in the vein when the IV insertion site is not properly maintained such as with dressing site changes. (Refer to A-0398) 7. The facility failed to ensure amiodarone (medication used to treat life-threatening heart rhythm problems called ventricular arrhythmias [a condition in which the heart beats with an irregular or abnormal rhythm]) was given as ordered (amiodarone bolus [a single dose of a drug given over a short period of time ] 150 milligrams [mg, measuring unit] to be administered within 10 min, followed by 1 mg per minute (mg/min, measuring unit and rate of infusion/administration) to run for 6 hours and then decrease infusion rate to 0.5 mg/min for 18 hours) for one of 30 sampled patients (Patient 4), in accordance with the physician order and the facility’s policy and procedure regarding medication administration. This deficient practice resulted in an incorrect treatment dose (amiodarone loading dose [loading dose is a means to quickly achieve a therapeutic drug concentration or prompt an immediate clinical response) administered to Patient 4 and had the potential for delaying Patient 4’s clinical response to the therapeutic drug administered for controlling life-threatening heart rhythm problems. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to provide and document the use of language assistance services (mechanisms used to facilitate communication with individuals who do not speak English, those who have limited English proficiency, and those who are deaf or hard of hearing) for one of thirty (30) sampled patients (Patient 3) who had limited English proficiency (individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English). Patient 3’s preferred language was Spanish. This deficient practice had violated Patient 3’s rights to receive considerate care by being denied a meaningful access to participate and understand information contained in consent to treatment forms provided to Patient 3 prior to a surgical procedure. This deficient practice also had the potential to result in inappropriate treatments thus putting a patient’s health at risk. Findings: During a review of Patient 3’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 6/10/2024, the H&P indicated, Patient 3 was admitted on 6/10/2024 due to a small bowel obstruction (a partial or complete blockage of the small or large intestines) and required a surgery (Laparotomy exploratory surgery, a surgical procedure that involves making a large incision in the abdomen to examine the abdominal organs for injury or disease). During a review of Patient 3’s medical record (MR) titled, “Nursing Flowsheet (a tool to help clinicians document patient data in a grid-like format),” dated 6/10/2024, the Medical Record indicated, Patient 3 ’ s preferred language was Spanish. During a review of Patient 3’s informed consent (permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits) titled, “Consent to Surgery or Special Procedure,” dated 6/10/2024, the informed consent indicated, on 6/10/2024, Patient 3 signed the consent form for “Exploratory laparotomy, with a possible bowel resection (a surgical procedure that removes part or all of a diseased, damaged, or blocked section of the small or large intestine).” During a concurrent interview and record review on 6/11/2024, with the manager of telemetry (area in hospital where patient undergoes continuous heart monitoring) /medical surgical (serves general population such as illness and surgery) units (Mngr 1), Patient 3 ’ s informed consent form titled, “Consent to Surgery or Special Procedure: Exploratory laparotomy, with a possible bowel resection,” dated 6/10/2024 was reviewed. The consent form indicated, the allocated for Translator/Interpreter Statement space was left blank and no record of interpreter services used was recorded. Mngr 1 stated, Patient 3 ’ s documented preferred language was Spanish, so the consent form had to be provided in Spanish language and the use of interpreter had to be recorded by documenting the interpreter ’ s identification number. Mngr 1 further stated, nursing did not document the use of interpreter services when obtaining the informed consent from Patient 3. During a review of the facility’s policy and procedure (P&P) titled, “Language assistance program-Interpretation and Hearing Impaired,” dated 5/18/2021, the P&P indicated, “Assistance will be offered for the communication of information contained in vital documents, such as consents to treatment forms, waivers of rights, etc. Language assistance will be provided using competent bilingual staff, providers, staff interpreters, contracts or formal arrangements with local organizations providing interpretation services, or technology, and telephonic interpretation services.” During a review of the facility’s policy and procedure (P&P) titled, “Consent and Informed Consent,” dated 01/2023, the P&P indicated, “If a patient cannot communicate with the practitioner because of language or communication barriers, the practitioner, the health care facility ’ s assistance should arrange for an interpreter. The interpreter ’ s responsibility will include translating the information regarding the recommended medical treatment that the patient needs to receive before deciding whether to give consent t, as well as instructions regarding medical care. Vital documents, including consent forms, presented by the health care facility staff to a patient must be written in a language that the patient can understand, or translated into such a language with an appropriate qualified interpreter.””

“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: 46238 Based on interview and record review, the facility failed to ensure the following: 1. The facility failed to assess and reassess one of 30 sampled patient’s pain level (Patient 11) in a timely manner, in accordance with the facility’s policy and procedure regarding pain assessment and management. The nurse did not follow up on Patient 11 ’ s pain level for over two hours, after pain level rating of 9/10 (indicates severe pain) and 6/10 (indicates moderate pain) was obtained and documented by the CNA (Certified Nursing Assistant) in Patient 11’s electronic medical record. This deficient practice had the potential to negatively affect Patient 11’s physiological (normal functioning of the body) and psychological (mental and emotional state) well-being and predispose Patient 11 to prolonged discomfort by not addressing pain in a timely manner. This deficient practice can also result in the delay of treatment of Patient 11’s pain, which can worsen Patient 11’s pain level. 2. The facility failed to assess one of 30 sampled patient’s (Patient 13) pain level after physical therapy (a type of treatment that can help a patient regain normal movement and ease pain) was performed, in accordance with the facility’s policy and procedure regarding pain assessment and management. Nursing staff did not assess Patient 13’s pain level after physical therapy session and did not document the findings in Patient 13’s medical chart. This deficient practice had the potential to worsen Patient 13’s pain and may prolong recovery from illness. Findings: 1. During a review of Patient 11’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 6/9/2024, the H&P indicated, Patient 11 was admitted on 6/8/2024, with a chief complaint of vomiting blood, watery stool, and abdominal pain with fever. During further review of Patient 11’s medical record (MR) titled, “Vital Signs (VS- include temperature, respiratory rate, heart rate, blood pressure and pain level) ,” dated 6/10/2024-6/11/2024, the MR indicated, on 6/10/2024 at 7:30 a.m., Patient 11’s pain level was recorded 9/10 (indicates severe pain); and at 9:59 a.m. the follow up pain level was recorded 6/10 (indicates moderate pain; pain levels are measured using a scale that ranges from 0 to 10, with 0 indicating no pain and 10 indicating the worst pain possible). The MR further indicated, on 6/11/2024 at 7:32 a.m., Patient 11’s pain level was recorded by the Certified Nurse Assistant (CNA 1) 10/10 (indicates severe pain), and at 9:21 a.m., the follow up pain level was recorded 6/10 (indicates moderate pain) by the primary nurse. During a concurrent interview and record review on 6/13/2024, at 11 a.m., with the manager of medical surgical (serves general population such as illness and surgery) and telemetry (area in hospital where patient undergoes continuous heart monitoring) units (Mngr 1), Patient 11’s pain assessment records, dated 6/10/2024-6/11/2024 were reviewed. The record indicated, on 6/10/2024, at 7:30 a.m., the Certified Nursing Assistant (CNA 1) documented, Patient 11 ’ s pain level was recorded 9/10 (indicates severe pain); and at 9:59 a.m., the follow up pain level was recorded 6/10 (indicates moderate pain) by the primary nurse. The record further indicated, on 6/11/2024 at 7:32 a.m., Patient 11 ’ s pain level was recorded 10/10 (indicates severe pain) by CNA 1, and at 9:21 a.m., the follow up pain level was recorded 6/10 (indicates moderate pain) by the Primary nurse. During an interview on 6/13/2024 at 11 a.m. with the manager of medical surgical and telemetry units (Mngr 1), Mngr 1 stated, the CNA should have reported and documented pain level assessment in the patient’s (Patient 11) medical record and the primary nurse should have been notified if patient was complaining of severe pain. Mngr 1 further stated, the primary nurse should try to address the pain as soon as possible and assess and/or reassess the patient’s pain level within 30 minutes to 1 hour because being in pain makes patients very uncomfortable and can also be an early sign of change in condition. Mngr 1 also said, primary nurse for Patient 11 did not document a timely pain assessment/re-assessment and Patient 11’s pain was not addressed for over 2 hours by the primary nurse. During a review of Patient 11’s Medical Record titled, “Medication Administration Record (MAR), dated 6/10/2024 through 6/11/2024, the MAR indicated, Patient 11 had an order for Norco (narcotic analgesic [pain medicine], acetaminophen-hydrocodone 325 milligrams [mg, measuring unit]-5 mg), oral tablet to be administered for pain every 4 hours as needed. During further review of Patient 11’s Medical Record titled, “Medication Administration Record (MAR), dated 6/10/2024 through 6/11/2024, the MAR indicated, Patient 11 was not medicated for pain on 6/10/2024 at 7:30 a.m. and or within 1 hour of reporting pain 9/10; and on 6/11/2024, Patient 11 was not medicated for pain on 6/11/2024, and/or within 1 hour after reporting pain 10/10 at 7:32 a.m. During a review of the facility’s policy and procedure (P&P), titled, “Opioid (medications to reduce pain) prescribing and pain management therapy,” dated 1/18/2022, the P&P indicated, “Patients will be assessed for pain and managed per the facility’s policy. Patient’s pain treatment plan is based on evidence-based practices and the patient’s clinical condition, past medical history, and pain management goals and may include non-pharmacologic (alternatives to medications such as hot and cold treatment, massage, etc.), pharmacologic (refers to medicines), or a combination of approaches.” The P&P also indicated, “If assessment/reassessment are outside of acceptable parameters: a. For vital signs or pain, RN should follow the facility policy to ensure patient safety and contact the responsible provider for orders and to discuss the plan of care...” 2. During a review of Patient 13’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 6/10/2024, the H&P indicated, Patient 11 was admitted on 6/9/2024 due to a closed pelvic fracture (a break in the bone between the hip bones, in the lower part of the abdomen that doesn’t break the skin), after a mechanical fall (a fall caused by an external force or object). The H&P further indicated Patient 11 required intravenous (IV, fluid administered directly into a vein) pain control and consultation with an orthopedic (a physician dealing with the correction of deformities of bones or muscles) and neurology (a doctor who specializes in diagnosing and treating conditions that affect the brain, spine, and nervous system through surgery and other methods) surgeons. During a review of Patient 11’s medical record (MR) titled, “Physical Therapy Interventions Document,” dated 6/12/2024, the MR indicated, Patient 11 had physical therapy (PT) on 6/12/2024 at 4 p.m. the MR further indicated, physical therapist documented, Patient 11 was noted with increased pain during movement, and was unable to progress due to pain. During a concurrent interview and record review on 6/13/2024 at 11 a.m., with the manager of Telemetry (area in hospital where patient undergoes continuous heart monitoring) and Medical Surgical (serves general population such as illness and surgery) units (Mngr 1), Patient 11’s medical record (MR) titled, “Vital Signs (VS- include temperature, respiratory rate, heart rate, blood pressure and pain level) -Pain Assessment,” dated 6/12/2024, was reviewed. The MR indicated, on 6/12/2024 from 3:30 p.m. to 7:11 p.m., primary nurse did not record pain assessment in Patient 11’s electronic medical record (EMR, digital version of the paper charts). Mngr 1 stated, typically, nursing staff shall assess patients for pain after physical therapy (a type of treatment that can help a patient regain normal movement and ease pain). During an interview on 6/13/2024 at 11:30 a.m. with physical therapist (PT 1), PT 1 stated, all patients are assessed for pain prior to beginning physical therapy. PT 1 said, primary nurse has to clear the patient prior to therapy session and medicate the patient for pain if necessary. PT 1 further stated, on 6/12/2024, after physical therapy with Patient 11, PT 1 endorsed Patient 11 back to primary nurse and informed the primary nurse that Patient 11 had pain. PT 1 further stated the facility’s process for the nurse is to assess patients for the presence of pain after physical therapy. During a review of the facility’s policy and procedure (P&P) titled, “Opioid (medications to reduce pain) prescribing and pain management therapy,” dated 1/18/2022, the P&P indicated, “Patients will be assessed for pain and managed per the facility ’ s policy. Patient’s pain treatment plan is based on evidence-based practices and the patient ’ s clinical condition, past medical history, and pain management goals and may include non-pharmacologic (alternatives to medications such as hot and cold treatment, massage, etc.), pharmacologic (refers to medicines), or a combination of approaches.” The P&P also indicated, “If assessment/reassessment are outside of acceptable parameters: a. For vital signs or pain, RN should follow the facility policy to ensure patient safety and contact the responsible provider for orders and to discuss the plan of care...””

“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: 36329 Based on interview and record review, the facility failed to initiate and implement an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) to address potential problems about infection and high blood pressure for one of 30 sampled patients (Patient 26), in accordance with the facility’s policy and procedure regarding care planning. This deficient practice had the potential for Patient 26’s needs and risks to not be addressed which may result in patient harm and or death resulting from infection or uncontrolled high blood pressure. Findings: During a review of the “Physician Face Sheet,” dated 6/10/2024, the face sheet (a document that gives a patient’s information at a quick glance) indicated that Patient 26 was admitted to the facility on 6/10/2024 at 2:54 p.m. During an interview on 6/12/2024 at 3:09 p.m. with the Manager of Accreditation and Regulatory (MAR), the MAR stated Patient 26 was admitted to the facility with a diagnosis of Coronary Artery Disease (CAD, a narrowing or blockage of the coronary [heart] arteries, which supply oxygen-rich blood to the heart), Hypertension (High blood pressure) and Hodgkin’s Lymphoma (a type of cancer that affects the white blood cells [responsible for fighting infection] in the blood). The MAR also said there was no documented nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) on file to address potential problems with high blood pressure and possible infection for Patient 26 at this time. During an interview on 6/11/2024 at 12:45 p.m. with the Risk Manager, the Risk Manager stated it is the responsibility of every RN (Registered Nurse) to create a care plan for each patient; the care plan is necessary to guide the patient’s (Patient 26) treatment. During a review of the facility’s policy and procedure (P&P) titled, “Policy: Nursing Care Plan, Collaborative Policy,” the P&P indicated the facility’s staff are responsible for involving the patient in their plan of care. This policy indicated problems identified in the patient’s electronic health record and the nursing initial assessment instigate patient related problems that are noted in the care plan; it is the role of the RN to start the care plan. This P&P indicated care plans support the RN in updating the priority of care and treatment goals.”

“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: 46238 Based on observation, interview, and record review, the facility failed to ensure the following: 1. The facility failed to notify the physician about a change in condition for one of 30 sampled patients (Patient 2) when Patient 2’s respiratory (breathing) rate significantly increased, in accordance with the facility ’ s policy and procedure regarding physician notification. This deficient practice had the potential to compromise health and safety of Patient 2 when nursing did not address change in respiratory status of Patient 2 and did not notify and document physician notification, which may result in worsening of Patient 2’s respiratory condition that may lead to respiratory arrest (absence of breathing) and or death. 2. The facility failed to label three multi dose insulin vials (vials of liquid medication intended for parenteral administration [injection or infusion] that contains more than one dose of medication) after opening to indicate the expiration date. This deficient practice had the potential to compromise safety and well being of the facility’s patients if outdated insulin [a hormone medication that helps the body use glucose (sugar) for energy and regulate blood sugar levels] was administered to patients for managing blood sugar levels. Expired medications may be less effective and will not be able to control the patients’ blood sugar levels, which can result in diabetic coma (a life-threatening disorder that causes unconsciousness) and or death. 3. The facility failed to follow the facility’s policy regarding IV (intravenous insertion where a small tube is inserted into a vein to supply fluids or medicine) dressing site labeling for two of 30 sampled patients (Patient 23 and Patient 24). This deficient practice had the potential to result in inflammation (swelling, which is the body’s natural reaction to injury and infection) and infection developing in the vein when the IV insertion site is not properly maintained such as with dressing site changes. Findings: 1. During a review of Patient 2’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 6/10/2024, the H&P indicated, Patient 2 was admitted due to weakness and shortness of breath (difficulty breathing). During further review of Patient 2’s medical record (MR) titled, “Nursing Flowsheet (a tool to help clinicians document patient data in a grid-like format),” dated 6/11/2024 at 9:49 p.m., Patient 2 ’ s respiratory rate (RR, the number of breaths a person takes per minute, the normal RR for an adult at rest is 12-18 breaths per minute [bpm]) was recorded to be 39 bpm and Patient 2 required administration of oxygen through Non-Rebreather mask (NRM, a medical device that provides oxygen to people who can still breathe on their own but need a high concentration of oxygen quickly). During an observation on 6/11/2024, at 11:45 a.m., Patient 2 was observed in the Emergency Department (ED), in bed. Patient 2’s monitor continuously alarmed and Patient 2 had labored breathing (an abnormal respiration characterized by evidence of increased effort to breathe, including the use of accessory muscles [using muscles other than those typically used for breathing to take in and expel air. Example: abdominal muscles] of respiration [breathing]). During a concurrent interview and record review on 6/11/2024 at 12:02 p.m., with Patient 2’s primary nurse (RN 1), Patient 2’s Vital Signs (VS, clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient’s essential body functions) record, dated 6/10/2024, was reviewed. VS record indicated: On 6/10/2024, at 6 a.m., Patient 2’s respiratory rate was 17 bpm. On 6/10/2024, at 8 a.m., Patient 2’s respiratory rate (RR) was recorded to be 42 bpm. On 6/10/2024, at 10:35 a.m., Patient 2’s RR was recorded 29 bpm. RN 1 stated, Patient 2’s breathing was labored, and respiratory rate significantly increased from last night. RN 1 further stated, Patient 2’s breathing effort got better by 11 a.m., but the physician was not notified. However, Patient 2 continued to be monitored and was placed on 2 Liters (L, measuring unit for oxygen) supplemental oxygen. During an interview on 6/11/2024 at 12:15 p.m. with the manager of Emergency Department/Intensive Care Unit (Mngr 2), Mngr 2 stated, per facility’s policy and procedure, the physician must be notified if there is a change in patient’s condition, such as increased respiratory rate, so new orders can be obtained. Mngr 2 further stated, the primary nurse shall also document notification of the physician in the patient’s electronic medical record. However, there was no documentation done. During a review of the facility’s policy and procedure (P&P) titled, “Physician Notification: Change in Patient’s Condition,” dated 5/24/2022, the P&P indicated, “In the event of adverse patient condition (any untoward effect or outcome experienced with medical treatment), the attending physician will be notified immediately. The patient shall receive appropriate and timely care.” 2. During a concurrent observation and interview on 6/11/2024 at 10:24 a.m. with charge nurse (CN 1), in a medication room located on a telemetry floor (a hospital floor where patients are continuously monitored for their cardiac [heart] health), multi dose (used multiple times) insulin (it turns the food into energy and manages the body’s blood sugar level) vials were observed. Insulin lispro (a rapid-acting, human insulin analog that works parenterally to lower blood glucose by regulating the metabolism of carbohydrates, proteins, and fats) vial was opened (removed from the original packaging) and contained no label indicating expiration date. Two regular insulin (a synthetic, short-acting human insulin hormone that helps people with type 1 (when the body cannot produce its own insulin) and type 2 (the body does not make enough insulin) diabetes (high blood sugar) manage their blood sugar levels) vials were also open and contained no label indicating expiration date for the medication. CN1 stated, all multi dose vials, such as insulin vials, shall be dated after opening with an expiration date, that is 28 days after opening the medication. CN 1 stated, all three vials were not dated by nursing, but were used for patient care. During an interview on 6/11/2024 at 10:45 a.m., with the Director of Pharmacy (DP), DP stated, nurses shall label multi dose insulin containers with a proper beyond use date (BUD, the date after which a compounded [the process of combining or mixing medications] preparation shall not be used). DP further stated, insulin vials expire twenty-eight days after opening and insulin should no longer be used beyond expiration date as it may be ineffective in treatment of patients. During a review of the facility’s policy and procedure (P&P) titled, “Expiration Date of Pharmaceuticals (encompass a variety of medicines) after Opening,” dated 5/25/2022, the P&P indicated, “Beyond Use Date (BUD), the date a pharmaceutical can no longer be used after being removed from the original manufacturer packaging. Multi dose containers must be dated with a proper BUD. Insulin (all vials) expire 28 days after opening.” 3. During an observation on 6/11/2024 at 11:45 a.m. in patient room 6517, there was an IV (intravenous, through the vein) inserted into Patient 23’s right wrist area. There was a clear plastic dressing over the insertion site but there was no marking on this dressing indicating when the IV had last been changed or its dressing changed. During an observation on 6/11/2024 at 12 p.m. in patient room 6516, there was an IV inserted into Patient 24’s left arm antecubital (related to the crook of the elbow) area. There was a clear plastic dressing over the insertion site but there was no marking on this dressing indicating when the IV had last been changed or its dressing changed. During an interview on 6/11/2024 at 12:45 p.m. outside room 6516 with the facility’s Risk Manager, the Risk Manager stated that all IV sites should be covered with clear plastic site dressing and marked with a pen or marker when the IV catheter was inserted and when the dressing was changed to prevent potential infection at the insertion site. During a review of the facility’s policy and procedure (P&P) titled, “Policy: Intravenous Therapy: General Guidelines for the Adult Patient,” this P&P indicated IV dressing changes will be performed by an RN; dressings will be labeled with the date of IV insertion; initials of the person inserting the IV; size of the IV catheter; date of the dressing change; initials of the person changing the dressing. This policy also stipulated that transparent dressings should be changed when the dressing is compromised or when the IV line (plastic tubing from the infused fluid to the IV site) is changed.”

“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: 46238 Based on interview and record review, the facility failed to ensure amiodarone (medication used to treat life-threatening heart rhythm problems called ventricular arrhythmias [a condition in which the heart beats with an irregular or abnormal rhythm]) was given as ordered (amiodarone bolus [a single dose of a drug given over a short period of time ] 150 milligrams [mg, measuring unit] to be administered within 10 min, followed by 1 mg per minute (mg/min, measuring unit and rate of infusion/administration) to run for 6 hours and then decrease infusion rate to 0.5 mg/min for 18 hours) for one of 30 sampled patients (Patient 4), in accordance with the physician order and the facility’s policy and procedure regarding medication administration. This deficient practice resulted in an incorrect treatment dose (amiodarone loading dose [loading dose is a means to quickly achieve a therapeutic drug concentration or prompt an immediate clinical response) administered to Patient 4 and had the potential for delaying Patient 4’s clinical response to the therapeutic drug administered for controlling life-threatening heart rhythm problems. Findings: During a review of Patient 4’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 6/4/2024, the H&P indicated, on 6/4/2024, Patient 4 was admitted to the facility for the evaluation of fever and back pain and was diagnosed with atrial fibrillation with rapid ventricular rate (Afib with RVR, a type of irregular heart rhythm that occurs when the heart’s upper chambers contract in an uncoordinated way, causing the lower chambers to beat too fast and irregularly). The H&P further indicated, Patient 4 had past medical history (PMH, a record of information about a person’s health) of hypertension (a condition where blood pressure in the blood vessels is persistently elevated) and arthritis (refers to inflammation or stress in one or more joints [the part of the body where two or more bones meet to allow movement). During a review of Patient 4’s medical record (MR) titled, “Inpatient Medication Orders,” dated 6/4/2024, the medical record indicated, the physician ordered amiodarone (a medication that prevents and treats irregular heart beat) bolus (a single dose of a drug given over a short period of time) 150 milligrams (mg, measuring unit) to be administered within 10 minutes. During further review of Patient 4’s medical record (MR) titled, “Inpatient Medication Orders,” dated 6/4/2024, the MR indicated, the physician placed an order for amiodarone intravenous (IV, administered into, a vein or veins) infusion at 1 mg per minute (mg/m, measuring unit, rate of infusion/administration) to run for 6 hours and then decrease infusion rate to 0.5 mg/min for 18 hours. During a concurrent interview and record review on 6/12/2024 at 2:05 p.m. with the manager of telemetry (area in hospital where patient undergoes continuous heart monitoring)/medical surgical (serves general population such as illness and surgery) floor (Mngr 1), Patient 4’s Medication Administration Record (MAR), dated 6/4/2024, was reviewed. The MAR indicated, on 6/4/2024, at 7 a.m., amiodarone 360 mg bag at a rate of 0.5 mg /min, was administered. The MAR contained no record of amiodarone bolus administration and no record of 1 mg/min ran for 6 hours administration. Mngr 1 stated, Patient 4’s MAR only contains documentation of amiodarone 360 mg (0.5 mg/min) administration. Mngr 1 stated, nursing did not administer and did not document administration of amiodarone as per physician ’ s order instructions. Patient 4 did not receive the ordered Amiodarone bolus or received Amiodarone 1mg/min to run for 6 hours. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration (Nursing),” dated 12/2023, the P&P indicated, “6.Before administering a medication, the appropriate health care professional administering the medication shall verify that the medication selected for the administration is the correct one based on the medication order and product label; shall verify the medication dose with the physician order and product label to assure that the correct dose is administered in the prescribed dose, by the correct route, and the proper time. Each dose administered must be promptly recorded and signed in the patient’s electronic medication administration record (MAR) by the nurse who administered the medication using the barcode bedside administration.””