Los Angeles General Medical Center

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure Medical Case Worker 2 honored Patient 1’s Advocate’s wish to speak to Medical Case Worker 2. This failure had a risk of violating the patient’s rights. Findings: On 7/21/26, Patient 1’s closed medical record was reviewed. Patient 1’s closed medical record showed Patient 1 presented to the ED and was discharged from the ED on 6/19/26. Review of the ED Note - Provider under Addendum dated 6/19/26 at 1533 hours, showed with the permission of Patient 1, Patient 1 and her Advocate were on the phone. Patient 1’s Advocate requested to speak with social work department. The ED Attending requested but was informed that Patient 1’s Advocate was not registered as a case manager with any of agencies. The social worker was aware of Patient 1’s Advocate’s wish and did not speak with the Advocate. Review of the Social Work Progress Note dated 6/19/26 at 1845 hours, performed by Medical Case Worker 2, showed at 1607 hours, the ED social work received call from the House Supervisor and on conference call from Patient 1 and her Advocate. On 7/21/26 at 1325 hours, Medical Case Worker 2 was interviewed in the presence of the Clinical Social Worker Supervisor. Medical Case Worker 2 stated she did not call to Patient 1’s Advocate because she did not know the identification of the Advocate. When asked if Medical Case Worker 2 clarified Patient 1’s Advocate’s identification with the ED Attending or Patient 1, Medical Case Worker 2 stated no. On 7/21/26 at 0930 hours, the ED Attending was interviewed in the presence of the Licensing Coordinator/Regulatory Affairs. When asked about ED Progress Note, the ED Attending stated Medical Case Worker 2 informed the ED Attending that Patient 1’s Advocate was not a registered case worker and she would not contact Patient 1’s Advocate. The ED Attending also stated he decided to document the encounter in EMR. On 7/22/26 at 0911 hours, the House Supervisor was interviewed in the presence of the Licensing Coordinator/Regulatory Affairs. The House Supervisor stated Patient 1 and her Advocate called due to placement concerns, so the House Supervisor contacted the ED Social Work Department. The Licensing Coordinator/Regulatory Affairs acknowledged the above findings.”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d)(1) The patient has the right to the confidentiality of his or her clinical records. This Standard is not met as evidenced by: 35310 Based on observation, interview, and record review, the hospital failed to ensure the medical record was secured for one of 13 sampled patients (Patient 5). This failure posed the risk of violating the patient’s rights. Findings: Review of the hospital’s P&P titled Health/Medical Record dated 11/21/22, showed the health/medical record is a confidential document. During a tour of the ED with Nurse Manager 7 and the Licensing Coordinator/Regulatory Affairs on 7/22/26 at 1000 hours, Patient 5’s medical record was open unattended at nursing station. The monitor containing Patient 5’s laboratory test results was facing to the hallway. The Licensing Coordinator/Regulatory Affairs acknowledged the findings.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure there was system in place to identify trained staff prior to assigning roles for the next shift in the ICU. This failure had potential to result in substandard care for the patients. Findings: On 7/21/26 at 0924 hours, the Clinical Nursing Director and Assistant Nursing Director 1 were interviewed. Assistant Nursing Director 1 stated CTICU was closed due to low census and CTICU patients moved to CICU with CTICU nurses on 5/20/26. The CTICU had been closed ever since 5/20/26. Review of the “Open Heart” Code Leader Checklist showed RN code leader/delegator trained in open arrest should be pre-assigned every shift. Review of the CICU Assignment dated 7/21/26 for day shift, showed RN 15 was assigned to be a code leader. On 7/22/26 at 1010 hours, Nurse Manager 8 was interviewed. Nurse Manager 8 stated the open heart code check list was effective on 6/25/26. When asked, RN 15 did not complete the Charge Nurse/Code Lead Checklist. Nurse Manager 8 stated the previous shift charge nurse assigned code assignment for next shift. When asked about system to identify trained staff prior to assigning roles for the next shift, Nurse Manager 8 stated she did not know the process.”

“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: 35310 Based on interview and record review, the hospital failed to ensure the assigned leader for open heart code had validated competencies prior to the assignment. This failure had potential to result in substandard care for the patients. Findings: On 7/21/26 at 0924 hours, the Clinical Nursing Director and Assistant Nursing Director 1 were interviewed. Assistant Nursing Director 1 stated CTICU was closed due to low census and CTICU patients moved to CICU with CTICU nurses on 5/20/26. The CTICU had been closed ever since 5/20/26. Review of the “Open Heart” Code Leader Checklist showed RN code leader/delegator trained in open arrest should be pre-assigned every shift. Review of the CICU Assignment dated 7/21/26 for day shift, showed RN 15 was assigned to be a code leader. On 7/22/26 at 1010 hours, Nurse Manager 8 was interviewed. Nurse Manager 8 stated the open heart code check list was effective on 6/25/26. When asked, RN 15 did not complete the Charge Nurse/Code Lead Checklist. Nurse Manager 8 verified RN 15 was assigned to be a code leader prior to the completion of the competency.”

“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 nursing staff followed the hospital’s P&P for the administration of blood and blood products for one of 13 sampled patients (Patient 11) as evidenced by: * Complete vital signs were not assessed and documented before and during the blood transfusion. This had the potential to delay the identification of a transfusion reaction or other change in the patient’s condition, which could delay timely intervention and compromise patient safety during the blood transfusion process. Findings: Review of the hospital’s Nursing Clinical Standard titled Blood and Blood Products revised 10/2025, showed the staff are to assess vital signs, mental status, and IV site patency no more than 30 minutes before transfusion. The P&P further required the staff to reassess vital signs after transfusing 50 ml of the blood product or after 15 minutes of administration, whichever occurred first, and within two hours after transfusion completion. On 7/22/26 at 0907 hours, a concurrent interview and medical record review for Patient 11 was conducted with Nurse Manager 1 and RN 13. Medical record review showed Patient 11 was admitted to the hospital on 1/19/26. Review of the physician’s order dated 1/31/26 at 0943 hours, showed an order to transfuse one unit of packed red blood cells to Patient 11. Review of Patient 11’s medical record showed the blood transfusion started on 1/31/26 at 1245 hours, and was completed at 1530 hours. However, further review of Patient 11’s medical record showed there was no documented evidence Patient 11’s blood pressure was assessed within 30 minutes prior to the transfusion, or that the patient’s temperature was assessed 15 minutes after the transfusion was initiated. On 7/22/26, during the concurrent interview and record review, Nurse Manager 1 verified the findings and stated complete vital signs, including temperature and blood pressure, should be assessed and documented before, during, and following a blood transfusion.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 39199 Based on observation, interview, and record review, the hospital failed to ensure preventive maintenance for equipment in the ED was conducted. This posed the risk of using equipment that had not been maintained in accordance with the manufacturer’s recommendations or the hospital’s preventive maintenance program, which could affect the safe and effective operation of the equipment and place patients and staff at risk. Findings: Review of the hospital’s P&P titled “Medical Equipment Management Plan,” dated 1/30/26, showed the purpose of the P&P is to provide an environment that minimizes the clinical and physical risks of equipment through the safe and effective use and maintenance of medical equipment in the hospital’s inventory. The P&P further showed all equipment items in the Clinical Engineering Health Services Preventative Maintenance Program are tested according to the manufacturer’s recommendation or at least annually after initial incoming testing. Items are affixed with an adhesive preventive maintenance sticker, which identifies to the operator that the equipment has been serviced and when the next inspection of the equipment is due. On 7/21/26 at 0923 hours, a tour of the ED was conducted with the ED Director, Nurse Manager 3, and Licensing Coordinator/Regulatory Affairs. During the tour, one bedside monitor and three defibrillators displayed preventive maintenance stickers indicating their maintenance was past due. The staff verified these findings. On 7/21/26 at 1318 hours, an interview and concurrent record review was conducted with the Medical Electronics Technician Working Supervisor who verified the preventive maintenance on the equipment was overdue and was required annually to ensure electrical safety for patient and staff use as intended by the manufacturer.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 35310 Based on observation, interview, and record review, the hospital failed to ensure the emergency department provided necessary and integrated services for two of 13 sampled patients (Patients 1 and 8) as evidenced by: 1. For Patient 1: a. The pain assessment and reassessments were not performed as per the hospital’s P&P and Nursing Clinical Standard for Patient 1. b. There was no documentation of meal offer to a homeless patient as per the hospital’s P&P for Patient 1. c. There was no specific discharge instructions provided related to the patient’s chief complaint for Patient 1. 2. The homeless discharge log was incomplete as per the hospital’s P&P. 3. For Patient 8, Patient 8’s head to toe assessment was not performed after Patient 8’s level of care was changed to the telemetry care level while boarded in the ED in a timely manner as per the hospital’s P&P. These failures had the potential to result in substandard care for the patients. Findings: 1. On 7/21/26, Patient 1’s closed medical record was reviewed. Patient 1’s closed medical record showed Patient 1 presented to the ED and was discharged from the ED on 6/19/26. a. Review of the hospital’s P&P titled Pain Management dated 11/15/24, showed all patients will be screened for the presence or absence of pain upon admission or initial contact in an ambulatory setting. The resulting numerical score or behavioral and physiologic indicators will be documented. If pain is present, it will be assessed, treated per the Pain Management Clinical Nursing Standard or patient may be referred for treatment. Review of the Nursing Clinical Standard titled Pain Management dated 1/2026 showed the following: * Assess/reassess pain characteristics as follows: - Baseline assessment (upon first complaint of pain/complaint of new type of pain): location, laterality, quality, time pattern. - Reassess pain level within one hour after any intervention provided for pain management (within two hours for non-opioid analgesics) or as clinically indicated by persistence of pain, initiation of potentially painful procedures or changes in medical status. - Reassess effectiveness of pharmacologic intervention and document pain score or physiologic/behavioral response. Review of the Pain dated 6/19/26 at 0659 hours, showed Patient 1 reported pain six out of 10 (on the pain scale of 0 to 10, zero being no pain and ten being the worst possible pain). However, further review of Patient 1’s medical record failed to show the comprehensive pain assessment including location, laterality, quality, and time pattern. In addition, there was no pain level reassessment until the discharge. Review of the Orders- Medications dated 6/19/26 at 1441 hours, showed to administer ketorolac (pain medication) 15 mg IM STAT once. Review of the Medication Administration Record dated 6/19/26 at 1453 hours, showed the ketorolac was administered. However, further medical record failed to show the pain level when the medication was administered and reassessment for intervention. On 7/22/26 at 1317 hours, Nurse Manager 7 verified the above findings. b. Review of the hospital’s P&P titled Nursing Guidelines for Patient Discharge under D. Homeless Patient Discharge dated 1/7/26, showed for homeless patients: check mark under the nursing discharge summary “Homeless” to trigger the Homeless Discharge Needs to be completed. Review of the Homeless Discharge Needs powerform for Patient 1 dated 6/19/26 at 1208 hours, showed the section for “Meal offered prior to discharge” was left blank. On 7/23/26 at 1031 hours, the Nursing Director - Quality, Regulatory Affairs, and Clinical Programs verified the above findings. c. On 7/23/26 at 1109 hours, Nurse Manager 7 was interviewed. Nurse Manager 7 stated nursing staff could perform some portions of instruction for discharge instruction. However, the ED provider should select what education needed based on the patient’s diagnosis and chief complaint. Review of the ED Note - Provider dated 6/19/26 at 1533 hours, showed Patient 1 presented to the ED today for evaluation of multiple complaints. Patient 1 reported that she had been feeling tired for the past four years, bilateral upper extremity numbness and neck pain for the past two years. Review of the Discharge Instructions under Diagnosis from Today’s Visit dated 6/19/26 at 1217 hours, showed “multiple complaints.” However, further review of Patient 1’s medical record failed to show the specific diagnosis for Patient 1. On 7/23/26 at 1109 hours, Nurse Manager 7 verified the above findings. 2. Review of the hospital’s P&P titled Discharge Planning for Patients Experiencing Homelessness or Unstable House Plan 2024-2025 dated 12/11/25, showed the hospital maintains a log of discharged patient experiencing homelessness and their destinations. (See Homeless Discharge Tab in the EMR). Review of Homeless Discharge - Inpatient and ED Job Aid showed the following: * “Senate Bill 1152 is a new California law that specifies discharge documentation requirements for homeless patients. In compliance with SB 1152, we must identify all homeless patients and document their post-discharge destination. State regulations mandate the coordination of support resources such as shelters, mental health providers, and other support services prior to discharge.” * The powerform can be used to document interventions to meet these legal requirements. The new Homeless Discharge Powerform can be found within existing Discharge Powerforms as a new tab. * The powerform showed “As required by law, this form should be completed in its entirety when patient is clinically stable for discharge.” * The Homeless Discharge Needs section may be completed by social work, nursing and/or providers. * The Homeless Discharge Needs section showed the following homeless discharge dispositions: shelter destination, homeless patient’s residence/principal dwelling place, alternative destination, offer resources but patient declined. On 7/23/26 at 0934 hours, the homeless discharge log for June 2026 was requested. Review of the homeless discharge log showed Patient 1 was discharged on 6/19/26. Further review of the log showed the discharge destination name was left blank. On 7/23/26 at 1031 hours, Assistant Nursing Director 2 was interviewed in the presence of the Nursing Director - Quality, Regulatory Affairs, and Clinical Programs. Assistant Nursing Director 2 stated the homeless discharge destination would be updated in the homeless discharge log when homeless discharge disposition in the powerform for the Homeless Discharge Needs was documented. The Nursing Director - Quality, Regulatory Affairs, and Clinical Programs acknowledged the above findings. 3. Review of the hospital’s P&P titled Inpatient Documentation Guidelines dated 1/7/26, showed baseline physical head to toe assessment must be initiated within four hours of admission for acute care unit. Review of the Nursing Clinical Standard titled Physiologic Monitoring/Hygiene/Comfort- Adult Acute Care Units dated 11/2024, showed to assess all body systems upon admission and every eight hours and more often as per Unit Structure Standards (USS)/patient During a tour of the ED with Nurse Manager 7 and the Licensing Coordinator/Regulatory Affairs on 7/22/26 at 1000 hours, Patient 8 was in ED with inpatient status. On 7/22/26, Patient 8’s medical record was reviewed. Patient 8’s medical record showed Patient 8 presented to the ED on 7/21/26. Review of the Admit/Transfer/Discharge dated 7/22/26 at 0158 hours, showed to admit Patient 8 to telemetry. During an interview and concurrent medical record with the Licensing Coordinator/Regulatory Affairs on 7/23/26 at 0902 hours, Patient 8’s medical record showed Patient 8’s head to toe assessment was performed on 7/22/26 at 1610 hours (approximately 15 hours after the admission order). On 7/23/26 at 1109 hours, Nurse Manager 7 acknowledged the findings.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure two of six sampled patients (Patients 2 and 3) rights were honored, as evidenced by: 1. A certified translator was not used when discussing goals of care for Patient 2, as required by the hospital’s P&P. 2. The medical record for Patient 3 did not contain a transfer package, including the transfer acknowledgment form and the physician’s order. These failures had the risk of violating patients’ rights to receive information regarding their care. Findings: 1. Review of the hospital’s P&P titled Language Access-Interpretation Services dated 4/25, showed for medically complex conversations, including but not limited to goals of care, end-of-life, informed consents, etc., staff should still utilize Language Assistance Services (LAS) to ensure that an accurate rendering of the information they are providing is offered to the individual, even if the patient and/or their legal representative(s) has/have refused LAS for themselves. Review of the hospital’s P&P titled Interpreter Services 8/24, showed hospital staff will use one of the following certified categories: * Utilize any of Video Remote Interpretation machines located throughout the medical center. * Dial ext. 9-3600 from any in house phone to be connected to a qualified health care interpreter via Telephonic Interpretations Services or dial 0 for the operator and ask to be connected to a certified healthcare interpreter via Telephone Interpretation Services. * Call the Cultural and Linguistic Competence Department Monday through Friday 0800 to 1700 hours to request an in-person qualified health care interpreter for other languages, or request an in-person interpreter in another language for a future appointment. * Use the DHS- approved interpreting services application for mobile phones. On 6/18/26, Patient 2’s medical record was reviewed and showed Patient 2 was admitted to the hospital on 4/3/26 and was discharged on 4/9/26. Review of the History and Physical examination dated 4/3/26 at 1408 hours, performed by MD 3, failed to show a qualified translator was used to discuss the plan. Review of the Admission History Adult dated 4/3/26 at 1545 hours, showed Patient 2’s current preferred language was Language 1 (a non-English language). Review of the Inpatient Progress Note under Goals of Care Discussion 4/7/26 dated 4/8/26 at 1150 hours, showed the following: * Discussed code status with patient and the patient’s family member at bedside. Reviewed her current clinical condition. * Discussed prognosis in the event of clinical deterioration, including that if she were to require intubation, there is high likelihood she may not tolerate it and could die despite aggressive interventions. On 6/22/26 at 1114 hours, MD 2 was interviewed in the presence of RN 1. MD 2 stated MD 2 was the supervising attending for MD 3. MD 2 stated MD 3 spoke the same language as Patient 2. When asked, MD 2 stated MD 3 was not a qualified translator. However, further medical record review failed to show a qualified translator was used during the discussion. 2. Review of the hospital’s P&P titled Transfer of Patients From the Medical Center to Another Facility dated 12/23, showed the following: * The sending physician writes an order for transfer in the medical record that includes the name of the accepting physician, facility and specifies the required mode of transportation and any necessary equipment to affect a safe transfer. * The medical center sends to the receiving facility all medical records (or copies thereof) available at the time of transfer related to the emergency condition of the patient including... b. The patient’s informed written consent to transfer c. The physician’s certification (or copy thereof) On 6/18/26, Patient 3’s medical record was reviewed and showed the patient came to the ED on 11/4/25 and was transferred to another facility on 11/6/25. Review of the Order dated 11/6/25 at 1908 hours, showed to transfer/discharge the patient to an outside facility. However, further review of the medical record failed to show the name of the accepting physician, the accepting facility and documentation specifying the required mode of transportation and any necessary equipment to affect a safe transfer. Review of ED Nursing Department Summary dated 11/6/25 at 2228 hours, showed Patient 3 left the ED with Patient 3’s family member. During a tour of the ED on 6/19/26 at 1213 hours, RN 4 was interviewed and stated that the transfer package would be completed when an ED patient was transferred to another facility. RN 4 stated that after the paperwork was completed, the record would be scanned in the electronic medical record by HIM. Review of the sample Transfer package provided by RN 4 showed the package included the following documents: * Psychiatric Patient Transfer Acknowledgement and Consent * Psychiatric Patient Transfer Checklist * Physician Transfer Orders and Certification However, further review of medical record failed to show the above transfer package was found in Patient 3’s electronic medical record. On 6/22/26 1400 hours, the Assistant Nursing Director and RN 1 acknowledged the above findings.”

“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: 35310 Based on interview and record review, the hospital failed to ensure one of six sampled patients’ (Patient 4) care plan was initiated to reflect the use of violent restraints during the hospitalization. This failure created the risk of substandard outcomes for the patient. Findings: Review of the hospital’s Nursing Clinical Standard titled Restraints/Seclusion: Violent or Self-Destructive Behavior dated July 2023 showed to document the initiation of individualized risk injury related to restrains interdisciplinary plan of care. On 6/18/29, Patient 4’s medical record was reviewed with RN 1. Patient 4’s medical record showed Patient 4 presented to the hospital on 6/17/26. Review of the Orders dated 6/18/26 at 0032 hours, showed to apply four point hard restraints to Patient 4 due to injury to self. Review of the Restraints Information under the restraint episode showed that Patient 4 was in 4-point hard restraints on 6/18/26 from 0028 to 0240 hours. However, further review of Patient 4’s medical record failed to show that the care plan was initiated to address the use of violent restraints on 6/18/26. On 6/22/26 at 1215 hours, Clinical Nursing Director 1 verified the above findings.”

“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 interview and record review, the hospital failed to ensure one of six sampled patients (Patient 4) was monitored during the application of a violent restraint as required by the hospital’s P&P and the Nursing Clinical Standard. This failure had the potential to result in the unsafe care and poor clinical outcomes to the patients. Findings: Review of the hospital’s P&P titled Restraints/Seclusion dated 6/23, showed the trained staff assess/monitor/perform at the initiation of restraints, prior to discontinuation, with every order obtained, or more frequently based on the patient’s needs per the Restraints: Non-Violent or Non-Self- Destructive Behavior Nursing Clinical Standard and Restraints/Seclusion: Violent or Self-Destructive Behavior Nursing Clinical Standard protocols. Review of the Nursing Clinical Standard titled Restraints/Seclusion: Violent or Self-Destructive Behavior dated July 2023 showed to monitor and document the following upon initiation of restraints or seclusion, every 15 minutes thereafter or more frequently based on patient’s condition: BH Patient activity (e.g. awake, eye closed), restraint site evaluation (restraint type, location, and signs of injury related to restraints), and respiratory rate. On 6/18/26, Patient 4’s medical record was reviewed with RN 1. Patient 4’s medical record showed Patient 4 presented to the hospital on 6/17/26. Review of the Orders dated 6/18/26 at 0032 hours, showed to apply four point hard restraints to Patient 4 due to injury to self. Review of the Face to Face Evaluation dated 6/18/26 at 0032 hours, showed Patient 4 was agitated and aggressive. Patient 4’s reaction to the intervention showed that the patient was still agitated, was unable to follow commands, and continued to exhibit aggression toward staff despite being in restraints. Review of the Restraints Information under the restraint episode showed that Patient 4 was in 4-point hard restraints on 6/18/26 from 0028 to 0240 hours. Review of the Restraints View under Restraint Site Evaluation dated 6/18/26 showed, restraint applied properly, and no evidence of injury related to restraint at 0049, 0105, 0120, 0135, 0150, and 0205 hours. However, the restraint site evaluations were performed by a Nursing Assistant (NA), rather than by licensed nursing staff as required. In addition, there was no documented restraint site evaluation at 0220 and 0235 hours. During an interview and concurrent medical record review on 6/22/26 at 1239 hours, the Clinical Nursing Director 1 verified the above findings.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure four of 11 sampled patients (Patients 1, 3, 5, and 11) or their representatives were provided with the information necessary to give permission and consent prior to treatment and receiving care, as evidenced by: 1. The required documentation supporting the immediate exception to informed consent was not present in the medical record for Patient 11, as required by the hospital’s P&P. 2. There was no documentation that Patients 1, 3, and 5 were informed of or educated about the use of a telesitter. These failures had the potential to limit the patients’ ability to make informed decisions about their care. Findings 1. Review of the hospital’s P&P titled Consent for Care dated 10/7/2024, showed the purpose of the P&P is to ensure that patients receiving medical care are provided with the information necessary to give permission and sign a consent prior to treatment (with the exception of immediate/emergency situations, as delineated in the policy), and to assure compliance with federal and state statutes and regulations regarding informed consent. Informed consent must be obtained prior to provision of care for all patients at the medical center, unless patients have conditions that meet California “immediate exception” criteria and lack surrogates. Per California code, treatments may be administered without consent to patients who lack decision-making capacity and who lack a surrogate decision maker, when a licensed practitioner reasonably believes that there is an “immediate” need to alleviate: severe pain, risk of serious disability, or risk of death. Provision of care using an immediate exception to informed consent requires documentation in the medical record to include: 1. The nature of the condition causing immediate sever pain or risk of disability or death, 2. The lack of availability of the patient or a surrogate decision maker to consent, and 3. Reasonable efforts by the hospital to contact the patient’s representative, 4. Why a delay in provision of care to contact a surrogate decision maker creates a risk of unacceptable prolongation of severe pain or disability or death. Such documentation must include the name of the licensed practitioner who has made the assessment that an immediate condition exists precluding the ability to obtain consent. On 4/2/26 at 0909 hours, medical record review for Patient 11 was initiated with Nurse Manager 4 and RN 2. Review of Patient 11’s Emergency Department Trauma/Resuscitation Flow Sheet dated 6/29/25, showed the patient arrived to the ED at 2224 hours with multiple gunshot wounds. Review of Patient 11’s ED Note-Provider dated 6/29/25 at 2258 hours, showed Patient 11 presented with gunshot wounds to the back, left upper extremity, and right forearm. On 4/2/26 at 1232 hours, medical record review for Patient 11 was initiated with Nurse Manager 5 and RN 2. Review of Patient 11’s Operative Report dated 6/30/25, showed the patient underwent an emergent exploratory laparotomy (a major surgical incision, or opening, made through the abdominal wall to examine, diagnose, and treat internal organs; used for procedures like treating severe abdominal trauma or addressing infections like peritonitis) due to multiple gunshot wounds, CT findings concerning for transverse colon injury, and peritonitis. Review of the Main OR Intraoperative Record dated 6/30/25, showed the patient was taken to the OR at 0509 hours, and general anesthesia began at 0535 hours. Review of Patient 11’s medical record failed to show written informed consents for the exploratory laparotomy or general anesthesia. Nurse Manager 5 verified no written informed consents were obtained because the patient presented as a trauma patient and required emergent operative services, and treatment was provided under implied consent. However, further review of the medical record failed to show documentation that: - The patient or surrogate was unavailable to provide consent, - Reasonable efforts were made to contact a surrogate, or - The elements required to use the immediate exception were documented, as specified in the hospital’s P&P. Nurse Manager 5 verified that the required documentation for using the immediate exception to informed consent was not present in the medical record for Patient 11. 35310 2. Review of the hospital’s P&P titled Telesitting: Remote Continuous Visual Monitoring dated 06/23, showed to educate the patient and family member that TeleSitting will be implemented to promote patient safety. Provide a copy of the educational handout to the family. Patient has the right to decline the TeleSitting intervention. a. Patient 1’s medical record was reviewed on 4/2/26. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 10/24/25 and was discharged on 11/7/25. Review of the Orders dated 10/24/25 at 0225 hours, showed to provide telesitter. Review of the Inpatient Progress Note- Nurse dated 10/25/25 at 0730 hours, showed Patient 1 was redirectable with telesitter in place. Further medical record review failed to show documentation that Patient 1 or family member was educated regarding Telesitting. b. Patient 3’s medical record was reviewed on 4/2/26. Patient 3’s medical record showed Patient 3 was admitted to the hospital on 2/2/26 and was discharged on 2/20/26. Review of the Orders dated 2/13/26 at 0724 hours, showed to provide telesitter. Review of TeleSitting Activity Log dated 2/13/26, showed Patient was placed on telesitter. However, further medical record review failed to show the documentation that Patient 3 or family member was educated regarding Telesitting. c. Patient 5’s medical record was reviewed on 4/2/26. Patient 5’s medical record showed Patient 5 was admitted to the hospital on 2/13/26 and was discharged on 2/22/26. Review of the Orders dated 2/16/26 at 1240 hours, showed to provide telesitter. However, further medical record review failed to show documentation that Patient 5 or family member was educated regarding Telesitting. During an interview and concurrent medical record review with the Assistant Nursing Director in the presence of the Licensing Coordinator/Regulatory Affairs on 4/3/26 at 1048 hours, the Assistant Nursing Director verified the above 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 that the investigation for the alleged telesitter’s poor performance was conducted as per the hospital’s P&P. This failure had the potential to result in unsafe care and poor clinical outcomes for the patient. Findings: Review of the hospital’s P&P titled Event Notification/Management Guidelines dated 4/8/24, showed the following: 1. No-Harm Patient Safety Events a. Patient safety events classified as no-harm events will require the area/service Director/Manager to complete an investigation and document their findings in the Patient Safety Evaluation System - Safety Intelligence (SI). b. The area/service Director/Manager completes the event review within 14 days after the event is entered into the Patient Safety Evaluation System - safety Intelligence. c. The investigation of the event includes interviews with workforce members and patient/family, actions/consultation to other disciplines and ancillary departments, referrals to committees for review, etc. d. The office of Risk Management and Patient Safety review events for completeness and closure. Review of the Patient Safety Evaluation System - Safety Intelligence dated 10/16/24, showed TeleSitter 1 monitored Patient 9 who had history of an episode of confusion and agitation. Patient 9 attempted to get out of bed and remove medical devices, but no attempt from TeleSitter 1 to notify the primary nurse or anyone on the unit during night shift on 10/15/24. On 4/3/26, Patient 9’s medical record was reviewed. Patient 9’s medical record showed Patient 9 was admitted to the hospital on 10/14/24 and was discharged on 10/21/24. Review of the Inpatient Progress Note dated 10/16/24 at 0627 hours, showed that Patient 9 was agitated and with altered mental status. During an interview with the Licensing Coordinator/Regulatory Affairs on 4/3/26 at 1008 hours, the Licensing Coordinator/Regulatory Affairs stated Nurse Manager 3 did not investigate the event because Nurse Manager 3 was not aware of the event. The Licensing Coordinator/Regulatory Affairs verified the event was not investigated as per the hospital’s P&P.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff implemented restraints as per the physician’s order for one of 11 sampled patients (Patient 5). This failure created a risk of unsafe care and poor clinical outcomes to the patient. Findings: On 4/2/26, Patient 5’s medical record was reviewed. Patient 5’s medical record showed Patient 5 was admitted to the hospital on 2/13/26 and was discharged on 2/22/26. Review of the physician orders showed the following: * On 2/15/26 at 2347 hours, to restrain right and left wrists for not being able to follow instructions. * On 2/15/26 at 2351 hours, to modify the restraints order from right and left wrists to right and left wrists and right and left ankles. Review of the Restraint Flowsheet dated 2/16/26 at 0003 hours, showed Patient 5 was on restraints to right and left wrists. Further medical record review failed to show Patient 5 was on restraints to right and left ankles as ordered by the physician. During an interview and concurrent medical record review with the Assistant Nursing Director in the presence of the Licensing Coordinator/Regulatory Affairs on 4/3/26 at 1048 hours, the Assistant Nursing Director verified the above findings.”

“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: 37548 Based on interview and record review, the hospital failed to ensure staff conducted and documented required reassessments and monitoring for one of 11 sampled patients (Patient 10) while the patient was in restraints. This failure posed a risk of unsafe care for the patient. Findings: Review of the hospital’s nursing clinical standard titled Restraints/Seclusion: Violent or Self-Destructive Behavior revised 7/2023, showed monitor and document the following upon initiation of restraints or seclusion, every 15 minutes thereafter or more frequently based on patient’s condition: - BH patient activity (e.g. awake, eyes closed) - Restraint site evaluation (restraint type, location, and signs of injury related to restraints) - Respiratory rate Review of the hospital’s P&P titled Restraints/Seclusion dated 6/10/23, showed documentation of the use of restraints and/or seclusion shall be consistent with the clinical protocols and maintained as required by regulatory agencies. The documentation of restraint or seclusion consists of assessments and reassessments of the patient’s status. On 4/3/26 at 1248 hours, medical record review for Patient 10 was initiated with Nurse Manager 7 and RN 2. Patient 10’s medical record showed the patient was admitted to the hospital on 3/27/26. Review of Patient 10’s Orders dated 4/1/26 at 1703 hours, showed an order to initiate hard restraints to all four extremities for violent or self-destructive behavior. Review of Patient 10’s Orders dated 4/1/26 at 2015 hours, showed the hard restraints for violent or self-destructive behavior were changed to soft restraints to the right wrist and left ankle for non-violent behavior. Review of Patient 10’s medical record showed the restraints were applied on 4/1/26 at 1615 hours and removed on 4/2/26 at 2010 hours. Further review showed no documented 15-minute reassessments of Patient 10’s activity, restraint site evaluation, and respiratory rate between 4/1/26 from 1915 hours to 2000 hours. Nurse Manager 7 confirmed the findings during the record review.”

“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: 35310 Based on interview and record review, the hospital failed to ensure that the nursing staff performed the assessment of the need of continued monitoring with the teleSitting as per the hospital’s P&P for three of 11 sampled patients (Patients 1, 3, and 5). These failures increased the risk of substandard healthcare outcomes to the patients. Findings: Review of the hospital’s P&P titled Telesitting: Remote Continuous Visual Monitoring dated 06/23, showed the following: B. Registered Nurse Documentation 1. Initiate TeleSitting and Document intervention in the electric health record (EHR) every shift and as needed. Documentation must include the following: a. Presence of TeleSitting device b. Reason for monitoring c. Behavioral status of the patient d. Additional safety measure implemented for patient safety e. Patient and family education. C. Registered Nurse Assessment/Reassessment 1. Reassess patient every shift and as needed for the need of continued monitoring with the TeleSitting device. 1. Patient 1’s medical record was reviewed on 4/2/26. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 10/24/25 and was discharged on 11/7/25. Review of the Orders dated 10/24/25 at 0225 hours, showed to provide telesitter. Review of the Inpatient Progress Note- Nurse dated 10/25/25 at 0730 hours, showed Patient 1 was redirectable with telesitter in place. However, further medical record review failed to show the documentation of the nurse’s intervention and assessment/reassessment for the telesitting. 2. Patient 3’s medical record was reviewed on 4/2/26. Patient 3’s medical record showed Patient 3 was admitted to the hospital on 2/2/26 and was discharged on 2/20/26. Review of the Orders dated 2/13/26 at 0724 hours, showed to provide telesitter. Review of TeleSitting Activity Log dated 2/13/26, showed Patient was placed on telesitter. However, further medical record review failed to show the documentation of the nurse’s intervention and assessment/reassessment for the telesitting. 3. Patient 5’s medical record was reviewed on 4/2/26. Patient 5’s medical record showed Patient 5 was admitted to the hospital on 2/13/26 and was discharged on 2/22/26. Review of the Orders dated 2/16/26 at 1240 hours, showed to provide telesitter. However, further medical record review failed to show the documentation of the nurse’s intervention and assessment/reassessment for the telesitting. During an interview and concurrent medical record review for Patient 1, 3, and 5 with the Assistant Nursing Director in the presence of the Licensing Coordinator/Regulatory Affairs on 4/3/26 at 1048 hours, the Assistant Nursing Director verified the above findings.”

“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: 22553 Based on interview and record review, the hospital failed to comply with the 24 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases and failed to ensure the hospital’s P&P related to AMA was reviewed or reviewed every three years. This failure had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services. Findings: 1. The hospital failed to ensure one of 20 sampled patients (Patient 17) had documented evidence of a completed physician’s medical screening examination to determine the presence or absence of an emergency medical condition. Cross reference to A2406. 2. The hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for one of 20 sampled patients (Patient 17). Cross reference to A2407. 3. Review of the hospital’s P&P titled Development and Maintenance of Departmental Policies dated 1/31/25, showed that existing policies must be reviewed at least once every three years by the Responsible Executive or their delegate to ensure currency. Review of the hospital’s P&P titled Leaving Against Medical Advice (MC) showed the effective date was 5/26/22; the review cycle would be three years, and the next review date would be 5/25/25. On 2/13/26 at 1355 hours, the Assistant Nursing Director stated the hospital’s P&P titled Leaving Against Medical Advice had not been reviewed as per the specified policy and procedure guidelines.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure one of 20 sampled patients (Patient 17) had documented evidence of a completed physician’s medical screening examination to determine the presence or absence of an emergency medical condition. This failure placed patients at risk for delayed identification and treatment of emergency medical conditions. Findings: Review of the hospital’s Rules and Regulations dated 4/5/17, showed: * Section 12 showed the MSE shall be performed by a physician or by a mid-level provider who has been granted privileges to conduct an MSE. On 2/11/26, review of Patient 17’s closed medical record was conducted. Patient 17 presented to the ED on 12/22/25 and left before treatment was completed on 12/23/25. Review of the Patient Summary Report showed Patient 17 presented to the ED on 12/22/25 at 1352 hours, as a walk-in with a complaint of left eye problems. Review of the Medical Screening Examination dated 12/22/25 at 1411 hours, showed NP 2 initiated the MSE as the screening provider. NP 2 documented a brief history of blurry vision for two weeks following a recent eye operation and a gradual headache for one week. Physical examination findings documented no proptosis. NP 2 documented Patient 17 as stable to wait for further evaluation by an ED provider. The plan included an eye evaluation; however, no eye evaluation was performed. Review of the Patient Summary Report showed Patient 17 was placed in the main waiting room on 12/22/25 at 1416 hours. Review of ED Notes dated 12/22/25 at 1841 hours, showed Patient 17 was not present when called to a booth. Additional attempts to locate Patient 17 were documented at 2359 hours, and on 12/23/25 at 0130 hours and 0419 hours. On 2/11/26 at 1144 hours, interview and concurrent record review was conducted with the Nurse Manager ED West/Base Station. The Nurse Manager stated documentation did not clearly support NP 2’s determination that Patient 17 was stable to wait, as the planned eye evaluation had not occurred to assess for the presence of an emergency medical condition related to the chief complaint. The Nurse Manager ED West/Base Station acknowledged concern regarding the lack of documentation supporting the decision to wait on the completion of the MSE without evidence that an emergency medical condition had been ruled out.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for one of 20 sampled patients (Patient 17) when the ED staff did not ensure the pain assessment and management for Patient 17 as per the hospital’s P&P. This failure had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services. Findings: Review of the hospital’s P&P titled Pain Management dated 11/15/24, showed to assess patients for the presence of pain upon initial contact with the patient. When pain is identified, the patient is treated based on the care setting and scope of services. Patient in the ambulatory care will have their pain level reassessed less than one hour after intervention or as clinically indicated. The physician/provider should be notified if the patient’s pain score remains unacceptable to the patient and is based on the patient’s acuity after the prescribed analgesic therapy or non-pharmacological therapy has been maximized. On 2/11/26, review of Patient 17’s closed medical record was conducted. Patient 17’s medical record showed Patient 17 presented to the ED on 12/22/25 and left before treatment was completed on 12/23/25. Review of the Patient Summary Report showed Patient 17 presented to the ED on 12/22/25 at 1352 hours, as a walk-in with a complaint of left eye problems. Review of the Medical Screening Examination dated 12/22/25 at 1411 hours, showed NP 2 initiated the MSE as the screening provider. NP 2 documented a brief history of blurry vision for two weeks following a recent eye operation and a gradual headache for one week. Review of the Pain Assessment showed Patient 17 stated the following numerical pain scores: - On 12/22/25 at 1356 hours, Patient 17 stated a pain level of eight out of ten on the pain scale. - At 1400 hours, Patient 17 stated a pain level of seven on the numeric pain scale. - At 1502 hours, Patient 17 stated a numeric pain score of six in the head. Review of the orders showed Patient 17 received acetaminophen (a pain medication) 1000 mg on 12/22/25 at 1415 hours. Review of the Patient Summary Report showed Patient 17 was placed in the main waiting room on 12/22/25 at 1416 hours. Review of ED Notes dated 12/22/25 at 1841 hours, showed Patient 17 was not present when called to a booth. Additional attempts to locate Patient 17 were documented at 2359 hours, and on 12/23/25 at 0130 hours and 0419 hours. However, further review of Patient 17’s medical record failed to show a comprehensive assessment of Patient 17’s pain including the quality, type, frequency, and acceptable level of pain. On 2/11/26 at 1144 hours, interview and concurrent record review was conducted with the Nurse Manager ED West/Base Station. The Nurse Manager acknowledged Patient 17’s pain assessment was incomplete and inconclusive if the patient’s pain was managed.”

“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: 45560 Based on interview and record review, the hospital failed to ensure that the plan of care for one of seven sampled patients (Patient 6) was updated to reflect the use of restraints. This failure posed a risk of substandard outcomes for the patient. Findings: Review of the hospital’s P&P titled Restraints/Seclusion dated 6/10/23, showed under documentation, documentation of the use of restraints and/or seclusion shall be consistent with the clinical protocols and maintained as required by the regulatory agencies. The documentation of restraint or seclusion consists of the: (8.) Modifications made to the plan of care to reflect the use and causes for the use of restraints and/or seclusion. During a concurrent interview and record review on 2/11/26 at 0900 hours, with RN 2, Patient 6’s medical record was reviewed. Patient 6’s medical record showed the patient was admitted to the hospital on 1/26/26. Review of Patient 6’s orders showed an order dated 1/26/26 at 0638 hours, to place hard restraints to all four extremities, with the reason for restraint being physical abuse to others. Review of Patient 6’s medical record did not show Patient 6’s plan of care was updated to reflect the use of restraints. On 2/11/26 at 1120 hours, the Licensing Coordinator/Regulatory Affairs acknowledged and verified the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 45560 Based on interview and record review, the hospital failed to ensure the order for restraints used for the management of violent or self-destructive behaviors was renewed within four hours for one of seven sampled patients (Patient 6). This failure posed the risk of unnecessary restraint use and substandard outcomes for the patient. Findings: Review of the hospital’s P&P titled Restraints/Seclusion dated 6/10/23, showed each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others may only be renewed in accordance with the following limits for up to a total of 24 hours: a. Four (4) hours for adults (18 years of age and over). On 2/11/26 at 0900 hours, review of Patient 6’s closed medical record was initiated. Patient 6’s medical record showed the patient was admitted to the hospital on 1/26/26. Review of Patient 6’s orders showed an order to initiate hard restraints (violent) to all four extremities with the reason for initiation of physical abuse to others. The special instructions showed the order was valid for four hours. Review of Patient 6’s Restraint documentation dated 1/26/26, showed the hard restraints were applied at 0630 hours, and discontinued on 1/26/26 at 1531 hours, for a total duration of 9 hours and 1 minute. On 2/11/26 at 0900 hours, a concurrent interview and record review was conducted RN 2. RN 2 was unable to locate an order renewing the violent restraints for Patient 6 after four hours from the initial order time. RN 2 acknowledged an additional order to renew the violent restraints for Patient 6 should have been obtained after four hours. On 2/11/25 at 1120 hours, the Licensing Coordinator/Regulatory Affairs was notified and acknowledged the above findings.”

“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: 45560 Based on interview and record review, the hospital failed to ensure an individualized treatment plan was developed or updated to address the care needs for one of seven sampled patients (Patient 1), creating the increased risk of not providing the necessary care and services to meet the care needs for the patient. Findings: Review of the hospitals P&P titled Interdisciplinary Plan of Patient Care dated 2/6/25, showed every patient...will have an individualized plan of care developed. The plan of care will be coordinated among all members of the patient’s health care team and will include problems, patient centered goals, outcomes, interventions, and approaches. Review of Patient 1’s medical record was initiated on 2/12/26. The Patient was admitted to the hospital on 12/11/25. Review of Patient 1’s neurosurgery H&P dated 12/11/25, showed Patient 1 was admitted with reported C4/5, C6/7, C6/7 disc bulges resulting severely central stenosis (significant narrowing of the spinal canal caused by bulging discs, compressing the spinal cord). Review of Patient 1’s operative report dated 12/12/25, showed Patient 1 underwent a C4-7 anterior cervical discectomy and fusion (a surgical procedure to treat multilevel cervical spinal cord compression or damaged discs). Review of Patient 1’s vital signs flowsheet dated 12/16/25, showed Patient 1 experienced 9/10 pain at 1037 hours, to an undocumented location and 6/10 pain to their abdomen at 1500 hours. On 2/12/26 at 1333 hours, a concurrent record review of Patient 1’s Interdisciplinary Plan of Care and interview was conducted with RN 2. RN 2 was unable to show a care plan problem was developed to address Patient 1’s pain and acknowledged a care plan problem for pain should have been initiated for Patient 1. On 2/12/26 at 1515 hours, the Licensing Coordinator/Regulatory Affairs was notified and acknowledged the above findings.”

“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: 45560 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff labeled the IV fluid tubing as per the hospital’s Nursing Clinical Standard for one of seven sampled patients (Patient 2). This failure created the risk of poor health outcomes to the patient. Findings: Review of the hospital’s Nursing Clinical Standard titled Intravenous Therapy dated June 2023 showed to change IV tubing every 24 hours for primary lines used intermittently and secondary lines (IV tubing used to intermittently administer a medication or fluid while the primary IV line is running); and label IV tubing every change with the following: date, time, initials, “IV” or name of continues medication close to insertion site. On 2/10/26 at 1145 hours, an observation of Patient 2’s IV medications was conducted. Patient 2 was observed with vancomycin (an antibiotic medication) 750mg in 150 ml of Normal Saline (NS) infusing as their secondary IV with a NS bag of 250ml as the primary bag. The IV tubing used to administer the vancomycin IV and NS IV was not labeled with the nurse’s initials, medication name, date, and time to show when the tubing needed to be changed. On 2/10/26 at 1200 hours, a concurrent observation and interview was conducted with RN 1. RN 1 acknowledged Patient 2’s tubing for the vancomycin and NS was not labeled as per the hospital’s policy and there was no way to know when the IV tubing was due to be changed. On 2/10/26 at 1210 hours, Interim Nurse Manager 1 was notified and acknowledged the above findings.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 45560 Based on interview and record review, the hospital failed to ensure one of seven sample patients (Patient 1) received the instructions on foley catheter, creating the risk for the patient to not have full understanding of the discharge instructions for a safe recovery. Findings: Review of the hospital’s P&P titled Patient Discharge dated 1/12/24, showed members of the interdisciplinary patient care team shall provide the patient with any necessary education and instruction prior to discharge. Discharge information may include prescriptions, use of medication, complete and reconciled list of medications along with education on the medications, diet treatment, post-hospitalization, and follow-up instructions. Review of the hospitals nursing clinical standard titled Indwelling Bladder Catheter dated 10/25 showed under patient/caregiver information, provide patient/family with “patient education information” instruct on the following: * Regarding purpose of the catheter * Regarding the risk of infection * Keep drainage bag below level of bladder and off the floor * Keep drainage tubing free of dependent loops * Adequate fluid intake * Notify nurse of pain, discomfort or feeling that the bladder is full * Avoid tension on the catheter * Maintain closed collection system * Encourage to ask about continued need for the catheter On 2/12/25 at 0915 hours, an interview and concurrent review of Patient 1’s medical record was conducted with RN 2. Patient 1 was admitted to the hospital on 12/11/25 and discharged home on 12/20/25. Review of the Discharge nursing note dated 12/20/25 at 1904 hours, showed discharge foley per MD order. Patient and family were educated on how to empty the foley catheter and when to seek medical attention regarding urine output. When asked to locate additional foley catheter patient teaching was documented regarding home care of the catheter, RN 2 was unable to show additional discharge instructions provided to Patient 1. On 2/12/26 at 1050 hours, an interview and concurrent review of Patient 1’s medical record was conducted with Interim Nurse Manager 1. Interim Nurse Manager 1 was unable to locate education at discharge showing patient was instructed on general care and precautions. On 2/12/26 at 1610 hours, the Licensing Coordinator/Regulatory Affairs was notified and acknowledged the above findings.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure electronic medical record accurately identified the need for interpreter services for one of two sampled patients (Patient 1) as required by the hospital’s P&P. This failure placed the patient at risk for not fully understanding their diagnosis, treatment, and plan of care. Findings: Review of the hospital’s P&P titled Interpreter Services dated 8/12/24, showed the preferred language when discussing health care is collected and updated in the electronic medical record system by registration staff and other staff performing patient registration. This information is located in the Patient Demographic section of the electronic medical record and on the banner bar indicating if an interpreter is requested. On 1/8/26, Patient 1’s medical record review was initiated with the Licensing Coordinator. Patient 1 received outpatient services on an ongoing basis at the hospital. Review of Patient 1’s Consultation Note dated 9/20/24 at 1624 hours, showed MD 1 discussed with the patient the need to have an interpreter for all visits to ensure good communication. The document showed Patient 1 was in agreement. Review of Patient 1’s banner bar showed the patient’s language was “English” and interpreter services were not required. On 1/9/26 at 1130 hours, the above finding was shared with the Licensing Coordinator.”

“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 interview and record review, the hospital failed to ensure one of two sampled patients (Patient 1) was monitored during the use of restraints as per the hospital’s P&P and Nursing Clinical Standards. This failure created a risk of unsafe care and poor clinical outcomes to the patient. Findings: During a review of the hospital’s P&P titled Restraints/Seclusion dated 6/10/23, showed “The trained staff assess/monitor/perform at the initiation of restraints, prior to discontinuation, with every order obtained, or more frequently based on the patient’s needs per the Restraints: Non-Violent or Non-Self- Destructive Behavior Nursing Clinical Standard and Restraints/Seclusion: Violent or Self-Destructive Behavior Nursing Clinical Standard protocols.” Review of the hospital’s Nursing Clinical Standard titled Restraints/Seclusion: Violent or Self-Destructive Behavior dated July 2023 showed to monitor and document the following upon initiation of restraints or seclusion, every 15 minutes thereafter or more frequently based on patient’s condition: BH Patient activity (e.g. awake, eye closed), restraint site evaluation (restraint type, location, and signs of injury related to restraints), and respiratory rate. On 7/31/25 at 1310 hours, Patient 1’s medical record was reviewed with the Licensing Coordinator. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 7/16/25. Review of the Orders showed an order dated 7/28/25 at 1315 hours, showing “Restraint Violent Initiate 9-17 Years”. The reason was injury to self, physical abuse to others, verbally threatening to harm self/others. Review of the Orders showed an order dated 7/28/25 at 1348 hours, showing “Restraint Violent Monitoring (RN).” Review of the Face-to-Face Evaluation dated 7/28/25 at 1335 hours, showed the patient was informed this afternoon that he would not be able to attend game room this afternoon due to not following his behavioral plan this morning. The patient became agitated, arguing with staff, and then started banging his head. The patient asked to go to seclusion room for a time out. He refused and continued banging his head. The patient was attempting to bite the staff while being transported to seclusion room, continued to yell at staff. Patient required 4 points restraint initiation for safety of himself. He continued to try to hit himself while in restraints, was given PRN oral medication to help calm down. Patient reaction intervention was “Agitated.” Review of the nursing assessment under the restraint episode showed Patient 1 was on hard restraints to all four extremities on 7/28/25 from 1315 hours to 1350 hours. Review of the Restraints Flowsheet dated 7/28/25, showed the following: * The neurovascular checks were completed on 7/28/25 at 1315 and 1350 hours. The neurovascular checks were not completed between 1315 to 1350 hours. * The respiratory rate assessment was documented on 7/28/25 at 1325 and 1350 hours. The respiratory rate assessment was not documented between 1315 to 1350 hours. * The restraint mental status was assessed on 7/28/25 at 1315 and 1350 hours. The restraint mental status was not assessed between 1315 to 1350 hours. * There was no documentation on BH patient activity, on 7/28/25 from 1315 to 1350 hours. On 7/31/25 at 1310 hours, the Licensing Coordinator verified the above findings.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure its P&P for complaints and grievances was followed. This failure created the risk of unresolved quality and safety concerns, as well as substandard patient care. Findings: Review of the hospital’s P&P titled Patient/Visitor or Complaints and Grievances dated 2/9/24, showed if staff is unable to resolve a complaint to the patient/visitor’s satisfaction within the same business day, the complaint becomes a grievance and shall be documented on a “Patient/Visitor Complaint Report” form and entered into the Grievance Tracking system. Grievances shall be acknowledged within seven business days of the stamped receipt date. The patient must receive a written response no more than 30 days after receipt of the complaint. The final written response should include the following: the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance, results of the grievance process and or investigation, corrective actions if indicated, and the date the investigation was completed. On 4/2/25 at 0902 hours, a telephone interview was conducted with Complainant 1 who alleged that she emailed a grievance to the hospital on 2/27/25, with concerns about a lack of supplies and staffing. Complainant 1 stated she did not receive a written acknowledgement of the receipt of her grievance, nor did she receive a written response indicating the investigation outcome. On 4/3/25 at 0935 hours, an interview and concurrent record review was conducted with Assistant Hospital Administrator 1 and the Licensing Coordinator. Review of the Patient/Visitor Complaint Report dated February 2025 showed Complainant 1 had emailed a grievance on 2/27/25. The report showed an acknowledgement letter was not sent to Complainant 1 and a final written response was due 4/10/25. Assistant Hospital Administrator 1 verified the final written response due date erroneously showed business days and stated the hospital did not send Complainant 1 an acknowledgement letter and final written response as per the hospital’s P&P.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the physician’s order for the restraint use for one of 11 sampled patients (Patient 1) was renewed as per the hospital’s Nursing Clinical Standard. This failure created the increased risk of the loss of freedom of movement for this patient. Findings: Review of the hospital’s Nursing Clinical Standard titled Restraints: Non - Violent or Non-Self-Destructive Behavior dated July 2023 showed to ensure the restraint order is completed and specifies for time limits (must be reordered by the end of the next calendar day); and notify the provider of need for new order for expired order (if the condition necessitating restraints persists). On 4/2/25, Patient 1’s closed medical record was reviewed with Nurse Manager 1. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 12/18/24 and left AMA on 12/24/24. Review of the nursing assessment under the restraint episode showed Patient 1 was on restraints from 12/18/24 at 1810 to 12/20/24 at 0200 hours. Review of the Physician’s Order dated 12/18/24 at 1926 hours, showed to initiate non-violent restraint to all four extremities for Patient 1 due to unable to follow instructions and interfering with medical care device, and the order was valid for one calendar day. Review of the Physician’s Order dated 12/20/24 at 0155 hours, showed to renew non-violent restraint to right and left wrist for Patient 1 due to interfering with medical care devices. However, further review of Patient 1’s medical record failed to show the restraint renewal order for 12/19/24. On 4/4/25 at 1020 hours, Assistant Nursing Director 2 verified the above findings.”

“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 interview and record review, the hospital failed to ensure two of 11 sampled patients (Patients 1 and 5) were monitored for the use of restraints as per the hospital’s P&P and Nursing Clinical Standard as evidenced by: 1. For Patient 1, the nursing staff failed to monitor the patient as per the hospital’s Nursing Clinical Standard when the violent restraint was applied to the patient. 2. For Patients 1 and 5, the non-violent restraint monitoring was not consistently performed as per the hospital’s Nursing Clinical Standard and hospital’s P&P. These failures had the potential to result in the unsafe care and poor clinical outcomes to the patients. Findings: Review of the hospital’s P&P titled Restraints/Seclusion dated 6/10/23, showed the trained staff assess/monitor/perform at the initiation of restraints, prior to discontinuation, with every order obtained, or more frequently based on the patient’s needs per the Restraints: Non-Violent or Non-Self- Destructive Behavior Nursing Clinical Standard and Restraints/Seclusion: Violent or Self-Destructive Behavior Nursing Clinical Standard protocols. 1. Review of the Nursing Clinical Standard titled Restraints/Seclusion: Violent or Self-Destructive Behavior dated July 2023 showed the following: * Assess and document the following upon application of restraints and a minimum of every two hours or more frequently based on patient’s condition: neurovascular check, restraint mental status assessment (level of consciousness, orientation assessment, affect/behavior), and restraint respiratory assessment. * Monitor and document the following upon initiation of restraints or seclusion, every 15 minutes thereafter or more frequently based on patient’s condition: BH Patient activity (e.g. awake, eye closed), restraint site evaluation (restraint type, location, and signs of injury related to restraints), and respiratory rate. On 4/2/25, Patient 1’s closed medical record was reviewed with Nurse Manager 1. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 12/18/24 and left AMA on 12/24/24. Review of the Physician’s Order dated 12/23/24 at 1233 hours, showed to apply violent restraint for Patient 1 and the order was valid for four hours. Review of the Physician’s Order dated 12/23/24 at 1234 hours, showed restraint violent monitoring by RN. Review of the Face to Face Evaluation dated 12/23/24 at 1231 hours, showed Patient 1 was agitated and combative. Patient 1’s reaction to intervention was pulling at restraints, unable to follow commands, continued aggression towards staff despite restraint, and verbally threatening staff. Review of the nursing assessment under the restraint episode showed Patient 1 was on 2- points soft restraints on 12/23/24 from 1200 to 1600 hours. However, further review of Patient 1’s medical record showed the following: * No neurovascular check between 1200 to 1600 hours on 12/23/24. * No respiration assessment while on restraints between 1200 to 1600 hours on 12/23/24. * The restraint mental status was assessed at 1200 and 1600 hours on 12/23/24. However, there was no restraint mental status assessment at 1400 hours on 12/23/24. In addition, there was no documentation of BH patient activity, restraint site evaluation, and respiratory rate every 15 minutes as per the hospital’s nursing clinical standard. 2. Review of the hospital’s P&P titled Restraints/Seclusion dated 6/10/23, showed the non-violent or non-self-destructive patient in restraints is monitored as follows: - At least every two hours or sooner based on patient need. - By observation, interaction with the patient, or related direct examination of the patient by qualified staff. Review of the Nursing Clinical Standard titled Restraints/Seclusion: Non-Violent or Non- self-Destructive Behavior dated July 2023 showed the following: * Assess and document the following upon application of restraints and a minimum of every two hours or more frequently based on patient’s condition: neurovascular check, restraint mental status assessment (level of consciousness, orientation assessment, affect/behavior), and restraint respiratory assessment. * Provide for and document the following upon application of restraints and a minimum of every two hours thereafter: range of motion, nutrition/hydration, elimination, hygiene, and patient position (repositioning). a. On 4/2/25, Patient 1’s closed medical record was reviewed with Nurse Manager 1. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 12/18/24 and left AMA on 12/24/24. Review of the nursing assessment under the restraint episode showed Patient 1 was on non-violent restraints on 12/21, 12/22, and 12/23/24. However, further review of Patient 1’s medical record showed restraint mental status assessment and restraint respiratory assessment were missing the following dates and times: * On 12/21/24 at 2100 and 2300 hours * On 12/22/24 at 0400, 0900, 1700, and 2200 hours. * On 12/23/24 at 0200, 0600, 1000, 1400, 1800, and 2200 hours. In addition, the restraint neurovascular check was performed on only 12/22/24 at 0254, 0540, 0656, 2012, 2200 hours and 12/23/24 at 0000 and 0200 hours. The neurovascular was not checked consistently every two hours as per the hospital’s clinical nursing standard. Review of the nursing assessment under the restraint episode showed there was no documentation of range of motion, nutrition/hydration, elimination, hygiene, and patient position (repositioning) between 1200 and 1600 hours on 12/23/24. On 4/4/25 at 0956 hours, Nurse Manager 1 verified the above findings. 45560 b. Review of Patient 5’s closed medical record was initiated on 4/2/25. Patient 5’s closed medical record showed the patient was admitted to the hospital on 2/3/25 and discharged on 2/20/25. Review of Patient 5’s physician orders showed an order dated 2/11/25 at 0800 hours, to initiate non-violent restraints to Patient 5’s left and right wrist with the indication that Patient 5 was unable to follow commands and was unsafe. Review of Patient 5’s restraint monitoring flowsheet dated 2/11/25, found no restraint monitoring documented as described in the hospitals P&P at 1600 hours. Review of Patient 5’s restraint monitoring flowsheet dated 2/11/25, showed the restraints were discontinued for Patient 5 on 2/11/25 at 1915 hours. On 4/2/25 at 1300 hours, an interview and concurrent review of Patient 5’s medical record was conducted with Nurse Manager 2. Nurse Manager 2 was unable to locate the restraint monitoring for Patient 5 from 2/11/25 at 1600 hours. Nurse Manager 2 acknowledged restraint monitoring for Patient 5 should have been done every 2 hours as per the hospital’s P&P. On 4/4/25 at 1130 hours, the Licensing Coordinator was notified and acknowledged the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(1) Training intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion- (i) Before performing any of the actions specified in this paragraph; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospital policy. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the competency for the us of restraints for RN 9. This failure posed the risk of substandard outcomes to the patient. Findings: Review of the hospital’s P&P titled Restraints/Seclusion dated 6/10/23, showed staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion before performing any of the above action, as part of the orientation, and every two years thereafter. On 4/4/25, when requested for RN 9’s restraint competency, Nurse Manager 1 provided the following documents: * CMS Restraints Education and Roster dated 11/22/24. * RN 9’s Orientation/Reorientation Handbook dated 1/22/24 and 4/3/25. * Nursing Staff Roles and Responsibilities during a Code Gold dated 5/10/24. * AVADE - Workplace Violence Prevention dated 12/23/24 and 5/10/24. Further review of the CMS Restraints Education and Roster dated 11/22/24, failed to showed RN 9 reviewed the hospital’s Nursing Clinical Standards for Restraints/Seclusion: Violent or Self-Destructive Behavior, Restraints: Non-Violent or Non-Self-Destructive Behavior, and emphasis on the behavioral criteria necessitating each type of restraint use, and the documentation and patient monitoring requirements. Further review of the educational material for Orientation/Reorientation Handbook, Nursing Staff Roles and Responsibilities during a Code Gold, AVADE - Workplace Violence Prevention failed to show the monitoring requirements of the restraints. On 4/4/25 at 0956 hours, Nurse Manager 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: 45560 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff labeled the IV fluid tubing as per the hospital’s Nursing Clinical Standard for one of 11 sampled patients (Patient 6). This failure created the risk of poor health outcomes to the patient. Findings: Review of the hospital’s Nursing Clinical Standard titled Intravenous Therapy dated June 2023 showed to change IV tubing every 24 hours for secondary lines (IV tubing used to intermittently administer a medication or fluid while the primary I.V. line is running); and label IV tubing every change with the following: date, time, initials, “IV” or name of continues medication close to insertion site. On 4/2/25 at 1015 hours, an observation of Patient 6’s medication pass was conducted with RN 3. Patient 6 was administered an IV solution of Zosyn (antibiotic medicattion) 3.375 grams via an electronic infusion pump. The IV tubing used to administer the Zosyn IV solution was not labeled with the nurse’s initials, medication name, date, and time to show when the tubing needed to be changed. On 4/2/25 at 1020 hours, an interview was conducted with RN 3. RN 3 stated the tubing for the Zosyn solution should be changed every 24 hours as per hospital’s policy. RN 3 acknowledged Patient 6’s tubing for the Zosyn solution IV was not labeled as per the hospital’s P&P and there was no way to know when the IV tubing was due to be changed. On 4/2/25 at 1022 hours, an interview was conducted with Nurse Manager 2. Nurse Manager 2 acknowledged there was no way to know when it would be time to change the IV tubing for Patient 6 since the IV tubing was unlabeled. On 4/4/25 at 1130 hours, the Licensing Coordinator was notified and acknowledged the above findings.”

“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 the administration and documentation of blood and blood products for one of 11 sampled patients (Patient 9). This posed the risk to transfusion tracking and monitoring due to the insufficient documentation, potentially compromising patient safety. Findings: Review of the hospital’s P&P titled Blood and Blood Products dated March 2025 showed the transfusion must be completed within six hours of the issuance from the blood bank and within four hours after the hermetic seal is broken. Documentation must be completed in accordance with the standards in iView and I&O: Blood Product Administration Navigator band and the Blood Products Transfusion Education. On 4/3/25 at 1336 hours, medical record review for Patient 9 was initiated with Assistant Nursing Director 1. Patient 9’s medical record showed that the patient received two units of packed red blood cells on 4/1/25. The first unit was transfused at 0925 hours and completed at 1245 hours, with documentation indicating the patient received 325 ml of packed red blood cells and tolerated the transfusion well, with no suspected transfusion reaction. Further record review showed the second unit of packed red blood cells was transfused at 1345 hours; however, there was no documentation to indicate the time the transfusion was completed, making it unclear whether it was completed within four hours, or if the patient had any suspected transfusion reaction. Following the interview and concurrent record review, Assistant Nursing Director 1 verified the findings.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 39199 Based on observation, interview, and record review, the hospital failed to ensure the preventative maintenance for three of seven observed overhead radiant heaters in the Burn Unit was conducted. This posed the risk of unsafe conditions for the patients. Findings: Review of the hospital’s P&P titled Medical Equipment Management Plan dated 11/21/24, showed the purpose of the P&P is to provide an environment that minimizes the clinical and physical risks of equipment through the safe and effective use and maintenance of medical equipment in the hospital’s inventory. All equipment items in the Clinical Engineering HSPMS program are tested according to manufacturer recommendation or at least annually after initial incoming testing. Items are affixed with an adhesive preventative maintenance sticker, which identifies to the operator that the equipment has been serviced and when the next inspection of the equipment is due. On 4/2/25 at 1447 hours, a tour of the Burn Unit was conducted with Clinical Nursing Director 4, Assistant Nursing Director 1, Nurse Manager 5, and Supervising Staff Nurse 3. During the tour, a total of seven overhead radiant heaters were observed: one in the hydrotherapy room and six in the Burn ICU rooms. Of the seven heaters observed, three displayed preventative maintenance stickers indicating their maintenance was past due (one in the hydrotherapy room and two in the Burn ICU rooms). The staff verified these findings. On 4/2/25 at 1515 hours, an interview was conducted with the Biomedical Supervisor, who stated preventative maintenance must be performed annually on the overhead radiant heaters to ensure safety and safe use, per the manufacturer’s recommendation and included checking for electrical safety, leakage tests, and proper grounding.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the Advance Directive brochure was provided to one of four sampled patients (Patient 2) as per the hospital’s P&P, creating the risk of violating the patient’s rights. Findings: Review of the hospital’s P&P titled Advance Directives dated 7/23/21, showed upon hospital admission or early during the hospitalization when the general consent is initially obtained, each patient or patient surrogate will be asked whether the patient has an advance directive, including POLST. The response will be noted in the appropriate field of the general consent form and in the automated electronic system. The patient, or the designee, will be provided a copy of the Advance Directive brochure, “Your Right to Make Decisions About Medical Treatment.” On 2/13/25 at 1300 hours, Patient 2’s closed medical record was reviewed with the Licensing Coordinator. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 12/5/24 and discharged on 12/6/24. Patient 2’s medical record showed Patient 2 did not have an advance directive. However, further review of Patient 2’s medical record failed to show if the Advance Directive brochure was provided. When asked, the Licensing Coordinator stated if a patient wished further information about advance directive, the social worker would be referred. In this case, a social worker was not referred, so the Advance Directive brochure was not provided to Patient 2. The Licensing Coordinator verified the above 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 the unexplained skin tears to the left upper arm were investigated for one of nine sampled patients (Patient 1). This failure had the potential to result in unsafe care and poor clinical outcomes to the patient. Findings: On 11/5/24, Patient 1’s closed medical record was reviewed. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 9/28/24 and discharged on 10/3/24. Review of the Incision/Wound/Skin Abnormality dated 9/30/24 at 0200 hours, showed Patient 1 was identified to have scattered skin tear to the left upper arm. However, further medical record failed to show physician’s notification and reason why the skin tears happened. On 11/6/24 at 1130 hours, Nurse Manager 1 was interviewed in the presence of the Officer of Regulatory Office. When asked, Nurse Manager 1 stated the unexpected skin tears should be reported to charge nurse and management to investigate to rule out abuse. On 11/6/24 at 1320 hours, Assistant Nursing Director 2 and the Licensing Coordinator verified the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the less restrictive interventions were used prior to using the hard restraints for one of nine sampled patients (Patient 1). This failure had the potential to result in unsafe care and poor clinical outcomes to the patient. Findings: Review of the hospital’s P&P titled Restraints/Seclusion dated 6/10/23, showed documentation of the use of restraints and/or seclusion shall be consistent with the clinical protocols and maintained as required by regulatory agencies. The documentation of restraint or seclusion consists of the alternatives or other less restrictive interventions used. Review of the hospital’s P&P titled Behavioral Response Team dated 8/16/21, showed the purpose is to describe the roles and responsibilities of the Behavior Response Team (BRT) in managing severely aggressive or self-destructive patient who places self or others in imminent danger. The development of the BRT shall assist the medical center in the accomplishment of this goal by utilizing the least restrictive form of restraint when restraint is necessary. Code Gold is for patient mental health and behavioral response episodes. In the event that a patient demonstrates an unanticipated severely aggressive of self-destructive behavior, which places the patient and others in imminent danger, the ward staff will utilize less restrictive measures. Less restrictive measures include, but are not limited to, verbal de-escalation, decrease stimulation, medication administration, and provision of diversion activities. When less restrictive measures are ineffective, the ward staff shall activate Code Gold. On 11/5/24, Patient 1’s closed medical record was reviewed with Clinical Nursing Director 1. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 9/28/24, and discharged on 10/3/24. Review of the ED Note-Nursing dated 9/28/24 at 0353 hours, showed Patient 1 was “resisting attempts to assess, slapping away attempted to bite MD and RN staff.” Code Gold was called for staff safety. Review of the nursing assessment under the restraint episode showed Patient 1 was on the 4- points hard restraints on 9/28/24 from 0409 to 0900 hours. However, further review of Patient 1’s medical record failed to show the documented less restrictive measures were used prior to initiating the 4- points hard restraints for Patient 1. On 11/5/24 at 1215 hours, Clinical Nursing Director 1 verified the above findings.”

“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: 35310 Based on interview and record review, the hospital failed to ensure one of nine sampled patients’ (Patient 1) care plan was updated to reflect the use of violent restraints during the hospitalization. This failure created the risk of substandard outcomes to the patient. Findings: Review of the hospital’s Nursing Clinical Standard titled Restraints/Seclusion: Violent or Self-Destructive Behavior dated July 2023 showed to document the initiation of individualized risk injury related to restrains interdisciplinary plan of care. On 11/5/24, Patient 1’s closed medical record was reviewed with Clinical Nursing Director 1. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 9/28/24 and discharged on 10/3/24. Review of the ED Note-Nursing dated 9/28/24 at 0353 hours, showed Patient 1 was “resisting attempts to assess, slapping away attempted to bite MD and RN staff.” Code Gold was called for staff safety. Review of the nursing assessment under the restraint episode showed Patient 1 was on 4- points hard restraints on 9/28/24 from 0409 to 0900 hours. However, further review of Patient 1’s medical record failed to show the care plan was initiated to address the use of violent restraints on 9/28/24. On 11/5/24 at 1215 hours, Clinical Nursing Director 1 verified the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the physician ordered for the use of restraints for three of nine sampled patients (Patients 1, 2, and 4) as evidenced by: 1. For Patient 1, the physician’s order was not obtained when using the 4-points hard restraints. 2. For Patient 2, the non-violent restraint was ordered when the patient was restrained for the violent behavior. 3. For Patient 4, the non-violent restraint was ordered when the patient was restrained for the violent behavior. These failures had the potential to result in unsafe care and poor clinical outcomes to the patients. Findings: Review of the hospital’s P&P titled Restraints/Seclusion dated 6/10/23, showed a licensed practitioner orders the use of restraint or seclusion. 1. On 11/5/24, Patient 1’s closed medical record was reviewed with Clinical Nursing Director 1. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 9/28/24 and discharged on 10/3/24. Review of the ED Note-Nursing dated 9/28/24 at 0353 hours, showed Patient 1 was “resisting attempts to assess, slapping away attempted to bite MD and RN staff.” Code Gold was called for staff safety. Review of the nursing assessment under the restraint episode showed Patient 1 was on 4- points hard restraints on 9/28/24 from 0409 to 0900 hours. However, further review of Patient 1’s medical record failed to show the physician’s order for restraints. On 11/5/24 at 1215 hours, Clinical Nursing Director 1 verified the above findings. 2. On 11/5/24 at 1222 hours, Patient 2’s medical record was reviewed with Supervising Staff Nurse 1 and Supervising Staff Nurse 2. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 11/4/24. Review of the Behavioral Response Team Form dated 11/4/24 at 0134 hours, showed the BRT was activated due to grabbing/striking out at staff and threatening staff. Review of the medical record showed Patient 2 was on 4-points hard restraints from 11/4/24 at 0143 hours. Review of the physician’s order showed the physician ordered non-violent restraints for Patient 2 on 11/4/24 at 0202 and 2223 hours. Review of the Restraint Forms, Face to Face Evaluation dated 11/4/24 at 2223 hours, showed Patient 2 was agitated. When asked, Supervising Staff Nurse 1 and Supervising Staff Nurse 2 stated Patient 2 was still on 4-points hard restraints due to violent behaviors towards to staff since the first BRT’s intervention. Supervising Staff Nurse 1 and Supervising Staff Nurse 2 verified the non-violent restraints were ordered Patient 2 when the patient was restrained for the violent/self-destructive behaviors. 3. On 11/6/24 at 0854 hours, Patient 4’s medical record was reviewed with Nurse Manager 2. Patient 4’s medical record showed Patient 4 was admitted to the hospital on 10/30/24. Review of the Inpatient Progress Note-Nurse dated 11/4/24 at 2330 hours, showed Patient 4 screamed at staff, got agitated, and verbally abused to staff. Review of the Behavioral Response Team Form dated 11/5/24 at 0058 hours, showed the BRT was activated. Further review of Patient 4’s medical record showed Patient 4 was on hard restraints to the right wrist and left ankle on 11/5/24 from 0107 hours to 0519 hours. However, review of the physician’s order showed the non-violent restraint was ordered for Patient 4 on 11/5/24 at 0107 hours. On 11/6/24, Nurse Manager 2 verified the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the use of hard restraints for violent behavior was not renewed in four hours for four of nine sampled patients (Patients 1, 2, 4, and 9). These failures posed a risk of substandard outcomes for the patients. Findings: Review of the hospital’s P&P titled Restraints/Seclusion dated 6/10/23, showed each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others may only be renewed in accordance with the following limits for up to a total of 24 hours: * four hours for adults (18 years of age and over). Review of the hospital’s Nursing Clinical Standard titled Restraints/Seclusion: Violent or Self-Destructive Behavior dated July 2023 showed to ensure the restraint order is completed and specifies: * Time limitation for four hours for ages 18 and older. Orders may be renewed according to the time limits for a maximum of 24 consecutive hours. 1. On 11/5/24, Patient 1’s closed medical record was reviewed with Clinical Nursing Director 1. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 9/28/24 and discharged on 10/3/24. Review of the ED Note-Nursing dated 9/28/24 at 0353 hours, showed Patient 1 was “resisting attempts to assess, slapping away attempted to bite MD and RN staff.” Code Gold was called for staff safety. Review of the nursing assessment under the restraint episode showed Patient 1 was on 4- points hard restraints on 9/28/24 from 0409 to 0900 hours. However, review of the subsequent physicians’ order showed the violent restraints were not renewed for approximately four hours and 51 minutes. On 11/5/24 at 1215 hours, Clinical Nursing Director 1 verified the above findings. 2. On 11/5/24 at 1222 hours, Patient 2’s medical record was reviewed with Supervising Staff Nurse 1 and Supervising Staff Nurse 2. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 11/4/24. Review of the Behavioral Response Team Form dated 11/4/24 at 0134 hours, showed the BRT was activated due to grabbing/striking out at staff and threatening staff. Review of the physician’s order showed the physician ordered non-violent restraints for Patient 2 on 11/4/24 at 0202 and 2223 hours. Further review of Patient 2’s medical record showed Patient 2 was on 4-points hard restraints from 11/4/24 at 0143 hours. However, the physician’s order was not renewed every four hours. Supervising Staff Nurse 1 and Supervising Staff Nurse 2 verified the above findings. When asked, Supervising Staff Nurse 1 and Supervising Staff Nurse 2 stated Patient 2 was still on 4-points hard restraints due to violent behaviors towards to staff since the first BRT’s intervention. 3. On 11/6/24 at 0854 hours, Patient 4’s medical record was reviewed with Nurse Manager 2. Patient 4’s medical record showed Patient 4 was admitted to the hospital on 10/30/24. Review of the Inpatient Progress Note-Nurse dated 11/4/24 at 2230 hours, showed Patient 4 screamed at staff, got agitated, and verbally abused to staff. Review of the Behavioral Response Team Form dated 11/5/24 at 0058 hours, showed the BRT was activated. Further review of Patient 4’s medical record showed Patient 4 was on hard restraints to the right wrist and left ankle on 11/5/24 from 0107 hours to 0519 hours (or for four hours and 12 minutes). On 11/6/24, Nurse Manager 2 verified the above findings. 36703 4. On 11/6/24, Patient 9’s closed medical record review was initiated with the Licensing Coordinator and Clinical Nursing Director 1. Patient 9’s medical record showed Patient 9’s arrived to the ED on 6/6/24, for altered mental status. Review of the ED Triage dated 6/6/24 at 1307 hours, shows Patient 9 was brought in by the fire department for evaluation of altered mental status. Patient 9 was combative and in moderate distress. Review of the restraints monitoring on 6/6/24 from 1425 hours to 2130 hours, showed Patient 9 was on hard restraints to all four extremities for continued violent behavior. Review of the physician’s order dated 6/6/24 at 1425 hours, showed Patient 9 was placed on violent restraints for physical abuse to others. Patient 9 was ordered hard restraints to all four extremities. The special instructions showed the order was valid for four hours. However, review of the subsequent physician’s order on 6/6/24 at 2130 hours, showed the violent restraints were not renewed for approximately six hours and 55 minutes. On 11/6/24 at 1139 hours, the above findings were shared and acknowledged by the Licensing Coordinator and Clinical Nursing Director 1.”

“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 interview and record review, the hospital failed to ensure four of nine sampled patients (Patients 1, 2, 4, and 9) who were restrained were monitored as evidenced by: 1. For Patients 1, 2, and 4, the patients were not monitored every 15 minutes when the patients were restrained for violent behaviors as per the hospital’s P&P. 2. For Patient 9, the face-to-face re-evaluation was not performed every four hours as per the hospitals’ P&P. These failures posed a risk of substandard outcomes for the patient. Findings: 1. Review of the hospital’s Nursing Clinical Standard titled Restraints/Seclusion: Violent or Self-Destructive Behavior dated July 2023 showed to monitor and document the following upon initiation of restraints or seclusion, every 15 minutes thereafter or more frequently based on patient’s condition: * Behavioral health patient activity (e.g. awake, eyes closed) * Restraint site evaluation (restraint type, location, and signs of injury related to restraints) * Respiratory rate. a. On 11/5/24, Patient 1’s closed medical record was reviewed with Clinical Nursing Director 1. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 9/28/24 and discharged on 10/3/24. Review of the ED Note-Nursing dated 9/28/24 at 0353 hours, showed Patient 1 was “resisting attempts to assess, slapping away attempted to bite MD and RN staff.” Code Gold was called for staff safety. Review of the nursing assessment under the restraint episode showed Patient 1 was on 4- points hard restraints on 9/28/24 from 0409 to 0900 hours. However, there was no documented evidence to show every 15 minutes monitoring for Patient 1 while Patient 1 was on hard restraints. On 11/5/24 at 1215 hours, Clinical Nursing Director 1 verified the above findings. b. On 11/5/24 at 1222 hours, Patient 2’s medical record was reviewed with Supervising Staff Nurse 1 and Supervising Staff Nurse 2. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 11/4/24. Review of the Behavioral Response Team Form dated 11/4/24 at 0134 hours, showed the BRT was activated due to grabbing/striking out at staff and threatening staff. Further review of Patient 2’s medical record showed Patient 2 was on 4-points hard restraints from 11/4/24 at 0143 hours. There was no documented evidence to show every 15 minutes monitoring for Patient 2 as per the hospital’s P&P. When asked, Supervising Staff Nurse 1 and Supervising Staff Nurse 2 stated Patient 2 was still on 4-points hard restraints due to violent behaviors towards to staff since the first BRT’s intervention. When asked, Supervising Staff Nurse 1 and Supervising Staff Nurse 2 stated the monitoring and assessment was performed for non-violent restraint protocol and was not performed for the violent restraint. Supervising Staff Nurse 1 and Supervising Staff Nurse 2 verified above findings. c. On 11/6/24 at 0854 hours, Patient 4’s medical record was reviewed with Nurse Manager 2. Patient 4’s medical record showed Patient 4 was admitted to the hospital on 10/30/24. Review of the Inpatient Progress Note-Nurse dated 11/4/24 at 2230 hours, showed Patient 4 screamed at staff, got agitated, and verbally abused to staff. Review of the Behavioral Response Team Form dated 11/5/24 at 0058 hours, showed the BRT was activated. Further of review of Patient 4’s medical record showed Patient 4 was on hard restraints to the right wrist and left ankle on 11/5/24 from 0107 hours to 0519 hours. There was no documented evidence to show every 15 minutes monitoring for Patient 4 as per the hospital’s P&P. On 11/6/24, Nurse Manager 2 verified the above findings. 36703 2. Review of the hospital’s P&P titled Restraints/Seclusion dated 6/10/23, showed the licensed practitioner must conduct a face-to-face evaluation within one hour after initiation of the intervention of violent restraints. The licensed practitioner must conduct a face-to-face re-evaluation every four hours for violent restraints. On 11/6/24, Patient 9’s closed medical record review was initiated with the Licensing Coordinator and Clinical Nursing Director 1. Patient 9’s medical record showed Patient 9’s arrived to the ED on 6/6/24, for altered mental status. Review of the ED Triage dated 6/6/24 at 1307 hours, shows Patient 9 was brought in by the fire department for evaluation of altered mental status. Patient 9 was combative and in moderate distress. Review of the physician’s order dated 6/6/24 at 1425 hours, showed Patient 9 was placed on violent restraints for physical abuse to others. Patient 9 was ordered hard restraints to all four extremities. The special instructions showed the order was valid for four hours. Review of the Face-to-Face Evaluation dated 6/6/24 at 1425 hours, showed the provider saw the patient at the time of initiation of the violent restraints. Review of the physician’s orders showed violent hard restraints were re-ordered as follows: - On 6/6/24 at 2130 hours, Patient 9 was ordered hard restraints on all four extremities. - On 6/7/24 at 0111 hours, Patient 9 was ordered hard restraints on all four extremities. - On 6/7/24 at 0516 hours, Patient 9 was ordered hard restraints for the right wrist and the left ankle. However, further review of Patient 9’s medical record failed to show the provider performed a face-to-face re-evaluation as per the hospital’s P&P for subsequent renewals of the violent restraint orders. On 11/6/24 at 1239 hours, the above findings were shared and acknowledged by the Licensing Coordinator and Clinical Nursing Director 1.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(i) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the face-to-face evaluation was performed within one hour of the initiation of the intervention for one of nine sampled patients (Patient 1). This failure had the potential to result in unsafe care and poor clinical outcomes to the patient. Findings: Review of the hospital’s P&P titled Restraints/Seclusion dated 6/10/23, showed the following: * A licensed practitioner must conduct a face-to-face patient evaluation within one hour after the initiation of the intervention. * The evaluation consists of patient’s immediate situation, patient’s reaction to the intervention, patient’s medical and behavioral condition, and the need to continue or terminate the restraint or seclusion. On 11/5/24, Patient 1’s closed medical record was reviewed with Clinical Nursing Director 1. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 9/28/24 and discharged on 10/3/24. Review of the ED Note-Nursing dated 9/28/24 at 0353 hours, showed Patient 1 was “resisting attempts to assess, slapping away attempted to bite MD and RN staff.” Code Gold was called for staff safety. Review of the nursing assessment under the restraint episode showed Patient 1 was on 4- points hard restraints on 9/28/24 from 0409 to 0900 hours. However, further review of Patient 1’s medical record failed to show the face-to-face evaluation was conducted within one hour after the initiation of the intervention. On 11/5/24 at 1215 hours, Clinical Nursing Director 1 verified the above findings.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure the nursing staff provided the patient teaching in the patient’s preferred language for one of two sampled patients (Patient 2). This failure had the potential for unsafe care to the patient. Findings: Review of the hospital’s P&P titled Interpreter Services dated 8/12/24, showed the purpose of the policy is to ensure compliance with regulatory requirements that protect the patient’s rights to access basic health care when limited by language or hearing impairment. The P&P showed the hospital shall provide interpreter services when a patient is Limited English Proficient (LEP), or non-English speaking. On 9/24/24 at 1033 hours, review Patient 2’s medical record was initiated with the Licensing Coordinator. Patient 2’s medical record showed the patient was admitted to the hospital on 9/19/24. Patient 2 was non-English speaking and required interpreter services. Review of the Education dated 9/23/24 at 0855 hours, showed RN 5 discussed multiple topics with Patient 2, including the activity precautions and restrictions, fall prevention, ADL care, mobility and positioning, DVT signs and symptoms, infection signs and symptoms, pain, PE signs and symptoms, and suicide prevention. RN 5 documented the teaching method was through the demonstration and explanation. However, further review of Patient 2’s medical record failed to show documented evidence an interpreter was utilized for Patient 2 when the family was not present to assist in translating. Review of the Education dated 9/24/24 at 0000 hours, showed RN 6 discussed multiple topics with Patient 2, including mobility, bladder management, fall prevention, pain, PE signs and symptoms, safety, self-care, and suicide prevention. RN 6 documented the teaching method was demonstration and explanation. However, further review of Patient 2’s medical record failed to show documented evidence an interpreter was utilized for Patient 2 when the family was not present to assist in translating. The Licensing Coordinator was informed of and acknowledged 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 supervised and evaluated the nursing care for two of two sampled patients (Patients 1 and 2) as evidenced by: 1. The nursing staff failed to notify Patient 1’s physician when the patient was off the continuous cardiac monitor for approximately two hours despite being newly diagnosed with a heart arrhythmia. In addition, the nursing staff failed to provide Patient 1 with consistent pain management as per the hospital’s Nursing Clinical Standards. 2. The nursing staff failed to follow the hospital’s Nursing Clinical Standard for Patient 2’s extravasation on the left arm including assessment and care management. Additionally, the left AC IV site was incorrectly documented as the right AC IV site. These failures had the potential for unsafe care to the patients. Findings: 1. On 9/24/24 at 1102 hours, Patient 1’s closed medical record was reviewed with Nurse Manager 1. Review of Patient 1’s medical record showed Patient 1 was admitted to the hospital on 9/12/24, and discharged on 9/13/24. Review of the Orders dated 9/12/24 at 1460 hours, showed to admit Patient 1 to telemetry unit. a. Review of the hospital’s Nursing Clinical Standard titled Cardiac Telemetry Monitoring - Acute Care Telemetry Unit dated October 2020 showed the following: * Continuous cardiac monitoring of patients is important for following reasons: - Prompt identification of cardiac rhythm changes or abnormalities and need for treatment which can prevent adverse events, including hemodynamic compromise and death. - Assistance in identifying those risks for life-threatening cardiac arrhythmias and/or myocardial ischemia (MI). * Apply telemetry monitor and pulse oximeter (as ordered) upon admission and ensure patients are monitored throughout telemetry stay. Review of the Cardiology Inpatient Progress Note dated 9/12/24 at 1534 hours, showed Patient 1 presented to the hospital with type II AV block seen after the outpatient stress test. Review of the Computed Tomography dated 9/13/24 at 1253 hours, showed the CT angiography coronary artery with evaluation was performed. Review of the TeleTracking for Patient 1 showed Patient 1 was picked up from the unit on 9/13/24 at 1208 hours and came back to the unit on 9/13/24 at 1355 hours. Patient 1 was off the unit for one hour and 47 minutes. On 9/24/24 at 1130 hours, Nurse Manager 1 was interviewed. When asked, Nurse Manager 1 stated patients on the telemetry unit would go to the diagnostic testing area without the cardiac monitoring. When asked, Nurse Manager 1 stated no physician’s notification or physician’s order was needed to remove the cardiac monitoring for the diagnostic procedure. The telemetry nursing staff did not accompany the patients for diagnostic procedures. When asked, Nurse Manager 1 stated it had been a practice on the telemetry unit. On 9/24/24 at 1320 hours, the CT area was toured with the Chief Radiologic and Supervisor Radiologic in the presence of the Assistant Nursing Director. There were three holding bays in the CT areas. When asked, the Supervisor Radiologic stated the holding bays were for patients who were waiting for transporting back to their units. When asked, the Supervisor Radiologic stated there was no nurse in the holding bays. On 9/25/24 at 0945 hours, the Internal Medicine- Cardiology was interviewed in the presence of the Officer of Regulatory Office. When asked, the Internal Medicine- Cardiology stated being off the continuous cardiac monitoring for one hours and 47 minutes was relatively long for a patient with new onset AV block cardiac condition. On 9/25/24 at 1000 hours, the Licensing Coordinator and Officer of Regulatory Office verified the above findings. b. Review of the hospital’s Nursing Clinical Standard titled Pain Management dated October 2023 showed the following: * Assess/reassess pain intensity/score a minimum of every four hours utilizing the pain assessment tools attached. * Assess/reassess pain characteristics as follows: - Baseline assessment (upon first complaint of pain/complaint of new type of pain): location, laterality, quality, time pattern. * Reassess pain level less than one hour after intervention or as clinically indicated. On 9/24/24 at 1102 hours, Patient 1’s medical record was reviewed with Nurse Manager 1. Review of Patient 1’s medical record showed Patient 1 was admitted to the hospital on 9/12/24 and discharged on 9/13/24. Review of the Pain Assessment showed the following: * On 9/12/24 at 1937 hours, Patient 1 complained of a pain level of six out of 10 (0 being no pain and 10 being the worse pain). However, the medical record failed show documentation of the location, laterality, quality, and time pattern. * On 9/13/24 at 1127 hours, Patient 1 complained of a pain level of 10 out of 10. Review of the Medication Administration Record dated 9/13/24 at 1133 hours, showed Patient 1 received acetaminophen (a pain medication) 650 mg for pain. Review of the Medication Administration Record dated 9/13/24 at 1233 hours, showed Patient 1’s pain level was unacceptable and the patient refused added analgesics. However, the medical record did not show documentation of the pain level. In addition, there was no added analgesics available for Patient 1 other than acetaminophen. On 9/24/24 at 1129 hours, Nurse Manager 1 verified the above findings. 36703 2. Review of the hospital’s Nursing Clinical Standard titled Extravasation, Management dated December 2023 showed the following: * Extravasation is a potential complication of IV therapy and is defined as leakage of intravenous fluid or medications out of the vein. Serious tissue damage may occur, particularly with vesicants. * Management of a patient with extravasation or suspected extravasation is as follows: - Assess the IV site and the surrounding area upon identification of extravasation at a minimum of every two hours for 72 hours; assess for swelling, induration, redness, bruising or discoloration, skin translucency, skin cool to touch, pain, itching, circulatory impairment of the distal area, drainage, streak formation, ulceration, and necrosis. - Upon identification of an extravasated medication which requires an antidote, notify the provider immediately, stop the IV fluid and medication, disconnect the tubing from the IV catheter, attach a 6 ml syringe to the IV catheter hub, apply a tourniquet above the site of the extravasation, then aspirate and check for blood return. If there is no blood return, slowly aspirate as much of the infiltrated fluid as possible, remove the tourniquet and IV catheter. - Notify the provider with the occurrence of the extravasation, name of the extravasated medication, condition of the extravasation site, and worsening of the extravasation site. Further review of the hospital’s Nursing Clinical Standard showed a table for recommended treatment for extravasation of amiodarone (antiarrhythmic) is to administer hyaluronidase (used to help drugs and other substances move more easily into tissues and be absorbed by the body) 15 units/ml given as a 1 ml subcutaneous injection approximately one-half inch apart of the entire affected area in a clock pattern. It is recommended to put a dry and warm compress. These interventions require physician’s orders. On 9/24/24, Patient 2’s medical record was reviewed. Patient 2 was admitted to the hospital on 9/19/24. On 9/21/24, Patient 2 was in the PCU. a. Review of Patient 2’s Vascular Access documentation dated 9/21/24 at 1800 hours, showed RN 7 documented Patient 2 had a right AC peripheral IV. On 9/25/24 at 0937 hours, an interview was conducted with RN 7 regarding Patient 2. RN 7 confirmed Patient 2’s peripheral IV was in the left AC and not the right AC. b. Review of the physician’s order for Patient 2 dated 9/20/24 at 1354 hours, showed to infuse amiodarone 900 mg in Dextrose 5% in water (an IV solution) at 33.33 ml/hr continuously. Further review of the order showed the order was discontinued on 9/21/24 at 1510 hours. Review of the Vascular Access dated 9/21/24 at 1800 hours, showed RN 7 documented Patient 2’s IV site condition had no complications, and the dressing was clean, dry, and intact. However, review of the Vascular Access documentation on 9/21/24 at 1900 hours, showed RN 8 documented Patient 2’s left AC IV was discontinued due to being infiltrated. RN 8 documented there was no blood return, and the IV site was red. RN 8 documented the catheter was removed intact with no complications. Further review of Patient 2’s medical record failed to show the physician was notified of the possible extravasation of the patient’s left AC IV as per the hospital’s Nursing Clinical Standard. The physician was not notified of the discontinued IV site condition of the left arm until 9/22/24 at 0016 hours, as shown on the Provider Notification flowsheet after Patient 2 was transferred to the Telemetry Unit. The Notification Details showed Patient 2’s left AC IV was infiltrated at 1900 hours. The IV was discontinued and a heat pack was applied with arm elevation. The documentation showed the Provider Requested Intervention was to continue to monitor and order US if the patient’s condition worsened. On 9/25/24 at 0937 hours, an interview was conducted with RN 7 regarding Patient 2. When asked, RN 7 stated she discontinued Patient 2’s amiodarone IV drip at approximately 1600 hours. RN 7 stated the patient’s IV site appeared patent on her assessment with no complications. RN 7 stated the IV was saline locked and no other medications were given through the left AC IV. c. Review of Patient 2’s medical record showed Patient 2 were not assessed or monitored every two hours for 72 hours, nor comprehensive to establish a baseline for subsequent changes within the 72 hours as per the hospital’s Nursing Clinical Standard. For example: - Review of the Incision/Wound assessment documentation showed on 9/22/24 at 2000 hours, Patient 2 had “IV Infiltration/Extravasation” with wound status as “Unchanged”. There was no skin dressing, and the site was open to air. - The Edema Assessment documentation showed on 9/22/24 at 2000 hours, Patient 2 had left arm edema which was localized and dependent. These assessments for Incision/Wound and Edema remained unchanged and were documented as assessed on 9/23/24 at 0000, 0400, 0855, and 2000 hours; and 9/24/24 at 0000, 0400, and 0800 hours. Review of the Inpatient Progress Note dated 9/22/24 at 0633 hours, showed RN 8 documented the left AC IV was infiltrated at 2000 hours. RN 8 documented the IV was taken out intact, and a warm pack was applied. Review of the Inpatient Progress Note dated 9/22/24 at 1929 hours, showed Patient 2 had some redness noted on the left arm and per the report it was due to infiltration. Review of the Inpatient Progress Note dated 9/23/24 at 1937 hours, showed Patient 2 had redness and induration to the left arm. On 9/24/24 at 1430 hours, an observation of Patient 2 in Room A was conducted with RN 9. Patient 2 was lying in bed with the HOB elevated in a sitting position. RN 9 stated Patient 2’s arm was hardened over the area where the old IV was and very warm to the touch. RN 9 stated Patient 2’s arm was swollen, red, and marked with pen. RN 9 stated Patient 2 stated having discomfort on the arm and needed encouragement to keep the left arm elevated. On 9/25/24 at 1016 hours, an interview was conducted with Patient 2’s attending physician, MD 2. When asked, MD 2 stated he assumed care for Patient 2 since 9/23/24. MD 2 stated he noted Patient 2’s left arm had pen marking on it, but he was not informed by the prior attending physician of Patient 2’s left arm, nor notified from nursing. When asked, MD 2 stated he would expect to be notified of the circumstance leading to the state of Patient 2’s arm. MD 2 stated that if he knew of a possible extravasation related to amiodarone on this patient, he would expect comprehensive documentation of what the affected arm looked like, as well as photographs to monitor how the wound was progressing. MD 2 stated if he knew, he would consult with pharmacy on the next steps for an antidote, if needed. On 9/25/24 at 1121 hours, the above concerns for incorrectly documenting Patient 2’s IV site as a right AC IV instead of left AC IV, the lack of timely notification of the IV infiltration and possible extravasation, and the lack of performing comprehensive assessments every two hours for 72 hours to capture how Patient 2’s left arm wound was progressing were shared and acknowledged by the Licensing Coordinator.”

“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 had evaluated the nursing care for one of three sampled patients (Patient 3) as evidenced by: 1. Patient 3’s fingernails and toenails were not trimmed properly. 2. The nursing staff did not consistently weigh Patient 3 weekly as per the hospital’s P&P. 3. The nursing staff did not consistently document the meal intakes for Patient 3. These failures had the potential for unsafe care to the patient. Findings: On 8/22/24, Patient 3’s medical record was reviewed with the Clinical Nursing Director and Licensing Coordinator. Patient 3’s medical record showed Patient 3 was admitted to the hospital on 1/26/24. 1. On 8/22/24 at 1035 hours, an observation of Patient 3’s fingernails and toenails was conducted with RN 1. The patient’s nails were thick and yellowish. The patient’s left hand was contracted, and the fingernails were curved to the palm. RN 1 was asked to measure the patient’s fingernails and toenails. The patient’s left 3rd fingernail measured 12 mm from the tip of the finger to the edge of the nail. The patient’s right and left big toenails measured 5 mm from the tip of the finger to the edge of the nail. On 8/22/24 at 1116 hours, RN 1 was interviewed. When asked, RN 1 stated if a patient’s nails were long, the RN would notify the provider, and many times, it was the NP who would cut the patient’s nails. When asked, RN 1 stated she was not aware if anyone had notified the provider of the patient’s long nails. Further review of Patient 3’s medical record failed to show the documentation on the nail care. On 8/22/24 at 1440 hours, during interview with Nurse Manager 1, Nurse Manager 1 stated Patient 3 was in the Medical Surgical Unit, and the physician should cut the patient nails. However, when the patient was transferred to the Behavior Unit on 6/6/24, the information that the physician would cut the patient’s nails was not communicated to the Behavior Unit. 2. Review of the hospital’s Nursing Clinical Standard titled Physiologic Monitoring/Hygiene/Comfort- Adult Acute Care Units dated December 2021 showed to weight the patient upon admission and weekly (i.e. every Tuesday). Patient 3’s weight records from 6/1 to 8/22/24 were requested. Review of the weight records showed the following: * On 6/4/24 at 0600 hours, Patient 3’s weight was 64.2 kg. * On 8/20/24 at 0536 hours, Patient 3’s weight was 69 kg. Further review of Patient 3’s medical record failed to show Patient 3’s weights were recorded weekly from 6/24 to 8/20/24, as per the hospital’s Nursing Clinical Standard. 3. Review of the hospital’s Nursing Clinical Standard titled Physiologic Monitoring/Hygiene/Comfort- Adult Acute Care Units dated December 2021 showed to assess the intake and output totals at a minimum of every eight hours. The random dates were selected to review Patient 3’s meal intakes. Review of the meal intakes showed the following: * On 6/1/24, there was no documentation of the meal intakes for breakfast, lunch, and dinner. * On 6/2/24, there was no documentation of the meal intakes for lunch and dinner. * On 6/3/24, there was no documentation of the meal intake for dinner. * On 7/21/24, there was no documentation of the meal intake for dinner. * On 7/22/24, there was no documentation of the meal intakes for breakfast and lunch. * On 8/2/24, there was no documentation of the meal intake for dinner. * On 8/3/24, there was no documentation of the meal intakes for lunch and dinner. On 8/22/24 at 1427 hours, the Clinical Nursing Director verified the above findings.”

“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: 29558 Based on observation, interview, and record review, the hospital failed to ensure to comply with the 24 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services. Findings: 1. The hospital failed to ensure the necessary stabilizing treatment was provided within the capabilities of the hospital provided for nine of 20 sampled patients (Patients 1, 4, 5, 7, 8, 9, 16, 19, and 20). Cross reference to A2407. 2. The hospital failed to ensure the ED staff completed the Psychiatric Patient Transfer Acknowledgment and Consent form when transferring one of 20 sampled patients (Patient 12) to other facility. Cross reference to A2409.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 36703 Based on observation, interview, and record review, the hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for nine of 20 sampled patients (Patients 1, 4, 5, 7, 8, 9, 16, 19, and 20) as evidenced by: 1. The ED staff did not ensure the pain management for Patients 4, 16, 19, and 20 as per the hospital’s P&P. 2. The ED staff did not conduct the reassessments including the vital signs every four hours for Patients 1, 5, 8, and 9 as per the hospital’s P&P. 3. The ED staff did not assess the vital signs every two hours for Patient 7. 4. The ED staff did not check the crash cart on the 1/23 and 1/28/24 day shifts and 1/26/24 night shift as per the hospital’s P&P. These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services. Findings: 1. Review of the hospital’s P&P titled Pain Management dated 9/8/23, showed Numerical Rating Scale (NRS) is one of the pain scales approved for use in the hospital. NRS is a numeric pain assessment tool in which patients are asked to verbally rate their current pain intensity on a scale of zero to 10 with zero being in no pain and 10 being the worst possible pain. All patients will be screened for the presence or absence of pain upon admission or initial contact in the ambulatory care setting utilizing one of the above-mentioned pain scales. Review of the hospital’s Nursing Clinical Standard titled Pain Management dated October 2023 showed assessment includes the following: * Assess/reassess pain intensity/score a minimum of every four hours (acute care units). * Assess/reassess pain characteristics as follows: - Baseline assessment (upon first complaint of pain/complaint of new type of pain): location, laterality, quality, and time pattern. * Reassess pain level less than one hour after intervention or as clinically indicated. a. Review of Patient 16’s closed medical record was initiated on 1/30/24. Patient 16’s medical record showed Patient 16 arrived in the ED on 10/2/23 at 1616 hours. Review of the ED Triage Form dated 10/2/23 at 1619 hours, showed Patient 16 had the right sided chest pain radiating to the back. Patient 16’s pain level was six out of 10. Review of the Pain showed on 10/2/23 at 1638 hours, the Patient 16’s primary pain location was on the chest. Patient 16’s pain level was 10 out of 10. However, further review of the pain assessment documentation failed to describe the quality and time pattern as per the hospital’s Nursing Clinical Standard. Review of the Medication Administration Record showed on 10/2/23 at 1658 hours, Patient 16 was administered with hydromorphone (an opioid pain medication) 0.5 mg IVP. Review of the Pain showed Patient 16’s pain level was zero out of 10 on 10/2/23 at 1916 hours (or approximately two hours and 18 minutes later). Further review of Patient 16’s medical record failed to show documented evidence of reassessing the patient’s pain within one hour, after administering hydromorphone as per the hospital’s Nursing Clinical Standard. On 1/30/24 at 1331 hours, the above findings were shared and verified with Nurse Manager 2 and Interim Clinical Nursing Director 1. b. Review of Patient 19’s closed medical record was initiated on 1/30/24. Patient 19’s medical record showed Patient 19 arrived in the ED on 12/13/23 at 1841 hours. Review of the ED Trauma Triage dated 12/13/23 at 1847 hours, showed Patient 19 had pain on the left back. Patient 19’s pain level was eight out of 10. However, the assessment was missing the pain quality and time pattern. Review of the Assessment dated 12/13/24 at 1930 hours, showed Patient 19 had throbbing pain in the left abdomen. However, there was no documented evidence to show the patient’s pain level was assessed. Review of the Medication Administration Record showed on 12/13/23 at 2046 hours, showed Patient 19 received acetaminophen (pain medication) 1000 mg by mouth. Review of the Discharge Documentation showed Patient 19 was discharged from the ED on 12/13/24 at 2118 hours. However, further review of Patient 19’s medical record failed to show Patient 19 was reassessed for pain after acetaminiphen was administered to the patient. On 1/30/24 at 1331 hours, the above findings were shared and verified with Nurse Manager 2 and Interim Clinical Nursing Director 1. c. Review of Patient 20’s closed medical record was initiated on 1/30/24. Patient 20’s medical record showed Patient 20 arrived in the ED on 1/2/24 at 0218 hours. Review of the ED Triage Form dated 1/2/24 at 0220 hours, showed Patient 20’s pain level was eight out of 10. However, there was no documented evidence showing the pain location, quality, or time pattern was assessed for the patient as per the hospital’s Nursing Clinical Standard. Review of the Pain showed the following: * On 1/2/24 at 0244 hours, Patient 20 had pain in the head. The patient’s pain level was a nine out of 10. However, there was no documented evidence showing the pain quality or time pattern was assessed for the patient as per the hospital’s Nursing Clinical Standard. * On 1/2/24 at 0413 hours, Patient 20 had intermittent cramping in the suprapubic area with the pain level of eight out of 10. Further review of the medical record failed to show Patient 20 received non-pharmacological or pharmacological pain interventions until 1/2/24 at 0640 hours. Review of the Medication Administration Record showed on 1/2/24 at 0640 hours, Patient 20 received ibuprofen (a pain medication) 400 mg by mouth. On 1/30/24 at 1331 hours, an interview and concurrent review of Patients 16, 19, and 20 was conducted with Nurse Manager 2. When asked what the expectation of pain assessment, reassessments, and intervention were for the patients in the ED, Nurse Manager 2 stated if a patient had a pain which needed to be addressed, the RN should contact the provider, provide treatment as ordered, and follow the hospital’s P&P. The RN should assess the patient’s pain completely, document the assessment, notify the provider, administer treatment, and reassess as per the hospital’s P&P and the provider’s order. On 1/30/24 at 1331 hours, the above findings were shared and verified with Nurse Manager 2 and Interim Clinical Nursing Director 1. 35310 d. Patient 4’s medical record was reviewed with Nurse Manager 2 on 1/30/24 at 1205 hours. Patient 4’s medical record showed Patient 4 arrived at the ED on 12/24/23 at 1032 hours. Review of the ED Triage Form dated 12/24/23 at 1032 hours, showed Patient 4 had pain with the pain level of 10 out of 10. Review of the ED Vital Signs and Pain dated 12/24/23 at 1054 hours, showed Patient 4 reported pain to his head. The patient’s pain level was eight out of 10. However, further review of Patient 4’s medical record failed to show the baseline pain assessment, including laterality, quality, and time pattern was completed for Patient 4 as per the hospital’s Nursing Clinical Standard. Review of the ED Note-Assessment dated 12/24/23 at 1306 hours, showed Patient 4 refused to be assessed. However, there was no documentation of pain management provided to the patient between 1054 hours and 1306 hours. When asked, Nurse Manager 2 stated the intake nurse performed quick assessment including pain assessment and categorized a patient’s ESI level. The next pain assessment should have included the baseline assessment. Nurse Manager 2 verified the above findings. 2. Review of the hospital’s P&P titled Triage-Nursing Role Responsibilities dated September 2021 showed the following: * The triage nursing team consists of a router, secondary assessment nurses, reassessment nurses, and ambulance triage nurses. * Router nurse will determine level of severity using the Emergency Severity Index (ESI), based on clinical presentation and chief complaint and complete the triage form in the EHR. Patients who have an ESI level 2 or greater will be taken to an available bed or to the North Lean Track (NLT). * Room 2/Adult Waiting Reassessment Nurse will provide limited diagnostic studies and treatment as ordered. Patients categorized as acuity 3 (ESI level 3) will be reassessed, including vital signs a minimum of every four hours. a. Patient 1’s medical record was reviewed with Nurse Manager 4 on 1/29/24 at 1037 hours. Patient 1’s medical record showed Patient 1 arrived at the ED on 1/8/24 at 1328 hours. Review of the ED Triage Form dated 1/8/24 at 1330 hours, showed Patient 1 was triaged with the acuity level “3”. Review of the Medical Screening Exam dated 1/8/24 at 1346 hours, showed Patient 1’s tracking acuity was “3.” Review of the ED Vital Signs and Pain dated 1/8/24 at 1421 hours, showed Patient 1’s vital signs were measured. Review of the ED Note-Assessment dated 1/8/24, showed Patient 1’s reassessment including the vital signs was performed at 2141 hours (or seven hours and 20 minutes later). When asked, Nurse Manager 4 stated patient whose acuity level was categorized as three, should be assessed every four hours, including the vital signs. Nurse Manager 4 stated Patient 1 should have been reassessed by 1821 hours, including the vital signs. Nurse Manager 4 verified the above findings. b. Patient 5’s medical record was reviewed with Nurse Manager 2 on 1/30/24 at 1205 hours. Patient 5’s medical record showed Patient 5 arrived at the ED on 1/2/24 at 1055 hours. Review of the ED Triage Form dated 1/2/24 at 1056 hours, showed Patient 5’s vital signs were taken. The patient was triaged with the acuity level “3.” Review of the Medical Screening Exam dated 1/2/24 at 1123 hours, showed Patient 5’s tracking acuity was “3”. However, review of the ED Notes dated 1/2/24 at 1918 hours, showed Patient 5 did not answer call. There was no documentation showing the nursing staff had encountered Patient 5 until 1/2/24 at 1918 hours (or eight hours and 22 minutes later). When asked, Nurse Manager 2 stated Patient 5’s assessment including the vital signs should have been performed by 1523 hours. Nurse Manager 2 verified the above findings. 40431 c. On 1/30/24 at 1245 hours, an interview and concurrent review of Patient 8’s medical record was conducted with Nurse Manager 3. Patient 8’s medical record showed Patient 8 presented to the Trauma ED on 1/28/24 at 1231 hours, for head injury. At 1244 hours, Patient 8 was triaged with the acuity level “3.” Review of the ED Note-Provider dated 1/28/24 at 1344 hours, showed Patient 8 had head injury. Review of the Assessment showed Patient 8 was assessed on 1/28/24 at 1334 and 1440 hours. Review of the Discharge Documentation dated 1/28/24 at 2116 hours, showed Patient 8 was transferred to the Psych ED. The patient’s pain level was eight out of 10. The patient’s vital signs were taken at 2113 hours. There were no documented evidence showing Patient 8 was assessed every four hours as per the hospital’s P&P. Nurse Manager 3 confirmed the findings. d. Review of Patient 9’s medical record was conducted with Nurse Manager 3 on 1/30/24 at 1315 hours. Patient 9’s medical record showed Patient 9 came to the ED on 8/31/23 and discharged on 9/1/23 2033 hours. Review of the ED Triage/Intake dated 9/1/23 at 0244 hours, showed Patient 9 was triaged with the acuity level “3.” Review of the Discharge Documentation showed Patient 9’s vital signs were taken on 8/31/23 at 1955 hours; 8/31/23 at 2321 hours; 9/1/23 at 0244 hours; 9/1/23 at 0444 hours; and 9/1/23 at 0738 hours. Review of the ED Vital Signs and Pain showed Patient 9’s vital signs were assessed on 9/1/23 at 1437 hours, or approximately seven hours later. There were no documented evidence showing Patient 9’s vital signs were assessed every four hours as per the hospital’s P&P. Nurse Manager 3 confirmed the findings. 3. On 1/30/24 at 1215 hours, an interview and concurrent review of Patient 7’s medical record review was conducted with Nurse Manager 3. When asked how often the patients with the acuity level 2 would be reassessed for vital signs, Nurse Manager 3 stated every two hours. Review of the Emergency Department Trauma/Resuscitation Flowsheet dated 1/28/24, showed Patient 7 arrived to the ED at 1555 hours. Review of the ED Note - Provider dated 1/28/24 at 1610 hours, showed Patient 7 had self-inflicted neck stab wound. Review of the ED Trauma Triage dated 1/28/24 at 1702 hours, showed Patient 7 was triaged with the acuity level “2.” Review of the Vital Signs showed Patient 7’s vital signs were taken on 1/28/24 at 1634, 1645, and 1700 hours. Review of the ED Clinician Discharge Summary dated 1/28/27 at 2039 hours, showed Patient 7 was discharged from the ED on 1/28/24 at 2039 hours. There were no documented evidence showing Patient 7’s vital signs were taken every two hours. Nurse Manager 3 confirmed the findings. 4. Review of the hospital’s P&P titled Emergency Crash Cart Exchange Program dated 10/22/19, showed the Emergency Crash Cart Checklist located in the Crash Cart Inventory/Log Book on the top of the emergency cart will be checked every shift by nursing personnel. On 1/29/24 at 0915 hours, a tour of the Psych ED was conducted with Nurse Manager 3. A crash cart was observed in the Psych ED. Review of the Emergency (Crash Cart) Equipment Check Log showed the nursing staff did not check the crash cart on 1/23/24 day shift, 1/26/24 night shift, and 1/28/24 day shift. The finding was confirmed by Nurse Manager 3.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 40431 Based on interview and record review, the hospital failed to ensure the ED staff completed the Psychiatric Patient Transfer Acknowledgment and Consent form when transferring one of 20 sampled patients (Patient 12) to other facility. This failure had the potential to result in poor clinical outcomes and serious adverse events to the patients receiving ED services. Findings: Review of Patient 12’s medical record was initiated on 1/30/24. Patient 12’s medical record showed Patient 12 came to the ED on 10/1/23 and was transferred or discharged to other facility on 10/1/23 at 2217 hours. Review of the Psychiatric Patient Transfer Acknowledgment and Consent form showed on 10/1/23, showed the following: * Patient 12 was transferred to the outside facility because there was no bed at the transferring hospital. * The comments section showed if a patient refuses to sign, check one of the following boxes - Patient cites his/her right to refuse to sign the form. - Patient denies any reason for psychiatric hospitalization. - Patient is acutely agitated and unable to sign. - Other (specify) However, these boxes were not checked. * The sections of Patient/Parent/or Legal Representative Signature and Date/Time were left On 1/30/24 at 1300 hours, an interview and concurrent review of Patient 12’s medical record was conducted with Nurse Manager 3. Nurse Manager 3 confirmed the Psychiatric Patient Transfer Acknowledgment and Consent form was not completed for Patient 12.”