Emanate Health Inter-Community Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36206 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient’s Rights was met, as evidenced by: 1. The facility failed to ensure that there was a follow-up attempt made to obtain one of 33 sampled patient’s (Patient 11) signature for the Condition of Admission form (COA, a formal contract between patient and hospital that outlines the patient’s rights, responsibilities, and consent to treatment), when Patient 11’s COA was initially marked “unable to sign due to condition,” on 10/12/2025, in accordance with the facility’s policy regarding COA. This deficient practice had the potential for Patient 11 to experience delays in non-emergency care, incur unintended financial liability, and not receive the information necessary to make an informed decision (a voluntary, collaborative process where the patient chooses a healthcare pathway after understanding the risks, benefits, alternatives, and costs, based on evidence-based information) regarding hospital admission and treatment. (Refer to A-0117) 2. The facility failed to ensure that patient rights (such as the right to receive safe care and the right to have care provided in a manner that protects the patient’s health and safety), were exercised and protected for one of 33 sampled patients (Patient 16), in accordance with the facility’s Patient Rights policy, when the facility discharged Patient 16 from the Emergency Department (ED), after Patient 16’s second ED visit on 12/28/2023, without ensuring that the patient (Patient 16) was clinically stable (meaning the patient’s condition was medically evaluated and determined not to pose an immediate risk of deterioration) and safe for discharge (meaning the patient was appropriately assessed, monitored, and determined to be at a condition where discharge would not place the patient at risk of harm). This deficient practice potentially resulted in a worsening of Patient 16’s medical condition after being discharged from the ED for the second time on 12/28/2023, culminating in a cardiac arrest (when the heart stops beating) within 72 hours following the second ED visit (Patient 16 was discharged on 12/28/2023 after a second ED visit on the same date; first ED visit was on 12/26/2023) and thus requiring a transfer of Patient 16 to a higher level of care (meaning a facility capable of providing more intensive, specialized treatment), in a critical condition (meaning the patient’s life was at risk and required urgent, intensive medical intervention), during the third ED visit on 12/31/2023. (Refer to A-0129) 3. The facility failed to report a reportable adverse event (events that are mandatory to report to state or federal authorities to ensure patient safety, enable investigation, and prevent recurrence. Example: sexual assault on a patient) for one of 33 sampled patients (Patient 27) to the state regulatory agency, within 24 hours, in accordance with state Health and Safety Code (laws designed to protect public welfare by enforcing standards) Section 1279.1 (b) (defines the specific types of “adverse events” that licensed health facilities [such as hospitals] must report to the California Department of Public Health [CDPH, a regulatory agency]. These are serious, largely preventable incidents that result in death or serious disability to a patient), when Patient 27 reported an alleged sexual assault (when someone either touches another person in a sexual manner without consent [agreement] or makes another person touch them in a sexual manner without consent) to the facility on 2/26/2026. Patient 27 alleged that a nurse (HD 1) grabbed Patient 27’s left breast during a hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) treatment session at the hospital on 2/25/2026. Patient 27 reported the sexual allegation to the facility on 2/26/2026, but the facility did not report to the state department of public health until 3/20/2026. This deficient practice had the potential to result in a delay of an independent investigation by the state department of public health and potentially putting Patient 27 and other patients at risk for further abuse or harassment. (Refer to A-0145) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 36206 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by: 1. The facility failed to ensure appropriate monitoring for one of 33 sampled patient’s (Patient 23) blood pressure (BP, amount of force used to move blood through the body, with a normal range of 90-120) result, when Patient 23’s Systolic blood pressure (SBP, systolic measures pressure when heart contracts) was in the 80s (normal SBP is between 90-120), and there was no rechecking/reassessment done by nursing staff from 12:17 a.m. to 3:17 a.m., and from 8:59 a.m. to 8:45 p.m. on 1/5/2026, in accordance with the facility’s policy regarding patient assessment/evaluation and reassessment. This deficient practice had the potential for Patient 23 to experience severe change of condition that is undetected due to lack of reassessment, which could lead to fatal consequences such as organ damage/failure and/or death. (Refer to A-0395) 2.a. The facility failed to ensure Nursing staff evaluated one of 33 sampled patient’s (Patient 2) wound care needs, in accordance with the facility’s policy regarding wound care, physician notification, and treatment plan, when the nursing staff did not follow-up with the attending physician regarding the Wound Care Nurse’s recommendations for Infectious Disease consultation and wound-care treatment for Patient 2’s perineum (the area of skin between the genitals and the rectum). In addition, the nursing staff did not obtain a physician’s order prior to continuing Patient 2’s use of a home medication (Boudreaux’s Butt Paste, an over-the-counter skin-protectant cream). This deficient practice had the potential to result in worsening perineal wounds for Patient 2 and delayed diagnosis and treatment of a possible infection due to lack of physician notification regarding wound care recommendations, continued use of unapproved home medications, and failure to obtain an infectious disease consultation. (Refer to A-0395) 2.b. The facility failed to ensure Nursing staff evaluated whether a PICC line (peripherally inserted central catheter, a long IV tube placed into a large vein for long-term medication or treatment) was still needed before one of 33 sampled patient (Patient 2) was discharged from the facility, with a PICC line, in accordance with the facility’s discharge planning process. This deficient practice had the potential to result in Patient 2 developing an infection and other serious complications, such as pain, swelling, or irritation at the insertion site, unnecessary exposure to invasive medical equipment, and a blood clot forming around the catheter. (Refer to A-0395) 3. The facility failed to ensure one of 33 sampled patient’s (Patient 12) pain level of 3 out of 10 (1-3, mild) and a pain level of 5 out of 10 (indicates moderate pain on the pain scale of 0-10), were properly addressed in the Emergency Department (ED), in accordance with the facility’s policy regarding pain management. Patient 12’s medical record did not indicate any pharmacological or non-pharmacological interventions when Patient 12 indicated being in pain on 3/23/2025 at 7:49 p.m. (pain score of 3/10) and at 9:29 p.m. (pain score of 5/10). This deficient practice had the potential for Patient 12 to suffer from worsening pain, psychological distress and/or delayed recovery from medical condition. (Refer to A-0395) 4. The facility failed to ensure nursing staff implemented fall preventions safety measures for one of 33 sampled patients (Patient 26), in accordance with the facility’s policy regarding falls prevention, when Patient 26’s bed alarm (a safety monitoring systems designed to alert healthcare staff when a patient at risk of falling to leave their bed) was not activated. This deficient practice could have contributed to Patient 26 experiencing a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) on 10/15/2025 and sustaining subdural hematoma (collection of blood between brain surface and its outer lining, usually caused by head trauma). (Refer to A-0395) 5. The facility failed to ensure that registered nursing staff developed and maintained a nursing care plan (a written nursing document that identifies a patient’s needs, risks, and the specific nursing actions required to keep the patient safe) for one of 33 sampled patients (Patient 2) that addressed required isolation precautions (steps used to prevent the spread of infection by separating the patient or using personal protective equipment) and infection-control needs (the actions and safeguards needed to prevent the spread of germs within the hospital), in accordance with the facility’s policy regarding care plans. This deficient practice had the potential to result in Patient 2 being cared for without the required isolation measures, staff being unaware of or not following essential infection-control steps, and an increased risk of transmitting infectious organisms (germs that can cause infections) to other patients, visitors, and staff. (Refer to A-0396) 6. The facility failed to ensure that vital signs (objective measurements of essential body functions, such as temperature, pulse, blood pressure, and respiration rate) for two of 33 sampled patients (Patient 1 and Patient 3), were assessed and reassessed, in accordance with the facility’s “Vital Signs” policy and procedures when: 6.a. Patient 1 had a physician order for vital signs assessment every hour that was not completed. This deficient practice had the potential to place Patient 1 at risk for unrecognized deterioration (worsening of condition) and may lead to a delay in treatment. (Refer to A-0398) 6.b. Patient 1 did not have vital signs taken after receiving fluid for sepsis (a life-threatening organ dysfunction caused by the body’s extreme response to infection) treatment, as required by the facility’s “Code Sepsis Checklist.” This deficient practice had the potential to delay recognition of Patient 1’s declining blood pressure (BP; the force of blood pushing against artery walls) and delay treatment, placing Patient 1’s health and safety at risk for an adverse outcome including death. (Refer to A-0398) 6.c. Patient 1 did not have temperature taken with every vital sign assessment. This deficient practice placed Patient 1 at risk for unrecognized severe sepsis (a critical stage of sepsis involving significant organ dysfunction), as temperature is one of the criteria used to determine whether a patient is experiencing sepsis. (Refer to A-0398) 6.d. Patient 3, who had a blood pressure (BP) of 183/105 (high blood pressure, adult normal BP systolic [top number]: below 120 mm Hg, and diastolic [bottom number]: below 80 mm Hg), was not reassessed. This deficient practice had the potential to delay recognition of Patient 3’s health deterioration and may lead to a delay in treatment resulting in patient harm and/or death. (Refer to A-0398) 7. The facility failed to ensure Nursing staff reassessed vital signs (VS; measurements of temperature [T], heart rate [HR], breathing rate [BR], blood pressure [BP]),and pain level, for one of 33 sampled patients (Patient 16) during two separate Emergency Department (ED; emergency care area of the hospital) visits on 12/26/2023 and 12/28/2023. The facility did not follow its own policy for vital-sign monitoring, when:\ 7.a. On 12/26/2023 (first ED visit), nursing staff did not obtain vital signs before discharging Patient 16 from the Emergency Department. This deficient practice had the potential to result in Patient 16 being discharged while unstable (with untreated changes in heart rate, breathing, blood pressure, or other symptoms that may have required further medical care), and placed Patient 16 at risk for worsening infection, uncontrolled pain, and continued or worsening tachycardia (elevated heart rate). (Refer to A-0398) 7.b. On 12/28/2023 (second ED visit), nursing staff did not re-assess vital signs (VS) during Patient 16’s visit in the Emergency Department (ED) and again a half hour prior to discharge. This deficient practice had the potential to result in Patient 16 being discharged while unstable, which could lead to delayed recognition of worsening symptoms, untreated medical conditions, and possible serious harm due to changes in heart rate, breathing, blood pressure, or pain that were not identified before the patient left the Emergency Department. (Refer to A-0398) 8. The facility failed to ensure Nursing staff adhered to the facility’s triage (a rapid, systematic process used in the emergency department [ED] to sort patients based on the severity of their condition, ensuring those with life-threatening issues are treated first, regardless of arrival order) policies and procedures for one of 33 sampled patients (Patient 16) to ensure appropriate use of the Emergency Severity Index (ESI) algorithm (a 5-level, flowchart-based triage algorithm used in emergency departments to rapidly categorize patients based on both acuity [stability] and predicted resource needs. It ranges from ESI 1 [most urgent/immediate life-saving intervention needed] to ESI 5 [least urgent/no resources needed]), resulting in the assignment of an incorrect acuity level. Patient 16 was assigned an ESI level 4 (meaning the patient was expected to need only one medical resource), despite presenting with symptoms that did not meet the criteria for this level 4. On a repeated visit (second ED visit on 12/28/2023; first ED visit was 12/26/2023) to the Emergency Department with worsening symptoms, Patient 16 presented with a heart rate of 145 beats per minute (normal adult range: 60-100 bpm, making 145 significantly elevated), and severe pain rated 9 out of 10 (indicating very strong, intense pain). These findings were inconsistent with an ESI level 4 classification and represented a higher-acuity presentation requiring a more urgent ESI assignment. This deficient practice potentially resulted in placing Patient 16 at risk for missed clinical deterioration (meaning the patient’s condition could worsen without being noticed in time) after Patient 16 was placed into the RTR (Rapid Treatment Room) area (an area where patients typically wait in chairs, receive minimal nursing oversight, and depend on providers to identify changes in condition) instead of the main area in the emergency department where Patient 16 would have been connected to a monitor, vital signs would be re-evaluated more frequently, and head-to-toe (a full physical assessment from head to feet) assessments would have been performed. (Refer to A-0398) 8. The facility failed to ensure that one of 33 sampled patients (Patient 2), who was identified as high risk for skin impairment, was encouraged to and/or turned and repositioned in bed, in accordance with the facility’s Skin Care Treatment protocol for patients at high risk for skin breakdown. This deficient practice had the potential to result in Patient 2 acquiring a pressure injury (defined as a localized injury to the skin and/or underlying soft tissue, typically over a bony prominence, as a result of sustained pressure or pressure in combination with shear). (Refer to A-0398) 9. The facility failed to ensure Nursing staff assessed one of 33 sampled patient’s (Patient 24) vital signs (temperature, pulse rate, blood pressure, respiratory rate and oxygen level) and pain level before being discharged from the Emergency Department (ED), in accordance with the facility’s policies and procedures (P&P) titled, “Vital Signs” and “Pain Management Plan.” This deficient practice could have led to continuing discomfort, pain, and an unsafe discharge for Patient 24. (Refer to A-0398) 10. The facility failed to ensure Licensed staff notified a physician/provider and a pharmacist regarding the critical laboratory value (result of a diagnostic test such as a blood sample) of Activated Partial Thromboplastin Time (aPTT/PTT, measures how many seconds it takes for blood to clot) for one of 33 sampled patients (Patient 6), who was receiving heparin (a fast acting “blood thinner” used to treat and prevent blood clots), in accordance with the facility’s policy and procedures regarding reporting of critical laboratory results. This deficient practice resulted in a 3-hour delay in adjusting Patient 6’s heparin dose which had the potential to place Patient 6 at high risk for bleeding. (Refer to A-0398) 11. The facility failed to ensure nursing staff reassessed one of 33 sampled patients (Patient 1) after administering intramuscular (IM, medication injected into a muscle) Morphine Sulfate (a strong pain-relief medication used to treat severe pain), as part of the multi-faceted medication administration process to allow for early identification of adverse effects and timely initiation of appropriate corrective action, in accordance with the facility’s “Medication Administration” policy and procedure. This deficient practice resulted in delayed recognition that Patient 1’s blood pressure dropped to 45/22 (severe low blood pressure; normal adult blood pressure is typically below 120 millimeters of mercury [mm Hg] systolic [top number] and below 80 mm Hg diastolic [bottom number]), which could lead to patient harm. (Refer to A-0405) 12. The facility failed to ensure nursing staff administered medication (a substance used to diagnose, treat, or prevent disease, or to relieve symptoms), as ordered by the physician or documented the reason for not administering prescribed blood pressure medication, for one of 33 sampled patients (Patient 3), in accordance with the facility’s policy regarding medication administration. This deficient practice had the potential to compromise timely management of elevated blood pressure and placed the patient (Patient 3) at risk for clinical deterioration (worsening of condition that could have been avoided with proper care). (Refer to A-0405) 13. The facility failed to ensure nursing staff adjusted one of 33 sampled patient’s (Patient 6) heparin dose (a fast acting “blood thinner” used to treat and prevent blood clots), as ordered by the pharmacist and in accordance with the facility’s policy and procedure regarding medication administration. This deficient practice resulted in Patient 6 receiving the wrong dose of heparin (a fast acting “blood thinner” used to treat and prevent blood clots), the potential for inappropriate heparin dose adjustments, and placed Patient 6 at increased risk of bleeding or developing blood clots. (Refer to A-0405) 14. The facility failed to ensure Nursing staff assessed the blood sugar levels every six (6) hours as ordered and administered insulin (a hormone that allows cells to take in glucose [sugar] from the blood stream for energy, thereby, lowers blood sugar levels) as ordered by the physician, for one of 33 sampled patients (Patient 9), in accordance with the physician’s order and the facility’s policy and procedure regarding medication administration. This deficient practice placed Patient 9 at risk of having uncontrolled blood sugar levels, which may cause harm to Patient 9. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 50594 Based on interview and record review, the facility failed to ensure that there was a follow-up attempt made to obtain one of 33 sampled patient’s (Patient 11) signature for the Condition of Admission form (COA, a formal contract between patient and hospital that outlines the patient’s rights, responsibilities, and consent to treatment), when Patient 11’s COA was initially marked “unable to sign due to condition,” on 10/12/2025, in accordance with the facility’s policy regarding COA. This deficient practice had the potential for Patient 11 to experience delays in non-emergency care, incur unintended financial liability, and not receive the information necessary to make an informed decision (a voluntary, collaborative process where the patient chooses a healthcare pathway after understanding the risks, benefits, alternatives, and costs, based on evidence-based information) regarding hospital admission and treatment. Findings: During a review of Patient 11’s “Inpatient Face Sheet (front page of the chart that contains a summary of basic information about the patient,” undated, the “Face sheet” indicated Patient 11 was admitted to the facility on 10/12/2025 for coffee ground emesis (vomiting). During a review of Patient 11’s “Wound Consultation Note,” dated 10/13/2025, the “Wound Consultation Note” indicated, Patient 11 was awake, alert, able to make needs known. During a concurrent interview and record review on 4/1/2026 at 9:58 a.m. with the Clinical Informatics Registered Nurse (CIRN) 2, Patient 11’s “Condition of Admission,” dated 10/12/2025, was reviewed. The COA form indicated “unable to sign (Patient 11) due to condition.” During a concurrent interview and record review on 4/2/2026 at 11:03 a.m. with the Director of Registration (DIR) 8, Patient 11’s “Condition of Admission (COA, a formal contract between patient and hospital that outlines the patient’s rights, responsibilities, and consent to treatment)” form, dated 10/12/2025, was reviewed. DIR 8 stated that the COA process required registration staff to visit the patient’s bedside. If the patient was altered (when a patient is not acting, thinking, or behaving like their normal selves) or otherwise unable to sign due to clinical condition, staff should attempt to have a family or legal representative sign the COA form. If no family was available, staff should conduct follow-up attempts, and the patient would remain on “the bucket list.” During an interview on 4/2/2026 at 11:23 a.m. with DIR 8, DIR 8 stated she (Dir 8) was unable to locate documentation showing any follow-up attempts made by staff to obtain Patient 11’s signature for the COA form during Patient 11’s hospitalization. Dir 8 said that staff should have followed up with Patient 11’s COA form signature. DIR 8 further stated that the COA form was important because the COA form notified Patient 11 about Patient 11’s treatment provision and insurance billing by the facility. During a concurrent interview and record review on 4/2/2026 at 2:32 p.m. with DIR 8, the facility’s policy and procedure (P&P) titled, “Condition of Admission,” dated 10/2024, was reviewed. DIR 8 stated that the COA form referred to a patient’s right to give consent for hospital treatment, and that it was the facility’s standard practice to follow up with the patient regarding the patient’s COA form signature. During a review of the facility’s policy and procedure (P&P) titled, “Condition of Admission,” last revised 10/2024, the P&P indicated, “All patients will sign a Condition of Admission from upon registering as a patient at [facility name] ...Every patient has a legal right to decide upon the medical treatment he/she is to be given. Therefore, every patient who is admitted to the hospital must sign a Condition of Admission form granting consent for hospital services prior to medical treatment except in the event of emergency ...If the patient cannot sign the Conditions of Admission and does not have legal representative, the staff member registering the patient should document under collection notes ...””

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 46238 Based on interviews and record reviews, the facility failed to ensure that patient rights (such as the right to receive safe care and the right to have care provided in a manner that protects the patient’s health and safety), were exercised and protected for one of 33 sampled patients (Patient 16), in accordance with the facility’s Patient Rights policy, when the facility discharged Patient 16 from the Emergency Department (ED), after Patient 16’s second ED visit on 12/28/2023, without ensuring that the patient (Patient 16) was clinically stable (meaning the patient’s condition was medically evaluated and determined not to pose an immediate risk of deterioration) and safe for discharge (meaning the patient was appropriately assessed, monitored, and determined to be at a condition where discharge would not place the patient at risk of harm). This deficient practice potentially resulted in a worsening of Patient 16’s medical condition after being discharged from the ED for the second time on 12/28/2023, culminating in a cardiac arrest (when the heart stops beating) within 72 hours following the second ED visit (Patient 16 was discharged on 12/28/2023 after a second ED visit on the same date; first ED visit was on 12/26/2023) and thus requiring a transfer of Patient 16 to a higher level of care (meaning a facility capable of providing more intensive, specialized treatment), in a critical condition (meaning the patient’s life was at risk and required urgent, intensive medical intervention), during the third ED visit on 12/31/2023. Findings: During a review of Patient 16’s History of Present Illness (HPI, a description of the patient’s current symptoms and how they developed), dated 12/26/2023 at 11:11 a.m., the record indicated that Patient 16 presented to the Emergency Department (ED) with complaints of body aches, abdominal pain, and headache for the past 11 days. Patient 16 reported being evaluated at an urgent care clinic (a walk-in medical facility that provides immediate, non-emergency care for illnesses and injuries requiring attention within 24-48 hours, usually when a primary care physician is unavailable) and was told that there was “some kind of abdominal infection,” for which antibiotics were prescribed (medications used to treat bacterial infections). The prescriptions listed were Cipro (ciprofloxacin: an antibiotic used to treat certain bacterial infections) and Doxycycline (an antibiotic used for a wide range of bacterial infections). During a review of Patient 16’s History of Present Illness (HPI), dated 12/26/2023 at 11:11 a.m., the HPI also indicated that Patient 16 reported head pain rated as 7 out of 10 (a pain scale used to measure the severity of pain, with 0 meaning no pain and 10 meaning the worst pain possible). Patient 16 denied having current abdominal pain and denied vaginal bleeding (any bleeding from the vagina that is not part of a normal menstrual cycle). During a concurrent interview and record review on 4/1/2026 at 11:30 a.m. with the Informatics Specialist (IS), Patient 16’s History of Present Illness (HPI), dated 12/26/2023, was reviewed. The record indicated that Patient 16 was diagnosed with a viral illness (an infection caused by a virus) and a headache (pain or discomfort in the head). The H&P also indicated that Patient 16 was “stable for discharge (meaning the patient was considered medically safe to leave the Emergency Department without the need for continued monitoring or treatment at that time).” The H&P further indicated that Patient 16 was instructed to return to the Emergency Department in two to three days for reassessment if needed. The IS confirmed that Patient 16 was discharged at 1:54 p.m. on 12/26/2023 (first ED discharge of Patient 16). During a concurrent interview and record review on 4/1/2026 at 11:30 a.m. with the Informatics Specialist (IS), the IS verified that Patient 16 had only one set of vital signs documented in triage (the initial rapid nursing assessment used to determine the patient’s acuity level [how sick a patient appears and how urgently they need care] based on the Emergency Severity Index [ESI, a system used to determine how urgent a patient’s condition is) at 11:17 a.m. on 12/26/2023. The IS also confirmed that Patient 16 did not have a recorded pain level reassessment or vital signs obtained within 30 minutes prior to discharge at 1:54 p.m. During a review of Patient 16’s History of Present Illness (HPI, a description of the patient’s current symptoms and how they developed), dated 12/28/2023, the HPI indicated that Patient 16 returned to the Emergency Department (ED), within 72 hours of the previous visit on 12/26/2023, for evaluation of dysuria (painful or difficult urination) for two days. The HPI also indicated that Patient 16 reported blood in the urine that started 12/28/2023, and blood in the stool that started the day prior (12/27/2023). The H&P indicated Patient 16 denied taking any pain medication at home. During a review of Patient 16’s Triage (the initial rapid nursing assessment used to determine the patient’s acuity level based on the Emergency Severity Index) record, dated 12/28/2023 (second ED visit) at 3:15 a.m., the triage record indicated that Patient 16 presented with the following symptoms: urinary urgency, urinary frequency, burning pain, and blood in the urine since “yesterday (12/27/2023).” The triage record also indicated that Patient 16’s vital signs were as follows: heart rate 145 (a significantly elevated heart rate indicating tachycardia [rapid heart rate]; normal is 60 to 100 beats per minute [bpm]), blood pressure 123/75 (normal), and a pain level of 9/10 (severe pain on the 0-10 pain scale, where 0 means no pain and 10 means the worst imaginable pain). The triage record indicated that Patient 16 was assigned an ESI 4 (a level indicating the patient requires one resource to determine disposition and is considered a lower acuity patient, meaning the patient is sick but not in danger and does not have severe or life-threatening symptoms). This review was conducted with the Informatics Specialist (IS) on 4/1/2026. During a review of Patient 16’s History of Present Illness (HPI), dated 12/28/2023 (second ED visit after initial discharge on 12/26/2023), the HPI indicated that the urine culture obtained during the visit on 12/26/2023 (first ED visit) showed no infection. The HPI also indicated an abnormal white blood cell (WBC) count (the number of white blood cells in the blood, used to detect infection or inflammation) of 12.2 (elevated; normal WBC range is generally 4.5-11.0, and elevated levels may indicate infection or inflammation; the WBC count was recorded as 12.4 in the laboratory results documented in the HPI dated 12/28/2023). The HPI further indicated that Patient 16 was re-evaluated by the ED physician, who documented that Patient 16 felt significantly improved after treatments provided in the Emergency Department and that Patient 16 “has been stable and vital signs were stable (meaning the patient’s blood pressure, heart rate, breathing rate, and temperature and pain levels were within acceptable limits).” The record also indicated that Patient 16’s final impression (the provider’s concluding diagnosis based on evaluation and test results) was urinary tract infection (UTI, an infection involving the urinary system, such as the bladder or urethra). During a concurrent interview and record review on 4/1/2026 at 11:30 a.m. with the Informatics Specialist (IS), Patient 16’s History of Present Illness (HPI) and Vital Signs (VS) records, both dated 12/28/2023 (second ED visit after the initial visit on 12/26/2023), were reviewed. The IS verified that Patient 16’s HPI contained no record of any treatment (medical interventions provided to a patient, such as medications, procedures, or supportive care) received in the Emergency Department, no medications administered, and no vital signs documented beyond the initial set (taken at triage on 12/28/2023 at 3:15 a.m.). The IS also confirmed that no reevaluation of pain level and no additional vital signs were recorded in Patient 16’s HPI or Vital Signs records, prior to Patient 16’s departure from the ED on 12/28/2023 at 8:18 a.m. (Patient 16 remained in the ED for 5 hours and 3 minutes during the second ED visit on 12/28/2023). During an interview on 4/1/2026 at 2:26 p.m. with the Director of the Emergency Department (DIR 5), DIR 5 stated that since Patient 16 was a pediatric patient (a child or adolescent who is under 18 years old and receives medical care in the pediatric age group), the pain level of 9/10 (severe pain) and heart rate of 145 beats per minute (bpm) should have been followed up on and reevaluated before discharge. DIR 5 confirmed that the discharging nurse should have taken vital signs prior to the discharge of Patient 16 on 12/28/2023 (second ED visit). During an interview on 4/2/2026 at 10:31 a.m. with the ED Charge Nurse (RN 14), RN 14 stated that patients with ESI 4 and 5 were typically seen in the fast-track area, also referred to as the rapid treatment rooms (RTR). RN 14 further explained that patients with ESI 3 could also be seen in the fast-track area if their vital signs were stable. RN 14 verified that all vital signs and patient-condition re-evaluations in the RTR were completed either by the registered nurses (RNs) or licensed vocational nurses (LVNs) assigned to the area. RN 14 stated that for patients with ESI levels 4 and 5, the provider’s (physician) assessment was sufficient to cover the patient assessment. RN 14 also stated that vital signs were obtained within one hour prior to discharge. During the same interview on 4/2/2026 at 10:31 a.m. with the Charge Nurse (RN 14), RN 14 stated that “even though triage assessment may be very subjective (meaning it is based on the patient’s symptoms as the patient describes them and, on the nurse’s clinical judgment), we still have to follow the algorithm (a step-by-step set of instructions or a guided pathway that helps someone decide what to do next) for triage per our triage policy.” During an interview on 4/2/2026 at 10:49 a.m. with the ED Charge Nurse (RN 14), RN 14 stated that patients’ vital signs, including pain level, should be reevaluated one hour before discharge to make sure the patient was stable for discharge (meaning the patient’s condition was safe and steady enough to leave the Emergency Department without needing further immediate medical care). During a concurrent interview and record review on 4/2/2026 at 11:14 a.m. with charge nurse (RN 14), Patient 16’s triage assessment documentation, dated 12/28/2023, was reviewed. The triage record indicated that Patient 16 was assigned an ESI level of 4 (meaning the patient was expected to need only one medical resource, such a blood test or a diagnostic procedure, and was considered stable). RN 14 said that she (RN 14) would have given Patient 16 an ESI of 3 (meaning the patient was expected to need two or more resources, which places the patient at a higher acuity [how sick a patient appears and how urgently they need care] level), due to the increased heart rate of 145 bpm and severe pain rated 9/10. RN 14 said, considering this was her (Patient 16) repeat visit with worsening symptoms, she (RN 14) would expect more resources to be pulled for this patient (Patient 16), thus the need for a higher ESI (meaning the patient would be triaged at a more urgent level because the patient’s condition required more testing, treatment, and monitoring). During an interview on 4/2/2026 at 11:51 a.m. with charge nurse(RN 14), RN 14 said, “There is an algorithm (a precise, step-by-step set of instructions or rules followed) that triage nurses use to reference the acuity (how sick a patient appears and how urgently they need care), and the ESI level can always change (meaning the patient can be reassigned to a higher or lower level depending on their condition and the number of medical resources they are likely to need).” RN 14 also said, “Clinical indicators suggested she (Patient 16) needed a higher acuity level (meaning the patient showed signs of being sicker and needing more urgent attention), and me (RN 14) as a nurse ... from the medical standpoint, I cannot say if she (Patient 16) was medically stable to be discharged, but from the nursing standpoint, I would advocate for this patient (Patient 16), based on the labs (laboratory results/blood work) and what the physician’s assistant has written in the HPI ...” During an interview on 4/2/2026 at 3:21 p.m. with the Director of the Emergency Department (MD 11), MD 11 stated that Physician Assistants (PAs) were able to make their own clinical decisions without consulting a physician, and there was no requirement for them to obtain a physician’s approval before managing a case. MD 11 explained that every PA note was co-signed by a supervising Emergency Department physician who was working the same day, and the co-signature should be completed within 72 hours. MD 11 stated, “If the ED physician disagrees with the note, we notify the PAs and tell them we disagree.” During a review of Patient 16’s History of Present Illness (HPI) attestations for 12/26/2023 and 12/28/2023, the HPI records on both ED visits indicated that both HPIs were signed by the supervising physicians. The HPI records indicated that the supervising physicians signed the attestations for each Patient 16’s visit on 12/26/2023 and 12/28/2023 (co-signing means that a supervising physician reviews the PA’s documentation and then signs it to show that the physician has looked at the note, agrees with the assessment, or has discussed any corrections with the PA). During a concurrent interview and record review on 4/3/2026 at 10:11 a.m. with the ED registered nurse (RN 13), Patient 16’s triage record, dated 12/28/2023, was reviewed. RN 13 said that based on the presenting symptoms (on 12/28/2023, second ED visit of Patient 16) of tachycardia (heart rate of 145 beats per minute; faster than the normal 60-100 bpm), severe abdominal pain rated 9/10, and suspicion of infection (urinary urgency, urinary frequency, burning pain, and blood in the urine), the ED physician should have been notified. RN 13 said, “Based on these criteria, the ESI cannot be 4.” RN 13 said she (RN 13) would have probably given Patient 16 an ESI of 2, saying that Patient 16 should have been sent to the main area for close monitoring. During the same interview on 4/3/2026 at 10:11 a.m. with the ED registered nurse (charge nurse, RN 13), a step-by-step, ESI-algorithm-based analysis, was applied to Patient 16’s presenting symptoms in triage and was reviewed. RN 13 stated that when the Emergency Severity Index (ESI) algorithm was applied directly to Patient 16’s symptoms and vital signs (during the second visit on 12/28/2023), the patient (Patient 16) did not meet the criteria for ESI 4 at any point. RN 13 confirmed that Patient 16 presented with worsening symptoms after a recent visit (a high-risk situation), severe pain rated 9/10, an abnormal heart rate of 145 beats per minute, and possible signs of infection, which together would have potentially met the criteria for ESI Level 2 instead of the documented ESI 4. During an interview on 4/3/2026 at 11:42 a.m. with the medical doctor (MD 12) regarding the criteria for sepsis, MD 12 said, “Timing is important in a sepsis protocol because it saves lives (meaning that sepsis is a life-threatening condition caused by the body’s extreme reaction to infection, and acting quickly helps prevent organs from failing and keeps the patient alive).” During an interview on 4/3/2026 at 11:42 a.m. with the medical doctor (MD 12), regarding the pediatric sepsis screening in the Emergency Department (ED), MD 12 said, “Sepsis protocol applies to adults only. There is no pediatric sepsis tool or protocol, and we do not screen for sepsis in the pediatric population (meaning the hospital does not have a specific checklist or guideline for identifying sepsis in children, even though children can also develop sepsis).” MD 12 also said the following: -MD 12 stated that with tachycardia (a fast heart rate; the child’s heart rate was 145 beats per minute) and elevated WBC (white blood cells; high levels can mean the body is fighting an infection), Patient 16 could qualify for sepsis (could meet early signs that suggest infection might be spreading in the body). However, this was the physician’s decision and call. -MD 12 said, “I would not follow the sepsis bundle (a sepsis bundle is a set of time?sensitive steps such as giving fluids, antibiotics, and checking labs quickly) ...” “but I would still order blood cultures (a test where blood is collected to see if bacteria or germs are present in the bloodstream, which helps identify the infection source) ...” “and would investigate further.” -MD 12 said, “I would also want the vital signs to be repeated (to re-check) to see the heart rate and the temperature, if I was worried about infection. (Repeating vital signs means checking them again to see if the child (Patient 16) is getting better or worse).” -MD 12 added, “I would also not expect the UTI to affect the Hgb (hemoglobin; the part of blood that carries oxygen, typically a urinary tract infection does not lower hemoglobin) ...” “but maybe the patient (Patient 16) received a lot of fluids. (Giving a large amount of IV fluids can dilute the blood and temporarily lower the hemoglobin number).” -MD 12 stated, “Dropping platelets could be due to infection ... yes ... (Low platelets can occur when the body is fighting a serious infection).” -MD 12 concluded, “And I would definitely want to see re-evaluated vital signs before discharge. (Meaning the child’s [Patient 16] heart rate, temperature, breathing, and blood pressure should be checked again to make sure the child is stable enough to go home).” During an interview on 4/3/2026 at 2:00 p.m. with the physician’s assistant (PA 1), PA 1 said, “Physician’s assistants can evaluate, diagnose, and treat patients; we order labs, make clinical decisions, and make diagnoses. Our scope is determined at the practice level, but we predominantly work in the rapid treatment area (RTR). PAs typically work under the general supervision of ED physicians who are working the same shift, and supervising physicians are required to review the PA’s charts for the day and co-sign them to indicate supervision.” During the same interview on 4/3/2026 at 2:00 p.m. with the physician’s assistant (PA 1), PA 1 said, “The triage nurse does the initial assessment, including the vital signs, and assigns the ESI level. The ESI level assigned by the triage nurse is not typically reviewed by the PAs. If a PA believes the patient is too sick for the Rapid Treatment Room (RTR), which is usually based on a combination of critical findings, such as abnormal laboratory values, the patient’s physical presentation, or abnormal vital signs-the patient can be moved to the main Emergency Department (ED) area for more frequent monitoring. Discharge disposition is determined based on the patient’s vital signs, imaging results, lab results, and overall clinical assessment. For a pediatric patient (such as Patient 16) with a heart rate of 145 beats per minute, I consider that abnormal and would want to recheck it before discharge.” During an interview on 4/3/2026 at 2:00 p.m. with the physician’s assistant (PA 1), regarding screening and identifying pediatric sepsis (a severe, body-wide response to infection in children that can lead to organ failure if not recognized and treated quickly), PA 1 said that physician assistants did not expect nurses to activate a code sepsis for pediatric patients because sepsis criteria applied to adults 18 years and older due to differences in pediatric vital signs and the wide variation in normal ranges for children based on age, weight, and developmental stage. PA 1 added that in pediatric patients (such as Patient 16), the evaluation relies more on the overall clinical picture rather than strict adult sepsis criteria clinical signs and symptoms used to identify possible sepsis in adults. During the same interview on 4/3/2026 at 2:00 p.m. with the physician’s assistant (PA 1), PA 1 further explained that if abnormal laboratory findings were noted, such as dropping platelets (platelets are blood cells that help with clotting; a low level may suggest infection or inflammation,), dropping hemoglobin (hemoglobin is the protein in red blood cells that carries oxygen; low hemoglobin can indicate bleeding or worsening illness), and increasing white blood cell count (white blood cells fight infection; a high level may indicate infection or inflammation), in combination with abnormal vital signs, it would warrant the need to “continue investigation (meaning the provider must keep evaluating the patient, repeat vital signs, order further tests, and reassess to determine whether the patient may be developing a serious infection or sepsis).” During a review of Patient 16’s HPI, dated 12/31/2023 (third ED visit of Patient 16 after the second ED discharge on 12/28/2023), the HPI indicated that Patient 16 was brought into the emergency department (for a third ED visit) after an unwitnessed cardiac arrest (meaning the heart suddenly stopped beating and no one saw it happen, so the exact cause or timing was unknown). The HPI also indicated that Patient 16’s impression was acute thrombocytopenia (a sudden drop in the number of platelets, which are blood cells that help with clotting), UTI (urinary tract infection; an infection in the bladder or urinary system), colitis, and possible colon perforation (a hole or tear in the colon) versus pneumatosis intestinalis (air trapped in the wall of the intestines). The record indicated Patient 16 was transferred to a children’s hospital for higher level of care (meaning the patient needed more specialized treatment than the current hospital could provide) in a critical condition (meaning the patient’s life was at risk and required immediate, intensive medical care). During an interview on 4/3/2026 at 4:03 p.m. with the Chief Nursing Officer (CNO), the CNO confirmed that there was no peer review completed for this case involving Patient 16 (Peer review means a formal process in which a patient case is evaluated by a group of physicians to determine whether the care provided met the expected medical standards. It is a quality-assurance activity used to identify possible issues in clinical judgment, communication, or treatment). During the same interview on 4/3/2026 at 4:03 p.m. with the Chief Nursing Officer (CNO), the CNO explained that the case involving Patient 16 was only reviewed by the Emergency Department chair because Patient 16 returned to the Emergency Department within 72 hours after discharge (second ED discharge was 12/28/2023), which was considered a trigger for closer review (Patient 16 was brought back to the ED for the third time on 12/31/2023 after suffering a cardiac arrest at home following the second ED discharge on 12/28/2023). However, the CNO stated that the case was never referred for peer review, meaning it was not forwarded into the formal physician review process that evaluated whether the care provided to Patient 16, met professional standards. The CNO reported that although the ED chair verbally confirmed that this case involving Patient 16, was reviewed, no documentation, minutes, or written evaluation were provided to the surveyor to show that such a review by the ED chair occurred. During an interview on 4/3/2026 at 4:31 p.m. with the Chief Nursing Officer (CNO), the CNO stated that in March 2025, the facility began a project to increase nursing awareness and education on the importance of re-assessing pediatric patients, especially in obtaining repeat vital signs before discharge. The CNO explained that this project was created because children’s conditions could change quickly, and repeat vital signs helped determine whether a child was clinically stable and safe to go home. The CNO also stated that the facility’s Emergency Department was designated as EDAP (Emergency Department Approved for Pediatrics, means the Emergency Department has been formally approved to care for children and must meet strict pediatric standards, such as having the right pediatric equipment, having trained staff, and following policies designed specifically for treating children safely). The CNO further stated that audits had been ongoing to make sure nurses were complying with the requirement to obtain vital signs in pediatric patients, including repeat vital signs prior to discharge, as part of ensuring pediatric safety and meeting EDAP expectations. During a review of the facility’s EDAP standards (EDAP stands for Emergency Department Approved for Pediatrics; it is a program that sets requirements for hospitals to safely care for children in the emergency department) titled “Standards for Care of Children in the Emergency Department (these standards establish and maintain the rules for designating Emergency Departments Approved for Pediatrics),” last revised 7/2025, the EDAP indicated that the facility’s ER was a licensed basic or comprehensive emergency department that was designated to receive and treat pediatric patients. The standards required the facility to meet specific criteria for professional staff, quality improvement, education, support services, equipment, supplies, medications, and established policies and procedures. The EDAP also indicated that the hospital must develop and maintain, at minimum, policies and procedures related to emergency department care of children. Pediatric assessment and reassessment should include identifying abnormal vital signs according to the patient’s age. If abnormal vital signs are found, there must be a plan or process to notify the physician. During a review of the facility’s policy and procedure (P&P) titled “Vital Signs,” dated 9/2020, the policy indicated the following: “All persons presenting to the Emergency Department will have their vital signs (T, P, R, BP, and Pain level) assessed during triage, and again as appropriate during their Emergency Department stay. All patients will have their vital signs reassessed within one-half hour of discharge or transfer from the Emergency Department. Vital signs will be done every four hours, or more frequently based on ESI acuity (ESI acuity: the Emergency Severity Index level that shows how urgent a patient’s condition is). Vital signs must be completed within one-half hour of discharge.” During a review of the facility’s policy and procedure (P&P) titled “General Medical Staff Rules and Regulations,” last revised 3/17/2023, the document indicated that “Each entry should clearly and accurately record the care provided during that visit (episode of care). The history of the present illness and the review of body systems must be checked and corrected (edited) to make sure the documentation is accurate. Emergency Department Medical Records must include: c. Important information (pertinent history) about the injury or illness, including any first aid or emergency care the patient received before arriving at the hospital; d. A description of important medical findings, including lab results and imaging results (roentgenologic findings, such as X?rays); e. The diagnosis; f. The treatment provided, including any medications and doses the patient received before arriving at the Emergency Department and medications given in the Emergency Department; g. The patient’s condition at the time of discharge or transfer.” During a review of the facility’s policy and procedure (P&P) titled “Triage,” dated 10/2018, the P&P indicated that, “The emergency department (ED) will triage all patients as rapidly as possible to determine the patient’s need for emergent treatment and give an acuity level based on the Emergency Severity Index (ESI). Patients will be treated based upon the assigned triage level based on ESI 1-emergent to 5 - non-emergent. Triage will prioritize urgency of need for care ... re-assess patients waiting every two hours (or more frequently) to assure the assigned triage level has not changed. Should a patient’s condition deteriorate, a bed will be made available for immediate treatment ...” During a review of the facility’s emergency severity algorithm with elaboration on the criteria for each decision point (the algorithm assumes the user has significant clinical knowledge to identify physiologic instability, anticipate resource needs, and determine risk for deterioration), the record indicated the following: “The ESI Triage Algorithm is a flowchart used by triage nurses to determine how urgently a patient needs care. It sorts patients using five levels: ESI 1 - Immediate life?saving intervention needed. ESI 2 - High?risk situation, severe pain, confusion, or distress. ESI 3 - Will require two or more resources (labs, imaging, IV meds, etc.). ESI 4 - Requires one resource. ESI 5 - No resources required.” During a review of the facility’s policy and procedure (P&P) titled “Assessment and Re-assessment,” dated 1/2023, the policy indicated that the policy applied to the entire hospital; defined a physical assessment as the nursing check of a patient’s physical condition, including areas such as the brain and nerves (neurological), heart and blood vessels (cardiovascular), lungs (respiratory), stomach and intestines (gastrointestinal), kidneys and bladder (genitourinary), muscles and bones (musculoskeletal), skin, emotional and mental status (psychosocial), and any tubes or lines in the body (invasive lines); and required that all patients be physically assessed by a registered nurse according to the attached grids, with documentation completed before the end of the shift. The policy did not include specific assessment and re-assessment requirements for the Emergency Department. During a review of the facility’s policy and procedure (P&P) titled “Patient Rights and Responsibilities,” dated 3/2023, the P&P indicated that “Certain patient rights, which protect a patient’s ability to make their own decisions (self-determination), are required by state and federal laws.””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to report a reportable adverse event (events that are mandatory to report to state or federal authorities to ensure patient safety, enable investigation, and prevent recurrence. Example: sexual assault on a patient) for one of 33 sampled patients (Patient 27) to the state regulatory agency, within 24 hours, in accordance with state Health and Safety Code (laws designed to protect public welfare by enforcing standards) Section 1279.1 (b) (defines the specific types of “adverse events” that licensed health facilities [such as hospitals] must report to the California Department of Public Health [CDPH, a regulatory agency]. These are serious, largely preventable incidents that result in death or serious disability to a patient), when Patient 27 reported an alleged sexual assault (when someone either touches another person in a sexual manner without consent [agreement] or makes another person touch them in a sexual manner without consent) to the facility on 2/26/2026. Patient 27 alleged that a nurse (HD 1) grabbed Patient 27’s left breast during a hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) treatment session at the hospital on 2/25/2026. Patient 27 reported the sexual allegation to the facility on 2/26/2026, but the facility did not report to the state department of public health until 3/20/2026. The deficient practice had the potential to result in a delay of an independent investigation by the state department of public health and potentially putting Patient 27 and other patients at risk for further abuse or harassment. Findings: During a review of Patient 27’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/22/2026, the “H&P” indicated, Patient 27 was admitted to the facility with diagnoses including but not limited to left hip fracture (broken bone) status post fall, end stage renal disease (ESRD, a stage where the kidneys can no longer support the body’s needs for waste removal and fluid balance) requiring hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly), diabetes (high blood sugar) and congestive heart failure (CHF, a chronic condition in which a weakness of the heart leads to a buildup of fluid in the lungs). During an interview on 4/1/2026 at 1:49 p.m. with Patient 27, Patient 27 stated that on 2/25/2026, after Patient 27’s hemodialysis treatment, was completed, the hemodialysis nurse (HD 1) reached down Patient 27’s tank top, grabbed her (Patient 27’s) right breast and squeezed it. Patient 27 further stated HD 1 did not explain why he (HD 1) touched her (Patient 27). Patient 27 further stated she (Patient 27) was in shock. Patient 27 stated she (Patient 27) reported to the Registered Nurse (RN 26) on 2/26/2026 before going home. During an interview on 4/1/2026 at 3 p.m. with the Corporate Director of Risk Management (RISK 1), RISK 1 stated the Risk Management Department received Patient 27’s alleged sexual assault (when someone either touches another person in a sexual manner without consent [agreement] or makes another person touch them in a sexual manner without consent) report on 2/26/2026. An internal investigation was conducted but was unable to substantiate the allegation of sexual assault. RISK 1 also said that the facility reported the alleged sexual assault to the state department of public health on 3/23/2026. During a review of the facility’s self-report letter issued to the state department of public health, dated 3/23/2026, the letter indicated, the facility reported Patient 27’s alleged sexual assault to the state department of public health on 3/23/2026. The letter also indicated, the incident was categorized as “26. The sexual assault of a patient within or on the grounds of a health facility.” During a concurrent interview and record review on 4/1/2026 at 3:16 p.m. with the Corporate Director of Risk Management (RISK 1), the facility’s policy and procedure (P&P) titled, “Reporting Adverse Events to [state] Department of Public Health,” dated 9/2025, was reviewed. The P&P indicated, “Any adverse event that causes death or serious disability of patients, personnel or visitors will be reported to the local office of [state] Department of Public Health within five days after the event has been detected. Declarations ... B. Specific adverse events that require reporting include any of the following ... sexual assault of patient ... Procedure ... All adverse events identified by staff will be promptly reported to the department director/supervisor and to Risk Management ... Reporting of the adverse event will be coordinated by the Chief Nursing and Clinical Executive (CNCE) or Administrator on-call at the time the event is detected or the Chief Compliance Officer or their designees. The event will be reported to [county] department of public health.” RISK 1 stated the facility was late on reporting the allegation of sexual assault to the [state] Department of Public Health. During a concurrent interview and record review on 4/1/2026 at 3:20 p.m. with RISK 1, the [state] regulation titled, “Code of Regulations: 22 CCR § 70972. Adverse Event Reporting Requirements.,” dated 1/2022, was reviewed. The [state] regulation indicated, “(a) Pursuant to Health and Safety Code sections 1279.1 and 1279.3, adverse events shall be reported by the hospital through a secure internet website maintained by the Department pursuant to the following timelines ... (2) Sexual assault of a patient, including allegations of sexual assault of a patient, provided for under Health and Safety Code section 1279.1(b)(6)(C), shall be reported within 24 hours after detection.” RISK 1 stated the definition of sexual assault was unclear and the facility wanted to perform the internal investigation first before confirming the allegation hence delayed the reporting. RISK 1 stated the facility was late on reporting the allegation of sexual assault to the [state] Department of Public Health. During an interview on 4/2/2026 at 11:52 a.m. with the Chief Nursing and Clinical Executive (CNCE), CNCE stated that alleged sexual allegation should be reported to the [state] department of public health so the regulatory agency could conduct its own investigation.”

“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: 50516 Based on observation, interview and record review, the facility failed to: 1. Ensure appropriate monitoring for one of 33 sampled patient’s (Patient 23) blood pressure (BP, amount of force used to move blood through the body, with a normal range of 90-120) result, when Patient 23’s Systolic blood pressure (SBP, systolic measures pressure when heart contracts) was in the 80s (normal SBP is between 90-120), and there was no rechecking/reassessment done by nursing staff from 12:17 a.m. to 3:17 a.m., and from 8:59 a.m. to 8:45 p.m. on 1/5/2026, in accordance with the facility’s policy regarding patient assessment/evaluation and reassessment. This deficient practice had the potential for Patient 23 to experience severe change of condition that is undetected due to lack of reassessment, which could lead to fatal consequences such as organ damage/failure and/or death. 2.a. Ensure Nursing staff evaluated one of 33 sampled patient’s (Patient 2) wound care needs, in accordance with the facility’s policy regarding wound care, physician notification, and treatment plan, when the nursing staff did not follow-up with the attending physician regarding the Wound Care Nurse’s recommendations for Infectious Disease consultation and wound-care treatment for Patient 2’s perineum (the area of skin between the genitals and the rectum). In addition, the nursing staff did not obtain a physician’s order prior to continuing Patient 2’s use of a home medication (Boudreaux’s Butt Paste, an over-the-counter skin-protectant cream). This deficient practice had the potential to result in worsening perineal wounds for Patient 2 and delayed diagnosis and treatment of a possible infection due to lack of physician notification regarding wound care recommendations, continued use of unapproved home medications, and failure to obtain an infectious disease consultation. 2.b. Ensure Nursing staff evaluated whether a PICC line (peripherally inserted central catheter, a long IV tube placed into a large vein for long-term medication or treatment) was still needed before one of 33 sampled patient (Patient 2) was discharged from the facility, with a PICC line, in accordance with the facility’s discharge planning process. This deficient practice had the potential to result in Patient 2 developing an infection and other serious complications, such as pain, swelling, or irritation at the insertion site, unnecessary exposure to invasive medical equipment, and a blood clot forming around the catheter. 3. Ensure one of 33 sampled patient’s (Patient 12) pain level of 3 out of 10 (1-3, mild) and a pain level of 5 out of 10 (indicates moderate pain on the pain scale of 0-10), were properly addressed in the Emergency Department (ED), in accordance with the facility’s policy regarding pain management. Patient 12’s medical record did not indicate any pharmacological or non-pharmacological interventions when Patient 12 indicated being in pain on 3/23/2025 at 7:49 p.m. (pain score of 3/10) and at 9:29 p.m. (pain score of 5/10). This deficient practice had the potential for Patient 12 to suffer from worsening pain, psychological distress and/or delayed recovery from medical condition. 4. Ensure nursing staff implemented fall preventions safety measures for one of 33 sampled patients (Patient 26), in accordance with the facility’s policy regarding falls prevention, when Patient 26’s bed alarm (a safety monitoring systems designed to alert healthcare staff when a patient at risk of falling to leave their bed) was not activated. This deficient practice could have contributed to Patient 26 experiencing a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) on 10/15/2025 and sustaining subdural hematoma (collection of blood between brain surface and its outer lining, usually caused by head trauma). Findings: 1. During a review of Patient 23’s “OB/GYN (focusing on women’s reproductive health, combining care for pregnancy/childbirth [obstetrics] with general health of the female reproductive system [gynecology]) Operative Report,” dated 1/4/2026, the report indicated Patient 23 had a vacuum assisted vaginal delivery (a procedure used during the final stage of labor to help guide the baby out of the birth canal. A soft suction cup is placed on the baby’s head, and the doctor gently pulls while the patient push) and delivered a baby girl at 4:10 p.m. During a review of Patient 23’s “Vital Signs” record, dated 1/5/2026, the record indicated the following vital signs (temperature, pulse/heart rate, blood pressure [BP], respiratory rate [RR, number of breaths per minute], oxygen level): -At 12:17 a.m., 97.8 Fahrenheit (F, a unit of temperature measurement), 98 beats per minute (bpm) pulse, 79/41 BP (low; normal is 120/90 millimeters of mercury [mmHg- a unit of measurement]), 16 RR, 97 Oxygen saturation (O2 sat, indicates the amount of oxygen in the blood) -At 3:17 a.m., 97.8 F, pulse 75, 84/46 BP (low), 16 RR, 97 O2 sat (two hours later) -At 3:35 a.m., 97.4 F, pulse 73, 82/47 BP, 16 RR, 97 O2 sat ; -At 5:48 a.m., 97.4 F, pulse 63, 92/49 BP, 16 RR, 97 O2 sat; -At 6:06 a.m., 97.4 F, pulse 63, 92/49 BP, 16 RR, 97 O2 sat; -At 6:26 a.m., 97.4 F, pulse 62, 90/42 BP, 16 RR, 97 O2 sat; -At 8:00 a.m., 98.0 F, pulse 76, 81/45 BP, 16 RR, 100 O2 sat; -At 8:59 a.m., 97.7 F, pulse 76, 88/47 BP, 16 RR, 97 O2 sat; -At 8:45 p.m., 97.8 F, pulse 80, 82/41 BP, 16 RR, 97 O2 sat; (12 hours after the last blood pressure check taken at 8 a.m.) -At 10:30 p.m., pulse 89, 96/43 BP During a concurrent interview and record review on 4/6/2026 at 11:10 a.m. with Registered Nurse (RN) 19, Patient 23’s “Vital Signs,” dated 1/5/2026, were reviewed. RN 19 stated there should have been another vital signs check between midnight and at 3:00 a.m. (on 1/5/2026) because Patient 23’s BP was low (Systolic Blood Pressure [SBP, maximum pressure in the arteries when heart contracts] was in the 80’s). RN 19 stated the BP (of Patient 23) could have dropped further, requiring a rapid response (a process for working with rapidly declining patients to improve patient safety). RN 19 stated she (RN 19) would have re-checked Patient 23’s BP at least 30 minutes (min) after the low BP reading which registered 79/41 mmHg at 12:17 a.m. on 1/5/2026 (The next vital signs check documented was at 3:17 a.m.). During a concurrent interview and record review on 4/6/2026 at 2:50 p.m. with the Manager of Mother and Baby unit (MA 3), Patient 23’s “Vital Signs,” dated 1/5/2026, were reviewed. MA 3 acknowledged Patient 23’s SBP was in the 80s, and noted the times from 12:17 a.m. to 3:17 a.m., and from 8:59 a.m. to 8:45 p.m. in which Patient 23’s SBP were in the low 80’s. MA 3 stated that nurses were expected to recheck the patient’s (Patient 23) BP within 30 minutes (from the initial reading taken at 12:17 a.m. on 1/5/2026) and monitor if Patient 23’s BP was trending (looking at the pattern or direction of multiple readings over time rather than relying on a single “snapshot” measurement). During a review of the facility’s policy and procedure (P&P) titled, “Standards of Patient Care and Nursing Practice: Postpartum Women,” dated 8/2025, the P&P indicated, “All women admitted to the mother/baby unit will have the following safety/equipment and basic care interventions provided from admission to transfer or discharge ...Documentation of the initial postpartum assessment will be completed by a RN and documented within two hours of transfer. Reassessment will be completed every 12 hours or more frequently as condition warrants. 2. Measurement of vital signs.” During a review of the facility’s policy and procedure (P&P) titled, “Plan for Nursing Care,” dated 5/2023, the P&P indicated, “A RN has the responsibility and accountability for planning the care of the patient including all functions within the scope of practice: patient assessment, nursing diagnosis, planning, intervention, evaluation and education ...The RN is responsible and accountable for the quality of care administered during their shift within their scope of practice. The assessment, planning implementation, and reevaluation of each patient are provided by an RN. Care, treatment and rehabilitation are planned to ensure that they are appropriate to patient needs, severity of disease, condition, impairment, disability, and age.” 2.a. During a review of Patient 2’s History and Physical (H&P, a medical document that records the patient’s current condition and past medical history), dated 10/18/2024, the H&P indicated that Patient 2 was transferred from another acute hospital (a hospital that provides short?term care for serious or emergency medical conditions) with a diagnosis of HLH (Hemophagocytic Lymphohistiocytosis, a rare and severe illness where the immune system becomes overactive and attacks the body) s/p (status post, “after”) chemotherapy (a type of cancer treatment that uses powerful drugs to destroy cancer cells by stopping them from growing, dividing, and spreading). The H&P also indicated that Patient 2 continued complaining of weakness and inability to walk. During a concurrent interview and record review on 4/3/2026 at 2:35 a.m. with the clinical informatics registered nurse (CIRN 3), Patient 2’s admission assessment record, dated 10/17/2024, was reviewed. The record also indicated that Patient 2 had multiple moisture-associated skin-damage wounds (MASD) and generalized skin peeling from chemotherapy. The record indicated that Patient 2 presented her own skin cream, called Boudreaux’s paste (Boudreaux’s Butt Paste, an over-the-counter skin-protectant cream made with zinc oxide, a mineral commonly used to protect irritated skin, reduce redness, and help heal rashes. It creates a barrier on the skin to keep moisture away and soothe damaged or sensitive areas). CIRN 3 verified that there was no physician order for the patient (Patient 2) to use her (Patient 2) own skin cream (Boudreaux’s Butt Paste). During a concurrent interview and record review on 4/6/2026 at 9:41 a.m. with the Quality Nurse (QRM 1), Patient 2’s “Wound Protocol for Dermatitis/Excoriation (dermatitis means irritated or inflamed skin; excoriation means skin that has been scratched or rubbed until it is raw)” order, dated 10/18/2024, was reviewed. The Wound protocol indicated to apply protective skin ointment (zinc oxide, menthol, calamine) daily and as needed as ordered by the MD. QRM 1 said this was a wound care protocol that nurses could reference and that the protocol did not require a physician order because zinc oxide was available from the facility’s stock. QRM 1 also said that according to nursing documentation from 10/18/2024 through 10/24/2024, nursing staff continued documenting that they were applying the patient’s (Patient 2’s) own cream brought from home (Boudreaux’s cream). QRM 1 said she (QRM 1) was not familiar with this cream and stated that when a patient brought a home medication, nurses were required to obtain a physician order to use it. However, there was no physician order regarding the use of Boudreaux’s cream in Patient 2’s record. During a review of Patient 2’s “Patient Notes,” dated 10/24/2024, the note indicated the following: “Patient’s (Patient 2’s) daughter called the charge nurse to the room to express her frustration that a wound care nurse had not yet seen the patient. The charge nurse assessed the patient’s wounds, and a call was then placed to the wound care nurse ...” During a review of Patient 2’s Wound Consultation Note, dated 10/24/2024, the note indicated that Patient 2 told the WCN, “the wound (perinium) has gotten worse in the last several days and the cream was not helping. Patient (Patient 2) also applied ‘Carpe No Sweat powder’ to skin folds with no improvement.” The note also indicated the following: “Perineum full-thickness wound (a wound where all layers of the skin are lost, exposing deeper tissue), multiple eroded painful lesions with yellow tissue, wound edges irregular, periwound erythematous (red), edematous (swollen), and tender to touch.” The note indicated “recommendations to consult Infectious Disease (ID) for additional recommendations, and that the plan was discussed with the nurse.” During a review of Patient 2’s physician orders, dated 10/24/2024 through 11/5/2024, the record showed there were no orders for wound-care treatment of the perineum. The absence of wound-care orders was reviewed and verified with the Quality Nurse (QRM 1) on 4/6/2026 at 10:25 a.m. During an interview on 4/6/2026 at 10:42 a.m. with the wound care nurse (WCN), the WCN said, “The patient (Patient 2) was using “Carpe No Sweat powder,” I am not sure what it is, but I recommended consulting ID. The bedside nurse should reach out to the attending (physician) with recommendations (written by the wound care nurse). ID had already been consulted. My recommendation was to keep the area clean. I did not recommend continuing the previous treatment (use of Boudreaux’s cream) and told the nurse to apply a skin barrier available from supplies to keep the lesions from getting infected. Boudreaux paste is similar to zinc oxide barrier paste. I did not follow up (with Patient 2) after the visit on 10/24/2024. The process is for the bedside nurse to ensure they follow the WCN recommendations.” WCN also confirmed that there was no follow-up regarding wound care treatment orders for the perinium in Patient 2’s medical records. WCN then said, “Patient’s (Patient 2) lesions needed a diagnosis, and the WCN cannot diagnose.” During a review of the facility’s policy and procedure (P&P) titled, “Patient’s Own Medication,” dated 3/2026, the policy indicated that “medications brought by or with the patient shall not be administered to the patient unless all of the following conditions are met: 1. the medication has been ordered by the physician and either the physician or pharmacist specifies the patient may use their own medications 2. the medication containers are clearly and properly labeled. 3. the contents of the containers have been examined, positively identified, and determined to be good quality by the hospital pharmacist.” During a review of the facility’s policy and procedure (P&P) titled “Medication Administration,” dated 2/2025, the policy indicated that an authorized prescriber’s order is required for administration of all medications... The patient will be assessed prior to the administration of medication for clinical need and in response to medication administration for side effects and effectiveness of treatment ...” During a review of the facility’s policy and procedure (P&P) titled, “Plan for Nursing Care,” dated 5/2023, the P&P indicated, “A RN has the responsibility and accountability for planning the care of the patient including all functions within the scope of practice: patient assessment, nursing diagnosis, planning, intervention, evaluation and education...The RN is responsible and accountable for the quality of care administered during their shift within their scope of practice. The assessment, planning implementation, and reevaluation of each patient are provided by an RN. Care, treatment and rehabilitation are planned to ensure that they are appropriate to patient needs, severity of disease, condition, impairment, disability, and age.” During a review of the facility’s policy and procedure (P&P) titled “Skin Care Wound Care,” dated 10/2023, the policy indicated, “...5. To notify physician of any alteration in the skin integrity and obtain treatment orders...” 2. b. During a review of Patient 2’s History and Physical (H&P, a medical document that records the patient’s current condition and past medical history), dated 11/7/2024, the H&P indicated that Patient 2 had been discharged on 11/5/2024 and returned on 11/7/2024 (second admission to the facility) because of pain and being “unable to move.” The H&P also indicated “new pus from breast ulceration wounds,” and showed that Patient 2 was admitted for wound care, for placement (meaning placement into a care facility or a safe discharge location), and weakness. During a review of Patient 2’s Discharge Summary (a medical document that explains the care the patient received in the hospital and outlines the plan for care after leaving the hospital), dated 11/15/2024, the record indicated that Patient 2 was discharged to home with home health services (home health services are medical or supportive services provided in the patient’s home, such as nursing visits, wound care, or therapy). During a concurrent interview and record review on 4/5/2026 at 11:36 a.m. with Quality Review Nurse (QRN 1), Patient 2’s PICC line (peripherally inserted central catheter, a long IV [intravenous, meaning “into the vein” ] tube placed into a large vein for giving medications or treatments) assessment record, dated 11/6/2024, was reviewed. The record showed that Patient 2 was admitted with her (Patient 2) own PICC line in place. QRN 1 also confirmed that the physician had written an order indicating, “ok to use Patient’s (Patient 2’s) PICC line.” During the same concurrent interview and record review on 4/5/2026 at 11:36 a.m. with Quality Review Nurse (QRN 1), QRN 1 reviewed Patient 2’s PICC line assessment documentation for the remainder of the stay (11/7/2024 through 11/17/2024) and stated the following: “The PICC line may have originally been placed for chemotherapy (there was no documentation when and why the PICC line was placed), but the PICC line must be checked (assessed) every day, and ideally every shift, to decide if it is still needed. If it is not needed, it must be removed because it carries a high risk for infection.” QRN 1 confirmed that Patient 2 was discharged on 11/17/2024 and the PICC line was not documented as being removed before discharge and/or whether there was a medical need for the PICC line to remain in place. QRN 1 also verified that there was no physician order indicating that it was acceptable for Patient 2 to be discharged with the PICC line in place. During an interview on 4/6/2026 at 11:40 a.m. with the manager of the Medical-Surgical Unit (MA 5), MA 5 stated the following regarding PICC lines: “The nurses must check with the physician to confirm whether the PICC line is still needed and whether any medications will be given at home through the PICC line. There should either be a nursing note or a specific physician order, an intervention order, stating whether the PICC line is to remain in place or be removed before discharge. The biggest concern with a PICC line is infection. Some home health (HH) agencies may have a nurse who can remove a PICC line, but it is not the expectation to leave that decision to the home health agency. The expectation is that nurses clarify with the physician about the PICC line before the patient is discharged.” During a review of a complaint received on 11/22/2024 by the Department of Public Health (DPH, the state agency responsible for enforcing health and safety laws in healthcare facilities), the complaint indicated that Patient 2 was discharged from the facility with no intravenous (IV, meaning “into the vein”) medications prescribed and with no orders related to the PICC line. The home health LVN (licensed vocational nurse, whose scope of practice does not allow them to manage or remove a PICC line because it is a central line that requires advanced training) who did a follow-up on Patient 2 did not know that Patient 2 had a PICC line in place. The PICC line was not addressed until 11/25/2024 (Patient 2 was discharged for the second time on 11/17/2024), and Patient 2 was concerned about the risks associated with having a PICC line left in place without proper medical indication, assessment, or handling. During a review of the facility’s policy and procedure (P&P) titled “Plan for Nursing Care,” dated 5/2023, the P&P indicated that “A registered nurse (RN) is responsible and accountable for planning the patient’s care. This includes all nursing duties within the RN’s scope of practice: patient assessment (checking the patient’s condition), nursing diagnosis (identifying patient needs), planning, interventions (actions taken for care), evaluation, and patient education. The RN’s main responsibility is to protect the patient’s health, safety, and well-being, and to act as a patient advocate by getting needed services and removing barriers to care when possible. The RN is responsible for the quality of care provided during their shift, within their scope of practice. Each patient’s plan of care is based on identified active problems, medical needs, and patient care standards, and is aligned with the treatments provided by other disciplines. Nursing care also includes providing education to the patient and family to help achieve specific health goals that support recovery, provide support, improve function, and enhance the patient’s overall health.” During a review of the facility’s policy and procedure (P&P) titled “Plan for Nursing Care,” dated 5/2023, the policy indicated, “The educational process is an integral component of discharge planning which is initiated upon admission and reassessed throughout the hospital stay. The evaluation process assists the educational participants to adjust and refine the education plan to fit the needs of the learner. In preparation for discharge, continuing care needs are assessed and referrals for such care are documented in the patient’s medical record.” 3. During a review of Patient 12’s “History of Present Illness (HPI, chronological description of the progression of a patient’s current complaint) ED (Emergency Department) General,” dated 3/23/2025, the “HPI” indicated, Patient 12 complained of anxiety and shortness of breath (SOB, feeling that you can’t get enough air into your lungs). During a concurrent interview and record review on 4/1/2026 at 2:27 p.m. with the Clinical Informatics Registered Nurse (CIRN) 2, Patient 12’s “ED Triage (a rapid, systematic process used in the emergency department [ED] to sort patients based on the severity of their condition, ensuring those with life-threatening issues are treated first, regardless of arrival order) Assessment,” dated 3/23/2025 at 7:49 p.m., was reviewed. The ED triage assessment indicated that Patient 12’s pain score was 3 on the pain scale of 0-10 (0- no pain; 1 to 3- mild pain; 4 to 6- moderate pain; 7 to 9- severe pain; 10- worst pain) indicating mild pain in the left lower extremity (lower left leg) and was described by Patient 12 as “ache.” In addition, Patient 12’s “Pain Assessment” record, dated 3/23/2025 at 9:29 p.m., was reviewed. Patient 12’s pain score was 5 indicating moderate pain. The pain location was not documented. During the same interview and record review on 4/1/2026 at 2:27 p.m. with CIRN 2, Patient 12’s “Active Orders,” dated 3/23/2025, was reviewed. CIRN 2 verified that there were no physician orders for medication to address Patient 12’s reported pain levels of 3/10 and 5/10, as documented on 3/23/2025. CIRN 2 stated there was also no documentation of any non-pharmacological interventions implemented to treat Patient 12’s pain of 5/10 on 3/23/2025 at 9:29 p.m., since the pain location was not documented. CIRN 2 stated that the nurse should have done non-pharmacological interventions to treat Patient 12’s documented pain score, based on where the pain was located. CIRN 2 also said that nursing staff should have notified the physician about Patient 12’s pain level so it could be treated appropriately. During a concurrent interview and record review on 4/2/2026 at 3:43 p.m. with the Director of Emergency Department (DIR) 5, Patient 12’s “Active Orders,” dated 3/23/2025, was reviewed. DIR 5 confirmed that Patient 12 had physician orders for Morphine (medication to treat severe pain) 4 mg (milligrams, a unit of measure) IV-push (rapid and direct injection of medication into a vein) on 3/24/2025 and Tylenol (over the counter medication to reduce fever and relieving minor aches and pains) 650 milligrams (mg, unit mass) by mouth on 3/25/2025. DIR 5 verified there were no pain treatment orders for Patient 12 on 3/23/2025. During an interview on 4/2/2026 at 3:57 p.m. with DIR 5, DIR 5 stated that the expectation was for the nurse to notify the physician regarding Patient 12’s pain, as pain was considered the sixth vital sign. Furthermore, DIR 5 stated that uncontrolled pain could lead to hyperthermic states (abnormally high body temperature), shortness of breath (difficulty breathing), hypertension (elevated blood pressure), which signal severe conditions. Dir 5 also emphasized that patient comfort was the main goal. During a review of the facility’s policy and procedures (P&P) titled, “Pain Management Plan #RI-370,” last revised 4/2025, the P&P indicated, “It is the philosophy of this organization that every patient has the right to be as pain free as possible, and that patients should have access to the best level of pain relief that may be safely provided ...All patients will be assessed by a nurse for the presence of pain on admission ...A plan for providing relief from physical and psychosocial symptoms associated with pain will be initiated once it is determined that the patient is experiencing pain ...Physicians will be contacted to obtain orders for appropriate pain control therapies considering the risk and benefits of the proposed treatment ...” During a review of the facility’s policy and procedures (P&P) titled, “Plan for Nursing Care #P-195,” last revised 5/2023, the P&P indicated, “Scope of responsibility ...RNs plan, delegate, and evaluate the nursing care provided throughout the hospital ...A RN has the responsibility and accountability for planning care of the patient including all functions within the scope of practice: patient assessment, nursing diagnosis, planning, intervention, evaluation and education ...” 4. During an interview on 3/31/2026 at 10:41 a.m. with Registered Nurse (RN) 24, RN 24 stated the facility utilized Morse Fall Scale (an assessment tool for assessing a patient’s fall risk to categorize patients into low: 0 -24, medium: 25 - 50 or high: greater than 51) to screen and identify a patient’s level of fall risk. RN 24 further stated fall prevention measures included providing patients with non-skid socks, posting a “Call, don’t fall” sign in the patient’s room, ensuring the room was free of clutter, and providing a patient with a call light (patient-activated communication devices used to request assistance, reducing fall risks and improving safety). RN 24 further stated nursing staff should also activate bed alarm (a safety monitoring systems designed to alert healthcare staff when a patient at risk of falling to leave their bed) for patients with high fall risk. During a review of Patient 26’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/14/2025, the “H&P” indicated, Patient 26 was admitted to the facility with diagnoses including but not limited to acute (new onset) kidney injury (sudden, often reversible, episode of kidney damage), hypocalcemia (a condition with abnormally low calcium levels in the blood), leukemia (blood cancer), pneumonia (lung infection) and hepatic liver cirrhosis (late stage of liver disease characterized by scarring in liver tissue). During a review of Patient 26’s “Admission Assessment,” dated 10/14/2025, the “Admission Assessment” indicated, Patient 26’s Morse Fall Scale score was 60 (high risk). During a review of Patient 26’s “Fall Assessment (assessment performed by nursing staff to determine fall risk level and interventions),” dated 10/15/2025, the “Fall Assessment” indicated that on 10/15/2025 at 8 a.m., Patient 26’s Morse Fall Scale score was 60 with interventions implemented including providing handout, non-skid socks, no more than three (3) bed rails up, bed in low position and wheels locked, instruct patient to call for assistance, frequent orientation, all belongings within reached, bed and room free of obstacles and tripping hazards, and use of bed alarm if available. During a review of Patient 26’s “nurses notes (nursing narrative notes),” dated 10/15/2025, the “nurses notes” indicated, “Patient (Patient 26) found on floor stated he (Patient 26) was trying to go to the restroom. Laceration (a tear on the body) to the left side of the head and left eyebrow. STAT (a medical abbreviation for immediately or without delay) CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) ordered ... CT shows a small acute subdural hematoma (collection of blood between brain surface and its outer lining, usually caused by head trauma) ...” During a review of Patient 26’s CT head (imaging test to check for blood vessels blockages or bleeding in the brain, and other brain injury) scan report, dated 10/15/2025, the CT scan report indicated, Patient 26 had a small acute (new onset) to subacute right parafalcine (location between the brain’s hemisphere inside the brain) subdural hematoma. During an interview on 4/1/2026 at 10:49 a.m. with RN 25, RN 25 stated she (RN 25) took care of Patient 26 on 10/15/2025. RN 25 further stated the following: Patient 26’s gait (manner of walking) was weak and unsteady. Patient 26 would get out of bed without calling for assistance. RN 25 had set bed alarm for Patient 26 since the morning (of 10/15/2025). In the afternoon (10/15/2025), RN 25 heard a big noise in Patient 26’s room. RN 25 went into Patient 26’s room and found Patient 26 on the floor. Patient 26 was found on the floor. RN 25 recalled that the bed alarm did not go off. RN 25 further stated she (RN 25) asked for help to get Patient 26 back to bed and notified the physician about the fall incident. During an interview on 4/1/2026 at 11:20 a.m. with the Director (DIR 4) of Definitive Observation Unit (DOU, hospital unit providing close monitoring care to patients), DIR 4 stated the following: it would be appropriate to use bed alarm for Patient 26. A post-fall debriefing (a structured review to analyze the root cause of the fall, improve safety protocols, and offer immediate support to staff involved) was completed after Patient 26’s fall incident. It was found that Patient 26’s bed alarm was not on. The purpose of utilizing bed alarm was to alert the staff to go into the room when the alarm went off. It might not prevent patients from falling but could at least alert the staff to go into the room faster. During a concurrent observation and interview on 4/1/2026 at 11:17 a.m. with RN 25 and DIR 4, in Patient 26’s room, where the fall incident happened, there were two beds (Bed A and Bend B) in the room. Bed A was located by the door and Bed B was located by the window. There was a patient’s bathroom located across Bed B. RN 25 stated Patient 26 was assigned to Bed A. Patient 26 was found lying on the floor in between Bed B and bathroom door (on 10/15/2025). RN 25 further stated there was a bedside table at that time and Patient 26 possibly hit the bedside table resulting in injury. During a review of the facility’s policy and procedure (P&P) titled, “Fall Reduction and Precaution,” dated 10/2024, the P&P indicated, “Staff assesses each patient for his or her fall risk and implements safety interventions. Safety measures will be implemented for all patients identified as being at risk for falls ... Patients will be assessed for fall risk on admission and each shift using the Morse Fall Scale. Fall prevention interventions are to be implemented for patients identified as moderate or high risk ... for patients identified as high risk, implement high risk prevention interventions: a. engage a companion or family member to stay at bedside as much as possible ... d. consider use of bed alarms if appropriate.””

“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: 46238 Based on interview and record review, the facility failed to ensure that registered nursing staff developed and maintained a nursing care plan (a written nursing document that identifies a patient’s needs, risks, and the specific nursing actions required to keep the patient safe) for one of 33 sampled patients (Patient 2) that addressed required isolation precautions (steps used to prevent the spread of infection by separating the patient or using personal protective equipment) and infection-control needs (the actions and safeguards needed to prevent the spread of germs within the hospital), in accordance with the facility’s policy regarding care plans. This deficient practice had the potential to result in Patient 2 being cared for without the required isolation measures, staff being unaware of or not following essential infection?control steps, and an increased risk of transmitting infectious organisms (germs that can cause infections) to other patients, visitors, and staff. Findings: During a review of Patient 2’s History and Physical (H&P, a medical document that records the patient’s current condition and past medical history), dated 10/18/2024, the H&P indicated that Patient 2 was transferred from another acute hospital (a hospital that provides short?term care for serious or emergency medical conditions) with a diagnosis of HLH (Hemophagocytic Lymphohistiocytosis, a rare and severe illness where the immune system becomes overactive and attacks the body) s/p (status post, “after”) chemotherapy (a type of cancer treatment that uses powerful drugs to destroy cancer cells by stopping them from growing, dividing, and spreading). During a concurrent interview and record review on 4/3/2026 at 2:35 a.m. with the clinical informatics registered nurse (CIRN 3), Patient 2’s admission assessment record, dated 10/17/2024, was reviewed. The record indicated that Patient 2 was transferred to the facility on 10/17/2024 as a direct admit (meaning the patient was sent straight to the hospital and admitted without going through the emergency department). The record also indicated that Patient 2 had a history of being C. auris positive (Candida auris, a type of yeast that can cause serious infections in hospitalized patients; it spreads easily in healthcare settings and is difficult to treat because it resists many common antifungal medications). During a concurrent interview and record review on 4/3/2026 at 2:55 p.m. with the clinical informatics registered nurse (CIRN 3), Patient 2’s “Patient Notes,” dated 10/18/2024, were reviewed. The Infection Control note indicated that Patient 2 required isolation precautions (steps used to keep infections from spreading by separating the patient or using protective equipment), contact precautions (safety measures used to prevent the spread of germs that are passed by touching the patient or their environment), and contact isolation (keeping the patient in a room where staff must wear gloves and gowns before entering). CIRN 3 verified that the note indicated these precautions were required for VRE urine (Vancomycin?Resistant Enterococcus found in the urine, a germ that resists common antibiotics and can spread in healthcare settings) and to maintain contact isolation precautions for history of Candida auris (a type of yeast that can cause serious infections and spreads easily in hospitals, often resistant to many antifungal medications). During a concurrent interview and record review on 4/3/2026 at 3:24 p.m. with the Clinical Informatics Registered Nurse (CIRN 3), Patient 2’s Care Plans (the written nursing plan that identifies the patient’s needs and required nursing actions), for the admission from 10/18/2024 through 11/5/2024, were reviewed. CIRN 3 verified that there was no care plan for infection, MDRO (Multidrug-Resistant Organism) with isolation precautions that should be maintained. CIRN 3 also said that the nurse could “customize (free text) the care plan to adjust the care plan to the patient’s (Patient 2’s) needs ...” During an interview on 4/6/2026 at 11:00 a.m. with the Quality Nurse (QRM 1), QRM 1 said, “Care plan is a tool to communicate with family and the patient, provide involvement in care, and guidance. Isolation precautions care plan should be initiated to ensure there is communication between staff if the patient has an infection, to monitor the infection, and to assist the nurses to follow the guidelines for isolation precautions. The care plan is reviewed every shift by the primary nurse.” During a review of the complaint received by the Department of Public Health (the state agency that investigates health-care complaints) on 11/22/2024, the complaint indicated: “There were several times when hospital staff did not follow proper infection control measures (steps used to stop the spread of germs). Multiple nurses and case managers went into my mother’s room without gowns, gloves, or masks, even though there were clear signs showing that my mother was in isolation ...” During a review of the facility’s policy and procedure (P&P) titled “Plan for Nursing Care,” dated 5/2023, the policy indicated, “The hospital’s plan for providing nursing care is designed to support improvement and innovation in nursing practice and is based on both the needs of the patients to be served and the hospital’s mission. A RN has the responsibility and accountability for planning the care of the patient including all functions within the scope of practice: patient assessment, nursing diagnosis, planning, intervention, evaluation and education. The RN’s primary commitment is to the health, welfare and safety of the patient and to act as a patient advocate by obtaining needed services and removing barriers to meeting patient needs as applicable. The RN is responsible and accountable for the quality of care administered during their shift within their scope of practice. Each patient’s plan of care is based on identified active problems, medical patient care needs, and patient care standards and is consistent with the therapies of other disciplines.””

“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: 46333 Based on observation, interview, and record review, the facility failed to: 1. Ensure that vital signs (objective measurements of essential body functions, such as temperature, pulse, blood pressure, and respiration rate) for two of 33 sampled patients (Patient 1 and Patient 3) were assessed and reassessed, in accordance with the facility’s “Vital Signs” policy and procedures when: 1.a. Patient 1 had a physician order for vital signs assessment every hour that was not completed. This deficient practice had the potential to place Patient 1 at risk for unrecognized deterioration (worsening of condition) and may lead to a delay in treatment. 1.b. Patient 1 did not have vital signs taken after receiving fluid for sepsis (a life-threatening organ dysfunction caused by the body’s extreme response to infection) treatment, as required by the facility’s “Code Sepsis Checklist.” This deficient practice had the potential to delay recognition of Patient 1’s declining blood pressure (BP; the force of blood pushing against artery walls) and delay treatment, placing Patient 1’s health and safety at risk for an adverse outcome including death. 1.c. Patient 1 did not have temperature taken with every vital sign assessment. This deficient practice placed Patient 1 at risk for unrecognized severe sepsis (a critical stage of sepsis involving significant organ dysfunction), as temperature is one of the criteria used to determine whether a patient is experiencing sepsis. 1.d. Patient 3, who had a blood pressure (BP) of 183/105 (high blood pressure, adult normal BP systolic [top number]: below 120 mm Hg, and diastolic [bottom number]: below 80 mm Hg), was not reassessed. This deficient practice had the potential to delay recognition of Patient 3’s health deterioration and may lead to a delay in treatment resulting in patient harm and/or death. 2. Ensure Nursing staff reassessed vital signs (VS; measurements of temperature [T], heart rate [HR], breathing rate [BR], blood pressure [BP]), and pain level, for one of 33 sampled patients (Patient 16) during two separate Emergency Department (ED; emergency care area of the hospital) visits on 12/26/2023 and 12/28/2023. The facility did not follow its own policy for vital-sign monitoring, when: 2.a. On 12/26/2023 (first ED visit), nursing staff did not obtain vital signs before discharging Patient 16 from the Emergency Department. This deficient practice had the potential to result in Patient 16 being discharged while unstable (with untreated changes in heart rate, breathing, blood pressure, or other symptoms that may have required further medical care), and placed Patient 16 at risk for worsening infection, uncontrolled pain, and continued or worsening tachycardia (elevated heart rate). 2.b. On 12/28/2023 (second ED visit), nursing staff did not re-assess vital signs (VS) during Patient 16’s visit in the Emergency Department (ED) and again a half hour prior to discharge. This deficient practice had the potential to result in Patient 16 being discharged while unstable, which could lead to delayed recognition of worsening symptoms, untreated medical conditions, and possible serious harm due to changes in heart rate, breathing, blood pressure, or pain that were not identified before the patient left the Emergency Department. 3. Ensure Nursing staff adhered to the facility’s triage (a rapid, systematic process used in the emergency department [ED] to sort patients based on the severity of their condition, ensuring those with life-threatening issues are treated first, regardless of arrival order) policies and procedures for one of 33 sampled patients (Patient 16) to ensure appropriate use of the Emergency Severity Index (ESI) algorithm (a 5-level, flowchart-based triage algorithm used in emergency departments to rapidly categorize patients based on both acuity [stability] and predicted resource needs. It ranges from ESI 1 [most urgent/immediate life-saving intervention needed] to ESI 5 [least urgent/no resources needed]), resulting in the assignment of an incorrect acuity level. Patient 16 was assigned an ESI level 4 (meaning the patient was expected to need only one medical resource), despite presenting with symptoms that did not meet the criteria for this level 4. On a repeated visit (second ED visit on 12/28/2023; first ED visit was 12/26/2023) to the Emergency Department with worsening symptoms, Patient 16 presented with a heart rate of 145 beats per minute (normal adult range: 60-100 bpm, making 145 significantly elevated), and severe pain rated 9 out of 10 (indicating very strong, intense pain). These findings were inconsistent with an ESI level 4 classification and represented a higher-acuity presentation requiring a more urgent ESI assignment. This deficient practice potentially resulted in placing Patient 16 at risk for missed clinical deterioration (meaning the patient’s condition could worsen without being noticed in time) after Patient 16 was placed into the RTR (Rapid Treatment Room) area (an area where patients typically wait in chairs, receive minimal nursing oversight, and depend on providers to identify changes in condition) instead of the main area in the emergency department where Patient 16 would have been connected to a monitor, vital signs would be re-evaluated more frequently, and head-to-toe (a full physical assessment from head to feet) assessments would have been performed. 4. Ensure that one of 33 sampled patients (Patient 2), who was identified as high risk for skin impairment, was encouraged to and/or turned and repositioned in bed, in accordance with the facility’s Skin Care Treatment protocol for patients at high risk for skin breakdown. This deficient practice had the potential to result in Patient 2 acquiring a pressure injury (defined as a localized injury to the skin and/or underlying soft tissue, typically over a bony prominence, as a result of sustained pressure or pressure in combination with shear). 5. Ensure Nursing staff assessed one of 33 sampled patient’s (Patient 24) vital signs (temperature, pulse rate, blood pressure, respiratory rate and oxygen level) and pain level before being discharged from the Emergency Department (ED), in accordance with the facility’s policies and procedures (P&P) titled, “Vital Signs” and “Pain Management Plan.” This deficient practice could have led to continuing discomfort, pain, and an unsafe discharge for Patient 24. 6. Ensure Licensed staff notified a physician/provider and a pharmacist regarding the critical laboratory value (result of a diagnostic test such as a blood sample) of Activated Partial Thromboplastin Time (aPTT/PTT, measures how many seconds it takes for blood to clot) for one of 33 sampled patients (Patient 6), who was receiving heparin (a fast acting “blood thinner” used to treat and prevent blood clots), in accordance with the facility’s policy and procedures regarding reporting of critical laboratory results. This deficient practice resulted in a 3-hour delay in adjusting Patient 6’s heparin dose which had the potential to place Patient 6 at high risk for bleeding. Findings: 1.a. During a review of Patient 1’s “History of Present Illness: ED General (HPI, a chronological and detailed narrative describing the development of the patient’s current medical problem),” dated 2/23/2026, the “H&P (History and Physical examination, a clinical document that includes the patient’s medical history and results of the physical exam),” indicated Patient 1 presented to the emergency department (ED, a hospital unit that provides immediate evaluation and treatment for urgent or emergency medical conditions) for evaluation of abdominal pain since yesterday (2/22/2026). Patient 1 had abdominal pain with some associated chest pain. The note indicated that the patient (Patient 1) experienced heart palpitations (a sensation of rapid, fluttering, or pounding heartbeat). The note further indicated, “I suspect severe sepsis (severe sepsis: a life?threatening condition in which an infection causes organ dysfunction).” During an interview on 3/31/2026 at 10:10 a.m. with the charge nurse for the ED (RN 1), RN 1 stated that the frequency of vital signs check for patients in the emergency department should follow the physician’s order, as physicians typically order vital signs check based on the patient’s condition. During a concurrent interview and record review on 3/31/2026 at 2:37 a.m. with the Quality Review Nurse (QRN 5), Patient 1’s “Order Detailed” record, dated 2/23/2026, was reviewed. The order indicated that on 2/23/2026 at 6:35 a.m., Patient 1 had a physician order for vital signs to be taken every hour. QRN 5 confirmed the order was active beginning 2/23/2026 and remained active until a physician issued an order to discontinue hourly vital signs. QRN 5 confirmed no discontinuation order was present. During a second concurrent interview and record review on 3/31/2026 at 2:45 a.m. with QRN 5, Patient 1’s “Vital Signs” flowsheet, dated 2/23/2026, was reviewed. The flowsheet indicated that after the hourly-vitals order became active on 2/23/2026 at 6:35 a.m., there was a 2-hour and 49-minute delay before vital signs were taken at 9:24 a.m. The 9:24 a.m. vital signs showed Patient 1 had a heart rate (HR) of 113, documented as tachycardia (a heart rate greater than 100 beats per minute at rest). QRN 5 confirmed that nursing staff were required to follow the physician’s order for hourly vital signs because failure to reassess as ordered may result in missing important changes in Patient 1’s condition. During a review of the facility’s policy and procedure (P&P) titled, “Vital Signs,” dated August 2023, the P&P indicated, “Vital signs will be obtained to monitor body temperature, pulse, respirations, and blood pressure ... at triage then as needed according to level of care ...” 1.b. During a review of Patient 1’s “History of Present Illness: ED General (HPI, a chronological and detailed narrative describing the development of the patient’s current medical problem),” dated 2/23/2026, the “H&P” indicated, “I suspect severe sepsis.” During an interview on 3/31/2026 at 10:10 a.m. with the charge nurse for the ED (RN 1), RN 1 stated that after administration of any PRN (as needed) medications or any fluid bolus, the nurse must reassess the patient to evaluate treatment effectiveness, and a set of vital signs must be taken after fluid resuscitation. During a concurrent interview and record review on 4/3/2026 at 11:05 a.m. with the Director of Quality and Performance Improvement/Sepsis Coordinator (DIR 1), the facility’s “Code Sepsis Checklist,” undated, was reviewed. The checklist specified, under “1-3 hours treatment,” that after fluid resuscitation (the emergency intravenous administration of fluids to restore blood volume, improve tissue perfusion, and treat shock caused by severe dehydration, hemorrhage, sepsis, or burns) staff must obtain repeat vital signs times 2, every 15 minutes, within one (1) hour after completion of fluid resuscitation to assess for persistent hypotension (low blood pressure). DIR 1 stated the checklist was developed by the ED physician to ensure timely sepsis treatment. During a concurrent interview and record review on 3/31/2026 at 2:37 p.m. with the Quality Review Nurse (QRN 5), Patient 1’s “Medication Administration Record (MAR, medical chart that lists all medications prescribed for a patient and records each dose administered by healthcare staff), dated 2/23/2026, was reviewed. The MAR indicated Sodium Chloride (0.9%) 1,500 mL (milliliter, a unit of measurement), administered on 02/23/2026, started 6:53 a.m. and completed 7:41 a.m. During a concurrent interview and record review on 3/31/2026 at 3:15 p.m. with QRN 5, Patient 1’s “Vital Signs” flowsheet, dated 2/23/2026, was reviewed. Documented vitals were recorded at: - 9:23 a.m. - 10:45 a.m. -The required 1-hour post fluid window according to the “Code Sepsis Checklist” -based on the documented completion time of 7:41 a.m.-was 7:41 a.m. to 8:41 a.m. -The first post fluid vital (9:23 a.m.) occurred 1 hour 42 minutes after completion, which was outside the required window. -The second post fluid vital (10:45 a.m.) occurred 3 hours 4 minutes after completion, which was also outside the required window. -In addition, the two vitals were not 15 minutes apart (actual interval: 1 hour 22 minutes). QRN 5 confirmed this was not in accordance with the checklist requirement. QRN 5 confirmed both vital sign entries were outside the required timeframe and were not spaced per the checklist. During an interview on 4/6/2026 at 10:23 a.m. with the Medical Director of ED (MD 12), MD 12 stated that the “Code Sepsis Checklist” was created to facilitate communication between the ED physician and nurses. MD 12 stated that taking the vitals two times within 1 hour after completion of fluid resuscitation was important to help reassess the patient’s fluid level. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated February 2025, the P&P indicated, “the patient will be assessed prior to the administration of medication for clinical need and in response to medication administration for side effects and effectiveness of treatment. Assessment parameters will include ... pertinent vital signs.” 1.c. During a review of Patient 1’s “History of Present Illness: ED General” (HPI, a chronological and detailed narrative describing the development of the patient’s current medical problem), dated 2/23/2026, the “H&P” indicated, “I suspect severe sepsis.” During a concurrent interview and record review on 3/31/2026 at 2:45 a.m. with QRN 5, Patient 1’s “Vital Signs” flowsheet, dated 2/23/2026, was reviewed. The flowsheet indicated that within a 24-hour period, only four temperature measurements were documented. The first temperature was taken at 6:12 a.m.; the second temperature was taken 7 hours and 48 minutes later. -The review also indicated that multiple instances in which other vital signs were taken without a temperature measurement, including documentation at: 9:24 a.m. 10:45 a.m. 11:14 a.m. 12:00 p.m. 1:15 p.m. 1:30 p.m. 1:35 p.m. 1:40 p.m. 1:45 p.m. 1:50 p.m. 2:16 p.m. 2:30 p.m. 3:00 p.m. 3:30 p.m. 4:00 p.m. 4:45 p.m. 5:15 p.m. 6:21 p.m. 7:00 p.m. 7:35 p.m. 8:00 p.m. 9:00 p.m. 10:00 p.m. 11:00 p.m. 11:45 p.m. -QRN 5 confirmed that these entries represented instances where vital signs were documented but the patient’s temperature was not obtained, contrary to the facility’s expectation that temperature be taken with each full set of vital signs. During a concurrent interview and record review on 3/31/2026 at 3:25 p.m. with the Director of Quality and Performance Improvement/Sepsis Coordinator (DIR 1), DIR 1 stated that one of the criteria to determine that a patient was having sepsis, was the temperature. The DIR 1 confirmed that a patient’s temperature must be measured and should continue to be monitored, in order to determine if the patient was having sepsis. During an interview on 4/3/2026 at 10:31 a.m. with ED Registered Nurse (RN 27), RN 27 stated that all set of vital signs taken must always include the temperature. RN 27 stated it was especially important to take the temperature with every vitals, if there was a suspected infection such as sepsis. During a review of the facility’s policy and procedure (P&P) titled, “Vital Signs V-140,” dated August 2023, the P&P indicated, “Vital signs will be obtained to monitor body temperature, pulse, respirations, and blood pressure.” During a review of the facility’s policy and procedure (P&P) titled, “Vital Signs V-101,” dated February 2024, the P&P indicated, “A standardized procedure will be followed to adequately assess and treat patients presenting to the Emergency Department (ED). Any persons presenting to the ED will have their vital signs assessed during triage and as appropriate during the ED stay ... A complete set of vital signs shall be obtained and documented in the ED Disposition.” 1.d. During a review of Patient 3’s “History of Present Illness: ED General (HPI, a chronological and detailed narrative describing the development of the patient’s current medical problem),” dated 2/23/2026, the HPI indicated that Patient 3 was brought into the emergency department (ED, a hospital unit that provides immediate care for urgent or emergent medical concerns) for chest pain. During a concurrent interview and record review on 4/2/2026 at 2:06 p.m. with the Quality Review Nurse (QRN 4), Patient 3’s electronic medical record document titled “Vital Signs” flowsheet, dated 2/23/2026, was reviewed. The flowsheet indicated that on 2/23/2026 at 6:00 p.m., Patient 3’s blood pressure (BP; the force of blood pushing against the walls of the arteries) was 183/105 (high blood pressure, adult normal BP systolic [top number]: below 120 mm Hg, and diastolic [bottom number]: below 80 mm Hg). During the same concurrent interview and record review on 4/2/2026 at 2:06 p.m. with the Quality Review Nurse (QRN 4), QRN 4 confirmed there was no documented evidence that the elevated blood pressure was addressed, and that no reassessment of the blood pressure was completed. QRN 4 further stated that, according to facility expectation, blood pressure should be reassessed within 15 to 30 minutes after an elevated reading. During a review of the facility’s policy and procedure (P&P) titled, “Assessment Reassessment,” dated October 2024, the P&P indicated, “All patients will be physically assessed or reassessed by a Registered Nurse (RN) ...reassessment determined by change in patient’s status or condition.” 2.a. During a review of Patient 16’s triage (the first nursing assessment used to determine how urgent a patient’s condition is) Pediatric Assessment, dated 12/26/2023 at 11:17 a.m., the record showed that Patient 16 was a walk?in patient who complained of abdominal pain and diarrhea (loose stools) since 12/15/2023. Patient 16’s heart rate was 123, and the blood pressure (BP, the force of blood pushing against the walls of the arteries) was 122/74 (for a pediatric patient who is 15-16 years old, a BP of 122/74 is within a normal range; however, a heart rate of 123 is elevated for this age group). The triage record also indicated that Patient 16 reported “no pain” at that time. During a review of Patient 16’s History of Present Illness (HPI, a description of the patient’s current symptoms and how they developed), dated 12/26/2023 at 11:11 a.m., the record showed that Patient 16 presented to the Emergency Department with complaints of body aches, abdominal pain, and headache for the past 11 days. Patient 16 reported being evaluated at an urgent care clinic and was told that there was “some kind of abdominal infection,” for which antibiotics were prescribed (medications used to treat bacterial infections). The prescriptions listed were Cipro (ciprofloxacin: an antibiotic used to treat certain bacterial infections) and Doxycycline (an antibiotic used for a wide range of bacterial infections). During further review of Patient 16’s History of Present Illness (HPI, a description of the patient’s current symptoms and how they developed), dated 12/26/2023 at 11:11 a.m., the HPI indicated that Patient 16 reported head pain rated as 7 out of 10 (a pain scale used to measure the severity of pain, with 0 meaning no pain and 10 meaning the worst pain possible). Patient 16 denied having current abdominal pain and denied vaginal bleeding (any bleeding from the vagina that is not part of a normal menstrual cycle). During a concurrent interview and record review on 4/1/2026 at 11:30 a.m. with the Informatics Specialist (IS), Patient 16’s History of Present Illness (HPI), dated 12/26/2023, was reviewed. The record indicated that Patient 16 was diagnosed with a viral illness (an infection caused by a virus) and a headache (pain or discomfort in the head). Patient 16 was documented as “stable for discharge [meaning the patient was considered medically safe to leave the Emergency Department without the need for continued monitoring or treatment at that time].” Patient 16 was instructed to return to the Emergency Department in two to three days for reassessment if needed. The IS confirmed that Patient 16 was discharged at 1:54 p.m. on 12/26/2023. During a concurrent interview and record review on 4/1/2026 at 11:30 a.m. with the Informatics Specialist (IS), the IS verified that Patient 16 had only one set of vital signs documented in triage at 11:17 a.m. on 12/26/2023. The IS also confirmed that Patient 16 did not have a recorded pain level reassessment or vital signs obtained within 30 minutes prior to discharge at 1:54 p.m. on 12/26/2023. During an interview on 4/1/2026 at 2:26 p.m. with the Director of the Emergency Department (DIR 5), DIR 8 stated that typically vital signs were obtained every two hours in the Emergency Department. DIR 8 also said that the frequency of vital-sign reassessment depended on the patient’s ESI acuity level (Emergency Severity Index, a system used to determine how urgent a patient’s condition is). DIR 8 further stated that a patient assigned an ESI level of 3 [Patient 16 had an ESI level of 3 assigned to them in triage] would require vital signs every four hours, and that nurses should reassess both pain level and vital signs prior to discharge. (Patient 16 was seen in triage at 11:17 a.m. and was discharged at 1:54 p.m., a total of 2 hours and 37 minutes). During a review of the facility’s policy and procedure (P&P) titled “Vital Signs,” dated 9/2020, the policy indicated the following: “All persons presenting to the Emergency Department will have their vital signs (T, P, R, BP, and Pain level) assessed during triage, and again as appropriate during their Emergency Department stay. All patients will have their vital signs reassessed within one-half hour of discharge or transfer from the Emergency Department. Vital signs will be done every four hours, or more frequently based on ESI acuity (ESI acuity: the Emergency Severity Index level that shows how urgent a patient’s condition is). Vital signs must be completed within one-half hour of discharge.” 2.b. During a review of Patient 16’s History of Present Illness (HPI, a description of the patient’s current symptoms and how they developed), dated 12/28/2023, the HPI indicated that Patient 16 returned to the Emergency Department (ED), (within 72 hours of the previous visit on 12/26/2023) for evaluation of dysuria (painful or difficult urination) for two days. The HPI also indicated that Patient 16 reported blood in the urine that started “today (12/28/2023),” and blood in the stool that started the day prior (12/27/2023) and denied taking any pain medication at home. During a review of Patient 16’s Triage (the initial rapid nursing assessment used to determine the patient’s acuity level based on the Emergency Severity Index) note, dated 12/28/2023 at 3:15 a.m., the record indicated that Patient 16 presented with the following symptoms: urinary urgency, urinary frequency, burning pain, and blood in the urine since the previous day (12/27/2023). The record also indicated that Patient 16’s vital signs were as follows: heart rate 145 (a significantly elevated heart rate indicating tachycardia), blood pressure 123/75 (a normal blood pressure for a 16 year old), and a pain level of 9/10 (severe pain on the 0-10 pain scale, where 0 means no pain and 10 means the worst imaginable pain). The record indicated that Patient 16 was assigned an ESI 4 (a level indicating the patient requires one resource to determine disposition and is considered a lower acuity patient, meaning the patient is sick but not in danger and does not have severe or life-threatening symptoms). This review was conducted with the Informatics Specialist (IS) on 4/1/2026. During a review of Patient 16’s History of Present Illness (HPI), dated 12/28/2023, the HPI indicated that the urine culture obtained during the visit on 12/26/2023 (first ED visit of patient 16) showed no infection. The HPI also showed an abnormal white blood cell (WBC) count (the number of white blood cells in the blood, used to detect infection or inflammation) of 12.2 (elevated; normal WBC range is generally 4.5-11.0, and elevated levels may indicate infection or inflammation) [the WBC count was recorded as 12.4 in the laboratory results documented in the HPI dated 12/28/2023]. The HPI further indicated that Patient 16 was re-evaluated by the provider (physician), who documented that Patient 16 felt significantly improved after treatments provided in the Emergency Department and that Patient 16 “has been stable and vital signs were stable (meaning the patient’s blood pressure, heart rate, breathing rate, and temperature and pain levels were within acceptable limits).” The record also indicated that Patient 16’s final impression (the provider’s concluding diagnosis based on evaluation and test results) was urinary tract infection (UTI, an infection involving the urinary system, such as the bladder or urethra). During a concurrent interview and record review on 4/1/2026 at 11:30 a.m. with the Informatics Specialist (IS), Patient 16’s History of Present Illness (HPI) and Vital Signs (VS) records, both dated 12/28/2023, were reviewed. The IS verified that Patient 16’s HPI contained no record of any treatment (medical interventions provided to a patient, such as medications, procedures, or supportive care) received in the Emergency Department, no medications administered, and no vital signs documented beyond the initial set (vital signs that were obtained during triage). The IS also confirmed that no re-evaluation of pain level and no additional vital signs were recorded in Patient 16’s HPI or Vital Signs records prior to Patient 16’s departure from the ED on 12/28/2023 (second ED discharge; first ED discharge was 1/26/2023) at 8:18 a.m. (Patient 16 remained in the ED for 5 hours and 3 minutes). During an interview on 4/1/2026 at 2:26 p.m. with the Director of the Emergency Department (DIR 5), DIR 5 stated that since Patient 16 was a pediatric patient (a child or adolescent who is under 18 years old and receives medical care in the pediatric age group), the pain level of 9/10 (severe pain) and heart rate of 145 beats per minute (bpm) should have been followed up on and re-evaluated before discharge. DIR 5 confirmed that the discharging nurse should have taken vital signs prior to the discharge of Patient 16 on 12/28/2023 (second ED discharge). During an interview on 4/1/2026 at 2:26 p.m. with the Director of the Emergency Department (DIR 5), DIR 5 stated that “ ... Vital signs are typically done every two hours and again prior to discharge. In the fast-track area (a section of the ED for patients with less serious problems who can be treated more quickly), no nursing assessment is completed by the nurses; only providers (physician) perform their own assessments. For ESI 3 (Will require two or more resources [labs, imaging, intravenous meds, etc. ]) and 4 patients, in the fast-track area, vital signs should be done every four hours, and pain should be re-assessed along with the other vital signs (heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation).” During an interview on 4/2/2026 at 10:49 a.m. with the ED Charge Nurse (RN 14), RN 14 stated that patients’ vital signs, including pain level, should be re-evaluated one hour before discharge to make sure the patient was stable for discharge (meaning the patient’s condition was safe and steady enough to leave the Emergency Department without needing further immediate medical care). During a review of Patient 16’s HPI, dated 12/31/2023 (Patient 16’s third ED visit; first visit was 12/26/2023 and second visit was 12/28/2023), the HPI indicated that Patient 16 was brought into the emergency department after an unwitnessed cardiac arrest (meaning the heart suddenly stopped beating and no one saw it happen, so the exact cause or timing was unknown). The HPI also indicated that Patient 16’s impression was acute thrombocytopenia (a sudden drop in the number of platelets, which are blood cells that help with clotting), UTI (urinary tract infection; an infection in the bladder or urinary system), colitis, and possible colon perforation (a hole or tear in the colon) versus pneumatosis intestinalis (air trapped in the wall of the intestines). The record indicated Patient 16 was transferred to a children’s hospital for higher level of care (meaning the patient needed more specialized treatment than the current hospital could provide) in a critical condition (meaning the patient’s life was at risk and required immediate, intensive medical care). During a review of the facility’s policy and procedure (P&P) titled “Vital Signs,” dated 9/2020, the policy indicated the following: “All persons presenting to the Emergency Department will have their vital signs (T, P, BR, BP, and Pain level) assessed during triage, and again as appropriate during their Emergency Department stay. All patients will have their vital signs reassessed within one-half hour of discharge or transfer from the Emergency Department. Vital signs will be done every four hours, or more frequently based on ESI acuity (ESI acuity: the Emergency Severity Index level that shows how urgent a patient’s condition is). Vital signs must be completed within one?half hour of discharge.” 3. During a review of Patient 16’s History of Present Illness (HPI, a description of the patient’s current symptoms and how they developed), dated 12/28/2023, the HPI indicated that Patient 16 returned to the Emergency Department (ED) [within 72 hours of the previous visit on 12/26/2023] for evaluation of dysuria (painful or difficult urination) for two days and pain on urination. The HPI also indicated that Patient 16 reported blood in the urine that started “today [12/28/2023],” and blood in the stool that started the day prior and denied taking any pain medication at home. During a review of Patient 16’s Triage (the initial rapid nursing assessment used to determine the patient’s acuity level based on the Emergency Severity Index) notes, dated 12/28/2023 (second ED visit of Patient 16; first ED visit was 12/26/2023) at 3:15 a.m., the record indicated that Patient 16 presented with the following symptoms: urinary urgency, urinary frequency, burning pain, and blood in the urine since “yesterday (12/27/2023).” The record also indicated that Patient 16’s heart rate was 145 (a significantly elevated heart rate indicating tachycardia) and a pain level of 9/10 (severe pain on the 0-10 pain scale, where 0 means no pain and 10 means the worst imaginable pain). The record indicated that Patient 16 was assigned an ESI 4 (a level indicating the patient requires one resource to determine disposition and is considered a lower acuity patient, meaning the patient is sick but not in danger and does not have severe or life?threatening symptoms). This record review was conducted with the Informatics Specialist (IS) on 4/1/2026. During an interview on 4/1/2026 at 2:26 p.m. with the Director of the Emergency Department (DIR 5), DIR 5 stated that “ ...depending on the ESI level (Emergency Severity Index, a five-level system used to categorize how sick a patient is and how quickly the patient needs medical attention), if the patient is in the main ED area (the primary treatment area where patients with more serious conditions are evaluated and treated), a nursing physical assessment is required for ESI 1 and 2, and may also be required for ESI 3 depending on the patient’s presentation (how the patient appears clinically, including symptoms, stability, and overall condition). Vital signs are typically done every two hours and again prior to discharge. In the fast-track area (a section of the ED for patients with less serious problems who can be treated more quickly), no nursing assessment is completed by the nurses; only providers perform their own assessments. For ESI 3 and 4 patients in the fast-track area, vital signs should be done every four hours, and pain should be re-assessed along with the other vital signs (heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation).” During an interview on 4/2/2026 at 10:31 a.m. with the ED Charge Nurse (RN 14), RN 14 stated that patients with ESI 4 and 5 were typically seen in the fast-track area, also referred to as the rapid treatment rooms (RTR). RN 14 further explained that patients with ESI 3 could also be seen in the fast-track area if their vital signs were stable. RN 14 verified that all vital signs and patient-condition re-evaluations in the RTR were completed either by the registered nurses (RNs) or licensed vocational nurses (LVNs) assigned to the area. RN 14 stated that for patients with ESI levels 4 and 5, the provider’s assessment was sufficient to cover the patient assessment. RN 14 also stated that vital signs were obtained within one hour prior to discharge. During the same interview on 4/2/2026 at 10:31 a.m. with the Charge Nurse (RN 14), RN 14 stated that “even though triage assessment may be very subjective (meaning it is based on the patient’s symptoms as the patient describes them and, on the nurse’s, clinical judgment), we still have to follow the algorithm (a step-by-step set of instructions or a guided pathway that helps someone decide what to do next) for triage per our triage policy.” During a concurrent interview and record review on 4/2/2026 at 11:14 a.m. with charge nurse (RN 14), Patient 16’s triage assessment documentation, dated 12/28/2023, was reviewed. The record indicated that Patient 16 was assigned ESI level of 4 (meaning the patient was expected to need only one medical resource, such a blood test or a diagnostic procedure, and was considered stable). RN 14 said that she (RN 14) would have given Patient 16 an ESI of 3 (meaning the patient was expected to need two or more resources, which places the patient at a higher acuity [how sick a patient appears and how urgently they need care] level) due to the increased heart rate of 145 bpm and severe pain rated 9/10. RN 14 said, considering this was her (Patient 16 repeat visit (second ED visit) with worsening symptoms, she (RN 14) would expect more resources to be pulled for this patient (Patient 16), thus higher ESI (meaning the patient would be triaged at a more urgent level because the patient’s condition required more testing, treatment, and monitoring). During an interview on 4/2/2026 at 11:51 a.m. with charge nurse(RN 14), RN 14 said, “ There is an algorithm (a step-by-step set of instructions or a guided pathway that helps someone decide what to do next) that triage nurses use to reference the acuity (how sick a patient appears and how urgently they need care), and the ESI level can always change (meaning the patient can be reassigned to a higher or lower level depending on their condition and the number of medical resources they are likely to need).” RN 14 also said, “Clinical indicators suggested she (Patient 16) needed a higher acuity level (meaning the patient showed signs of being sicker and needing more urgent attention), and me (RN 14) as a nurse ... from the medical standpoint, I cannot say if she was medically stable to be discharged, but from the nursing standpoint, I would advocate for this patient, based on the labs and what the physician’s assistant has written in the HPI ...” During a concurrent interview and record review on 4/3/2026 at 10:11 a.m. with the ED registered nurse (RN 13), Patient 16’s triage notes, dated 12/28/2023, was reviewed. RN 13 said that based on the presenting symptoms (on 12/28/2023) of tachycardia (heart rate of 145 beats per minute; faster than the normal 60-100 bpm), severe abdominal pain rated 9/10, and a suspicion of infection, urinary frequency, burning pain, and blood in the urine, the provider should have been notified. RN 13 said, “Based on these criteria, the ESI cannot be 4.” RN 13 said she would have probably given Patient 16 an ESI of 2, saying that Patient 16 should have been sent to the main area of the ED for close monitoring. During the same interview on 4/3/2026 at 10:11 a.m. with the ED registered nurse (charge nurse, RN 13), a step-by-step, ESI-algorithm-based analysis was applied to Patient 16’s presenting symptoms in triage and reviewed. RN 13 stated that when the Emergency Severity Index (ESI) algorithm was applied directly to Patient 16’s symptoms and vital signs, the patient did not meet the criteria for ESI 4 at any point. RN 13 confirmed that Patient 16 presented with worsening symptoms after a recent visit (a high-risk situation on 12/28/2023), severe pain rated 9/10, an abnormal heart rate of 145 beats per minute, and possible signs of infection, which together would have potentially met the criteria for ESI Level 2 instead of ESI Level 4. During a review of the facility’s policy and procedure (P&P) titled “Triage,” dated 10/2018, the P&P indicated that, “The emergency department (ED) will triage all patients as rapidly as possible to determine the patient’s need for emergent treatment and give an acuity level based on the Emergency Severity Index (ESI). Patients will be treated based upon the assigned triage level based on ESI 1-emergent to 5 - non-emergent. Triage will prioritize urgency of need for care ... re-assess patients waiting every two hours (or more frequently) to assure the assigned triage level has not changed. Should a patient’s condition deteriorate, a bed will be made available for immediate treatment ...” During a review of the facility’s emergency severity algorithm with elaboration on the criteria for each decision point (the algorithm assumes the user has significant clinical knowledge to identify physiologic instability, anticipate resource needs, and determine risk for deterioration). The ESI Triage Algorithm is a flowchart used by triage nurses to determine how urgently a patient needs care. It sorts patients using five levels: ESI 1 - Immediate life-saving intervention needed. ESI 2 - High-risk situation, severe pain, confusion, or distress. ESI 3 - Will require two or more resources (labs, imaging, IV meds, etc.). ESI 4 - Requires one resource. ESI 5 - No resources required. 4. During a review of Patient 2’s History and Physical (H&P, a medical document that records the patient’s current condition and past medical history), dated 10/18/2024, the H&P indicated that Patient 2 was transferred from another acute hospital (a hospital that provides short-term care for serious or emergency medical conditions) with a diagnosis of HLH (Hemophagocytic Lymphohistiocytosis, a rare and severe illness where the immune system becomes overactive and attacks the body) s/p (status post, “after”) chemotherapy. The H&P also indicated that Patient 2 continued complaining of weakness and inability to walk. During a concurrent interview and record review on 4/3/2026 at 2:35 a.m. with the Clinical Informatics Registered Nurse (CIRN 3), Patient 2’s admission assessment record, dated 10/17/2024, was reviewed. The record indicated that Patient 2 had multiple moisture-associated skin-damage (MASD) wounds and generalized skin peeling related to chemotherapy. CIRN 3 confirmed that Patient 2 was identified as a high-risk for skin injury patient (defined as a patient whose underlying medical condition, treatment-related factors, or existing skin integrity concerns significantly increase the likelihood of developing skin breakdown or pressure-related injury) and the High-Risk Turning Protocol was initiated on 10/18/2024. During an interview on 4/6/2026 at 10:42 a.m. with the wound care nurse (WCN), the WCN stated that turning and repositioning was important (an essential nursing intervention) especially for patients who cannot walk and were identified as high risk for skin impairment. During a review of Patient 2’s Wound Consultation Note, dated 10/24/2024, the note indicated that the Wound Care Nurse (WCN) documented to continue promoting skin integrity (defined as implementing measures to maintain healthy, intact skin and prevent further breakdown, including appropriate assessment, pressure-relief interventions, moisture management, and wound-care treatments). During a concurrent interview and record review on 4/6/2026 at 11:05 a.m. with the Quality Registered Nurse (QRN 1), Patient 2’s High-Risk Turning Protocol, dated 10/18/2024 through 10/19/2024 and 10/23/2024 through 10/24/2024, was reviewed. -The record indicated that from 10/18/2024 through 10/19/2024, Patient 2’s positioning in bed (defined as documentation of the patient being turned or repositioned at the required 2-hour intervals) was not documented. -For the period of 10/23/2024 through 10/24/2024, documentation of Patient 2’s positioning in bed did not begin until 11:59 p.m. on 10/23/2024. -QRN 1 verified that documentation of patient positioning was not reflected in the record as required by the High-Risk Turning Protocol and stated that there was no documentation indicating that Patient 2 refused turning, whether self-turning or assisted. During a review of the facility’s policy and procedure (P&P) titled “Skin Care Wound Care,” dated 10/2023, the P&P indicated: “Pressure Injury Prevention Protocol (a standardized, evidence-based approach to protect skin integrity and avoid pressure ulcers, typically involving regular risk assessments [e.g., Braden Scale], repositioning, specialized support surfaces, moisture management, and nutritional support. ) will be initiated for all patients identified as moderate risk, high risk, or with any actual skin breakdown. For moderate-risk patients, the P&P specifies that interventions “should include frequent turning a minimum of every two hours... For high-risk and very high-risk patients, the P&P indicates that interventions include “frequent turning a minimum of every two hours...” 5. During a review of Patient 24’s “Emergency Department (ED) General” record, dated 12/1/2025, the record indicated Patient 24 arrived at the ED at 8:33 p.m. for left sided back pain for two days. The record further indicated Patient 24 had a medical history of sciatica (nerve in the lower back) pain and hypertension (HTN, high blood pressure). During a concurrent interview and record review on 4/2/2026 at 9:40 a.m. with the Corporate Director of Clinical Informatics (DIR 6), Patient 24’s “Medication Administration Record (MAR),” dated 12/1/2025, was reviewed. Patient 24’s MAR indicated that at 10:45 p.m., Patient 24 received Toradol (a powerful anti-inflammatory drug) 30 milligrams (mg, a unit of measure) intramuscular (IM, into the muscle) and Flexeril (a muscle relaxant to relieve muscle pain) 10 mg orally for severe pain 8/10 (based on a pain scale score of 0-10; [0- no pain; 1 to 3- mild pain; 4 to 6- moderate pain; 7 to 9- severe pain; 10- worst pain]) . During a continued interview and record review on 4/2/2026 at 9:40 a.m. with DIR 6, Patient 24’s “ED Disposition Assessment” record, dated 12/1/2025, was reviewed. Patient 24’s ED Disposition Assessment record indicated Patient 24 was discharged at 11:40 p.m. (almost one hour after being medicated for pain at 10:45 p.m.). During an interview on 4/2/2026 at 10:00 a.m. with the Director of Emergency Department (DIR 5), DIR 5 stated patients should have their vital signs checked prior to discharge to determine if the patient was stable to go home and was not in an emergent state (life-threatening medical condition requiring immediate intervention). During a concurrent interview and record review on 4/2/2026 at 10:22 a.m. with DIR 5 and DIR 6, Patient 24’s “ED Disposition Assessment” record and “Vital Signs Flowsheet,” both dated 12/1/2025, were reviewed. DIR 5 and DIR 6 confirmed Patient 24 had one set of vital signs taken at 8:33 p.m. DIR 5 stated Patient 24 should have vital signs checked before discharge and confirmed that vital signs check should include a patient’s pain assessment. DIR 5 stated, “Despite the physician stating the patient (Patient 24) was stable, with no repeat vital signs [taken] we would not have the nurses’ final documentation saying the patient was good to go.” During a review of the facility’s policy and procedure (P&P) titled, “Vital Signs,” dated 2/2024, the P&P indicated, “Vital signs shall be obtained and documented in the ED Disposition Assessment within one (1) hour of discharge. Appropriate aftercare instructions shall also be documented within the ED Disposition Assessment.” During a review of the facility’s policy and procedure (P&P) titled, “Pain Management Plan,” dated 4/2025, the P&P indicated, “Pain reassessment to assess if the pain medication is working or if there are any adverse effects must be completed within 60 minutes of intervention and documented before end of shift.” 6. During a review of Patient 6’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/30/2023, the H&P indicated the following: Patient 6’s reason for hospitalization was for shortness of breath and throwing up blood. The H&P also indicated “History of present illness: The patient (Patient 6) had an underlying history of hypertension (high blood pressure), diabetes (high blood sugar), history of mitral valve replacement (a surgical procedure to replace mitral valves, in the heart, with a mechanical or biological prothesis) on anticoagulation (medication that prevent harmful blood clots from forming) with warfarin (an anticoagulant or “blood thinner” that prevents and treats blood clots) who was in her usual state of health a couple of days ago when she (Patient 6) threw up blood. Patient (Patient 6) was also more short of breath and hence presented to the Emergency Department (a facility providing immediate, unscheduled services to stabilize seriously ill or injured patients). Upon presentation, INR (International Normalized Radio, a standard blood test that measures how long it takes for blood to clot) was noted to be 8 (critically high or supratherapeutic, requires immediate medical attention to reduce bleeding risk) and hemoglobin (an iron-rich protein in red blood cells that transports oxygen from lungs to body tissues) was noted to be 7.9 (moderately low, indicates significant anemia) with baseline hemoglobin of around 9.6.” During further review of Patient 6’s “History and Physical (H&P), dated 1/30/2023, the H&P indicated “The patient (Patient 6) was admitted and was being given 1 unit of packed red blood cells ...Patient (Patient 6) also had a history of atrial fibrillation (a common, often chronic, heart rhythm disorder where the upper chambers [atria] quiver chaotically instead of beating effectively, leading to a fast, irregular, and often inefficient heartbeat). Assessment and plan included, status post (after) aortic and mitral value replacement and warfarin is being held. In fact, Patient (Patient 6) received vitamin K (a fat-soluble nutrient essential for blood clotting) and fresh frozen plasma (a blood component created from the liquid portion of donated blood, separated and frozen within 8 hours of collection to preserve clotting factors) and INR will be following [will be followed up on]. Once INR comes below 2, patient (Patient 6) will have to be anticoagulated with IV (intravenous, in the vein) heparin (an injectable anticoagulant [“blood thinner”] used to treat and prevent dangerous blood clots) while watching her (Patient 6) closely for any evidence of bleeding ...” During a review of Patient 6’s physician’s order, dated 1/30/2023 at 9:50 a.m., the physician’s order indicated the following: “Pharmacy Consult, 1 each. Heparin - Dosed by pharmacy (Pha). Label text: All initial dosing and adjustments are managed by pharmacy protocols. Please contact pharmacy for any concerns.” During a review of Patient 6’s “Laboratory Results,” dated 2/4/2023 at 5:01 a.m., the laboratory results indicated APTT (a blood test measuring how long [usually 21-35 seconds] it takes for blood to clot), level was 109.8 (High, PTT therapeutic range = 43.0 - 69.0 seconds). The Laboratory Results also indicated “Critical results called to ‘Registered Nurse (RN)’ 22. Results called & verbal readback at 7:05 a.m.,” on 2/4/2023. During a review of Patient 6’s “Laboratory Results,” dated 2/4/2023 at 8:50 a.m., the laboratory results indicated APTT level was 87.8 (High, PTT therapeutic range = 43.0 - 69.0 seconds). During a review of note titled, “Provider Notification,” for Patient 6, dated 2/4/2023 at 7 a.m., the note indicated “critical results: lab received at 7:05 a.m. Lab results repeated back: Yes. Provider notification - Provider paged: No. Comment: Endorsed to ‘Registered Nurse (RN) 4,’ PTT 109.80.” During a review of Patient 6’s “Nurse Note,” dated 2/4/2023 at 7:45 a.m., the nurses note indicated the following: “Report given to RN (RN 4) to continue care, Pt (Patient 6) is rest [resting]/ sleeping at bed, on NC (nasal cannula, a device used to deliver oxygen) 2 Liters, SpO2 (oxygen saturation, measures the amount of oxygen in the blood) 96 %, critical lab APTT 109.8 endorsed to f/u (follow up) by day shift ...” During a review of Patient 6’s “Nurse Note,” dated 2/4/2023 at 8 a.m., the nurse’s note, documented by RN 4, indicated the following: “Received Patient (6) in bed appears sleepy arousable. On 2L O2 (oxygen). Denies pain nor SOB (shortness of breath) at this time... Bedrest for now. IV heparin going on LT (left) arm. POC (plan of care) discussed with Patient (Patient 6). Agreeable to it. Encouraged to call for help if needed. Call light within reach.” During an interview on 3/31/2026 at 11:07 a.m. with the Clinical Nurse Educator (CNEDU), the CNEDU stated the following: “Heparin drip requires a physician’s order with pharmacy to manage. The pharmacist orders labs, monitors the lab results and adjusts the heparin dose based on the lab values of APTT (PTT) or INR. Patients who receive heparin are at risk of bleeding. Nurses are responsible for monitoring signs and symptoms of bleeding, such as bleeding gums, blood in the stool or urine, monitoring for decrease in hemoglobin, changes in vital signs, such as blood pressure, or altered mental status (any sudden, noticeable change in a person’s awareness, alertness, or mental sharpness, ranging from mild confusion to being unresponsive), which is a late sign of bleeding.” During a concurrent interview and record review on 4/1/2026 at 9:47 a.m. with the Quality Review Nurse (QRN 3), QRN 3 stated the following: Patient 6’s PTT (APTT) level was elevated on 2/4/2023 at 5:01 a.m. QRN 3 verified that the laboratory notified Registered Nurse (RN) 22 of Patient 6’s critical lab results of APTT 109.8 on 2/4/2023 at 7:05 a.m. QRN 3 reviewed Patient 6’s “Provider Notification” notes, dated 2/4/2023 at 7 a.m., and verified that nursing staff received the critical lab results for Patient 6. There was no documentation that the provider/physician or the pharmacist had been notified of the lab results. The note also indicated that the lab results (PTT 109.80) were endorsed to RN 4. QRN 3 also reviewed Patient 6’s nurse’s notes dated 2/4/2023 and verified that there was no documentation indicating that the provider/physician or pharmacist had been notified of Patient 6’s critical lab results. The nurse’s note also indicated that the heparin was still going. QRN 3 verified that the pharmacist adjusted Patient 6’s heparin dose, three (3) hours later, at 10:18 a.m. During a concurrent interview and record review on 4/1/2026 at 1:06 p.m. with the Director of Pharmacy Services (DIR 10) and the Clinical Coordinator for Pharmacy (CCPH), DIR 10 and CCPH stated the following: “The pharmacist usually manages patients on heparin if the physician orders a pharmacy consult. The pharmacist orders and monitors lab results. PTT (APTT) is ordered and monitored for patients who receive heparin. Heparin dose is adjusted per APTT lab results to achieve a physician desired (therapeutic) range of 56 - 73. The provider/physician and the pharmacist should be immediately notified of critical lab results, PTT, to respond right away and make any necessary adjustment to the heparin dose. If APTT value is too high, it places patients at risk of increased bleeding and if the PTT is too low, it places patients at risk of developing a blood clot.” DIR 10 stated Patient 6’s APTT level was 109.8 on 2/4/2023 at 7:05 a.m. DIR 10 and CCPH verified that the pharmacist had not been notified of the critical lab value. DIR 10 and the CCPH said that the pharmacist should have been notified immediately to make necessary adjustments to heparin dose, if indicated. DIR 10 also stated that pharmacists also monitored the lab values and Patient 6’s heparin dose was adjusted by the pharmacist on 2/4/2023 at 10:16 a.m., from 500 Units/hour to 450 Units/hour. During a review of the facility’s policy and procedure (P&P) titled, “Critical Results, Timely Reporting of # C-350,” dated 9/2023, the P&P indicated the following: “Critical results of test and diagnostic procedures are defined as results which fall significantly outside the normal range and may indicate a life-threatening situation. Licensed staff will notify the physician or Licensed Independent Practitioner (LIP) within sixty (60) minutes of receipt of critical test results. Evidence of the critical test being reported timely will come either from documentation or another order/intervention placed addressing the result. Procedure: Information will be communicated from the department technician/therapist to the RN/LVN assigned to the patient or to the charge nurse. If neither nurse is available, the critical result will be reported to another RN/LVN who is then responsible for communicating the value to the assigned nurse or physician/LIP ...The RN/LVN will document the time the physician was notified of the critical test result. Critical test results include a PTT greater than 100 for adults.””

“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: 46333 Based on interview and record review the facility failed to: 1. Ensure nursing staff reassessed one of 33 sampled patients (Patient 1) after administering intramuscular (IM, medication injected into a muscle) Morphine Sulfate (a strong pain-relief medication used to treat severe pain), as part of the multi-faceted medication administration process to allow for early identification of adverse effects and timely initiation of appropriate corrective action, in accordance with the facility’s “Medication Administration” policy and procedure. This deficient practice resulted in delayed recognition that Patient 1’s blood pressure dropped to 45/22 (severe low blood pressure; normal adult blood pressure is typically below 120 millimeters of mercury [mm Hg] systolic [top number] and below 80 mm Hg diastolic [bottom number]), which could lead to patient harm. 2. Ensure nursing staff administered medication (a substance used to diagnose, treat, or prevent disease, or to relieve symptoms), as ordered by the physician or documented the reason for not administering prescribed blood pressure medication, for one of 33 sampled patients (Patient 3), in accordance with the facility’s policy regarding medication administration. This deficient practice had the potential to compromise timely management of elevated blood pressure and placed the patient (Patient 3) at risk for clinical deterioration (worsening of condition that could have been avoided with proper care). 3. Ensure nursing staff adjusted one of 33 sampled patient’s (Patient 6) heparin dose (a fast acting “blood thinner” used to treat and prevent blood clots), as ordered by the pharmacist and in accordance with the facility’s policy and procedure regarding medication administration. This deficient practice resulted in Patient 6 receiving the wrong dose of heparin (a fast acting “blood thinner” used to treat and prevent blood clots), the potential for inappropriate heparin dose adjustments, and placed Patient 6 at increased risk of bleeding or developing blood clots. 4. Ensure Nursing staff assessed the blood sugar levels every six (6) hours as ordered and administered insulin (a hormone that allows cells to take in glucose [sugar] from the blood stream for energy, thereby, lowers blood sugar levels) as ordered by the physician, for one of 33 sampled patients (Patient 9), in accordance with the physician’s order and the facility’s policy and procedure regarding medication administration. This deficient practice placed Patient 9 at risk of having uncontrolled blood sugar levels, which may cause harm to Patient 9. Findings: 1. During a review of Patient 1’s “History of Present Illness: ED General (HPI, a chronological and detailed narrative describing how the patient’s current illness developed),” dated 2/23/2026, the History and Physical (H&P, a clinical document that includes the patient’s medical history and results of the physical examination) indicated that Patient 1 presented to the emergency department (ED, a hospital unit that provides immediate evaluation and emergent medical treatment) for abdominal pain that began the day prior (2/22/2026). The H&P also indicated that the patient (Patient 1) reported chest pain and heart palpitations (a sensation of rapid, fluttering, or pounding heartbeat). In the H&P, the ED provider documented, “I suspect severe sepsis (a life-threatening condition in which an infection causes organ dysfunction).” During a concurrent interview and record review on 3/31/2026 at 2:37 p.m. with the Quality Review Nurse (QRN 5), Patient 1’s Medication Administration Record (MAR, a medical record listing all ordered and administered medications), dated 2/23/2026, was reviewed. The MAR showed that at 9:28 a.m., Patient 1 was administered Morphine Sulfate (a strong pain?relief medication used to treat severe pain) 10 mg (milligram, a unit of measurement) via IM (intramuscular, medication injected into muscle tissue). QRN 5 confirmed that the Registered Nurse (RN) should reassess Patient 1 for any unwanted side effects (such as low blood pressure) and for the effectiveness (therapeutic effect) of the medication within 15-30 minutes of administration, because the IM route generally took effect within that time frame. During a concurrent interview and record review on 3/31/2026 at 2:40 p.m., Patient 1’s Vital Signs flowsheet, dated 2/23/2026, was reviewed. The flowsheet showed that at 10:45 a.m.-1 hour and 17 minutes after Morphine Sulfate was administered-Patient 1’s blood pressure had dropped to 45/22 (a critically low blood pressure level; normal is 120/90). QRN 5 stated there was also no reassessment of pain documented. QRN 5 further stated that this represented a delay in reassessing the patient for pain and any adverse effects (unexpected or harmful reactions) related to the medication (Morphine Sulfate). During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated February 2025, the P&P indicated, “The patient will be assessed prior to the administration of medication for clinical need and in response to medication administration for side effects and effectiveness of treatment. Assessment parameters will include: Pertinent vital signs ...When administering a first dose of a medication the patient will be monitored for adverse reactions.” 2. During a review of Patient 3’s “History of Present Illness: ED General (HPI, a chronological and detailed narrative describing the development of the patient’s current medical problem), dated 2/23/2026, the HPI indicated that Patient 3 was brought into the emergency department (ED, a hospital unit that provides immediate care for urgent or emergent medical concerns) for chest pain. During a concurrent interview and record review on 4/2/2026 at 2:06 p.m. with the Quality Review Nurse (QRN 4), Patient 3’s “Vital Signs” flowsheet, dated 2/23/2026, was reviewed. The flowsheet showed an increase in Patient 3’s blood pressure (BP, the force of blood pushing against the walls of the arteries) throughout the day: o At 10:23 a.m., BP was 97/59 o At 12:00 p.m., BP was 121/75 o At 1:36 p.m., BP was 137/78 o At 6:00 p.m., BP was 183/105 (elevated blood pressure requiring clinical attention; normal adult BP is typically below 120/80). -QRN 4 confirmed that there was no documented evidence that the BP of 183/105 was addressed, and no evidence of BP reassessment until 9:50 p.m., which indicated that patient 3’s BP remained elevated at 151/93. QRN 4 stated the RN should have checked for PRN medications (as needed medications ordered for specific symptoms or clinical parameters) that may be prescribed to maintain Patient 3’s BP within required limits. During the same interview on 4/2/2026 at 2:06 p.m. with QRN 4, Patient 3’s Medication Administration Record (MAR), dated 2/23/2026, was reviewed. The MAR indicated that Patient 3 had a physician order for PRN hydralazine 10 mg (milligrams) every 2 hours to maintain BP below 180. QRN 4 confirmed that the medication was not administered. During the same interview on 4/2/2026 at 2:10 p.m. with QRN 4, Patient 3’s electronic medical record documents titled, “Nursing Narrative” Note and “Comments” Note, dated 2/23/2026, were reviewed. QRN 4 confirmed neither note indicated any reason for not administering the ordered hydralazine. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated February 2025, the P&P indicated, “Before administering a medication, the licensed independent practitioner or qualified individual administering the medication shall follow the seven (7) rights of medication administration. Medications must be administered as ordered.” 3. During a review of Patient 6’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/30/2023, the H&P indicated the following: Patient 6’s reason for hospitalization was for shortness of breath and throwing up blood. The H&P also indicated “History of present illness: The patient (Patient 6) had an underlying history of hypertension (high blood pressure), diabetes (high blood sugar), history of mitral valve replacement (a surgical procedure to replace mitral valves, in the heart, with a mechanical or biological prothesis) on anticoagulation (medication that prevent harmful blood clots from forming) with warfarin (an anticoagulant or “blood thinner” that prevents and treats blood clots) who was in her usual state of health a couple of days ago when she (Patient 6) threw up blood. Patient (Patient 6) was also more short of breath and hence presented to the Emergency Department (a facility providing immediate, unscheduled services to stabilize seriously ill or injured patients).” During further review of Patient 6’s H&P, dated 1/30/2023, the H&P indicated “Upon presentation, INR (International Normalized Radio, a standard blood test that measures how long it takes for blood to clot) was noted to be 8 (critically high or supratherapeutic, requires immediate medical attention to reduce bleeding risk) and hemoglobin (an iron-rich protein in red blood cells that transports oxygen from lungs to body tissues) was noted to be 7.9 (moderately low, indicates significant anemia) with baseline hemoglobin of around 9.6. Patient (Patient 6) was admitted and was being given 1 unit of packed red blood cells ...Patient (Patient 6) also had a history of atrial fibrillation (a common, often chronic, heart rhythm disorder where the upper chambers [atria] quiver chaotically instead of beating effectively, leading to a fast, irregular, and often inefficient heartbeat). Assessment and plan included, status post aortic and mitral value replacement and warfarin is being held. In fact, Patient (Patient 6) received vitamin K (a fat-soluble nutrient essential for blood clotting) and fresh frozen plasma (a blood component created from the liquid portion of donated blood, separated and frozen within 8 hours of collection to preserve clotting factors) and INR will be following [will follow-up INR]. Once INR comes below 2, Patient (Patient 6) will have to be anticoagulated with IV (intravenous- in the vein) heparin (an injectable anticoagulant [“blood thinner”] used to treat and prevent dangerous blood clots) while watching her (Patient 6) closely for any evidence of bleeding ...” During a review of Patient 6’s “Laboratory Results,” dated 2/4/2023 at 5:01 a.m., the laboratory results indicated APTT (a blood test measuring how long [usually 21-35 seconds] it takes for blood to clot) level was 109.8 (High, PTT therapeutic range = 43.0 - 69.0 seconds). “Critical results called to Registered Nurse (RN)” 22. “Results called & verbal readback at 7:05 a.m.,” on 2/4/2023. During a review of Patient 6’s “Laboratory Results,” dated 2/4/2023 at 8:50 a.m., the laboratory results indicated APTT level was 87.8 (High, PTT therapeutic range = 43.0 - 69.0 seconds). During a review of Patient 6’s “PHA (Pharmacy) Order,” the PHA order indicated the following: -2/03/2023 at 9:36 a.m., Edit Heparin order: Ordered rate 350 Units/Hour (HR) to 450 Units/HR. -2/03/2023 at 5:02 p.m., Edit Heparin order: Ordered rate from 450 Units/HR to 600 Units/HR. -2/04/2023 at 1:48 a.m., Edit Heparin order: Ordered rate from 600 Units/HR to 500 Units/HR. -2/4/2023 at 10:16 a.m., Edit Heparin order: Ordered rate from 500 Units/HR to 450 Units/HR. -2/4/2023 at 5:04 p.m., Edit Heparin order: Ordered rate from 450 Units/HR to 350 Units/HR. During a review of Patient 6’s “Medication Administration Record (MAR),” dated 2/03/2023 to 2/04/2023, the MAR indicated the following: For Heparin Sodium/Sodium Chloride (Heparin 250 ml/hour (milliliters/hr [HR]) IV Titrate. -2/03/2023 at 10:25 a.m., administered heparin dose: 450 Units/HR, 4.5 mls/hr. -2/04/2023 at 1:56 a.m., administered heparin dose: 500 Units/HR, 5 mls/hr. -2/04/2023 at 10:18 a.m., administered heparin dose: 450 Units/HR, 4.5 mls/hr. During a concurrent interview and record review on 4/1/2026 at 1:06 p.m. with the Director of Pharmacy Services (DIR 10) and the Clinical Coordinator for Pharmacy (CCPH), DIR 10 and CCPH stated the following: “The pharmacist usually manages patients on heparin if the physician orders a pharmacy consult. The pharmacist orders and monitors lab results. PTT (APTT) is ordered and monitored for patients who receive heparin. The pharmacist adjusts the heparin dose, per the APTT lab value to achieve a physician desired (therapeutic) range of 56 - 73 for patient. If APTT value is too high, it places patients at risk of increased bleeding and if the PTT is too low, it places patients at risk of developing a blood clot.” DIR 10 verified that on 2/03/2023 at 5:02 p.m., the order for heparin was increased from 450 Units/HR to 600 Units/HR. DIR 10 and CCPH reviewed Patient 6’s Medication Administration Record (MAR) and verified that the heparin dose increase to 600 Units/HR was not reflected in the MAR and Patient 6 continued to receive 450 Units/HR of heparin instead of 600 Units/HR (from the ordered time range of 5:02 p.m. on 2/3/2023 to 1:48 a.m. on 2/4/2023 for the administration rate of 600 Units/HR), until the correct dose was then administered on 2/4/2023 at 1:56 a.m., for 500 Units/HR (the PHA order to start the rate of 500 Units/HR was made on 2/4/2023 at 1:48 a.m.). During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 2/2025, the P&P indicated the following: “Medications must be administered as ordered ...” 4. During a review of Patient 9’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 3/31/2026, the H&P indicated the following: “Patient (Patient 9) is an 80-year-old female with dementia (a decline in mental ability severe enough to interfere with daily life) who came from home. Patient (Patient 9) was recently discharged from this hospital on 3/25/2026. At that time, Patient (Patient 9) was treated for a urinary tract infection (an infection caused by bacteria entering the urinary system [bladder, urethra, or kidneys], leading to inflammation and discomfort) ...This admission, Patient (Patient 9) reportedly fell from her bed and was complaining of pain on her right wrist and right knee. Patient (Patient 9) had a history of diabetes mellitus (high blood sugar) ... Will put on insulin (a hormone that allows cells to take in glucose [sugar] from the blood stream for energy, thereby, lowers blood sugar levels) sliding scale (a personalized chart that tells how many units of insulin to inject before a meal based on a patient’s current blood sugar level. The higher the blood sugar, the more insulin to take, allowing the dose to ‘slide’ up or down to keep levels in a safe range) ...” During a review of Patient 9’s provider order, dated 3/31/2026 at 9:36 a.m., the order indicated the following: “Glucose Check (bedside) every six (6) hours (q6hr).” During a review of Patient 9’s provider order, dated 3/31/2026 at 9:36 a.m., the order indicated the following: “Insulin Aspart (Novolog, a rapid-acting, man-made insulin) See Protocol SUB-Q (subcutaneous, under the skin), with meals, HS (at bedtime) PRN (as needed). Protocol: Insulin Correctional Scale. -Fingerstick Blood Glucose, Insulin Units < (less than) 70, none (insulin units) -70-150 mg/dl (milligrams/deciliter, units of measurement) - Give no correctional Insulin -151-200 mg/dl - Give 2 insulin units -201-250 mg/dl - Give 4 insulin units -251-300 mg/dl -Give 6 insulin units -301-350 mg/dl - Give 8 insulin units -351-400 mg/dl - Give 10 insulin units -Greater (>) than 400 mg/dl, Call MD (medical doctor/provider) -Protocol Text: Check blood glucose prior to administration of nutritional dose - ADD correctional dose per results. If blood glucose is less than 50 or greater than 400 mg/dl, notify MD (provider).” During a review of Patient 9’s laboratory results titled, “POC (point of care) Glucose,” the laboratory results, were reviewed and indicated the dates and times Patient 9’s blood glucose level was checked, as follows: -3/31/2026 at 8:41 p.m., glucose level was 170 (high, reference range 70 - 110) -4/01/2026 at 3:18 a.m., glucose level was 166 (high) -4/01/2026 at 5:35 p.m., glucose level was 204 (high) During a review of Patient 9’s “Medication Administration Record (MAR), dated 3/31/2026 through 4/1/2026, the MAR was reviewed and indicated the following: -On 3/31/2026 at 8:45 p.m., Insulin Aspart 2 Units were administered. During a concurrent interview and record review on 4/2/2026 at 11:22 a.m. with the Quality Review Nurse (QRN) 3, QRN 3 stated the following: Patient (Patient 9) had a history of diabetes and the physician ordered for patient’s (Patient 9) glucose level to be checked every six (6) hours. Insulin was ordered to be given in accordance with the sliding scale. Glucose levels should be checked at 6 a.m., 12 noon, 6 p.m., and 12 midnight or with meals (breakfast, lunch, dinner) and at bedtime. On 4/1/2026 at 3:18 a.m., patient’s (Patient 9) glucose level was 166 mg/dl and Patient 9 should have received 2 units of Insulin. On 4/1/2026 at 5:36 p.m., patient’s (Patient 9) glucose level was 204 mg/dl and patient (Patient 9) should have received 4 units of insulin. QRN 3 stated that if insulin was not given as ordered, the reason should be documented. QRN 3 verified that there was no documentation in the medical record indicating the reason why insulin was not given. In addition, QRN 3 verified that Patient 9’s glucose level was not checked every 6 hours, as ordered. Patient 9’s glucose was only checked on 3/31/2026 at 8:41 p.m., 4/01/2026 at 3:18 a.m., and 4/01/2026 at 5:35 p.m. QRN 3 stated glucose should be checked every 6 hours, and insulin should be given as ordered to control Patient 9’s blood glucose levels. QRN 3 stated nursing staff should follow physician’s orders. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 2/2025, the P&P indicated the following: “Medications must be administered as ordered ...””

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 50516 Based on interview and record review, the facility failed to ensure one of 33 sampled patient’s (Patient 21) “Transfer Consent (document signed by the patient, family or legal guardian giving permission to transfer)” and “Transfer Summary (document indicating personnel, facility, transport and medical records involved)” forms, from Hospital 2 to Hospital 1, were filled out completely, in accordance with the facility’s policy and procedure (P&P) titled, “Transfer of Patients, Interfacility,” dated 5/2023. This deficient practice could have led to Patient 21 and Patient 21’s family or legal representative to not be fully informed of Patient 21’s plan of care, which could result in treatment noncompliance, emotional/psychological distress, and loss of trust in healthcare providers. Findings: During a review of Patient 21’s “Emergency Department (ED) General” record, dated 2/15/2026, the record indicated Patient 21 arrived at Hospital 2’s emergency department (ED) for hypotensive (low blood pressure) episode, with complaints of nausea (a feeling of sickness, queasiness, or discomfort in the stomach that creates a strong urge to throw up) and abdominal pain. During a review of Patient 21’s “Consultation” record, dated 2/15/2026, the record indicated Patient 21 had a ruptured (open) abdominal aortic aneurysm (AAA, balloon in the aorta, a large blood vessel, that can turn life threatening if ruptured). The record further indicated Patient 21 was transferred to Hospital 1 for surgery to address the AAA. During an interview on 4/2/2026 at 10:07 a.m. with the Director of Emergency Department (DIR 5), DIR 5 stated that part of the transfer process included filling out transfer forms and should be completely filled out. During a concurrent interview and record review on 4/3/2026 at 11:24 a.m. with Registered Nurse (RN) 8, Patient 21’s “Transfer Summary,” dated 2/15/2026, was reviewed. RN 8 acknowledged each section should have been filled out. During a concurrent interview and record review on 4/6/2026 at 1:38 p.m. with Registered Nurse (RN) 20, Patient 21’s “Transfer Summary,” dated 2/15/2026, was reviewed and indicated the following sections were blank: - Condition (Patient 21’s medical condition); -Patient Assessment upon transfer; - Transport Personnel; - Hospital Personnel; - Transport Reason; - Patient Records Sent; -Consents; -Transferring Facility; -Follow-up Required; -Portions of the Receiving Facility Information including who report was given to, the date, time and Registered Nurse signature. -RN 20 stated the “Transfer Summary” should have indicated where the patient (Patient 21) was going, who accepted the patient, what was the receiving unit, to whom the transfer report was given to, how the patient (Patient 21) was transported, who were the transport personnel, what was the reason for transport, and an indication that patient records were sent out with the patient (Patient 21). RN 20 stated the transfer summary form should have been filled out/completed because it contained essential information and was mandated by policy. During a continued interview and record review on 4/6/2026 at 1:38 p.m. with RN 20, Patient 21’s “Transfer Consent,” dated 2/15/2026, was reviewed and indicated the following areas were blank: -The risks and benefits of being transported to [name of facility] in the Physician Certification for Transfer section; -Physician’s name at the receiving facility consenting to transfer; -Patient or Legal Representative signature; -Witness signature; -Date and Time of signature -RN 20 stated there should have been a witness for the physician certification and for the patient or legal representative signature, and the witness should be a nurse. RN 20 further stated it was important for there to be witness signatures to make sure the patient or family knew why they were being transferred and validate their consent. RN 20 stated if it was not written it was not done. RN 20 also said that the discharging nurse should verify that all steps were taken to ensure completeness of the form. During a review of the facility’s policy and procedure (P&P) titled, “Transfer of Patients, Interfacility,” dated 5/2023, the P&P indicated, “Transfer to another facility with patient approval: a. Complete all sections on the “Transfer Consent Form” B. Complete “Transfer Summary Form.””

“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: 46238 Based on interview and record review, the facility failed to ensure that required discharge instructions for wound care were provided to one of 33 sampled patients (Patient 2), prior to discharge, in accordance with the facility’s policy regarding the discharge process. This deficient practice resulted in Patient 2 not knowing how to take care of her (Patient 2) wounds which led to Patient 2’s readmission to the facility only 2 days after discharge. Findings: During a review of Patient 2’s History and Physical (H&P, a medical document that records the patient’s current condition and past medical history), dated 10/18/2024, the H&P indicated that Patient 2 was transferred from another acute hospital (a hospital that provides short?term care for serious or emergency medical conditions) with a diagnosis of HLH (Hemophagocytic Lymphohistiocytosis, a rare and severe illness where the immune system becomes overactive and attacks the body) s/p (status post, “after”) chemotherapy [meaning the patient already received chemotherapy treatment]. The H&P also indicated that Patient 2 continued complaining of weakness and inability to walk. During a concurrent interview and record review on 4/3/2026 at 2:35 a.m. with the clinical informatics registered nurse (CIRN 3), Patient 2’s admission assessment record, dated 10/17/2024, was reviewed. The record indicated that Patient 2 had multiple moisture-associated skin-damage wounds (MASD) and generalized skin peeling from chemotherapy. CIRN 3 also verified that no wound consult (a request for a wound-care specialist to examine and treat the patient’s skin problems) was placed on 10/17/2024 for Patient 2. During a review of Patient 2’s “Patient Notes,” dated 10/24/2024, the note indicated the following: “Patient’s [Patient 2’s] daughter called the charge nurse to the room to express her frustration that a wound care nurse had not yet seen the patient. The charge nurse assessed the patient’s wounds, and a call was then placed to the wound care nurse ...” During a review of Patient 2’s Wound Consultation Note, dated 10/24/2024, the note indicated that Patient 2 told the WCN, “the wound [perinium] has gotten worse in the last several days and the cream was not helping. Patient [Patient 2] also applied ‘Carpe No Sweat powder’ to skin folds with no improvement.” The note also indicated the following: “Perineum full-thickness wound (a wound where all layers of the skin are lost, exposing deeper tissue), multiple eroded painful lesions with yellow tissue, wound edges irregular, periwound erythematous (red), edematous (swollen), and tender to touch.” The note indicated recommendations to consult Infectious Disease (ID) for recommendations, and that the plan was discussed with the nurse.” During a review of Patient 2’s Nurse Note, dated 10/28/2024, the note indicated the following: “2400 (12:00 a.m.), family member at the bedside who was taking care of the patient called me on the phone to show the left breast-fold open wound. The wound looked like blisters that had popped, appearing yellow in color. The surrounding skin on the breast-fold appeared darker. I told the family member and the patient that I would cleanse the wound and take pictures of the wound ...” During a concurrent interview and record review on 4/6/2026 at 9:52 a.m. with the Quality Nurse (QRM 1), Patient 2’s wound-care treatment orders for the perineum and breast folds, were reviewed. QRM 1 stated that there was no order for wound-care treatment of the perineum throughout Patient 2’s stay from 10/18/2024 through 11/5/2024. QRM 1 also verified that Patient 2 had an order for Nystatin powder (an antifungal medication used to treat yeast or fungal infections on the skin) that was ordered on 10/24/2024 by the infectious disease physician to apply under the breast folds. During an interview on 4/6/2026 at 10:25 a.m. with the Quality Nurse (QRM 1), QRM 1 said that nurses typically go over wound care instructions with patients before discharge and stated, “We want to ensure the continuity of care is ongoing, that they follow up with the primary MD, and that we prevent readmissions or worsening of the skin injury.” QRM 1 verified that there was no wound care instructions included in the nursing discharge documentation for Patient 2 when Patient 2 was discharged on 11/5/2024 (discharge date after Patient 2’s first admission on 10/17/2024). During an interview on 4/6/2026 at 10:42 a.m. with the wound care nurse (WCN), the WCN said, “The patient (Patient 2) was using “Carpe No Sweat powder,” I am not sure what it is, but I recommended consulting ID. The bedside nurse should reach out to the attending with recommendations (to inform the physician regarding wound care recommendations made by the WCN). ID had already been consulted. My recommendation was to keep the area clean. I did not recommend continuing the previous treatment and told the nurse to apply a skin barrier available from supplies to keep the lesions from getting infected. Boudreaux paste (the cream that Patient 2 was using at home and continued to use at the facility without a physician order) is similar to zinc oxide barrier paste. I did not follow up [with Patient 2] after the visit on 10/24/2024. The process is for the bedside nurse to ensure they follow the WCN recommendations.” WCN also confirmed that there was no follow-up regarding wound care treatment orders for the perinium in Patient 2’s medical records. WCN then said, “Patient’s [Patient 2’s] lesions needed a diagnosis, and the WCN cannot diagnose.” During a review of Patient 2’s Discharge Summary (a document that explains the patient’s diagnosis, treatment, and instructions at the time of discharge), dated 11/5/2024, the record showed that Patient 2 was discharged home with the instructions indicating that the patient (Patient 2) could advance to a usual diet and included an order for the case manager (CM) to arrange home durable medical equipment (DMEs, medical devices used at home to support patient care), set up home health (home medical care provided by licensed professionals), and continue wound care. During a review of Patient 2’s Nursing Discharge Instructions, dated 11/5/2024, the record showed that wound care instructions were not documented as having been provided to Patient 2 prior to discharge on 11/5/2024. The discharge instructions were reviewed on 4/6/2026 with Quality RN (QRN 1), who confirmed that the Nursing Discharge Instructions provided to Patient 2 during her discharge on 11/5/2024, did not include wound care guidance. During an interview on 4/6/2026 at 10:42 a.m. with the wound care nurse (WCN), the WCN said, “The wound care instructions are important for discharge, so the patient can monitor [their wounds and skin issues] and follow up, and the patient would need wound care instructions to ensure continuity of care.” During a review of Patient 2’s History and Physical (H&P, a medical document that records the patient’s current condition and past medical history), dated 11/7/2024 (second admission to the facility), the H&P indicated that the patient (Patient 2) had been discharged on 11/5/2024 and returned on 11/7/2024 because of pain and being “unable to move.” The H&P also indicated “new pus from breast ulceration wounds,” and showed that the patient (Patient 2) was admitted (for the second time) for wound care and placement (meaning placement into a care facility or a safe discharge location). During a review of the facility’s policy and procedure (P&P) titled “Discharge Process,” dated 9/2025, the policy indicated: “The discharge process will be utilized to ensure the patient’s access to all supportive care necessary and available in the community following discharge from the hospital. B. The role of the nurse in discharge planning and patient education includes, but is not limited to: Completing the initial assessment of the patient and/or family needs for assistance at discharge. Providing self-care instructions, including pain management and medication reconciliation, upon discharge. The RN completes the discharge plan and, under the Instructions section, adds instructions, educational materials, and prints any patient handouts by type.” During a review of the facility’s policy and procedure (P&P) titled “Plan for Nursing Care,” dated 5/2023, the policy indicated, “The educational process is an integral component of discharge planning which is initiated upon admission and reassessed throughout the hospital stay. The evaluation process assists the educational participants to adjust and refine the education plan to fit the needs of the learner. In preparation for discharge, continuing care needs are assessed and referrals for such care are documented in the patient’s medical record.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36206 Based on interview and record review, the facility failed to meet the Condition of Participation for Patient’s Rights as evidenced by: 1. The facility failed to provide the appropriate translator services (helps bridge language barriers and ensure accurate interpretations and translation of medical information), in accordance with the facility’s policy and procedure regarding the use of translation services, for one of 30 sampled patients (Patient 10), when a consent (a process in which a patient or their legal representative receives information about a medical procedure or treatment) was obtained. Patient 10’s consent for blood transfusion (procedure that involves transferring blood or blood products) indicated no interpreter was used, instead Registered Nurse 11 (RN 11) was used in place of an interpreter. Patient 10’s preferred language was Spanish. This deficient practice violated Patient 10’s right to receive effective communication in their preferred language (Spanish) to understand the information contained in the consent form and make informed decisions about the proposed procedure. This deficient practice also had the potential to result in inappropriate treatments thus putting a patient’s health at risk. (Refer to A-0129) 2. The facility failed to ensure for one (1) of 30 sampled patients (Patient 20), safe care was provided when Patient 20 was observed not wearing an identification (ID, include patient’s full name, hospital number, medical record number, date of birth, age, sex, and attending physician) band in accordance with the facility’s policy and procedure regarding patient identification. This deficient practice resulted in Patient 20 to not be accurately identified and had the potential for the patient’s safety, while in the facility, be jeopardized such as with medication errors, etc. due to lack of proper identification. (Refer to A-0142) 3. The facility failed to ensure nine of nine patients received care in a safe environment, when one (Crash Cart 1) of two crash carts (or code cart, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) in the Critical Care Unit (CCU, provides care for people who have life-threatening injuries or illnesses) was missing the backboard (provides a firm surface for a patient who requires chest compressions during cardiopulmonary resuscitation [CPR, emergency treatment when someone’s breathing or heartbeat stops]). This deficient practice had the potential for emergency supplies to not be readily available in case of a medical emergency and may cause a delay in care. (Refer to A-0144) 4. The facility failed to ensure for two (2) of 30 sampled patients (Patients 26 and 29), Patient 26 and Patient 29 were free from restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) when, Patients 26 and 29’s four siderails of the bed were raised without a physician order, in accordance with the facility’s policy and procedure regarding restraints use. This deficient practice resulted in inappropriate, unnecessary, and prolonged use of restraints, and had violated Patients 26 and 29’s right to be free from restraints. In addition, this deficient practice had the potential for Patients 26 and 29 to suffer from physical harm such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia [lack of oxygen]), skin tear, loss of consciousness, broken skull, bleeding in the brain, etc., due to the lack of proper monitoring in relation to the use of restraints. (Refer to A-0154) 5. The facility failed to ensure for one (1) of 30 sampled patients (Patient 20), Patient 20’s soft wrist restraint (a manual method, physical or mechanical devices, material or equipment that immobilizes or reduces the ability of patient to move his or her arms, legs, body or head freely) was appropriately applied to the patient’s (Patient 20) left and right wrist, in accordance with the physician’s order. This deficient practice resulted in an appropriate use of restraint and had the potential to compromise Patient 20’s safety with complications such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia (lack of oxygen), skin tear, etc. (Refer to A-0167) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe setting.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 36206 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to ensure fall precautions (actions taken to prevent a fall) were in place, in accordance with the facility’s policy and procedure regarding fall reduction and precautions, at one of two facilities (Facility 1), for one of 30 sampled patients (Patient 3), who was a high fall risk (at high risk for falls) patient, when Patient 3’s bed alarm (detect a patient’s movement out of bed) was off at the time of the patient’s (Patient 3) fall (an unintentional event that results in the person coming to rest on the ground or another lower level). This deficient practice resulted in Patient 3 falling and sustaining a traumatic brain injury (TBI, when a sudden, external, physical assault damages the brain causing a disruption in the normal function of the brain). (Refer to A-0395) 2. The facility failed to ensure a baseline neurological (relating to the nervous system, which includes the brain, spinal cord, and nerves) pupil (the black opening in the middle of the colored part of your eye) assessment (systematic and continuous process of collecting, analyzing, and interpreting data to evaluate a patient’s health) and ongoing neurological assessments were completed, per the Intensive Care Unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients) standard of care and Policy & Procedure, every two hours, for one of 30 sampled patients (Patient 3), when Patient 3 was transferred to the ICU. This deficient practice had the potential for neurological changes not to be identified, resulting in delayed diagnosis or treatment of neurological changes, which may worsen the patient’s (Patient 3) condition and prolong hospitalization. (Refer to A-0398) 3. The facility failed to ensure the policies and procedures were implemented when: 3.a. Registered Nurse 9 (RN 9), who was assigned to the care of Patient 19, was observed coming out of the patient’s (Patient 19) room wearing gloves after providing patient care. This deficient practice had the potential for the introduction of pathogens (a microorganisms such as bacteria or virus that can cause a disease process) from RN 9 not performing hand hygiene and the potential for risk of transmission of microorganism to other patients and staff in the facility. (Refer to A-0398) 3.b. Patient 19’s midline catheter (a thin, flexible tube inserted into a vein in the upper arm to deliver medication or fluids directly into the bloodstream) dressing did not have a label with the insertion date and the dressing was not changed every 7 days, in accordance with the facility’s policy and procedure regarding intravenous (IV, into the vein) catheter management. This deficient practice had the potential to result in Patient 19 developing bloodstream infection and other fatal complication that could negatively affect Patient 19’s recovery. (Refer to A-0398) 3.c. Patient 20, who was on seizure (a sudden, uncontrolled burst of electrical activity in the brain) precaution, was observed with all the side rails x (times) 4 not padded, in accordance with the facility’s policy and procedure regarding seizure precautions (safety measures to reduce the risk of harm to people who are at risk of having a seizure). This deficient practice had the potential for Patient 20 to suffer from pain and injury during seizure activity. (Refer to A-0398) 3.d. Patient 20 and Patient 27, who were at risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level), were observed not wearing a fall risk armband (a yellow armband indicating the patient was at risk for fall) and Patient 27’s bed was not in a low position, in accordance with the facility’s policy and procedure regarding fall precautions (actions or interventions taken to reduce the risk of accidental falls). This deficient practice had the potential to result in an unsafe care that may lead to Patients 20 and patient 27 suffering from a fall injury. (Refer to A-0398) 4. The facility failed to ensure nursing staff followed the facility’s “Transmission Based Precaution (a set of infection control measures used when a patient may be infected to prevent transmission) Policy,” for one of 30 sampled patients (Patient 12), when Patient 12 was admitted to the facility with a diagnosis for COVID-19 (COVID-19 is caused by the SARS-CoV-2 virus. COVID-19 can cause mild to severe respiratory illness, including death) and staff did not properly discard Personal Protective Equipment (PPE, equipment used to prevent contagious infection from spreading, PPE examples include regular mask, N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles [a mixture of solid particles and liquid droplets found in the air]), gowns, gloves,) after providing care to Patient 12. This deficient practice had the potential to spread infection to other staff members and patients in the unit, when a used N95 respirator mask is not discarded after each use. (Refer to A-0398) 5. The facility failed to ensure nursing staffed followed the facility’s “Peripherally Inserted Central Venous Catheter Policy” for one of 30 sampled patients (Patient 13) when Patient 13 had a PICC line (Peripheral Inserted Central Catheter, is an intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period) placement done and staff did not verify PICC placement by calling the Radiologist to verify if the PICC line is okay to use. This deficient practice had the potential for unsafe use of a PICC line that was not verified for proper placement which may result in complications such as intravenous infiltration (medication is absorbed in the tissues and not the blood), serious burns, scarring, nerve damage, etc. (Refer to A-0398) 6. The facility failed to ensure for one of 30 sampled patients (Patients 28), Patient 28’s Norco (narcotic pain medication) was administered as ordered by the physician. This deficient practice resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect Patient 28’s health and safety due to unsafe medication administration and may lead to prolonged hospitalization. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 45743 Based on interview and record review the facility failed to provide the appropriate translator services (helps bridge language barriers and ensure accurate interpretations and translation of medical information), in accordance with the facility’s policy and procedure regarding the use of translation services, for one of 30 sampled patients (Patient 10), when a consent (a process in which a patient or their legal representative receives information about a medical procedure or treatment) was obtained. Patient 10’s consent for blood transfusion (procedure that involves transferring blood or blood products) indicated no interpreter was used, instead Registered Nurse 11 (RN 11) was used in place of an interpreter. Patient 10’s preferred language was Spanish. This deficient practice violated Patient 10’s right to receive effective communication in their preferred language (Spanish) to understand the information contained in the consent form and make informed decisions about the proposed procedure. This deficient practice also had the potential to result in inappropriate treatments thus putting a patient’s health at risk. Findings: During a review of Patient 10’s Face sheet (document that gives a patient’s information at a quick glance and includes the patient’s name, date of birth, address, etc.) dated 9/17/2024, the FS indicated Patient 10 was admitted to the Facility (Facility 2) on 9/17/2024. The Face Sheet indicated that Patient 10’s language was Spanish. During a review of Patient 10’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 9/17/2024, the H&P indicated, Patient 10 was admitted for an active gastrointestinal bleeding (GI, bleeding that occur anywhere in the digestive [a long tube of organs that food and liquids pass through as they are digested and absorbed, and then leave the body as feces] from the mouth to the anus [where stool passes out of the body]). During a concurrent interview and record review on 9/18/2024 at 3:37 p.m. with the Regulatory Compliance 1 (RC 1), Patient 10’s informed consent (a process in which a patient or their legal representative receives information about a medical procedure or treatment) for blood transfusion (procedure that involves transferring blood or blood products), dated 9/17/2024, was reviewed. RC 1 stated that no interpreter was needed because RN 11 that obtained the consent spoke Spanish. During an interview with the Chief Nursing and Clinical Executive 2 (CNCE 2) on 9/18/204 at 5:05 p.m., CNCE 2 stated that RN 11 was not formally trained in Spanish and the staff should have obtained a formally trained Spanish interpreter. During a review of the facility’s policy and procedure (P &P) titled, “Language Interpreter Services and Special Needs for the Hearing and Sight Impaired,” revised 12/2021, the P &P indicated, “under most circumstances interpreters providing medical interpretation must be formally trained in medical terminology.””

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 50594 Based on observation, interview, and record review, the facility failed to ensure for one (1) of 30 sampled patients (Patient 20), safe care was provided when Patient 20 was observed not wearing an identification (ID, include patient’s full name, hospital number, medical record number, date of birth, age, sex, and attending physician) band, in accordance with the facility’s policy and procedure (P&P) regarding patient identification. This deficient practice resulted in Patient 20 to not be accurately identified and had the potential for the patient’s safety, while in the facility, be jeopardized such as with medication errors, etc. due to lack of proper identification. Findings: During a concurrent observation and interview on 9/17/2024 at 1:56 p.m. with Registered Nurse 3 (RN 3), Patient 20 was observed in bed awake and was not wearing an ID band (ID, include patient’s full name, hospital number, medical record number, date of birth, age, sex, and attending physician). RN 3 was observed to have called Patient 20 two different names and Patient 20 did not respond. Subsequently, RN 3 addressed Patient 20 with the name indicated in the intravenous (IV, in the vein) medication bag that was hanging in the patient’s IV pole, Patient 20 was able to answer yes. RN 3 stated, Patient ID band was important to identify a patient for medication administration to prevent error in medication, procedure and care given to the wrong patient. During a review of Patient 20’s “History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem),” dated on 9/13/2024, the H&P indicated Patient 20 was admitted to Facility 1 with a chief complaint of intracranial hemorrhage (bleeding from the skull). The H&P further indicated Patient 20 was brought in by ambulance to the Emergency Department (ED, provides treatment to patients in need of immediate care) following a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) incident. During a review of the facility policy and procedure (P&P) titled, “Patient Identification for Clinical Care and Treatment” revised in 07/2021, the P&P indicated, “The identification band will include the patient’s full name, hospital number, and medical record number, date of birth, age, sex, and attending physician ...Before any procedure is carried out, the identification band shall be on the patient and will be checked by the responsible care provider for the following two (2) identifies to ensure that the right patient is involved: Patient name, Patient date of birth ...Whenever possible, staff should also verbally assess the patient to assure proper identification, asking patient’s name and date of birth and matching the verbal confirmation to the written information on the identification band””

“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: 36206 Based on observation, interview, and record review, the facility failed to ensure nine of nine patients received care in a safe environment, when one (Crash Cart 1) of two crash carts (or code cart, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) in the Critical Care Unit (CCU, provides care for people who have life-threatening injuries or illnesses) was missing the backboard (provides a firm surface for a patient who requires chest compressions during cardiopulmonary resuscitation [CPR, emergency treatment when someone’s breathing or heartbeat stops]). This deficient practice had the potential for emergency supplies to not be readily available in case of a medical emergency and may cause a delay in care. Findings: During a concurrent observation and interview on 9/17/2024 at 3:06 p.m. with the Director of Emergency Services (DES), two crash carts (or code cart, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) were observed in the Critical Care Unit (CCU, provides care for people who have life-threatening injuries or illnesses). One of the carts (Crash Cart 1) was missing the backboard (provides a firm surface for a patient who requires chest compressions during cardiopulmonary resuscitation [CPR, emergency treatment when someone’s breathing or heartbeat stops]). The DES verified that the backboard was missing and stated that the backboard was used during cardiopulmonary resuscitation (CPR). The DES stated the crash cart should be checked daily to ensure all supplies are available for use in the event of a medical emergency. Supplies should be replaced after each use. During a review of the “Code Cart Checklist,” dated 9/2024 in the Critical Care Unit, the Check list indicated the following: The Crash Cart is to be checked each calendar day and marked with a check mark in all columns when completed ...Your signature and lock number below indicate that the cart is properly locked, the defibrillator (devices that apply an electrical charge to the heart to restore a normal heart beat)/supplies have been checked and corrected as needed ...Items listed to be checked marked include ...backboard present. During a review of the facility’s policy and procedure (P&P) titled, “Emergency Cart-Code Cart Maintenance - [initials of the facility] # EC=140,” dated 1/2023, the P&P indicated the following: “Equipment, supplies, and medication usually required to treat a life-threatening situation, such as cardiac and/or respiratory arrest (when the heart stops beating and the person stops breathing) are maintained in an emergency cart for ready access on patient care areas. An itemized list of contents is attached to each cart ...All equipment will be operable and ready for use ...””

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 50521 Based on observation, interview, and record review, the facility failed to ensure for two (2) of 30 sampled patients (Patients 26 and 29), Patient 26 and Patient 29 were free from restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) when, Patients 26 and 29’s four siderails of the bed were raised without a physician order, in accordance with the facility’s policy and procedure regarding restraints use. This deficient practice resulted in inappropriate, unnecessary, and prolonged use of restraints, and had violated Patients 26 and 29’s right to be free from restraints. In addition, this deficient practice had the potential for Patients 26 and 29 to suffer from physical harm such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia [lack of oxygen]), skin tear, loss of consciousness, broken skull, bleeding in the brain, etc. Findings: 1. During a concurrent observation and interview on 9/17/2024 at 2:46 p.m. with Registered Nurse (RN 4) 4, Patient 26 was observed in bed, awake and able to respond only with a yes or no to questions. Patient 26’s 4 side rails of the bed were raised. RN 4 stated she (RN 4) was the RN assigned to Patient 26 and the patient does not have a physician order for restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely). RN 4 stated Patient 26’s four (4) side rails should not be raised; it is a risk for the patient (Patient 26) to fall if all four (4) side rails are up. During a review of Patient 26’s “History & Physical (H & P, a formal and complete assessment of the patient and the problem),” dated 9/12/2024, the H&P indicated Patient 26 was admitted to Facility 1 for Diabetic Ketoacidosis (a complication of diabetes [a disease that results in too much sugar in the blood] in which acids build up in the blood to levels that can be life-threatening.) During a concurrent interview and record review on 9/18/2024 at 12:26 p.m. with RN 7, RN 7 stated Patient 26’s record did not indicate an order for restraints. During a review of the facility’s policy and procedure (P & P) titled, “Restraints Seclusion PC-380,” reviewed on 07/2024, the P & P indicated, “Restraint/seclusion (involuntary confinement of a patient alone in a room or area and prevented from leaving) has the potential to produce serious consequences such as physical or psychological harm, safety issues, loss of dignity, violation of an individual’s rights and even death ...Physical Restraint: is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely, or a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition ...Use of 4 side rails for a patient that is not in seizure (a sudden, uncontrolled burst of electrical activity in the brain) precautions is considered a restraint and requires an order.” 2. During a concurrent observation and interview on 9/18/2024 at 10:14 a.m. with Registered Nurse (RN 8) 8, Patient 29 was observed awake, oriented x (times) 4 (someone who is fully aware of their person, place, time, and situation), with 4 side rails of the bed raised. RN 8 stated it should only be 3 side rails up for patient safety. RN 8 stated the 4 side rails is considered a restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely). During a review of Patient’s 29’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem)” dated 9/17/2024, the H&P indicated Patient 29 was admitted to Facility 1 for left side weakness. During a concurrent interview and record review on 9/19/2024 at 11:03 a.m. with Quality Review Nurse (QRN 2) 2, QRN 2 stated Patient 29’s medical record had no physician’s order for restraints of 4 side rails up. QRN 2 stated the patient could fall if the 4 side rails are up. During a review of the facility’s policy and procedure (P & P) titled, “Restraints Seclusion (involuntary confinement of a patient alone in a room or area and prevented from leaving) PC-380,” reviewed on 07/2024, the P & P indicated, “Restraint/seclusion has the potential to produce serious consequences such as physical or psychological harm, safety issues, loss of dignity, violation of an individual’s rights and even death ...Physical Restraint: is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely, or a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition ...Use of 4 side rails for a patient that is not in seizure (a sudden, uncontrolled burst of electrical activity in the brain) precautions is considered a restraint and requires an order.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50594 Based on observation, interview, and record review, the facility failed to ensure for one (1) of 30 sampled patients (Patient 20), Patient 20’s soft wrist restraint (a manual method, physical or mechanical devices, material or equipment that immobilizes or reduces the ability of patient to move his or her arms, legs, body or head freely) was appropriately applied to the patient’s (Patient 20) left and right wrist, in accordance with the physician’s order. This deficient practice resulted in an appropriate use of restraint and had the potential to compromise Patient 20’s safety with complications such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia (lack of oxygen), skin tear, etc. Findings: During a concurrent observation and interview, on 9/17/24 at 1: 56 p.m., with Registered Nurse 3 (RN 3), Patient 20 was observed in bed awake and calm. Patient 20 had a soft vest restraint and a right soft wrist restraint. Patient 20’s right soft wrist restraint was placed near the patient’s right elbow. Patient 20’s left wrist was not on restraint. During the same observation and interview on 9/17/2024 at 1: 56 p.m., RN 3 stated, Patient 20’s right soft wrist restraint was applied incorrectly. RN 3 stated, Patient 20 should also have the left soft wrist restraint applied. RN 3 stated Patient 20 was on soft wrist restraint to prevent pulling out intravenous (IV, in the vein) line. During a review of Patient 20’s “History & (and) Physical (H&P),” dated 9/13/24, the H&P indicated Patient 20 was admitted to Facility 1 with a chief complaint of intracranial hemorrhage (bleeding from the skull). The H&P further indicated Patient 20 was brought in by ambulance to the Emergency Department (ED, provides treatment to patients in need of immediate care) following a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) incident. During a concurrent interview and record review on 9/18/2024 at 11:20 a.m. with Charge Nurse (CN 1), CN 1 verified Patient 20’s “View Order Detail -Restraint Non-Violent Protocol,” had a renewal order for Patient 20’s Restraint Non-Violent wrist restraint to the left and right arm on 9/17/2024 at 1:47 p.m. During a review of the facility’s policy and procedure (P&P) titled, “Restraints Seclusion (involuntary confinement of a patient alone in a room or area and prevented from leaving),” revised in 7/2024, the P&P indicated, “Types of Restraints ...2. Cloth limb (soft wrist restraints, soft ankle restraints) ...b. Care should be taken to avoid placing the restraint, which would compromise integrity of an area ...Assure cuffs are secure and snug (two finger width space) to prevent circulation impairment ...Ongoing Monitoring every two (2) hours the RN will conduct the patient assessment which will include the following ...Appropriate type of restraint.””

“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: 48186 Based on interview and record review, the facility failed to ensure fall precautions (actions taken to prevent a fall) were in place, in accordance with the facility’s policy and procedure regarding fall reduction and precautions, at one of two facilities (Facility 1), for one of 30 sampled patients (Patient 3), who was a high fall risk (at high risk for falls) patient, when Patient 3’s bed alarm (detect a patient’s movement out of bed) was off at the time of the patient’s (Patient 3) fall (an unintentional event that results in the person coming to rest on the ground or another lower level). This deficient practice resulted in Patient 3 falling and sustaining a traumatic brain injury (TBI, when a sudden, external, physical assault damages the brain causing a disruption in the normal function of the brain). Findings: During an interview on 9/17/2014 at 2:50 p.m. with Registered Nurse (RN 4) 4, RN 4 stated the following: Patients are identified as low (not a fall risk), moderate or high risk for falls using the Morse fall scale (MFS, a rapid and simple method of assessing a patient’s likelihood of falling). If a patient is moderate or high risk for falls, interventions are implemented including the bed alarm (detect a patient’s movement out of bed). During an interview on 9/19/2024 at 8:35 a.m. with Registered Nurse 10 (RN 10), RN 10 stated that he (RN 10) was the primary nurse for Patient 3 on 6/6/2024, when Patient 3 had a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) and suffered a traumatic brain injury (TBI, when a sudden, external, physical assault damages the brain causing a disruption in the normal function of the brain). RN 10 also said the following: After Patient 3 fell in the hallway, he (Patient 3) had no pulse, was resuscitated (to revive someone from unconsciousness or apparent death) by cardiopulmonary resuscitation (CPR, an emergency treatment that is done when someone’s breathing or heartbeat has stopped), then transferred to the Intensive Care Unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients). He (RN 10) does not recall if Patient 3’s bed alarm was on when he (RN 10) responded to the fall. The bed alarm is a high-pitched sound and if the alarm was going off, it would be noticeable. It is important to use the bed alarm for patients identified as a high fall risk for safety and so nearby staff can intervene to prevent a patient fall. Patient 3’s fall was witnessed by the Painter Plant Operations (PPO). During an interview on 9/19/2024 at 9:45 a.m. with the Monitor Tech/Unit Clerk (MTUC), the MTUC stated the following: She (MTUC) was at the nurse’s station when she (MTUC) heard a yell and thump. She (MTUC) observed Patient 3 on the floor with visible bleeding from the head. She (MTUC) did not hear a bed alarm coming from Patient 3’s room. The bed alarm is a loud sound that could have been heard by her (MTUC) from the nurse’s station if alarming. The PPO was near Patient 3’s room. During an interview on 9/19/2024 at 10:43 a.m. with the PPO, the PPO stated the following: On 6/6/2024, he (PPO) was in front of Patient 3’s room and witnessed Patient 3 fall. Patient 3 was standing in his (Patient 3’s) room doorway for about 2 minutes. Patient 3 was looking and calling for the nurse when he (PPO) heard Patient 3 say “oh, shit” and fall onto the floor in the hallway hitting his head. Patient 3 had blood coming out of one ear in a flow. He (PPO) did not hear a bed alarm. If a bed alarm was going off, he (PPO) would have heard it and he (PPO) knows what it sounds like. During a review of Patient 3’s face sheet (gives information at a quick glance), the face sheet indicated Patient 3 was admitted to the facility on 5/24/2024 at 5:59 p.m. During a review of Patient 3’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/24/2024, the H&P indicated Patient 3 had a history of end-stage-renal disease (ESRD, a chronic medical condition where a person’s kidneys stop functioning on a permanent basis), cirrhosis (permanent scarring of the liver that causes an interference with its functioning) of the liver with ascites (a condition where fluid builds up in the abdomen, or belly, and can cause swelling), gangrene (when tissue in the body dies due to a lack of blood supply) of the right heel, and amputation (surgical removal of a body part or limb) of the 1st and 2nd toes of the left foot. Patient 3 presented to the facility on 5/24/2024 with a chief complaint of fluid overload (too much fluid in your body), gross ascites, and gangrene of the heel. During a review of Patient 3’s “Morse Fall Scale,” dated 5/24/2024 at 6:01 p.m., the fall scale indicated Patient 3 had a score of 80, high fall risk, on admission. The fall scale further indicated Patient 3 had the bed alarm in use. During a review of Patient 3’s “Morse Fall Scale,” dated 6/6/2024 at 8:00 a.m., the fall scale indicated Patient 3 had a score of 85, high fall risk. The fall scale further indicated Patient 3 had the bed alarm in use. During a review of Patient 3’s “Nurse Note,” dated 6/6/2024 at 4:15 p.m., the note indicated the following: “1:10 p.m., Patient found on hallway floor by [MTUC] ... Blood noted on floor coming from nose and ears. Pulseless, apneic (temporary cessation of breathing), seizing (a sudden, uncontrolled episode of abnormal electrical activity in the brain). Code blue (a hospital emergency code that indicates a patient is in critical condition and needs immediate medical attention) initiated ...” During a review of Patient 3’s “neurosurgery consultation,” dated 6/6/2024 at 4:34 p.m., the neurosurgery consultation indicated the following: “ ...Traumatic brain injury with delayed recovery ... 43-year-old male who reportedly fell today and appears to have sustained a moderate traumatic brain injury ...” During a review of the facility Policy and Procedure (P&P) titled, “Fall Reduction and Precautions,” dated 12/2021, the P&P indicated: “Statement of Policy: Safety measures will be implemented for all patients identified as being at risk for falls . ... Definitions: B. Morse Scale ... High risk is greater than 45 ... Procedure: 2. Fall prevention interventions are to be implemented for patients identified as moderate or high risk ... 5. In addition to above strategies, for patients identified as high risk, implement high risk prevention interventions: d. consider use of bed alarms if appropriate...””

“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: 42976 Based on observation, interview, and record review, the facility failed to: 1. Ensure a baseline neurological (relating to the nervous system, which includes the brain, spinal cord, and nerves) pupil (the black opening in the middle of the colored part of your eye) assessment (systematic and continuous process of collecting, analyzing, and interpreting data to evaluate a patient’s health) and ongoing neurological assessments were completed, per the Intensive Care Unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients) standard of care and Policy & Procedure, every two hours, for one of 30 sampled patients (Patient 3), when Patient 3 was transferred to the ICU. This deficient practice had the potential for neurological changes not to be identified, resulting in delayed diagnosis or treatment of neurological changes, which may worsen the patient’s (Patient 3) condition and prolong hospitalization. 2. Ensure the policies and procedures were implemented when: 2.a. Registered Nurse 9 (RN 9), who was assigned to the care of Patient 19, was observed coming out of the patient’s (Patient 19) room wearing gloves after providing patient care. This deficient practice had the potential for the introduction of pathogens (a microorganisms such as bacteria or virus that can cause a disease process) from RN 9 not performing hand hygiene and the potential for risk of transmission of microorganism to other patients and staff in the facility. 2.b. Patient 19’s midline catheter (a thin, flexible tube inserted into a vein in the upper arm to deliver medication or fluids directly into the bloodstream) dressing did not have a label with the insertion date and the dressing was not changed every 7 days, in accordance with the facility’s policy and procedure regarding intravenous (IV, into the vein) catheter management. This deficient practice had the potential to result in Patient 19 developing bloodstream infection and other fatal complication that could negatively affect Patient 19’s recovery. 2.c. Patient 20, who was on seizure (a sudden, uncontrolled burst of electrical activity in the brain) precaution, was observed with all the side rails x (times) 4 not padded, in accordance with the facility’s policy and procedure regarding seizure precautions (safety measures to reduce the risk of harm to people who are at risk of having a seizure). This deficient practice had the potential for Patient 20 to suffer from pain and injury during seizure activity. 2.d. Patient 20 and Patient 27, who were at risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level), were observed not wearing a fall risk armband (a yellow armband indicating the patient was at risk for fall) and Patient 27’s bed was not in a low position, in accordance with the facility’s policy and procedure regarding fall precautions (actions or interventions taken to reduce the risk of accidental falls). This deficient practice had the potential to result in an unsafe care that may lead to Patients 20 and patient 27 suffering from a fall injury. 3. Ensure nursing staff followed the facility’s “Transmission Based Precaution (a set of infection control measures used when a patient may be infected to prevent transmission) Policy,” for one of 30 sampled patients (Patient 12), when Patient 12 was admitted to the facility with a diagnosis for COVID-19 (COVID-19 is caused by the SARS-CoV-2 virus. COVID-19 can cause mild to severe respiratory illness, including death) and staff did not properly discard Personal Protective Equipment (PPE, equipment used to prevent contagious infection from spreading, PPE examples include regular mask, N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles [a mixture of solid particles and liquid droplets found in the air]), gowns, gloves,) after providing care to Patient 12. This deficient practice had the potential to spread infection to other staff members and patients in the unit, when a used N95 respirator mask is not discarded after each use. 4. Ensure nursing staffed followed the facility’s “Peripherally Inserted Central Venous Catheter Policy” for one of 30 sampled patients (Patient 13) when Patient 13 had a PICC line (Peripheral Inserted Central Catheter, is an intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period) placement done and staff did not verify PICC placement. This deficient practice had the potential for unsafe use of a PICC line that was not verified for proper placement which may result in complications such as intravenous infiltration (medication is absorbed in the tissues and not the blood), serious burns, scarring, nerve damage, etc. Findings: 1. During a concurrent interview and record review on 9/18/2024 at 2:28 p.m. with the Charge Nurse 2 (CN 2) and the Director of Emergency Services and Critical Care (DES), the CN 2 verified the following information in Patient 3’s medical record: The neurological (relating to the brain, spine and nerves) assessment (systematic and continuous process of collecting, analyzing, and interpreting data to evaluate a patient’s health) documentation dated 6/6/2024 at 2:00 p.m. through 6/8/2024 at 11:59 p.m., indicated Patient 3’s neurological assessments were not documented every 2 hours. The CN 2 stated the following: Patient 3’s neurological assessments should have been documented at least every two hours per the Intensive Care Unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients) standard of care. However, this was not completed every two hours. It is important to perform neurological assessments per standards of care and document, to ensure neurological changes are identified and reported to the physician right away. If neurological assessments are not completed per the ICU standard of care, the patient can have a neurological decline. During a concurrent interview and record review on 9/18/2024 at 3:00 p.m. with the Charge Nurse 1 (CN 1), the CN 1 stated the following should be documented within the medical record for neurological assessments: parameter (a limit that affects how something can be done), level of consciousness (describes a person’s awareness, alertness, and how well they respond to attempts to get their attention), arousable to, neurological symptoms, speech pattern, eye opening, verbal response, motor response (muscle movement), Glasgow Coma Scale (GCS, a scale used to objectively describe the extent of impaired consciousness in all types of acute [sudden and severe in onset, and symptoms appear, change, or worsen quickly] medical and trauma (a sudden and severe physical injury that requires immediate medical attention] patients) total, pupils (the black opening in the middle of the colored part of your eye) size and reaction, strength (left upper extremity, left lower extremity, right upper extremity, right lower extremity), cough/gag reflex (reflex is to contract the throat to prevent a person from choking), and neurological comment. RN 1 verified Patient 3’s neurological assessments were incomplete and not completed every 2 hours. During a concurrent interview and record review on 9/19/2024 at 3:45 p.m. with the DES, the DES verified the following information in Patient 3’s medical record: There was no baseline neurological assessment for pupil size and reaction upon transfer to the ICU on 6/6/2024 at 2:00 p.m. The neurological assessments dated 6/6/2024 at 2:00 p.m. through 6/8/2024 at 11:59 p.m. were documented every 4 hours. The DES stated the following: Patient 3 should have had a baseline pupil assessment when transferred to the ICU to establish a baseline for ongoing assessments to detect neurological changes. The baseline pupil assessment can be compared to ongoing assessments to determine if there is a worsening of condition and to trigger a notification to the physician. The physician should be notified of any pupil changes as soon as identified, as this can be an indication of neurological changes. The neurological assessments should have been documented every two hours. During a review of Patient 3’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/24/2024, the H&P indicated Patient 3 had a history of end-stage-renal disease (ESRD, a chronic medical condition where a person’s kidneys stop functioning on a permanent basis), cirrhosis (permanent scarring of the liver that causes an interference with its functioning) of the liver with ascites (a condition where fluid builds up in the abdomen, or belly, and can cause swelling), gangrene (when tissue in the body dies due to a lack of blood supply) of the right heel, and amputation (surgical removal of a body part or limb) of the 1st and 2nd toes of the left foot. Patient 3 presented to the facility on 5/24/2024 with a chief complaint of fluid overload (too much fluid in your body), gross ascites, and gangrene of the heel. During a review of Patient 3’s “Physical Assessment,” dated 6/6/2024 at 2:00 p.m. through 6/9/2024 at 12:00 a.m., the physical assessment indicated Patient 3’s neurological assessments were completed on the following dates and times: 6/6/2024 at 4:00 p.m., 8:00 p.m., and 11:59 p.m.; 6/7/2024 at 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., 8:00 p.m., and 11:59 p.m.; 6/8/2024 at 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., 8:00 p.m., and 11:59 p.m. During a review of Patient 3’s “Nurse Note,” dated 6/6/2024 at 2:31 p.m., the nurse note indicated “Patient arrived in ICU ... 2:00 p.m., this Registered Nurse (RN) assumed care of patient at this time ...” During review of a document provided by the facility, no date, titled “ICU/Critical Care Unit (CCU) Unit Standard of Practice,” the standard of practice indicated that every two hours neurological checks were to be conducted and documented. 2.a. During a concurrent observation and interview on 9/18/2024 at 9:32 a.m. with the Corporate Director for Performance Improvement and Accreditation (CDPIA) and the Registered Nurse (RN 9) 9, in the Medical Surgical Unit (provides care to patients with various medical conditions who are not critically ill), RN 9 was observed walking out of Patient 19’s room wearing gloves in his hands. RN 9 walked towards the portable computer, located outside of Patient 19’s room, and started documenting in the portable computer with gloves on both hands. RN 9 stated he (RN 9) just finished administration of intravenous (IV, through the vein) medication to Patient 19. During an interview on 9/18/2024 at 9:35 a.m., with RN 9, RN 9 stated he (RN 9) administered IV medication to Patient 19 and forgot to remove his gloves. RN 9 stated “I apologize for that, I need to remove gloves and perform hand hygiene to prevent infection to others.” During a review of the facility’s policy and procedure (P&P) titled, “Hand Hygiene Policy,” revised on 04/2022, the P&P indicated, “All health care staff is to perform hand hygiene when entering/exiting a patient room/cubicle/bay ...Hand hygiene is to be done a. before and after having direct contact with patients. b Before entering patient room/after leaving patient room. C. Before performing an aseptic task, i.e., IV starts/stops, dressing changes, medication preparation ...e. Remember to always perform hand hygiene after the removal of personal protective equipment, including gloves.” 2.b. During a concurrent observation and interview on 9/18/2024 at 9:32 a.m., with Registered Nurse (RN 9) 9, Patient 19 was observed in bed with a midline catheter (a thin, flexible tube inserted into a vein in the upper arm to deliver medication or fluids directly into the bloodstream) on his right upper arm. The midline catheter dressing did not have a label. RN 9 stated Patient 19’s midline dressing should have a label with the date the midline catheter was inserted and initial of the RN. RN 9 said the importance of dating a midline dressing was to know the time and day it was inserted or the last dressing change. RN 9 stated midline catheter dressing should be changed once a week. During a review of Patient 19’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/8/2024, the H&P indicated Patient 19 was admitted to Facility 1 with a chief complaint of Covid-19 (respiratory illness caused by a virus), respiratory failure (a condition where there’s not enough oxygen or too much carbon dioxide [a waste product or gas that is breathed out after the body uses oxygen] in the body), seizure (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain) and sepsis (a serious condition in which the body responds improperly to an infection and may progress to septic shock which is a life-threatening condition). During a review of Patient 19’s “Interventional Radiology” note, dated 9/9/2024, the note indicated Patient 19 had an order for Interventional Radiology (IR, medical specialty that uses minimally invasive procedure and imaging to diagnose and treat variety of condition) guided catheter (a flexible tube that can be inserted into the vein to deliver fluids, medications, or blood products directly into the bloodstream), insert midline stat (without delay) due to difficult IV (in the vein) access. During a concurrent interview and record review on 9/19/2024 at 11:46 a.m. with Charge Nurse 1 (CN 1), CN 1 stated Patient 19’s “PICC (Peripheral Inserted Central Catheter, is an intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period)/Mid Line Insertion,” dated 9/9/2024 indicated, Patient 19’s Midline catheter was placed on the patient’s (Patient 19) right upper extremity. During the same interview and record review on 9/19/2024 at 11:46 a.m. with CN 1, CN 1 stated, Patient 19’s “IV/Invasive Line, Place/Manage - flowsheet,” indicated Patient 19’s midline dressing was changed on 9/18/2024 at 8 p.m. (total of 9 days since Patient 19’s midline was inserted). CN 1 stated, Patient 19’s midline catheter dressing should have been changed on 9/16/2024 (on the seventh day of insertion) to help prevent development of infection. During an interview on 9/19/2024 at 11:50 a.m. with the Quality Review Nurse (QRN) 2, QRN 2 stated the Midline should be changed every 7 days. During a review of the facility’s Policy & Procedure (P&P) titled, “Peripherally Inserted Central Venous (PICC),” last reviewed in 4/2024, the P&P indicated, “A Midline catheter will be utilized for short or long-term peripheral access to the peripheral venous system for selected intravenous therapies and blood sampling ...Dressing Change and Site Care ...Procedure 2. Post insertion, change dressing every 7 days or in 24 hours if a gauze dressing was used.” 2.c. During a concurrent observation and interview on 9/17/2024 at 1:56 p.m. with Registered Nurse 3 (RN 3), Patient 20 was observed in bed with side rails x (times) 4 raised, the two upper and one lower side rails were padded (with a blue blanket) and the one lower side rails had no pads. RN 3 stated, Patient 20’s side rails x 4 should all have been padded for seizure (a sudden, uncontrolled burst of electrical activity in the brain) precaution. During a review of Patient 20’s “History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/13/2024, the H&P indicated Patient 20 was admitted to Facility 1 for intercranial hemorrhage (bleeding within the skull). The H&P further indicated Patient 20 was brought in by ambulance to the Emergency Department (ED, provides treatment to patients in need of immediate care) following a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) incident and Patient 20’s plan included placing the patient on seizure precaution (safety measures taken before an individual experiences seizure). During a concurrent interview and record review on 9/18/2024 at 11:20 a.m. with Charge Nurse (CN 1) and the Director of Emergency Services (DES), CN 1 stated, Patient 20’s “Care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) document,” dated 9/14/2024 indicated, seizure precautions were initiated. The interventions included padded bedrails with all four bedrails up and locked. The DES stated, Patient 20’s siderails x 4 should all be padded to ensure patient safety in case of episode of patient convulsing (involuntary contraction of the muscles resulting in an uncontrolled shaking of the body). During a review of the facility policy and procedure (P&P) titled, “Seizure Precautions,” revised in 01/2024, the P&P indicated, “Obtain seizure pads from Sterile Processing Department (SPD)/Central Services (CS) and pad side rails on bed, assuring that the bed controls are accessible. Keep (4) side rails up at all times.” 2.d. 1. During a concurrent observation and interview on 9/17/2024 at 1:45 p.m. with the Director of Neuro Science Unit (DNSU), Patient 20’s room was observed to have a “falling star” signage by the door. The DNSU stated the falling star signage indicated the patient was at risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level). The DNSU stated fall risk intervention included a bed alarm, the falling star magnet and the patient should have a fall risk arm band and yellow socks. In addition, Patient 20 was observed not wearing a fall wrist arm band. During an interview on 9/17/2024 at 1: 56 p.m. with Registered Nurse 3 (RN 3), RN 3 stated, Patient 20 should have a yellow Fall Risk armband to indicate the patient (Patient 20) was at risk for fall. During a review of Patient 20’s “History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/13/2024, the H&P indicated, Patient 20 was admitted to Facility 1 with a chief complaint of intracranial hemorrhage (bleeding within the skull). The H&P further indicated Patient 20 was brought in by ambulance to the Emergency Department (ED, provides treatment to patients in need of immediate care) following a fall incident. During a review of Patient 20’s “Care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) document,” the care plan indicated, Patient 20’s fall prevention intervention included “fall risk wristband on.” During a concurrent interview and record review on 9/18/2024 at 11:20 a.m. with Charge Nurse (CN 1), Patient 20’s “Morse Fall Scale -Assessment,” dated 9/15/2024 through 9/18/2024, indicated, Patient 20’s Morse Fall Scale (a tool use for patient to identify risk factors for falls) was 75 (above 45 is high risk). CN 1 stated, Patient 20 was a high risk for fall. CN 1 said the importance of yellow Fall Risk armband was for everyone to identify patients who were at risk for fall to ensure patient safety. During a review of the facility’s policy and procedure (P&P) titled, “Fall Reduction and Precautions,” revised in 12/2021, the P&P indicated, “For Patient identified as moderate risk, implement moderate fall risk prevention interventions when able ...Apply yellow Fall Risk armband ...In addition to above strategies, for patients identified as high risk, implement high risk prevention interventions ...” 2. During a concurrent observation and interview on 9/17/2024 at 3:25 p.m. with Registered Nurse (RN 5) 5, Patient 27’s room was observed to have a falling star signage magnet (symbol magnet that the hospital adopts for the fall risk patient) located at the patient’s (Patient 27) room door. In addition, Patient 27 was observed in bed, awake, and oriented to name. RN 5 stated Patient 27 has a Morse fall scale (is a rapid and simple method of assessing a patient’s likelihood of falling) score of 50. RN 5 said a patient is considered high fall risk if the score was 45 or greater. RN 5 stated for the patient that was high risk for fall, the patient should have a fall armband. RN 5 verified Patient 27 did not have the fall armband. During the same observation and interview on 9/17/2024 at 3:25 p.m. Patient 27’s bed was observed to be in a high position, to the level of the waistline. RN 5 stated Patient 27’s bed was on a high position. RN 5 stated Patient 27’s bed should be in a low bed position to ensure safety and prevent fall. During a concurrent interview and record review on 9/18/2024 at 2:17 p.m. with Quality Review Nurse (QRN 2), QRN 2 stated the patient’s “History & Physical (H & P, a formal and complete assessment of the patient and the problem)” dated 9/15/2024, indicated, Patient 27 was admitted to the facility for Shortness of Breath (difficulty breathing) and hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). During the same interview on 9/18/2024 at 2:17 p.m. with QRN 2, the QRN 2 stated Patient 27’s “Morse Fall Scale,” dated 9/17/2024 indicated a score of 50 (high fall risk). Patient 27’s Morse fall scale intervention included “fall risk armband on” and “bed in low position.” During a review of the facility’s policy and procedure (P & P) titled, “Fall Reduction and Precautions,” dated 12/2021, the P & P indicated, “...for patients identified as moderate risk, implement moderate fall risk prevention interventions, when able: ...apply yellow fall risk armband ...maintain bed in low position with wheels locked ...In addition to above strategies, for patients identified as high risk, implement high risk prevention interventions.” 3. During a review of Patient 12’s “Face Sheet (document that gives a patient’s information at a quick glance and includes the patient’s name, date of birth, address, etc.),” dated 9/15/2024, the Face Sheet indicated Patient 12 was admitted to the facility on 9/15/2024 at 5:57 p.m. for being COVID (respiratory illness caused by a virus) positive and “Hard time to breathe.” During a review of Patient 12’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/15/2024, the “H&P” indicated the following: Patient 12 with a history of weakness and fatigue (a feeling of tiredness or lack of energy that interferes with daily activities). Chief Complaint of having COVID. During a review of Patient 12’s “ED Nurse Note,” dated 9/15/2024, the ED Nurse Note indicated the following: “Patient 12 is alert and oriented (a person’s level of awareness of their surroundings, including time, place, and identity), and COVID precautions (interventions to prevent the spread of infection) in place with ongoing plan of care.” During a review of Patient 12’s “Infection Control Note,” dated 9/16/2024, the “Infection Control Note” indicated the following: “Patient 12 is on isolation precaution (a set of measures used to prevent the spread of germs and infectious agents in healthcare settings) with positive COVID results confirmed. N-95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles [a mixture of solid particles and liquid droplets found in the air]) required for all high-risk procedure. Limit the number of health care workers attending to patient. Contact & Droplet Isolation.” During a review of Patient 12’s “Care Plan (provides a framework for evaluating and providing patient care needs related to the nursing process),” dated 9/16/2024, the Care Plan indicated the following: Patient 12 has a care plan for SARS-CoV-2 (virus that causes COVID), COVID-19 Infection care plan was started on 9/16/2024 and targeted dated outcome on 9/21/2024. The care plan also indicated to maintain isolation precaution for SARS-CoV-2 until cleared per isolation discontinuation guidelines. During a concurrent observation and interview on 9/17/2024 at 3:10 p.m. with Registered Nurse (RN 18) 18, in the Anteroom (small room leading to a patient’s main room, a room used for Personal Protective Equipment [PPE] donning and doffing) of Patient 12’s room, a N95 mask (respirator mask used to protect from airborne infection) was observed with a name written on top of the N95 mask, was observed lying on top of the counter in the anteroom. RN 18 stated the following: Confirmed N95 mask on the counter belonged to RN 18 and had a written name on the N95 mask. Wrote name on the N95 mask to know the N95 mask belongs to RN 18. Confirmed RN 18 reuses N95 mask and does not discard N95 mask after each use or visit to Patient 12. Been doing this for a while. Confirmed Patient 12 was on airborne (a mixture of solid particles and liquid droplets found in the air) isolation for positive COVID results and needed to wear N95 mask when caring for Patient 12 During an interview 9/17/2024 at 3:17 p.m. with the Corporate Director of Nursing (CDN 1) 1, CDN 1 stated the following: CDN 1 confirmed that the anteroom for Patient 12 had N95 mask with written name by RN 18, lying on top of the counter. CDN 1 confirmed having heard RN 18 stated N95 mask belonged to RN 18 and was not discarded after each use. RN 18 was not following infection control policy for COVID patients. RN 18 should be discarding N95 mask after each use and getting a new mask when entering Patient 12’s room. It is an infection control risk for not following infection control policy. Will educate staff about donning (putting on) and doffing (taking off) PPE (Personal Protective Equipment, equipment used to prevent contagious infection from spreading, PPE examples include regular mask, N95 respirator mask [a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles]). Confirmed the facility had plenty of N95 mask for staff to use. During an interview 9/18/2024 at 10:05 a.m. with the Infection Preventionist (IP) 1, IP 1 stated the following: Patient confirmed to have COVID, the staff should not be reusing N95 mask, should be discarding N95 mask after exiting room of the COVID positive patient. Reusing N95 mask can potentially spread infection. “We have plenty of PPE for staff. We will be providing Inservice education for staff on PPE training donning and doffing.” During a concurrent interview and record review on 9/18/2024 at 4:25 p.m. with the Corporate Director of Nursing (CDN 1) 1, the facility’s policy and procedure (P&P) titled, “Transmission Based Precaution Policy,” dated October 2023 was reviewed. The P&P indicated, Policy: Transmission based precautions (airborne, droplet and contact) will be used when caring for patients documented with or suspected of being infected with highly transmissible or epidemiologically significant organisms to prevent the transmission of these organisms. MASK OR RESPIRATOR: Front of mask/respirator is contaminated - DO NOT TOUCH! If your hands get contaminated during mask/respirator removal, immediately wash your hands or use an alcohol-based hand sanitizer. Grasp bottom ties or elastics of the mask/respirator, then the ones at the top, and remove without touching the front. Discard in a waste container.” The CDN 1 stated the following: This is the policy staff should be following for donning and doffing PPE. N95 mask should be discarded not reused. Staff did not follow it, should discard N95 mask. Will provide education to staff regarding PPE donning and doffing. 4. During a review of Patient 13’s “Face Sheet (document that gives a patient’s information at a quick glance and includes the patient’s name, date of birth, address, etc.),” dated 9/13/2024, the Face Sheet indicated, Patient 13 was admitted to the facility on 9/13/2024 at 3:09 p.m. During a review of Patient 13’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/13/2024, the “H&P” indicated the following: Patient 13 with a history of Arterial Bleed (the most severe and urgent type of bleeding), Acute Kidney Injury (when the kidneys suddenly lose their ability to filter waste from the blood), and Lung Cancer (a disease that occurs when cells in the lungs grow out of control and form a tumor [a mass of abnormal cells in the body]). During a review of Patient 13’s “Intraoperative Report,” dated 9/11/2024 (performed at Facility 1 before Patient 13 was transferred to Facility 2 [sister facility]), the Intraoperative Report indicated the following: Patient 13 with PICC (Peripheral Inserted Central Catheter, is an intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period) line placement to the Left Upper Arm. During a review of Patient 13’s “Assessment Flowsheet,” dated 9/13/2024 to 9/16/2024, the Assessment Flowsheet indicated the following: PICC line was used on 9/13/2024 to 9/16/2024 for Chemotherapy and fluid medication infusion. No documentation by nurses notifying the primary medical doctor or radiologist verifying PICC line was ok to use. During a concurrent interview and record review on 9/18/2024 at 10:20 a.m. with the Quality Review Nurse (QRN 4) 4, Patient 13’s “Xray (used to generate images of structures inside the body for diagnostics) Report,” dated 9/11/2024, was reviewed. The Xray report indicated, on 9/11/2024, Xray was done with a position location of the PICC line placement noted and with no documentation indicating “Ok to use” PICC line. QRN 4 stated the following: Confirmed there was no documentation “Ok to use” PICC line documented in the Xray report. During an interview 9/18/2024 at 10:46 a.m. with the PICC Registered Nurse (PRN 1) 1, PRN 1 stated the following: PRN 1 confirmed placing PICC line for patients in the hospital. Chest Xray was done after placement of PICC line to patients and the radiologist will report “ok to use” PICC line. The nurses on the unit will know if the PICC line is ok to use based on the reading in the Xray report with the positioning of the PICC line. During a concurrent interview and record review on 9/18/2024 at 3:59 p.m. with the Director of Intensive Care Unit (DICU) 1, the facility’s policy and procedure (P&P) titled, “Peripherally Inserted Central Venous Catheter Policy,” dated 2024 was reviewed. The P&P indicated, “Confirm the placement of the catheter tip before initiating infusion therapy. Radiologist to read x-ray and state “ok to use.” The DICU 1 stated the following: Radiology Xray report should indicate from the Radiologist “Ok to use PICC line.” Confirmed P&P for PICC Line was not being followed and will educate the staff. Nursing staff will not know location of the PICC line based off the Xray reading of the Radiologist and not know when it was ok to use or not if it was not documented by the Radiologist. During a concurrent interview and record review on 9/18/2024 at 4:18 p.m. with the Corporate Director of Nursing (CDN) 1, the facility’s policy and procedure (P&P) titled, “Peripherally Inserted Central Venous Catheter Policy,” dated 2024, was reviewed. The P&P indicated, “Confirm the placement of the catheter tip before initiating infusion therapy. Radiologist to read x-ray and state “ok to use.” The CDN 1 stated the following: MD reading the X ray report have to put “Ok to use” PICC line in the Xray reading report. The nurses on the floor will not know based on the documentation of the PICC line if ok to use it. Radiologist not following PICC line P&P, will educate staff. During an interview 9/19/2024 at 2:31 p.m. with Professional Developer Nursing Education (PDNE) 1, PDNE 1 stated the following: PICC line education for nurses happens during orientation. There is no training for nurses to read X ray reports and determine if it is “ok to use” PICC line. Nursing cannot determine correct PICC line position based off the X ray readings. It is up to the physician to determine “Ok to use” PICC line. Nurses need to get “Ok to use” confirmation from the doctors prior to using the PICC line. During a review of the facility’s policy and procedure (P&P) titled, “Peripherally Inserted Central Venous Catheter Policy,” dated 4/2024, the “P&P” indicated, “Scope of Responsibility: Registered Nurse (RN), Statement of Policy: Peripherally inserted central catheters (PICC) will be utilized for short or long-term peripheral access to the central venous system for intravenous therapy (IV, into the vein), blood sampling and for vasopressor drugs. Procedure: 38. Obtain x-ray to verify placement of PICC line. 42.Document the date and time the dressing was applied and the initials on the external dressing. Confirm the placement of the catheter tip before initiating infusion therapy. Radiologist to read x-ray and state “ok to use” or results called to admitting physician and physician gives telephone order, “ok to use.””

“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: 50521 Based on interview and record review, the facility (Facility 1) failed to ensure for one of 30 sampled patients (Patients 28), Patient 28’s Norco (narcotic pain medication) was administered as ordered by the physician. This deficient practice resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect Patient 28’s health and safety due to unsafe medication administration and may lead to prolonged hospitalization. Findings: During a review of Patient 28’s “Neurointerventional Consult Note,” dated 9/17/2024, the Neurointerventional Consult Note indicated Patient 28 was admitted to Facility 1 after a surgical procedure of an anterior (in front of) cervical (relating to the neck) discectomy (surgical removal of abnormal disc material) and fusion (ACDF, a surgical procedure that treats spinal cord or nerve root compression in the neck.) During a review of Patient 28’s “Medication Administration Report (MAR),” dated 9/17/2024, the MAR indicated a physician’s order for Patient 28 to receive the following: - Norco 7.5/325 milligram (mg, a unit of measurement) 1 tablet by mouth every 4 hours as needed (PRN) for moderate pain (pain score 4-6 is moderated pain) with a start date of 9/17/2024; and, - Norco 10/325 mg 1 tablet by mouth every 4 hours PRN for severe pain (pain score 7-10 is severe pain) with a start date of 9/17/2024. During a concurrent interview and record review on 9/18/2024 at 2:52 p.m. with Registered Nurse (RN 7) 7, RN 7 verified that Patient 28’s MAR indicated on 9/17/24 at 6:38 p.m., Patient 28 was given Norco 7.5/325 mg 1 tablet by mouth (ordered for moderate pain). The corresponding pain assessment indicated Patient 28’s pain score was 8 (severe pain). During the same interview on 9/18/2024 at 2:52 p.m., RN 7 stated it was important to give the right medication based on the patient’s (Patient 28) pain score assessment to manage the patient’s pain. RN 7 confirmed Patient 28 received Norco 7.5/325 mg 1 tablet by mouth that was ordered for moderate pain, Patient 28 should have been given pain medication as ordered for severe pain During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 02/2022, the P&P indicated, “Before administering a medication, the licensed independent practitioner or qualified individual administering the medication shall follow the seven (7) right of medication administration. Medications must be administered as ordered.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36206 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by: 1. The facility failed to ensure the staff obtained a specific physician order for each episode of restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use including the type of restraint used and the indication for restraints use for one of two sampled patients (Patient 24) in accordance with the facility’s policy and procedure regarding the use of restraints. This deficient practice resulted in Patient 24 being restrained without proper physician order reflecting the type of restraint in use and the indication for restraint use, which may result in complications of improper restraint use such as dehydration, choking, skin problems, etc. (Refer to A-0168) 2. The facility failed to ensure restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) orders were renewed daily for two of 30 sampled patients (Patient 10 and Patient 13) in accordance with the facility’s policy and procedure regarding renewal of orders for restraint use. This deficient practice resulted in Patients 10 and 13 being restrained without a physician’s order and indication for restraint use, which had the potential to result in improper patient restraints use and may lead to patient harm with complications such as choking, dehydration, etc. (Refer to A-0172) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality care in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to initiate a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) regarding hemodialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) and cholecystitis (inflammation of the gallbladder, a small, digestive organ beneath the liver),respectively, upon admission, for two of 30 sampled patients (Patient 22 and Patient 30) in accordance with the facility’s policy and procedure regarding care plan initiation. This deficient practice had the potential to result in the delay of treatment by not identifying the patients’ (Patient 22 and Patient 30) needs and risks, which may result in worsening of the patients’ (Patient 22 and Patient 30) condition and prolonged hospitalization. (Refer to A-0396) 2. The facility failed to document review of the care plan and update the care plan regarding infection, every shift, for one of 30 sampled patients (Patient 16) in accordance with the facility’s policy and procedure regarding updating care plans. This deficient practice had the potential to result in worsening of infection for Patient 16 when the interventions indicated in the care plan are not being implemented and evaluated to determine Patient 16’s response to the interventions. (Refer to A-0396) 3. The facility failed to ensure nursing admission assessments (the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected) were conducted within twenty-four (24) hours of admission and vital signs (measure basic function of the body including body temperature, blood pressure, heart rate or pulse and respiration) were checked and documented according to the appropriate level of care (from the most seriously ill to the less serious) for three of 30 sampled patients (Patients 9, 15, and 18), in accordance with the facility’s policies and procedures regarding assessment, reassessment, and vital signs check. This deficient practice had the potential for the inability to identify potential changes in patients’ (Patients 9, 15, and 18) condition and can result in a delay of care, which may lead to worsening of patient condition and/or death. (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“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: 48212 Based on observation, interview and record review, the facility failed to ensure the staff obtained a specific physician order for each episode of restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use including the type of restraint used and the indication for restraints use for one of two sampled patients (Patient 24) in accordance with the facility’s policy and procedure regarding the use of restraints. This deficient practice resulted in Patient 24 being restrained without a proper physician order reflecting the type of restraint in use and the indication for restraint use, which may result in complications of improper restraint use such as dehydration, choking, skin problems, etc. Findings: During an observation on 1/24/2024 at 10:25 a.m., in Patient 24’s room, with the Director of Medical Surgical (serves the general population hospitalized for various cases such as surgery, etc.) and Telemetry (a unit in the hospital where patients undergo continuous heart monitoring) Unit (DIR 7), Patient 24 was observed to have bilateral (both) wrist restraints (restraints made of foam padding applied to wrists area to restrict movement of the arms) and bilateral mittens (cloth mittens placed on the hands to restrict movement of the hands and fingers). During a review of Patient 24’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/15/2024, the H&P indicated, Patient 28 was admitted to the facility with diagnoses of cholecystitis (inflammation of gallbladder, a small, digestive organ beneath the liver) and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Patient 24’s physician order of restraints, dated 1/26/2024, the order indicated, “restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) type: bilateral mittens, bilateral wrists, vest (a jacket placed on someone to restrict body movement), and 4 bed side rails (side rails of the hospital bed were up to restrict someone from getting out of the bed).” During a review of Patient 24’s physician order titled “continuation of restraints,” with dates from 1/17/2024 to 1/25/2024, the physician orders indicated, “I (the signed physician) have assessed the patient (Patient 24) and have determined that the reason for and type of restraints is unchanged.” The physician order did not indicate the type of restraints being used and the indication for restraint use on Patient 24. This was validated by the Supervisor of Clinical Informatics Registered Nurse (SCIRN) during an interview. During a review of Patient 24’s restraints flowsheet (documentation for restraints indication and type of restraints used), the restraints flowsheet indicated the following: Restraints started on 1/16/2024 at 4 p.m. with bilateral mittens, vest and 4 bed side rails On 1/16/2024 at 8 p.m., restraint was decreased to vest and 4 bed side rails. Bilateral mittens were removed On 1/17/2024 at 8 a.m., nurse added bilateral mittens along with vest and 4 bed side rails On 1/17/2024 at 12 p.m., nurse added bilateral wrist restraints along with bilateral mittens, vest and 4 bed side rails On 1/19/2024 at 8 p.m., restraint was decreased to bilateral wrists. Bilateral mittens, 4 bed side rails and the vest were not in use. On 1/21/2024 at 12 p.m., nurse added restraint of bilateral mittens along with bilateral wrist restraints During an interview on 1/25/2024 at 3:41 p.m. with the Supervisor of Clinical Informatics Registered Nurse (SCIRN), SCIRN stated that the nurse should have obtained a new and specific physician order when adding restraints for a patient (Patient 24). Likewise, the SCIRN stated, restraint order should reflect the type of restraints being used and the specific indication for restraint use. However, in the case of Patient 24, the type of restraints to be used were not indicated in the physician orders from 1/17/2024 to 1/25/2024. In addition, the reason for the type of restraint use was not documented in each of the physician orders from 1/17/2024 to 1/25/2024. During a review of the facility’s policy and procedure (P&P) titled, “Restraints Seclusion,” dated 12/2021, the P&P indicated, “Orders for restraint use are episode specific. For a patient experiencing early release, a new order is required to re-apply the restraint when a new need is identified ... Orders contain the type of restraints device ordered, the rationale for the order, and the time frame for restraints use if less than the maximum allowed time.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (ii) After 24 hours, before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, 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 must see and assess the patient. This Standard is not met as evidenced by: 36206 Based on observation, interview, and record review the facility failed to ensure restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) orders were renewed daily for two of 30 sampled patients (Patient 10 and Patient 13) in accordance with the facility’s policy and procedure regarding renewal of orders for restraint use. This deficient practice resulted in Patients 10 and 13 being restrained without a physician’s order and indication for restraint use, which had the potential to result in improper patient restraints and may lead to patient harm with complications such as choking, dehydration, etc. Findings: 1. During an observation on 1/24/2024 at 10:25 a.m., with Registered Nurse (RN) 3, in the Medical Surgical (serves the general population hospitalized for various cases such as surgery, etc.) and Telemetry (a unit in the hospital where patients undergo continuous heart monitoring) unit, Patient 10 was observed asleep in bed and receiving oxygen via a BiPAP (Bilevel positive airway pressure, a machine that helps push air into the lungs). Patient 10 had soft restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) placed on both left and right wrists. Concurrently, on 1/24/2024 at 10:25 a.m., Registered Nurse (RN) 3 stated Patient 10 had restraints to the wrist to prevent Patient 10 from removing her (Patient 10) oxygen tubing. During a review of Patient 10’s History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/11/2024, the H&P indicated Patient 10 “was admitted to the facility for altered mental status (change in mental function) ...Patient is alert and awake but not following any commands.” During a review of Patient 10’s “Flowsheets,” for restraint documentation, dated from 1/15/2024 at 6:48 p.m. to 1/19/2024 at 10 a.m., the Flowsheets indicated, Patient 10 had non-violent restraints (when a restraint is used to promote healing and improve the patient’s well-being as opposed to violent behavior in which the behavior places the patient at risk for injuring self or others) to the left and right wrist for repeated attempts to remove medical equipment. The Flowsheet also indicated Patient 10 was confused and unable or does not understand instructions. Patient 10’s restraints were removed on 1/19/2024 at 12 p.m. During a review of Patient 10’s “Restraint Orders,” the restraint orders indicated the following: 1/15/2024 at 6:47 p.m., Restraint Non-Violent Routine. There were no restraint renewal orders for 1/16/2024, 1/17/2024, 1/18/2024, and 1/19/2024. This finding was validated during an interview with the SIRN and the CDCI. During a concurrent interview and record review of Patient 10’s restraint orders and nursing flowsheet, on 1/25/2023 at 12 p.m., with the Senior Clinical Informatics Registered Nurse (SIRN) and the Corporate Director of Clinical Informatics (CDCI), the SIRN and CDCI stated the following: Patient 10 was admitted to the facility for altered mental status. Patient 10 was placed on non-violent restraints to both wrists on 1/15/2024 at 6:47 p.m. The restraints were placed because Patient 10 was confused, and the facility wanted to prevent Patient 10 from removing her IV (intravenous, in the vein) lines. The restraints were removed on 1/19/2024 at 12 p.m. Restraint orders should be renewed by a physician every day, after completing a face-to-face assessment. A physician assessment was required to determine whether or not Patient 10’s restraints could be discontinued or continued. The SIRN and the CDCI verified there were no restraint renewal orders for 1/16/2024, 1/17/2024, 1/18/2024, and 1/19/2024 despite Patient 10 having bilateral (both) wrist restraints applied on the said dates. During an interview on 1/25/2024 at 3:42 p.m., with the Director of the Medical Surgical and Telemetry unit (DIR7), the DIR7 verified that Patient 10’s restraint orders were not renewed on 1/16/2024, 1/17/2024, 1/18/2024, and 1/19/2024. DIR7 stated nursing staff should have contacted the physician regarding the need to renew the restraint orders. DIR7 also said the physician should conduct a face-to-face assessment in order to determine if it was still appropriate for Patient 10 to be restrained. During a review of the facility’s policy and procedure (P&P) titled, “Restraints Seclusion #PC-380,” dated 12/2021, the P&P indicated, “Renewal Orders-Orders are time limited and only good through the end of the calendar day following the order date. Physicians who renew restraint orders do so after a face-to-face assessment of the patient’s need to continue restraint use ...” 2. During a review of Patient 13’s History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/21/2023, the H&P indicated the following: Patient 13 was admitted for a brain mass (a growth of abnormal cells in the brain) and encephalopathy (a disturbance in brain function). In addition, Patient 13 had altered mental status (change in mental function). During a review of Patient 13’s nurse’s notes titled, “Care Assessments,” the Care Assessments indicated a non-violent (when a restraint is used to promote healing and improve the patient’s well-being as opposed to violent behavior in which the behavior places the patient at risk for injuring self or others) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body): Vest Restraint was applied on 12/27/2023 at 2 a.m., and removed on 12/29/2024 at 10 p.m. During a review of Patient 13’s physician’s order titled, “Continuation of Restraints,” dated 12/27/2023, the order indicated “I have assessed the patient and have determined that the reason for and type of restraints is unchanged. There was no restraint renewal order for 12/28/2023 and 12/29/2023. This was confirmed by the SCIRN during an interview. During a concurrent interview and record review of Patient 13’s restraint orders and nursing flowsheet for restraint use, on 1/25/2023 at 5:45 p.m., with the Senior Clinical Informatics Registered Nurse (SIRN) and the Corporate Director of Clinical Informatics (CDCI), the SIRN and CDCI stated the following: Patient 13 had an order for non-violent restraints on 12/27/2023. Per the nursing flowsheets, Patient 13 was restrained with a vest (a jacket placed on someone to restrict body movement) from 12/27/2023 through 12/29/2023 due to confusion. The SIRN and CDCI verified that there was no restraint renewal order for 12/28/2023 and 12/29/2023 despite Patient 13 being on vest restraint during the dates of 12/28/2023 and 12/29/2023. During a review of the facility’s policy and procedure (P&P) titled, “Restraints Seclusion #PC-380,” dated 12/2021, indicated, “Renewal Orders-Orders are time limited and only good through the end of the calendar day following the order date. Physicians who renew restraint orders do so after a face-to-face assessment of the patient’s need to continue restraint use ...””

“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: 48212 Based on interview and record review, the facility failed to: 1. Initiate a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) regarding hemodialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) and cholecystitis (inflammation of the gallbladder, a small, digestive organ beneath the liver), respectively, upon admission, for two of 30 sampled patients (Patient 22 and Patient 30) in accordance with the facility’s policy and procedure regarding care plan initiation. This deficient practice had the potential to result in the delay of treatment by not identifying the patients’ (Patient 22 and Patient 30) needs and risks, which may result in worsening of the patients’ (Patient 22 and Patient 30) condition and prolonged hospitalization. 2. Document review of the care plan and update the care plan regarding infection, every shift, for one of 30 sampled patients (Patient 16) in accordance with the facility’s policy and procedure regarding updating care plans. This deficient practice had the potential to result in worsening of infection for Patient 16 when the interventions indicated in the care plan are not being implemented and evaluated to determine Patient 16’s response to the interventions. Findings: 1a. During a review of Patient 22’s “Nephrology (specialty of internal medicine that concerns that study of the kidneys) Consultation,” dated 12/9/2023, the Nephrology Consultation record indicated, Patient 22 was admitted to the facility with diagnosis of chronic kidney disease (longstanding disease of the kidneys leading to renal failure [when kidneys stop working]) and plan to initiate hemodialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) at the facility by Monday 12/11/2023. During a review of Patient 22’s “care assessment,” dated 12/11/2023, the care assessment notes indicated, Patient 22 had his (Patient 22) first hemodialysis at the facility on 12/11/2023. During a concurrent interview and record review on 1/25/2024 at 10:49 a.m. with the Senior Clinical Informatics Registered Nurse (SCIRN), Patient 22’s care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was reviewed. The care plan indicated a new nursing problem with “dialysis - risk for injury” was initiated on 12/13/2023. SCIRN stated that the care plan should have been initiated on the day Patient 22 was admitted which was on 12/9/2023 in preparation for the scheduled hemodialysis on 12/11/2023. SCIRN said the care plan was not initiated in a timely manner. SICRN also said the care plan needed to be implemented in a timely manner to ensure interventions were implemented to meet Patient 22’s needs. During a review of the facility’s policy and Procedure (P&P) titled, “Multidisciplinary Plan of Care,” dated 12/2022, the P&P indicated, “Planning for medical, nursing, and other clinical discipline(s) care, treatment, and service(s) is individualized to meet the patient’s unique needs ... the plan is maintained and revised based on patient’s response ...The care plan is initiated upon admission and the plan for presenting problems should be fully developed within 24 hours of admission. During the course of hospitalization, the plan should be updated as new issues arise or change in condition occur.” 1b. During a review of Patient 30’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 11/27/2023, the H&P indicated, Patient 30 was admitted to the facility with diagnoses of cholecystitis (inflammation of gallbladder, a small, digestive organ beneath the liver). During a review of Patient 30’s face sheet (face sheet, information including patient’s basic information and demographic data), dated 11/27/2023, the face sheet indicated Patient 30 was admitted to the facility on 11/27/2023 at 6:48 a.m. During a concurrent interview and record review on 1/25/2024 at 10 a.m. with the Director of Emergency Services (DIR5), Patient 30’s care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was reviewed. The record indicated that the care plan regarding cholecystitis was initiated on 11/28/2023 at 11:57 a.m. DIR5 verified that the care plan was not initiated and completed within 24 hours of admission (admission date was 11/27/2023 at 6:48 a.m.). DIR5 also said the care plan was important to ensure that appropriate interventions were implemented and the patient’s (Patient 30) response to interventions were evaluated if there was a need to make changes to ensure that patient’s (Patient 30) needs (such as the need to adjust the dose of pain medication to address any patient complaint of pain resulting from the diagnosis of cholecystitis) were being met. During a review of the facility’s policy and Procedure (P&P) titled, “Multidisciplinary Plan of Care,” dated 12/2022, the P&P indicated, “Planning for medical, nursing, and other clinical discipline(s) care, treatment, and service(s) is individualized to meet the patient’s unique needs ... the plan is maintained and revised based on patient’s response ...The care plan is initiated upon admission and the plan for presenting problems should be fully developed within 24 hours of admission. During the course of hospitalization, the plan should be updated as new issues arise or change in condition occur.” 2. During a review of Patient 16’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/21/2023, the H&P indicated, Patient 16 was admitted to the facility on 9/20/2023 with diagnoses of altered mental status (confusion), urinary tract infection (an infection in any part of the urinary system such as the kidneys, bladder [organ in the body that holds urine], or urethra [the tube that lets the urine leave the bladder and the body]), and sepsis (a life-threatening complication of an infection). During a review of Patient 16’s “Care Plan (provides a framework for evaluating and providing patient care needs related to the nursing process),” the care plan indicated the nursing problem of infection risk was initiated on 9/20/2023 indicating the absence of infection signs and symptoms and knowledge of infection control as the outcomes. During a concurrent interview and record review on 1/25/2024 at 10:26 a.m. with the Senior Clinical Informatics Registered Nurse (SCIRN), Patient 16’s care plan was reviewed. SCIRN verified that the care plan with nursing problem of infection was not documented to have been reviewed or updated by the nursing staff on 9/21/2023 day shift, 9/21/2023 night shift, 9/22/2023 day shift, 9/22/2023 night shift, 9/23/2023 day shift, 9/23/2023 night shift, 9/24/2023 day shift and 9/24/2023 night shift (total 8 shifts). SCIRN stated the nursing staff should address each nursing problem on the care plan every shift so that nursing staff can provide appropriate care and address the nursing problem. During a review of the facility’s policy and Procedure (P&P) titled, “Multidisciplinary Plan of Care,” dated 12/2022, the P&P indicated, “Planning for medical, nursing, and other clinical discipline(s) care, treatment, and service(s) is individualized to meet the patient’s unique needs ... the plan is maintained and revised based on patient’s response ...The care plan is initiated upon admission and the plan for presenting problems should be fully developed within 24 hours of admission. During the course of hospitalization, the plan should be updated as new issues arise or change in condition occur.””

“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: 36206 Based on interview and record review, the facility failed to ensure nursing admission assessments (the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected) were conducted within twenty-four (24) hours of admission and vital signs (measure basic function of the body including body temperature, blood pressure, heart rate or pulse and respiration) were checked and documented according to the appropriate level of care (from the most seriously ill to the less serious) for three of 30 sampled patients (Patients 9, 15, and 18), in accordance with the facility’s policies and procedures regarding assessment, reassessment, and vital signs check. This deficient practice had the potential for the inability to identify potential changes in patients’ (Patients 9, 15, and 18) condition and can result in a delay of care, which may lead to worsening of patient condition and/or death. Findings: 1. During a review of Patient 9’s History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/20/2024, the H&P indicated the following: Patient 9’s chief complaint was congestive heart failure (CHF, a chronic condition in which the heart does not pump blood as well as it should) and morbid obesity (over 100 pounds of ideal weight). Likewise, Patient 9 reported eye redness and swelling. During a review of Patient 9’s “Admission Assessment (the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected),” the Admission Assessment indicated, Patient 9’s admission assessment was conducted on 1/21/2024 at 6:09 p.m., which was over 24 hours after admission orders were placed on 1/20/2024. During a concurrent interview and record review, on 1/25/2024 at 11:45 a.m., with the Senior Clinical Informatics Registered Nurse (SCIRN) and the Corporate Director of Clinical Informatics (CDCI), the SCIRN and the CDCI stated the following: Patient 9 presented to the Emergency Department (ED, responsible for providing treatment to patients arriving in the facility who are in need of immediate care) on 1/19/2024 at 10:48 p.m., for shortness of breath (difficulty breathing) and needlestick injury (skin is accidently punctured by a used needle). In addition, Patient 9 had an order to be admitted to the Critical Care Unit (CCU, a unit that cares for serious, acute, and/or unstable cardiac [heart] conditions) on 1/20/2024 at 5:53 a.m. However, Patient 9 physically remained in the ED until he (Patient 9) was transferred to the CCU on 1/21/2024 at 6:25 p.m. Patient 9’s admission assessment was performed on 1/21/2024 at 6:09 p.m., over 24-hours after the admission order was written. The SCIRN stated the admission assessment should have been completed within 24-hours of admission to help identify the patient’s needs. The SCIRN confirmed there was a delay in completing the admission assessment for Patient 9. During a review of the facility’s policy and procedure (P&P) titled, “Assessment Reassessment #PC-160,” dated 1/2024, the P&P indicated the following: “All admitted patients coming from the Emergency Department will have the Admission Assessment completed and documented within 24 hours of admission. The Admission assessment includes items such as: general patient history, screenings (travel ...) interpreter needs, communication and education needs, fall risk assessments ...abuse screenings ...” 2. During a review of Patient 15’s History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/27/2023, the H&P indicated Patient 15 was admitted for diabetic ketoacidosis (DKA, serious complication of diabetes [high blood sugar] that can be life-threatening). Patient 15’s diagnoses included “uncontrolled diabetes and hypertension (high blood pressure) ... Plan: We will admit this patient (Patient 15) to intensive care unit (ICU, a unit that handles severe potentially life-threatening cases).” During a review of Patient 15’s “Physician’s Order,” dated 11/27/2023 at 9:06 a.m., the Physician’s Order indicated “Admit to ICU.” During a review of Patient 15’s “Admission Assessment (the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected),” the Admission Assessment indicated Patient 15’s admission assessment was conducted on 11/28/2023 and 2:55 p.m., over 24 hours after admission orders were placed. During a review of Patient 15’s nursing “Flowsheet,” record for vital signs (measure basic function of the body including body temperature, blood pressure, heart rate or pulse and respiration) documentation, dated 11/27/2023, the Flowsheet indicated the following: At 6 a.m., Temperature (Temp) was 97.2 Fahrenheit (F, a unit of measurement), (normal 97.6 to 99.6 F), Blood pressure (BP) was 165/77 (high, normal 90/60 to 120/80), Heart Rate (HR) was 100 (normal is 60 to 100). Respiratory Rate (RR) was 18 (normal is 12 to 20), oxygen saturation (O2 sat) was 98 % (normal is 92 - 100 %). At 8 a.m., no vital signs documented. At 10 a.m., no vital signs documented. At 11: 11 a.m., BP was 136/79 (high), HR was 99, RR was 16, and O2 sat was 98 %. At 2 p.m., BP was 129/73 (high), HR was 91, HR was 86, RR was 12, and O2 sat was 99%. At 4 p.m., no vital signs documented. At 6 p.m., no vital signs documented. At 8 p.m., Temp was 99.2, BP was 131/68 (high), HR was 83, RR was 14, and O2 sat was 96 %. During a concurrent interview and record review, on 1/25/2024 at 4:23 p.m., with the Senior Clinical Informatics Registered Nurse (SIRN) and the Corporate Director of Clinical Informatics (CDCI), the SIRN and the CDCI stated the following: Patient 15 presented to the Emergency Department (ED) on 11/27/2023 at 5:27 a.m., for leg weakness and diabetic ketoacidosis. Patient 15 had an order to be admitted to the Intensive Care Unit (ICU) on 11/27/2023 at 9:06 a.m. The SIRN stated when there was an order to admit a patient and a bed was not available, the nurse in the ED was expected to perform the same duties as if Patient 15 was physically in the ICU, including completing an initial admission assessment within 24-hours of admission and vital signs monitoring documentation, which should be done every 2 hours. However, the ED nurse did not complete an initial admission assessment within 24 hours of admission as well as vital signs monitoring documentation when the patient (Patient 15) remained in the ED for more than 24 hours and had orders for ICU admission. Both the SIRN and the CDCI confirmed that Patient 15 physically remained in the ED on 11/27/2023 and was not transferred to ICU due to lack of bed availability. There was a second admission order for Patient 15 to be admitted to the Neurology-Science unit (a specialized unit in the hospital that cares for patients with brain and spinal disorders) on 11/28/2023 at 9:12 a.m., since Patient 15 cannot be accommodated in the ICU. Patient 15 was then physically admitted to the Neurology- Science unit (responsible for the care of patients with immediate life-threatening problems of the brain, spinal cord [a column of nerve tissue that runs from the base of the skull down the center of the back], and nerves) on 11/28/2023 at 2:38 p.m. Patient 15’s nursing admission assessment was only performed on 11/28/2023 at 2:55 p.m. The SIRN and the CDCI verified the nursing admission assessment was performed over 24-hours after Patient 15’s order for admission to the ICU was written on 11/27/2023. Likewise, the SIRN and the CDCI said that Patient 15’s vital signs were not checked every two hours, on 11/27/2023, in accordance with the facility’s policy and procedure. During a review of the facility’s policy and procedure (P&P) titled, “Assessment Reassessment #PC-160,” dated 1/2024, the P&P indicated the following: “All admitted patients coming from the Emergency Department will have the Admission Assessment completed and documented within 24 hours of admission. The Admission assessment includes items such as: general patient history, screenings (travel ...) interpreter needs, communication and education needs, fall (an unintentional event that results in the person coming to rest on the ground or another lower level) risk assessments ...abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient; abuse can be physical, verbal, emotional, or financial) screenings ....” During a review of the facility’s policy and procedure (P&P) titled, “Vital Signs,” dated 8/2023, the P&P indicated vital signs will be done as follows: Critical Care Units - every two (2) hours ...Emergency Department (ED) - at triage (the process of quickly examining patients who are taken to the hospital in order to decide which ones are the most seriously ill and must be treated first) then as needed according to level of care (from the most seriously ill to the less serious). 3. During a review of Patient 18’s “Emergency Face Sheet (face sheet, information including patient’s basic information and demographic data), the face sheet indicated, Patient 18 went to the facility on 1/22/2024 at 4:11 a.m. due to right foot pain. During a review of Patient 18’s medical record titled “Hospitalist Consult Note (physician notes),” dated 1/23/2024, the physician notes indicated, Patient 18 had a mechanical fall (an unintentional event that results in the person coming to rest on the ground or another lower level) with blunt head trauma (injury to head due to head collides with a surface or object) and right minimally displaced fracture (broken bone, the ends of the bone came out of alignment) at 5th base metatarsal (the long bone on the outside of the foot that connects to the small toe). The physician notes also indicated Patient 18 had medical history of hypertension (high blood pressure). During an interview on 1/23/2024 at 12:13 p.m. with Patient 18, Patient 18 stated she (Patient 18) was upset because her (Patient 18) blood pressure was high upon arrival to the facility’s emergency room, but no one rechecked her (Patient 18) blood pressure or gave her (Patient 18) medication for the elevated blood pressure. Patient 18 stated she (Patient 18) had to tell the nurse to check her (Patient 18) blood pressure and after that she (Patient 18) eventually received blood pressure medication. During a concurrent interview and record review on 1/24/2024 at 2:45p.m. with the Senior Clinical Informatics Registered Nurse (SCIRN), Patient 18’s vital signs record (VS record) was reviewed. The VS record indicated the first set of vital signs were documented on 1/22/2024 at 4:10 a.m. with blood pressure of 205/86 (high, normal range 90/60 to 120/80) millimeters of Mercury (mmHg, a unit of measurement). The vital signs record indicated the next set of vital signs were documented on 1/22/2024 at 11:58 a.m. with blood pressure documented as 188/73 mmHg. SCIRN stated there was an eight-hour gap between the first set of vital signs and second set of vital signs. SCIRN said vital signs should have been taken every 2 hours while patient (Patient 18) was in the emergency room. SCIRN stated that if the blood pressure was left untreated, there would be risk for stroke (brain attack, occurs when something blocks blood supply to part of the brain) and other complications. During an interview on 1/25/2024 at 10:06 a.m. with the Director of Emergency Services (DIR 5), DIR 5 stated Patient 18’s vital signs should have been checked every 2 hours. During a review of the facility’s policy and procedure (P&P) titled, “Vital Signs #V-101,” dated 09/2022, the P&P indicated, “Vital signs will be done minimally every one hour or more often as needed for emergent (immediate attention is required. Example: intervention for cardiac arrest [when the heart stops beating]) patients and every two hours for urgent (quick but not immediate action is required. Example: surgery that can be postponed for another day)/non-urgent (routine care for patients whose condition will not deteriorate over time and/or typically resolve on its own. Example: seasonal allergies, pregnancy tests, etc.) patients.””