Hemet Global Medical Center

“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: 50304 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures were implemented, for four of 45 sample patients ( Patients 11, 17, 26, and 33), when, : 1. For Patients 11 and 17, pain was not reassessed; 2. For Patient 26, the physician was not notified of a low oxygen saturation (O2 Sat, measurement of the percentage of oxygen in the blood, normal is 92 percent [%] or greater) level; and 3. For Patient 33, the atropine (a medication for low heart rate [HR, normal is 60 to 100 beats per minute]) ordered by the physician to be administered as needed was not administered to Patient 33 when the patient’s heart rate dropped below 50 beats per minute. These failures had the potential to delay the treatment for Patients 11, 17, 26, and 33, and may contribute to the worsening of their medical conditions. Findings: 1a. On April 15, 2026, at 3:26 p.m., Patient 11’s record was reviewed with the Clinical Nurse Manger (CNM). A facility document titled, “Pain Score,” dated January 25, 2026, at 10:37 p.m., was reviewed. The document indicated Patient 11 reported a pain score (a pain assessment tool with 0 [zero] meaning no pain and seven to 10 meaning severe pain) of seven out of 10 pain to the abdomen. A facility document titled, “Emergency Continuation,” dated January 26, 2026, was reviewed. The document indicated Patient 11 presented to the Emergency Department (ED, a 24 hour healthcare department providing unscheduled services to patients whose condition requires immediate care) on January 25, 2026, and was diagnosed with kidney stones (hard mineral and salt deposits which form inside the kidneys often causing severe pain). A facility document titled, “Medication Administration Record,” dated January 25, 2026, through January 26, 2026, was reviewed. The document indicated ketorolac (a pain medication) 30 mg/ml (milligrams per milliliter, units of measurement) intravenous (IV, administered through the vein) was administered to Patient 11 on January 26, 2026, at 12:21 a.m. There was no documented evidence a pain reassessment was conducted for Patient 11 after ketolrolac was administered to the patient on January 26, 2026, at 12:21 a.m.. b. On April 14, 2026, at 10 a.m., a review of Patient 17’s record was conducted with the Quality Registered Nurse (QRN). An untitled and undated facility document was reviewed. The document indicated Patient 17 was admitted to the facility on December 10, 2025, for multiple rib fracture (broken bone) and pain. A facility document titled, “History & [and] Physical Note,” dated December 10, 2025, was reviewed. The document indicated, “...The patient [Patient 17] reports he was riding when he swerved to avoid another vehicle, causing him and the motorcycle to slide on the ground...He [Patient 17] currently reports pain in his left ribs...Physical Examination...LUNG: Clear [normal, quiet air movement] to auscultation [listening to the lungs using a stethoscope (an instrument)]...Tenderness [pain when pressure is applied to an area of the body] over the left chest...” A facility document titled, “Results,” dated December 11, 2025, was reviewed. The document indicated, “...[Name of Patient 17]...Order: Chest 1 [one] view [chest x-ray, an imaging procedure]...Findings: Left-sided rib fractures are again noted...” A facility document titled, “Med [Medication] Admin [Administration],” dated December 12, 2025, was reviewed. The document indicated, “...hydrocodone-acetaminophen [a pain medication]...1 tablet...oral...Adm[administration] Time: 12/12/2025 [December 12, 2025] 04:32 [4:32 a.m.]...By: [name of Registered Nurse (RN) 1]...Pain Score...8...ribs...” There was no documented evidence Patient 17’s pain was reassessed after hydrocodone-acetaminophen was administered to the patient on December 12, 2025, at 4:32 a.m. On April 14, 2026, at 11:20 a.m., an interview was conducted with the QRN. The QRN stated the RN did not reassess Patient 17’s pain on December 12, 2025, after the pain medication was administered at 4:32 a.m. The QRN stated the nurse should have reassessed Patient 17’s pain after the pain medication was administered on December 12, 2025, at 4:32 a.m. The QRN stated it is important to reassess a patient’s pain “to make sure interventions worked and to make sure patient is comfortable.” A facility policy and procedure titled, “PAIN MANAGEMENT,” dated September 2024, was reviewed. The facility policy and procedure indicated, “...To Assure that patients receive an assessment and management of their pain consistent with the scope of care, treatment and service provided by the organization...Reassessment Following Treatment for Pain...If a treatment intervention for pain is provided, the response to that intervention should be assessed. Reassessment is recommended to occur within 15 - 60 minutes following treatment...”` 2. On April 15, 2026, at 10:27 a.m., a review of Patient 26’s record was conducted with the QRN. An untitled and undated facility document was reviewed. The document indicated Patient 26 was admitted to the facility on April 6, 2026, for pleural effusion (a buildup of fluid in the space between the lungs and the chest cavity). A facility document titled, “History & Physical Note,” dated April 6, 2026, was reviewed. The document indicated, “...Patient [Patient 26]...came in from home for SOB [shortness of breath]...Physical Examination...Inspiratory [act of breathing in] wheezes [high pitched sound heard using a stethoscope] while breathing in or out]...” An undated facility document title, “Flowsheets,” was reviewed. The document indicated, “...04/13/2026 [April 13, 2026] 08:00 [8 a.m.]...BP [blood pressure, the force of blood pushing against the blood vessel walls as the heart pumps blood throughout the body, normal is 120/80]...122/60...HR...77...O2 Sat...88%...” There was no documented evidence a physician was notified when Patient 26’s O2 Sat was 88% on April 13, 2026, at 8 a.m. On April 15, 2026, at 10:27 a.m., an interview was conducted with the QRN. The QRN stated the RN did not notify the physician when Patient 26’s O2 Sat was low at 88% on April 13, 2026. The QRN stated a low O2 Sat is considered a change in Patient 26’s condition. The QRN stated the RN should have reported Patient 26’s low O2 sat to the physician. The QRN stated, “anything outside of the normal, [the RN should] let the provider [physician] know and [should] reassess [the patient].” The QRN stated the physician should be aware of the change in a patient’s condition so interventions which needed to be done could be ordered by the physician. A facility policy and procedure titled, “CHANGE IN PATIENT CONDITION,” dated May 2024, was reviewed. The policy indicated, “...PURPOSE: To clearly define guidelines for timely notification of a change in patient condition...Any sudden or serious change in the patient’s condition manifested by a marked change in physical or mental behavior will be communicated to the physician at once...” 3. On April 14 , 2026, at 10:41 am., Patient 33’s record was reviewed with the Director of Critical Care (DCC). A facility document titled, “History & Physical,” dated April 13, 2026, at 5:07 a.m., was reviewed. The document indicated Patient 33 was admitted to the facility on April 12, 2026, for a syncopal episode (a temporary loss of consciousness caused by poor blood flow to the brain) while walking. On April 14, 2026, at 11:05 a.m., a facility document titled, “Order Inquiry,” dated April 13, 2026, was reviewed. The document indicated, “...Atropine...AS NEEDED...Route...INTRAVENOUS [administered through the vein]...Start Date...04/13/2026 [April 13, 2026]...04:38 [4:38 a.m.]...Dose...0.5 MG/5 ML...Reason/Indication...Bradycardia...Comment...PRN [as needed] x1 [one time] DOSE FOR SYMPTOMATIC BRADYCARDIA [heart rate less than 60 beats per minute], hr [hour] LESS THAN 50 NOTIFY PHYSICIAN IMMEDIATELY...” An undated and untitled facility document was reviewed. The document indicated the following heart rate for Patient 33: - 43 on April 13, 2026, at 4:15 p.m.; - 45 on April 13, 2026, at 4:16 p.m.; - 48 on April 13, 2026, at 4:17 p.m.; - 46 on April 13, 2026, at 10 p.m.; - 41 on April 14, 2026, at 12 a.m.; and - 38 on April 14, 2026, at 1:20 a.m. There was no documented evidence the physician was immediately notified when Patient 33’s heart rate dropped below 50 beats per minute on April 13, 2026, and April 14, 2026. There was no documented evidence the PRN atropine was administered to Patient 33 given when Patient 33’s heart rate dropped below 50 beats per minute on April 13, 2026, and April 14, 2026. On April 14, 2026, at 11:11 a.m., an interview was conducted with the CNM. The CNM stated the RN should have reported the drop in Patient 33’s heart rate to the physician. The CNM further stated the RN should have administered the PRN atropine when Patient 33’s heart rate dropped below 50 beats per minute. A facility policy and procedure titled, “STANDARD MEDIATION ADMINISTRATION TIMES,” dated June 2024, was reviewed. The document indicated, “...Medications NOT eligible for scheduled dosing times include...Drugs prescribed on an as needed basis (prn doses)...PRN (as needed) medications shall be administered at the intervals or within the parameters prescribed. The first dose shall be administered at the time “prn” parameters are met...””

“RESPIRATORY CARE SERVICES POLICIES CFR(s): 482.57(b) Services must be delivered in accordance with medical staff directives. This Standard is not met as evidenced by: 35056 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for three of 45 sampled patients (Patient 29, 35, and 44), when: 1. For Patient 29, the physician was not notified of a critical value (a test result which is so far outside the normal range that it indicates a potentially life-threatening situation) for an arterial blood gas (ABG, a laboratory test which measures the levels of oxygen, carbon dioxide, and the acid-base balance [pH, refers to the levels of acidity and alkalinity [base] the blood needs in order to keep the body functioning]) test; 2. For Patient 35, the ABG was not completed as ordered by the physician; and 3. For Patient 44, a stat (to be performed immediately) ABG test was not completed as ordered by the physician. These failures had the potential to delay the care and treatment for Patients 29, 44, and 35 and may contribute to the worsening of their medical conditions. Findings: 1. On April 15, 2026, at 2:49 p.m., a review of Patient 29’s record was conducted with the Quality Registered Nurse (QRN). A facility document titled, “History & [and] Physical Note,” dated February 12, 2026, was reviewed. The document indicated Patient 29 was admitted to the facility on February 12, 2026, for acute metabolic encephalopathy (a sudden change in how the brain works due to an underlying condition) and acute kidney injury (AKI, a sudden reduction in kidney function). A facility document title, “Laboratory Detail,” dated February 13, 2026, was reviewed. The document indicated, “...Arterial blood Gas...Ordered Dttm [Date Time]: 02/13/2026 [February 13, 2026] 02:00 [2 a.m.]...HGB [hemoglobin, an iron-rich protein located inside red blood cells which carries oxygen from the lungs to the body’s tissues and organs]-ABG...7.2...Reference Range [upper and lower limits of the results] 12.2-16.2 g/dl [grams per deciliter (a unit of measurement)]...” There was no documented evidence the critical result for the HGB-ABG was reported to a physician. On April 15, 2026, at 3:10 p.m., an interview was conducted with the QRN. The QRN stated the respiratory therapist (RT, a specialized healthcare professionals who diagnose, treat, and manage patients with breathing disorders) did not report the critical result for Patient 29 to the physician. The QRN stated the RT should have reported Patient 29’s critical result to the physician. On April 15, 2026, at 3:50 p.m., an interview was conducted with Lead Respiratory Therapist (LRT). The LRT stated the RTs are responsible for the ABG tests. The LRT stated when they have a critical value, they notify the physician within an hour and “document on the critical value tab in the computer.” The LRT stated, “The critical result [for Patient 29] should have been called to the physician.” The LRT stated, it is important “to follow the [facility’s] policy to protect the patient.” On April 16, 2026, at 12:22 p.m., an interview was conducted with the Director of Laboratory services (DOL). The DOL stated, it is important to report critical results because “critical results on a patient requires immediate clinician intervention.” A facility policy and procedure titled, “CRITICAL POINTS IN ARTERIAL BLOOD GASES (CRITICAL LAB [laboratory] VALUES,” dated May 2023, was reviewed. The facility policy and procedure indicated, “...Manual: Respiratory Care Services [specialized diagnostic and therapeutic procedures performed by licensed Respiratory Therapists to manage, treat, and support patient breathing and cardiopulmonary function]...Respiratory therapists who draw Arterial Blood Gases will notify physicians should the ABG show any value outside the reference range...Hemoglobin...0-7 Notify physician...” 2. On April 14 , 2026, at 2:52 p.m., Patient 35’s record was reviewed with the Director of Critical Care (DCC). A facility document titled, “History & Physical,” dated April 3, 2026, at 10:28 p.m., was reviewed. The document indicated Patient 35 was admitted to the facility on April 3, 2026, for difficulty breathing (shortness of breath) and productive cough (cough with mucus secretion). The document indicated Patient 35 has a history of right lower lobe nodule (a growth in the lung). On April 14, 2026, at 3:05 p.m., a facility document titled, “Order Inquiry,” dated April 3, 2026, at 12:07 a.m., was reviewed. The document indicated, “...1 [one] ABG...start date...04/03/2026 [April 3, 2026] 20:52 [8:52 p.m.]...once...” There was no documented evidence the ABG laboratory test was completed for Patient 35 as ordered by the physician. On April 14, 2026, at 3:09 p.m., an interview was conducted with the Emergency Department Director (EDD). The EDD stated the ABG test ordered for Patient 35 on April 3, 2026, at 8:52 p.m., was not completed. The EDD stated the RT is responsible for completing the blood draw for the ABG. The EDD stated the RN assigned to Patient 35 should have followed up with the laboratory or the RT for the ABG result based on the physician’s order. On April 14, 2025, at 3:33 p.m., an interview was conducted with the Lead Respiratory Therapist (LRT). The LRT stated there was an order placed for the ABG for Patient 35 and based on the record, there was no result for the ordered ABG. The LRT stated the blood draw for the ABG was not completed and should have been drawn based on the physician’s order. The LRT stated the RT should have placed a note in Patient 35’s record as to why the ordered ABG was not completed. A facility P&P titled, “ARTERIAL BLOOD GAS ANALYSIS,” dated May 2023, was reviewed. The P&P indicated, “...Respiratory Care Services to provide...blood gas and pH [potential of hydrogen, measurement of the acidity or alkalinity of the blood] analysis and hemoximetry [measurement of the oxygen in the blood]...as ordered by the patient’s physician...” 3. On April 16, 2026, at 9:56 a.m., a review of Patient 44’s medical record was conducted with the Quality Registered Nurse (QRN). A facility document titled, “History & Physical Note,” dated February 12, 2026, was reviewed. The document indicated Patient 44 was admitted to the facility on December 30, 2025, for uncomplicated urinary tract infection (an infection caused by bacteria entering the urinary system, typically the bladder and urethra, leading to inflammation, pain, and a strong, persistent urge to urinate). A facility document titled, “Order Entry,” dated December 30, 2025, was reviewed. The document indicated, “...Order...Arterial Blood Gas...Start Date...12/30/2025 [December 30, 2025] 08:00 [8 a.m.]...Priority...Stat [immediately or without delay]...” An undated facility document titled, “LAB [laboratory] SPECIMEN INTERNAL INQUIRY,” was reviewed. The document indicated, “...[Name of Patient 44]...CANCELLED...01/01/26 [January 1, 2026] 0005 [12:05 a.m.]...BY: AutoCancel...Auto-cancelled after 1 day...Ordered: BLOOD GASES...STAT [to be performed immediately] 12/30/2025...<No results entered>...” On April 16, 2026, at 10:45 a.m., an interview was conducted with the QRN. The QRN stated there was no result for the stat ABG ordered for Patient 44 on December 30, 2025, at 8 am. The QRN stated the ABG ordered for Patient 44 on December 30, 2025, was not done. On April 16, 2026, at 10:45 a.m., an interview was conducted with the Director of Respiratory Therapy (DORT). The DOR stated the stat ABG ordered on December 30, 2025, at 8 a.m., for Patient 44, was automatically cancelled after one day and was not completed. The DOR stated the ABG order for Patient 44 on December 30, 2025, should have been done by the RT. The DOR stated there was no documentation from the RT on why the ABG ordered for Patient 44 on December 30, 2025, was not completed. On April 16, 2026, at 12:22 a.m., an interview was conducted with the DOL. The DOL stated for stat orders, “The [facility’s] policy says collection is within 10 minutes to 15 minutes otherwise they will be drawn within 60 minutes and result will be in 60 minutes.” The DOL stated it is important to perform stat orders on time “to make sure patient care is provided in a timely manner.” A facility policy and procedure titled, “REQUESTS FOR LABORATORY TESTS,” dated February 2024, was reviewed. The facility policy and procedure indicated, “...PRIORITY OF REQEUSTS...The priority of the request...should be indicated on all order requisitions...LABORATORY RESPONSE AND TURNAROUND [the total time taken from receiving a specimen to delivering the final validated test results to the clinician] TIME...Stat...Provided this level of urgency is phoned to the Lab, requests for tests ordered as STAT will be collected within 10 to 15 minutes from the time they were ordered otherwise they will be drawn within 60 minutes...Once received into the Clinical Laboratory all staff orders will be processed to completion in less than 60 minutes...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 45431 Based on interview and record review, the facility failed to comply with the provisions in 42 CFR §489.2(l), § and 489.24, when the facility failed to ensure the emergency medical condition (EMC, serious medical condition) was stabilized, for two of 20 sampled patients (Patient 5 and 8), when: 1. Patient 5 was discharged from the Emergency Department (ED, a unit which provides immediate unscheduled care for of acute [rapid onset] illnesses and life-threatening condition) while still demented (someone exhibiting severe mental deterioration, often from a condition like dementia, a condition with persistent impairment of memory) and without notifying the family and the facility to which the patient was being discharged to before discharging Patient 5; and 2. Patient 8 was transferred to another facility (Facility C) while the patient was having active bleeding and had low blood pressure (BP, normal is 120/80). These failures resulted in Patient 5 to be discharged while the patient was confused and brought back by the ambulance to the facility. These failures resulted in Patient 8 to continue to suffer from low BP and be admitted to the intensive care unit (ICU, unit for critically ill patients) at Facility C where the patient underwent emergency surgery.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure the emergency medical condition (EMC, serious medical condition) was stabilized, for two of 20 sampled patients (Patient 5 and 8), when: 1. Patient 5 was discharged from the Emergency Department (ED, a unit which provides immediate unscheduled care for of acute [rapid onset] illnesses and life-threatening condition) while still demented (someone exhibiting severe mental deterioration, often from a condition like dementia, a condition with persistent impairment of memory) and without notifying the family and the facility to which the patient was being discharged to before discharging Patient 5; and 2. Patient 8 was transferred to another facility (Facility C) while the patient was having active bleeding and had low blood pressure (BP, normal is 120/80). These failures resulted in Patient 5 to be discharged while the patient was confused and brought back by the ambulance to the facility. These failures resulted in Patient 8 to continue to suffer from low BP and be admitted to the intensive care unit (ICU, unit for critically ill patients) at Facility C where the patient underwent emergency surgery. Findings: 1. A review of Patient 5’s record was conducted on February 10, 2026, at 2:30 p.m., with the Emergency Department Director (EDD). A facility document titled, “Triage [the preliminary assessment of patients in order to determine the urgency of their need for treatment and the nature of treatment required],” dated January 6, 2026, was reviewed. The document indicated, “...[Name of Patient 5]...Chief Complaint: AMS [altered mental status, a sudden or gradual change in a person’s baseline mental state, including confusion]...Arrival Date/Time: 01/06/2026 [January 6, 2026]...13:21 [1:21 p.m.]...Patient Narrative: BIBA [brought in by ambulance] for increased confusion and multiple falls, [family member] worried about her hitting head 2 [two] weeks ago and confusion getting worse...speech: disoriented...” A facility document titled, “Emergency Department Record,” dated January 6, 2026, was reviewed. The document indicated, “ ...History of Present Illness ...Patient [Patient 5] ...presenting to the ED via EMS [Emergency Medical Services, an ambulance service] from [Name of Facility A] ...Family reported to EMS the patient’s mentation [the ability, activity, or result of using your mind to think] has been declining over the past 2 months ...Past medical history ...HTN [hypertension, high blood pressure], neuropathy [nerve damage], chronic [constantly recurring] back pain ...Diagnosis ....fall, no serious injuries ....” A facility document titled, “Emergency Continuation,” dated January 6, 2026, was reviewed. The document indicated, “...ED Course/Medical Decision Making...I was kindly asked to follow up on the pleasant demented [elderly] [Patient 5] with recent fall...Patient [Patient 5] referred for evaluation of confusion above baseline [the usual, stable, everyday level of awareness and thinking]... Episodic confusion is noted...” A facility document titled, “Daily Focus Assessment,” dated January 6, 2026, was reviewed. The document indicated, “ ...22:00 [10 p.m.] ...Pt [Patient 5] @ [at] CT [Computed Tomography, a diagnostic imaging procedure] ...Pt medicated for CT, pt confused attempting to get out bed ...” A facility document titled, “CT Brain w/o [without] Contrast,” dated January 6, 2026, at 8:10 a.m. was reveiwed. The document indicated, “...Study Reason...Falling injury...Impression...No acute intracranial [within the skull] hemorrhage [bleeding] nor acute osseous [bone] abnormality...mild to moderate generalized brain parenchymal [tissue] volume loss...” A facility document titled, “Emergency Continuation,” dated January 6, 2026, indicated, “...21:33 [9:33 p.m.]...Diagnosis: Dementia [a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory]...ED disposition...home...” A facility document titled, “Discharge Assessment/Summary Report,” dated January 7, 2026, at 1:15 a.m. was reveiwed. The document indicated, “...Discharge instructions....Discharge disposition: skilled nursing facility [SNF - are places for people to live temporarily while they’re getting rehabilitation and medical treatments after hospitalization for an illness or injury]...Discharge instructions given to EMS...” An untitled document dated January 7, 2026, at 1:15 a.m. was reviewed. The document indicated, “...Fall Prevention for Older Adults - Discharge Care...Dementia - After Care...Instructions (ER/ED)...Patient/Guardian’s Signature...Patient unable to sign...” A facility document titled, “Daily Focus Assessment,” dated January 7, 2026, was reviewed. The document indicated, “...01:15 [1:15 a.m.]...Pt was discharged back to [Name of Facility A]...[name of ambulance service] ambulance transported back pt to facility...” A facility document titled, “Triage,” dated January 7, 2026, was reviewed. The document indicated Patient 5 returned to the ED on January 7, 2026, at 2:51 a.m. (approximately one hour and 36 minutes after being discharged from the facility). The document indicated Patient 5 had worsening confusion and inability to care for herself. The document indicated Patient 5 required transfer to another facility (Facility B) for placement after the second visit to the ED on January 7, 2026, at 2:51 a.m. A facility document titled, “Emergency Department Record,” dated January 7, 2026, at 5:32 a.m. was reviewed. The document indicated, “...[Patient 5] presenting to the ED via EMS...altered mentation with confusion...Patient thought to be unable to care for self, paramedics forced to return as patient will likely require placement [a transfer to another facility for continuation of care]...Disposition...Diagnosis...Failure to thrive...Discharge Disposition...Transfer to [name of Facility B]...” During review of Patient 5’s record, there was no documented evidence Facility A and Patient 5’s family were notified before Patient 5 was discharged from the facility. On February 10, 2026, at 2:58 p.m., an interview was conducted with the EDD. The EDD stated the facility’s policy was not followed when the receiving facility and the family was not notified of Patient 5’s discharge. A facility policy and procedure (P&P) titled, “Discharge from Emergency Department,” dated August 2019, was conducted and indicated, “ ... After being evaluated in the Emergency Department (ED) by a Licensed Independent Practitioner [LIP, individuals other than Medical Staff members who are permitted by law and by the facility to provide patient care services]] and or MD [physician], appropriate discharge planning [a centralized, collaborative process that prepares patients for a safe, smooth transition from the hospital to home or another facilitydefine] for a patient includes completing a medical record, making a plan to follow-up care suitable to the individual patient’s needs and ensures that the patient understands all aspects of their care and discharge plan ...The ER [ED] RN [Registered Nurse]/LVN [Licensed Vocational Nurse]/LIP will be the shared but primary facilitator of the patient discharge process ...review of discharge instructions with patient and/or responsible party ...Patient’s and/pr responsible party’s attestation to receipt and understanding of discharge instructions ...” 2. On Febuary 9, 2026, at 3:42 p.m., an interview was conducted with Physician 1. Physician 1 stated a pregnant patient who is having an abruptio placenta (a serious pregnancy complication where the placenta [an organ that forms in the womb] detaches from the uterus [womb] before the delivery of the unborn child) should be transferred to another facility for higher level of care (a facility which provides for a more intense, structured, and specialized treatment) right away after being stabilized which includes providing fluid and blood and the patient’s vital signs (objective, essential measurements of the body’s most basic functions which include heart rate, blood pressure, and temperature) should be stable. On February 10, 2026, at 1: 58 p.m., a review of Patient 8’s record was conducted with the EDD. A facility document titled, “Triage,” dated January 29, 2026, was reviewed. The document indicated, “...Chief complaint...seizure [a temporary, uncontrolled disturbance in the brain resulting in convulsions]...Arrival Date/Time...01/29/2026 [January 29, 2026] 17:23 [5:23 p.m.]...BIBA for seizures x [times] 2, pt [Patient 8] about 17 weeks 3 days pregnant [normal pregnancy duration is between 39 weeks 0 days and 40 weeks 6 days]...patient c/o [complains of] abd [abdominal] pain 5/10 [a pain scale where 0 means no pain and 10 means worst pain] with no vaginal bleeding...Vitals and Measurement...BP 117/90...” A facility document titled, “Emergency Department Record,” dated January 29, 2026, was reviewed.The document indicated, “...28 year old patient...reports to the ER for the evaluation of seizure while currently 4-5 [four to five] months pregnant...Chief complaint: seizure...1741[5:41 p.m.] Phone consult with [Name of MD 2] an OBGYN [obstetrics gynecologist, a physician who specializes in the care of pregnant patients before and during childbirth] physician at [Name of Facility C], discussed patient’s [Patient 8’s] case at length including work up...[MD 2] accepts patient to her service...1825 [6:25 p.m.]...Called [Name of Facility C] and gave then the critical read from US [ultrasound, an imaging procedure] and they [Facility C] agree patient needs to be transferred faster...1909 [7:09 p.m.] was called by radiologist [a physician who specializes in the use of imaging procedures for the diagnosis and treatment of disease] and patient is possible having an placental abruption [abruptio placenta]...Called [Name of Facility C] once again to give them the official read [official result of the ultrasound]...1915 [7:15 p.m.]...[Name of Facility C] was then called once again and they wanted us to keep the patient in the ICU till she [Patient 8] was more stable. Called [Name of MD 3] our ICU physician and he does not accept to take over patient care...Diagnosis: acute placental abruption...acute hypotension...condition...Critical...Discharge disposition: Treatment in progress...” An untitled facility document, dated January 29, 2026, was reviewed. The document indicated the following documentation of Patient 8’s BP and heart rate (HR, normal is 60-100) on January 29, 2026: - At 5:50 p.m., the document did not indicate a BP reading, HR: 137; - At 5:55 p.m., BP: 62/30, HR:129; - At 6 p.m., the document did not indicate a BP reading, HR: 128; - At 6:05 p.m., BP: 55/31, HR: 130; - At 6:10 p.m., BP: 56/44, HR:138; - At 6:15 p.m., BP: 52/26, HR: 135; - At 6:20 p.m., BP: 53/30, HR: 132; - At 6:25 p.m., BP: 62/34, HR: 125; - At 6:30 p.m., BP: 69/37, HR:120; - At 6:35 p.m.,BP:69/49, HR: 116; - At 6:40 p.m., BP: 76/44, HR: 114; - At 6:45 p.m., BP: 59/16, HR: 118; and - At 6:50 p.m., BP: 59:16, HR: 126. A facility document titled, “Daily Focus Assessment Report,” dated January 29, 2026, was reviewed. The document indicated, “...1815 [6:15 p.m.] Pt [Patient 8] is extremely lethargic [lacking energy], pale, cool, clammy, and diaphoretic [extensive sweating]. Pts [sic] eyes continuously roll in back of her head- pt goes in and out of consciousness...Pts [sic] abdomen extremely distended...[family member] states pt is 17 weeks pregnant...1820 [6:20 p.m.] Pt quickly became unstable- hypotensive [low BP] and remains tachycardic [with fast heart rate] BP 50/40. [Name of MD 1] verbally orders for emergency blood...1850 [6:50 p.m.] BP remains unstable, frequently fluctuating...1903 [7:03 p.m.] [Name of Air Transport, a team of healthcare workers who transports a patient using an aircraft] arrived at bedside...Pts [sic] BP remains unstable, HR remains tachycardic...1910 [7:10 p.m.]...This RN [registered nurse] attempted to call [Name of Facility C] to give report to RN [from Facility C]- RN who was taking patient stated per her charge nurse she was unable to accept pt due to BP being unstable and that [Name of MD 1] needs to recontact transfer center [a centralized, 24 hours a day department within a hospital or healthcare system which coordinates the transfer of patients in or out of a facility] so pt can go to the SICU [Surgical Intensive Care Unit, a unit providing care for patients who require intensive monitoring following complex surgeries or has life-threatening conditions]...” A facility document titled, “US OB [Obstetrics, the branch of medicine and surgery concerned with childbirth and the care of women before, during, and immediately after they give birth] Limited,” was reviewed. The document indicated, “...Impression: Fluid [amniotic fluid, clear yellow fluid in the womb which protects the unborn child during pregnancy] anterior [in front of] to the placenta raising the possibility of placental abruption...Free fluid is noted in all four quadrants [divisions of thewomb, created by intersecting a vertical and a horizontal line which passes through the navel]...” A facility document titled, “Discharge Assessment/Summary Report,” dated January 19, 2026, was reviewed. The document indicated, “...Patient [Patient 8] departed from the ED Date and Time...01/29/2026 [January 29, 2026] 1930 [7:30 p.m.]...Transferred...Transferred to Higher Level of Care facility [Facility C]...Reason for transfer Placental Abruption...Transferred Status...Critical condition...” A facility document titled, “High Risk OB Interim Patient Care Record,” dated January 29, 2026, was reviewed. The document indicated the following on January 29, 2026: - at 7:15 p.m., no blood pressure reading indicated, pulse [heart rate] 135 bpm [beats per minute]; - at 7:16 p.m., blood pressure 89/65, pulse 109 bpm; - at 7:31 p.m., no blood pressure rading indicated, pulse 137 bpm; - at 7:37 p.m., no blood pressure reading indicated, pulse 135 bpm; - at 7:42 p.m., blood pressure 68/37, pulse 131 bpm; - at 7:50 p.m., blood pressure 97/56, pulse 145 bpm; - at 7:56 p.m., blood pressure 85/55, pulse 136 bpm; and - at 8:02 p.m., no blood pressure reading indicated, pulse 140. During review of Patient 8’s record, there was no documented evidence Patient 8 was transferred to the ICU for stabilization before Patient 8 was transferred to Facility C. There was no documented evidence Patient 8’s blood pressure was stabilized before the patient was transferred to Facility C. On February 11, 2026, at 11 a.m., an interview was conducted with the EDD. The EDD stated Patient 8 should have been admitted to ICU for stabilization before transferring to FAcility C for higher level of care. On February 11, 2026, at 11:27 a.m., an interview was conducted with MD 3. MD 3 stated abruptio placenta is an emergent urgent situation. MD 3 stated he was called about Patient 8 by MD 1. MD 3 stated he is a general surgeon and OB/GYN is not his specialty. MD 3 stated he did not admit Patient 8 because he does not have privileges to admit patients to the facility. On February 12, 2026, at 11:02 a.m., an interview was conducted with MD 4. MD 4 stated his expectation for patients presenting with abruptio placenta is for the ED physician to start the treatment then admit the patient to the ICU and consult a cardiologist (a physician who specializes in the treating heart conditions) to help stabilize the patient. MD 4 stated if it is not possible to stabilize the patient, the patient needs to be air lifted (transport usually by helicopter used for medical emergency) and transferred to a tertiary [a facility providing highly specialized and complex medical services] facility. The facility’s P&P titled, “EMTALA- Definition and General Requirements,” dated April 2023, was reviewed. The P&P indicated, “...Stabilized with respect to an EMC means that no material deterioration of the condition is likely within reasonable medical probability, to result from occurring during the transfer of the individual from the facility or in the case of a woman in labor, that the woman delivered the child and the placenta...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44871 Based on interview, and record review, the hospital failed to ensure patients’ rights were protected and care was provided in a safe setting for two of 20 sampled patients (Patients 5 and 8) when: 1. For Patient 5, the facility did not notify the patient’s family member or the receiving facility, when Patient 5 was assessed to be demented (someone exhibiting severe mental deterioration, impaired memory) (Refer to A-130). 2. For Patient 8, the facility transferred Patient 8 to another facility (Facility C) while the patient was having active bleeding and low blood pressure (BP, normal 120/80) (Refer to A-0144).”

“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: 44871 Based on interview and record review, the facility failed to ensure the patient’s family member was notified before the patient was discharged from the facility, for one of 20 sampled patients (Patient 5), when Patient 5, who was assessed to be demented (someone exhibiting severe mental deterioration, often from a condition like dementia, a condition with persistent impairment of memory), was discharged without notifying the patient’s family and the facility to which the patient was being discharged to (Refer to A0398). The cumulative effect of this resulted in Patient 5 being discharged while the patient was confused and brought back by the ambulance to the facility. This failure had the potential to cause harm to Patient 5.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure the emergency medical condition (EMC, serious medical condition) was stabilized, for two of 20 sampled patients (Patient 5 and 8), when: 1. Patient 5 was discharged from the Emergency Department (ED, a unit which provides immediate unscheduled care for of acute [rapid onset] illnesses and life-threatening condition) while still demented (someone exhibiting severe mental deterioration, often from a condition like dementia, a condition with persistent impairment of memory) and without notifying the family and the facility to which the patient was being discharged to, before discharging Patient 5; and 2. Patient 8 was transferred to another facility (Facility C) while the patient was having active bleeding and had low blood pressure (BP, normal is 120/80). These failures resulted in Patient 5 to be discharged while the patient was confused and brought back by the ambulance to the facility and had the potential to cause harm to Patient 5. These failures resulted in Patient 8 to continue to suffer from low BP and be admitted to the intensive care unit (ICU, unit for critically ill patients) at Facility C where the patient underwent emergency surgery. Findings: 1. A review of Patient 5’s record was conducted on February 10, 2026, at 2:30 p.m., with the Emergency Department Director (EDD). A facility document titled, “Triage [the preliminary assessment of patients in order to determine the urgency of their need for treatment and the nature of treatment required],” dated January 6, 2026, was reviewed. The document indicated, “...[Name of Patient 5]...Chief Complaint: AMS [altered mental status, a sudden or gradual change in a person’s baseline mental state, including confusion]...Arrival Date/Time: 01/06/2026 [January 6, 2026]...13:21 [1:21 p.m.]...Patient Narrative: BIBA [brought in by ambulance] for increased confusion and multiple falls, [family member] worried about her hitting head 2 [two] weeks ago and confusion getting worse...speech: disoriented...” A facility document titled, “Emergency Department Record,” dated January 6, 2026, was reviewed. The document indicated, “ ...History of Present Illness ...Patient [Patient 5] ...presenting to the ED via EMS [Emergency Medical Services, an ambulance service] from [Name of Facility A] ...Family reported to EMS the patient’s mentation [the ability, activity, or result of using your mind to think] has been declining over the past 2 months ...Past medical history ...HTN [hypertension, high blood pressure], neuropathy [nerve damage], chronic [constantly recurring] back pain ...Diagnosis ....fall, no serious injuries ....” A facility document titled, “Emergency Continuation,” dated January 6, 2026, was reviewed. The document indicated, “...ED Course/Medical Decision Making...I was kindly asked to follow up on the pleasant demented [elderly] [Patient 5] with recent fall...Patient [Patient 5] referred for evaluation of confusion above baseline [the usual, stable, everyday level of awareness and thinking]... Episodic confusion is noted...” A facility document titled, “Daily Focus Assessment,” dated January 6, 2026, was reviewed. The document indicated, “ ...22:00 [10 p.m.] ...Pt [Patient 5] @ [at] CT [Computed Tomography, a diagnostic imaging procedure] ...Pt medicated for CT, pt confused attempting to get out bed ...” A facility document titled, “CT Brain w/o [without] Contrast,” dated January 6, 2026, indicated, “...Study Reason...Falling injury...Impression...No acute intracranial [within the skull] hemorrhage [bleeding] nor acute osseous [bone] abnormality...mild to moderate generalized brain parenchymal [tissue] volume loss...” A facility document titled, “Emergency Continuation,” dated January 6, 2026, indicated, “...21:33 [9:33 p.m.]...Diagnosis: Dementia [a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory]...ED disposition...home...” A facility document titled, “Discharge Assessment/Summary Report,” dated January 7, 2026, indicated, “...Discharge instructions....Discharge disposition: skilled nursing facility...Discharge instructions given to EMS...” An untitled document dated January 7, 2026, indicated, “...Fall Prevention for Older Adults - Discharge Care...Dementia - After Care...Instructions (ER/ED)...Patient/Guardian’s Signature...Patient unable to sign...” A facility document titled, “Daily Focus Assessment,” dated January 7, 2026, was reviewed. The document indicated, “...01:15 [1:15 a.m.]...Pt was discharged back to [Name of Facility A]...[name of ambulance service] ambulance transported back pt to facility...” A facility document titled, “Triage,” dated January 7, 2026, was reviewed. The document indicated Patient 5 returned to the ED on January 7, 2026, at 2:51 a.m. (approximately one hour and 36 minutes after being discharged from the facility). The document indicated Patient 5 had worsening confusion and inability to care for herself. The document indicated Patient 5 required transfer to another facility (Facility B) for placement after the second visit to the ED on January 7, 2026, at 2:51 a.m. A facility document titled, “Emergency Department Record,” dated January 7, 2026, was reviewed. The document indicated, “...[Patient 5] presenting to the ED via EMS...altered mentation with confusion...Patient thought to be unable to care for self, paramedics forced to return as patient will likely require placement [a transfer to another facility for continuation of care]...Disposition...Diagnosis...Failure to thrive...Discharge Disposition...Transfer to [name of Facility B]...” During review of Patient 5’s record, there was no documented evidence Facility A and Patient 5’s family were notified before Patient 5 was discharged from the facility. On February 10, 2026, at 2:58 p.m., an interview was conducted with the EDD. The EDD stated the facility’s policy was not followed when the receiving facility and the family was not notified of Patient 5’s discharge. A facility policy and procedure (P&P) titled, “Discharge from Emergency Department,” dated August 2019, was conducted and indicated, “ ... After being evaluated in the Emergency Department (ED) by a Licensed Independent Practitioner [LIP, individuals other than Medical Staff members who are permitted by law and by the facility to provide patient care services]] and or MD [physician], appropriate discharge planning [a centralized, collaborative process that prepares patients for a safe, smooth transition from the hospital to home or another facility] for a patient includes completing a medical record, making a plan to follow-up care suitable to the individual patient’s needs and ensures that the patient understands all aspects of their care and discharge plan ...The ER [ED] RN [Registered Nurse]/LVN [Licensed Vocational Nurse]/LIP will be the shared but primary facilitator of the patient discharge process ...review of discharge instructions with patient and/or responsible party ...Patient’s and/pr responsible party’s attestation to receipt and understanding of discharge instructions ...” 2. On February 9, 2026, at 3:42 p.m., an interview was conducted with Physician 1. Physician 1 stated a pregnant patient who is having an abruption placenta (a serious pregnancy complication where the placenta [an organ that forms in the womb] detaches from the uterus [womb] before the delivery of the unborn child) should be transferred to another facility for higher level of care (a facility which provides for a more intense, structured, and specialized treatment) right away after being stabilized which includes providing fluid and blood and the patient’s vital signs (objective, essential measurements of the body’s most basic functions which include heart rate, blood pressure, and temperature) should be stable. On February 10, 2026, at 1: 58 p.m., a review of Patient 8’s record was conducted with the EDD. A facility document titled, “Triage,” dated January 29, 2026, was reviewed. The document indicated, “...Chief complaint...seizure [a temporary, uncontrolled disturbance in the brain resulting in convulsions]...Arrival Date/Time...01/29/2026 [January 29, 2026] 17:23 [5:23 p.m.]...BIBA for seizures x [times] 2, pt [Patient 8] about 17 weeks 3 days pregnant [normal pregnancy duration is between 39 weeks 0 days and 40 weeks 6 days]...patient c/o [complains of] abd [abdominal] pain 5/10 [a pain scale where 0 means no pain and 10 means worst pain] with no vaginal bleeding...Vitals and Measurement...BP 117/90...” A facility document titled, “Emergency Department Record,” dated January 29, 2026, was reviewed and indicated, “...reports to the ER for the evaluation of seizure while currently 4-5 [four to five] months pregnant...Chief complaint: seizure...1741[5:41 p.m.] Phone consult with [Name of MD 2] an OBGYN [obstetrics gynecologist, a physician who specializes in the care of pregnant patients before and during childbirth] physician at [Name of Facility C], discussed patient’s [Patient 8’s] case at length including work up...[MD 2] accepts patient to her service...1825 [6:25 p.m.]...Called [Name of Facility C] and gave then the critical read from US [ultrasound, an imaging procedure] and they [Facility C] agree patient needs to be transferred faster...1909 [7:09 p.m.] was called by radiologist [a physician who specializes in the use of imaging procedures for the diagnosis and treatment of disease] and patient is possible having an placental abruption [abruptio placenta]...Called [Name of Facility C] once again to give them the official read [official result of the ultrasound]...1915 [7:15 p.m.]...[Name of Facility C] was then called once again and they wanted us to keep the patient in the ICU till she [Patient 8] was more stable. Called [Name of MD 3] our ICU physician and he does not accept to take over patient care...Diagnosis: acute placental abruption...acute hypotension...condition...Critical...Discharge disposition: Treatment in progress...” An untitled facility document, dated January 29, 2026, was reviewed. The document indicated the following documentation of Patient 8’s BP and heart rate (HR, normal is 60-100) on January 29, 2026: - At 5:50 p.m., the document did not indicate a BP reading, HR: 137; - At 5:55 p.m., BP: 62/30, HR:129; - At 6 p.m., the document did not indicate a BP reading, HR: 128; - At 6:05 p.m., BP: 55/31, HR: 130; - At 6:10 p.m., BP: 56/44, HR:138; - At 6:15 p.m., BP: 52/26, HR: 135; - At 6:20 p.m., BP: 53/30, HR: 132; - At 6:25 p.m., BP: 62/34, HR: 125; - At 6:30 p.m., BP: 69/37, HR:120; - At 6:35 p.m., BP:69/49, HR: 116; - At 6:40 p.m., BP: 76/44, HR: 114; - At 6:45 p.m., BP: 59/16, HR: 118; and - At 6:50 p.m., BP: 59:16, HR: 126. A facility document titled, “Daily Focus Assessment Report,” dated January 29, 2026, was reviewed. The document indicated, “...1815 [6:15 p.m.] Pt [Patient 8] is extremely lethargic [lacking energy], pale, cool, clammy, and diaphoretic [extensive sweating]. Pts [sic] eyes continuously roll in back of her head- pt goes in and out of consciousness...Pts [sic] abdomen extremely distended...[family member] states pt is 17 weeks pregnant...1820 [6:20 p.m.] Pt quickly became unstable- hypotensive [low BP] and remains tachycardic [with fast heart rate] BP 50/40. [Name of MD 1] verbally orders for emergency blood...1850 [6:50 p.m.] BP remains unstable, frequently fluctuating...1903 [7:03 p.m.] [Name of Air Transport, a team of healthcare workers who transports a patient using an aircraft] arrived at bedside...Pts [sic] BP remains unstable, HR remains tachycardic...1910 [7:10 p.m.]...This RN [registered nurse] attempted to call [Name of Facility C] to give report to RN [from Facility C]- RN who was taking patient stated per her charge nurse she was unable to accept pt due to BP being unstable and that [Name of MD 1] needs to recontact transfer center [a centralized, 24 hours a day department within a hospital or healthcare system which coordinates the transfer of patients in or out of a facility] so pt can go to the SICU [Surgical Intensive Care Unit, a unit providing care for patients who require intensive monitoring following complex surgeries or has life-threatening conditions]...” A facility document titled, “US OB [Obstetrics, the branch of medicine and surgery concerned with childbirth and the care of women before, during, and immediately after they give birth] Limited,” was reviewed. The document indicated, “...Impression: Fluid [amniotic fluid, clear yellow fluid in the womb which protects the unborn child during pregnancy] anterior [in front of] to the placenta raising the possibility of placental abruption...Free fluid is noted in all four quadrants [divisions of the womb, created by intersecting a vertical and a horizontal line which passes through the navel]...” A facility document titled, “Discharge Assessment/Summary Report,” dated January 19, 2026, was reviewed. The document indicated, “...Patient [Patient 8] departed from the ED Date and Time...01/29/2026 [January 29, 2026] 1930 [7:30 p.m.]...Transferred...Transferred to Higher Level of Care facility [Facility C]...Reason for transfer Placental Abruption...Transferred Status...Critical condition...” A facility document titled, “High Risk OB Interim Patient Care Record,” dated January 29, 2026, was reviewed. The document indicated the following on January 29, 2026: - at 7:15 p.m., no blood pressure reading indicated, pulse [heart rate] 135 bpm [beats per minute]; - at 7:16 p.m., blood pressure 89/65, pulse 109 bpm; - at 7:31 p.m., no blood pressure reading indicated, pulse 137 bpm; - at 7:37 p.m., no blood pressure reading indicated, pulse 135 bpm; - at 7:42 p.m., blood pressure 68/37, pulse 131 bpm; - at 7:50 p.m., blood pressure 97/56, pulse 145 bpm; - at 7:56 p.m., blood pressure 85/55, pulse 136 bpm; and - at 8:02 p.m., no blood pressure reading indicated, pulse 140. During review of Patient 8’s record, there was no documented evidence Patient 8 was transferred to the ICU for stabilization before Patient 8 was transferred to Facility C. There was no documented evidence Patient 8’s blood pressure was stabilized before the patient was transferred to Facility C. On February 11, 2026, at 11 a.m., an interview was conducted with the EDD. The EDD stated Patient 8 should have been admitted to ICU for stabilization before transferring to Facility C for higher level of care. On February 11, 2026, at 11:27 a.m., an interview was conducted with MD 3. MD 3 stated abruptio placenta is an emergent urgent situation. MD 3 stated he was called about Patient 8 by MD 1. MD 3 stated he is a general surgeon and OB/GYN is not his specialty. MD 3 stated he did not admit Patient 8 because he does not have privileges to admit patients to the facility. On February 12, 2026, at 11:02 a.m., an interview was conducted with MD 4. MD 4 stated his expectation for patients presenting with abruptio placenta is for the ED physician to start the treatment then admit the patient to the ICU and consult a cardiologist (a physician who specializes in the treating heart conditions) to help stabilize the patient. MD 4 stated if it is not possible to stabilize the patient, the patient needs to be air lifted (transport usually by helicopter used for medical emergency) and transferred to a tertiary [a facility providing highly specialized and complex medical services] facility.”

“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: 42512 Based on interview and record review, the facility failed to ensure care was provided in a safe setting for one of 20 sampled patients (Patient 8), when Patient 8 was transferred to another facility (Facility C) while the patient was having active bleeding and had low blood pressure (BP, normal is less than 120/80). This failure resulted in Patient 8 to continue to suffer from low BP and having to be admitted to the intensive care unit (ICU, unit where patients are critical) at Facility C and underwent emergency surgery. Findings: On February 9, 2026, at 3:42 p.m., an interview was conducted with Physician 1. Physician 1 stated a pregnant patient who is having an abruptio placenta (a serious pregnancy complication where the placenta [an organ that forms in the womb] detaches from the uterus [womb] before the delivery of the unborn child) should be transferred to another facility for higher level of care (more intense, structured, and specialized treatment than standard outpatient care, designed for acute, severe, or high-risk situations) right away after being stabilized which includes providing fluid and blood and the patient’s vital signs (objective, essential measurements of the body’s most basic functions) should be stable. On February 10, 2026, at 1: 58 p.m., a review of Patient 8’s record was conducted with the EDD. A facility document titled, “Triage,” dated January 29, 2026, was reviewed. The document indicated, “...Chief complaint...seizure [a temporary, uncontrolled disturbance in the brain]...Arrival Date/Time...01/29/2026 [January 29, 2026] 17:23 [5:23 p.m.]...BIBA for seizures x [times] 2, pt [Patient 8] about 17 weeks 3 days pregnant [normal pregnancy duration is between 39 weeks 0 days and 40 weeks 6 days]...patient c/o [complaints of] abd [abdominal] pain 5/10 [Pain scale where 0 is no pain and 10 is worst pain ever] with no vaginal bleeding...Vitals and Measurement...BP 117/90...” A facility document titled, “Emergency Department Record,” dated January 29, 2026, was reviewed and indicated, “...reports to the ER for the evaluation of seizure while currently 4-5 [four to five] months pregnant...Chief complaint: seizure...1741[5:41 p.m.] Phone consult with [Name of MD 2] an OBGYN [obstetrics gynecologist, [Medical doctor specializing in female reproductive health, pregnancy, and childbirth] physician at [Name of Facility C], discussed patient’s [Patient 8’s] case at length including work up...[MD 2] accepts patient to her service...1825 [6:25 p.m.]...Called [Name of Facility C] and gave then the critical read from US [ultrasound, an imaging procedure] and they [Facility C] agree patient needs to be transferred faster...1909 [7:09 p.m.] was called by radiologist [physician who reads imaging] and patient is possible having an placental abruption...Called [ Name of Facility C] once again to give them the official read [result of the ultrasound]...1915 [7:15 p.m.]...[Name of Facility C] was then called once again and they wanted us to keep the patient in the ICU till she [Patient 8] was more stable. Called [Name of MD 3] our ICU physician and he does not accept to take over patient care...Diagnosis: acute placental abruption...acute hypotension...condition...Critical...Discharge disposition: Treatment in progress...” An untitled facility document, dated January 29, 2026, was reviewed. The document indicated the following documentation of Patient 8’s BP and heart rate (HR, normal is 60-100) on January 29, 2026: - At 5:50 p.m., the document did not indicate a BP reading , HR: 137; - At 5:55 p.m., BP: 62/30, HR:129; - At 6 p.m., BP, no reading, HR: 128; - At 6:05 p.m., BP: 55/31, HR: 130; - At 6:10 p.m., BP: 56/44, HR:138; - At 6:15 p.m., BP: 52/26, HR: 135; - At 6:20 p.m., BP: 53/30, HR: 132; - At 6:25 p.m., BP: 62/34, HR: 125; - At 6:30 p.m., BP: 69/37, HR:120; - At 6:35 p.m., BP:69/49, HR: 116; - At 6:40 p.m., BP: 76/44, HR: 114; - At 6:45 p.m., BP: 59/16, HR: 118; and - At 6:50 p.m., BP: 59:16, HR: 126. A facility document titled, “Daily Focus Assessment Report,” dated January 29, 2026, was reviewed. The document indicated, “...1815 [6:15 p.m.] Pt [Patient 8] is extremely lethargic [lack of energy], pale, cool, clammy, and diaphoretic [extensive sweating]. Pts [sic] eyes continuously roll in back of her head- pt goes in and out of consciousness...Pts [sic] abdomen extremely distended...[family member] states pt is 17 weeks pregnant...1820 [6:20 p.m.] Pt quickly became unstable- hypotensive [low BP] and remains tachycardic [with fast heart rate] BP 50/40. [Name of MD 1] verbally [sic] orders for emergency blood...1850 [6:50 p.m.] BP remains unstable, frequently fluctuating...1903 [7:03 p.m.] [Name of Air Transport, transportation using air/flying method] arrived at bedside...Pts [sic] BP remains unstable, HR remains tachycardic...1910 [7:10 p.m.]...This RN [registered nurse] attempted to call [Name of Facility C] to give report to RN - RN who was taking patient stated per her charge nurse she was unable to accept pt due to BP being unstable and that [Name of MD 1] needs to recontact transfer center so pt can go to the SICU [Surgical Intensive Care Unit, a unit providing care for patients who require intensive monitoring following complex surgeries or due to life-threatening conditions]...” A facility document titled, “US OB [Obstetrics, the branch of medicine and surgery concerned with childbirth and the care of women before, during, and immediately after they give birth] Limited,” was reviewed. The document indicated, “...Impression: Fluid [amniotic fluid, clear yellow fluid that protects the fetus during pregnancy] anterior [in front of] to the placenta raising the possibility of placental abruption...Free fluid is noted in all four quadrants[divisions of the abdomen, created by intersecting a vertical line (median plane) and a horizontal line (transumbilical plane) that passes through the navel]...” A facility document titled, “Discharge Assessment/Summary Report,” dated January 19, 2026, was reviewed. The document indicated, “...Patient [Patient 8] departed from the ED Date and Time...01/29/2026 [January 29, 2026] 1930 [7:30 p.m.]...Transferred...Transferred to Higher Level of Care facility [Facility C]...Reason for transfer Placental Abruption...Transferred Status...Critical condition...” A facility document titled, “High Risk OB Interim Patient Care Record,” dated January 29, 2026, was reviewed. The document indicated the following: -7:15 p.m., no blood pressure, pulse [heart rate] 135 bpm [beats per minute]; -7:16 p.m., blood pressure 89/65, pulse 109 bpm; -7:31 p.m., no blood pressure, pulse 137 bpm; -7:37 p.m., no blood pressure, pulse 135 bpm; -7:42 p.m., blood pressure 68/37, pulse 131 bpm; -7:50 p.m., blood pressure 97/56, pulse 145 bpm; -7:56 p.m., blood pressure 85/55, pulse 136 bpm; and -8:02 p.m., no blood pressure, pulse 140. During review of Patient 8’s record, there was no documented evidence Patient 8 was transferred to the ICU at Facility D for stabilization. There was no documented evidence Patient 8’s blood pressure was stabilized before the patient was transferred to Facility C. On February 11, 2026, at 11 a.m., an interview was conducted with the EDD. The EDD stated Patient 8 should have been admitted to ICU for stabilization before transferring to higher level of care. On February 11, 2026, at 11:27 a.m., an interview was conducted with MD 3. MD 3 stated abruptio placenta is an emergent urgent situation. MD 3 stated he was called about Patient 8 by MD 1. MD 3 stated he is a general surgeon and OB/GYN is not his specialty. MD 3 stated he did not admit Patient 8 because he does not have privileges to admit patients to Facility D. On February 12, 2026, at 11:02 a.m., an interview was conducted with MD 4. MD 4 stated his expectation for patients presenting with abruptio placenta is for the ED physician to start the treatment then admit the patient to the ICU and consult a cardiologist (physician that specialized in the heart) to help stabilize the patient. MD 4 stated if it is not possible to stabilize the patient, the patient needs to be air lifted (transport usually by helicopter used for medical emergency) and transferred to a tertiary [a facility providing highly specialized and complex medical services] facility. The facility’s P&P titled, “PLAN FOR THE PROVISION OF PATIENT CARE AND SERVICES,” dated May 2024, was reviewed. The document indicated, “...provide a plan for the provision of patient care and services...Provision of services that are appropriate to the scope and level required by the patient population to be served...requires specialized knowledge, judgement and skill...The right procedures, treatments, interventions and care will be provided...Efficiency based upon the individualized needs of our patients...Coordination through multidisciplinary team collaboration to ensure continuity and seamless delivery of care to the greatest extent...””

“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: 42512 Based on interview and record review, the facility failed to ensure the patient’s family member was notified before the patient was discharged from the facility, for one of 20 sampled patients (Patient 5), when Patient 5, who was assessed to be demented (someone exhibiting severe mental deterioration, often from a condition like dementia, a condition with persistent impairment of memory), was discharged without notifying the patient’s family and the facility to which the patient was being discharged to. This failure resulted in Patient 5 being discharged while the patient was confused and brought back by the ambulance to the facility. Findings: A review of Patient 5’s record was conducted on February 10, 2026, at 2:30 p.m., with the Emergency Department Director (EDD). A facility document titled, “Triage [the preliminary assessment of patients in order to determine the urgency of their need for treatment and the nature of treatment required],” dated January 6, 2026, was reviewed. The document indicated, “...[Name of Patient 5]...Chief Complaint: AMS [altered mental status, a sudden or gradual change in a person’s baseline mental state, including confusion]...Arrival Date/Time: 01/06/2026 [January 6, 2026]...13:21 [1:21 p.m.]...Patient Narrative: BIBA [brought in by ambulance] for increased confusion and multiple falls, [family member] worried about her hitting head 2 [two] weeks ago and confusion getting worse...speech: disoriented...” A facility document titled, “Emergency Department Record,” dated January 6, 2026, was reviewed. The document indicated, “ ...History of Present Illness ...Patient [Patient 5] ...presenting to the ED via EMS [Emergency Medical Services, an ambulance service] from [Name of Facility A] ...Family reported to EMS the patient’s mentation [the ability, activity, or result of using your mind to think] has been declining over the past 2 months ...Past medical history ...HTN [hypertension, high blood pressure], neuropathy [nerve damage], chronic [constantly recurring] back pain ...Diagnosis ....fall, no serious injuries ....” A facility document titled, “Emergency Continuation,” dated January 6, 2026, was reviewed. The document indicated, “...ED Course/Medical Decision Making...I was kindly asked to follow up on the pleasant demented [elderly] [Patient 5] with recent fall...Patient [Patient 5] referred for evaluation of confusion above baseline [the usual, stable, everyday level of awareness and thinking]... Episodic confusion is noted...” A facility document titled, “Daily Focus Assessment,” dated January 6, 2026, was reviewed. The document indicated, “ ...22:00 [10 p.m.] ...Pt [Patient 5] @ [at] CT [Computed Tomography, a diagnostic imaging procedure] ...Pt medicated for CT, pt confused attempting to get out bed ...” A facility document titled, “CT Brain w/o [without] Contrast,” dated January 6, 2026, indicated, “...Study Reason...Falling injury...Impression...No acute intracranial [within the skull] hemorrhage [bleeding] nor acute osseous [bone] abnormality...mild to moderate generalized brain parenchymal [tissue] volume loss...” A facility document titled, “Emergency Continuation,” dated January 6, 2026, indicated, “...21:33 [9:33 p.m.]...Diagnosis: Dementia [a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory]...ED disposition...home...” A facility document titled, “Discharge Assessment/Summary Report,” dated January 7, 2026, indicated, “...Discharge instructions....Discharge disposition: skilled nursing facility...Discharge instructions given to EMS...” An untitled document dated January 7, 2026, indicated, “...Fall Prevention for Older Adults - Discharge Care...Dementia - After Care...Instructions (ER/ED)...Patient/Guardian’s Signature...Patient unable to sign...” A facility document titled, “Daily Focus Assessment,” dated January 7, 2026, was reviewed. The document indicated, “...01:15 [1:15 a.m.]...Pt was discharged back to [Name of Facility A]...[name of ambulance service] ambulance transported back pt to facility...” A facility document titled, “Triage,” dated January 7, 2026, was reviewed. The document indicated Patient 5 returned to the ED on January 7, 2026, at 2:51 a.m. (approximately one hour and 36 minutes after being discharged from the facility). The document indicated Patient 5 had worsening confusion and inability to care for herself. The document indicated Patient 5 required transfer to another facility (Facility B) for placement after the second visit to the ED on January 7, 2026, at 2:51 a.m. A facility document titled, “Emergency Department Record,” dated January 7, 2026, was reviewed. The document indicated, “...[Patient 5] presenting to the ED via EMS...altered mentation with confusion...Patient thought to be unable to care for self, paramedics forced to return as patient will likely require placement [a transfer to another facility for continuation of care]...Disposition...Diagnosis...Failure to thrive...Discharge Disposition...Transfer to [name of Facility B]...” During review of Patient 5’s record, there was no documented evidence Facility A and Patient 5’s family were notified before Patient 5 was discharged from the facility. On February 10, 2026, at 2:58 p.m., an interview was conducted with the EDD. The EDD stated the facility’s policy was not followed when the receiving facility and the family was not notified of Patient 5’s discharge. A facility policy and procedure (P&P) titled, “Discharge from Emergency Department,” dated August 2019, was conducted and indicated, “ ... After being evaluated in the Emergency Department (ED) by a Licensed Independent Practitioner [LIP, individuals other than Medical Staff members who are permitted by law and by the facility to provide patient care services]] and or MD [physician], appropriate discharge planning [a centralized, collaborative process that prepares patients for a safe, smooth transition from the hospital to home or another facility] for a patient includes completing a medical record, making a plan to follow-up care suitable to the individual patient’s needs and ensures that the patient understands all aspects of their care and discharge plan ...The ER [ED] RN [Registered Nurse]/LVN [Licensed Vocational Nurse]/LIP will be the shared but primary facilitator of the patient discharge process ...review of discharge instructions with patient and/or responsible party ...Patient’s and/pr responsible party’s attestation to receipt and understanding of discharge instructions ...””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 42512 Based on observation, interview, and record review, the facility failed to ensure supplies and equipment were maintained, for three of four crash carts (a wheeled container containing medications and equipment for use in emergency resuscitations [lifesaving emergency procedure performed on someone whose breathing or heartbeat stopped]) observed, when the three crash carts of three crash cart observed (Carsh carts 29, 3, and 14) were observed to have plastic seals (a single-use, tamper-evident plastic lock with numbers which secures the cart’s drawers or doors) which did not match the lock number indicated on the daily crash cart logs (record which documents the contents and condition of a crash cart) observed on tour. This failure had the potential for the Crash carts 29, 3, and 14 to not be fully stocked and readily available for use which may cause delay in the provision of treatment to patients who require emergency resuscitation. Findings: 1. On February 9, 2026, at 2:41 p.m., a tour was conducted on Unit A with the Chief Nursing Officer (CNO), the Critical Care Manager (CCM), and the Charge Nurse (CN) 1. Crash cart 29 was observed pulled away from the wall in the hall of Unit A. Crash cart 29 was observed to have two plastic seals located on the front of the crash cart. One plastic seal was labeled for medications, and the other plastic seal was labeled for respiratory supplies. The log for Crash cart 29 was observed to be on top of the Crash cart 29. The plastic seal on Crash cart 29 was observed to indicate the number 012782. During a concurrent review of the crash cart log the number for the plastic seal did not match the lock numbers on Crash 29’s log. A concurrent interview and review of a facility document titled, “DAILY CRASH CART CHECK,” dated February 2026, was conducted with the (CN) 1...The document indicated, “...Crash Cart [Crash cart 29]...Serial # [number] 012236...” CN 1 stated Crash cart 29 was pulled from the wall because there had been a code stroke (protocol activated when a patient is suspected of having a stroke; when blood flow to part of the brain is blocked) earlier in the unit on February 9, 2026. CN 1 stated Crash cart 29 had not been opened during the code stroke on February 9, 2026, and the plastic seal on Crash cart 29 had not been broken nor changed on February 9, 2026. CN 1 stated she was not sure why the crash cart log did not match the number on the plastic seals. CN 1 stated the crash cart log should match the number on the plastic seal on the crash cart. She stated this would ensure the contents of the crash cart were accurate and ready for use during an emergency. 2. On February 9, 2026, at 2:54 p.m., a tour was conducted on Unit B with the CNO and the Medical Surgical/Telemetry Manager (MSTM). Crash cart 3 was observed in the hallway. Upon review of log on top of Crash cart 3, the number indicated on the crash cart log did not match the numbers plastic seal on Crash cart 3. During a concurrent interview with the MSTM, the MSTM stated the charge nurse on the unit was responsible for checking the plastic seal numbers on the crash cart and documenting them on that crash cart log daily. On February 9, 2026, at 3 p.m., an interview and review of Crash cart 3’s log were conducted with CN 2. The facility document titled, “DAILY CRASH CART CHECK,” dated February 2026, was reviewed. The document indicated, “...Crash Cart [Crash cart 3]...Serial #...012396...” The plastic seal on Crash cart 3 indicated lock number was 12789...” CN 2 stated she checked the crash cart this morning. CN 2 stated she was not sure why the log did not match the plastic seal number on Crash cart 3. CN 2 stated the log should match the number on the crash cart plastic seal. On February 9, 2026, at 3:06 p.m., an interview was conducted with the MSTM. The MSTM stated pharmacy might have come and reviewed the medications in Crash cart 3 and broke the plastic seal. The MSTM stated when the plastic seal is broken and replaced, staff must add the new plastic seal number to the back of the log to indicate the plastic seal was changed. The MSTM stated the back of the log had not been updated. 3. On February 9, 2026, at 3:16 p.m., a tour on Unit C with the CNO, the MSTM, and CN 3. Crash cart 14 was observed in the hallway. The plastic seal on Crash cart 14 was observed to indicate the number 12708. The facility document titled, “DAILY CRASH CART CHECK,” dated February 2026, observed on top of Crash 14 was concurrently reviewed. The document indicated, “...Crash Cart [Crash cart 14]...Serial # 012350...” During a concurrent interview with CN 3, CN 3 stated the plastic seal numbers did not match the numbers indicated on Crash cart 14’s log and they should match. CN 3 stated she did not know why the plastic seal numbers and the numbers on Crash cart 14’s log did not match. A review of the facility’s policy and procedure (P&P) titled, “CRASH CART EXCHANGE SYSTEM,” dated September 2024, was conducted. The document indicated, “...To ensure the continuity and accountability of supplies and equipment...A clean stocked emergency crash cart will always be readily available...” A review of the facility’s P&P titled, “CRASH CART,” dated September 2024, was conducted. The document indicated, “...Crash cart is stocked with supplies and equipment necessary to ensure the effectiveness of cardio-pulmonary resuscitation...When not in use, all crash carts are to be locked with two (2) plastic seals...Verification of the contents of the crash cart is to be checked according to the following...All twenty-four (24) hour nursing units are to do crash cart checks once per day by a Licensed Nurse or designated licensed personnel...Verification of completing the crash cart checklist will be documented on the Crash Cart Check Form...””

“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: 38479 Based on observation, interview, and record review, the facility failed to ensure, for nine of 10 sampled patients (Patient 1, 2, 3, 4, 6, 7, 8, 9, and 10), weights were obtained daily in accordance with the facility’s policy and procedure. This facility failure had the potential to result in serious, even fatal, complications, primarily which may include severe medication dosage errors as accurate weight is vital for dosing medications with narrow therapeutic ranges, undetected fluid overload which is crucial in patients with heart failure (a heart condition which occurs when the heart muscle doesn’t pump blood as well as it should), and untreated malnutrition. Findings: 1. On January 28, 2026, at 2:39 p.m., a review of Patient 1’s record was conducted with the Clinical Nurse Manager (CNM) and Patient Safety Coordinator (PSC). A facility document titled, “History and Physical,” dated January 19, 2026, was reviewed and indicated Patient 1 was admitted to the facility on January 19, 2026, with diagnoses which included urinary retention (condition when a patient could not urinate on his own), on tube feeding (enteral nutrition, a method of delivering nutrients, fluids, and medication directly into the stomach or small intestine using a feeding tube such as a gastrostomy tube [G tube], a percutaneous endoscopic gastrostomy tube [PEG tube, a tube inserted directly into the stomach], or a nasogastric tube [NG tube, a feeding tube inserted through the nares]), and seizure (convulsions). A facility document titled, “Daily Assessment Inquiry,” dated January 20, 2026, was reviewed. The document indicated Patient 1 was in the Telemetry Unit (a specialized unit for patients requiring continuous remote monitoring of their heart rates and rhythm). The document indicated, “...Initial assessment...Tube feed [when food, fluids, or medication is delivered using a flexible plastic tube]...weight loss, decreased appetite...Weight/lbs [pounds, unit of measurement] 154...Diet/Nutrition Needs...Enteral nutrition...Tube feeding...G tube...” There was no documented evidence weight was taken again for Patient 1 after January 20, 2026. During a concurrent interview with the CNM, the CNM confirmed no other weight was documented for Patient 1 on Patient 1’s record after January 20, 2026. 2. On January 29, 2026, at 9:07 a.m., a review of Patient 2’s record was conducted with the PSC. A facility document titled, “History & [and] Physical Note,” dated November 21, 2025, was reviewed. The document indicated Patient 2 was admitted to the facility on November 20, 2025, with diagnoses which included acute kidney injury (AKI, a sudden reduction in kidney function), atrial fibrillation (a type of irregular heart rhythm), and pneumonia (a lung infection). A facility document titled, “RN [registered nurse] MST [malnutrition screening tool] Assessment,” was reviewed. The document indicated, “...11/22/26 [November 22, 2026]...Malnutrition Screening Tool...Recently Lost Weight...” A facility document titled, “RDN [Registered Dietary Nutritionist] Assessment,” was reviewed. The document indicated, “...11/25/2025 [November 25, 2025]...Monitor...weight...” A facility document titled, “Daily Assessment Inquiry,” was reviewed. The document indicated, “...Location: ICU [Intensive Care Unit, a specialized unit providing 24 hours, high-intensity care, monitoring, and life support for patients with severe, life-threatening injuries or illnesses]...01/07/26 [January 7, 2026]...Started on TPN [total parenteral nutrition, a method of delivering all essential nutrients directly into a person’s bloodstream via an intravenous catheter (a small, flexible, thin tube inserted into a patient’s vein)]...01/16/26 [January 16, 2026]...Glucerna [a brand of calorie dense formula given during tube feeding] tube feeds ongoing...” There was no documented evidence Patient 2’s weight was taken on November 21 and 22, 2025, November 24, 2025, through November 27, 2025, November 30, 2025, through January 7, 2026, January 9, 2026, through January 11, 2026, January 15, 2026, through January 18, 2026, January 24, 2026, and January 25, 2026. 3. On January 29, 2026, at 10:50 a.m., a review of Patient 3’s record was conducted with the CNM. A facility document titled, “History & Physical Note,” dated January 15, 2026, was reviewed. The document indicated Patient 3 was admitted to the facility on January 15, 2026, after a fall. The document indicated Patient 3 had a history of heart murmur (an extra, whooshing or swishing sound heard during a heartbeat using a stethoscope) and chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). A facility document titled, “RN MST Assessment,” was reviewed. The document indicated, “...01/15/26 [January 15, 2026]...Recently lost Weight...” A facility document titled, “Daily Assessment Inquiry,” was reviewed. The document indicated, “...Location: ICU...Initial Assessment...Weight/lbs...89...Weight Status...Underweight...Dental/Oral Note...poor dentition [the arrangement or condition of the teeth]...” A facility document titled, “Progress Note Inquiry,” dated January 17, 2026, was reviewed. The document indicated, “...RD Recommendation...Monitor...weight...” There was no documented evidence weight was taken again for Patient 3, during her 14 days admission at the facility, after January 20, 2026. 4. On January 29, 2026, at 11:27 a.m., a review of Patient 4’s record was conducted with the CNM. A facility document titled, “History & Physical Note,” dated December 19, 2025, was reviewed. The document indicated Patient 4 was admitted to the facility on December 19, 2025, for generalized weakness and with diagnoses which included pneumonia and AKI. An untitled facility document was reviewed and indicated, “...Order entry...Admit to Inpatient- Telemetry...12/19/2025 [December 19, 2025]...Transfer to ICU...12/20/2025 [December 20, 2025]...NG Tube Placement...12/21/2025 [December 21, 2025]...” A facility document titled, “Progress Note,” dated January 28, 2026, was reviewed. The document indicated, “...Admit Weight...124 pounds...18-Dec-2025 [December 18, 2025]...” There was no documented evidence Patient 4’s weight was taken on December 19, 2025, December 20, 2025, December 22, 2025, through 24, 2025, December 26, 2025, through January 17, 2026, and January 23, 2026, through January 29, 2026. 5. On January 29, 2026, at 12:29 p.m., a review of Patient 6’s record was conducted with the Director of Critical Care Unit/DOU (DCCU/DOU). A facility document titled, “History & Physical Note,” dated January 24, 2026, was reviewed. The document indicated Patient 6 was admitted to the facility on January 25, 2026, for overdose. An untitled facility document was reviewed and indicated, “...Order entry...Admit to Inpatient- ICU...01/25/2026 [January 25, 2026]...NG Tube insertion...01/24/2026 [January 24, 2026]...” A facility document titled, “Daily Assessment Inquiry,” was reviewed. The document indicated, “...Location: ICU...01/25/26 [January 25, 2026]...Initial Assessment...Weight/lbs...160...” A facility document titled, “...Orders Report,” was reviewed. The document indicated, “...Read Back & verified: 01/26/2026 [January 26, 2026]...Glucerna...Tube Feeding...” There was no documented evidence Patient 6’s weight was taken on January 25, 2026, through January 27, 2026, and on January 29, 2026. 6. On January 29, 2026, at 11:00 a.m., a review of Patient 7’s record was conducted with the CNM. A facility document titled, “History and Physical,” dated January 9, 2026, was reviewed. The document indicated Patient 7 was admitted to the facility on January 10, 2026, for nausea (a feeling of sickness with an inclination to vomit) and vomiting, with a diagnosis of small bowel (intestine) obstruction. A facility document titled, “Progress Note,” dated January 28, 2026, was reviewed. The document indicated, “...09-Jan-2026 [January 9, 2026]... Wt [weight]: 205 lbs...” There was no documented evidence weight was taken again for Patient 7, during her 19 days admission at the facility, after January 9, 2026. 7. On January 29, 2026, at 11:20 a.m., a review of Patient 8’s record was conducted with the CNM. A facility document titled, “History & Physical Note,” dated January 25, 2026, was reviewed. The document indicated Patient 8 was admitted to the facility on January 25, 2026, for generalized weakness. The document indicated, “...25-Jan-2026 [January 25, 2026]...Wt: 83 (kgs [kilograms, unit of measurement] Standing)...” A facility document titled, “Progress Note,” dated January 28, 2026, was reviewed. The document indicated, “...1/27/2026 [January 27, 2026]...stable on telemetry...” There was no documented evidence weight was taken again for Patient 8, during her four days admission at the facility, after January 25, 2026. 8. On January 29, 2026, at 12:09 p.m., a review of Patient 9’s record was conducted with the DCCU/DOU. A facility document titled, “History & Physical Note,” dated January 25, 2026, was reviewed. The document indicated Patient 9 was admitted to the facility on January 25, 2026, for gangrene (the death of a body tissue). The document indicated, “...25-Jan-2026...Wt: 165 (kgs Lying)..” A facility document titled, “Progress Note,” dated January 28, 2026, was reviewed. The document indicated, “...1/27 [January 27, 2026...Patient is now on telemetry floor...” There was no documented evidence weight was taken again for Patient 9, during her four days admission at the facility, after January 25, 2026. 9. On January 29, 2026, at 12:39 p.m., a review of Patient 10’s record was conducted with the DCCU/DOU. A facility document titled, “History & Physical Note,” dated January 9, 2026, was reviewed. The document indicated Patient 10 was admitted to the facility on January 9, 2026, for chest pain. The document indicated, “...Past medical history...CHF [congestive heart failure, a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues]...09-Jan-2026...Wt: 88.45 (kgs Stated)...” There was no documented evidence weight was taken again for Patient 10, during his 17 days admission at the facility, after January 9, 2026. On January 29, 2026, at 8:43 a.m., an interview was conducted with the RDN. The RDN stated she doesn’t know about the other unit but in the ICU, weight was taken daily and in accordance with the physician’s order. The RDN stated a patient’s first weight had to be taken upon admission and all patients with nutrition support should be seen/followed up every three days in accordance with the facility’s protocol. The RDN further stated she does not know the other units’ protocol for weight monitoring but she expects the staff to follow their own unit’s weight protocol because the patients had to be assessed for weight loss or gain so they can possibly change the patient’s dietary recommendation based on the weight change. The RDN stated an example would be if the patient had fluid overload, then the RD can drop the amount of fluid being given to the patient. The RDN further stated, “Weight is an important indicator of nutritional status especially with patients with skin breakdown. Their protein needs are higher to support wound healing.” On January 29, 2026, at 9:43 a.m., an interview was conducted with the RDN and the PSC regarding the facility’s policy for patient weight monitoring. The RDN and the PSC stated, “Daily weight should be taken for ICU, Telemetry, and DOU [Definitive Observation Unit, a unit which provides specialized, close monitoring for patients who are stable to be admitted to the ICU but requiring closer monitoring] patients.” On January 29, 2026, at 10:50 a.m., an interview was conducted with the CNM regarding the facility’s policy for patient weights monitoring. The CNM stated, “Yes” weights should have been taken daily according to the facility’s policy. On January 29, 2026, at 12:09 p.m., an interview was conducted with the DCCU/DOU was interviewed regarding the facility’s policy for patient weights monitoring. The DCCU/DOU stated, “Yes” patients should have been weighed daily in accordance with the facility’s policy. A review of the facility’s policy and procedure (P&P) titled, “PATIENT WEIGHTS,” dated May 2024, was conducted. The P&P indicated, “...PURPOSE: To ensure complete and accurate record of patient weight upon admission to the Emergency Department and Inpatient Unit of the Hospital...POLICY...ICU/Telemetry/DOU...Patients are weighed on admission, and per physician order...Daily weights are done by the night shift...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50454 Based on interview and record review, the facility failed to ensure safety measures were implemented, for twp of 31 sampled patients (Patients 9 and 31), when, 1. For Patient 31, the patient’s designated family member was not informed and updated regarding the patient’s condition or plan of care (Refer to A-0131); and 2. For Patient 9, the patient was allowed to sign herself out of the hospital against medical advice (AMA, when a patient chooses to leave a hospital or clinic before the physician recommends his discharge) when her decision-making capabilities (the ability to understand important information about a choice) was not fully assessed by the provider, at the time she signed the AMA form and was allowed to leave the facility (Refer to A-0144). The cumulative effect of these systemic failures had the potential to result in harm and increase the risk forreadmission for Patient 9 and for Patient 31’s family to not be fully informed of Patient 31’s condition.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 45431 Based on interview and record review, the facility failed to ensure the patient’s designated family member was informed and updated regarding the patient’s condition or plan of care, for one of 31 sampled patients (Patient 31). This failure resulted in Patient 31’s family to not be informed of Patient 31’s status in a timely manner. Findings: A review of Patient 31’s record was conducted on December 8, 2025, at 2:15 p.m. with the Emergency Department Director (EDD). A facility document titled, “Emergency Department [ED] Record,” dated September 16, 2025, was reviewed. The document indicated, “...[Patient 31] with history of extreme anxiety presents to the ED with complaint of “vomiting bright red blood” time stool [sic], 1 [one]- time last night and last episode was at 3:00 AM [3 a.m.] today...Dx [diagnosis, the identified nature of an illness]...Upper GI [gastrointestinal, pertaining to the organs that food and liquids travel through for digestion] bleed...” A facility document titled, “Emergency Patient,” dated September 16, 2025, was reviewed. The document indicated, “...Contact Information...emergency contact: [Name]...relationship...family member, FM]...” A facility document titled, “Emergency Continuation,” dated September 16, 2025, authored by Physician (MD) 1, was reviewed. The document indicated, “...Patient [Patient 31] was initially seen by...PA [name of physician assistant, a licensed and highly skilled health care professional who examine, diagnose, and treat patients under the supervision of a physician]...was signed out to the night physician...who then signed out to me...the patient’s [name of FM], called to state that he wanted to speak with me about an inappropriate discharge. The nurse told him that I was busy with a code [code blue, code for a critical, life-threatening medical emergency requiring immediate resuscitation of the patient], which I was at the time and could not come to the phone. He proceeded to total (sic) the nurse that this was totally inappropriate and that he was going to call the charge nurse. [Name of FM] continue to call the emergency department multiple times...I will let the charge nurse and/or the supervisor know to speak with [name of FM]...” A facility document titled, “Progress Notes Report,” dated September 16, 2025, was reviewed. The document indicated, “...Entered by Registered Nurse [(RN) 1]...@ [at] 1620 [4:20 p.m.]: Call received from patient’s [FM] who stated he wanted to speak to MD 1. MD 1 was advised that the pts [Patient 31’s] [FM] was on the phone and the MD 1 stated he was unavailable to speak to him...[Name of FM] stated he wants to give me his phone number so MD 1 can call him back. When I asked for his name and phone number, he then stated that he was not giving it to me because I didn’t ask for it, that he now wants to speak with the house supervisor...advised MD 1 and [Name] RN Charge Nurse...I was advised to obtain his phone number so [Name of Director of Emergency Department] can return the call since she is not available...” A review of the facility document titled, “Patient & Family Complaint,” dated September 17, 2025, was conducted on December 9, 2025, at 9:33 a.m., with the Regional Quality Director (RQD) and the EDD. The document indicated, “...Name of person filing a complaint...[FM]...feels [Patient 31] was unsafely discharged...Stated he had questions that can only be addressed by MD...Still has not received a call from a provider...” There was no documented evidence the ED charge nurse nor the ED director called Patient 31’s FM. The EDD stated she was unable to find documentation of any phone call made to update Patient 31’s FM of the patient’s condition. The EDD stated she also did not call Patient 31’s FM to follow up and notify the FM of Patient 31’s condition. A review of an undated facility document titled, “Medical Staff Bylaws and Rules and Regulations,” was conducted on December 9, 2025, at 3 p.m., with the ED Medical Director (EDMD). The document indicated, “...Admission and Discharge of Patients...Responsibility...A physician member of the professional staff shall be responsible for the medical care and treatment of each patient in the Hospital...and for transmitting reports of the condition of the patient to the referring practitioner and to the relatives of the patient...” An interview was conducted on December 9, 2025, at 3:05 p.m., with the EDMD. The EDMD stated, “Yes. our process is to try to talk to the patient or the family and discuss with them their condition or patient’s condition.””

“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: 50454 Based on interview and record review, the facility failed to ensure safety measures were implemented, for one of 31 sampled patients (Patient 9), when Patient 9 was allowed to sign herself out of the hospital against medical advice (AMA, when a patient chooses to leave a hospital or clinic before the physician recommends his discharge) when her decision-making capabilities (the ability to understand important information about a choice) was not fully assessed by the provider, at the time she signed the AMA form and was allowed to leave the facility. This failure had the potential to result in harm for Patient 9 and may increase the risk for readmission for Patient 9. Findings: On December 8, 2025, at 10:17 a.m., a review of Patient 9’s record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, “History & [and] Physical,” dated September 25, 2025, was reviewed. The document indicated Patient 9 was admitted to the facility on September 25, 2025, and presented to the emergency department (ED, a unit in the facility where patients go to receive emergency care) with a chief complaint (symptoms which lead a patient to go to the ED) of altered mental status (any significant change in a person’s usual awareness or ability to think). The document indicated Patient 9 was alert and oriented times one (which means a person is awake and knows who they are, but is confused about their location, the date/time, or the event) when she arrived at the ED. The document indicated Patient 9 was placed on a 5150 hold (a state law allowing involuntary hold for up to 72 hours) for being gravely disabled (when one is unable to provide for one’s basic personal needs such as food, clothing, shelter, personal safety, or necessary medical care) prior to the patient’s arrival at the ED. The document indicated, “...Malnutrition Risk Screening: At increased risk of deficient food intake; Nutrition Assessment: Cachexia [a condition which causes significant weight loss and muscle loss]...Laboratory Results...Urine Drug Screen [a test which checks urine for illegal drugs or prescription medications to see if they are present in a person’s body]...AMPHETAMINES [a type of drug which speeds up messages between the brain and body]...POSITIVE...” A document titled, “Name of Facility,” dated September 25, 2025, at 1:18 p.m., was reviewed. The document indicated, “...DETAINMENT ADVISEMENT [the process of formally notifying an individual who is being held in custody of their legal rights and the reasons for their detention]...To...[name of emergency treatment facility] or other facility...Application is hereby made the assessment and evaluation of [name of Patient 9]...I have probable cause to believe that the person is, as a result of a mental health disorder, a danger to self, or a danger to others, or gravely disabled because...[name of Patient 9] listed above was altered and has open sore [wounds] on her ankle. [Patient 9] has a history of stroke [lack of oxygen to the brain] and had disheveled [untidy, messy, or in a state of disorder] clothing and was unable to care for herself...Voluntary treatment is not available/not viable option due to gravely disabled...” A facility document titled, “Progress Note,” dated September 26, 2025, at 6:13 a.m., authored by the Internal Medicine (a medical specialty which specializes on preventing, diagnosing, and treating diseases in adults) Physician (IMMD), was reviewed. The document indicated, “...Pt [sic, Patient] 9 is A/O [alert and oriented] x [times] 2 [two], person and place [oriented to person and place]...repeats herself multiple times...” A facility document titled, “Progress Note,” dated September 26, 2025, at 3:58 p.m., authored by the Social Worker (SW), was reviewed. The document indicated, “...Department: Social Services [department which provide support in connecting patients and families with resources for health, emotional, and logical needs]...The patient presented as alert and oriented to person and partially to place (A/Ox2 was in tears and in distress and was unable to articulate the circumstances that led to her hospital admission...The patient was unable to state her current location and appeared confused throughout the interaction...Given the patient’s disorientation and inability to provide coherent information regarding her circumstances, it remains clinically challenging to determine whether she meets criteria for a mental health condition. At this time, further assessment is required to evaluate whether the current hold should be discontinued...” A facility document titled, “Progress Note,” dated September 26, 2025, at 4:08 p.m., authored by the SW was reviewed. The document indicated, “...Department: Social Services...[name of govenrment agency case worker] reported that the patient [Patient 9] cannot return home due to unsafe living conditions observed during a recent visit...” A facility document titled, “Progress Note,” dated September 27, 2025, at 3:07 p.m., authored by the IMMD, was reviewed. The document indicated, “...Overnight the patient [Patient 9] was agitated and trying to leave. Pt confused about where she is...[Family member, FM] would like to have more information regarding POA [power of attorney, a legal document which allows someone else to act on another person’s behalf]...” A facility document titled, “Progress Note,” dated September 29, 2025, at 10:42 a.m., authored by the IMMD, was reviewed. The document indicated, “...[Patient 9] Not entirely aware of why she was brought to the hospital. States it was a “mixup.” A/O x 4 [four, oriented to person, place, time, and situation]...Patient lives by herself...” A facility document titled, “Progress Note,” dated September 29, 2025, at 11:09 a.m., was reviewed. The document indicated, “...Department: Nursing...The notes from the MD [sic, medical doctor] referred to recommendations from psych [sic, psychiatry, the branch of medicine which specializes in the diagnosis and treatment of mental illnesses] but there were no notes from psych in the patient EMR [electronic medical record, an electronic version of a patient’s record] nor paper chart. There was no note also indicating the release of the 5150 hold and that patient no longer a harm to self...” A facility document titled, “Progress Note,” dated September 29, 2025, at 3:37 p.m., authored by the SW, was reviewed. The document indicated, “...Department: Social Services...The patient remains intermittently [occurring at irregular intervals and not continuous] confused but is alert and oriented to person, place, and time (A/Ox3 [three])...the patient was recently diagnosed with vascular dementia [a decline in memory, thinking, and judgment caused by reduced blood flow to the brain] and has an active wound on her leg...consulted with [Name of government agency which investigates and helps vulnerable adults] who shared concerns regarding the patient safety. [Name of government agency] reported a recent incident in which the patient was found eloping [the act of running away] in the middle of the street with feces on her feet and became physically combative [displaying an aggressive attitude which involves actions such as hitting, kicking, punching, or other acts which cause or intend to cause physical hurt] with law enforcement...[Name of government agency] expresses significant concern for [Patient 9’s] well-being if discharged home...spoke with the patient [FM], who voiced apprehension about [Patient 9’s] condition and expressed hope that she would agree to placement in a skilled nursing facility (SNF) [a licensed healthcare facility which provides medical care and rehabilitation services from licensed professionals]...[name of Resident (a fully licensed doctor who has graduated from medical school but is undergoing intensive, hands-on training in a specific medical specialty) (Res) 1] has placed an order for SNF wound care services, and the discharge planning team [a group of healthcare professionals and the patient/caregiver who work together to create a safe and smooth plan for moving a patient from the hospital] is actively working on securing placement [where the patient would be discharged to]...” A facility document titled, “Discharge Summary,” dated September 29, 2025, at 11:02 a.m., authored by the IMMD, was reviewed. The document indicated, “...On admission patient [Patient 9] was initially on a 5150 for unsafe living conditions and grave disability...patient is alert and oriented times 3 and states that she has a home and lives on her own and is able to care for herself...discharge diagnosis altered level of consciousness [a person’s awareness, alertness, or ability to react to their surroundings has changed from normal]...acute ischemic stroke [a sudden brain injury where a blood clot blocks a blood vessel and cuts off blood flow and oxygen to a part of the brain]...vascular dementia...” A facility document titled, “Progress Note,” dated September 30, 2025, at 12:04 p.m., authored by Registered Nurse (RN) 2 was reviewed. The document indicated, “...Department: Nursing...Pt is ANO [sic, Alert and oriented] x3. Pt still confused and demanding to leave. Notified primary team and social services. Social services working with primary team to get a stat [immediate] psych [psychiatric, relating to mental illness or its treatment] consult to assess patients’ [Patient 9’s] ability to make decisions on her own. Social service recommending custodial bed [a nursing facility which helps with activities of daily living like bathing, dressing, using the bathroom, and eating]...” A facility document titled, “LEAVING THE HOSPITAL AGAINST MEDICAL ADVICE,” dated September 30, 2025, at 2:30 p.m., was reviewed. The document indicated it was signed by Patient 9 and Res 1 signed the document as a witness. A facility document titled, “Progress Note,” dated September 30, 2025, at 3:08 p.m., authored by RN 2, was reviewed. The document indicated, “...Department: Nursing...Pt [Patient 9] is ANOX3 [sic, alert and oriented times 3]. Pt demanding to leave notified primary team [a group of healthcare professionals working together to provide coordinated, continuous care for a patient’s overall health] who stated pt is able to leave AMA. [Name of Res 1] stated that pt is able to leave AMA despite mental status. This RN informed [name of Res 1] that due to mental status they would need to come witness pt sign AMA form due to pt not being ANOx4 [sic, alert and oriented times four]. [Name Res 1] came to bedside and signed AMA form with patient. Per [name of Res 1] and primary team patient is free to go...” A facility document titled, “Progress Note,” dated September 30, 2025, at 3:45 p.m., authored by RN 2, was reviewed. The document indicated, “...Department: Nursing...Notified [name of Res 1] that pt [Patient 9] does not have a ride. Dr. [name of Res 1] stated he was aware, Dr. [name of Res 1] attempted to have patient stay another night and patient refused...pt wheeled down to lobby...” There was no documented evidence a psychiatric evaluation (a professional assessment using interviews, observations, and tests to understand a person’s thoughts, feelings, and behaviors) was ordered or conducted on Patient 9, after the release of the 5150 hold on or during Patient 9’s hospital stay. There was no documented evidence Res 1 assessed Patient 9’s decision making capacity at the time the AMA form was signed allowing Patient 9 to leave AMA on September 30, 2025, at 2:30 p.m. There was no documented evidence Res 1 informed Patient 9’s emergency contacts at the time Patient 9 was allowed to leave AMA. On December 9, 2025, at 3:45 p.m., an interview was conducted with the SW. The SW stated Patient 9 eventually became oriented, but it came in waves due to her dementia. The SW stated Patient 9 was approved for custodial placement at a locked skilled nursing facility. The SW stated, “I can’t say whether or not she was deemed mentally stable to sign herself out AMA.” The SW further stated the facility recently lost its physiatrist, so the psychiatric evaluation was taking “forever.” On December 10, 2025, at 9:26 a.m., an interview was conducted with RN 2. RN 2 stated during her morning assessment, Patient 9 was to be observed anxious, roaming the room, refusing medications, and refusing assessments. RN 2 stated Patient 9 continuously stated she wanted to leave and became very agitated and started yelling. RN 2 stated Patient 9 did not have a stable walk and walked very slowly. RN 2 stated during her assessment Patient 9 wasn’t aware of year, the day, and did not know why she was in the hospital. RN 2 stated she informed the physicians Patient 9 was not fully alert and oriented, had no ride, and wasn’t sure where she was going once she left. RN 2 stated she called the Res 1 and informed him she did not feel comfortable signing the AMA form and Patient 9 does not appear safe to leave. RN 2 stated Patient 9 was not alert and oriented at the time she was allowed to leave the facility AMA. RN 2 stated she stressed her concerns regarding Patient 9’s mental status multiple times to the primary team. RN 2 further stated Res 1 acknowledged Patient 9 was not fully alert and oriented, and was still allowed to leave AMA. On December 10, 2025, at 10:14 a.m., an interview was conducted with Res 1. Res 1 stated in general, if a patient with dementia wants to leave AMA, he would assess them to see if they were alert and oriented and understood the consequences of leaving. On December 10, 2025, at 10:35 a.m., an interview was conducted with the IMMD. The IMMD stated in general, if a patient was previously on a 5150 hold for being gravely disabled, he would not let them leave AMA until a psychiatrist or a social worker has deemed the patient able to make the right decisions. The IMMD stated that morning, on September 30,2025, around 11:02 a.m., Patient 9 was alert and oriented during his assessment (four hours and 43 minutes before Patient 9 was allowed to leave AMA). The IMMD stated, “In all honestly, I was not comfortable sending this patient home considering the [name of government agency] case and her living conditions.” The IMMD stated he does not recall Patient 9’s mental status at the time Patient 9 was allowed to leave AMA. The IMMD stated Res 1 informed him Patient 9 was awake and oriented however, he did not assess Patient 9 at the time Patient 9 was allowed to leave AMA on September 30, 2025, at 3:45 p.m. The IMMD further stated, “We need to be more careful with these things, we should have involved social workers more than we did and involved psychiatry. Next time we will be more careful.” An article published online by the National Institute of Neurological Disorders and Strokes (a nationally recognized organization for research) titled, “Dementias,” dated October 25, 2025, was reviewed. The article indicated, “...Dementia is the loss of cognitive functioning-the ability to think, remember, or reason-to such an extent that it interferes with a person’s daily life and activities. These functions include memory, language skills, visual perception, problem solving, self-management, and the ability to focus and pay attention...” A facility’s document titled, “MEDICAL STAFF BYLAWS AN RULES AND REGULATIONS,” was reviewed. The bylaws indicated, “...Progress Note...Pertinent progress notes shall be recorded at the time of observation...Whenever possible, each of the patient’s clinical problems should be clearly identified in the progress notes and correlated with specific orders...Patient Protections...The physician admitting the patient shall have the responsibility of giving such information as may be necessary to assure the protection of...the patient from self-harm...Consultant...Psychiatric consultation and treatment is to be offered to all patients who have...become emotionally ill while in the hospital and/or those who suffer from...drug abuse. The fact that such services or referrals were at least offered shall be documented in the Patients medical records...””

“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: 50433 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for three of 31 sampled patients (Patient’s 4,17, and 18), when: 1. For Patient 4, the physician was not notified of critical laboratory results (dangerously abnormal test results). In addition, Patient 4’s surgical incision (a deliberate cut through the skin and tissue made during an operation) was not assessed each shift and wound care was not provided and wound care orders were not obtained from the physician; 2. For Patients 4 and 17, pain reassessment were not conducted; and 3. For Patient 18, the physician was not notified by nursing staff of Patient 18’s abnormal vital signs (measurements of the body’s functions which consist of heart rate, respiratory rate, temperature, blood pressure, and pain). These failures had the potential to compromise patient safety, delay treatment and may result in inadequate pain management and prolonged hospitalization for Patient’s 4, 17, and 18. Findings: 1. On December 9, 2025, at 10:28 a.m., a review of Patient 4’s record was conducted with the Director of Critical Care (DCC). A facility document titled, “History and Physical (H&P),” dated July 5, 2022, was reviewed. The document indicated Patient 4 was admitted to the facility on July 5, 2022, with a diagnosis of acute abdomen (sudden severe abdominal pain) with pneumoperitoneum (a condition with free air in the abdomen). The document indicted, “...Patient [Patient 4] was recently admitted here with posterior dislocation [a condition in which bones in a joint are forced out of their normal position] of the ulnohumeral joint [the hinge component of the elbow joint] and a radial head fracture [a break in the lower arm arm bone]/left toe fracture...” a. A facility document titled, “Results,” dated July 9, 2022, was reviewed. The document indicated Patient 4 had critical laboratory results of carbon dioxide (CO2, a type of exhaled gas, normal range is 21-31 mEq/L [milliequivalents per liter, units of measurement]) level of 8 and calcium (a type of mineral, normal range is 8.6-10.3 mg/dL [milligrams per deciliter, units of measurement]) level of 5 which were reported to Patient 4’s registered nurse (RN) on July 9, 2022, at 6:58 a.m. There was no documented evidence the physician was notified by nursing staff of the critical CO2 and calcium levels for Patient 4 on July 9, 2022. On December 10, 2025, at 1:32 p.m., an interview was conducted with the DCC. The DCC stated critical laboratory results should be reported to the physician because the results could be life-threatening and immediate action could be required. The facility policy and procedure (P&P) titled, “Critical Lab Values and Diagnostic Test Results; Notification Of,” dated September 2024, was reviewed. The P&P indicated, “...Critical results: Test and diagnostic procedures fall significantly outside the normal range and may indicate a life-threatening situation...The objective is to provide the responsible licensed caregiver these results within an established time frame so the patient can be treated...The responsible physician will be notified as soon as possible, but not later than, 60 minutes...The following laboratory values are defined as critical in this facility...Serum [the clear, yellowish liquid part of the blood] calcium...< [less than] 6.0 mg/dl...CO2...< 10 mEq/L...” b. A facility document titled, “Operative Report,” dated July 6, 2022, was reviewed. The document indicated, “...midline incision [a vertical cut down the center of the abdomen] extended to the umbilicus [belly button] and below...” A facility document titled, “Wound,” dated July 6, 2022, through July 9, 2022, was reviewed. There was no documented evidence an assessment of Patient 4’s midline incision wound was conducted. There was no documented evidence wound care for Patient 4’s midline abdominal incision was provided from July 7, 2022, at 10:07 p.m., through July 10, 2022, when Patient 4 was discharged. There was no documented evidence wound care for Patient 4’s midline incision wound was ordered by the physician. On December 10, 2025, at 1:57 p.m., an interview was conducted with the DCC. The DCC stated wound documentation was missing on Patient 4’s record. The DCC stated an assessment of a patient’s wounds or incisions should be documented every shift and if a patient does not have wound care orders, the physician should be contacted to obtain an order or clarify the care to be provided for the patient’s wound. A facility P&P titled, “Skin and Wound Care,” dated May 2024, was reviewed. The P&P indicated, “...If wound is identified...Notify physician and obtain treatment orders...Skin impairments are to be documented in daily skin integrity flow sheet every shift...This is the responsibility of the licensed nurses assigned to the patient...” 2a. On December 9, 2025, at 10:28 a.m., a review of Patient 4’s record was conducted with the Director of Critical Care (DCC). A facility document titled, “History and Physical (H&P),” dated July 2, 2022, when Patient 4 was first admitted to the facility, was reviewed. The document indicated Patient 4 was admitted to the facility on July 2, 2022, with a diagnosis of dislocation of the ulnohumeral joint and a left radial head fracture. A facility document titled, “Medication Administration Record (MAR),” dated July 2, 2022, was reviewed. The document indicated Patient 4 was administered fentanyl citrate (a powerful pain medication) 40 mcg/ml (micrograms per milliliter, units of measurement) intravenous (IV, administered into a vein) on July 2, 2022, at 3:48 p.m., for a pain score of eight out of 10 on the numeric pain scale (a pain assessment tool, with 0 [zero] meaning no pain, and 10 meaning severe pain) to the left arm. The document further indicated Patient 4 was administered ketorolac (a pain medication) 15 mg (milligrams, a unit of measurement) IV on July 2, 2022, at 11:07 p.m., for a pain score of six out of 10 to the left arm on the numeric pain scale. A facility document titled, “Flowsheets, Nursing, Pain Score,” dated July 2, 2022, was reviewed. There was no documented evidence a pain reassessment was conducted after the administration of fentanyl to Patient 4 on July 2, 2022, at 3:48 p.m. There was no documented evidence a pain reassessment was conducted after the administration of ketorolac to Patient 4 on July 2, 2022, at 11:07 p.m. 2b. On December 9, 2025, at 9:35 a.m., a review of Patient 17’s record was conducted with Registered Nurse (RN) 15. A facility document titled, “History & Physical Note,” dated October 31, 2025, was reviewed. The document indicated Patient 17 was admitted to the facility on October 31, 2025, with a diagnosis of acute pancreatitis (inflammation of the pancreas, an organ behind the stomach which makes digestive enzymes and hormones). A facility document titled, “Vital Signs,” was reviewed. The document indicated Patient 17 reported four out of 10 pain (a tool used to assess a person’s pain on a scale of 0 to 10, with zero meaning no pain and 10 meaning worst possible pain) to her abdomen (stomach area) on November 5, 2025, at 8:58 a.m. A facility document titled, “Med [medication] Admin [administration]- PRN [as needed],” was reviewed. The document indicated Patient 17 received hydrocodone-acetaminophen (a pain medication) 5-325 mg (milligrams, unit of measurement) one tablet by mouth on November 5, 2025, at 8:58 a.m. There was no documented evidence a pain reassessment was conducted after hydrocodone-acetaminophen was administered to Patient 17 on November 5, 2025, at 8:58 a.m. On December 10, 2025, at 1:32 p.m., an interview was conducted with the DCC. The DCC stated once a patient is treated for pain, a reassessment should be conducted within one hour. The DCC stated pain reassessment is important to evaluate the pain treatment provided and to know if the pain is better. The DCC stated uncontrolled pain could have negative impacts on patients and may affect the patients’ ability to care for themselves. A facility P&P titled, “Pain Management,” dated September 2024, was reviewed. The P&P indicated, “...Patients will be routinely reassessed for pain during the initial daily shift assessment, upon change of condition, after procedures known to cause pain, with new complaints, and as needed. At a minimum, this reassessment shall consist of noting the intensity of the patient’s pain...If a treatment intervention for pain is provided, the response to that intervention should be assessed...Reassessment is recommended to occur within 15 - 60 minutes following treatment...” 3. On December 9, 2025, at 10:15 a.m., a review of Patient 18’s record and concurrent interview was conducted with RN 15. A facility document titled, “History and Physical Note,” dated October 31, 2025, was reviewed. The document indicated Patient 18 was admitted to the facility on October 31, 2025, with a chief complaint of altered level of consciousness (confusion). A facility document titled, “Vital Signs,” dated November 1, 2025, was reviewed. The document indicated Patient 18 had the following blood pressure [BP, normal blood pressure for most adults is below 120/80] readings: - On November 1, 2025, at 3 a.m., BP was 192/66; - On November 1, 2025, at 4 a.m., BP was 166/64; - On November 1, 2025, at 5 a.m., BP was 167/65; - On November 1, 2025, at 6 a.m., BP was 176/65; and - On November 1, 2025, at 7 a.m., BP was 144/59. RN 15 stated there was no documentation PRN blood pressure medications were ordered for Patient 18. RN 15 stated there was no documentation Patient 18’s physician was notified to report any of Patient 18’s elevated blood pressures on November 1, 2025. On December 9, 2025, at 11:30 a.m., an interview was conducted with the DCC. The DCC stated the expectation is the RN will call the physician within 30 minutes to notify of the patient’s elevated BP and for the physician to receive treatment orders to lower the patient’s BP. The facility’s P&P titled, “Vital Signs-Standard of Care,” dated September 29, 2024, was reviewed. The P&P indicated, “...Vital Signs are indicators of the patients present physiological status...Vital Signs should be repeated per patient condition and per interventions to assess response...””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 34933 Based on observation, interview, and record review, the facility failed to ensure the facility had an effective Governing Body (GB, an individual or group of individuals, who are legally responsible for the hospital’s overall management, operation, and ultimate accountability) to address the needs of the patients in the facility when the GB was not aware of and systems were not implemented by the GB to address the insufficient supply of blood culture (BC) bottles (sealed containers used to grow and identify bacteria or fungi from a patient’s blood sample) to perform BC testing (a diagnostic test to determine the presence of bacteria, fungi and other germs in the blood), for 40 of 80 sample patients (Patients 25, 26, 27, 32, 35, 36, 37, 43, 44, 45, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, and 80) which resulted in BC tests not being drawn (blood draw, a medical procedure where a healthcare professional uses a needle to collect a blood specimen from a vein) in accordance with recommended guidelines and the facility’s policy and procedure (P&P) since August 7, 2025. In addition, the GB was not aware and did not implement interventions when the preventative maintenance (PM, planned inspections, cleaning, and servicing of equipment to prevent breakdowns and improve reliability) for 101 pieces of laboratory equipment has not been performed by the date the PM was due (Refer to A083). The cumulative effects of these systemic failures resulted in systems not being implemented by the GB to ensure adequate BC bottles were available which led to incomplete BC testing for Patients 25, 26, 27, 32, 35, 36, 37, 43, 44, 45, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, and 80, on whom BC testing were conducted at the facility’s laboratory. These systemic failures had the potential to negatively impact patient health and safety by delaying the identification and treatment of blood infections and to cause delays in the provision of the necessary treatment which may result in delay of treatment of infection, use of incorrect treatment modalities and antibiotics, longer hospital stay, and increase of the risk of death for these patients.”

“LABORATORY SERVICES CFR(s): 482.27 The hospital must maintain, or have available, adequate laboratory services to meet the needs of its patients. The hospital must ensure that all laboratory services provided to its patients are performed in a facility certified in accordance with Part 493 of this chapter. This Condition is not met as evidenced by: 34933 50433 Based on observation, interview, and record review, the facility failed to ensure laboratory services were provided and maintained to meet the patients’ needs, for 40 of 80 sample patients (Patients 25, 26, 27, 32, 35, 36, 37, 43, 44, 45, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, and 80 ), when: 1. For Patients 25, 26, 27, 32, 35, 36, 37, 43, 44, 45, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, and 80, blood cultures (BC, a laboratory test to determine if bacteria, fungi, or other germs are growing in the blood) were not drawn (blood draw, a medical procedure where a healthcare professional uses a needle to collect a blood specimen from a vein) according to recommended guidelines and the facility’s policy and procedure (P&P) (Refer to A0582); and 2. The preventative maintenance (PM, planned inspections, cleaning, and servicing of equipment to prevent breakdowns and improve reliability) for 101 pieces of the facility’s laboratory equipment was not performed by the date the PM was due (Refer to A0582). The cumulative effects of these systemic failures had the potential to result in missed or incorrect diagnoses and treatment for Patients 25, 26, 27, 32, 35, 36, 37, 43, 44, 45, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, and 80, on whom laboratory testing were conducted at the facility’s laboratory which may result in delay of treatment of infection, use of incorrect treatment modalities and antibiotics, longer hospital stay, and increase of the risk of death for these patients.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 48776 Based on observation, interview, and record review, the facility failed to ensure the facility had an effective Governing Body (GB, an individual or group of individuals, who are legally responsible for the hospital’s overall management, operation, and ultimate accountability) to address the needs of the patients in the facility when the GB was not aware of and systems were not implemented by the GB to address the insufficient supply of blood culture (BC, a diagnostic test to determine the presence of bacteria, fungi and other germs in the blood) bottles (sealed containers used to grow and identify bacteria or fungi from a patient’s blood sample) to perform BC testing, for 40 of 80 sample patients (Patients 25, 26, 27, 32, 35, 36, 37, 43, 44, 45, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, and 80) which resulted in BC tests not being drawn (blood draw, a medical procedure where a healthcare professional uses a needle to collect a blood specimen from a vein) in accordance with recommended guidelines and the facility’s policy and procedure (P&P) since August 7, 2025. In addition, the GB was not aware and did not implement interventions when the preventative maintenance (PM, planned inspections, cleaning, and servicing of equipment to prevent breakdowns and improve reliability) for 101 pieces of laboratory equipment has not been performed by the date the PM was due. These failures resulted in systems not being implemented by the GB to ensure adequate BC bottles were available which led to incomplete BC testing for Patients 25, 26, 27, 32, 35, 36, 37, 43, 44, 45, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, and 80, on whom BC testing were conducted at the facility’s laboratory. These systemic failures had the potential to negatively impact patient health and safety by delaying the identification and treatment of blood infections and to cause delays in the provision of the necessary treatment which may result in delay of treatment of infection, use of incorrect treatment modalities and antibiotics, longer hospital stay, and increase of the risk of death for these patients. Findings: 1. On September 2, 2025, at 12 p.m., during a tour of the laboratory with the Laboratory Supervisor (LS), a communication board was observed located in the laboratory. On the communication board was observed written, “Blood Cultures: Draw One bottle [referring to a BC bottle which could be either an aerobic (a laboratory test used to detect and identify microorganisms [living organisms which are invisible to the naked eye and may cause infections] which grow in the presence of oxygen) or anaerobic (a laboratory test to detect bacteria that can only grow in an oxygen-free environment) for the set [a set of BC test includes transferring a specific volume of blood into the aerobic and anaerobic BC bottles; for each BC test ordered, a set of BC test should be drawn from two different body sites 15 minutes apart from each other]. We are extermly [sic, extremely] low.” On September 2, 2025, at 12 p.m., during a concurrent interview conducted with the LS, the LS stated the laboratory staff had been transferring the blood of the patients who had orders for BC tests into either an aerobic or an anaerobic BC bottle but not to both aerobic and anaerobic BC bottles, depending on which BC bottle was available at the laboratory. The LS stated the laboratory staff would draw a second set of BC testing for the same patient 15 minutes later and would transfer the blood to either an aerobic or an anaerobic BC bottle, but not to both. The LS stated the blood of the patients for whom BC testing have been ordered had not been transferred to both aerobic and anaerobic BC and a complete set of two aerobic and two anaerobic BC bottles have not been used to transfer the patients’ blood for each BC test ordered by the physician, since August 7, 2025. The LS stated this was due to supply shortages of the anaerobic and aerobic BC bottles in the facility because of nonpayment of the invoice for both types of BC bottles. On September 3, 2025, at 9:55 a.m., an interview was conducted with the Chief Quality Officer (CQO). The CQO stated the medical staff was not made aware that only one bottle of either aerobic or anaerobic BC for each set was being drawn from the patients for each BC test ordered. The CQO stated she was not aware of the shortage of BC bottles at the facility until September 2, 2025. The CQO stated by not testing both aerobic and anaerobic BC, all forms of microorganisms which could be present in a patient’s blood would not be detected. On September 3, 2025, at 11:19 a.m., an interview was conducted with the Director of Laboratory Services (DLS). The DLS stated he informed the facility’s administration of the BC bottle shortage but he did not provide them with the information about only one type of BC (only either aerobic or anaerobic BC) was being drawn from each patient who had an order for BC testing. The DLS stated the medical staff at the hospital were not informed of the shortage of BC bottles nor of the plan to use one BC bottle of either aerobic or anaerobic only for each BC test ordered instead of a set of both. The DLS stated it is not best practice (the best practice is transferring of the blood drawn from a patient into one aerobic and one anaerobic blood culture bottles, then drawing blood again from the same patient but from a different body site 15 minutes apart). The DLS stated it is not the facility’s policy to draw only aerobic or anaerobic BC for each set of blood draw for each blood culture testing ordered for a patient. The DLS stated laboratory testing cannot exclude all forms of microorganisms that may be present in the patient’s blood if both aerobic and anaerobic BCs are not drawn. On September 3, 2025, at 1:17 p.m., an interview was conducted with the DLS. The DLS stated the laboratory had used pediatric (for children) BC bottles (a pediatric BC bottle is a specially formulated, smaller BC bottle for children, which supports the growth of microorganisms requiring oxygen [aerobes] and not the anaerobes [microorganisms which do not require oxygen which may limit the growth of bacteria being tested and may affect the result of the BC test) vials on some adult patients since August 7, 2025. The DLS stated this was “not best practice” (best practice is using a pediatric BC bottle only for pediatric patients whose age and condition prevent drawing greater than three milliliter [unit of measurement] of blood). On September 8, 2025, at 11:35 a.m., a concurrent interview and record review were conducted with the DLS. The facility report titled, “[Brand name of BC machine] Instrument Inventory Report,” dated August 7, 2025, through September 3, 2025, was reviewed with the DLS. The DLS stated the report contained a comprehensive list of the patients who had BC test collected and conducted from August 7, 2025, to September 3, 2025, and included the information of the BC bottles used for each blood draw. The DLS stated Patients 25, 26, 27, 32, 35, 36, 37, 43, 44, 45, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, and 80 did not have two sets of blood drawn. The DLS stated the facility’s policies titled, “Blood Cultures,” and “Adult Sepsis [a life-threatening complication of an infection] Screening and Physician Approved Nursing Sepsis Protocol,” were not followed. On September 3, 2025, at 2:18 p.m., the information for use (IFU, instructions, safety information, and details about a product’s intended purpose, proper use, and necessary precautions, provided by a manufacturer) for pediatric BC bottles titled, “[brand name] Peds [pediatric] Plus/F Culture Vials,” was reviewed. The IFU indicated, “...Peds Plus/F Culture Vials are for aerobic blood cultures...” On September 8, 2025, at 2:45 p.m., an interview was conducted with the Governing Body. Physician (MD) 1 stated she is part of the Governing Body. MD 1 stated the governing body was not aware of the shortage of BC bottle supplies in the facility’s laboratory to perform complete blood culture testing. An undated article published by the Centers for Disease Control and Prevention (CDC, a nationally recognized organization) titled, “Preventing Adult Blood Culture Contamination: A Quality Tool for Clinical Laboratory Professionals,” was reviewed. The article indicated, “...Laboratory analysis of blood cultures is vital to the accurate and timely diagnosis of bloodstream infections [occurs when infectious microorganisms, such as bacteria, viruses, or fungi, enter and multiply in the blood]. However, the reliability of your testing depends on clinical compliance with collection procedures...The volume of blood collected is critically important to the laboratory diagnosis of bloodstream infection, which generally requires two or more sets to achieve...two sets are required...” According to an article titled, “Effects of Blood Culture Aerobic/Anaerobic Bottle Collection Patterns from Both Sides of the Body on Positive Blood Culture [when bacteria, yeast, or other microorganisms have been detected in a patient’s blood sample, indicating an infection in the bloodstream] Rate [measures the occurrence of positive results in blood cultures collected to diagnose infections] and Time-to-Positivity [time it takes for a blood culture to show a positive result, indicating the presence of bacterial or fungal growth],” dated June 10, 2022, published by the National Institute of Health (a nationally recognized research center), “...a combination of aerobic and anaerobic bottles from a single site was superior to two aerobic bottles from two different sites. Neglecting the use of anaerobic BC [blood culture] bottles may reduce the rate of positive BCs, and was not conducive to the early detection of pathogens [microorganisms which may cause infection]...” The facility’s policy and procedure (P&P) titled, “Blood Cultures,” dated February 2024, was reviewed. The P&P indicated, “...Blood cultures are collected whenever there is a reason to suspect a clinically significant bacteremia [presence of bacteria in the blood]...Blue-labeled bottles (for aerobes), purple-labeled bottles (for anaerobes) and yellow labeled bottles (for infants) are utilized in our institution...Bottle Preparation and Inoculation [the process of placing a patient’s blood sample into specialized bottles containing culture media to grow any bacteria or fungi present in the bloodstream]...First, inject 1/2 [one half] of the sample into the purple anaerobic bottle, and then inject the remaining amount into the blue aerobic bottle...Do not use peds [pediatric] bottles [blood culture bottles] on adults...Optimal blood culture volume is 10 ml [milliliter, a unit of measurement] in each of the aerobic and anaerobic bottles...” The facility P&P titled, “Adult Sepsis Screening and Physician Approved Nursing Sepsis Protocol,” dated May 2024, was reviewed. The P&P indicated, “...order/obtain two (2) sets of blood cultures (to be obtained from two different sites [body sites] 15 minutes apart)...” 2. On September 2, 2025, at 10:30 a.m., a tour of the laboratory was conducted with the LS. Multiple pieces of equipment in the laboratory were observed with PM labels indicating PM was performed in January 2025 or April 2025. The PM labels indicated the PM was due in July 2025. On September 2, 2025, at 10:52 a.m., an interview was conducted with the Bio-medical (biomedical engineering, the team of technicians and engineers who install, maintain, and repair medical equipment in the facility) Supervisor (BMS). The BMS stated the equipment Biomed uses to perform PM on the laboratory equipment has not been calibrated because the vendor contracted to conduct the calibration of the facility’s equipment necessary to conduct a PM has not been paid. The BMS stated the PM had not been done because the accuracy of the results of the laboratory testing could not be verified without PM completed on the laboratory equipment. The BMS stated the biomed equipment used to conduct the PM on the laboratory equipment would need to be calibrated first. On September 3, 2025, at 2 p.m., a facility document titled, “Equipment List - Active Equipment Only,” with a print date of September 3, 2025, at 4:56 a.m., was reviewed. The document indicated a list of 101 pieces of laboratory equipment requiring PM. On September 3, 2025, at 2:27 p.m., a phone interview was conducted with the BMS. The BMS stated the facility document titled, “Equipment List - Active Equipment Only,” was a comprehensive list of all the equipment in the laboratory which was overdue for PM (101 pieces of laboratory equipment). The BMS stated, without a complete PM, the equipment used to process laboratory tests for patients had the potential to provide inaccurate results. On September 8, 2025, at 2:45 p.m., an interview was conducted with the Governing Body. MD 1 stated she is part of the Governing Body. MD 1 stated the governing body was not aware the PM of the 101 laboratory equipment has not been performed since July 2025 when the PM was due. The facility’s P&P titled, “Preventative Maintenance Program - Ensuring Operation Ability,” dated April 2021, was reviewed. The P&P indicated, “...preventative maintenance is a key factor in assuring the ongoing performance and reliability...whereby each system is properly...maintained...The Facilities Administrator is responsible for the proper and safe functioning of all equipment within the facility...” The facility’s P&P titled, “Organizational Decisions-Corporate Level,” dated March 2021, was reviewed. The P&P indicated, “...Chief Hospital Executive Officer will meet with the Governing Board to discuss plans and implement policies affecting services throughout the hospital and corporate system. Results of performance improvement activities and patient safety activities will be included in these discussions...””

“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: 50122 Based on interview and record review, the facility failed to ensure allegations of patient abuse were reported to the House Supervisor and the Supervisor/Manager/Director of the unit and investigated timely, in accordance with the facility’s policy and procedure, for one of 80 sample patients (Patient 32). This failure had the potential for Patient 32 and other patients to experience abuse and harm. Findings: On September 4, 2025, at 11:15 a.m., a concurrent interview and record review of Patient 32’s record were conducted with the Deputy Regional Director of Quality (DRDQ). The DRDQ stated, on September 1, 2025, Patient 32 alleged a certified nursing assistant (CNA 1) had hit her. A facility document titled, “Admission Assessment Report,” dated August 29, 2025, at 11:40 p.m., was reviewed. The document indicated, “...Neurological Assessment...Awake, alert and oriented to person, place, time and purpose...” A facility document titled, “Daily Focus Assessment Report,” dated August 29, 2025, through September 1, 2025, was reviewed. The document indicated, “...Neurological Assessment...Awake, alert and oriented to person, place, time, and purpose...” A facility document titled, “History and Physical Note,” dated August 30, 2025, was reviewed. The document indicated Patient 32 was admitted to the facility on August 29, 2025, with a diagnosis of urinary tract infection (an infection that occurs when bacteria enters the urinary system which consist of the kidneys, ureters, bladder, and urethra) with sepsis (a life-threatening reaction of the body to an infection). A facility document titled, “Progress Notes Report - Department: Nursing,” dated August 31, 2025, at 7:39 p.m., authored by Registered Nurse (RN) 4, was reviewed. The document indicated, “...At about 1500 [3 p.m.]...The pt [Patient 32] told me that the CNA [CNA 1] slapped [name of Patient 32] as hard as [name of CNA 1] could...There was not a red mark on [Patient 32’s] face...” A facility document titled, “Progress Notes Report - Department: Case Management,” dated September 1, 2025, at 3:51 p.m., was reviewed. The document indicated, “...RNCM [Registered Nurse Case Manager] placed a call to the patient’s [family member]...to inform her of the patient’s discharge...[Patient 32’s family member] accepted the discharge but reported that the patient told her a CNA had slapped [name of Patient 32] in the face...At the time of notification, RN [Registered Nurse], house supervisor, and charge nurse reported they were unaware of the alleged incident...” On September 4, 2025, at 1:40 p.m., an interview and record review were conducted with the Clinical Nurse Manager (RNM) 1 for the medical/surgical/telemetry units. RNM 1 stated that she was not informed of Patient 32’s abuse allegation until September 1, 2025. RNM 1 stated this allegation should have been immediately reported by RN 1 when it was made by the patient on August 31, 2025. RNM 1 stated the facility also noted CNA 1 was not placed on administrative leave until September 1, 2025, even though this should have happened on the day the allegation was reported to the RN. RNM 1 stated an assessment of Patient 32 was not done at the time of the alleged incident. RNM 1 further stated Patient 32’s physician, family, other agencies, and law enforcement should have been informed about the alleged abuse on August 31, 2025. RNM 1 stated a social service consult should have been initiated when Patient 32 made the allegation of abuse on August 31, 2025, and none of which was done. RNM 1 acknowledged the facility’s abuse Policy and Procedure (P&P) was not followed correctly. On September 4, 2025, at 2:15 p.m., an interview was conducted with the House Supervisor (HS). The HS stated she received a call from the RNCM on September 1, 2025, regarding an alleged abuse involving Patient 32. The HS stated Patient 32 reported on August 31, 2025, that a CNA had slapped her in the face. The HS stated RNM 1 was contacted and CNA 1 was placed on administrative leave and sent home in accordance with the facility’s P&P on September 1, 2025 (one day after Patient 32 made the allegation of abuse). On September 5, 2025, at 10:15 a.m., an interview was conducted with RN 4. RN 4 stated she provided care for Patient 32 on August 31, 2025. RN 4 stated CNA 1 reported Patient 32 had the television remote/call light cord wrapped around the patient’s left arm where the intravenous (IV, through the vein) catheter (a thin, flexible tube placed in the vein in the arm or hand used to give fluids or medications) was. RN 4 stated CNA 1 attempted to unwrap the cord, but Patient 32 became agitated, flung the call light at CNA 1, and then the call light “whipped around and hit [name of Patient 32] in the face.” RN 4 stated when they entered the patient’s room with CNA 1, Patient 32 reported CNA 1 “slapped me in the face as hard as [name of CNA 1] could.” RN 4 stated the Charge Nurse (CN) was informed of the incident. RN 4 stated, in hindsight, the house supervisor should have been notified “whether it [the allegation of abuse] was real or not.” RN 4 stated neither the physician nor the family was notified of the allegation of abuse. On September 5, 2025, at 1:40 p.m., an interview was conducted with the Charge Nurse (CN). The CN stated on August 31, 2025, RN 5 informed her Patient 32 was upset with CNA 1 alleging abuse and being slapped in the face. The CN stated Patient 32 reported CNA 1 “slapped me so hard” and wanted to speak to a social worker. The CN stated she did not contact a social worker and forgot to notify the house supervisor. When asked about the process when a patient alleges abuse, the CN stated the house supervisor, physician, social worker, law enforcement, and the agency protecting the elder from abuse should be notified and these were not done. A review of P&P titled, “RECOGNIZING AND REPORTING SUSPECTED AND KNOWN CHILD ABUSE AND NEGLECT, DEPENDENT ADULT AND ELDER ABUSE/NEGLECT/EXPLOITATION,” dated January, 2022, was conducted. The policy indicated, “...PROCEDURES...If an employee, healthcare professional or contracted employee is involved in the suspected or known abuse/neglect then the House Supervisor and the Supervisor/Manager/Director of the unit will be notified immediately by the individual who discovered the suspected or know abuse/neglect. The offending individual will be removed from working any further and restricted from access to patients. The offending individual will be placed on Administrative leave until an investigation can be completed...The Supervisor/Manager/Director of the unit or House Supervisor will immediately report by telephone to the Chief Hospital Executive Officer or Administrator in call, and the Chief Nursing Officer, the Administrator on call or the Chief Nursing Officer to contact the Chief of Staff (if applicable), when a healthcare professional, contracted or employee of [Name of facility] is the suspected abuser...Hospital personnel who discovered the known abuse/neglect will immediately report by telephone to the [name of county agency investigating elder abuse]...Hospital personnel who discovered the suspected or known abuse/neglect will immediately report by telephone Local Law enforcement...The Nurse caring for the patient will call the attending physician, social services (set up consult), and the patients representative...Make sure to document accordingly. Completed an updated patient assessment and care plan (include photos with measurements if indicated). Careful assessment and documentation of physical findings can help provide the data that are believed to confirm diagnosis...” A review of P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES,” dated November, 2022, was conducted. The policy indicated, “...Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective and advocacy services including notifying governmental agencies of neglect or abuse...””

“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: 48776 Based on interview and record review, the facility failed to ensure allegations of patient abuse were reported to the House Supervisor and the Supervisor/Manager/Director of the unit and investigated timely, in accordance with the facility’s policy and procedure, for one of 80 sample patients (Patient 32). This failure had the potential for Patient 32 and other patients to experience abuse and harm. Findings: On September 4, 2025, at 11:15 a.m., a concurrent interview and record review of Patient 32’s record were conducted with the Deputy Regional Director of Quality (DRDQ). The DRDQ stated, on September 1, 2025, Patient 32 alleged a certified nursing assistant (CNA 1) had hit her. A facility document titled, “Admission Assessment Report,” dated August 29, 2025, at 11:40 p.m., was reviewed. The document indicated, “...Neurological Assessment...Awake, alert and oriented to person, place, time and purpose...” A facility document titled, “Daily Focus Assessment Report,” dated August 29, 2025, through September 1, 2025, was reviewed. The document indicated, “...Neurological Assessment...Awake, alert and oriented to person, place, time, and purpose...” A facility document titled, “History and Physical Note,” dated August 30, 2025, was reviewed. The document indicated Patient 32 was admitted to the facility on August 29, 2025, with a diagnosis of urinary tract infection (an infection that occurs when bacteria enters the urinary system which consist of the kidneys, ureters, bladder, and urethra) with sepsis (a life-threatening reaction of the body to an infection). A facility document titled, “Progress Notes Report - Department: Nursing,” dated August 31, 2025, at 7:39 p.m., authored by Registered Nurse (RN) 4, was reviewed. The document indicated, “...At about 1500 [3 p.m.]...The pt [Patient 32] told me that the CNA [CNA 1] slapped [name of Patient 32] as hard as [name of CNA 1] could...There was not a red mark on [Patient 32’s] face...” A facility document titled, “Progress Notes Report - Department: Case Management,” dated September 1, 2025, at 3:51 p.m., was reviewed. The document indicated, “...RNCM [Registered Nurse Case Manager] placed a call to the patient’s [family member]...to inform her of the patient’s discharge...[Patient 32’s family member] accepted the discharge but reported that the patient told her a CNA had slapped [name of Patient 32] in the face...At the time of notification, RN [Registered Nurse], house supervisor, and charge nurse reported they were unaware of the alleged incident...” On September 4, 2025, at 1:40 p.m., an interview and record review were conducted with the Clinical Nurse Manager (RNM) 1 for the medical/surgical/telemetry units. RNM 1 stated that she was not informed of Patient 32’s abuse allegation until September 1, 2025. RNM 1 stated this allegation should have been immediately reported by RN 1 when it was made by the patient on August 31, 2025. RNM 1 stated the facility also noted CNA 1 was not placed on administrative leave until September 1, 2025, even though this should have happened on the day the allegation was reported to the RN. RNM 1 stated an assessment of Patient 32 was not done at the time of the alleged incident. RNM 1 further stated Patient 32’s physician, family, other agencies, and law enforcement should have been informed about the alleged abuse on August 31, 2025. RNM 1 stated a social service consult should have been initiated when Patient 32 made the allegation of abuse on August 31, 2025, and none of which was done. RNM 1 acknowledged the facility’s abuse Policy and Procedure (P&P) was not followed correctly. On September 4, 2025, at 2:15 p.m., an interview was conducted with the House Supervisor (HS). The HS stated she received a call from the RNCM on September 1, 2025, regarding an alleged abuse involving Patient 32. The HS stated Patient 32 reported on August 31, 2025, that a CNA had slapped her in the face. The HS stated RNM 1 was contacted and CNA 1 was placed on administrative leave and sent home in accordance with the facility’s P&P on September 1, 2025 (one day after Patient 32 made the allegation of abuse). On September 5, 2025, at 10:15 a.m., an interview was conducted with RN 4. RN 4 stated she provided care for Patient 32 on August 31, 2025. RN 4 stated CNA 1 reported Patient 32 had the television remote/call light cord wrapped around the patient’s left arm where the intravenous (IV, through the vein) catheter (a thin, flexible tube placed in the vein in the arm or hand used to give fluids or medications) was. RN 4 stated CNA 1 attempted to unwrap the cord, but Patient 32 became agitated, flung the call light at CNA 1, and then the call light “whipped around and hit [name of Patient 32] in the face.” RN 4 stated when they entered the patient’s room with CNA 1, Patient 32 reported CNA 1 “slapped me in the face as hard as [name of CNA 1] could.” RN 4 stated the Charge Nurse (CN) was informed of the incident. RN 4 stated, in hindsight, the house supervisor should have been notified “whether it [the allegation of abuse] was real or not.” RN 4 stated neither the physician nor the family was notified of the allegation of abuse. On September 5, 2025, at 1:40 p.m., an interview was conducted with the Charge Nurse (CN). The CN stated on August 31, 2025, RN 5 informed her Patient 32 was upset with CNA 1 alleging abuse and being slapped in the face. The CN stated Patient 32 reported CNA 1 “slapped me so hard” and wanted to speak to a social worker. The CN stated she did not contact a social worker and forgot to notify the house supervisor. When asked about the process when a patient alleges abuse, the CN stated the house supervisor, physician, social worker, law enforcement, and the agency protecting the elder from abuse should be notified and these were not done. A review of P&P titled, “RECOGNIZING AND REPORTING SUSPECTED AND KNOWN CHILD ABUSE AND NEGLECT, DEPENDENT ADULT AND ELDER ABUSE/NEGLECT/EXPLOITATION,” dated January, 2022, was conducted. The policy indicated, “...PROCEDURES...If an employee, healthcare professional or contracted employee is involved in the suspected or known abuse/neglect then the House Supervisor and the Supervisor/Manager/Director of the unit will be notified immediately by the individual who discovered the suspected or know abuse/neglect. The offending individual will be removed from working any further and restricted from access to patients. The offending individual will be placed on Administrative leave until an investigation can be completed...The Supervisor/Manager/Director of the unit or House Supervisor will immediately report by telephone to the Chief Hospital Executive Officer or Administrator in call, and the Chief Nursing Officer, the Administrator on call or the Chief Nursing Officer to contact the Chief of Staff (if applicable), when a healthcare professional, contracted or employee of [Name of facility] is the suspected abuser...Hospital personnel who discovered the known abuse/neglect will immediately report by telephone to the [name of county agency investigating elder abuse]...Hospital personnel who discovered the suspected or known abuse/neglect will immediately report by telephone Local Law enforcement...The Nurse caring for the patient will call the attending physician, social services (set up consult), and the patients representative...Make sure to document accordingly. Completed an updated patient assessment and care plan (include photos with measurements if indicated). Careful assessment and documentation of physical findings can help provide the data that are believed to confirm diagnosis...” A review of P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES,” dated November, 2022, was conducted. The policy indicated, “...Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective and advocacy services including notifying governmental agencies of neglect or abuse...””

“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: 50433 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for seven of 80 sampled patients (Patients 32, 33, 34, 39, 40, 41, and 42), when: 1. For Patients 39, 40, 41, and 42, pain treatment and/or pain reassessment were not conducted; 2. For Patient 39, abnormal vital signs (measurements of the body’s functions which consist of heart rate, respiratory rate, temperature, blood pressure, and pain) were not reported to the physician; 3. For Patient 39, medications were not administered as prescribed by the physician; 4. For Patient 41, a near miss (an event or situation that has the potential to cause harm to a patient but does not) was not reported to the facility; 5. For Patient 32, an allegation of abuse was not reported in a timely manner; and 6. For Patients 33 and 34, the a rate change (adjustment of the infusion speed at which a drug or fluid is delivered through a vein) for a high-risk medication (a medication which has a high likelihood of causing serious harm or even fatal injury if misused or when an error occurs during its use) fentanyl (a potent drug used to reduce moderate to severe pain) was not witnessed by another registered nurse (RN). These failures had the potential to compromise patient safety, result in inadequate pain management, and increased risk of patient abuse. Findings: 1a. On September 2, 2025, at 10 a.m., during a tour of Unit B conducted with the Patient Advocate (PA), Patient 39 was observed sitting upright in bed. During a concurrent interview with Patient 39, Patient 39 stated she had a broken clavicle and was in pain. Patient 39 stated she did not remember when she had received pain medication. On September 4, 2025, at 10:24 a.m., a review of Patient 39’s record and concurrent interview were conducted with the Director of the Emergency Department (DED). A facility document titled, “History and Physical (H&P),” dated September 1, 2025, was reviewed. The document indicated Patient 39 was admitted to the facility on September 1, 2025, with a diagnosis of ETOH (the medical abbreviation for ethanol, the type of alcohol found in beverages) withdrawal (alcohol withdrawal, symptoms can include anxiety, shakiness, sweating, vomiting, fast heart rate, mild fever, and seizures which occur when someone stops using alcohol). The document indicated Patient 39 had reported a broken clavicle and a pain score of seven out of 10 on the pain scale (a pain assessment tool, with 0 [zero] meaning no pain, and 10 meaning severe pain). A facility document titled, “Flowsheets, Nursing, Pain Score,” dated September 1, 2025, was reviewed. The document indicated Patient 39 reported seven out of 10 pain to the left shoulder on September 1, 2025, at 1:30 p.m. The document indicated Patient 39 reported seven out of 10 pain to the left arm on September 1, 2025, at 3:28 p.m. The document further indicated Patient 39 reported seven out of 10 pain to the left arm on September 1, 2025, at 7 p.m. A facility document titled, “Medication Administration Record,” was reviewed. The document indicated Patient 39 received Norco (a pain medication) 10 mg (milligrams, a unit of measurement)/325 mg on September 1, 2025, at 3:28 p.m. There was no documented evidence pain intervention (treatment) was provided nor pain reassessment was conducted for Patient 39 on September 1, 2025, at 1:30 p.m., and on September 1, 2025, at 7 p.m. There was no documented evidence a pain reassessment was conducted for Patient 39 on September 1, 2025, at 3:28 p.m. The DED stated the pain assessments on September 1, 2025, were performed in the Emergency Department (ED) and the expectation would be for pain management to begin within 10 to 15 minutes after a patient is seen by a physician. The DED stated Patient 39 was first seen by a physician on September 1, 2025, at 1:28 p.m. 1b. On September 5, 2025, at 10:10 a.m., a review of Patient 40’s record was conducted with the Director of Critical Care (DOC) and Registered Nurse (RN) 2. A facility document titled, “H&P,” dated August 30, 2025, was reviewed. The document indicated Patient 40 was admitted to the facility on August 30, 2025, with a diagnosis of right intertrochanteric fracture (broken hip). A facility document titled, “Flowsheets, Nursing, Pain Score,” was reviewed. The document indicated Patient 40 reported eight out of 10 pain to her right hip on August 31, 2025, at 12:37 p.m. A facility document titled, “Medication Administration Record,” was reviewed. The document indicated Patient 40 received morphine (a pain medication) 4 mg, intravenously (IV, administered through the vein) on August 31, 2025, at 12:37 p.m. There was no documented evidence a pain reassessment was conducted after the administration of morphine to Patient 40 on August 31, 2025, at 12:37 p.m. 1c. On September 5, 2025, at 1:25 p.m., a review of Patient 41’s record was conducted with the DOC. A facility document titled, “H&P,” dated July 19, 2025, was reviewed. The document indicated Patient 41 was admitted to the facility on July 19, 2025, with a diagnosis of acute toxic metabolic encephalopathy (a condition characterized by a rapid decline in brain function caused by an accumulation of toxins [substances from organ failure, infections, or exposure to external poisons] in the body). A facility document titled, “Flowsheets, Nursing, Pain Score,” was reviewed. The document indicated Patient 41 reported five out 10 pain on July 23, 2025, at 9:09 p.m., with non-pharmacological (a treatment that does not involve the use of medication) intervention of relaxation/position change documented as provided to Patient 41. There was no documented evidence pain reassessment was conducted for Patient 41 after the interventions were administered on July 23, 2025, at 9:09 p.m. 1d. On September 8, 2025, at 9:30 a.m., a review of Patient 42’s record was conducted with the Patient Safety Sepsis Coordinator (PSSC). A facility document titled, “H&P,” dated July 17, 2025, was reviewed. The document indicated Patient 42 was admitted to the facility on July 17, 2025, with a diagnosis of acute metabolic encephalopathy. A facility document titled, “Flowsheets, Nursing, Pain Score,” was reviewed. The document indicated Patient 42 reported four out 10 pain to the left groin on July 23, 2025, at 8 a.m. The document further indicated calazime ointment (a skin protectants used to treat skin conditions caused by moisture, irritation, and rash) was applied and the patient was repositioned as interventions for pain. There was no documented evidence pain reassessment was conducted for Patient 42 after the interventions were administered on July 23, 2025, at 8 a.m. On September 8, 2025, at 4:05 p.m., an interview was conducted with the Chief Quality Officer (CQO). The CQO stated pain should be assessed by the RN, compared to previous pain assessments, and orders should be checked to see if pain medication is ordered. The CQO stated, if there are no pain medication orders, the RN should communicate the patient’s pain with the patient’s physician. The CQO stated there are pharmacological and non-pharmacological managements for pain, and when treatment intervention is provided, it should be reassessed for effectiveness. The facility’s P&P titled, “Pain Management,” dated September 2024, was reviewed. The P&P indicated, “...Patients have the right to main management...inpatients [patients admitted to the facility] shall receive treatment for any active pain issue...Treatment is to provided in a timely manner...If a treatment intervention for pain is provided, the response to that intervention should be assessed...reassessment is recommended to occur within 15-60 minutes following treatment...” 2. On September 4, 2025, at 10:24 a.m., a review of Patient 39’s record and concurrent interview was conducted with the Director of the Emergency Department (DED). A facility document titled, “History and Physical (H&P),” dated September 1, 2025, was reviewed. The document indicated Patient 39 was admitted to the facility on September 1, 2025, with a diagnosis of ETOH withdrawal. A facility document titled, “Vitals (measurements of body functions including temperature, heart rate, respiratory rate, and blood pressure [BP, normal blood pressure for most adults is below 120/80],” dated from September 2, 2025, through September 3, 2025, was reviewed. The document indicated Patient 39 had the following blood pressure readings: - On September 2, 2025, at 8 a.m., BP was164/78; - On September 2, 2025, at 12 p.m., BP was 167/95; - On September 2, 2025, at 4 p.m., BP was 157/99; - On September 3, 2025, at 8 a.m., BP was 158/111; and - On September 3, 2025, at 4 p.m., BP was 154/118. A facility document titled, “Order Inquiry,” dated September 1, 2025, was reviewed. The document indicated, “...Call Admitting MD [physician] Immediately if Change in Patient Condition...” The DED stated there was no documentation blood pressure medications were ordered for Patient 39. The DED stated there was no documentation Patient 39’s physician was notified to report any of Patient 39’s elevated blood pressures. The DED stated the physician should have been notified of Patient 39’s elevated blood pressures. On September 2, 2025, at 10:25 a.m., an interview was conducted with RN 1. RN 1 stated he would be concerned about blood pressure readings over 160 and would notify the physician if there were no scheduled or as needed medications ordered for the patient to bring the blood pressure down. The facility’s P&P titled, “Vital Signs - Standard of Care,” dated September 29, 2024, was reviewed. The P&P indicated, “ ...Vital signs are indicators of the patients present physiological status ...Vital Signs should be repeated per patient condition and per interventions to assess response ...Refer to Perry Potter Ostendorf Clinical Nursing Skills and Techniques 9th Edition [a nursing reference book] for normal adult vital signs ...” An untitled article on “Clinical Nursing Skills and Techniques 9th Edition,” published 2017, was reviewed. The article indicated, “...Hypertension is a major factor underlying death from heart attack and stroke [damage to the brain that occurs when blood supply is blocked or reduced] in the United States...Hypertension is defined as systolic [top number] BP of 140 mm Hg [millimeters of mercury, a unit of measurement] or greater, diastolic [bottom number] BP of 90 mm Hg or greater...Unexpected Outcomes...Patient’s BP is above acceptable range...Report BP to nurse in charge or health care provider to initiate appropriate evaluation and treatment ...” According to an undated article from the American Heart Association (AHA, a nationally recognized organization) titled, “Understanding Blood Pressure Readings,” “...High blood pressure, also known as hypertension, can lead to serious health problems including heart attack or stroke...Stage II Hypertension [a type of hypertension] 140 or higher for systolic or 90 or higher for diastolic...In hypertension Stage 2, your health care professional should prescribe blood pressure medication...” 3. On September 2, 2025, at 10 a.m., during a tour of Unit B conducted with the PA, Patient 39 was observed sitting upright in bed. Patient 39 was observed with the intravenous (administered through the vein) fluid (IVF) Normal Saline (a type of IVF) infusing at KVO (keep vein open, a medical abbreviation used to indicate an IV is being administered at a slow rate to maintain the patency [openness] of the vein). On September 4, 2025, at 10:24 a.m., a review of Patient 39’s record and concurrent interview was conducted with the Director of the Emergency Department (DED). A facility document titled, “History and Physical (H&P),” dated September 1, 2025, was reviewed. The document indicated Patient 39 was admitted to the facility on September 1, 2025, with a diagnosis of ETOH withdrawal. A facility document titled, “Flowsheets, MAR, Intravenous,” dated September 1, 2025, through September 4, 2025, was reviewed. The document indicated “...IV NaCl [sodium chloride, salt] 0.9% Water [a type of IVF] 1,000 mL [milliliter, a unit of measurement] 75 ml/hr [milliliter per hour] intravenous...” was ordered for Patient 39 on September 1, 2025, at 1 p.m., with a last administered time of September 2, 2025, at 12:23 p.m. The document indicated, “ ..MVI [multivitamin infusion, a type of IVF with multivitamins added]...100 ml/hr every 24 hours intravenous...” was ordered for Patient 39 on September 3, 2025, at 1 p.m., with a last administered time of September 3, 2025, at 11:33 p.m. On September 2, 2025, at 10:25 a.m., an interview was conducted with RN 1. RN 1 stated Patient 39 had IVF infusing at KVO. RN 1 stated all intravenous fluids require a physician order. On September 4, 2025, at 11:45 a.m., Patient 39 was observed with the DED. RN 5 was observed present at the bedside. Patient 39 was observed to be with an MVI infusing through a vein at 75 ml/hr. On September 4, 2025, at 11:50 a.m., an interview and concurrent record review were conducted with RN 5. RN 5 stated Patient 39 had an order for IV NaCl 0.9% to infuse at 75 ml/hr and an order for MVI at 100 ml/hr. RN 5 stated the MVI was infusing at 75 ml/hr on Patient 39 on September 4, 2025, at 11:50 a.m., was not the ordered rate of infusion. RN 5 stated the IV NaCl 0.9% was not infusing and had not been administered since September 2, 2025, at 12:23 p.m., and it was still an active order. RN 5 stated the orders should have been clarified with the physician. RN 5 stated she did not know if the physician wanted both ordered IV fluids infusing simultaneously on Patient 39 as ordered. The facility P&P titled, “Medication Safety,” dated December 2023, was reviewed. The P&P indicated, “...Medication Management is a critical component in the safe treatment of patients...the implementation of an effective program addresses the critical processes of...ordering/transcribing, preparing/dispensing, administration, and monitoring...” The facility P&P titled, “High-Alter Medications,” dated June 2024, was reviewed. The P&P indicated, “...The factors to be verified...include...Right Drug...Right dose or rate...Right time of administration...” 4. On September 5, 2025, at 1:25 p.m., a review of Patient 41’s record and concurrent interview were conducted with the DOC. A facility document titled, “H&P,” dated July 19, 2025, was reviewed. The document indicated Patient 41 was admitted to the facility on July 19, 2025, with a diagnosis of acute toxic metabolic encephalopathy. A photograph provided by a complainant was reviewed with the DOC. The DOC stated the photograph showed a bag of D5W with dated July 23, 2025. The DOC stated the name of the patient on the bag in the photograph was not the name of Patient 41. A facility document titled, “Order Inquiry,” dated July 23, 2025, was reviewed. The document indicated Patient 41 had an order for Dextrose (a type of sugar) 5% in Water (D5W, a type of IV fluid) on July 23, 2025, at 11 a.m. The DOC stated he was the house supervisor on July 24, 2025, and was present during an incident on that day where Patient 41’s family had asked why D5W was infusing into Patient 41. The DOC stated Patient 41’s assigned RN and the charge nurse of the unit were involved in the incident. On September 8, 2025, at 10:43 a.m., an interview was conducted with the DOC. The DOC stated Patient 41’s arm band and the label on the IV bag did not match. On September 8, 2025, at 2:20 p.m., an interview was conducted with the DQ. The DQ stated there were no safety events reported for Patient 41. On September 8, 2025, at 2:55 p.m., an interview was conducted with the DOC. The DOC stated a safety event should have been reported for Patient 41. The DOC stated he remembered telling the RN to file a safety event report. On September 8, 2025, at 3:58 a.m., an interview was conducted with the DQ and the CQO. The DQ stated a mislabeled IVF should have been reported to the facility. The CQO stated the incident would have been classified as a “near-miss.” The facility P&P titled, “Electronic Occurrence Reporting & [and] Safe Medical Devices Act of 1990 Reporting,” dated January 2022, was reviewed. The P&P indicated, “...Purpose...to promptly and accurately report an occurrence event, or near miss events that occur...to provide the opportunity for assessment and corrective action...to help identify, evaluate, and control risks...An occurrence is any event that directly affects a patient...and is not consistent with routine care or service...It may be, but is not limited to a...Medication variance [a action that is different from established protocols or guidelines]...Any near miss or actual occurrence that takes place must be reported in the Safety and Risk Management System...” The facility P&P titled, “High-Alter Medications,” dated June 2024, was reviewed. The P&P indicated, “...The factors to be verified...include...Right patient identification using two identifiers...” 5. On September 4, 2025, at 11:15 a.m., a concurrent interview and record review of Patient 32’s record were conducted with the Deputy Regional Director of Quality (DRDQ). The DRDQ stated, on September 1, 2025, Patient 32 alleged a certified nursing assistant (CNA 1) had hit her. A facility document titled, “Admission Assessment Report,” dated August 29, 2025, at 11:40 p.m., was reviewed. The document indicated, “...Neurological Assessment...Awake, alert and oriented to person, place, time and purpose...” A facility document titled, “Daily Focus Assessment Report,” dated August 29, 2025, through September 1, 2025, was reviewed. The document indicated, “...Neurological Assessment...Awake, alert and oriented to person, place, time, and purpose...” A facility document titled, “History and Physical Note,” dated August 30, 2025, was reviewed. The document indicated Patient 32 was admitted to the facility on August 29, 2025, with a diagnosis of urinary tract infection (an infection that occurs when bacteria enters the urinary system which consist of the kidneys, ureters, bladder, and urethra) with sepsis (a life-threatening reaction of the body to an infection). A facility document titled, “Progress Notes Report - Department: Nursing,” dated August 31, 2025, at 7:39 p.m., authored by Registered Nurse (RN) 4, was reviewed. The document indicated, “...At about 1500 [3 p.m.]...The pt [Patient 32] told me that the CNA [CNA 1] slapped [name of Patient 32] as hard as [name of CNA 1] could...There was not a red mark on [Patient 32’s] face...” A facility document titled, “Progress Notes Report - Department: Case Management,” dated September 1, 2025, at 3:51 p.m., was reviewed. The document indicated, “...RNCM [Registered Nurse Case Manager] placed a call to the patient’s [family member]...to inform her of the patient’s discharge...[Patient 32’s family member] accepted the discharge but reported that the patient told her a CNA had slapped [name of Patient 32] in the face...At the time of notification, RN [Registered Nurse], house supervisor, and charge nurse reported they were unaware of the alleged incident...” On September 4, 2025, at 1:40 p.m., an interview and record review were conducted with the Clinical Nurse Manager (RNM) 1 for the medical/surgical/telemetry units. RNM 1 stated that she was not informed of Patient 32’s abuse allegation until September 1, 2025. RNM 1 stated this allegation should have been immediately reported by RN 1 when it was made by the patient on August 31, 2025. RNM 1 stated the facility also noted CNA 1 was not placed on administrative leave until September 1, 2025, even though this should have happened on the day the allegation was reported to the RN. RNM 1 stated an assessment of Patient 32 was not done at the time of the alleged incident. RNM 1 further stated Patient 32’s physician, family, other agencies, and law enforcement should have been informed about the alleged abuse on August 31, 2025. RNM 1 stated a social service consult should have been initiated when Patient 32 made the allegation of abuse on August 31, 2025, and none of which was done. RNM 1 acknowledged the facility’s abuse Policy and Procedure (P&P) was not followed correctly. On September 4, 2025, at 2:15 p.m., an interview was conducted with the House Supervisor (HS). The HS stated she received a call from the RNCM on September 1, 2025, regarding an alleged abuse involving Patient 32. The HS stated Patient 32 reported on August 31, 2025, that a CNA had slapped her in the face. The HS stated RNM 1 was contacted and CNA 1 was placed on administrative leave and sent home in accordance with the facility’s P&P on September 1, 2025 (one day after Patient 32 made the allegation of abuse). On September 5, 2025, at 10:15 a.m., an interview was conducted with RN 4. RN 4 stated she provided care for Patient 32 on August 31, 2025. RN 4 stated CNA 1 reported Patient 32 had the television remote/call light cord wrapped around the patient’s left arm where the intravenous (IV, through the vein) catheter (a thin, flexible tube placed in the vein in the arm or hand used to give fluids or medications) was. RN 4 stated CNA 1 attempted to unwrap the cord, but Patient 32 became agitated, flung the call light at CNA 1, and then the call light “whipped around and hit [name of Patient 32] in the face.” RN 4 stated when they entered the patient’s room with CNA 1, Patient 32 reported CNA 1 “slapped me in the face as hard as [name of CNA 1] could.” RN 4 stated the Charge Nurse (CN) was informed of the incident. RN 4 stated, in hindsight, the house supervisor should have been notified “whether it [the allegation of abuse] was real or not.” RN 4 stated neither the physician nor the family was notified of the allegation of abuse. On September 5, 2025, at 1:40 p.m., an interview was conducted with the Charge Nurse (CN). The CN stated on August 31, 2025, RN 5 informed her Patient 32 was upset with CNA 1 alleging abuse and being slapped in the face. The CN stated Patient 32 reported CNA 1 “slapped me so hard” and wanted to speak to a social worker. The CN stated she did not contact a social worker and forgot to notify the house supervisor. When asked about the process when a patient alleges abuse, the CN stated the house supervisor, physician, social worker, law enforcement, and the agency protecting the elder from abuse should be notified and these were not done. A review of P&P titled, “RECOGNIZING AND REPORTING SUSPECTED AND KNOWN CHILD ABUSE AND NEGLECT, DEPENDENT ADULT AND ELDER ABUSE/NEGLECT/EXPLOITATION,” dated January, 2022, was conducted. The policy indicated, “...PROCEDURES...If an employee, healthcare professional or contracted employee is involved in the suspected or known abuse/neglect then the House Supervisor and the Supervisor/Manager/Director of the unit will be notified immediately by the individual who discovered the suspected or know abuse/neglect. The offending individual will be removed from working any further and restricted from access to patients. The offending individual will be placed on Administrative leave until an investigation can be completed...The Supervisor/Manager/Director of the unit or House Supervisor will immediately report by telephone to the Chief Hospital Executive Officer or Administrator in call, and the Chief Nursing Officer, the Administrator on call or the Chief Nursing Officer to contact the Chief of Staff (if applicable), when a healthcare professional, contracted or employee of [Name of facility] is the suspected abuser...Hospital personnel who discovered the known abuse/neglect will immediately report by telephone to the [name of county agency investigating elder abuse]...Hospital personnel who discovered the suspected or known abuse/neglect will immediately report by telephone Local Law enforcement...The Nurse caring for the patient will call the attending physician, social services (set up consult), and the patients representative...Make sure to document accordingly. Completed an updated patient assessment and care plan (include photos with measurements if indicated). Careful assessment and documentation of physical findings can help provide the data that are believed to confirm diagnosis...” A review of P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES,” dated November, 2022, was conducted. The policy indicated, “...Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective and advocacy services including notifying governmental agencies of neglect or abuse...” 6a. On September 2, 2025, at 11:12 a.m., a review of Patient 33’s record was conducted with the Director of Critical Care Unit (DOC). A facility document titled, “History and Physical Note,” dated August 31, 2025, at 11:17 p.m., authored by Physician (MD) 1, was reviewed. The document indicated Patient 33 was brought to the facility for altered mental status (a significant change in a person’s level of consciousness, cognition [the process of thinking], and behavior) and vaginal bleeding. The document indicated Patient 33 had a medical history of metastatic cervical cancer (an advanced form of cervical cancer that has spread to the other parts of the body) and blood clots in her lower extremities (blockages in the veins of both legs). A facility document titled, “Order Entry,” dated September 1, 2025, at 9:46 a.m., was reviewed. The document indicated an order for “...FENTANYL 500 mcg [micrograms, a unit of measurement] NS [normal saline, a type of intravenous (IV, administered through a vein) fluid] 100 ML [milliliters, unit of measurement]...Frequency...TITRATE [adjust] PER PROTOCOL [actions or analyses that strictly adhere to the defined procedures]...Route...INTRAVENOUS...Dose...500 MCG/100 ML [micrograms per milliliter, unit of measurement]...Strength...5 [five] MCG/ML...COMMENT...(SUBLIMAZE [a brand name for fentanyl])*ANALGESIA [the inability to feel pain]/SEDATION [a state of calm or sleep] IN MECH VENT [mechanical ventilation, the use of a machine to assist in breathing]...GOAL: RASS SCORE [Richmond Agitation-Sedation Scale, a 10-point scale used to assess the level of agitation or sedation in critically ill patients, with scores ranging from plus four (combative) to minus five (unarousable)]...-2 to -3...INITIAL RATE...25 MCG/HR [micrograms per hour, unit of measurement]...TITRATE...12.5 MCG/HR Q [every] 30 MINUTES...MAX [maximum]...200 MCG/HR...” A facility document titled, “Measurement,” dated September 2, 2025, at 3:30 p.m., was reviewed. The document indicated a change of rate for fentanyl for Patient 33 from 112.5 mcg/hr to 100 mcg/hr. There was no documented evidence another RN witnessed the change in rate for fentanyl administered by RN 55 to Patient 33. 6b. On September 2, 2025, at 12 p.m., a review of Patient 34’s record was conducted with the DOC. A facility document titled, “History and Physical Note,” dated August 24, 2025, at 12:46 a.m., authored by MD 2, was reviewed. The document indicated Patient 34 was brought to the facility for unresponsiveness (unconscious), lethargy (weakness), and hypoxia (a condition where there is an inadequate supply of oxygen in the body). The document indicated Patient 34 had a medical history of diabetes (abnormal blood sugar levels), atrial fibrillation (a common heart rhythm disorder), coronary artery disease (a condition where the arteries that supply blood to the heart muscle become narrowed or blocked), liver cirrhosis (a liver disease characterized by the irreversible scarring and destruction of liver tissue), and hypertension (high blood pressure). A facility document titled, “Order Entry,” dated September 1, 2025, at 8:50 p.m., authored by MD 2, was reviewed. The document indicated an order for, “...FENTANYL 500 MCG/100 ML NS...Frequency...TITRATE PER PROTOCOL...Rate...5 ML/HR...Route...INTRAVENOUS...Dose...500 MCG/100 ML...Strength...5 MCG/ML... COMMENT...[SUBLIMAZE]*ANALGESIA/SEDATION IN MECH [Mechanical]. VENT [ventilation]. PTS [patients].**GOAL: RASS SCORE...-3...5MCG/ML [micrograms per hour]...INITIAL RATE...25 MCG/HR...TITRATE...12.5 MCG/HR Q [every] 30 MINUTES...MAX [maximum]...200 MCG/HR...” A review of the facility document titled, “Measurement,” dated September 2, 2025, indicated a change in rate of the fentanyl being administered to Patient 34 on the following date and times: - On September 2, 2025, at 6 a.m., the rate was changed by RN 7 to 62 mcg/hr; - On September 2, 2025, at 4 p.m., the rate was changed by RN 6 to 88 mcg/hr; and - On September 2, 2025, at 4:30 p.m., the rate was changed by RN 6 to 100 mcg/hr. There was no documented evidence another RN witnessed the change in rate for the fentanyl administered by RNs 6 and 7 to Patient 34 on the above dates and times. On September 8, 2025, at 2 p.m., an interview was conducted with the DOC. The DOC stated when changing a rate, the RN needs to have a witness and document the RN’s name and employee ID number, the new rate, and the new Rass score in accordance with the facility’s P&P. The DOC stated there were no witnesses documented for Patients 33 and 34. The DOC stated the new RASS score was not documented for Patient 33. A review of the facility P&P titled, “High-Alert Medications,” revised May 2024, was conducted. The P&P indicated, “...Opiate [A substance used to treat pain or cause sleep]/Narcotic [a drug or other substance which affects mood or behavior] Infusions [the process of introducing a liquid medication, solution, or other substance directly into the bloodstream over a period of time]...An independent double check by two qualified health care practitioners (e.g. nurse, pharmacist, physician) is required initially at each bag change, rate change, and at hand-offs...””

“ADEQUACY OF LABORATORY SERVICES CFR(s): 482.27(a) The hospital must have laboratory services available, either directly or through a contractual agreement with a certified laboratory that meets the requirements of part 493 of this chapter. This Standard is not met as evidenced by: 50433 Based on observation, interview, and record review, the facility failed to ensure laboratory services were provided and maintained to meet the patients’ needs, for 40 of 80 sample patients (Patients 25, 26, 27, 32, 35, 36, 37, 43, 44, 45, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, and 80 ), when: 1. For Patients 25, 26, 27, 32, 35, 36, 37, 43, 44, 45, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, and 80, blood cultures (BC, a laboratory test to determine if bacteria, fungi, or other germs are growing in the blood) were not drawn (blood draw, a medical procedure where a healthcare professional uses a needle to collect a blood specimen from a vein) according to recommended guidelines and the facility’s policy and procedure (P&P); and 2. The preventative maintenance (PM, planned inspections, cleaning, and servicing of equipment to prevent breakdowns and improve reliability) for 101 pieces of the facility’s laboratory equipment was not performed by the date the PM was due. These failures had the potential to result in missed or incorrect diagnoses and treatment for Patients 25, 26, 27, 32, 35, 36, 37, 43, 44, 45, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, and 80, on whom laboratory testing were conducted at the facility’s laboratory which may result in delay of treatment of infection, use of incorrect treatment modalities and antibiotics, longer hospital stay, and increase of the risk of death for these patients. Findings: 1. On September 2, 2025, at 12 p.m., during a tour of the laboratory with the Laboratory Supervisor (LS), a communication board was observed located in the laboratory. On the communication board was observed written, “Blood Cultures: Draw One bottle [referring to a BC bottle which could be either an aerobic (a laboratory test used to detect and identify microorganisms [living organisms which are invisible to the naked eye and may cause infections] which grow in the presence of oxygen) or anaerobic (a laboratory test to detect bacteria that can only grow in an oxygen-free environment) for the set [a set of BC test includes transferring a specific volume of blood into the aerobic and anaerobic BC bottles; for each BC test ordered, a set of BC test should be drawn from two different body sites 15 minutes apart from each other]. We are extermly [sic, extremely] low.” On September 2, 2025, at 12 p.m., during a concurrent interview conducted with the LS, the LS stated the laboratory staff had been transferring the blood of the patients who had orders for BC tests into either an aerobic or an anaerobic BC bottle but not to both aerobic and anaerobic BC bottles, depending on which BC bottle was available at the laboratory. The LS stated the laboratory staff would draw a second set of BC testing for the same patient 15 minutes later and would transfer the blood to either an aerobic or an anaerobic BC bottle, but not to both. The LS stated the blood of the patients for whom BC testing have been ordered had not been transferred to both aerobic and anaerobic BC and a complete set of two aerobic and two anaerobic BC bottles have not been used to transfer the patients’ blood for each BC test ordered by the physician, since August 7, 2025. The LS stated this was due to supply shortages of the anaerobic and aerobic BC bottles in the facility because of nonpayment of the invoice for both types of BC bottles. On September 3, 2025, at 9:55 a.m., an interview was conducted with the Chief Quality Officer (CQO). The CQO stated the medical staff was not made aware that only one bottle of either aerobic or anaerobic BC for each set was being drawn from the patients for each BC test ordered. The CQO stated she was not aware of the shortage of BC bottles at the facility until September 2, 2025. The CQO stated by not testing both aerobic and anaerobic BC, all forms of microorganisms which could be present in a patient’s blood would not be detected. On September 3, 2025, at 11:19 a.m., an interview was conducted with the Director of Laboratory Services (DLS). The DLS stated he informed the facility’s administration of the BC bottle shortage but he did not provide them with the information about only one type of BC (only either aerobic or anaerobic BC) was being drawn from each patient who had an order for BC testing. The DLS stated the medical staff at the hospital were not informed of the shortage of BC bottles nor of the plan to use one BC bottle of either aerobic or anaerobic only for each BC test ordered instead of a set of both. The DLS stated it is not best practice (the best practice is transferring of the blood drawn from a patient into one aerobic and one anaerobic blood culture bottles, then drawing blood again from the same patient but from a different body site 15 minutes apart). The DLS stated it is not the facility’s policy to draw only aerobic or anaerobic BC for each set of blood draw for each blood culture testing ordered for a patient. The DLS stated laboratory testing cannot exclude all forms of microorganisms that may be present in the patient’s blood if both aerobic and anaerobic BCs are not drawn. On September 3, 2025, at 1:17 p.m., an interview was conducted with the DLS. The DLS stated the laboratory had used pediatric (for children) BC bottles (a pediatric BC bottle is a specially formulated, smaller BC bottle for children, which supports the growth of microorganisms requiring oxygen [aerobes] and not the anaerobes [microorganisms which do not require oxygen which may limit the growth of bacteria being tested and may affect the result of the BC test) vials on some adult patients since August 7, 2025. The DLS stated this was “not best practice” (best practice is using a pediatric BC bottle only for pediatric patients whose age and condition prevent drawing greater than three milliliter [unit of measurement] of blood). On September 8, 2025, at 11:35 a.m., a concurrent interview and record review were conducted with the DLS. The facility report titled, “[Brand name of BC machine] Instrument Inventory Report,” dated August 7, 2025, through September 3, 2025, was reviewed with the DLS. The DLS stated the report contained a comprehensive list of the patients who had BC test collected and conducted from August 7, 2025, to September 3, 2025, and included the information of the BC bottles used for each blood draw. The DLS stated Patients 25, 26, 27, 32, 35, 36, 37, 43, 44, 45, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, and 80 did not have two sets of blood drawn. The DLS stated the facility’s policies titled, “Blood Cultures,” and “Adult Sepsis [a life-threatening complication of an infection] Screening and Physician Approved Nursing Sepsis Protocol,” were not followed. On September 3, 2025, at 2:18 p.m., the information for use (IFU, instructions, safety information, and details about a product’s intended purpose, proper use, and necessary precautions, provided by a manufacturer) for pediatric BC bottles titled, “[brand name] Peds [pediatric] Plus/F Culture Vials,” was reviewed. The IFU indicated, “...Peds Plus/F Culture Vials are for aerobic blood cultures...” An undated article published by the Centers for Disease Control and Prevention (CDC, a nationally recognized organization) titled, “Preventing Adult Blood Culture Contamination: A Quality Tool for Clinical Laboratory Professionals,” was reviewed. The article indicated, “...Laboratory analysis of blood cultures is vital to the accurate and timely diagnosis of bloodstream infections [occurs when infectious microorganisms, such as bacteria, viruses, or fungi, enter and multiply in the blood]. However, the reliability of your testing depends on clinical compliance with collection procedures...The volume of blood collected is critically important to the laboratory diagnosis of bloodstream infection, which generally requires two or more sets to achieve...two sets are required...” According to an article titled, “Effects of Blood Culture Aerobic/Anaerobic Bottle Collection Patterns from Both Sides of the Body on Positive Blood Culture [when bacteria, yeast, or other microorganisms have been detected in a patient’s blood sample, indicating an infection in the bloodstream] Rate [measures the occurrence of positive results in blood cultures collected to diagnose infections] and Time-to-Positivity [time it takes for a blood culture to show a positive result, indicating the presence of bacterial or fungal growth],” dated June 10, 2022, published by the National Institute of Health (a nationally recognized research center), “...a combination of aerobic and anaerobic bottles from a single site was superior to two aerobic bottles from two different sites. Neglecting the use of anaerobic BC [blood culture] bottles may reduce the rate of positive BCs, and was not conducive to the early detection of pathogens [microorganisms which may cause infection]...” The facility’s policy and procedure (P&P) titled, “Blood Cultures,” dated February 2024, was reviewed. The P&P indicated, “...Blood cultures are collected whenever there is a reason to suspect a clinically significant bacteremia [presence of bacteria in the blood]...Blue-labeled bottles (for aerobes), purple-labeled bottles (for anaerobes) and yellow labeled bottles (for infants) are utilized in our institution...Bottle Preparation and Inoculation [the process of placing a patient’s blood sample into specialized bottles containing culture media to grow any bacteria or fungi present in the bloodstream]...First, inject 1/2 [one half] of the sample into the purple anaerobic bottle, and then inject the remaining amount into the blue aerobic bottle...Do not use peds [pediatric] bottles [blood culture bottles] on adults...Optimal blood culture volume is 10 ml [milliliter, a unit of measurement] in each of the aerobic and anaerobic bottles...” The facility P&P titled, “Adult Sepsis Screening and Physician Approved Nursing Sepsis Protocol,” dated May 2024, was reviewed. The P&P indicated, “...order/obtain two (2) sets of blood cultures (to be obtained from two different sites [body sites] 15 minutes apart)...” 2. On September 2, 2025, at 10:30 a.m., a tour of the laboratory was conducted with the LS. Multiple pieces of equipment in the laboratory were observed with PM labels indicating PM was performed in January 2025 or April 2025. The PM labels indicated the PM was due in July 2025. On September 2, 2025, at 10:52 a.m., an interview was conducted with the Bio-medical (biomedical engineering, biomed, the team of technicians and engineers who install, maintain, and repair medical equipment in the facility) Supervisor (BMS). The BMS stated the equipment Biomed uses to perform PM on the laboratory equipment has not been calibrated because the vendor contracted to conduct the calibration of the facility’s equipment necessary to conduct a PM has not been paid. The BMS stated the PM had not been done because the accuracy of the results of the laboratory testing could not be verified without PM completed on the laboratory equipment. The BMS stated the biomed equipment used to conduct the PM on the laboratory equipment would need to be calibrated first. On September 3, 2025, at 2 p.m., a facility document titled, “Equipment List - Active Equipment Only,” with a print date of September 3, 2025, at 4:56 a.m., was reviewed. The document indicated a list of 101 pieces of laboratory equipment requiring PM. On September 3, 2025, at 2:27 p.m., a phone interview was conducted with the BMS. The BMS stated the facility document titled, “Equipment List - Active Equipment Only,” was a comprehensive list of all the equipment in the laboratory which was overdue for PM (101 pieces of laboratory equipment). The BMS stated, without a complete PM, the equipment used to process laboratory tests for patients had the potential to provide inaccurate results. The facility’s P&P titled, “Preventative Maintenance Program - Ensuring Operation Ability,” dated April 2021, was reviewed. The P&P indicated, “...preventative maintenance is a key factor in assuring the ongoing performance and reliability...whereby each system is properly...maintained...The Facilities Administrator is responsible for the proper and safe functioning of all equipment within the facility...” On September 3, 2025, at 5:43 p.m., the survey team identified significant concerns with the laboratory services at the facility. Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation which had the potential to cause harm to the health and safety of the patients) was called in the presence of the facility’s Corporate Quality Officer (CQO), the Deputy Regional Director of Quality (DRDQ), the Director of Facilities (DF), and the Executive Assistant to the Chief Executive Officer (EA). They were notified of the following: there was an insufficient supply of BC bottles since August 7, 2025, due to the non-payment of the invoice for the BC bottles; the laboratory staff had been drawing one bottle of either aerobic or anaerobic BC instead of a set of two BC bottles which should consist of one aerobic and one anaerobic BC bottle; the facility had been drawing a second BC bottle 15 minutes later using either aerobic or anaerobic BC bottle instead of drawing a set of aerobic and anaerobic BC bottles, in accordance with the facility’s policy and procedure [P&P]); a complete set of four bottles using two aerobic BC bottles and two anaerobic BC as indicated in the facility’s policy and procedure, for each BC test ordered; the facility has been utilizing pediatric BC bottles for adult BC tests due to the insufficient supply of adult BC bottles; and preventative maintenance of 101 laboratory equipment and laboratory machines were labeled conducted either on January 2025 or on April 2025, and due to be completed on July 2025, has not been conducted, in accordance with the facility’s P&P because the vendor contracted to conduct the calibration of the facility’s equipment necessary to conduct a PM has not been paid. On September 4, 2025, at 3:15 p.m., the facility provided a removal plan (RP) for the IJ. The RP submitted by the facility indicated the following: -On September 3, 2025, at 3 p.m., the facility reverted to collecting blood cultures in accordance with the facility’s policy. The facility located adequate supplies of both adult aerobic and adult anaerobic BC bottles, with 350 bottles of each type. The facility also placed an order with another vendor for additional five boxes of 50 BC bottles per box of each type of adult BC bottle. The shipment will be received by September 5, 2025; -On September 3, 2025, the Medical Director of the Laboratory was informed of the IJ and circumstances leading to the citation by the Laboratory Director; -On September 4, 2025, members of the Governing Board (the ultimate legal authority responsible for the hospital’s overall management) and the Medical Executive Committee (MEC) were notified of the findings by the Chief Executive Officer (CEO) via an electronic memo; -The facility identified all patients impacted and likely to be impacted by the deficiency currently being cared for at the facility. By September 4, 2025, all providers of patients currently hospitalized with orders for BC performed not in accordance with hospital policy will be contacted and informed of the issue and redrawn if ordered by the MD; -On September 4, 2025, all providers were informed of the deviation from hospital policy related to BC collecting (blood draw) and testing and advised of follow up options; -As soon as the facility was informed of the issuance of an IJ, the leadership team met and started developing and implementing this Removal Plan; -On September 4, 2025, the facility initiated education for all laboratory and Emergency Department (ED) licensed nursing staff responsible for collecting/testing BCs on the hospital policy for BC collection. Education will continue until 100% of staff are educated. Staff who are not scheduled today will be educated on their next scheduled shift. Besides laboratory staff, only ED registered nurses draw BCs;. -On September 4, 2025, the facility contacted the vendor responsible for performing the calibration services on the facility’s equipment used in conducting the PM on the laboratory equipment and machines and confirmed that payment was received and requested the tools to be picked up from the facility for calibration. The vendor will pick up the past due tools/equipment on September 5, 2025, and take them to their shop to calibrate them. The tools/equipment will be returned to the facility on Monday, September 8, 2025. In the meantime, the facility reached out to other hospitals within their health system to obtain calibrated instruments to perform required maintenance. The maintenance started on September 4, 2025, and is expected to be completed by September 5, 2025, utilizing tools/instruments borrowed from sister facilities that were calibrated and are appropriate to use;. -The CEO met with the Director of the Laboratory and educated him on proper notification to providers, MEC, and the Governing Body with any process change and deviation from established policies and their impact on patient care. He (Director of Laboratory) verbalized understanding; -By September 5, 2025, the CEO will educate the biomed staff on the importance of ensuring preventative maintenance is done timely and escalating any issues to administration as soon as possible to prevent delays; -The CEO approved additional labor, overtime, and qualified biomed personnel from other facilities to facilitate the performance of needed preventative maintenance; and -The CEO will continue to update the MEC and medical staff members, on the progress with the implementation of this Removal Plan. On September 4, 2025, at 4 p.m., the survey team found the RP for the IJ acceptable and the CQO and DRDQ were notified. On September 8, 2025, at 1 p.m., through observations, interviews, and record review, the RP was verified onsite to have been fully implemented. On September 8, 2025, at 3:58 p.m., the IJ was removed in the presence of the CQO, the DRDQ, the CEO, and the DF.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 50433 Based on observation, interview, and record review, the facility failed to ensure supplies and equipment were maintained when: 1. Blood culture (a lab test to see if bacteria, fungi, or other germs are growing in the blood) bottles were not available in quantities sufficent to ensure proper collection for patients admitted to the facility for 40 of 80 sample patients (Patients 25, 26, 27, 32, 35, 36, 37, 43, 44, 45, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, and 80); and 2. The preventative maintenance (PM, planned inspections, cleaning, and servicing of equipment to prevent breakdowns and improve reliability) for 101 pieces of the facility’s laboratory equipment was not performed in a timely manner. These facility failures had the potential to result in missed or incorrect diagnoses for patients on whom laboratory testing were conducted at the facility which may delay the treatment of infection, lead to the use of incorrect treatment modalities and antibiotics, longer hospital stay for the patients, and increase the risk of death for these patients. Findings: On September 2, 2025, at 12 p.m., during a tour of the laboratory with the Laboratory Supervisor (LS), a communication board was observed in the laboratory with writing which indicated, “Blood Cultures: Draw One bottle for the set [a set of blood culture test includes one aerobic (laboratory test used to detect and identify microorganisms [living organisms which are invisible to the naked eye and may cause infections] that grow in the presence of oxygen) and one anaerobic (a laboratory test to detect bacteria that can only grow in an oxygen-free environment) bottle, with two sets taken from different body sites 15 minutes apart from each other]. We are extermly [sic, extremely] low.” On September 2, 2025, at 12 p.m., during a concurrent interview conducted with the LS, the LS stated the laboratory staff had been collecting one bottle of either aerobic or anaerobic blood cultures and then a second bottle 15 minutes later, depending on the availability of the aerobic and anaerobic blood culture bottles. The LS stated patients for whom blood culture testing have been ordered have not had both aerobic and anaerobic blood cultures drawn, nor a complete set of four bottles for each blood culture test ordered by the physician, since August 7, 2025, due to supply shortages of the anaerobic and aerobic blood culture bottles in the facility. On September 3, 2025, at 9:55 a.m., an interview was conducted with the Chief Quality Officer (CQO). The CQO stated the medical staff was not made aware that only one bottle of either aerobic or anaerobic blood cultures for each set was being drawn from the patients for each ordered blood culture test. The CQO stated she was not aware of the shortage of blood culture bottles at the facility until September 2, 2025. The CQO stated by not testing both aerobic and anaerobic blood cultures, all forms of microorganisms which could be present in a patient’s blood would not be detected. On September 3, 2025, at 11:19 a.m., an interview was conducted with the Director of Laboratory Services (DLS). The DLS stated he informed the facility’s administration of the blood culture bottle shortage but he did not provide them with the information about only one type of blood culture was being drawn from each patients who had an order for blood culture testing. The DLS stated the medical staff at the hospital were not informed of the shortage of blood culture bottles nor of the plan to use one blood culture bottle of either aerobic or anaerobic for each blood culture ordered instead of a set of both. The DLS stated it is not best practice nor is it the facility’s policy to draw only aerobic or anaerobic blood culture for each set of blood draw for each blood culture testing ordered for a patient. The DLS stated laboratory testing cannot exclude all forms of microorganisms that may be present in the patient’s blood if both aerobic and anaerobic blood cultures are not drawn. On September 3, 2025, at 1:17 p.m., an interview was conducted with the DLS. The DLS stated the laboratory had used pediatric (for children) blood culture tubes on adult patients since August 7, 2025, and it was “not best practice.” On September 8, 2025, at 11:35 a.m., a concurrent interview and record review were conducted with the DLS. The facility report titled, “[Brand name of blood culture processor] Instrument Inventory Report,” dated August 7, 2025, through September 3, 2025, was reviewed with the DLS. The DLS stated the report contained a comprehensive list of the patients who had blood cultures collected from August 7, 2025, to September 3, 2025, and included the information of the blood culture bottles used for collection. The DLS stated Patients 25, 26, 27, 32, 35, 36, 37, 43, 44, 45, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, and 80 did not have two sets of blood cultures drawn. The DLS stated the facility’s policy was not followed. On September 3, 2025, at 2:18 p.m., the information for use (IFU, instructions, safety information, and details about a product’s intended purpose, proper use, and necessary precautions, provided by a manufacturer) for pediatric blood cultures titled, “[brand name] Peds Plus/F Culture Vials,” was reviewed. The IFU indicated, “...Peds Plus/F Culture Vials are for aerobic blood cultures...” An undated article published by the Centers for Disease Control and Prevention (CDC, a nationally recognized organization) titled, “Preventing Adult Blood Culture Contamination: A Quality Tool for Clinical Laboratory Professionals,” was reviewed. The article indicated, “...Laboratory analysis of blood cultures is vital to the accurate and timely diagnosis of bloodstream infections. However, the reliability of your testing depends on clinical compliance with collection procedures...The volume of blood collected is critically important to the laboratory diagnosis of bloodstream infection, which generally requires two or more sets to achieve...two sets are required...” The facility’s policy and procedure (P&P) titled, “Blood Cultures,” dated February 2024, was reviewed. The P&P indicated, “...Blood cultures are collected whenever there is a reason to suspect a clinically significant bacteremia [presence of bacteria in the blood]...Blue-labeled bottles (for aerobes), purple-labeled bottles (for anaerobes) and yellow labeled bottles (for infants) are utilized in our institution...Optimal blood culture volume is 10 ml [milliliter, a unit of measurement] in each of the aerobic and anaerobic bottles...” The facility P&P titled, “Adult Sepsis [a life-threatening complication of an infection] Screening and Physician Approved Nursing Sepsis Protocol,” dated May 2024, was reviewed. The P&P indicated, “...order/obtain two (2) sets of blood cultures (to be obtained from two different sites 15 minutes apart)...” 2. On September 2, 2025, at 10:30 a.m., a tour of the laboratory was conducted with the LS. Multiple pieces of equipment in the laboratory were observed with PM labels indicating PM was performed in January 2025 or April 2025. The PM labels indicated the PM was due in July 2025. On September 2, 2025, at 10:52 a.m., an interview was conducted with the Bio-medical (biomedical engineering, the team of technicians and engineers who install, maintain, and repair medical equipment in the facility) Supervisor (BMS). The BMS stated the equipment Biomed uses to perform PM on the laboratory equipment has not been calibrated. The BMS stated the PM had not been done because the accuracy of the results could not be verified without properly calibrated equipment needed to conduct the PM on the laboratory equipment. On September 3, 2025, at 2 p.m., a facility document titled, “Equipment List - Active Equipment Only,” with a print date of September 3, 2025, at 4:56 a.m., was reviewed. The document contained a list of 101 pieces of laboratory equipment requiring PM. On September 3, 2025, at 2:27 p.m., a phone interview was conducted with the BMS. The BMS stated the instrument list was a comprehensive list of all the equipment in the laboratory which was overdue for PM. The BMS stated, without a complete PM, the equipment used to process laboratory tests for patients had the potential to provide inaccurate results. The facility’s P&P titled, “Preventative Maintenance Program - Ensuring Operation Ability,” dated April 2021, was reviewed. The P&P indicated, “...preventative maintenance is a key factor in assuring the ongoing performance and reliability ...whereby each system is properly...maintained...The Facilities Administrator is responsible for the proper and safe functioning of all equipment within the facility...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47071 Based on interview and record review, the facility failed to ensure patients at the Emergency Department (ED) waiting to be transferred to the Intensive Care Unit (ICU, a unit for patients who require intensive monitoring) were transferred in a timely manner (Refer to A-0144) . The cumulative effects of this systemic failure had the potential to cause a delay in care of the patients and increased the risk for infections for the patients due to prolonged exposure to other patients at the ED who may have infectious diseases.”

“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: 47071 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented for seven of 55 sample patient (Patients 21, 23, 28, 29, 30, 33, and 35), when: 1. For Patients 23, 33, and 35, oral (mouth) care was not completed every 12 hours (Refer to A0398); 2. For Patients 29 and 30, the documentation for Fentanyl (a narcotic used to control pain and induce sleep) medications ordered by the physician was not signed by staff in a timely manner on the Electronic Medication Administration Record (eMAR, documentation of medications ordered by the physician for and administered to patients) (Refer to A0398); 3. For Patient 28, midazolam (a medication used for anesthesia, sedation, and severe agitation) was administered in a telemetry unit (telemetry, a unit for patients who require continuous remote monitoring of their heart rates and rhythm) which was not a unit designated where midazolam could be administered to the patients (Refer to A0398); 4. For Patient 21, the record documented a discrepancy on Patient 21’s name, sanitary environment was not maintained in the patient’s room, and Patient 21 was not repositioned in accordance with the facility’s policies and procedures (P&P) (Refer to A0398); and 5. In addition, the facility failed to ensure patients at the Emergency Department (ED) waiting to be transferred to the Intensive Care Unit (ICU, a unit for patients who require intensive monitoring) were transferred in a timely manner, for 11 of 55 sample patients (Patients 36, 47, 48, 49, 50, 51, 52, 53, 54, 55, and 56) (Refer to A0392). The cumulative effects of these systemic failures resulted in Patients 21, 23, 35 to not receive the oral or nasal care in accordance with the facility’s policy and procedure and could have contributed to the patients to experience maggots infestation and for Patient to not be repositioned. In addition, these systemic failures resulted in Patient 28 to not receive the needed monitoring and experience shortness of breath, decreased oxygen saturation (O2 sat, a measurement of how much oxygen the blood is carrying as a percentage, normal is 90%), intubation (insertion of a plastic tube inserted through the mouth into the windpipe to help a person breathe), and subsequent transfer to the Intensive Care Unit (ICU, unit for critically ill patients). These systemic failures could impact the quality of care provided to the patients, inadequate pain management, delayed recognition of changes in the patients’ condition, and increased risk of harm to these patients.”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 25281 Based on observation, interview, and record review, the hospital failed to provide pharmaceutical services that meet the needs of the patients as evidenced by: 1. The facility failed to ensure accountability procedures were in place and implemented to control the use of all controlled substances (CS) and to readily identify and determine the extent of loss or diversion of all CS in such a manner as to minimize the time frame between start of the actual loss or diversion to the time of detection as evidenced by: - The hospital did not have an effective written policy and procedure for audit and prevention of drug diversion; - The hospital’s electronic Health Record System (eHR) allowed to initiate, change bags of IV (intravenous, into vein) fentanyl (potent synthetic narcotic to manage severe pain and highly addictive and associated with overdose death) for infusion without having a second nurse witness against the hospital policy and procedure; - Nurses were able to back date and retroactively chart the administration of medications to resolve discrepancies without consequences; - The charting by the ICU nurses on the flowsheet (document used by nursing to enter various aspects of patient care, including vital signs, medication administration, fluid intake and output) in the patients’ medical records was not audited by nursing and/or pharmacy department to ensure compliance and completeness of documentation to fully account for controlled drug use (Refer to A494); 2. The facility failed to ensure wasted CS in the patient care units were irretrievable (Refer to A494); 3. The facility failed to ensure patient’s own medications were stored in accordance with hospital policy for two of seven toured patient care units (Refer to A500); 4. The facility failed to ensure patient’s own medications were destroyed in accordance with hospital policy for two of seven toured patient care units (Refer to A500); 5. The facility failed to ensure injectable midazolam (medication used for procedural sedation and used primarily in procedural areas) was not used on the non-critical units in accordance with the hospital policy and procedure and the recommendations from the pharmacy in dealing with nationwide shortage of injectable Ativan (medication used for seizures and anxiety) (Refer to A500); 6. The facility failed to maintain a clean environment in the sterile compounding room (Refer to A501); 7. The facility failed to maintain daily records of cleaning the sterile compounding room (Refer to A501); 8. The facility failed to label compounded medications (Refer to A501); 9. The facility failed to maintain complete compounding records for compounded medications (Refer to A501) 10. The facility failed to ensure the pharmacy and four of seven toured hospital units did not have expired and unusable medications available for use (Refer to A505); and 11. the facility failed to ensure two of seven toured hospital units did not have unlabeled opened medication multiple dose vials (MDV) available for use (Refer to A505) The cumulative effect of the systemic problems resulted in the hospital’s failure to ensure the provision of pharmaceutical services in a safe environment that met the needs of the patients.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 47071 Based on observation and interview and record review, the facility failed to ensure a sanitary environment was maintained, when: 1. Flies were observed throughout the facility (Refer to A0701); 2. Maggots (a soft-bodied legless immature form of a fly) were observed in the nasal (nose) cavity and in the specimen cup in the patient’s room which were suctioned from the patient’s nares (nose), for one of 55 sample patient (Patient 27) (Refer to A0701); 3. Maggots in the oral (mouth) or nasal cavities were observed in four of 55 sample patients (Patients 31, 32, 33, and 34) (Refer to A0701); 4. Multiple areas of the hospital were observed to have gaps around doors and windows (Refer to A0701) 5. Five corrugated boxes containing medical supplies were observed on the floor of Zone 1 doorway (Refer to A0724); 6. Three corrugated boxes observed filled with copy paper and stacked on top of each other, and two clear bags observed filled with admission kits (patient care items given to the patient upon admission) were observed on the floor of one of five supply rooms (SR 1) (Refer to A0724); and 7. For one of one pharmaceutical (pertaining to medications)/sharps (containers for disposals of needles and other sharp items) waste bins in the Intensive Care Unit (ICU, a specialized unit which provides monitoring for patients with life-threatening conditions) and one of one pharmaceutical/sharps waste bins in the Medical Surgical unit (M/S, general nursing unit which provides care for patients with a wide range of medical and surgical conditions) were observed to be overfilled (Refer to A0724). The cumulative effects of these systemic failures had the potential to increase the risk for infection and patient safety to the already immunocompromised (condition when the immune system is weakened) patients admitted in the facility.”

“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: 34933 Based on interview and record review, the facility failed to ensure patients at the Emergency Department (ED) waiting to be transferred to the Intensive Care Unit (ICU, a unit for patients who require intensive monitoring) were transferred in a timely manner. This failure had the potential to cause a delay in care and increased the risk for infections for the patients at the ED waiting to be transferred to the ICU due to prolonged exposure to other patients at the ED who may have infectious diseases. Findings: On July 10, 2025, a report was received by the California Department of Public Health (CDPH, a state agency) from the facility. The report indicated, “...Event Date: July 7, 2025, Details: The ED is severely understaffed with holding ICU patients. There are ICU patients on the DOU (Definitive Observation Unit, stepdown, a unit for patients who require continuous monitoring) floor, tele (telemetry, a unit for patients who require continuous remote monitoring of their heart rates and rhythm) floor and in the PACU (post anesthesia care unit, a unit for patients who require intensive monitoring after surgery) because there isn’t working equipment to open our CCU (critical care unit, an ICU unit for patients who require intensive monitoring) unit...” On July 15, 2025, at 1:15 p.m., a review of the facility document titled, “ED Daily Staffing Assignment,” sheet, dated July 7, 2025, and a concurrent interview were conducted with the ED Manager (EDM) 1. A facility document titled, “Bed Board Admits,” dated July 7, 2025, was reviewed. The document indicated there were 23 patients holding in the ED and 11 of them were ICU patients waiting to be transferred to the ICU. An untitled and undated facility document was reviewed. The document indicated the timeline the patients were held [stayed in the ED after being admitted] in the ED and the time these patients were transferred to a nursing unit is as follows: - Patient 47 arrived in the ED on July 3, 2025, and transferred to Unit A on July 7, 2025; - Patient 48 arrived in the ED on July 4, 2025, and transferred to Unit H on July 10, 2025; - Patient 49 arrived in the ED on July 5, 2025, and transferred to Unit H on July 10, 2025; - Patient 36 arrived in the ED on July 5, 2025, and transferred to Unit H on July 13, 2025; - Patient 50 arrived in the ED on July 6, 2025, and transferred to Unit A on July 11, 2025; - Patient 51 arrived in the ED on July 6, 2025, and transferred to Unit A on July 6, 2025; - Patient 52 arrived in the ED on July 6, 2025, and transferred to Unit G on July 8, 2025; - Patient 53 arrived in the ED on July 7, 2025, and transferred to Unit A on July 20, 2025; - Patient 54 arrived in the ED on July 7, 2025, and transferred to Unit A on July 8, 2025; - Patient 55 arrived in the ED on July 7, 2025, and transferred to Unit A on July 11, 2025; and - Patient 56 arrived in the ED on July 7, 2025, and transferred to Unit B on July 8, 2025. On July 17, 2025, at 10:15 a.m., an interview was conducted with Registered Nurse (RN) 4. Registered Nurse 4 stated, “...the ED is not equipped to care for ICU patients...these patients have not been moved to the CCU because there are issues with the monitors in the CCU...” On July 21, 2025, at 4:38 p.m., an interview was conducted with the Emergency Department Manager (EDM) 1. The EDM 1 stated all ICU patients on hold in the ED should always be in direct line of site for the RN’s to be able to observe the patients. The EDM 1 stated, when the doors to patient rooms are closed, the RNs are not able to directly observe the patient. The EDM 1 stated the ED has two portable cardiac monitors for use for the ICU patients on hold and the two monitors are not connected with the central monitoring (when the monitoring is conducted remotely by a staff) system in the ED. The EDM 1 stated the RNs can only see the monitors in the patient’s room and this would potentially cause a delay in care. On July 21, 2025 at 4:15 p.m., an interview was conducted with the Corporate Quality Officer (CQO). The CQO stated ED holding affects patient care and staffing. The CQO stated ED holding process impacts the ED flow process and the expectation for ED holding of ICU patients is ICU patients will receive the same level of care they would in the ICU unit including documentation, assessment, and care. The CQO stated there was no facility policy to address ED holding.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 47071 Based on interview and record review, the facility failed to ensure patients at the Emergency Department (ED) waiting to be transferred to the Intensive Care Unit (ICU, a unit for patients who require intensive monitoring) were transferred in a timely manner, for 11 of 55 sample patients (Patients 36, 47, 48, 49, 50, 51, 52, 53, 54, 55, and 56). This failure had the potential to cause a delay in care and increased the risk for infections for the patients at the ED waiting to be transferred to the ICU due to prolonged exposure to other patients at the ED who may have infectious diseases. Findings: On July 10, 2025, a report was received by the California Department of Public Health (CDPH, a state agency) from the facility. The report indicated, “...Event Date: July 7, 2025, Details: The ED is severely understaffed with holding ICU patients. There are ICU patients on the DOU (Definitive Observation Unit, stepdown, a unit for patients who require continuous monitoring) floor, tele (telemetry, a unit for patients who require continuous remote monitoring of their heart rates and rhythm) floor and in the PACU (post anesthesia care unit, a unit for patients who require intensive monitoring after surgery) because there isn’t working equipment to open our CCU (critical care unit, an ICU unit for patients who require intensive monitoring) unit...” On July 15, 2025, at 1:15 p.m., a review of the facility document titled, “ED Daily Staffing Assignment,” sheet, dated July 7, 2025, and a concurrent interview were conducted with the ED Manager (EDM) 1. A facility document titled, “Bed Board Admits,” dated July 7, 2025, was reviewed. The document indicated there were 23 patients holding in the ED and 11 of them were ICU patients waiting to be transferred to the ICU. An untitled and undated facility document was reviewed. The document indicated the timeline the patients were held [stayed in the ED after being admitted] in the ED and the time these patients were transferred to a nursing unit is as follows: - Patient 47 arrived in the ED on July 3, 2025, and transferred to Unit A on July 7, 2025; - Patient 48 arrived in the ED on July 4, 2025, and transferred to Unit H on July 10, 2025; - Patient 49 arrived in the ED on July 5, 2025, and transferred to Unit H on July 10, 2025; - Patient 36 arrived in the ED on July 5, 2025, and transferred to Unit H on July 13, 2025; - Patient 50 arrived in the ED on July 6, 2025, and transferred to Unit A on July 11, 2025; - Patient 51 arrived in the ED on July 6, 2025, and transferred to Unit A on July 6, 2025; - Patient 52 arrived in the ED on July 6, 2025, and transferred to Unit G on July 8, 2025; - Patient 53 arrived in the ED on July 7, 2025, and transferred to Unit A on July 20, 2025; - Patient 54 arrived in the ED on July 7, 2025, and transferred to Unit A on July 8, 2025; - Patient 55 arrived in the ED on July 7, 2025, and transferred to Unit A on July 11, 2025; and - Patient 56 arrived in the ED on July 7, 2025, and transferred to Unit B on July 8, 2025. On July 17, 2025, at 10:15 a.m., an interview was conducted with Registered Nurse (RN) 4. Registered Nurse 4 stated, “...the ED is not equipped to care for ICU patients...these patients have not been moved to the CCU because there are issues with the monitors in the CCU...” On July 21, 2025, at 4:38 p.m., an interview was conducted with the Emergency Department Manager (EDM) 1. EDM 1 stated all ICU patients on hold in the ED should always be in direct line of site for the RN’s to be able to observe the patients. EDM 1 stated, when the doors to patient rooms are closed, the RNs are not able to directly observe the patient. EDM 1 stated the ED has two portable cardiac monitors for use for the ICU patients on hold and the two monitors are not connected with the central monitoring (when the monitoring is conducted remotely by a staff) system in the ED. EDM 1 stated the RNs can only see the monitors in the patient’s room and this would potentially cause a delay in care. On July 21, 2025 at 4:15 p.m., an interview was conducted with the Corporate Quality Officer (CQO). The CQO stated ED holding affects patient care and staffing. The CQO stated ED holding process impacts the ED flow process and the expectation for ED holding of ICU patients is ICU patients will receive the same level of care they would in the ICU unit including documentation, assessment, and care. The CQO stated there was no facility policy to address ED holding.”

“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: 47071 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented for seven of 55 sample patients (Patients 21, 23, 28, 29, 30, 33, and 35), when: 1. For Patients 23, 33, and 35, oral (mouth) care was not completed every 12 hours. This failure resulted in Patients 21, 23, 35 to not receive the oral or nasal care in accordance with the facility’s policy and procedure and could have contributed to the patients to experience maggots infestation; 2. Patients 29 and 30, the Electronic Medication Administration Record (eMAR, a documentation of medications ordered by a physician for and administered to a patient) was not signed by staff in a timely manner, for Fentanyl (narcotic, a drug used to control pain and induce sleep) medication ordered by the physician. This failure had the potential to result in medication errors (any preventable event that may cause or lead to inappropriate medication use or patient harm) and/or drug diversion (illegal act of redirecting prescription medications, particularly controlled substances, from their intended destination for personal use, sale, or distribution to others); 3. For Patient 28, midazolam (a medication used for anesthesia, sedation, and severe agitation) was administered in a telemetry unit (telemetry, a unit for patients who require continuous remote monitoring of their heart rates and rhythms) which was not a unit designated for the administration of midazolam to the patients. This failure resulted in Patient 28 to experience shortness of breath, decreased oxygen saturation (O2 sat, a measurement of how much oxygen the blood is carrying as a percentage, normal is 90%), intubation (insertion of a plastic tube inserted through the mouth into the windpipe to help a person breathe), and subsequent transfer to the Intensive Care Unit (ICU, unit for critically ill patients); and 4. For Patient 21, the record documented a discrepancy on Patient 21’s name, sanitary environment was not maintained in the patient’s room, and Patient 21 was not repositioned in accordance with the facility’s policy and procedure (P&P). This failure resulted in a discrepancy in Patient 21’s name and had the potential to put Patient 21 at risk for deveoping infection and pressure injuries (wounds due to pressure on a body area) to Patient 21. Findings: 1a. On July 21, 2025, at 9:40 a.m., Patient 23’s record was reviewed with the Patient Safety Coordinator (PSC). A facility document titled, “History and Physical [H&P],” dated June 14, 2025, at 12:34 p.m., was reviewed. The document indicated Patient 23 came to the Emergency Department (ED) with abdominal distention (swelling of the stomach beyond normal size) and shortness of breath (SOB). An undated facility document titled, “Progress Note,” was reviewed. The document indicated Patient 23 was intubated (when a plastic tube is inserted through the mouth into the windpipe to help a person breathe) on June 19, 2025, at 8:51 a.m., and was transferred to the Intensive Care Unit (ICU, a specialized unit which provides monitoring for patients with life-threatening conditions) on Unit B. An undated facility document titled, “ICU RN [Registered Nurse] Daily Assessment,” was reviewed. The document indicated oral care was not completed by the RN on the following dates and times: - On June 23, 2025, at 10 a.m., 12 p.m., 2 p.m., 6 p.m.; and - On June 24, 2025, at 12 p.m., 2 p.m., 6 p.m. An interview was conducted with the PSC on July 21, 2025, at 9:47 a.m. The PSC stated oral care on an intubated patient is to be completed every two hours. The PSC stated when oral care is not completed on a patient, the patient is at greater risk for complications and maggot (a soft-bodied legless immature form of a fly) infestation (presence of large number of maggots). b. On July 21, 2025, at 12:15 p.m., Patient 33’s record was reviewed with the PSC. A facility document titled, “H&P,” dated May 12, 2025, at 7:08 p.m., was reviewed. The document indicated Patient 33 came to the ED for altered level of consciousness (when a person’s awareness and responsiveness to the environment is different from the normal) and hypernatremia (high levels of salt). An untitled facility document, dated May 19, 2025, was reviewed. The document indicated Patient 33 was intubated on May 19, 2025, at 12:20 a.m. An undated facility document titled, “Activities of Daily Living,” was reviewed. The document indicated oral care was not provided to Patient 33 on the following dates and times: - On May 23, 2025, at 10 p.m.; - On May 24, 2025, at 12 a.m., 2 a.m., 4 a.m., 6 a.m., 2 p.m.; - On May 25, 2025, at 2 p.m., 4 p.m., 10 p.m.; - On May 26, 2025, at 12 a.m., 2 a.m., 4 a.m., 6 a.m., - On May 27, 2025, at 2 a.m., 10 a.m., 8 p.m., - On May 28, 2025, at 2 a.m.; - On May 29, 2025, at 12 a.m., 2 a.m., 4 a.m., 6 a.m., 10 a.m., 6 p.m., 10 p.m., - On May 30, 2025, at 12 a.m., 2 a.m., 4 a.m., 6 a.m., 10 a.m., 2 p.m., 10 p.m.; - On June 12, 2025, at 10 a.m.; - On June 15, 2025, at 10 a.m.; - On June 16, 2025, at 6 p.m.; - On June 18, 2025, at 8 p.m.; - On June 21, 2025, at 12 a.m., 2 a.m., 4 a.m., 6 a.m., 10 p.m.; - On June 24, 2025, at 09:55 a.m.; 1:55 p.m.; - On June 27, 2025, at 6 a.m., 10 a.m., 12 p.m., 2 p.m., 4 p.m., 6 p.m., - On June 29, 2025, at 2 p.m., 4 p.m., 6 p.m., - On July 5, 2025, at 10 p.m.; - On July 8, 2025, at 6 p.m.; and - On July 11, 2025, at 10 a.m., 2 p.m., 6 p.m., A facility document titled, “Self-report,” dated July 3, 2025, at 1:54 p.m., was reviewed with the Deputy Regional Director of Quality (DRDQ). The document indicated Patient 33 was identified to have maggots in the nasal cavity (nose). An interview was conducted with the PSC on July 21, 2025, at 12:25 p.m., the PSC stated oral care on an intubated patient is to be completed every two hours. The PSC stated when oral care is not completed on a patient, the patient is at greater risk for complications and maggot infestation. c. On July 24, 2025, at 10:30 a.m., Patient 35’s record was reviewed with the PSC. A facility document titled, “H&P,” dated June 24, 2025, at 12:37 a.m., was reviewed and indicated the patient came to the ED for a fall at home. An undated facility document titled, “Progress Note,” was reviewed. The document indicated Patient 35 was intubated on June 24, 2025, at 2:46 a.m. An undated facility document titled, “Daily...General,” was reviewed. The document indicated oral care was not performed on Patient 35 on June 25, 2025, June 26, 2025, June 27, 2025, and June 29, 2025. A facility document titled, “Self-report,” dated July 3, 2025, at 1:54 p.m., was reviewed with the DRDQ. The document indicated Patient 35 was identified to have maggots in the patient’s nasal cavity. An interview with the PSC on July 21, 2025, at 12:35 p.m., was conducted. The PSC stated oral care on an intubated patient is to be completed every two hours. The PSC stated, when oral care is not completed, the patient is at greater risk for complications and maggot infestation. A facility policy and procedure (P&P) titled, “Oral Care of the Ventilated Patient,” dated April 2023, was reviewed. The P&P indicated, “...Respiratory Care Practitioners [RCP] will do chlorhexidine [a chemical compound used as an antiseptic (prevents the growth of bacteria) and disinfectant (destroys bacteria) to kill or prevent the growth of bacteria] oral care Q [every] 12 hrs [hours] and assist with nursing’s Q2 [every 2 hours] oral care...obtain oral care kit and place in patients room daily, kits is used for 24 hours...moisten oral mucosa [moist lining of the inside of the mouth] and lips every 2-4 hours...” 2a. On July 7, 2025, a report was received by the California Department of Public Health (CDPH, a state agency) from the facility. The report indicated, “...Event Date: June 1, 2025 Details: There is a [name of Unit A] nurse by the name of [name of RN 3] who has several discrepancies (any inconsistency or difference between two or more medication listed for the same patient) with pharmacy for missing narcotics and pain medications...” On July 15, 2025, at 2:50 p.m., an interview was conducted with the CNO. The CNO stated the process to prevent diversion of narcotics for Unit A is to count the narcotic medications (a procedure which aims to ensure the accurate tracking and accountability of the narcotics by verifying the quantity of narcotics held within the Pyxis (an automated drug delivery system for medications) against the Pyxis system’s recorded inventory every shift]) with one Registered Nurse (RN) from the current shift and one RN from the incoming shift. The CNO stated if the narcotic medication count is not correct, the pharmacy will be notified by the two RNs to rectify the inaccuracy. The CNO stated she received a call on June 1, 2025, at 6 p.m., about RN 3 exhibiting odd behavior and the pharmacy was called on June 1, 2025, to check the medications while RN 3 was working on Unit A. The CNO stated the pharmacy staff did not find evidence of an incorrect narcotic count for the June 1, 2025, narcotic count on Unit A. The CNO stated RN 3 was given a verbal warning [a disciplinary measure where a supervisor speaks to an employee about a performance or conduct issue] and there was no cause for the facility to complete a random drug testing [a drug screening without prior notice] on RN 3. On July 17, 2025, at 8:50 a.m., an interview was conducted with the Director of Pharmacy (DOP). The DOP stated there is no direct communication between the eMAR and the Pyxis (an automated medication dispensing system) systems about what narcotic medication was taken from the Pyxis and subsequently administered to a patient. The DOP stated the pharmacy will stock the Pyxis with medications and all the narcotics are checked and documented manually. The DOP stated, if the medication is not documented by the RN, the pharmacy will send an email to the RN and the Nurse Supervisor of the department concerning the discrepancy and a response is expected. The DOP stated multiple emails were sent by the pharmacy to the Nursing Supervisor Registered Nurse (NSRN) and the CNO concerning RN 3’s lack of documentation of multiple Fentanyl (a synthetic opioid drug used for pain and anesthesia, medication used for pain management during surgery) IV (intravenous, administered through a vein) solution bags retrieved by RN 3 from the Pyxis but were not documented as administered to a patient on the eMAR. The DOP stated there were verbal conversations with the NSRN and the CNO about RN 3’s discrepancies but they were not documented. The DOP stated the only response the pharmacy received from the NSRN regarding the narcotic count discrepancies involving RN 3 was a notation on an email in which it was indicated that the discrepancies were resolved. The DOP stated there was no explanation about how the narcotic count discrepancies involving RN 3 were resolved. On July 17, 2025, at 9:56 a.m., an interview was conducted with Registered Nurse (RN) 4. RN 4 stated if Fentanyl intravenous solution needs to be wasted (a process of discarding IV medications that remains after a patient has received their prescribed dose), there must be another RN acting as a witness to sign off on the Pyxis. RN 4 stated one RN may start a Fentanyl IV infusion drip without another RN witnessing the Fentanyl administration. RN 4 stated [name of Unit A] practices the honor system (relying solely on the honesty of those concerned). RN 4 stated an RN can remove a Fentanyl IV solution bag from the Pyxis and waste it and no one will call and question whether the medication was wasted because the Pyxis will not generate a red flag (a warning) when a narcotic medication is taken from the Pyxis machine. RN 4 stated the Pyxis will allow a Fentanyl IV solution bag to be removed from it at a certain time, and another Fentanyl IV solution bag to be removed from it two hours later. RN 4 stated, if 80 milligrams (mg, unit of measurement) of Fentanyl IV solution needed to be wasted because a new IV site was inserted and the RN who wasted the 80 mg Fentanyl IV solution documented the waste, the act of wasting will not be questioned by the facility. RN 4 stated RN 3 had multiple investigations regarding narcotic discrepancies and the previous Unit A managers, House Supervisor 1, and the NSRN were aware of the investigations. On July 21, 2025, 9:45 a.m., a review of Patient 29’s record and concurrent interview were conducted with the Nurse Manager (NMRN). The eMAR for Patient 29 indicated, on June 1, 2025, at 4:24 p.m., RN 3 removed a bag of Fentanyl 500 mcg (micrograms, unit of measurement)/100 ml (milliliters, unit of measurement) NS (normal saline, a type of IV fluid) solution from the Pyxis but was not documented on the eMAR until June 18, 2025, at 10:35 p.m., with a note which indicated, “removed at 1619 [4:19 p.m.] and hung right after, late entry.” The charting on the MAR (medication administration record) in the patient’s medical record indicated RN 3 documented administration/starting the fentanyl IV bags four times at 9:49 a.m. and 2:08 p.m., 4:24 p.m., and 7:36 p.m. on June 1, 2025. The charting on the flowsheet in the patient’s medical record, where RNs document I/O (input/output, tracks the amount of fluids and nutrients entering and exiting the body) and the measurement of IV infusions including fentanyl, indicated RN 3 did not document hourly fentanyl measurement and/or the total amount of fentanyl administered during RN 3’s shift on June 1, 2025. During the concurrent interview, the NMRN stated, on May 31, 2025, at 1:50 p.m., RN 3 removed a bag of Fentanyl 500 mcg/100 ml NS IV solution from the Pyxis but the narcotic medication was not documented on the eMAR as administered to the patient at the time of administration but was documented on the eMAR for Patient 29 on June 18, 2025, at 10:47 p.m., with a note which indicated, “removed at 1350 [1:50 p.m.] and hung right after, late entry.” The NMRN stated the RN’s should document all medications at the time of administration and definitely by the end of shift. b. On July 21, 2025, at 11:08 a.m., a review of Patient 30’s record and concurrent interview were conducted with the NMRN. The NMRN stated on May 23, 2025, at 9:19 a.m., RN 3 removed a bag of Fentanyl 500 mcg/100ml NS solution from the Pyxis but it was not documented on the eMAR until June 18, 2025, at 10:32 p.m., with a note which indicated, “removed from pyxis at 0915 [9:15 a.m.] and hung immediately.” The NMRN stated all medications should be documented at the time of administration, especially narcotic medications. The untitled facility documents, dated May 5, 2025, and June 4, 2025, were reviewed. The documents indicated, “...Event Date 5/23/2025 [May 23, 2025] Time pulled [removed] 09:14 [9:14 a.m.]...User [name of RN 3]...Medication Fentanyl 500 mcg/100 ml SOLP [Standards for the Operation of Licensed Pharmacies] Issue Removed 1 bag, but did not chart whether given to patient or not note/follow-up/resolved Not charted/wasted/returned, checked on 06/04/25 [June 4, 2025]...Event Date 5/31/2025 [May 31, 2025] Time pulled 13:45 [1:45 p.m.]...User [name of RN 3]...Medication Fentanyl Drip (500 mcg/100 ml/1 bag) Issue Removed 1 bag but pharmacy could not find transaction of Administered, Wasted, or Returned note/follow-up/resolved Not charted/wasted/returned, checked on 06/04/25 [June 4, 2025]...Event Date 6/1/2025 [June 1, 2025] Time pulled 16:19 [4:19 p.m.]...User [name of RN 3]...Medication Fentanyl Drip (500 mcg/100 ml/1 bag) Issue Removed 1 bag but pharmacy could not find transaction of Administered, Wasted, or Returned note/follow-up/resolved Not charted/wasted/returned, checked on 06/04/25 [June 4, 2025]...” On July 17, 2025, 2 p.m., an interview was conducted with the CNO. The CNO stated she was not aware of multiple medication discrepancies made by RN 3 and never received emails from the pharmacy regarding this issue. The CNO stated a Record of Discussion (a written warning issued to the staff) was made with RN 3 and the Human Resources department was also notified. A facility document email titled, “Controlled Med Discrepancy: RN 3,” dated February 26, 2025, was reviewed. The document indicated, “...Please review the details below in regards to a narcotic discrepency...” The document further indicated the CNO was carbon copied on this email. On July 21, 2025, at 9:13 a.m., during an interview, the CNO stated the CNO was informed on a Friday in June 2025, there was a report RN 3 was acting strange, which led the CNO to initiate CS count with the night shift manager and the pharmacy, who told the CNO the count showed no discrepancies. The CNO stated there wasn’t a two-way communication between nursing and pharmacy for narcotic discrepancies in charting before the reported incident with RN 3 in June 2025. On July 21, 2025, at 3:30 p.m., an interview was conducted with the Human Resources Business Partner (HRBP). The HRBP stated a record of discussion was filed with RN 3 regarding not following the facility’s protocols for medication administration documentation. A review of the facility policy and procedures (P&P) titled, “High-Alert Medications,” dated May 2024, indicated, “...High Alert medications are defined as those drugs, which are involved in a higher percentage of medication incidents and/or sentinel events or carry an increased risk for error or other adverse outcomes. These medications are identified from [name of Facility A] data, literature, and regulatory agency standards...All high-alert medications will be documented on medication administration record/anesthesia record/ambulatory medical record or other part of the medical record where drug administration is documented...” 3. On July 7, 2025, a report was received by the California Department of Public Health (CDPH, a state agency) from the facility. The report was reviewed and indicated, “...Event Date: June 21, 2025, Details: On June 21, 2025, [name of Patient 28] was administered Midazolam 1 mg IV push one dose for agitation which resulted in an adverse drug event [any injury or harm that results from the use of a medication]. The patient was intubated and transferred to [name of Unit B]...” On July 15, 2025, at 2:15 p.m., a review of Patient 28’s record was conducted with the DRDQ. A facility document titled, “History & Physical Note,” dated June 19, 2025, authored by Physician (MD) 1, was reviewed. The document indicated, “...Chief Complaint: Seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]...History of Present Illness...[name of Patient 28] had a witnessed seizure and was brought to the facility by ambulance...” On July 16, 2025, at 1:30 p.m., an interview was conducted with the CQO. The CQO stated Patient 28 had a physician’s order for Ativan (a medication used to treat anxiety and seizures) but there was a shortage of Ativan so Pharmacist 4 and MD 2 substituted Ativan with midazolam for Patient 28. The CQO stated midazolam can be administered in the Emergency Department (ED), the Peri-Operative unit [unit where care is provided to patients before, during, and after surgical procedures] unit, or the ICU only. The CQO stated RN 21 administered midazolam on Unit B (a telemetry unit) and this is against policy. On July 17, 2025, 2:30 p.m., a review of Patient 28 ’ s record was conducted with RN 6. A facility document titled, “Progress Notes Report,” dated June 22, 2025, at 9:55 a.m., was reviewed. The document indicated, “...Late entry called MD 2 the dr [doctor] assigned to Patient 28 at 1530 [3:30 p.m.] patient agitated climbing out of bed and pulling at foley [Foley catheter, a tube which drains urine from the bladder into a bag] and iv’s [intravenous catheter, a thin fexible tube inserted into a vein to administer fluids, medications, or blood products] patient pulled out and [name of RN 6] replaced 6 iv’s ...” A facility document titled, “Medication Administration Record,” was reviewed. The document indicated, “...Medication Midazolam 1MG /Ml [milliliters, unit of measurement] injectable intravenous every 5 [five] minutes- as needed...Last Administered: 06/21/2025 [June 21, 2025] 17:35 [5:35 p.m.] Adm. [administered] By: [name of RN 21]...” A facility document titled, “Progress Notes Report,” dated June 22, 2025, was reviewed. The document indicated after the midazolam was administered, Patient 28 continued to have agitation, shortness of breath, and decreased oxygen saturation in the 60-70%. The document indicated a code-blue (a hospital emergency code indicating a patient needs immediate attention) was called on June 21, 2025, at 11:11 p.m., and Patient 28 was intubated and transferred to Unit A (ICU unit) on June 21, 2025 at 11:43 p.m. On July 18, 2025, at 10:30 a.m., an interview was conducted with RN 21. RN 21 stated he was uncomfortable with administering the midazolam to Patient 28 but the pharmacist and MD 2 stated it could be administered on a telemetry unit. RN 21 stated the medication was pulled directly from the Pyxis and administered very slowly to Patient 28. RN 21 stated Patient 28 continued with agitation but his vital signs and oxygen saturation was in the low 90%. RN 21 stated he should have called the House Supervisor or the CNO for help but the pharmacist “sealed the deal” and he felt there was no alternative but to give the midazolam to relieve Patient 28’s agitation while the patient was in the telemetry unit. On July 21, 2025, at 9 a.m., an interview was conducted with the NMRN. The NMRN stated Midazolam is not given on the telemetry unit and the pharmacy should have verified what unit Patient 28 was on prior to authorizing the medication. The NMRN stated the telemetry unit is not a critical care floor and the nurse-to-patient ratio on the telemetry unit will not support close monitoring of adverse effects from high-risk medications administered on the patients. A review of the facility’s P&P titled, “Titratable Drip Medications [medications administered intravenously (IV) via a drip system],” dated December 2023, was conducted. The policy indicated, “...It is the policy of [name of Facility A] to standardize all titratable drip medications to ensure safe, appropriate and effective use if these medications...Sedatives/Analgesic...Midazolam (Versed [brand name of Midazolam]) 100 mg/NS [normal saline, a type of IV fluid] 100 ml...Unit...ICU PERIOP ED Precautions...can cause CNS [central nervous system, made up of the brain and the spinal cord] depression [a condition where the activity of the brain and spinal cord is slowed down], have airway equipment [any device or tool used to maintain, secure, or assist a patient’s breathing] ready...” A review of the facility’s P&P titled, “Intravenous Medications: IV Push by a Registered Nurse,” dated February 2024, was conducted. The policy indicated, “...A licensed person has the right to refuse to carry out a physician’s order if, in his/her professional judgment, it could be harmful to the patient or if policy dictates the order as a physician responsibility. In the event of refusal to carry out a physician’s order the following sequence of actions will occur: 1. The licensed person will immediately notify nursing management. 2. The physician will be notified regarding the refusal. 3. Notification will be documented in the medical record. 4. The basis for a policy which permits the nurse to refuse to administer a physician’s order is contained in the Nursing Practice Act...” A facility document titled, “IV Push List,” approved by P&T Committee, September 2018 was reviewed. The document indicated, “...Midazolam (brand name: Versed) requires cardiac and BP monitoring approved use in PACU, ICU/CCU, ER, and telemetry (with a footnote, during cardioversion only)...” The current hospital’s policy and procedure titled, “Intravenous Medications: IV push by a Registered Nurse,” last revised February 2024, was reviewed. The policy indicated midazolam was not included as a medication approved for IV Push administration on any patient care unit. The policy also indicated, “...Medications not included on this list will be administered according to manufacturer recommendations...” The manufacturer’s prescribing information for midazolam has a boxed warning (the strongest warning required by the Food and Drug Administration and alerts healthcare professionals and consumers to serious risks associated with a drug’s use) which indicated, “...Intravenous midazolam has been associated with respiratory depression and respiratory arrest, especially when used for sedation in noncritical care settings. In some cases, where this was not recognized promptly and treated effectively, death or hypoxic encephalopathy has resulted...” 4a. On July 15, 2025, at 2:09 p.m., Patient 21’s record was reviewed with the NMRN. A facility document titled, “History and Physical,” dated June 30, 2025, was reviewed. The document indicated Patient 21 was admitted to the facility on June 30, 2025, with diagnoses which included hypotension (low blood pressure) and CHF exacerbation (build up of fluid in the lungs, legs and stomach due to the hearts decreased ability to pump blood effectively). The document indicated a misspelled name for Patient 21. An interview with the Patient Access Manager (PAM) was conducted on July 17, 2025 at 3:20 p.m. The PAM stated, for identifying patients during admission to the facility, patients arriving at the Emergency Department (ED) are expected to present an identification for verification. The PAM stated the patient’s name was spelled incorrectly and the name was corrected on July 6, 2025. The PAM stated the facility did not become aware of the discrepancy in Patient 21’s name until July 6, 2025, when the nurse notified her after a family member brought the discrepancy on Patient 21’s name to the nurse’s attention. A follow-up interview with the PAM was conducted on July 21, 2025, at 1:52 p.m. The PAM stated, when patients arrive by Emergency Medical Services (EMS, an ambulance service), the registration staff generally rely on the information provided by EMS. The PAM stated, if the patient is alert and able to respond, staff are expected to request identification directly from the patient. The PAM stated the facility did not request an identification directly from patient 21. A review of the facility’s P&P titled, “[Name of Facility] Patient Identification,” was conducted. The P&P indicated, “...at the time of arrival, staff who register patients will request either a photo or non-photo identification from the patient...” b. An observation of Patient 21’s room was conducted with RN 13 on July 14, 2025, at 11:30 a.m. Empty medication wrappers and various small plastic round white and blue cylindrical cap-like pieces were observed on the floor of Patient 21’s room and under Patient 21’s bed. A clear bag containing assorted items was observed under a chair. Two pillows covered with white pillowcases were observed placed on top of a commode (a portable toilet, often a chair-like device with a receptacle for waste) covered with a clear plastic bag in Patient 21’s bathroom. An unlabeled plastic graduated triangular container was observed on the toilet seat and two soiled linen hampers, one of which was observed to hold a clear plastic bag containing trash and the other a blue plastic bag containing linen, were observed inside the bathroom in Patient 21’s room. The bathroom was observed to have a noticeable foul smell. An interview with RN 13 was conducted on July 14, 2025, at 11:37 a.m. RN 13 stated the Environmental Services Department (EVS) is responsible for removing trash from patients’ rooms once in a shift. She stated the pillows should not have been inside the bathroom. She stated the bag under the chair contained Patient 21’s personal belongings and she was not sure where the patient’s belongings were supposed to be stored. A review of the facility’s P&P titled “[Name of Facility] Police Cleaning Patient Areas” was conducted. The P&P indicated “...cleaning in the patient area is light cleaning of key areas to ensure they appear neat and tidy until thorough cleaning can occur...All cleaning personnel must be continually alert for...Debris on carpets...Spills on floors...Full waste receptacles...Untidy bathrooms...Everyone in the Housekeeping Department is responsible for keeping the hospital areas sparkling and free of debris...” c. On July 21, 2025, at 9:15 a.m., a facility untitled and undated document flowsheet was reviewed with RN 20. There was no documented evidence Patient 21 was repositioned on the following dates and times: - On July 3, 2025, at 8 p.m.; - On July 4, 2025, at 12 a.m.; - On July 4, 2025, from 4 a.m. until 8 a.m. (four hours); - On July 5, 2025, at 2 a.m.; - On July 5, 2025, at 8 a.m.; - On July 5, 2025, from 6 p.m. until 10 p.m. (four hours); - On July 6, at 12:00 a.m.; - On July 6, 2025, at 8 a.m.; - On July 6, 2025, from 10 p.m. until July 7, 2025, 4 a.m. (six hours); - On July 7, 2025, at 6 a.m.; - On July 7, 2025, at 10 p.m.; - On July 8, 2025, at 2 a.m.; - On July 8, 2025, at 6 a.m., - On July 9, 2025, at 8 a.m.; - On July 11, 2025, at 8 a.m.; - On July 12, 2025, from 4 p.m. until 10 p.m. (six hours); - On July 13, 2025, at 10 a.m.; and - On July 13, 2025, at 8 p.m. During a concurrent interview conducted with RN 20 on July 21, 2025, at 9:15 a.m., RN 20 stated Patient 21 was not repositioned every two hours. On July 21, 2025, at 2:28 p.m., a follow-up interview was conducted with RN 13. RN 13 stated the patients should be repositioned every two hours. On July 21, 2025, at 2:31 p.m., an interview was conducted with RN 12. RN 12 stated patients must be repositioned every two hours. On July 21, 2025, at 2:35 p.m., an interview was conducted with RN 14 RN. 14 stated patients must be repositioned every two hours. On July 21, 2025, at 2:50 p.m., an interview was conducted with RN 15. RN 15 stated patients must be repositioned every two hours. A review of the facility’s P&P titled, “[Name of Facility] Skin and Wound care,” was conducted. The P&P indicated “...regular repositioning. Avoid direct pressure to at-risk body surfaces...””

“PHARMACY DRUG RECORDS CFR(s): 482.25(a)(3) Current and accurate records must be kept of the receipt and distribution of all scheduled drugs. This Standard is not met as evidenced by: 25281 Based on observation, interview, and document review, the facility failed to ensure: 1. Accountability procedures were in place and implemented to control the use of all controlled substances (CS) and to readily identify and determine the extent of loss or diversion of all CS in such a manner as to minimize the time frame between start of the actual loss or diversion to the time of detection as evidenced by: - The hospital did not have an effective written policy and procedure for audit and prevention of drug diversion; - The hospital’s electronic Health Record System (eHR) allowed to initiate, change bags of IV (intravenous, into vein) fentanyl (potent synthetic narcotic to manage severe pain and highly addictive and associated with overdose death) for infusion without having a second nurse witness against the hospital policy and procedure; - Nurses were able to back date and retroactively chart the administration of medications to resolve discrepancies without consequences; - The charting by the ICU nurses on the flowsheet (document used by nursing to enter various aspects of patient care, including vital signs, medication administration, fluid intake and output) in the patients’ medical records was not audited by nursing and/or pharmacy department to ensure compliance and completeness of documentation to fully account for controlled drug use. These failures resulted in multiple doses of fentanyl for IV infusion that were not fully accounted for and potentially led to one ICU nurse diverting multiple doses of fentanyl; and 2. Wasted CS in the patient care units were irretrievable. This failure led to incomplete disposition of controlled medications and had the potential for unauthorized access to wasted controlled medications. Findings: 1. On July 14, 2025, at 2:08 p.m., during an interview, the DOP stated pharmacists reviewed daily, the removal of all CS from the Pyxis MedStations (an automated drug delivery system for medications) on nursing units and the matching documentation of administration on the hospital electronic health system (eHR), Paragon. The DOP stated recently missed charting (documenting) on the electronic medication administration record (eMAR) was increasing. The DOP stated discrepancies identified as CS removal from the Pyxis without corresponding documentation by nursing staff would be communicated to the identified nurse, the nurse manager, and the CNO daily in emails for investigation and resolution. The DOP stated the summary of discrepancies were also sent weekly to nursing leadership. The DOP stated these discrepancies would be resolved when the nurse that created the discrepancy completed the charting as a late entry. These resolved discrepancies then would not be included in the report presented at quarterly hospital committees. The DOP stated there was nothing else the pharmacy could do once the discrepancies were resolved this way. On July 16, 2025, at 9:55 a.m., during concurrent interview and document review, Pharmacist 3 stated the Pyxis CS transaction report was automatically generated for review by pharmacists for the presence of documentation of administration, waste, and return to stock. The pharmacists would open a case, and emails would be sent if there was a Pyxis removal and no charting on the patient’s medical record corresponding to the removal by the nurse. Pharmacist 3 stated the pharmacy maintained records in Excel documents called, “Unresolved Narcotic Audits Quarterly Sheet.” Review of the Excel documents indicated RN 3, an ICU Nurse, did not document the administration of IV fentanyl 500 mcg/100 ml for infusion on the medication administration record (MAR) in the patients’ medical records four times in May and five times in June 2025. Seven of these cases were closed as resolved with the resolved date shown to match the date the event was created. Two remained unresolved. On July 16, 2025, at 10:45 a.m., during an interview, Pharmacist 3 stated nurses were able to retroactively chart the missing administration to resolve the cases by backdating. The eHR would not show the time and date nurses charted retroactively. Pharmacist 3 stated there was no witness required to chart retroactively. Pharmacist 3 stated he used to be the informatics pharmacist. The DOP stated, monthly to the CNO, the DOP sent emails with the “Proactive Diversion Report,” a hospital-wide user report that included the list of users with more removals of controlled substances (high users) compared to the mean removal by all users. The DOP stated the monthly report was sent to the CNO for information purposes but could be useful if one was to investigate. The DOP stated the purpose of the report was for someone to investigate the high users but there were no follow-up procedures on how or who was to investigate. The DOP expected the CNO to contact the DOP for assistance, but the CNO never asked the pharmacy for help. The DOP stated there was no written policy and procedure on controlled drug diversion. On July 21, 2025, at 9:13 a.m., during an interview, the CNO stated the CNO was informed on a Friday in June 2025, there was a report RN 3 was acting strange, which led the CNO to initiate CS count with the night shift manager and the pharmacy, who told the CNO the count showed no discrepancies. The CNO stated there were no concerns about behaviors and charting patterns of RN 3 in the past. The CNO stated Managers and charge nurses initiated reconciliation for completeness and accuracy of documentation and if the managers could resolve and reconcile then it would not be brought to her attention. The CNO stated the CNO relied on the managers to look into the monthly “Proactive Drug Diversion Report” and report to the CNO if there were any concerns. The CNO stated the monthly diversion report from the DOP did not have enough information and was not detailed enough. The CNO stated the monthly diversion report would need to be clearer on the concerns and issues with the staff or the manager. CNO stated the reports were generic and would also like to see the number of discrepancies per staff over a time period. The CNO stated there wasn’t a two-way communication between nursing and pharmacy for narcotic discrepancies in charting before the reported incident with RN 3 in June 2025. On July 18, 2025, the monthly “Proactive Drug Diversion Report” emailed to the CNO was reviewed, and it indicated RN 3 was not identified as one of the high users in any of the 2025 monthly reports. The report was not specific to each nursing unit and CS. On July 14, 2025, at 3:21 p.m., the DOP stated RN 3 did not show up on May 2025 report because the DOP pulled the hospital wide report that included all Pyxis users and aggregate of all CS. On July 17, 2025, the “All Device Events Report” for fentanyl 500 mcg/100 ml infusion bag removal from Pyxis by the ICU nurses from May 1 to June 15, 2025, was reviewed and it indicated RN 3 was the highest user who removed 49 fentanyl infusion bags during this period, 22 bags more than the next highest user of fentanyl infusion bags. On July 16, 2025, the medical record of Patient 29 was reviewed, and the following was noted: Patient 29 had a physician order to start on June 1, 2025, fentanyl 500 mcg/100 ml IV infusion with the initial rate to start at 25 mcg/hour and the maximum rate to 200 mcg/hour, and titrate to a goal RASS (Richmond Agitation-Sedation Scale, measurement of a patient’s level of consciousness and agitation ranging from +4 to -5) score of -3 (moderate sedation); The charting on the MAR (medication administration record) in the patient’s medical record indicated RN 3 documented administration/starting the fentanyl IV bags four times at 9:49 a.m. and 2:08 p.m., 4:24 p.m., and 7:36 p.m. on June 1, 2025; The charting on the flowsheet in the patient’s medical record, where RNs document I/O (input/output, tracks the amount of fluids and nutrients entering and exiting the body) and the measurement of IV infusions including fentanyl, indicated RN 3 did not document hourly fentanyl measurement and/or the total amount of fentanyl administered during RN 3’s shift on June 1, 2025. On July 16, 2025, at 2:15 p.m., during an interview, ICU Charge Nurse (CRN) 5 stated there was no documentation of fentanyl measurement during RN 3’s shift between 7 a.m. and 6 p.m. on June 1, 2025. On July 16, 2025, the medical record of Patient 37 was reviewed, and the following was noted: Patient 37 had a physician order to start on May 16, 2025, fentanyl 500 mcg/100 ml IV infusion with the initial rate to start at 25 mcg/hour and the maximum rate to 200 mcg/hour, and titrate to a goal RASS (Richmond Agitation-Sedation Scale, measurement of a patient’s level of consciousness and agitation ranging from +4 to -5) score of -1 to -2 (drowsy to light sedation); The charting on the MAR in the patient’s medical record indicated RN 3 documented administration/starting the fentanyl IV bags two times at 2:25 p.m. and 4:42 p.m. on May 17, 2025; The charting of I/O and the fentanyl infusion measurement on the flowsheet in the patient’s medical record indicated RN 3 did not document hourly fentanyl measurement and/or the total amount of fentanyl administered during RN 3’s shift on May 17, 2025. On July 16, 2025, at 2:15 p.m., during an interview, CRN 5 stated the intake volume of IV medications for infusion needed to be documented hourly for all ICU patients. On July 16, 2025, the medical record of Patient 33 was reviewed, and the following was noted: Patient 33 had a physician order to start on June 6, 2025, fentanyl 500 mcg/100 ml IV infusion with the initial rate to start at 25 mcg/hour and the maximum rate to 200 mcg/hour, and titrate to a goal RASS score of -2 (light sedation); The charting on the MAR in the patient’s medical record indicated RN 3 documented administration/starting the fentanyl IV bags two times at 9:58 a.m. and 2:18 p.m. on June 6, 2025; The Pyxis “All Device Events Report” for fentanyl 500 mcg/100 ml infusion bags indicated RN 3 removed three times at 9:54 a.m., 2:41 p.m., and 6:33 p.m.; and The charting on the flowsheet in the patient’s medical record, where RNs document I/Os and the measurement of IV infusions including fentanyl, indicated RN 3 did not document hourly fentanyl measurement and the total amount of fentanyl administered during RN 3’s shift. On July 16, 2025, at 2:15 p.m., during an interview, CRN 5 stated there was no documentation of fentanyl measurement during RN 3’s shift between 7 a.m. and 6 p.m. on June 6, 2025. On July 21, 2025, the medical record of Patient 39 was reviewed, and the following was noted: Patient 39 had a physician order to start on June 14, 2025, fentanyl 500 mcg/100 ml IV infusion with the initial rate to start at 25 mcg/hour and the maximum rate to 200 mcg/hour, and titrate to a goal RASS score of -3 (moderate sedation); The charting on the MAR in the patient’s medical record indicated RN 3 documented administration/starting the fentanyl IV bags four times at 8:13 a.m., 11:32 a.m., 2:18 p.m., and 5:35 p.m. on June 16, 2025, and five times at 8:10 a.m., 8:15 a.m., 10:15 a.m., 12:55 p.m., and 5:35 p.m. on June 17, 2025; and The charting on the flowsheet in the patient’s medical record indicated RN 3 did not document hourly fentanyl and the total amount of fentanyl administered during RN 3’s shift. On July 21, 2025, at 4 p.m., during an interview, RN 20 and PSC confirmed the flowsheet in the patient’s medical record did not contain hourly charting of I/O that included hourly fentanyl measurements. On July 16, 2025, at 2:15 p.m., during an interview, CRN 5 stated charge nurses would audit charts for completeness. CRN 5 stated there was not enough time to audit nurses. CRN 5 stated no second nurse witness was required to initiate and change IV fentanyl infusion bags. On July 21, 2025, at 9:13 a.m., during an interview, the CNO stated the CNO knew ICU nurses needed to document I&O every hour but was not informed RN 3 was not charting I&Os On July 14, 2025, at 2:05 p.m., during an interview, the DOP agreed if the dose of medications administered was not documented in the patients’ medical records, it is missing and not accounted for. The hospital’s document titled, “ICU Standards of Care,” was reviewed, and it indicated: “Vital Signs...Minimum frequency is hourly or as ordered by physician...Medication Management: Independent double checks on high-risk medications...Elimination/Nutrition...Intake and Output to be documented at minimum every two hours...Unit norm: Every hour...” The hospital’s document titled, “ICU Documentation Standards,” was reviewed, and it indicated: “...Intake and Output every hour...” The hospital’s policy and procedure titled, “High-Alert Medications,” last approved, June 2024, was reviewed, and it indicated: “...High-Alert Medications are defined as those drugs, which are involved in a higher percentage of medication incidents and/or sentinel events or carry an increased risk for error or other adverse outcomes... Opiate/Narcotic infusions...An independent double check by two qualified health care practitioners (e.g. nurse, pharmacist, physician) is required initially, at each bag change, rate change and at hand-offs...” 2. During a concurrent observation and interview on July 21, 2025 at 10:21 a.m. with Clinical Nurse Manager 2 (CNM 2), the chemical dependency unit (CDU) medication room tour was conducted. A blue lidded pharmaceutical waste bin with a clear base was observed hanging on the wall. The waste bin contained multiple medication vials, pills, and syringes of different medications visible through the bin. CNM 2 stated controlled medications, including narcotic pain medications, were wasted into the blue bin. CNM 2 verified the nurse would put the complete pill into the bin to waste the controlled medication. During a concurrent observation and interview on July 21, 2025 at 10:32 a.m. with Pharmacist 1, the CDU medication room blue pharmaceutical waste bin was observed. Pharmacist 1 stated the patient care units disposed of controlled medications into the blue pharmaceutical waste container. Pharmacist 1 stated the pharmacy used a chemical solvent to destroy wasted controlled medications. Pharmacist 1 then stated the patient care units did not have access to the chemical solvent to make controlled medications irretrievable. Pharmacist 1 agreed the medications in the CDU blue bin could be retrieved by facility staff. During a concurrent record review and interview on July 21, 2025 at 10:54 a.m. with Pharmacist 1, the printout “Summary of Medical Waste Streams,” undated, posted on the wall of the CDU medication room, was reviewed. The record indicated “...Controlled substance ‘wastage’ sequestered in the Cactus Smart sink cartridge [chemical solvent product] or Rx Destroyer [chemical solvent product]...” Pharmacist 1 stated the facility is not following the process described on the printout. During an interview on July 21, 2025 at 3:18 p.m., the Director of Pharmacy (DOP) stated the CDU was not following facility procedures for destruction of medications. DOP stated the medications in the blue pharmaceutical waste bin were retrievable with the CDU’s current practice. The DOP stated controlled medications needed to be destroyed when wasted. The DOP acknowledged that none of the patient care units have access to a chemical solvent to destroy the medications. A review of the facility’s policies and procedures (P&P) titled, “Controlled Substances,” dated June 2024, indicated: “...If the dose ordered necessitates wastage ...Pharmacy to dispose of the damaged drug...” and “...All controlled substances shall be wasted, destroyed or disposed of and documented as required...” and “...Destruction (or wastage) of any controlled substance must be done...””

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 25281 Based on observation, interview, and record review, the facility failed to ensure: 1. Patient’s own medications were stored in accordance with hospital policy for two of seven toured patient care units; 2. Patient’s own medications were destroyed in accordance with hospital policy for two of seven toured patient care units; and 3. Injectable midazolam (medication used for procedural sedation and used primarily in procedural areas) was not used on the non-critical units in accordance with the hospital policy and procedure and the recommendations from the pharmacy in dealing with nationwide shortage of injectable Ativan (medication used for seizures and anxiety). These failures resulted in medications being vulnerable for theft and diversion, and Patient 28 receiving one dose of midazolam 1 milligram (mg) via intravenous push (IVP, quick injection of medication directly into vein using a syringe) on the Telemetry Unit on the 3rd Floor and suffering from aspiration and enduring emergency life resuscitating (reviving) measures. Findings: 1a. During a concurrent observation and interview on July 21, 2025 at 10:21 a.m. with Clinical Nurse Manager 2 (CNM 2), the Unit E medication room tour was conducted. The Unit E medication room contained a safe on the counter. CNM 2 stated the safe was used when patients brought in medications from outside the facility. CNM 2 stated nursing staff put controlled medications (those with high potential for abuse and addiction) into the safe and non-controlled medications in a locked cabinet in the medication room. The safe contained one vial with 54 capsules of chlordiazepoxide (a medication to treat anxiety) 25 milligram (mg) for Patient 41. During an interview on July 21, 2025 at 10:32 a.m., Pharmacist 1 stated the pharmacy was not involved in Unit E’s storage process for patients’ own medications. A review of Patient 41’s medical record indicated the patient was admitted to the facility on January 27, 2025 and February 3, 2025. The record indicated Patient 41 discharged from the facility on February 17, 2025. A review of “Patient Own Medications Receipt,” dated January 28, 2025, indicated Patient 41 brought 54 capsules of chlordiazepoxide 25 mg to Unit E upon admission. The record also indicated “Deliver to Pharmacy” and “To be signed when prescriptions are deposited with the pharmacy.” 1b. During a concurrent observation and interview on July 21, 2025 at 11:31 a.m. with Pharmacist 1, the Unit D medicine room tour was conducted. A gray bin labeled “Returns” was on the counter. The gray bin contained the following vials of patient’s own medications from an outside pharmacy: - One vial of Eliquis (brand name for apixaban, a blood thinner) 5 mg tablets for Patient 40; - One vial of atorvastatin (generic for Lipitor, to lower cholesterol) 40 mg tablets for Patient 40; - One vial of Tagrisso (brand name for Osimertinib, chemotherapy) 40 mg tablets for Patient 45; and - One vial of Eliquis 5 mg tablets for Patient 46. Pharmacist 1 stated pharmacy staff went to the unit medications rooms every day to pick up returns. Pharmacist 1 stated nurses were supposed to place the patient’s own medications in a security bag, write a list of the medications, seal the bag, and deliver to the pharmacy. Pharmacist 1 stated this was supposed to be done on the day medications arrived at the facility. Pharmacist 1 stated he did not know whether Patients 40, 45, and 46 were currently admitted to the facility. During an interview on July 21, 2025 at 2:28 p.m., Registered Nurse 20 (RN 20) stated the admitting nurse was supposed to put the patient’s own medications in a security bag, seal the bag, and give the medications to the pharmacy. RN 20 then stated the patient’s own medications were supposed to be returned to the patient upon discharge. RN 20 stated if the patient’s own medications were left behind, the nurse needed to put the medications in the pharmacy return bin for the pharmacy to pick up. During an interview on July 21, 2025 at 3:11 p.m., the Director of Pharmacy (DOP) stated patient’s own medications were not supposed to be in the unit medication rooms. The DOP stated the Unit E staff were supposed to bring the patient’s own medications to the pharmacy. The DOP stated she was not aware Unit E staff were storing patient’s own medications in the medication room. A review of the facility’s policies and procedures (P&P) titled, “Patient’s Own Medication,” dated March 2025, indicated: “...When medications are brought into the hospital by a patient...the nurse will fill out a patient’s own medication receipt, place medications in the security bag and will notify the pharmacy...” and “...When the sealed medication bag containing the listed medications is sent to the pharmacy, the bag will be placed in a secured location ...The sealed bag will be maintained in the secured area until the patient is discharged...Upon discharge, the Pharmacy will surrender the sealed bag to nursing for return to the patient...” and “...If the medication(s) cannot be returned to the family, it is to be sent to the Pharmacy Department for storage...” 2a. During an interview on July 21, 2025 at 10:21 a.m., CNM 2 stated the patient’s own controlled medications were stored in the Unit E medication room safe and destroyed after a patient discharged. CNM 2 stated two nurses would count the controlled medication and put the medications into the blue pharmaceutical waste bin in the Unit E medication room. CNM 2 stated medications needed to be wasted within 90 days of discharge. During a concurrent interview and record review on July 21, 2025 at 10:29 a.m. with CNM 2, Patient 41’s “Patient Own Medications Receipt,” dated January 28, 2025, was reviewed. The record indicated Patient 41 brought 54 capsules of chlordiazepoxide 25 mg to Unit E upon admission. CNM 2 stated the medication was still in the safe and Patient 41 discharged over 90 days ago. During an interview on July 21, 2025 at 10:32 a.m., Pharmacist 1 stated the pharmacy did not monitor the destruction of patients’ own medications brought to Unit E. A review of Patient 42’s medical record indicated the patient was admitted to the facility on January 31, 2025, and February 8, 2025. The record indicated Patient 42 discharged from the facility on March 5, 2025. A record review of “Patient Own Medications Receipt,” dated January 31, 2025, indicated Patient 42 brought eight tablets of alprazolam (a medication to treat anxiety) 0.25 mg to Unit E upon admission. A record review of “Medication Destruction Log,” dated April 2, 2025 to July 7, 2025, indicated two Unit E nurses destroyed eight tablets of Patient 42’s alprazolam 0.25 mg on May 27, 2025. 2b. During a concurrent observation and interview on July 21, 2025 at 11:31 a.m. with Pharmacist 1, the Unit D medicine room tour was conducted. The gray bin on the counter contained patient’s own medication vials for Patients 40, 45, and 46. Pharmacist 1 stated he did not know whether Patients 40, 45, and 46 were currently admitted to the facility. During a concurrent interview and record review on July 21, 2025 at 2:28 p.m. with RN 20, Patient 40’s medical record was reviewed. The medical record indicated Patient 40 was admitted to the facility on May 18, 2025 and discharged on June 6, 2025. RN 20 stated there was no record of patient’s own medications in the chart. During a concurrent interview and record review on July 21, 2025 at 2:44 p.m. with RN 20, Patient 45’s medical record was reviewed. The medical record indicated Patient 45 was admitted to the facility on May 25, 2025 and discharged on June 6, 2025. RN 20 stated there was no record of patient’s own medications in the chart. During a concurrent interview and record review on July 21, 2025 at 2:37 p.m. with RN 20, Patient 46’s medical record was reviewed. The medical record indicated Patient 46 was admitted to the facility on June 18, 2025 and discharged on June 25, 2025. RN 20 stated there was no record of patient’s own medications in the chart. During an interview on July 21, 2025 at 3:11 p.m., the Director of Pharmacy (DOP) stated the patient’s own medications found in the Unit D and Unit E medication rooms were supposed to be discarded. The DOP stated patient’s own medications were supposed to be destroyed by the pharmacy 30 days after discharge. The DOP further stated Unit E was not following facility procedures for destruction of patient’s own medications. A review of the facility’s policies and procedures (P&P) titled, “Controlled Substances,” dated June 2024, indicated: “Controlled substances brought to the medical facility by a patient upon admission, the medications shall be handled as outlined in the Patient’s Own Medication Policy and Procedure...” A review of the facility’s P&P titled, “Patient’s Own Medication,” dated March 2025, indicated: “...If the medications are not claimed within 30 days after discharge, they will be destroyed...” and “...Drugs listed in Schedule II, III, IV, or V [controlled medications]...shall be destroyed in the presence of two (2) pharmacists employed by the hospital...[and] shall be recorded in the Patient’s Own Medication Log...” and “...Drugs not listed in Schedule II, III, IV, or V...shall be destroyed in the presence of a pharmacist and noted in the Patient’s Own Medication Log ...” 3. On July 14, 2025, the medical record of Patient 28 was reviewed, and the following was noted: There was a Physician order on June 19, 2025, for midazolam 1 mg to be given intravenously (into vein) every 5 minutes as needed for seizure; There was one dose of midazolam 1 mg intravenously (IV) administered on June 21, 2025, at 5:35 p.m. by RN 21; The progress note by the attending physician dated June 22, 2025, indicated: “62 yo (year-old)...presented to the hospital with seizure and admitted to the ICU overnight for acute hypoxic respiratory failure and septic shock (serious medical condition that could lead to organ failure) in the setting of witnessed aspiration event. CXR (chest x-ray) shows dense consolidation on right...”; and The progress note by the resident physician dated June 22, 2025, indicated: “...Patient evaluated at bedside, intubated and sedated...Code blue was called last night because patient was desatting (desaturating, drop in blood oxygen saturation level) to the 70s (in the 70s %) unammenable to HFNC (high-flow nasal cannula, breathing support technique to deliver oxygen)...” On July 15, 2025, at 2 p.m., during an interview, Pharmacist 4 stated Pharmacist 4 recommended to the physician to change the midazolam to add 1 mg every 5 minutes as needed thinking Patient 28 was still in ED (emergency department) on June 19, 2025. Pharmacist 4 stated midazolam could be used in PACU (Post-Acute Care Unit), ICU (Intensive Care Unit), and ED (Emergency Department), but not DOU or Telemetry Unit. Pharmacist 4 stated the electronic Health Record System (eHR) allowed the ED midazolam order to be administered to patients on the 3rd floor. All ED orders could carry through from the ED to the 3rd floor. During a concurrent interview, the DOP stated there was no way to prevent the use of midazolam in other non-critical units such as the 3rd floor units. The DOP stated it was not clear where the midazolam order came from on June 19 and that the guidance for Ativan shortage was not clear enough. On July 16, 2025, at 9:55 a.m., during an interview, Pharmacist 3 stated the pharmacists were instructed in emails about using the alternatives to Ativan (medication for anxiety and seizures) which was on nationwide shortage such as, diazepam (medication for anxiety) and Versed (brand name for midazolam, medication for sedation and anxiety). The pharmacists were instructed to confirm with the physicians for indication and recommend alternatives to Ativan if the indication was not for seizure. Pharmacist 3 stated midazolam was allowed to be used in DOU (Direct Observation Unit), Telemetry Unit, ICU, ED, and PACU, but not in M/S (Medical/Surgical) Unit. On July 16, 2025, at 2:20 p.m., during an interview, RN 21 stated the dose was given on the Third Floor Telemetry Unit by RN 21. On July 17, 2025, at 3:40 p.m., during an interview, the DOP stated previously approved list of medications that could be given via IV Push included midazolam but only in ICU and ED. The DOP stated midazolam was not allowed to be used on Telemetry Unit. On July 18, 2025, at 2 p.m., during a telephone interview, RN 21 stated midazolam 1 mg dose was given for anxiety. RN 21 stated there were two resident physicians and a pharmacist who all said it was ok to give midazolam as a substitute for Ativan. RN 21 stated the pharmacy informed the nurses to use midazolam due to nationwide shortage of Ativan. On July 14, 2025, at 10:15 a.m., during an interview, the DOP stated there was a shortage of injectable Ativan that had been ongoing for 2 to 3 months and the pharmacy was reserving the existing supply for seizures only. The DOP stated emails were sent out to CMO, Chief CMO, and CNO with suggested alternatives to Ativan. The DOP stated there needed to be monitoring of respiratory depression when using midazolam per nursing protocol, but the DOP was not aware how the monitoring needed to be done. The DOP stated on non-critical nursing units, the DOP did not expect midazolam IVP to be used. Review of the email sent to the hospital leadership dated June 4, 2025, indicated there would be temporary therapeutic interchange from lorazepam (generic name for Ativan) IM (intramuscularly, into deep muscle) to midazolam IM only in Unit E. Review of the email sent out to the Pharmacy Department by the DOP on May 21, 2025, indicated midazolam IV was the preferred alternative to Ativan only for procedural sedation use and not for seizures and anxiety. The hospital document titled, “IV Push List,” approved by P&T Committee, September 2018 was reviewed, and it indicated: “...Midazolam (brand name: Versed) requires cardiac and BP monitoring approved use in PACU, ICU/CCU, ER, and telemetry (with a footnote, during cardioversion only)...” The current hospital’s policy and procedure titled, “Intravenous Medications: IV push by a Registered Nurse,” last revised, February 2024, was reviewed, and it indicated midazolam was not included as a medication approved for IV Push administration on any patient care unit. It also indicated: “...Medications not included on this list will be administered according to manufacturer recommendations...” The manufacturer’s prescribing information for midazolam has a boxed warning (the strongest warning required by the Food and Drug Administration and alerts healthcare professionals and consumers to serious risks associated with a drug’s use) that indicated: “...Intravenous midazolam has been associated with respiratory depression and respiratory arrest, especially when used for sedation in noncritical care settings. In some cases, where this was not recognized promptly and treated effectively, death or hypoxic encephalopathy has resulted...””

“PHARMACIST SUPERVISION OF SERVICES CFR(s): 482.25(b)(1) §482.25(b)(1) - All compounding, packaging, and dispensing of drugs and biologicals must be under the supervision of a pharmacist and performed consistent with State and Federal laws. This Standard is not met as evidenced by: 49613 Based on observation, interview, and record review, the facility failed to maintain a sterile compounding environment and compounding documentation consistent with professional standards of practice and facility policies, when: 1. The facility failed to maintain a clean environment in the sterile compounding room; 2. The facility failed to maintain daily records of cleaning the sterile compounding room; 3. The facility failed to label compounded medications; and 4. The facility failed to maintain complete compounding records for compounded medications. These failures had the potential for compounded sterile preparations to fail to meet required quality standards. Findings: 1. During a concurrent observation and interview on July 17, 2025 at 11:05 a.m. with Pharmacy Technician 1 (PT 1), the pharmacy intravenous (IV, into the vein) sterile compounding room tour (IV Room) was conducted. The following observations were noted in the IV Room shelving: - White residue covering one-third of the bottom surface in an empty plastic tote labeled for injectable sterile water; - Six-inch long dark hair in the tote of pantoprazole (generic for Protonix, a heartburn medication) IV vials; - White dust and half-inch square white sticker residue on the bottom of the tote of sodium bicarbonate (an electrolyte) IV vials; - Gray dust and debris in the tote of Vabomere (brand name for meropenem-vaborbactam, an antibiotic) IV vials; - Gray dust in the tote of valproate (medication for seizures) 500 milligram (mg) IV vials; - Gray dust in the tote of vancomycin (an antibiotic) 5 gram (gm) IV vials; - Red-brown specks and residue in the tote for meropenem (an antibiotic) 1 gm IV vials; - Red-brown residue in the tote of meropenem 500 mg IV vials; - White dust, white specks, and white fuzz visible on brown light protective bag in the tote of ceftriaxone (an antibiotic) 1 gm IV vials; and - Additional totes also contained gray dust and white specks. There was gray dust and white specks on the white surface of the bottom shelf and on top of the shelving unit’s wheel casters. PT 1 stated the totes and shelves were “dusty.” PT 1 further stated no one was cleaning the inside of the totes. During a continued concurrent observation and interview on July 17, 2025 at 11:34 a.m., in the IV Room with PT 1, the floor inside the segregated compounding area (SCA, designated area within the IV room where sterile compounding is performed) was observed. PT 1 stated the floors did not look clean and stated the floor looked “sticky” with white residue. PT 1 verified the lids and side of the blue pharmaceutical waste and the red sharps biohazard waste bins had visible white residue. During a continued concurrent observation and interview on July 17, 2025 at 11:55 a.m., in the IV Room with PT 1, the IV Room refrigerator was observed. The outside of the refrigerator had two black environmental monitoring boxes attached to the side. The top surfaces of the boxes had a layer of white specks and particles. PT 1 confirmed the surveyor’s gloved finger was covered in visible white particles after wiping the top of the boxes. PT 1 stated the surfaces were dusty. During an interview on July 17, 2025 at 3:40 p.m., the Director of Pharmacy (DOP) agreed the photographs of the IV Room taken that day showed the IV Room floors and shelving were “not clean.” The DOP stated pharmacy technicians were responsible for cleaning the shelves and totes in the IV Room. The DOP stated the IV Room floors were supposed to be cleaned daily by the EVS (environmental services) staff. The DOP stated the expectation is for the IV Room to be clean. A review of the “EVS - IV Room CLEANING LOG,” dated July 2025, indicated daily cleaning tasks included “Clean floors,” “Empty trash & bio waste,” and “Clean and reline trash bins.” A review of the facility’s policies and procedures (P&P) titled, “Sterile Preparation and Handling,” dated June 2024, indicated: “EVS personal [sic]...Weekly cleaning...include...trash cans, red/blue bins and stands...” and “...Pharmacy technician shall decontaminate all drug, syringe and needle bins, shelving and carts within the IV room weekly...” 2. During a concurrent interview and record review on July 17, 2025 at 3:40 p.m. with the DOP, the “EVS - IV Room CLEANING LOG,” dated July 2025, was reviewed. The DOP acknowledged that daily cleaning was not documented for six of 16 days in July 2025 - July 4, 5, 12, 13, 14, and 15. The DOP stated the IV Room floors were supposed to be cleaned daily by the EVS staff. The DOP stated missing entries indicated the IV Room was not cleaned on those days. A review of the facility’s P&P titled, “Sterile Preparation and Handling,” dated June 2024, indicated: “...Daily cleaning for EVS includes counter, sink, stool and floor and documentation to be provided on cleaning log...” and “...EVS personnel will record cleaning activities on the Cleaning Log...” 3. During a concurrent observation and interview on July 17, 2025 at 11:48 a.m., with PT 1, medications stored in the IV Room shelving were reviewed. The following compounded sterile preparations (CSP, medications prepared by the pharmacy in a sterile environment) were noted: - Two unlabeled mini-bags (common name for IV medication vial attached by pharmacy to a bag of sterile IV fluid for a nurse to activate before medication administration) of ampicillin-sulbactam (generic for Unasyn, IV antibiotic) 3 gm with 100 milliliters (ml) of normal saline (NS, IV salt water); - One unlabeled mini-bag of vancomycin 1.5 gm with 500 ml NS; - One unlabeled mini-bag of methylprednisolone (an injectable steroid) with 250 ml NS; - Two unlabeled mini-bags of piperacillin-tazobactam (generic for Zosyn, IV antibiotic) 3.375 gm with 50 ml of 5% dextrose (D5, IV sugar water); and - One unlabeled mini-bag of meropenem 500 mg with 100 ml NS PT 1 verified that the CSP sticker labels had been removed before storage in the IV Room. During an interview on July 17, 2025 at 2:34 p.m. with the DOP and PT 2, the DOP stated unused CSP could be returned to the pharmacy and used for a different patient. PT 2 stated the patient label was removed and the CSP was added to the pharmacy stock after returned. During an interview on July 17, 2025 at 3:40 p.m., the DOP stated the mini-bags found in the IV room were not labeled according to the facility’s policy. The DOP also acknowledged the mini-bags were not labeled with an assigned reference number. A review of the facility’s P&P titled, “Labeling, Pharmaceutical,” dated June 2024, indicated: “...The Department of Pharmacy will implement and monitor guidelines on the proper labeling of all sterile and inhalational products prepared by both pharmacy and non-pharmacy personnel...” A review of the facility’s P&P titled, “Sterile Preparation and Handling,” dated June 2024, indicated: “...Sterile products shall be labeled with at least the following information...Patient’s name, location, account number...All solution and ingredient names, amounts, strength and concentrations...Identification (e.g. initials) of the responsible pharmacist and technician...” and “...Labels shall be legible and affixed to the final container...” and “REFERENCES ...USP Chapter <797> [professional standards for sterile compounding]...” A review of USP Chapter 797 “Pharmaceutical Compounding - Sterile Preparations,” dated November 1, 2023, indicated: “...The label on each immediate container of the CSP must, at a minimum, display prominently and legibly the following information...Assigned internal identification number...Active ingredient(s) and their amount(s)...” 4. During a medication pass observation on July 15, 2025, at 8:24 a.m., Registered Nurse (RN) 22 was observed administering IV fentanyl (a narcotic pain medication) 500 micrograms (mcg, a unit of measurement) in 100 ml NS for Patient 43. The IV bag was labeled with a beyond use date (BUD) of July 15, 2025 at 2:30 p.m. and a sticker “Compounded by this pharmacy.” During a concurrent interview and record review on July 17, 2025 at 2:42 p.m., with Pharmacist 2, the compounding log for Patient 43’s fentanyl, administered during the medication pass observation on July 15, 2025 at 8:24 a.m., was requested. Pharmacist 2 stated fentanyl bags were not compounded for specific patients. Pharmacist 2 then stated fentanyl bags had a BUD of 12 hours after compounding, so the bag was compounded around 2 a.m. on July 15, 2025. A “Standard Compounding Record” for ten IV bags of fentanyl 500 mcg solution, prepared July 15, 2025 at 2:06 a.m., was reviewed. Pharmacist 2 verified Patient 43’s fentanyl bag and compounding log did not have an assigned reference number to link them. Pharmacist 2 acknowledged the compounding log did not include a BUD. Pharmacist 2 stated the BUD was supposed to be on the compounding log. During a concurrent interview and record review on July 17, 2025 at 3:54 p.m. with the DOP, the “Standard Compounding Record” for ten IV bags of fentanyl 500 mcg solution, prepared July 15, 2025 at 2:06 a.m., was reviewed. The DOP acknowledged the compounding log did not include any information about the IV diluent (type of IV solution used to dilute IV medications for safe administration). The DOP stated the IV diluent information was supposed to be on the compounding log to show the identity and quantity of the solution used. The DOP stated the compounding log should also have an assigned reference number for the compounded preparations. A review of the facility’s P&P titled, “Sterile Preparation and Handling,” dated June 2024, indicated: “...I.V. Compounding Log - Record keeping of CSPs is done on the IV compounding log. The record shall include...Name and strength of the compounded preparation...The quantity of each component used in compounding...The manufacturer, expiration date and lot number of each component...The pharmacy assigned reference number or lot number for the final CSP...The beyond use date of the CSP...””

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 25281 Based on observation, interview, and record review, the facility failed to implement safe and effective systems for medication storage when: 1. The pharmacy and four of seven toured hospital units had expired and unusable medications available for use; and 2. Two of seven toured hospital units had unlabeled opened medication multiple dose vials (MDV) available for use in patient care areas. These failures had the potential to expose patients to contaminated or ineffective medications. Findings: 1a. During a concurrent observation and interview on July 17, 2025 at 11:49 a.m. with Pharmacy Technician 1 (PT 1), the pharmacy intravenous (IV, into the vein) compounding room tour (IV Room) was conducted. The IV Room shelving contained the following: - One IV vial of ampicillin-sulbactam (generic for Unasyn, IV antibiotic) 1.5 gram (gm, unit of measurement) with white crusted residue on the label and the glass surface; - One mini-bag (common name for IV medication vial attached by pharmacy to a bag of sterile IV fluid for nurse to activate before medication administration) of meropenem (IV antibiotic) 500 milligrams (mg) with 100 milliliters (ml) of normal saline (NS, IV salt water) with red-brown residue on the vial label and glass surface; - Two IV vials of meropenem with red-brown residue on the vial top and glass surface; and - One activated mini-bag (IV fluid mixed with the medication powder) of piperacillin-tazobactam (generic for Zosyn, IV antibiotic) 3.375 gm in 50 ml of 5% dextrose (D5, IV sugar water). PT 1 stated mini-bags expired a few hours after activation so activated mini-bags were not supposed to be kept in stock. PT 1 stated the items should not be in the pharmacy stock and needed to be discarded. During a concurrent observation and interview on July 17, 2025 at 11:55 a.m. with PT 1, the IV Room tour continued. The IV Room medication refrigerator contained one vial of tuberculin purified protein derivative (TB PPD, an injection to test for tuberculosis, a disease of the lungs that can make you cough mucus) multiple dose vial (MDV) with a sticker indicating “6/27.” PT 1 stated she did not know if the labeled date was when the TB PPD vial was opened or the beyond use date (BUD, expiration date). PT 1 stated pharmacy labeling of MDV was not consistent and the TB PPD vial needed to be discarded. The IV Room medication refrigerator also contained over 50 boxes of Evusheld (brand name for tixagevimab, an experimental COVID-19 medication) expired August 2022. PT 1 stated pharmacy staff were told to leave the expired Evusheld in the refrigerator. PT 1 acknowledged the pharmacy stored Evusheld on a shelf with medication available for patient use. During an interview on July 17, 2025 at 2:34 p.m., the Director of Pharmacy (DOP) stated mini-bags that were not activated were considered usable for patients. During an interview on July 17, 2025 at 3:54 p.m., the DOP acknowledged the expired medications stored in the IV Room refrigerator. The DOP agreed expired medications should not be in the IV Room medication refrigerator. A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for TB PPD injection, dated 8/20/24, retrieved from DailyMed, indicated: “...Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency...” A review of the facility’s policies and procedures (P&P) titled, “Sterile Preparation and Handling,” dated June 2024, indicated: “...Products that have exceeded their expiration dates shall be removed from active storage areas and placed in designated containers for expired medications...” 1b. During a concurrent observation and interview on July 21, 2025 at 10:43 a.m. with Pharmacist 1, the chemical dependency unit (CDU) medication room tour was conducted. The medication fridge contained the following: - One partial box of Fluarix (flu vaccine), expired June 30, 2025; - One 1 ml vial of sterile water, expired July 2024; and - One opened vial of insulin lispro (injection to treat high blood sugar), expired July 16, 2025. Pharmacist 1 stated expired medications should not be in the medication fridge. During a concurrent observation and interview on July 21, 2025 at 11:00 a.m. with Pharmacist 1, the CDU medication room tour continued. There were two opened vials of Accu-Chek glucometer (brand name for a machine to check blood sugar) control solution (liquid to calibrate the glucometer) on the counter. The vials were labeled “Discard 3 months after opening or after Expiration date on label” with no date indicated. Pharmacist 1 verified the vials were not labeled. During an interview on July 21, 2025 at 11:03 a.m., Clinical Nurse Manager 2 (CNM 2) verified the glucometer control solution vials should be labeled and the vials should be treated as expired. 1c. During a concurrent observation and interview on July 21, 2025 at 11:36 a.m. with Pharmacist 1, the direct observation unit (DOU, patient care unit) medicine room tour was conducted. There was one vial of Accu-Check control solution on the counter labeled “Date Opened 1/16/25.” Pharmacist 1 stated the control solution vials expired three months after the date opened. Pharmacist 1 stated the vial was expired. There was one opened 10 ml vial of sterile water for injection on the counter. The label indicated “Single-dose.” Pharmacist 1 stated the sterile water vials are single use only and should not be reused. Pharmacist 1 stated the vial needed to be discarded. 1d. On July 17, 2025, at 2:24 p.m., during a tour of the pharmacy, it was noted there were, on the pharmacy shelf, two 200-ml bags of 20% mannitol (medication to reduce pressure inside the skull and eyes) labeled with a sticker that indicated: “Do not use after 7/7/25.” In a concurrent interview, the Pharmacy Technician Supervisor (PTS) stated the bags had been stored in the warmer and the sticker indicated the date after which the bags should be discarded. The PTS stated the bags should have been removed from the pharmacy shelf. 1e. On July 21, 2025, at 10:30 a.m., during a tour of ICU A Medication Room, there was an open single dose vial of diltiazem (medication to lower blood pressure) 25 mg/5 ml on the shelf. 1f. On July 21, 2025, at 11:50 a.m., during a tour of the ED (Emergency Department) RME Unit, there were one open single dose vial of lidocaine (numbing agent) 1% 5 ml and three open single dose vials of sterile water for injection 10 ml in the IV (intravenous) Cart. In a concurrent interview, RN 23 stated all used single dose vials should have been thrown away. On July 21, 2025, at 3:30 p.m., during an interview, the DOP stated all single dose vials should be thrown away after use. A review of the facility’s P&P titled, “Single-Dose vs. Multi-Dose Vial,” dated May 2024, indicated: “...Single-dose vials/ampules are for immediate use only and once opened must not be stored for any time period ...Single-dose vials must be discarded immediately after use...” and “...Use a single-dose/single-use vial for a single patient...Do not re-puncture the vial...Discard the vial after the single use...Used vials should never be returned to stock on clinical units...” and “...Do not store used single-dose/single-use vials for later use no matter what the size of the vial...” The hospital’s policy and procedure titled, “Medication Storage and Labeling,” last approved, May 2024, was reviewed, and it indicated: “...All outdated medications are removed from medication storage areas and disposed per pharmacy policy and procedure...” The hospital’s policy and procedure titled, “Storage of Medications,” last approved, September 2023, was reviewed, and it indicated: “...Pharmacists shall periodically inspect all medication storage areas to assure the proper storage of all pharmaceuticals...Inspections shall focus on...removal of expired and other unusable medications and devices...” 2a. On July 21, 2025, at 10:30 a.m., during a tour of ICU A Medication Room, there was one open 50-ml multi-dose vial of Marcaine 0.25% with Epinephrine 1:200000 (numbing agent used in specific area of the body during procedure) with an open date on the vial. 2b. On July 21, 2025, at 11:50 a.m., during a tour of the ED (Emergency Department) RME Unit, there was one 20-ml open multi-dose vial of lidocaine 1% 200 mg/20 ml without an open date on the vial. On July 21, 2025, at 11:50 a.m., during an interview, RN 23 stated the multi-dose vials should have been dated. On July 21, 2025, at 3:30 p.m., during an interview, the DOP stated all multi-dose vials should be dated. A review of the facility’s P&P titled, “Single-Dose vs. Multi-Dose Vial,” dated May 2024, indicated: “...Once a multiple-dose vial is punctured, it should be assigned a “beyond-use” date. The beyond-use date for an opened or entered...multiple-dose container with antimicrobial preservatives is 28 days...All vials should be dated with 28-days expiration and initialed when opened or taken from the refrigerator...””

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 47071 Based on observation and interview, the facility failed to ensure a sanitary environment was maintained, when: 1. Flies were observed throughout the facility; 2. Maggots (a soft-bodied legless immature form of a fly) were observed in the nasal (nose) cavity and in the specimen cup in the patient’s room which were suctioned from the patient’s nares (nose), for one of 55 sample patient (Patient 27); 3. Maggots in the oral (mouth) or nasal cavities were observed in four of 55 sample patients (Patients 31, 32, 33, and 34); and 4. Multiple areas of the hospital were observed to have gaps around doors and windows. These failures had the potential to cause infection and prolonged hospitalizations to Patients 27, 31, 32, 33, and 34. Findings: 1. On July 14, 2025, at 11:41 a.m., during a tour of Unit C conducted with the Deputy Regional Director of Quality (DRDQ) and the Patient Safety Coordinator (PSC), multiple dead flies, earwigs (dark red-brown crawling bugs), and black and yellow winged organisms were observed in Unit C. On July 14, 2025, at 11:40 a.m., during a tour of Unit C and Unit GC conducted with the DRDQ and the PSC, flies were observed on the celling of Unit GC. On July 14, 2025, at 11:45 a.m., an interview was conducted with the DRDQ. The DRDQ stated there should not be flies and other bugs in the facility. The DRDQ stated flies in the building put the patients at risk. On July 14, 2025, at 10:30 a.m., during a tour of Zone 1 located outside of the building, flies were observed flying around the trash compactor (large machine for crushing trash) and grease bin (bin for holding used cooking grease). 2a. On July 21, 2025, at 12 p.m., Patient 27’s record was reviewed with PSC. A facility document titled, “History and Physical (H&P),” dated July 8, 2025, was reviewed. The document indicated Patient 27 came to the Emergency Department [ED] with altered level of consciousness and was admitted to the facility. A facility document titled, “Emergency Department Record,” dated July 8, 2025, at 11:44 p.m., was reviewed. The document indicated Patient 27 was intubated on July 8, 2025, at 11:50 p.m. An undated facility document titled, “Room and Bed,” was reviewed. The document indicated Patient 27 was in the Emergency Department holding (area in the ED where patients are temporarily placed while waiting for a bed to be admitted to the facility) for seven days from July 9, 2025, to July 16, 2025. The document indicated Patient 27 was in in the following rooms on the following dates and times: - In ED holding (EDH) A on July 9, 2025, at 2:42 a.m.; - In EDH B on July 14, 2025, at 12:59 p.m.; and - In Intensive Care Unit (ICU, unit for critically ill patients) Room A on July 16, 2025, at 12:51 a.m. On July 16, 2025, at 9:21 a.m., a tour of the Unit B was conducted with the DRDQ and Registered Nurse (RN) 11. Patient 27 was observed to be on his back in his bed and was intubated (a flexible tube was inserted in the airway to help the patient breath). During a concurrent interview, RN 11 stated, on the night shift (7 p.m. to 7 a.m. shift) of July 15, 2025, the RN providing care to Patient 27 noticed blood in Patient 27’s nose and upon the RN’s assessment, maggots were found in Patient 27’s nose. RN 11 further stated the night shift RN noticed there was a fly in Patient 27’s room. On July 16, 2025, at 9:22 a.m., an observation of Patient 27’s room was conducted with RN 11. A clear cup with a blue lid on top was observed on the sink in Patient 27’s room.. The cup was observed filled with a clear liquid, with many little white organisms observed wiggling in the cup. During a concurrent interview, RN 11 stated the little white organisms were the maggots which were suctioned out of the Patient 27’s nose. RN 11 stated she will send the maggots to the laboratory (lab). On July 16, 2025, at 9:06 a.m., a facility document titled, “Self-report,” dated July 16, 2025, at 10:45 a.m., was reviewed with the DRDQ. The document indicated Patient 27 was identified to have maggots in the nasal cavity (nose). On July 21, 2025, at 12:05 p.m., an untitled facility document, dated July 17, 2025, was reviewed with the PSC. The document indicated the maggots removed from Patient 27’s nose were sent to the lab. 3a. On July 21, 2025, at 12:10 p.m., Patient 31’s record was reviewed with PSC. A facility document titled, “H&P,” dated June 29, 2025, at 12:14 a.m., was reviewed. The document indicated Patient 31 was unresponsive and was admitted to the facility on June 29, 2025. A facility document titled, “Emergency Department Record,” dated June 29, 2025, was reviewed. The document indicated Patient 31 was intubated in the ED on June 29, 2025. An undated facility document titled, “Room and Bed,” was reviewed. The document indicated Patient 31 was in the Emergency Department holding for 17 days from June 29, 2025, to July 15, 2025. The document indicated Patient 31 was in in the following rooms on the following dates and times: - In EDH C holding on June 29, 2025, at 10:40 p.m.; - In EDH D holding on June 30, 2025, at 10:40 a.m.; and - In ICU Room B on July 15, 2025, at 4:30 a.m. An untitled facility document, dated June 30, 2025, was reviewed. The document indicated the maggots removed from Patient 31’s nose were sent to the lab. b. On July 21, 2025, at 12:15 p.m., Patient 32’s record was reviewed with PSC. A facility document titled, “H&P,” dated June 13, 2025, at 9:24 p.m., was reviewed. The document indicated Patient 32 was admitted to the facility for generalized weakness. The document indicated Patient 32 had a history of chronic obstructive pulmonary disease (COPD, a group of lung diseases which cause long-term breathing problems), liver cirrhosis (condition when the liver tissue is replaced by scar tissue disrupting its normal function), and pancreatitis (swelling of the pancreas). An undated facility document titled, “Room and Bed,” was reviewed. The document indicated Patient 32 was in the Emergency Department holding for 17 days from June 13, 2025, to June 20, 2025. The document indicated Patient 32 was in in the following rooms on the following dates and times: -In ED04H holding on June 13, 2025, at 9:56 p.m.; -In ED012H holding on June 13, 2025, at 10:39 p.m.; -In 2T4 ED4-F2 holding on June 16, 2025, at 1:44 p.m.; - In 2T6T ED6D holding on June 16, 2025, at 4:34 p.m.; - In 2T6T 621-B on June 20, 2025, at 1:39 p.m.; and -In ICUA 155 on July 15, 2025, at 1:19 a.m. A facility document titled, “Progress Note,” dated June 21, 2025, at 3:19 p.m., was reviewed. The document indicated Patient 32 was intubated on June 21, 2025. c. On July 21, 2025, at 12:25 p.m., Patient 33’s record was reviewed with PSC. A facility document titled, “H&P” dated May 12, 2025, at 7:08 p.m., was reviewed. The document indicated Patient 33 was admitted to the facility for altered level of consciousness (a person’s awareness and responsiveness to their environment is different from their normal state) and hypernatremia (high levels of salt in the blood). An undated facility document titled, “Room and Bed,” was reviewed. The document indicated the Patient 33 was in the Emergency Department holding for four days from May 12, 2025, to May 15, 2025. The document indicated Patient 33was in in the following rooms on the following dates and times: -In ED04H (holding) on May 12, 2025, at 2:09 p.m.; -In 2T2T 619 on May 15, 2025, at 3:18 p.m.; and -In ICUB 161 on July 21, 2025, at 2:40 a.m. An untitled facility document, dated May 19, 2025, was reviewed. The document indicated the patient was intubated on May 19, 2025. d. On July 21, 2025, at 12:35 p.m., Patient 34’s record was reviewed with PSC. An untitled facility document, dated July 17, 2025, was reviewed. The document indicated the maggots removed from Patient 34’s nose were sent to the lab. A facility document titled, “H&P,” dated July 2, 2025, at 12:06 a.m., was reviewed. The document indicated Patient 34 was admitted for altered level of consciousness, weakness, and hypotension (low blood pressure). An undated facility document titled, “Room and Bed,” was reviewed. The document indicated the Patient 34 was in the Emergency Department holding for 10 days from July 2, 2025, to July 13, 2025. The document indicated Patient 34 was in in the following rooms on the following dates and times: -In ED19H (holding) on July 2, 2025, at 4:47 p.m.; -In ED4F (holding) on July 3, 2025, at 12:23 p.m.; -In 2T6T 624 on July 13, 2025, at 5:10 a.m.; and -In ICUB 160 on July 18, 2025, at 5:52 p.m. e. On July 21, 2025, at 12:35 p.m., Patient 35’s record was reviewed with PSC. An undated facility document titled, “H&P,” dated June 24, 2025, at 12:37 a.m., was reviewed. The document indicated Patient 35 came to the Emergency Room post [after] fall at home. Patient 35 has a history of chronic obstructive pulmonary disease [a progressive lung disease which makes it hard to breathe]. An undated facility document titled, “Progress Note,” was reviewed with the PSC. The document indicated Patient 35 was intubated on June 24, 2025, at 2:46 a.m. An undated facility document titled, “Room and Bed,” was reviewed with the PSC. The document indicated Patient 35 was in the Emergency Department holding for 20 days from June 23, 2025, to July 14, 2025. The document indicated Patient 35 was in in the following rooms on the following dates and times: -In ED01H (holding) on June 23, 2025, at 10:08 p.m.; -In 2T4 ED4F (holding) on June 23, 2025, at 2:04 p.m.; -In ICUA EDH on June 24, 2025, at 11:52 a.m.; and -In ICUA 158 on July 14, 2025, at 4:48 p.m. An untitled facility document, dated July 17, 2025, was reviewed with the PSC. The document indicated the maggots removed from Patient 35’s nose were sent to the lab. A facility document titled, “Self-report,” dated July 3, 2025, at 1:54 p.m., was reviewed with the DRDQ. The document indicated Patients 27, 31, 32, 33, and 35 were identified to have maggots in their nasal cavity. 4. On July 14, 2025, at 10:15 a.m., a tour of the loading dock area (area in the back for receiving supplies) was conducted with the DRDQ and the PSC. During the tour, the following areas were observed to have flies: - Loading dock; - Trash compactor (machine used to crush the trash) area; and - Around the grease bin (a bin for the collection of used cooking grease). On July 14, 2025, at 11:41 a.m., during a tour of Units C and GC conducted with the DRDQ and the PSC, gaps around the windows and doors were observed in the following areas: - On one of the four windows, around the window in Room C in Unit C; - On one of the two doors, on the left side of the opening in the exit door in GC; and - On an outside window in the Critical Care Unit (CCU, a unit for patients needing close monitoring and intensive medical care) Room A. On July 14, 2025, at 11:45 a.m., an interview was conducted with the DRDQ. The DRDQ stated the windows should not have gaps to the outside. The DRDQ stated the gaps possibly allow bugs to crawl in through the windows. On July 16, 2025, at 9:56 a.m., an interview was conducted with the Corporate Quality Officer (CQO). The CQO stated the Unit GC exit doors should not have any gaps in the door. The CQO stated the gaps will allow flies and other bugs to get in the building. On July 16, 2025, at 2:15 p.m., the survey team identified significant concerns with the maintenance of a sanitary environment at the facility. Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation which had the potential to cause harm to the health and safety of the patients) was called in the presence of the facility’s Chief Executive Officer (CEO), Corporate Chief Medical Officer (CCMO), Chief Medical Officer (CMO), Corporate Quality Officer (CQO), Chief Nursing Officer (CNO), and Deputy Regional Director of Quality (DRDQ). They were notified Patient 27 was observed to have maggots (a soft-bodied legless immature form of a fly) in the nasal cavity (inside the nostril), maggots were observed inside a specimen cup in the room of Patient 27 which were suctioned from Patient 27’s nares, and four additional patients (Patients 31, 32, 33, and 34) were confirmed to have maggots in their oral (mouth) or nasal cavities. There were gaps observed in one of two doors and one of four windows in the facility. A gap was observed in an outside window in the Critical Care Unit (CCU, a unit for patients needing close monitoring and intensive medical care) Room A. A visible gap was observed along the bottom and center of the door and on top of the left side of the door in the lobby near the visitors’ cafeteria. The intensive care unit (ICU, unit for patients with serious life-threatening illness or injuries) is located on the first floor with its doors opening to the hall that is near the main entrance doors and the loading dock (area located in the back of the building designed for the transfer of goods from building to trucks), doors. Trash was observed scattered outside the loading doors, around the trash compactor, in the loading areas (area located at the back of the building where the loading docks are located), and the grease collection bin (a sturdy bin to keep and secure used grease from the kitchen). Flies were observed in the outside entrance of the main lobby, inside the main lobby, at the loading dock entrance, and at the lobby near the visitors’ cafeteria. In the CCU, multiple dead flies, earwigs (dark red-brown crawling bugs), and black and yellow winged organisms were observed. On July 17, 2025, at 3:57 p.m., the CQO provided a removal plan (RP). The RP was reviewed and indicated, “...Immediately upon being notified of the IJ, members of the Governing Board and the Medical Executive Committee (MEC) were notified of the findings by the CEO via an electronic memo...The facility identified all patients impacted/likely to be impacted by the deficiency. By 7/17/25 [July 17, 2025], all ventilated [requiring mechanical assistance to breathe] patients will be assessed for the presence of myiasis [infestation of fly larvae/maggots on or in human tissue] by their primary nurses. Any identified issues will be addressed immediately. All ventilated patients, regardless of their location, will be assessed each shift for the presence of nasal or oral maggots and provided with oral/nasal care. Notification of the presence of maggots will be done by the RN (registered nurse) as soon as possible after discovery no later than end of shift...As soon as the facility was informed of the issuance of an IJ, the leadership team met and started developing and implementing this Removal Plan...The facility created a detailed education for nursing staff in ICU, ED [Emergency Department, unit for patients with emergent illness or injuries], DOU [Definitive Observation Unit, unit for specialized care for patients who require more monitoring than in a regular hospital room) and all RT [Respiratory Therapist, healthcare professional specializing in the care of breathing disorders] on Myiasis to include prevention, treatment, recognition and identification. Staff education started on 7/16/25 [July 16, 2025], and will continue until 100% of staff are educated. The education also emphasized the importance of oral care for ventilated patients. Education will be done by the next scheduled shift for nurses not scheduled today. On 7/16/25, the facility contacted the vendor for pest control to devise a plan for flies’ control and to advise the facility on any additional actions to mitigate the risk. On 7/16/25, the vendor provided the facility with a flies treatment plan to include the following: 1 [one] time purchase 6ft [six feet, unit of measurement] [name of brand of air curtain (a machine which blows air over an opening, like a doorway, to prevent the exchange of air, insects, dust, and other particles in the air between different spaces, such as inside and outside a building) approved air curtain (back receiving doors)...1 time purchase 7 [seven] ft [brand of air curtain] approved air curtain (front Lobby)...one time purchase plastic curtains and installation (back receiving [area for receiving supplies]), 1 time per month [name of fly treatment] flies’ [sic] treatment [a form of pest control] @ [at] two flies bait [a device which attract flies with a bait and then killing them when they consume the bait] stations service back area...1 time install flies light [an electronic insect trap which uses light to attract insects] front lobby...service monthly...On 7/16/2025, the COO, CNO, CMO, and the quality team met with the facilities staff to round facility wide and evaluate any structural gaps in doors or windows. By 7/16/25, the facility initiated the process of sealing any structural gaps including windows and door gaps. By 7/17/25 [July 17, 2025], any identified gaps will be sealed. On 7/16/25, the leadership team rounded on the trash collection areas to ensure trash is sealed, and any attractants or trash are promptly removed. Garbage collection areas both inside and outside the facility were cleaned. Trash bins in close proximity to the building were relocated further away (when possible). The EVS [Environmental Services] Director reviewed the trash removal schedule and found it adequate, however [sic] trash in ICU, DOU and ED will be collected at least twice a day. Trash collection areas both inside and outside will be cleaned at least once a day and as needed if trash is noticed. The EVS Director/ designee will round at least twice a day to ensure cleanliness. The cleaning scheduled [sic] will be modified as needed...On 7/16/25, the CEO sent a facility wide communication on flies’ control and how to report any sighting [of flies]. The communication was sent via email. Staff were encouraged to limit use of doors leading to the outside and to use the main entrance...The Facilities staff examined all existing air curtains to ensure they are functional. Any curtains requiring adjustment of flow or change from intermittent to continues [sic, continuous], if possible, were adjusted...The COO approved additional labor and personnel to facilitate the prompt repair and sealing of any structural gaps...On 7/17/25, the facility-initiated education for EVS Staff on flies control and trash management. The education will continue until 100% compliance is achieved. The staff not scheduled today will be educated by their next scheduled shift...The facility will continue to monitor the flies’ [sic] traps weekly, and the UV [Ultra violet, a type of light] light traps to detect trends, outbreaks and efficiency of treatments...The facility will continue to monitor high risk areas such as ICU, ORs [operating rooms], Kitchen, cafeteria, loading docks and waste handling zones for flies’ [sic] presence or increased activity...The facilities team initiated a comprehensive inspection of the ventilation system [a mechanism which provides fresh air to a space while removing stale or contaminated air] in the ICU, DOU and the ED...The facility will initiate daily rounds on all UV lights, curtains, and zappers [an electronic device used for killing insects] to ensure they are functional. Any issues will be reported immediately, and the vendor will be contacted...The CEO will continue to update the MEC, medical staff members, on the progress with the implementation of this Removal Plan...” On July 17, 2025, at 4:10 p.m., the Chief Executive Officer (CEO), Corporate Chief Medical Officer (CCMO), Chief Medical Officer (CMO), Corporate Quality Officer (CQO), Chief Nursing Officer (CNO), and Deputy Regional Director of Quality (DRDQ) was notified the RP was found to be acceptable. On July 21, 2025, at 3:15 p.m., through observations, interviews, and record review, the Removal Plan was verified onsite to have been fully implemented. On July 21, 2025, at, 5:02 p.m., the IJ was removed in the presence of the Chief Executive Officer (CEO), Corporate Chief Medical Officer (CCMO), Chief Medical Officer (CMO), Corporate Quality Officer (CQO), Chief Nursing Officer (CNO), and Deputy Regional Director of Quality (DRDQ).”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 47071 Based on observation, interview, and record review, the facility failed to ensure a functional and sanitary environment was maintained, when: 1. Five corrugated boxes containing medical supplies were observed on the floor of Zone 1 doorway; 2. Three corrugated boxes observed filled with copy paper and stacked on top of each other and two clear bags observed filled with admission kits (patient care items given to the patient upon admission) was observed on the floor of one of five supply rooms (SR 1); and 3. One of one pharmaceutical (pertaining to medications)/sharps (containers for disposals of needles and other sharp items) waste bins in the Intensive Care Unit (ICU, a specialized unit which provides monitoring for patients with life-threatening conditions) and one of one pharmaceutical/sharps waste bins in the Medical Surgical unit (M/S, general nursing unit which provides care for patients with a wide range of medical and surgical conditions) were observed to be overfilled. These failures could result in an increased risk for infection and patient safety. Findings: 1. On July 14, 2025, at 10:21 a.m., during a tour of Zone 1 conducted with the Deputy Regional Director of Quality (DRDQ) and the Patient Safety Coordinator (PSC), five corrugated boxes containing medical supplies were observed on the floor, two corrugated boxes were observed on the floor by the exit, and three corrugated boxes were observed down the hall leading to the exit. On July 14, 2025, at 10:42 a.m., an interview was conducted with the PSC. The PSC stated the corrugated boxes should not be stored on the floor. 2. On July 14, 2025, at 2:45 p.m., a tour of Unit D was conducted with the DRDQ, the PSC, and the Nurse Supervisor (NSRN). During the tour of Storage Room (SR) 1, three office paper corrugated shipping boxes and two clear bags full of hospital admission kits each containing a water pitcher, a box of tissues, an emesis basin (a medical device used to collect bodily fluids and other medical waste), and a wash basin (a rectangular bin for washing/cleaning of patients) were observed on the floor of SR 1. On July 14, 2025, at 3:22 p.m., an interview was conducted with the NRSN. The NSRN stated the boxes and supplies observed in SR 1 should not be on the floor. The NSRN stated supplies observed on the floor in SR 1 should be put away and not left on the floor of the supply room. On July 14, 2025, at 3:23 p.m., an interview was conducted with the Chief Medical Officer (CMO). The CMO stated the corrugated boxes should not be stored directly on the floor. The CMO further stated the bags of patient care supplies should not be on the floor as well. The CMO stated the supplies in the corrugated boxes should be put away on the shelves. A facility policy and procedure (P&P) titled, “Material Resource Management,” dated May 2024, was reviewed. The policy indicated, “...All supply items are to be stored...no lower than six inches from the floor...No supply items are to be stored directly on the floor...” 3. On July 14, 2025, at 1:40 p.m., a tour of the ICU was conducted with the DRDQ and the NSRN. During the tour of Room D, the red sharps container mounted on the wall in the room was observed to be filled past the three-quarters line. Multiple syringes and vials were observed sticking up from the red sharps container past the fill line [equals three-quarters full]. On July 14, 2025, at 2 p.m., an interview was conducted with the NSRN. The NSRN stated the sharps container is to be emptied when the contents reach the fill line or when it is three-quarters filled. The NSRN stated the sharps container should have been emptied. On July 14, 2025, at 2:45 p.m., a tour of the Medical/Surgical unit (M/S, unit for patients various conditions not necessitating close monitoring) was conducted with the DRDQ and the NSRN. During the tour of the mediation room of the M/S unit, the sharps container was observed to be filled past the fill line and the black bin with white lid (a bin regulated by Resource Conservation and Recovery Act [a federal law which governs the disposal of solid and hazardous waste] due to their potential to harm human health or the environment) was observed to be over filled past the opening on the lid. On July 14, 2025, at 2:45 p.m., an interview was conducted with the DRDQ. The DRDQ stated the bins were full and should have been reported to the Environmental Services Department (EVS) and emptied. A facility P&P titled, “Disposal of hazardous waste including Pharmaceutical & Radioactive Waste,” dated April 2021, was reviewed. The policy indicated, “...All sharps [needles and other sharp objects] shall be placed in a puncture-resistant container...These containers must be properly closed when three-quarters full to avoid spillage of sharps. All sharps containers shall be placed into a biohazard container, labeled with the universal biohazard symbol...””

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 35056 Based on interview and record review, the facility failed to ensure the facility’s policy and procedure (P&P) was implemented when wound care supplies were observed by the sides of the sink inside a patient’s room. This failure had the potential to increase the risk for infection for the patient. Findings: On July 15, 2025, at 9:34 a.m., an observation and concurrent interview were conducted with the Corporate Quality Officer (CQO), Chief Nursing Officer (CNO) and the DRDQ. During the tour of Room D in Unit B, multiple lemon glycerin swabs (swabs to moisten the patients mouth), multiple 4x4 gauze pads (a square-shaped piece of gauze measuring four inches by four inches, used for wound care and medical procedures), a medical tape (a type of adhesive tape designed for use in healthcare settings to secure bandages, dressings, and medical devices to the skin), a wound measure guide (a tool used to accurately assess the size and characteristics of a wound) and a 1000 mL (milliliter, unit of measurement) sterile irrigation water (special water used to clean a wound) bag, and a 50 ml piston syringe (large syringe used for patient care) were found on the sides of the sink. The DRDQ stated the supplies should not be kept on the patients’ sink. The CQO stated the wound care supplies should not be on the sides of the sink where the staff are washing their hands because it is an infection control risk if water splashes on the supplies. An interview with the CQO on July 21, 2025, at 1:15 p.m., was conducted. The CQO stated staff should not be storing wound care supplies on the patients’ sink. The CQO stated they do not have a direct policy relating to storing the supplies on the sink. The CQO further stated it is common sense for infection control to not store patient supplies in the splash zone on the sink. The CQO stated getting water or soap on the packages of the supplies can potentially contaminate the supplies. A facility P&P titled, “Infection Control and Construction Safety,” dated April 2021, was reviewed. The document indicated, “...Hand washing facilities should be situated to avoid splashing clean supplies...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure the facility complied with the provisions in 42 CFR 489.20 and 42 CFR 489.24, when the facility’s policies and procedures were not implemented, for two of 20 sample patients (Patients 1 and 2). Patient 1 was not stabilized before the patient was discharged from the Emergency Department (ED) while on a 5250 hold and Patient 2’s Medical Screening Exam was not completed timely by the ED physician. This failure had the potential to result in delay in treatment, compromise the patient’s health, and could have contributed to patient death.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure medical screening examination (MSE, the process a hospital uses to determine if a patient presenting to the emergency department has an emergency medical condition) and treatment were provided timely in the Emergency Department (ED), for one of 20 sampled patients (Patient 2). In addition, the facility failed to ensure the MSE was conducted by a qualified provider, in accordance with the facility’s policy and procedure and rules and regulations. This failure resulted in a delay of treatment for Patient 2. In addition, this failure may have contributed to Patient 2’s death. Findings: On July 15, 2025, at 11 a.m., a review of Patient 2’s record and concurrent interview were conducted with the Patient Safety Coordinator (PSC). A facility document titled, “Triage [a system to prioritize which patient needs treatment first],” dated June 15, 2025, authored by Registered Nurse (RN) 1, was reviewed. The document indicated, “...Triage start: 15-Jun-2025 [June 15, 2025]18:22 [6:22 p.m.]...Triage Stop...18:27 [6:27 p.m.] Chief Complaint: Low back pain, bilat [bilateral, both sides] leg numbness...Acuity [the severity of a patient’s illness or injury, determining the level of care and monitoring needed] 3-Urgent [a score using the Emergency Severity Index (ESI), an algorithm to quickly assess and categorize patients based on acuity-1 most urgent to 5 least urgent]...” A facility document titled, “Emergency Department Record,” dated June 15, 2025, at 8:24 p.m., authored by Resident (a physician in training) 1 was reviewed. The document indicated, “...Location: RME [rapid medical exam, a treatment area in the ED where patients with less severe illnesses are cared for]...Care Start Date/Time: 06/15/2025 [June 15, 2025] 19:07 [7:07 p.m.]...Chief Complaint...presents to the ER [emergency room] via POV [private vehicle] for evaluation of low back pain and LE [lower extremity, leg] weakness...sudden onset of low back pain...unable to feel his b/l [bilateral] lower extremities, and has numbness and tingling...pt [Patient 2] urinated on himself in the ER lobby and seems more disoriented and lethargic...has no sensation to light touch, pinprick. No active ROM [range of motion, the full movement potential of a joint] B/l feet feel cool to touch, pulses difficult to palpate. Absent DTR’s [deep tendon reflexes, involuntary muscle contractions triggered by tapping a tendon]...Differential Diagnoses: cauda equina syndrome [syndrome where a bundle of nerves at the end of the spinal cord become compressed causing weakness of legs, urinary incontinence, and bowel disfunction]...Talked to charge nurse about obtaining an acute bed [a bed in the hospital]. There are no vascular surgery [a specialized field of medicine focused on the diagnosis, management, and treatment of diseases affecting the blood vessels] or neurovascular surgery [a branch of medicine which deals with the diagnosis, treatment, and prevention of diseases affecting the brain and spinal cord] consultants on service at this hospital...Care transferred to [name of Physician 1]. Pending imaging studies and lab [laboratory] results. Pending possible transfer...” (1 hour and 57 minutes from the time Patient 2 was triaged). A facility document titled, “Emergency Continuation,” dated June 15, 2025, at 9:22 p.m., authored by Physician 1, was reviewed. The document indicated, “...Reason: Patient care transferred to me due to end of shift...sudden onset of low back pain around 5:30PM [p.m.]...started abruptly...unable to feel his b/l lower extremities, and has numbness and tingling in b/l LE...pt [Patient 2] urinated on himself in the ER lobby and seems more disoriented and lethargic...Procedures in the Emergency Department while patient was getting CT angio [computed tomography angiography, an imaging procedure to visualize the blood vessels and blood flow] completed he went into full arrest [when the heart stops beating and the patient stops breathing]...Patient was resauated [sic, resuscitated, revived]...for 22 minutes. In no pint [sic, point] were pateint [sic, patient] puelse [sic, pulse] brought back. Patient had no signs of life during the entire time. Patient was in agumal [sic, agonal, a very slow and erratic heart rhythm, usually less than 20 beats per minute, which occurs before the heart stops beating in dying patients] rythem [sic, rhythm] and was asystole [flatline, no heart beat] the whole time...patient unfortunately expired...This patient was seen by...resident...rotating in the emergency department and I took care of the patient after she left. On examination patient’s lower extremities were cool to touch with diminished pulses bilaterally [sic, .] patient also had no strength, no motor or sensory sensation in the lower extremities. Initially patient had MRI [magnetic resonance imaging, an imaging procedure creating detailed images of soft tissues, organs, and structures within the body] and CT scan of the lumbar spine [lower back] ordered in order to rule out...cauda equina syndrome. However when I saw the patient I suspected a vascular [veins that carry blood] compromise for the cause of patient’s neurologic symptoms despite the fact that patient had no abdominal pain and no chest pain diagnosis of aortic dissection [tear in the inner layer of the aorta, the main blood vessel which carries the blood from the heart to the body] or ruptured aneurysm [burst of the blood vessel causing bleeding] was suspected and CT scan angio of the chest abdomen pelvis with extension in the proximal [near the center] extremities was ordered...About an hour after the patient expired I received a call from the radiologist informing me that the patient had a complete dissection of aorta infrarenally [situated below kidneys] with with [sic] complete cessation [ending] of blood flow and also dissection into the ascending aorta [large blood vessel supplying blood to the brain] all the way into the coronary arteries [blood vessels of the heart] with pericardial [sac around the heart] tamponade [compression of the heart due to accumulation of blood in the pericardium, the sac around the heart]...” (58 minutes from the time Resident 1 examined Patient 2, three hours from the time the patient was triaged). A facility document titled, “...Orders Report,” dated June 15, 2025, was reviewed. The document indicated, “...CT Angio Chest/Abdomen/Pelvis...Start Date: 06/15/2025 21:02 [9:02 p.m.]...” A facility document titled, “Daily Focus Assessment Report,” dated June 15, 2025, at 9:50 p.m., was reviewed. The document indicated, “...first contact with pt [Patient 2]...pt very gray/pale in color...pt taken to CT...” (58 minutes from the time the CT angio was ordered for Patient 2). A facility document titled, “FINAL REPORT,” dated June 15, 2025, was reviewed. The document indicated, “...Procedure: CT Angio Abdomen and Bil [bilateral] Lower Extremities...Acute dissection [a life threatening emergency due to a tear in the aorta causing sudden chest or back pain requiring immediate surgical treatment to avoid rupture of the artery] involving ascending colon [the first part of the large intestine] near reaching the level of coronary arteries...dissection is extending to the aortic arch [large vessel connecting the top and bottom portion of the aorta] and descending thoracic aorta [large vessel which carries blood from the heart to theabodmen and lower extremities]....aortic arch [the curved portion of the aorta which connects the ascending aorta to the descending aorta] major branches are arising from the true lumen [inner passageway in the blood vessel through which the blood flows] with evidence of extensions of the dissection into the left subclavian [a major artery found in the upper body] and right innominate artery [the first and largest branch of the aortic arch]. Large hemorrhagic [bleeding] pericardial effusions [accumulation of blood in the pericardium] indicating that the dissection has extending into the pericardium with collapse of the cardiac chamber [a hollow space in the heart] indicating progressive cardiac tamponade [blood build up in the space between the lining and the muscles of the heart causing pressure on the heart preventing it from pumping]...Impression: Extensive thoracic [chest] aorta dissection extending to the heart resulting in cardiac tamponade and hemorrhagic pericardial effusion. Extensive abdominal aorta dissection as described in detail above with occlusion [a block] of the true lumen in the infrarenal [below the kidneys] abdominal aorta resulting in absent blood flow bilateral lower extremities...” A facility document titled, “Code Blue Record,” dated June 15, 2025, indicated the code blue [a hospital code for a patient experiencing a life-threatening medical emergency when the patient stops breathing and the heart stops beating] initiated at 2200 [10 p.m.]....Time of Death 2224 [10:24 p.m.]...” (Three hours and 55 minutes after arriving to the ED) During a concurrent interview with the PSC, the PSC stated Patient 2 arrived in the ED at 6:19 p.m., on June 15, 2025. On July 15, 2025, at 11:14 a.m., an interview was conducted with the Chief Quality Officer (CQO). The CQO stated Resident 1 was a first-year medical resident. She stated the MSE should not have been conducted by a resident physician. The CQO stated the facility’s rules and regulations indicated the MSE needed to be completed by an attending licensed emergency room physician. On July 21, 2025, at 11:02 a.m., an interview was conducted with Emergency Room Physician (Physician) 1. Physician 1 stated Patient 2 was first assessed by a resident (Resident 1) who was a first-year resident. Physician 1 stated Resident 1 presented the case to him after the resident’s assessment. Physician 1 stated he thought he saw Patient 2 in a reasonable time, but an hour is not an acceptable time. Physician 1 stated he took over the case because Resident 1 signed off for the day, and ultimately, he was responsible for the patient. Physician 1 stated the patient was flagged as not being very critical, with an ESI of 3. Physician 1 stated he was not aware the Medical Screening Examination (MSE) needed to be completed by an ED physician and not a resident. On July 21, 2025, at 12:59 p.m., an interview was conducted with Resident 1. Resident 1 stated that at the time of this incident, she was a first-year resident. Resident 1 stated residents were not assigned to patients. Resident 1 stated the residents were able to look at the ED list and pick who to see from patients listed with an ESI of 2 or 3. Resident 1 further stated Patient 2 was triaged with an ESI of 3 which was urgent but not emergent. Resident 1 stated Patient 2 had been in the lobby for a while before she called Patient 2 back for the exam. Resident 1 stated she presented the case to Physician 1 right after assessment and Physician 1 instructed her to place orders for what was thought to be cauda aquina. Resident 1 stated, later she went back to reassess Patient 2, and the patient looked less stable than before and that was when she requested Physician 1 to come see the patient. Resident 1 stated Patient 2 should have been an ESI of 2. On July 21, 2025, at 1:46 p.m., an interview was conducted with RN 1. RN 1 stated she is not a triage nurse and had never been trained to be a triage nurse. RN 1 stated the day Patient 2 presented to the ED was the first day she was assigned to be a triage nurse. RN 1 stated the ED was short staffed and the ED charge nurse asked her to triage patients due to staff shortage. On July 21, 2025, at 3:05 p.m., an interview was conducted with the ED Manager (EDM). The EDM stated the charge nurse assigned RN 1 to triage patients at the ED and she should not have. The EDM stated RN 1 was not trained to be a triage nurse. The EDM stated there was another nurse in the ED who was trained to be a triage nurse who should have been assigned to triage. She stated if the triage would have been done sooner, Patient 2’s outcome could have been different. A review of the facility document titled, “GENERAL RULES AND REGULATIONS,” dated May 22, 2024, were conducted. The document indicated, “...Medical Screening Examinations...Medical screening examinations may be performed by the following categories of professionals...Credentialed physicians on the Medical Staff with privileges in Emergency Department. Mid-level practitioners with service authorizations to perform such exams. Registered Nurse assigned to the Labor and Delivery (L&D) Department who has met criteria for certification as outlined in standardized procedure for L&D patients only...” A review of the facility’s policy and procedure titled, “EMTALA - MEDICAL SCREENING AND STABILIZATION POLICY,” dated April 2023, was reviewed. The document indicated, “...The MSE must be completed by an individual (i) qualified to perform such an examination to determine whether an EMC (emergency medical condition) exists...Only the following individuals may perform an MSE...qualified physician with appropriate privileges...Other qualified licensed independent practitioner (LIP) with appropriate competencies and privileges; or...A qualified staff member who...is qualified to conduct such an examination through appropriate privileging and demonstrated competencies...is functioning within the scope of his or her license...is performing the screening examination based on medical staff approved guidelines, protocols or algorithms...is approved by the facility’s governing board as set forth in a document such as the hospital bylaws or medical staff rules and regulations...””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure stabilizing treatment was provided, for one of 20 sample patients (Patient 1), when Patient 1, who was determined to be a danger to self and was gravely disabled (inability of the patient to provide for his or her basic personal needs for food, clothing, or shelter) and was on a 5250 (a legal 14 day involuntary hold) hold was discharged from the Emergency Department (ED). This failure resulted in Patient 1 being discharged while on a legal hold and could have resulted in harm and/or injury to Patient 1. Findings: On July 15, 2025, a review of Patient 1’s record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, “Triage,” dated May 23, 2025, was reviewed. The document indicated, “...Triage [a preliminary assessment of patients using a number system with 1 being most urgent and 5 being least urgent] start: 23-May-2025 [May 23, 2025] 11:00 [a.m.]...Chief Complaint: Social Problem...BIBA [brought in by ambulance] after walking into clinic and refused to answer any questions - pt [Patient 1] appears ti [sic, to] be hallucinating [seeing or hearing things which are not there] upon triage...” A facility document titled, “Emergency Department Record,” date May 23, 2025, at 11:21 a.m., was reviewed. The document indicated, “...presenting to the emergency room via EMS [emergency medical services, an ambulance service] for evaluation of social problem...Differential Diagnosis [a physician’s assessment of two or more conditions which share similar signs or symptoms]: psychosis [a mental health condition characterized by a loss of contact with reality], drug intoxication, schizophrenia [a seious mental condition which impacts a person’s feelings and behaviors, including delusions (a fixed, false belief that is not based on reality) and hallucinations (an experience of seeing or hearing something which is not present)]...Nurse reports patient [Patient 1] is trying to leave the department [ED] but she is not fully A&Ox4 [alert and oriented to person, place, time, and situation]...Patient placed on an 8 [eight] hour hold by myself until she is able to be evaluated by REACH [Response, Early intervention, and Assessment in Community Mental Health, programs which aim to improve mental health outcomes through early intervention, crisis support, and community-based services]...1900 [7:00 p.m.] Patient care transitioned to the next ED attending physician due to change of shift...” A facility document titled, “APPLICATION FOR ASSESSMENT, EVALUATION, AND CRISIS INTERVENTION OR PLACEMENT FOR EVALUATION AND TREATMENT,” dated May 23, 2025, was reviewed. The document indicated, “...pursuant to...Code 5150 [a 72 hour involuntary legal hold]...[name of Patient 1]...for up to 72 hour assessment, evaluation and crisis intervention or placement for evaluation treatment at a designated facility pursuant to Section 5150...The Above person’s condition was called to my attention under the following circumstances: client was placed on a 8 [eight] our hold due to experiencing bizarre behavior. Hospital requesting re-evaluation...Client [Patient 1] presented with flat affect [reduced or absent expression of emotions]. She appears to be responding to internal stimuli [sensations and feelings originating from within the body that can influence behavior and perception] as evidenced by mumbling and looking from side to side. Has history of psychosis, when asked safety questions she was unable to verbalize... anger to self... Date:05/23/2025 [May 23, 2025]...Time: 11:54 p.m...” A facility document titled, “DETENTION OF PATIENT WITH PSYCHIATRIC EMERGENCY IN A NON DESIGNATED [sic] HEALTH FACILITY,” dated May 23, 2025, at 2:09 p.m., was reviewed. The document indicated, “... [Name of Patient 1]...Danger to self...Gravely disabled...If the patient is detained beyond 8 hours, but less than 24 hours, both of the following additional conditions must be met: A discharge or transfer for appropriate evaluation or treatment for the patient has been delayed because of the need for continuous and ongoing care, observation, or treatment that the hospital is providing...The Patient named above continues to be, as a result of a mental disorder, one or more of the following: a danger to herself...Gravely disabled...Date:05/23/25...Time: 2224 [10:24 p.m.]...” A facility document titled, “Notice of certification for intensive treatment pursuant to section 5250 ,” dated May 26, 2025, was reviewed. The document indicated, “...14-day hold...[Name of Patient 1]... Address unknown... A danger to self as a result of a mental health disorder...Gravely disabled...The specific facts which formed the basis of our opinion that the above named person meets one or more of the classification indicated above are as follows...Danger to self by not being able to express an ability to provide her medications, food, shelter...Date: 05/26/25 [May 26, 2025] Time: 0900 [9 a.m.]...” A facility document titled, “Daily Focus Assessment Report,” dated May 23, 2025, through May 27, 2025, was reviewed. The document indicated, “...05/24/2025 [May 24, 2025] 00:00 [12 a.m.]...Reach placed pt [Patient 1] on 5150 hold for danger to self due to continued bizarre behavior, appears to be hallucinating...05/26/2025 07:30 [7:30 a.m.]...Pt informed at 0905 [9:05 a.m.] of 5250 hold signed by MD...at 0900 [9 a.m.]...” A facility document titled, “Daily Focus Assessment Report, dated May 23, 2025, through May 27, 2025, authored by Registered Nurse (RN) 2, was reviewed. The document indicated, “...05/26/2025 20:00 [8 p.m.]...PT BIBA for 5150 hold...22:00 [10 p.m.]...Pt updated on plan of care. Pt Developmentally delayed [individual who continues to experience significant limitations in one or more major life activities due to a mental or physical impairment ] and does not answer questions appropriately...00:26 [12:26 a.m.]...Pt to be discharged home patient is alert and oriented x3-4, MD [physian] at bedside. Pt vitals [measurable physiological parameters that indicate the body’s essential functions, temperature, heart rate, respiratory rate, and blood pressure] stable for DC [discharge]...” A facility document titled, “CPOE Orders Report,” dated May 23, 2025, through May 27, 2025, was reviewed. The document indicated, “...Discharge to Home...Start Date: 05/27/2025 [May 27, 2025] 00:19 [12:19 a.m.]...” A facility document titled, “Discharge Instructions,” dated May 27, 2025, at 00:30 [12:30 a.m.] was reviewed. The document indicated, “...Discharge Instructions...Patient Departed from the ED Date and Time...05/27/2025 [May 27, 2025] 00:28 [12:28 a.m.]...” During review of Patient 1’s record, there was no documented evidence the night shift (7 a.m. to 7 a.m.) RN acknowledged Patient 1 was on a 5250 hold. During a concurrent interview, the PSC indicated Patient 1 arrived in the ED on May 23, 2025, at 10:40 a.m. The PSC stated Patient 1 was discharged on May 27, 2025, at 12:28 a.m. On July 21, 2025, at 2:02 p.m., an interview was conducted with ED Physician (ED) 2. ED 2 stated he cannot cancel a 5250 hold. He stated the 5250 hold can only be interrupted or broken by a psychiatrist. ED 2 stated he was not aware Patient 1 was on a 5250 hold. ED 2 stated there was a communication error, and he should have never discharged Patient 1. On July 21, 2025, at 3:34 p.m., an interview was conducted with RN 2. RN 2 stated she was aware a patient on a 5250 hold could not be discharged. RN 2 stated she was unable to find the 5250-hold documentation in Patient 1’s record. RN 2 stated she spoke to ED 2 and ED 2 told her he did not know Patient 1 was on a 5250 hold. RN 2 stated Patient 1’s 5250 hold documentation was placed in a wrong patient’s chart. On July 21, 2025, at 3:45 p.m., an interview was conducted with the Chief Quality Officer (CQO) and the Deputy Regional Director of Quality (DRDQ). The CQO stated Patient 1, who was on a 5250 hold, was discharged in error. She stated it was due to a lack of communication. The CQO stated ED 2 was not aware Patient 1 was on a 5250 hold. The CQO stated ultimately a 5250-hold patient should not have been discharged. A facility policy and procedure titled, “Behavior Health Management,” dated September 2024, was reviewed. The document indicated, “...To appropriately manage patients in the Emergency Department (ED) with an acute psychiatric condition...includes, but is not limited to, identifying whether the patient is a danger to self or others or gravely disabled (and is already on a involuntary 5150 or 8 hour hold or requires one), determining whether the patient’s condition warrants an appropriate transfer to a psychiatric facility, and ensuring the health and safety of the patient...Physicians will reassess for continued need for an additional involuntary hold, leading to a 5250...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48776 Based on interview and record review, the facility failed to ensure care was provided in a safe setting, for four of 12 sample patients (Patients 3, 4, 8, and 12), in accordance with the facility’s policy and procedure, when: 1. For Patient 3, a signed informed consent was not obtained prior to the drainage of a retropharyngeal hematoma (an accumulation of blood in the neck area) and the insertion of a Hemovac drain (a flexible plastic used to remove excess blood and fluid from a surgical site) (Refer to A- 0131); 2. For Patient 3, a physician who had not been granted credentials (a process facilities use to make sure a physician is qualified to care for patients which includes checking the physician’s education, training, licensee, background, and work history) and privileges (a process which is completed after credentialing to allow a physician to care for patients in the facility) to practice in the facility was allowed to perform a procedure on the patient in the Emergency Department (ED). In addition, the facility failed to ensure time out (a safety step conducted by the surgery staff before the drainage of the retrophyrangeal hematoma and insertion of the Hemovac drain on Patient 3 to ensure the procedure is done with the correct patient, procedure, procedure site, and whether the informed consent was signed by the patient) was conducted prior to the procedure being performed (Refer to A-0144); 3. For Patient 8, the informed consent was not obtained prior to the completion of a lumbar puncture (a procedure where a needle is inserted in the lower back into the spinal canal to collect fluid) (Refer to A-0131); and 4. For Patients 4 and 12, pain was not reassessed after a pain medication was administered (Refer to A-0144). The cumulative effects of these systemic failures had the potential to cause delays in treatment and jeopardize the patients’ safety and cause harm to the patients.”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 48776 Based on interview and record review, the facility failed to ensure only providers who have been granted credentials (a process facilities use to make sure a physician is qualified to care for patients which includes checking the physician’s education, training, licensee, background, and work history) and privileges (a process which is completed after credentialing to allow a physician to care for patients in the facility) are allowed to provide care to patients at the facility, for one of 12 sample patients (Patient 3), when a physician (MD 2), who have not been credentialed nor been granted privileges in the facility performed the drainage of a retropharyngeal hematoma (an accumulation of blood which develop in the neck area) and insertion of a Hemovac drain (a closed suction system used to remove excess blood and fluid from a surgical site) in the Emergency Department (ED) (Refer to A- 0353). The cumulative effect of this systemic failure had the potential to jeopardize the treatment and quality of care provided to Patient 3 and may cause harm to the patient.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 48776 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for one of 12 sample patients (Patient 3), when a signed informed consent was not obtained prior to the drainage of a retropharyngeal hematoma (an accumulation of blood which develop in the neck area) and insertion of a Hemovac drain (a closed suction system used to remove excess blood and fluid from a surgical site), time out (a safety step conducted by the surgery staff before a surgical procedure to ensure the procedure is done with the correct patient, procedure, procedure site, and whether the informed consent was signed by the patient) was not conducted prior to the procedure, and a physician who had not been granted credentials (a process facilities use to make sure a physician is qualified to care for patients which includes checking the physician’s education, training, licensee, background, and work history) and privileges (a process which is completed after credentialing to allow a physician to care for patients in the facility) performed a procedure on the patient in the Emergency Department (ED) (Refer to A-1104). The cumulative effects of these systemic failures had the potential to impact the health, safety, and treatment of Patient 3, and may cause harm to the patient.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48776 Based on interview and record review, the facility failed to ensure an informed consent (a process where individuals are provided with all necessary information about a procedure including the risks and benefits of the procedure) was signed by two of 12 sample patients (Patients 3 and 8), in accordance with the facility’s policy and procedure (P&P). 1. For Patient 3, a signed informed consent was not obtained prior to the drainage of a retropharyngeal hematoma (an accumulation of blood which develop in the neck area) and the insertion of a Hemovac drain (a closed suction system used to remove excess blood and fluid from a surgical site); and 2. For Patient 8, the informed consent was not obtained prior to the completion of a lumbar puncture (a procedure where a needle is inserted in the lower back into the spinal canal to collect fluid). These failures resulted in Patients 3 and 8 not being informed of the benefits and risks related to their surgical procedures and may jeopardize the patients’ safety and cause harm to the patients. Findings: 1. On June 11, 2025, at 10 a.m., an interview was conducted with the Emergency Department Manager (EDM). The EDM stated a physician (MD 2) dressed in street clothes with a badge which indicated “Surgeon” gained entrance to the Emergency Department (ED) through the ambulance bay doors on May 29, 2025. The EDM stated MD 2 was known to Patient 3. The EDM stated MD 2 contacted the ED physician on duty (MD 1) earlier that day to notify MD1 Patient 3 would be coming to the ED. EDM stated MD 2 did not have credentials (a process facilities use to make sure a physician is qualified to care for patients which includes checking the physician’s education, training, licensee, background, and work history) nor privileges (a process which is completed after credentialing to allow a physician to care for patients in the facility) at the facility. The EDM stated MD 2 asked multiple ED staff members for supplies and was provided with the items needed to drain Patient 3’s retropharyngeal hematoma and insert a Hemovac drain. The EDM stated these were invasive procedures which required a written informed consent from the patient, but an informed consent was not obtained from the patient for the procedures which were performed by MD 2. On June 11, 2025, at 10:20 a.m., an interview was conducted with Registered Nurse (RN) 1 who cared for Patient 3 on May 29, 2025. RN 1 stated she saw MD 2 speaking with Patient 3. RN 1 stated she was not informed by MD 2 Patient 3 needed a procedure or an informed consent. RN 1 stated Patient 3’s retropharyngeal hematoma drainage and Hemovac insertion were invasive procedures which required an informed consent from the patient. On June 11, 2025, at 2 p.m., an interview was conducted with the Chief Quality and Patient Safety Officer (CQO). The CQO verified MD 2 did not have credentials and privileges to treat patients at the facility. The CQO stated Patient 3’s retropharyngeal hematoma drainage and Hemovac insertion were invasive procedures and an informed consent should have been obtained from Patient 3 prior to MD 2 performing the procedures. The CQO further stated MD 2 should not have performed the procedures because MD 2 did not possess the necessary credentials and privileges at the facility. On June 11, 2024, at 3:30 p.m., Patient 3’s record was reviewed with the CQO. A facility document, titled, “Triage,” dated May 29, 2025, was reviewed and indicated Patient 3 arrived to the ED on May 29, 2025, at 4:26 p.m., with bleeding in his neck lasting two days. A facility document titled, “[Name of Facility] Emergency Department Record,” authored by MD 1, dated May 29, 2025, was reviewed and indicated Patient 3 presented to the ED, “...complaining of difficulty swallowing over the past two days. Patient [Patient 3] had a surgery performed by Dr. [Name of MD 2], who advised the patient to present to the ED for further evaluation for possible postsurgical [after a surgery] retropharyngeal hematoma...In conversation with MD 2, he ias [sic] concerned that patient may have a large retropharyngeal hematoma, which would make it impossible to intubate [inserting a breathing tube down the throat to help a person breath] patient or otherwise secure an airway unless retropharyngeal hematoma is evacuated emergently. He stated that if this is necessary, he could walk me through the procedure...” A facility document, titled “[Name of Facility 2] Operative Report,” authored by MD 2, dated June 2, 2025, was reviewed and indicated, “...DATE OF OPERATION: 05/29/2025 [May 29, 2025]...LOCATION: [Name of Facility]...INDICATIONS FOR PROCEDURE: The patient [Patient 3]...is 2 [two] days status post [after] anterior cervical decompression and fusion [neck surgery where damaged disc is removed from the spine bone, filling the space, and connecting the spine bones together)...which was performed at [Name of Facility 3] and was admitted overnight with a postoperative Hemovac drain...He was doing reasonably well postoperatively [after the surgery] and after the drain was removed, he was discharged home the day after surgery, but I was instructed by his son the evening after discharge that he had sanguinous [bloody] drainage on his dressings, but was not in undue distress at that time. I instructed them to monitor this and let me know if things worsened and unfortunately, the following day I was contacted by the patient who informed me that he had severe difficulty swallowing and was starting to have increased swelling in his neck as well as generalized distress. I was concerned that this likely represented an expanding retropharyngeal hematoma that was potentially life threatening because of obstruction. He presented to [Name of Facility] ED...PROCEDURE IN DETAIL...Under sterile technique at bedside in the Emergency Department...a suture [surgical stitch] removal kit was used...the retropharyngeal hematoma was evacuated [removed]...Hemovac drain was inserted and the wound was closed with skin staples...” Based on record review, there was no documented evidence an informed consent was obtained from Patient 3 prior to the evacuation of the retropharyngeal hematoma and the insertion of a Hemovac drain procedures being done. A review of the facility’s P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES,” revised November 2022, was conducted. The policy indicated, “...All patients at [name of Facility] have the right to...Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as they may need in order to give informed consent or to refuse a course of treatment...This information shall include a description of the procedure or treatment, the medically significant risks involved, alternate courses of treatment or non-treatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment...” 2. On June 11, 2025, at 2 p.m., a review of Patient 8’s record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, “Emergency Department Record,” dated June 8, 2025, at 2:47 p.m., was reviewed and indicated Patient 8 was admitted to the ED on June 8, 2025, for two witnessed febrile seizures (convulsions caused by fever). The document indicated a lumbar puncture was performed by MD 1 on Patient 8. A facility document titled, “Daily Focus Assessment Report,” dated June 8, 2025, at 5:10 p.m., was reviewed. The document indicated, “...Procedure Name...Lumbar Puncture...Present at bedside...Physician...Nursing...Emergency Department Tech...Procedure checklist-Action List...Verified physician order...consent signed...Explained the need for the procedure to patient/family/caregiver...Specimen collected and sent to lab...” A facility document titled, “CONSENT TO SURGERY OR SPECIAL PROCEDURE,” dated June 8, 2025, at 4:15 p.m., was reviewed. The document indicated MD 1 recommended a lumbar puncture for Patient 8. The document included a signature from a parent of Patient 8 and a signature by MD 1. There was no documented evidence a witness was present when the informed consent was obtained from Patient 8. On June 12, 2025, at 2:15 p.m., an interview was conducted with the EDM. The EDM verified the document titled “Consent to Surgery or special procedure,” for Patient 8 did not indicate a signature of a witness. The EDM stated, “...There should have been a witness signature on the consent...” A review of the facility’s P&P titled, “INFORMED CONSENT,” revised September 2024, was conducted. The policy indicated, “...the hospital is required to obtain documentation of consent to hospital services and to verify that the physician has obtained informed consent as appropriate...A procedural consent form, dated, timed, and signed by the patient and witnesses by hospital staff are required for surgical invasive procedures...””

“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: 48776 Based on interview and record review, the facility failed to ensure the patient’s right to receive care in a safe setting was provided, for three of 12 sample patients (Patient 3, 4, and 12), in accordance with the facility’s policy and procedure, when: 1. For Patient 3, a physician who had not been granted credentials (a process facilities use to make sure a physician is qualified to care for patients which includes checking the physician’s education, training, licensee, background, and work history) and privileges (a process which is completed after credentialing to allow a physician to care for patients in the facility) to practice in the facility was allowed to perform the drainage of a retropharyngeal hematoma (an accumulation of blood which develop in the neck area) and the insertion of a Hemovac drain (a closed suction system used to remove excess blood and fluid from a surgical site) on the patient in the Emergency Department (ED). In addition, the facility failed to ensure time out (a safety step conducted by the surgery staff before a surgical procedure to ensure the procedure is done with the correct patient, procedure, procedure site, and whether the informed consent was signed by the patient) was conducted prior to the procedure being performed; and 2. For Patients 4 and 12, pain was not reassessed after the pain medication was administered. These failures compromised the safety, quality, and integrity of patient care and placed the patients at risk for potential harm. Findings: 1. On June 11, 2025, at 10 a.m., an interview was conducted with the Emergency Department Manager (EDM). The EDM stated a physician (MD 2) dressed in street clothes with a badge which indicated “Surgeon” gained entrance to the Emergency Department (ED) through the ambulance bay doors on May 29, 2025. The EDM stated MD 2 was known to Patient 3. The EDM stated MD 2 contacted the ED physician on duty (MD 1) earlier that day to notify MD1 Patient 3 would be coming to the ED. EDM stated MD 2 did not have credentials (a process facilities use to make sure a physician is qualified to care for patients which includes checking the physician’s education, training, licensee, background, and work history) nor privileges (a process which is completed after credentialing to allow a physician to care for patients in the facility) at the facility. The EDM stated MD 2 asked multiple ED staff members for supplies and was provided with the items needed to drain Patient 3’s retropharyngeal hematoma and insert a Hemovac drain at Patient 3’s room at theED. The EDM stated these were invasive procedures which required a written informed consent from the patient, but an informed consent was not obtained from the patient for the procedures which were performed by MD 2. On June 11, 2025, at 10:10 a.m., an interview was conducted with the Deputy Regional Director of Quality (DOQ). The DOQ stated MD 2 did not have privileges at the facility and should not have performed the procedure on Patient 3. The DOQ further stated MD 2 could have asked for emergency privileges (a process where in an emergency, a facility temporarily allows a physician to treat the patient) and this was not done. On June 11, 2025, at 10:20 a.m., an interview was conducted with Registered Nurse (RN) 1 who cared for Patient 3 on May 29, 2025. RN 1 stated she saw MD 2 speaking with Patient 3. RN 1 stated she was not informed by MD 2 Patient 3 needed a procedure or an informed consent. RN 1 stated Patient 3’s retropharyngeal hematoma drainage and Hemovac insertion were invasive procedures which required an informed consent from the patient and the performance of a time-out. On June 11, 2025, at 2 p.m., an interview was conducted with the Chief Quality and Patient Safety Officer (CQO). The CQO verified MD 2 did not have credentials and privileges to treat patients at the facility. The CQO stated Patient 3’s retropharyngeal hematoma drainage and Hemovac insertion were invasive procedures and an informed consent should have been obtained from Patient 3 prior to MD 2 performing the procedures. The CQO further stated MD 2 should not have performed the procedures because MD 2 did not possess the necessary credentials and privileges at the facility. On June 11, 2025, at 2:20 p.m., an interview was conducted with the Chief Medical Officer (CMO). The CMO stated the facility staff should not have provided supplies to MD 2 to perform the drainage of the retropharyngeal hematoma and Hemovac drain insertion on Patient 3. The CMO stated MD 2 did not have privileges at the facility and should not have performed the procedures on Patient 3. On June 11, 2025, at 3:30 p.m., Patient 3’s record was reviewed with the CQO. A facility document titled, “Triage,” dated May 29, 2025, was reviewed and indicated Patient 3 arrived at the Emergency Department (ED) on May 29, 2025, at 4:26 p.m., with bleeding on his neck lasting two days. A facility document titled, “[Name of Facility] Emergency Department Record,” authored by MD 1, dated May 29, 2025, was reviewed and indicated Patient 3 presented to the ED, “...complaining of difficulty swallowing over the past two days. Patient [Patient 3] had a surgery performed by Dr. [Name of MD 2], who advised the patient to present to the ED for further evaluation for possible postsurgical [after a surgery] retropharyngeal hematoma...In conversation with MD 2, he ias [sic] concerned that patient may have a large retropharyngeal hematoma, which would make it impossible to intubate [inserting a breathing tube down the throat to help a person breath] patient or otherwise secure an airway unless retropharyngeal hematoma is evacuated emergently. He stated that if this is necessary, he could walk me through the procedure...” A facility document, titled “[Name of Facility 2] Operative Report,” authored by MD 2, dated June 2, 2025, was reviewed and indicated, “...DATE OF OPERATION: 05/29/2025 [May 29, 2025]...LOCATION: [Name of Facility]...INDICATIONS FOR PROCEDURE: The patient [Patient 3]...is 2 [two] days status post [after] anterior cervical decompression and fusion [neck surgery where damaged disc is removed from the spine bone, filling the space, and connecting the spine bones together)...which was performed at [Name of Facility 3] and was admitted overnight with a postoperative Hemovac drain...He was doing reasonably well postoperatively [after the surgery] and after the drain was removed, he was discharged home the day after surgery, but I was instructed by his son the evening after discharge that he had sanguinous [bloody] drainage on his dressings, but was not in undue distress at that time. I instructed them to monitor this and let me know if things worsened and unfortunately, the following day I was contacted by the patient who informed me that he had severe difficulty swallowing and was starting to have increased swelling in his neck as well as generalized distress. I was concerned that this likely represented an expanding retropharyngeal hematoma that was potentially life threatening because of obstruction. He presented to [Name of Facility] ED...PROCEDURE IN DETAIL...Under sterile technique at bedside in the Emergency Department...a suture [surgical stitch] removal kit was used...the retropharyngeal hematoma was evacuated [removed]...Hemovac drain was inserted and the wound was closed with skin staples...” On June 12, 2025, at 9 a.m., an interview was conducted with the Director of Medical Staff Administration (DMS). The DMS stated MD 2 did not have privileges to treat patients at the facility. The DMS stated there are credentialing and privileging processes which is followed by the facility before a physician could provide treatment to the patients at the facility. A review of the facility document titled, “MEDICAL STAFF BYLAWS AND RULES & REGULATIONS - Medical Staff Administration,” revised June 25, 2024, was conducted. The document indicated, “...No physician...shall admit or provide medical or health-related services to patients in the Hospital unless he or she is a member of the Medical Staff or has been granted privileges in accordance with the procedures set forth in these Bylaws. Appointment to the Medical Staff shall confer only such clinical privileges as have been granted in accordance with these Bylaws...” A review of the facility’s P&P titled, “UNIVERSAL PROTOCOL- COMPREHENSIVE SURGICAL CHECKLIST,” revised May 2024, was conducted. The policy indicated, “...All patients having an operative or other invasive procedure shall have steps taken in the pre procedure [before the procedure] period to assure verification of the correct person, procedure, and site. The patient should be awake and aware and able to participate if possible...The team confirms the following during Time-out...Team member introductions...Patient identity using two patient identifiers...Procedure and procedure site/side...Completion of consent form (s)...DEFINITION OF SURGICAL OR OTHER PROCEDURES FOR APPLICATION OF UNIVERSAL PROTOCOL...Surgical or other invasive procedures are those involving a skin incision or puncture including insertion of an instrument or foreign material into the body. These procedures expose patients to more than minimal risk and may be performed in settings other than the operating room...” 2a. On June 11, 2025, at 3 p.m., a review of Patient 4’s record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, “Emergency Department Record,” dated June 11, 2025, at 7:38 a.m., was reviewed. The document indicated Patient 4 was admitted to the emergency room on June 11, 2025, for a head injury after an assault. A facility document titled, “Flowsheet,” dated June 11, 2024, at 8 a.m., was reviewed. The document indicated Patient 4 complained of forehead pain using a pain rating scale (a tool used to measure and quantify pain intensity, with ten meaning severe pain) rating of seven out of ten. A facility document titled, “Med [Medication] Admin [Administration],” dated June 11, 2025, at 8:13 a.m., was reviewed. The document indicated, “...Acetaminophen [a pain medication] 500 mg [milligram, unit of measurement] Tablet...Order Dose...1000 MG...Route...Oral...,” was administered to Patient 4 on June 11, 2025, at 8:15 a.m. Based on record review, there was no documented evidence Patient 4’s pain was reassessed after acetaminophen was administered on June 11, 2025, at 8:15 a.m. On June 11, 2025, at 3:30 p.m., an interview was conducted with the PSC. The PSC stated, “...there should have been a pain level reassessed [sic] after pain medication was administered and there was nothing documented by the nurse...” 2b. On June 12, 2025, at 2:30 p.m., a review of Patient 12’s record was conducted with the Clinical Nurse Manager (CNM). A facility document titled, “History and Physical Note,” dated June 9, 2025, at 7:53 a.m., was reviewed. The document indicated Patient 12 was admitted to the facility on June 9, 2025, for increased weakness and diarrhea. A facility document titled, “Flowsheet,” dated June 9, 2025, at 2:47 a.m., was reviewed. The document indicated a pain scale rating of six out of ten to the right foot on June 9, 2025, at 2:47 a.m. A facility document titled, “Medication Administration History Report,” dated June 9, 2025, at 2:47 a.m., was reviewed. The document indicated, “...Medication...KETOROLAC [a pain medication] 30 MG/ML [milligram per milliliter, unit of measurement]...TORADOL [brand name of ketorolac]...Order Dose...15 MG/0.5 ML...Frequency...EVERY 6 [six] HOURS AS NEEDED...Route...INTRAVENOUS [administered through a vein]...” The document indicated a dose of ketorolac was administered to Patient 4 on June 9, 2025, at 2:47 a.m. Based on record review, there was no documented evidence Patient 12’s pain was reassessed after ketorolac was administered on June 9, 2025, at 2:47 a.m. On June 12, 2025, at 2:45 p.m., an interview was conducted with the CNM. The CNM stated, “...they should have reassessed the pain after pain medication was given...it was not documented...” A review of the facility policy and procedure titled, “Pain Management,” dated September 2024, was conducted. The policy indicated, “...If a treatment intervention for pain is provided, the response to that intervention should be assessed...within 15-60 minutes following treatment...””

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 48776 Based on interview and record review, the facility failed to ensure only providers who have been granted credentials (a process facilities use to make sure a physician is qualified to care for patients which includes checking the physician’s education, training, licensee, background, and work history) and privileges (a process which is completed after credentialing to allow a physician to care for patients in the facility) are allowed to provide care to patients at the facility, for one of 12 sample patients (Patient 3), when a physician (MD 2), who have not been credentialed nor been granted privileges in the facility performed the drainage of a retropharyngeal hematoma (an accumulation of blood which develop in the neck area) and insertion of a Hemovac drain (a closed suction system used to remove excess blood and fluid from a surgical site) in the Emergency Department (ED). This failure had the potential to cause harm to Patient 3 due to MD 2’s unverified clinical education, skills, and experience. Findings: On June 11, 2025, at 10 a.m., an interview was conducted with the Emergency Department Manager (EDM). The EDM stated a physician (MD 2) dressed in street clothes with a badge which indicated “Surgeon” gained entrance to the Emergency Department (ED) through the ambulance bay doors on May 29, 2025. The EDM stated MD 2 was known to Patient 3. The EDM stated MD 2 contacted the ED physician on duty (MD 1) earlier that day to notify MD1 Patient 3 would be coming to the ED. EDM stated MD 2 did not have credentials (a process facilities use to make sure a physician is qualified to care for patients which includes checking the physician’s education, training, licensee, background, and work history) nor privileges (a process which is completed after credentialing to allow a physician to care for patients in the facility) at the facility. The EDM stated MD 2 asked multiple ED staff members for supplies and was provided with the items needed to drain Patient 3’s retropharyngeal hematoma and insert a Hemovac drain. The EDM stated these were invasive procedures which required a written informed consent from the patient, but an informed consent was not obtained from the patient for the procedures which were performed by MD 2. On June 11, 2025, at 10:10 a.m., an interview was conducted with the Deputy Regional Director of Quality (DOQ). The DOQ stated MD 2 did not have privileges at the facility and should not have performed the procedure on Patient 3. The DOQ further stated MD 2 could have asked for emergency privileges (a process where in an emergency, a facility temporarily allows a physician to treat the patient) and this was not done. On June 11, 2025, at 10:20 a.m., an interview was conducted with Registered Nurse (RN) 1 who cared for Patient 3 on May 29, 2025. RN 1 stated she saw MD 2 speaking with Patient 3. RN 1 stated she was not informed by MD 2 Patient 3 needed a procedure or an informed consent. RN 1 stated Patient 3’s retropharyngeal hematoma drainage and Hemovac insertion were invasive procedures which required an informed consent from the patient. On June 11, 2025, at 10:30 a.m., an interview was conducted with the Emergency Department technician (EDT) 1, who provided care for Patient 3 on May 29, 2025. EDT 1 stated MD 2 was wearing a badge which indicated “Surgeon.” EDT 1 stated MD 2 requested for a suture (surgical stitch) removal kit, gauze, tape, and a Hemovac drain. EDT 1 stated he and MD 2 gathered the supplies from the supply room. On June 11, 2025, at 11:15 a.m., an interview and review of video footage of the incident on May 29, 2025, was conducted with the Director of Facilities and Security (DOF). MD 2 was observed gaining access to the ED by entering through the ambulance bay doors, which was still open after a staff member exited through the bay doors. MD 2 was then observed looking at room numbers in the hall and eventually entering (number of Patient 3’s room). MD 2 was then observed putting gloves on and setting up supplies on a linen cart located inside Patient 3’s room. Then, MD 1 and RN 1 were observed to be in Patient 3’s room prior to MD 2 leaving the facility. The DOF stated MD 2 should not have entered the ED through the secured ambulance bay doors on May 29, 2025. On June 11, 2025, at 2 p.m., an interview was conducted with the Chief Quality and Patient Safety Officer (CQO). The CQO verified MD 2 did not have credentials and privileges to treat patients at the facility. The CQO stated Patient 3’s retropharyngeal hematoma drainage and Hemovac insertion were invasive procedures and an informed consent should have been obtained from Patient 3 prior to MD 2 performing the procedures. The CQO further stated MD 2 should not have performed the procedures because MD 2 did not have the necessary credentials and privileges at the facility. On June 11, 2025, at 2:20 p.m., an interview was conducted with the Chief Medical Officer (CMO). The CMO stated the facility staff should not have provided supplies to MD 2 to perform the drainage of the retropharyngeal hematoma and Hemovac drain insertion on Patient 3. The CMO stated MD 2 did not have privileges at the facility and should not have performed the procedures on Patient 3. On June 11, 2025, at 3:30 p.m., Patient 3’s record was reviewed with the CQO. A facility document titled, “Triage,” dated May 29, 2025, was reviewed and indicated Patient 3 arrived at the Emergency Department (ED) on May 29, 2025, at 4:26 p.m., with bleeding on his neck lasting two days. A facility document titled, “[Name of Facility] Emergency Department Record,” authored by MD 1, dated May 29, 2025, was reviewed and indicated Patient 3 presented to the ED, “...complaining of difficulty swallowing over the past two days. Patient [Patient 3] had a surgery performed by Dr. [Name of MD 2], who advised the patient to present to the ED for further evaluation for possible postsurgical [after a surgery] retropharyngeal hematoma...In conversation with MD 2, he ias [sic] concerned that patient may have a large retropharyngeal hematoma, which would make it impossible to intubate [inserting a breathing tube down the throat to help a person breath] patient or otherwise secure an airway unless retropharyngeal hematoma is evacuated emergently. He stated that if this is necessary, he could walk me through the procedure...” A facility document, titled “[Name of Facility 2] Operative Report,” authored by MD 2, dated June 2, 2025, was reviewed and indicated, “...DATE OF OPERATION: 05/29/2025 [May 29, 2025]...LOCATION: [Name of Facility]...INDICATIONS FOR PROCEDURE: The patient [Patient 3]...is 2 [two] days status post [after] anterior cervical decompression and fusion [neck surgery where damaged disc is removed from the spine bone, filling the space, and connecting the spine bones together)...which was performed at [Name of Facility 3] and was admitted overnight with a postoperative Hemovac drain...He was doing reasonably well postoperatively [after the surgery] and after the drain was removed, he was discharged home the day after surgery, but I was instructed by his son the evening after discharge that he had sanguinous [bloody] drainage on his dressings, but was not in undue distress at that time. I instructed them to monitor this and let me know if things worsened and unfortunately, the following day I was contacted by the patient who informed me that he had severe difficulty swallowing and was starting to have increased swelling in his neck as well as generalized distress. I was concerned that this likely represented an expanding retropharyngeal hematoma that was potentially life threatening because of obstruction. He presented to [Name of Facility] ED...PROCEDURE IN DETAIL...Under sterile technique at bedside in the Emergency Department...a suture [surgical stitch] removal kit was used...the retropharyngeal hematoma was evacuated [removed]...Hemovac drain was inserted and the wound was closed with skin staples...” On June 12, 2025, at 8:05 a.m., an interview was conducted with MD 1. MD 1 stated Patient 3 presented to the ED for evaluation of bleeding from a surgical site previously operated on by MD 2. MD 1 stated the patient was stable and medications and a computed tomography scan (an imaging procedure) were ordered for Patient 3. MD 1 stated MD 2 had contacted him earlier in the day, with concerns Patient 3’s presumed retropharyngeal hematoma might require emergent evacuation to prevent a life-threatening situation. MD 1 stated MD 2 informed him that he would be coming to the ED to evaluate Patient 3. MD 1 stated Patient 3 arrived at the ED several hours later and upon MD 2’s arrival, MD 2 did not inform him he intended to perform a procedure on Patient 3’s bedside. MD 1 stated, when he entered Patient 3’s room, MD 2 had already evacuated the retropharyngeal hematoma and placed a surgical drain. MD 1 stated he informed MD 2 that he did not have privileges to provide care to Patient 3. MD 1 stated MD 2 responded he should have requested emergency privileges, but had not done so. MD 1 stated MD 2 subsequently left the ED. On June 12, 2025, at 9 a.m., an interview was conducted with the Director of Medical Staff Administration (DMS). The DMS stated MD 2 did not have privileges to treat patients at the facility. The DMS stated there are credentialing and privileging processes which is followed by the facility before a physician could provide treatment to the patients at the facility. On June 12, 2025, at 9:50 a.m., an interview was conducted with MD 2. MD 2 stated he spoke to MD 1 earlier in the day on May 29, 2025, and informed him Patient 3 would be coming to the facility’s and he would be coming in to evaluate Patient 3 due to a concern for a life threatening retropharyngeal hematoma. MD 2 acknowledged that he did not have privileges at the facility and did not request emergency privileges to treat Patient 3 at the facility. MD 2 stated he performed bedside procedures on Patient 3, during which he evacuated the retropharyngeal hematoma and inserted a surgical drain. MD 2 stated he did not consult with MD 1 prior to performing the procedures. MD 2 stated he dictated a procedure note at a sister facility (Facility 2) because he did not have privileges at the facility and requested the note to be placed in Patient 3’s chart. A review of the facility document titled, “MEDICAL STAFF BYLAWS AND RULES & REGULATIONS - Medical Staff Administration,” revised June 25,2024, was conducted. The document indicated, “...No physician...shall admit or provide medical or health-related services to patients in the Hospital unless he or she is a member of the Medical Staff or has been granted privileges in accordance with the procedures set forth in these Bylaws. Appointment to the Medical Staff shall confer only such clinical privileges as have been granted in accordance with these Bylaws...TEMPORARY CLINICAL PRIVILEGES...Temporary privileges are allowed under two circumstances only: to address a patient care need and to permit patient care to be provided while an application is pending. Temporary privileges for applicants may be granted for no more than 120 cumulative days per 12 months...Care of specific patient...temporary clinical privileges may be granted where good cause exists to allow a physician, dentist or podiatrist to provide care to a specific patient, but not more than 60 days...””

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 48776 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for one of 12 sample patients (Patient 3), when a signed informed consent was not obtained prior to the drainage of a retropharyngeal hematoma (an accumulation of blood which develop in the neck area) and insertion of a Hemovac drain (a closed suction system used to remove excess blood and fluid from a surgical site), time out (a safety step conducted by the surgery staff before a surgical procedure to ensure the procedure is done with the correct patient, procedure, procedure site, and whether the informed consent was signed by the patient) was not conducted prior to the procedure, and a physician who had not been granted credentials (a process facilities use to make sure a physician is qualified to care for patients which includes checking the physician’s education, training, licensee, background, and work history) and privileges (a process which is completed after credentialing to allow a physician to care for patients in the facility) performed a procedure on the patient in the Emergency Department (ED). These failures had the potential to impact the health, safety, and treatment of Patient 3, and may cause harm to the patient. Findings: On June 11, 2025, at 10 a.m., an interview was conducted with the Emergency Department Manager (EDM). The EDM stated a physician (MD 2) dressed in street clothes with a badge which indicated “Surgeon” gained entrance to the Emergency Department (ED) through the ambulance bay doors on May 29, 2025. The EDM stated MD 2 was known to Patient 3. The EDM stated MD 2 contacted the ED physician on duty (MD 1) earlier that day to notify MD1 Patient 3 would be coming to the ED. EDM stated MD 2 did not have credentials (a process facilities use to make sure a physician is qualified to care for patients which includes checking the physician’s education, training, licensee, background, and work history) nor privileges (a process which is completed after credentialing to allow a physician to care for patients in the facility) at the facility. The EDM stated MD 2 asked multiple ED staff members for supplies and was provided with the items needed to drain Patient 3’s retropharyngeal hematoma and insert a Hemovac drain. The EDM stated these were invasive procedures which required a written informed consent from the patient, but an informed consent was not obtained from the patient for the procedures which were performed by MD 2. On June 11, 2025, at 10:10 a.m., an interview was conducted with the Deputy Regional Director of Quality (DOQ). The DOQ stated MD 2 did not have privileges at the facility and should not have performed the procedure on Patient 3. The DOQ further stated MD 2 could have asked for emergency privileges (a process where in an emergency, a facility temporarily allows a physician to treat the patient) and this was not done. On June 11, 2025, at 10:20 a.m., an interview was conducted with Registered Nurse (RN) 1 who cared for Patient 3 on May 29, 2025. RN 1 stated she saw MD 2 speaking with Patient 3. RN 1 stated she was not informed by MD 2 Patient 3 needed a procedure or an informed consent. RN 1 stated Patient 3’s retropharyngeal hematoma drainage and Hemovac insertion were invasive procedures which required an informed consent from the patient and time out was required. On June 11, 2025, at 10:30 a.m., an interview was conducted with the Emergency Department technician (EDT) 1, who provided care for Patient 3 on May 29, 2025. EDT 1 stated MD 2 was wearing a badge which indicated “Surgeon.” EDT 1 stated MD 2 requested for a suture (surgical stitch) removal kit, gauze, tape, and a Hemovac drain. EDT 1 stated he and MD 2 gathered the supplies from the supply room. On June 11, 2025, at 11:15 a.m., an interview and review of video footage of the incident on May 29, 2025, was conducted with the Director of Facilities and Security (DOF). MD 2 was observed gaining access to the ED by entering through the ambulance bay doors, which was still open after a staff member exited through the bay doors. MD 2 was then observed looking at room numbers in the hall and eventually entering (number of Patient 3’s room). MD 2 was then observed putting gloves on and setting up supplies on a linen cart located inside Patient 3’s room. Then, MD 1 and RN 1 were observed to be in Patient 3’s room prior to MD 2 leaving the facility. The DOF stated MD 2 should not have entered the ED through the secured ambulance bay doors on May 29, 2025. On June 11, 2025, at 2 p.m., an interview was conducted with the Chief Quality and Patient Safety Officer (CQO). The CQO verified MD 2 did not have credentials and privileges to treat patients at the facility. The CQO stated Patient 3’s retropharyngeal hematoma drainage and Hemovac insertion were invasive procedures and an informed consent should have been obtained from Patient 3 prior to MD 2 performing the procedures. The CQO further stated MD 2 should not have performed the procedures because MD 2 did not have the necessary credentials and privileges at the facility. On June 11, 2025, at 2:20 p.m., an interview was conducted with the Chief Medical Officer (CMO). The CMO stated the facility staff should not have provided supplies to MD 2 to perform the drainage of the retropharyngeal hematoma and Hemovac drain insertion on Patient 3. The CMO stated MD 2 did not have privileges at the facility and should not have performed the procedures on Patient 3. On June 11, 2025, at 3:30 p.m., Patient 3’s record was reviewed with the CQO. A facility document titled, “Triage,” dated May 29, 2025, was reviewed and indicated Patient 3 arrived at the Emergency Department (ED) on May 29, 2025, at 4:26 p.m., with bleeding on his neck lasting two days. A facility document titled, “[Name of Facility] Emergency Department Record,” authored by MD 1, dated May 29, 2025, was reviewed and indicated Patient 3 presented to the ED, “...complaining of difficulty swallowing over the past two days. Patient [Patient 3] had a surgery performed by Dr. [Name of MD 2], who advised the patient to present to the ED for further evaluation for possible postsurgical [after a surgery] retropharyngeal hematoma...In conversation with MD 2, he ias [sic] concerned that patient may have a large retropharyngeal hematoma, which would make it impossible to intubate [inserting a breathing tube down the throat to help a person breath] patient or otherwise secure an airway unless retropharyngeal hematoma is evacuated emergently. He stated that if this is necessary, he could walk me through the procedure...” A facility document, titled “[Name of Facility 2] Operative Report,” authored by MD 2, dated June 2, 2025, was reviewed and indicated, “...DATE OF OPERATION: 05/29/2025 [May 29, 2025]...LOCATION: [Name of Facility]...INDICATIONS FOR PROCEDURE: The patient [Patient 3]...is 2 [two] days status post [after] anterior cervical decompression and fusion [neck surgery where damaged disc is removed from the spine bone, filling the space, and connecting the spine bones together)...which was performed at [Name of Facility 3] and was admitted overnight with a postoperative Hemovac drain...He was doing reasonably well postoperatively [after the surgery] and after the drain was removed, he was discharged home the day after surgery, but I was instructed by his son the evening after discharge that he had sanguinous [bloody] drainage on his dressings, but was not in undue distress at that time. I instructed them to monitor this and let me know if things worsened and unfortunately, the following day I was contacted by the patient who informed me that he had severe difficulty swallowing and was starting to have increased swelling in his neck as well as generalized distress. I was concerned that this likely represented an expanding retropharyngeal hematoma that was potentially life threatening because of obstruction. He presented to [Name of Facility] ED...PROCEDURE IN DETAIL...Under sterile technique at bedside in the Emergency Department...a suture [surgical stitch] removal kit was used...the retropharyngeal hematoma was evacuated [removed]...Hemovac drain was inserted and the wound was closed with skin staples...” On June 12, 2025, at 8:05 a.m., an interview was conducted with MD 1. MD 1 stated Patient 3 presented to the ED for evaluation of bleeding from a surgical site previously operated on by MD 2. MD 1 stated the patient was stable and medications and a computed tomography scan (an imaging procedure) were ordered for Patient 3. MD 1 stated MD 2 had contacted him earlier in the day, with concerns Patient 3’s presumed retropharyngeal hematoma might require emergent evacuation to prevent a life-threatening situation. MD 1 stated MD 2 informed him that he would be coming to the ED to evaluate Patient 3. MD 1 stated Patient 3 arrived at the ED several hours later and upon MD 2’s arrival, MD 2 did not inform him he intended to perform a procedure on Patient 3’s bedside. MD 1 stated, when he entered Patient 3’s room, MD 2 had already evacuated the retropharyngeal hematoma and placed a surgical drain. MD 1 stated he informed MD 2 that he did not have privileges to provide care to Patient 3. MD 1 stated MD 2 responded he should have requested emergency privileges, but had not done so. MD 1 stated MD 2 subsequently left the ED. On June 12, 2025, at 9 a.m., an interview was conducted with the Director of Medical Staff Administration (DMS). The DMS stated MD 2 did not have privileges to treat patients at the facility. The DMS stated there are credentialing and privileging processes which is followed by the facility before a physician could provide treatment to the patients at the facility. On June 12, 2025, at 9:50 a.m., an interview was conducted with MD 2. MD 2 stated he spoke to MD 1 earlier in the day on May 29, 2025, and informed him Patient 3 would be coming to the facility’s and he would be coming in to evaluate Patient 3 due to a concern for a life threatening retropharyngeal hematoma. MD 2 acknowledged that he did not have privileges at the facility and did not request emergency privileges to treat Patient 3 at the facility. MD 2 stated he performed bedside procedures on Patient 3, during which he evacuated the retropharyngeal hematoma and inserted a surgical drain. MD 2 stated he did not consult with MD 1 prior to performing the procedures. MD 2 stated he dictated a procedure note at a sister facility (Facility 2) because he did not have privileges at the facility and requested the note to be placed in Patient 3’s chart. A review of the facility’s P&P titled, “INFORMED CONSENT,” revised September 2024, was conducted. The policy indicated, “...the hospital is required to obtain documentation of consent to hospital services and to verify that the physician has obtained informed consent as appropriate...A procedural consent form, dated, timed, and signed by the patient and witnesses by hospital staff are required for surgical invasive procedures...” A review of the facility’s P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES,” revised November 2022, was conducted. The policy indicated, “...All patients at [name of Facility] have the right to...Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as they may need in order to give informed consent or to refuse a course of treatment...This information shall include a description of the procedure or treatment, the medically significant risks involved, alternate courses of treatment or non-treatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment...” A review of the facility’s P&P titled, “UNIVERSAL PROTOCOL- COMPREHENSIVE SURGICAL CHECKLIST,” revised May 2024, was conducted. The policy indicated, “...All patients having an operative or other invasive procedure shall have steps taken in the pre procedure period to assure verification of the correct person, procedure, and site. The patient should be awake and aware and able to participate if possible...The team confirms the following during Time-out...Team member introductions...Patient identity using two patient identifiers...Procedure and procedure site/side...Completion of consent form (s)...DEFINITION OF SURGICAL OR OTHER PROCEDURES FOR APPLICATION OF UNIVERSAL PROTOCOL...Surgical or other invasive procedures are those involving a skin incision or puncture including insertion of an instrument or foreign material into the body. These procedures expose patients to more than minimal risk and may be performed in settings other than the operating room...” A review of the facility document titled, “MEDICAL STAFF BYLAWS AND RULES & REGULATIONS - Medical Staff Administration,” revised June 25,2024, was conducted. The document indicated, “...No physician...shall admit or provide medical or health-related services to patients in the Hospital unless he or she is a member of the Medical Staff or has been granted privileges in accordance with the procedures set forth in these Bylaws. Appointment to the Medical Staff shall confer only such clinical privileges as have been granted in accordance with these Bylaws...TEMPORARY CLINICAL PRIVILEGES...Temporary privileges are allowed under two circumstances only: to address a patient care need and to permit patient care to be provided while an application is pending. Temporary privileges for applicants may be granted for no more than 120 cumulative days per 12 months...Care of specific patient...temporary clinical privileges may be granted where good cause exists to allow a physician, dentist or podiatrist to provide care to a specific patient, but not more than 60 days...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to comply with the provisions in 42 CFR 489.20 and 42 CFR 489.24, when the facility’s policies and procedures were not implemented, for one of 22 sample patients (Patient 22). Patient 22 was not stabilized before the patient was transferred from the Emergency Department (ED) to an outpatient clinic in another county. This failure had the potential to result in delay in treatment and may compromise the patient’s condition.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 42512 Based on interview and record review, the hospital failed to ensure an accurate central log (a list of patients who came to the Emergency Department [ED]) of each individual who came to the ED was maintained, when the mode of transportation of the patients who came to the ED was not documented for multiple days. This failure resulted in incomplete information for patients seen in the ED. Findings: On May 28, 2025, at 9:45 a.m., a review of the ED log was conducted. The review indicated the facility did not enter the mode of transportation for each patient who came to the ED from March 19, 2025, through May 21, 2025 (64 days). On May 28, 2025, at 9:49 a.m., an interview with the Chief Quality Officer (CQO) was conducted. The CQO stated it was important to keep an accurate ED central log. The CQO stated the upgrade to the facility’s electronic medical record system must have caused the issue. The CQO stated the ED central log should have been complete and it was not. A facility policy and procedure titled, “EMTALA-CENTRAL LOG POLICY,” dated April 2023, was reviewed. The document indicated, “...The logs must contain at a minimum, the name of the individual, the date, time and means of the individual’s arrival, the individual age, the individual’s sex, the individual’s record number, the nature of the individual’s complaint, the individual’s disposition, the individual’s time of departure...””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 44871 Based on interview and record review, the facility failed to ensure a patient was stabilized before the patient was transferred from the Emergency Department (ED) to an outpatient clinic in another county, for one of 22 sample patients (Patient 22). This failure could have caused the Patient 22’s condition to further decline and had the potential to cause harm and/or death to the patient. Findings: On May 29, 2025, at 11:13 a.m., a concurrent interview and review of Patient 22’s record were conducted with Registered Nurse (RN) 1. A facility document titled, “Triage [a system for prioritizing patients for treatment],” dated March 31, 2025, at 7:22 a.m., was reviewed. The document indicated Patient 22 was seen at the facility for a chief complaint of abnormal laboratory (lab) results. The document indicated, “...Acuity [severity of patient’s illness]: 3 - Urgent...Vitals and Measurements...31-Mar-2025 [March 31, 2025] 07:25 [7:25 a.m.]...Temp [temperature]: 97 F [Fahrenheit, unit of measurement, normal is 97.7 - 99.0] (Forehead)...Resp [respiration, normal is 12-20 breaths per minute]:16...HR[heart rate, normal is 60-100 beats per minute (bpm)]: 86...BP [blood pressure, normal is 120/80] 1: 90/45...” A facility document titled, “Assessment Type: Daily,” dated March 31, 2025, 7:24 a.m., authored by Case Manager (CM) 1 was reviewed. The document indicated, “...Spoke with [name of Facility A Clinic Staff 1] at [Name of outpatient Facility A’s telephone number] to confirm pt’s [Patient 22] outpatient appointment. Per [Name of Internal Medicine Physician 1] to transfer pt from ER to her appointment in [Name of Facility A] Per [Facility Clinic Staff 1], pt has appointment on 4-1-25 [April 1, 2025] W [with] [Name of physician scheduled to see patient at the outpatient clinic], for pt to be there at 0945 [9:45 a.m.] for a 1045am [10:45 a.m.] procedure. Procedure will be done at [Name of Facility A] med [medical] ctr. [center] Comp. [Comprehensive] Digestive Disease Center, [address of outpatient clinic]. Pre procedure instructions received [name of Facility A Clinic Staff 1]. ALS [Advanced Life Support (lifesaving protocols, interventions airway management and cardiac monitoring] transport arranged w/ [Name of person who works at transportation company] for a 5am [5 a.m.] ETA [estimated time of arrival]...will call return transport back to [Name of facility] arranged w/ [Name of employee who works at transportation company]...” A facility document titled, “Emergency Department Record,” dated March 31, 2025, at 7:27 a.m., was reviewed. The document indicated, “...female presents to the ER [Emergency Room, ED] via [by way of] EMS [Emergency Medical Services, ambulance service] for evaluation of abnormal lab values [results]. Patient [Patient 22] reported to have a gallbladder surgery and was found to have a doubled white count [WBC, white blood cells, a component of the blood with high levels signifying possible infection, normal range is between 3.6-11.2] at [name of skilled nursing facility]...Past surgical history: Cholecystectomy [a surgery to remove the gallbladder], Biliary Stent Placement [a thin hollow tube inserted into the bile duct to keep it open]...Physical Examination...Abdomen...Purulent [with pus drainage from JP [Jackson-Pratt drain, a medical device used to drain fluid] drain...WBC 15.8...1232 [12: 32 p.m.] Patient will be admitted to Telemetry [unit where the patient will receive continuous remote monitoring of the heart rate and rhythm]...1257 [12:57 p.m.] [Name of Surgeon 1]...General Surgery, called back and states to try to send patients [sic] to [name of Facility A] instead...1330 [1:30 p.m.] [name of Facility A] unable to accept patient for transfer but patient can follow upas [sic] she has an appointment...1340 [1:40 p.m.]...Patient is appearing septic [a serious medical condition that occurs when body responds to an infection]. Heart rate is 115bpm with blood pressure at 89/49. Will give vanco [vancomycin, a medication to treat infections] and more fluids [fluids administered through the vein]...Disposition Time...12:32 [12:32 p.m.]...Condition: Critical...Diagnosis: Acute Intraabdominal Abscesses [collection of pus in the abdomen]...” A facility document titled, “Vitals,” dated March 31, 2025, at 7:50 a.m., through April 1, 2025, at 6:06 a.m., was reviewed. The document indicated Patient 22’s vital signs (HR, Resp, Temp, and BP) on the following dates and times: - on March 31, 2025, at 7:50 a.m., Temp 98.2 F...HR 86...Resp 14...BP 105/52; - on March 31, 2025, at 10 a.m., Temp 98.4 F...HR 94...Resp 14...BP 110/58; - on March 31, 2025, at 12 p.m., Temp 98.2 F...HR 102...Resp 16...BP 125/52; - on March 31, 2025, at 2 p.m., Temp 98.4 F...HR 108...Resp 16...BP 109/51; - on March 31, 2025, at 8 p.m., Temp 96 F...HR 114...Resp 20...BP 100/51; - on March 31, 2025, at 10 p.m., Temp 97.8 F...HR 116...Resp 22 ...BP 103/42; - on April 1, 2025, at 2 a.m., Temp 98 F...HR 102...Resp 19...BP 97/50; - on April 1, 2025, at 4 a.m., Temp 98.1...HR 104...Resp 21...BP 100/48; and - on April 1, 2024, at 6:06 a.m., Temp 98 F...HR 92 ...Resp 18...BP 123/42. A facility document titled, “Order Entry,” dated March 31, 2025, at 12:35 p.m., was reviewed. The document indicated, “...Admit to Inpatient Telemetry...Instructions...Intrabdominal Abscesses s/p [status post, after] recent Cholecystectomy under [Name of Internal Medicine Physician 1]...Reason/Indication: Epigastric pain...” A facility document titled, “Order Entry,” dated March 31, 2025, at 12:39 p.m., was reviewed. The document indicated, “...Admit To Inpatient - Telemetry...Discontinued...” (Four minutes after the initial admission order was given) A facility document titled, “TRANSFER SUMMARY AND CERTIFICATION,” dated March 31, 2025, at 4:54 p.m., authored by [Internal Medicine Physician] 1, was reviewed. The document indicated, “...Patient has been stabilized such that within medical probability, no material deterioration of the patient’s condition or the condition of the unborn child(ren) is likely to result from transfer...Time of Transfer...0606 [6:06 a.m.]...Vital Signs...BP 124/62; HR 92; RR 18; O2 sat 99; Temp 98.0...TRANSFER REQUIREMENTS...The receiving facility [Name of Facility A Digestive Disease Center] has available space and qualified personnel for treatment as acknowledged by [Facility A Clinic Staff 1]...The receiving physician has agreed to accept transfer and to provide appropriate medical treatment as acknowledged by...[Name of physician scheduled to see patient at the outpatient clinic]...Appropriate medical records of the examination and treatment of the patient are provided at the time of transfer as follows...Physician’s record; Lab Results; Diagnostics; EKG...The physician has determined that appropriate means of transportation for transfer which includes qualified personnel and transportation equipment as required...CCT [Critical Care Transport]...Provider Certification...Signature of Physician: [signed by Internal Medicine Physician 1]...” A facility document titled, “Assessment Type, Daily,” dated March 31, 2025, at 5:15 p.m., authored by RN 2 was reviewed. The document indicated, “...[Name of ED Physician] at bedside, assessing pt [Patient 22], Dr. [doctor] stated tht [sic, that] the pt appears septic. MD does nto [sic, not] want to call a cde [sic, code] sepsis [serious medical condition that occurs when body responds to an infection], he requested luids [sic, fluids] and antibiotics [medications to treat infections], pt is having a procedure tomorrow at [Name of Facility A], pt neds [sic, needs] to be at the appointment to have her stent [tiny tube placed in a hollow structure of the body] removed as it is cauing [sic, causing] an infection in her abdomen. MD made aware of pts low pbp [sic, blood pressure], he requested fluids until her bp improves. 2 [two] L [liters, unit of measurement] in so far...” A facility document titled, “Order Entry,” dated March 31, 2025, at 6:09 p.m., was reviewed. The document indicated, “...Discharge to Home...Instructions...Intraabdominal pain/ abscess...to [Name of Facility A] gi [gastrointestinal, pertaining to the stomach and intestines] lab...” A facility document titled, “Assessment Type Daily,” dated March 31, 2025, at 8 pm., was reviewed. The document indicated, “...patient had cholecystectomy 2 weeks ago then another surgery for stents placement, patient was discharged to [name of skilled nursing facility], patient had a JP to low right quadrant [an area o f the abdomen] with green discharge...bloodpressure [sic, blood pressure ] low withSBP [sic] [systolic blood pressure, top number in blood pressure reading that represents pressure in the artery when heart beats, normal is 120] in 90’s...at this time patient is pending transport to [Name of Facility A] for surgery to remove stents. NPO [nothing by mouth] after midnight...” A facility document titled, “Assessment Type Daily,” dated April 1, 2025, at 6:06 a.m., was reviewed. The document indicated, “...patient departed ED with medical transport, on monitor, with vanoc [sic, vancomycin] running at 125ml/hr [milliliter per hour, unit of measurement]...patient transferred to [Name of Facility A]...” There was no documented evidence the Internal Medicine Physician evaluated or assessed Patient 22. There was no documented evidence Patient 22 was assessed in accordance with the facility’s sepsis protocol. There was not documented evidence a Code Sepsis was called for Patient 22. On May 29, 2025, at 11:47 a.m., a concurrent interview and review of Patient 22’s record were conducted with RN 1. RN 1 stated the SIRS [systemic inflammatory response syndrome, a group of symptoms resulting from an inflammatory response in body] criteria [criteria for evaluating for sepsis] was not followed. RN 1 stated Patient 22 met the SIRS criteria due to increased heart rate, increased WBCs, and having a cholecystectomy two weeks ago. He further stated the sepsis protocol [set of guidelines designed to help healthcare providers to quickly identify and treat sepsis] should have been called. On May 29, 2025, at 12:02 p.m., a concurrent interview and review of Patient 22’s record were conducted with RN 2. RN 2 stated a code sepsis should have been called because Patient 22’s heart rate was 108, the blood pressure was low at 109/51, and the patient’s JP drain had light green drainage which would have been the source of sepsis. RN 2 further stated a code sepsis was not called even though the patient met criteria. On May 29, 2025, at 1:27 p.m., a concurrent interview and record review were conducted with CM 1. CM 1 stated she was told to transfer Patient 22 to an appointment that had been previously made before her hospitalization. CM 1 stated, “I did not give anyone report at the facility because the patient was going to an appointment.” She stated, “I set up transportation the day before.” CM 1 further stated there was no transfer order in the chart and there was an order to the patient to her home. CM 1 stated, as far as I knew, the patient was transferred to an outpatient appointment and was not transported to their home. On May 29, 2025, at 2:20 p.m., a concurrent interview and review of Patient 22’s record were conducted with ED Physician 1. ED Physician 1 stated, due to the patient’s blood pressure, Patient 22 could have met the sepsis criteria. ED physician 1 stated he did not order a lactic acid test (blood test to determine that cells are not getting enough oxygen due to serious infection because he felt Patient 22 was probably not septic. After reading his ED notes which indicated, “Patient is appearing septic...Condition: Critical...,” ED Physician 1 stated, “If it’s there then I wrote it.” ED Physician 1 stated he spoke with Internal Medicine Physician 1 and the general surgeon on call who both agreed Patient 22 needed to be transferred to [name of Facility A] to have the infected stent removed. ED Physician 1 stated a direct transfer to [name of Facility 2] was attempted but there were no beds available, and he was told [name of Facility 2] was closed to transfers. ED physician 1 stated Patient 22 was too sick to go back to a skilled nursing facility. The facility policy and procedure (P&P) titled, “VITAL SIGNS-STANDARD OF CARE,” dated September 2024, was reviewed. The policy indicated, “...Vital signs should be obtained on all patients ESI level 3 [three], 4 [four], and 5 [five], upon triage. Vital Signs should be repeated per patient condition and per interventions to assess response or at least every 2 hours...” A facility P&P titled, “ADULT SEPSIS SCREENING AND PHYSICIAN APPROVED NURSING SEPSIS,” dated May 2024, was reviewed. The policy indicated, “...This health system protocol applies to Registered Nurses (RNs) only and include the Emergency Department (ED) and inpatient populations >18 years of age...Systemic Inflammatory Response Syndrome (SIRS) = two (2) or more of the following....Temperature above 100.9F or less than 96.8 °F...Heart rate greater than 90 beats/min...Respiration rate is greater than 20 breaths/min or PaCO2 less than 32mmHg...WBC greater than 12,000 cells/mm3 or less than 4,000 cells/mm3, or greater than 10% bands...Sepsis = Two (2) or more SIRS criteria plus a suspected or confirmed infection...SEPSIS TEAM MEMBERS & RESPONSIBILITIES...Registered Nurse caring for the patient....Initiate code sepsis when sepsis, severe sepsis, or septic shock is recognized...Initiate and maintain the sepsis protocol as outlined under procedure ...Completing the Sepsis Worksheet and forwarding to appropriate department Leader when complete...Emergency Department Physician...Team Lead for ED code sepsis...Must work collaboratively with Charge Nurse & Registered Nurse...Must oversee completion of Sepsis Worksheet and confirm with print name...” A facility P&P titled, “EMTALA - DEFINITION AND GENERAL REQUIRMENTS,” dated April 2023, was reviewed. The policy indicated, “...To require, in conjunction with state-specific policies, that an acute care or specific hospital with an emergency department provide an appropriate medical screening examination and any necessary stabilizing treatment to ant individual, including every infant who id born alive, at any stage of development, who comes to the emergency Department and request such examination, as required by EMTALA and all Federal regulations and interpretive guidelines promulgated thereunder...Appropriate transfer occurs when...the transferring hospital provides medical treatment within its capacity that minimizes the risks of the individual’s health and, in the case of a woman in labor, the health and safety of the unborn child...the receiving facility has the available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate medical treatment...the transferring hospitals sends to the receiving hospital all medical records...related to the EMC for which the individual has presented, available at the time of transfer, including records related to the individual’s EMC, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of diagnostic studies or telephone reports of the studies, and the informed written consent for transfer or certification if applicable, name and address of any on-call physician who has refused or failed to appear within a reasonable and that any other records that are not readily available at the time of transfer are sent as soon as practicable after the transfer...the transfer is effected through qualified personnel, transportation and equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer...Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment of the transferred individual...Emergency Medical Treatment and Labor Act (“EMTALA”) refers to Sections 1866 and 1867 of the Social Security Act, 42 U.S.C. §§ 1395dd, which obligate hospitals to provide medical screening, treatment and transfer of individuals with EMCs or women in labor. It is also referred to as the “anti-dumping” statute and COBRA...Stabilized with respect to an EMC means that no material deterioration of the condition is likely within reasonable medical probability, to result from or occur during the transfer of the individual from the facility or in the case of a woman in labor, that the woman delivered the child and the placenta...Exception applicable to inpatient...If a hospital has screened an individual and found that the individual has an EMC and admits that individual as an inpatient in good faith in order to stabilize the EMC, the hospital has satisfied its responsibilities with respect to the individual under EMTALA...The hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer...””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 44871 Based on interview and record review, the facility failed to ensure medical examination and/or treatment were provided in accordance with the facility’s policies and procedures, for one of 22 sample patients (Patient 22), when Patient 22 was not stabilized before the patient was transferred from the Emergency Department (ED) to an outpatient clinic in another county. Findings: On May 29, 2025, at 11:13 a.m., a concurrent interview and review of Patient 22’s record were conducted with Registered Nurse (RN) 1. A facility document titled, “Triage [a system for prioritizing patients for treatment],” dated March 31, 2025, at 7:22 a.m., was reviewed. The document indicated Patient 22 was seen at the facility for a chief complaint of abnormal laboratory (lab) results. The document indicated, “...Acuity [severity of patient’s illness]: 3 - Urgent...Vitals and Measurements...31-Mar-2025 [March 31, 2025] 07:25 [7:25 a.m.]...Temp [temperature]: 97 F [Fahrenheit, unit of measurement, normal is 97.7 - 99.0] (Forehead)...Resp [respiration, normal is 12-20 breaths per minute]:16...HR[heart rate, normal is 60-100 beats per minute (bpm)]: 86...BP [blood pressure, normal is 120/80] 1: 90/45...” A facility document titled, “Assessment Type: Daily,” dated March 31, 2025, 7:24 a.m., authored by Case Manager (CM) 1 was reviewed. The document indicated, “...Spoke with [name of Facility A Clinic Staff 1] at [Name of outpatient Facility A’s telephone number] to confirm pt’s [Patient 22] outpatient appointment. Per [Name of Internal Medicine Physician 1] to transfer pt from ER to her appointment in [Name of Facility A] Per [Facility Clinic Staff 1], pt has appointment on 4-1-25 [April 1, 2025] W [with] [Name of physician scheduled to see patient at the outpatient clinic], for pt to be there at 0945 [9:45 a.m.] for a 1045am [10:45 a.m.] procedure. Procedure will be done at [Name of Facility A] med [medical] ctr. [center] Comp. [Comprehensive] Digestive Disease Center, [address of outpatient clinic]. Pre procedure instructions received [name of Facility A Clinic Staff 1]. ALS [Advanced Life Support (lifesaving protocols, interventions airway management and cardiac monitoring] transport arranged w/ [Name of person who works at transportation company] for a 5am [5 a.m.] ETA [estimated time of arrival]...will call return transport back to [Name of facility] arranged w/ [Name of employee who works at transportation company]...” A facility document titled, “Emergency Department Record,” dated March 31, 2025, at 7:27 a.m., was reviewed. The document indicated, “...female presents to the ER [Emergency Room, ED] via [by way of] EMS [Emergency Medical Services, ambulance service] for evaluation of abnormal lab values [results]. Patient [Patient 22] reported to have a gallbladder surgery and was found to have a doubled white count [WBC, white blood cells, a component of the blood with high levels signifying possible infection, normal range is between 3.6-11.2] at [name of skilled nursing facility]...Past surgical history: Cholecystectomy [a surgery to remove the gallbladder], Biliary Stent Placement [a thin hollow tube inserted into the bile duct to keep it open]...Physical Examination...Abdomen...Purulent [with pus drainage from JP [Jackson-Pratt drain, a medical device used to drain fluid] drain...WBC 15.8...1232 [12: 32 p.m.] Patient will be admitted to Telemetry [unit where the patient will receive continuous remote monitoring of the heart rate and rhythm]...1257 [12:57 p.m.] [Name of Surgeon 1]...General Surgery, called back and states to try to send patients [sic] to [name of Facility A] instead...1330 [1:30 p.m.] [name of Facility A] unable to accept patient for transfer but patient can follow upas [sic] she has an appointment...1340 [1:40 p.m.]...Patient is appearing septic [a serious medical condition that occurs when body responds to an infection]. Heart rate is 115bpm with blood pressure at 89/49. Will give vanco [vancomycin, a medication to treat infections] and more fluids [fluids administered through the vein]...Disposition Time...12:32 [12:32 p.m.]...Condition: Critical...Diagnosis: Acute Intraabdominal Abscesses [collection of pus in the abdomen]...” A facility document titled, “Vitals,” dated March 31, 2025, at 7:50 a.m., through April 1, 2025, at 6:06 a.m., was reviewed. The document indicated Patient 22’s vital signs (HR, Resp, Temp, and BP) on the following dates and times: - on March 31, 2025, at 7:50 a.m., Temp 98.2 F...HR 86...Resp 14...BP 105/52; - on March 31, 2025, at 10 a.m., Temp 98.4 F...HR 94...Resp 14...BP 110/58; - on March 31, 2025, at 12 p.m., Temp 98.2 F...HR 102...Resp 16...BP 125/52; - on March 31, 2025, at 2 p.m., Temp 98.4 F...HR 108...Resp 16...BP 109/51; - on March 31, 2025, at 8 p.m., Temp 96 F...HR 114...Resp 20...BP 100/51; - on March 31, 2025, at 10 p.m., Temp 97.8 F...HR 116...Resp 22 ...BP 103/42; - on April 1, 2025, at 2 a.m., Temp 98 F...HR 102...Resp 19...BP 97/50; - on April 1, 2025, at 4 a.m., Temp 98.1...HR 104...Resp 21...BP 100/48; and - on April 1, 2024, at 6:06 a.m., Temp 98 F...HR 92 ...Resp 18...BP 123/42. A facility document titled, “Order Entry,” dated March 31, 2025, at 12:35 p.m., was reviewed. The document indicated, “...Admit to Inpatient Telemetry...Instructions...Intrabdominal Abscesses s/p [status post, after] recent Cholecystectomy under [Name of Internal Medicine Physician 1]...Reason/Indication: Epigastric pain...” A facility document titled, “Order Entry,” dated March 31, 2025, at 12:39 p.m., was reviewed. The document indicated, “...Admit To Inpatient - Telemetry...Discontinued...” (Four minutes after the initial admission order was given) A facility document titled, “TRANSFER SUMMARY AND CERTIFICATION,” dated March 31, 2025, at 4:54 p.m., authored by [Internal Medicine Physician] 1, was reviewed. The document indicated, “...Patient has been stabilized such that within medical probability, no material deterioration of the patient’s condition or the condition of the unborn child(ren) is likely to result from transfer...Time of Transfer...0606 [6:06 a.m.]...Vital Signs...BP 124/62; HR 92; RR 18; O2 sat 99; Temp 98.0...TRANSFER REQUIREMENTS...The receiving facility [Name of Facility A Digestive Disease Center] has available space and qualified personnel for treatment as acknowledged by [Facility A Clinic Staff 1]...The receiving physician has agreed to accept transfer and to provide appropriate medical treatment as acknowledged by...[Name of physician scheduled to see patient at the outpatient clinic]...Appropriate medical records of the examination and treatment of the patient are provided at the time of transfer as follows...Physician’s record; Lab Results; Diagnostics; EKG...The physician has determined that appropriate means of transportation for transfer which includes qualified personnel and transportation equipment as required...CCT [Critical Care Transport]...Provider Certification...Signature of Physician: [signed by Internal Medicine Physician 1]...” A facility document titled, “Assessment Type, Daily,” dated March 31, 2025, at 5:15 p.m., authored by RN 2 was reviewed. The document indicated, “...[Name of ED Physician] at bedside, assessing pt [Patient 22], Dr. [doctor] stated tht [sic, that] the pt appears septic. MD does nto [sic, not] want to call a cde [sic, code] sepsis [serious medical condition that occurs when body responds to an infection], he requested luids [sic, fluids] and antibiotics [medications to treat infections], pt is having a procedure tomorrow at [Name of Facility A], pt neds [sic, needs] to be at the appointment to have her stent [tiny tube placed in a hollow structure of the body] removed as it is cauing [sic, causing] an infection in her abdomen. MD made aware of pts low pbp [sic, blood pressure], he requested fluids until her bp improves. 2 [two] L [liters, unit of measurement] in so far...” A facility document titled, “Order Entry,” dated March 31, 2025, at 6:09 p.m., was reviewed. The document indicated, “...Discharge to Home...Instructions...Intraabdominal pain/ abscess...to [Name of Facility A] gi [gastrointestinal, pertaining to the stomach and intestines] lab...” A facility document titled, “Assessment Type Daily,” dated March 31, 2025, at 8 pm., was reviewed. The document indicated, “...patient had cholecystectomy 2 weeks ago then another surgery for stents placement, patient was discharged to [name of skilled nursing facility], patient had a JP to low right quadrant [an area o f the abdomen] with green discharge...bloodpressure [sic, blood pressure ] low withSBP [sic] [systolic blood pressure, top number in blood pressure reading that represents pressure in the artery when heart beats, normal is 120] in 90’s...at this time patient is pending transport to [Name of Facility A] for surgery to remove stents. NPO [nothing by mouth] after midnight...” A facility document titled, “Assessment Type Daily,” dated April 1, 2025, at 6:06 a.m., was reviewed. The document indicated, “...patient departed ED with medical transport, on monitor, with vanoc [sic, vancomycin] running at 125ml/hr [milliliter per hour, unit of measurement]...patient transferred to [Name of Facility A]...” There was no documented evidence the Internal Medicine Physician evaluated or assessed Patient 22. There was no documented evidence Patient 22 was assessed in accordance with the facility’s sepsis protocol. There was not documented evidence a Code Sepsis was called for Patient 22. On May 29, 2025, at 11:47 a.m., a concurrent interview and review of Patient 22’s record were conducted with RN 1. RN 1 stated the SIRS [systemic inflammatory response syndrome, a group of symptoms resulting from an inflammatory response in body] criteria [criteria for evaluating for sepsis] was not followed. RN 1 stated Patient 22 met the SIRS criteria due to increased heart rate, increased WBCs, and having a cholecystectomy two weeks ago. He further stated the sepsis protocol [set of guidelines designed to help healthcare providers to quickly identify and treat sepsis] should have been called. On May 29, 2025, at 12:02 p.m., a concurrent interview and review of Patient 22’s record were conducted with RN 2. RN 2 stated a code sepsis should have been called because Patient 22’s heart rate was 108, the blood pressure was low at 109/51, and the patient’s JP drain had light green drainage which would have been the source of sepsis. RN 2 further stated a code sepsis was not called even though the patient met criteria. On May 29, 2025, at 1:27 p.m., a concurrent interview and record review were conducted with CM 1. CM 1 stated she was told to transfer Patient 22 to an appointment that had been previously made before her hospitalization. CM 1 stated, “I did not give anyone report at the facility because the patient was going to an appointment.” She stated, “I set up transportation the day before.” CM 1 further stated there was no transfer order in the chart and there was an order to the patient to her home. CM 1 stated, as far as I knew, the patient was transferred to an outpatient appointment and was not transported to their home. On May 29, 2025, at 2:20 p.m., a concurrent interview and review of Patient 22’s record were conducted with ED Physician 1. ED Physician 1 stated, due to the patient’s blood pressure, Patient 22 could have met the sepsis criteria. ED physician 1 stated he did not order a lactic acid test (blood test to determine that cells are not getting enough oxygen due to serious infection because he felt Patient 22 was probably not septic. After reading his ED notes which indicated, “Patient is appearing septic...Condition: Critical...,” ED Physician 1 stated, “If it’s there then I wrote it.” ED Physician 1 stated he spoke with Internal Medicine Physician 1 and the general surgeon on call who both agreed Patient 22 needed to be transferred to [name of Facility A] to have the infected stent removed. ED Physician 1 stated a direct transfer to [name of Facility 2] was attempted but there were no beds available, and he was told [name of Facility 2] was closed to transfers. ED physician 1 stated Patient 22 was too sick to go back to a skilled nursing facility. The facility policy and procedure (P&P) titled, “VITAL SIGNS-STANDARD OF CARE,” dated September 2024, was reviewed. The policy indicated, “...Vital signs should be obtained on all patients ESI level 3 [three], 4 [four], and 5 [five], upon triage. Vital Signs should be repeated per patient condition and per interventions to assess response or at least every 2 hours...” A facility P&P titled, “ADULT SEPSIS SCREENING AND PHYSICIAN APPROVED NURSING SEPSIS,” dated May 2024, was reviewed. The policy indicated, “...This health system protocol applies to Registered Nurses (RNs) only and include the Emergency Department (ED) and inpatient populations >18 years of age...Systemic Inflammatory Response Syndrome (SIRS) = two (2) or more of the following....Temperature above 100.9F or less than 96.8 °F...Heart rate greater than 90 beats/min...Respiration rate is greater than 20 breaths/min or PaCO2 less than 32mmHg...WBC greater than 12,000 cells/mm3 or less than 4,000 cells/mm3, or greater than 10% bands...Sepsis = Two (2) or more SIRS criteria plus a suspected or confirmed infection...SEPSIS TEAM MEMBERS & RESPONSIBILITIES...Registered Nurse caring for the patient....Initiate code sepsis when sepsis, severe sepsis, or septic shock is recognized...Initiate and maintain the sepsis protocol as outlined under procedure ...Completing the Sepsis Worksheet and forwarding to appropriate department Leader when complete...Emergency Department Physician...Team Lead for ED code sepsis...Must work collaboratively with Charge Nurse & Registered Nurse...Must oversee completion of Sepsis Worksheet and confirm with print name...” A facility P&P titled, “EMTALA - DEFINITION AND GENERAL REQUIRMENTS,” dated April 2023, was reviewed. The policy indicated, “...To require, in conjunction with state-specific policies, that an acute care or specific hospital with an emergency department provide an appropriate medical screening examination and any necessary stabilizing treatment to ant individual, including every infant who id born alive, at any stage of development, who comes to the emergency Department and request such examination, as required by EMTALA and all Federal regulations and interpretive guidelines promulgated thereunder...Appropriate transfer occurs when...the transferring hospital provides medical treatment within its capacity that minimizes the risks of the individual’s health and, in the case of a woman in labor, the health and safety of the unborn child...the receiving facility has the available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate medical treatment...the transferring hospitals sends to the receiving hospital all medical records...related to the EMC for which the individual has presented, available at the time of transfer, including records related to the individual’s EMC, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of diagnostic studies or telephone reports of the studies, and the informed written consent for transfer or certification if applicable, name and address of any on-call physician who has refused or failed to appear within a reasonable and that any other records that are not readily available at the time of transfer are sent as soon as practicable after the transfer...the transfer is effected through qualified personnel, transportation and equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer...Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment of the transferred individual...Emergency Medical Treatment and Labor Act (“EMTALA”) refers to Sections 1866 and 1867 of the Social Security Act, 42 U.S.C. §§ 1395dd, which obligate hospitals to provide medical screening, treatment and transfer of individuals with EMCs or women in labor. It is also referred to as the “anti-dumping” statute and COBRA...Stabilized with respect to an EMC means that no material deterioration of the condition is likely within reasonable medical probability, to result from or occur during the transfer of the individual from the facility or in the case of a woman in labor, that the woman delivered the child and the placenta...Exception applicable to inpatient...If a hospital has screened an individual and found that the individual has an EMC and admits that individual as an inpatient in good faith in order to stabilize the EMC, the hospital has satisfied its responsibilities with respect to the individual under EMTALA...The hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer...””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 44871 Based on interview and record review, the facility failed to ensure stabilizing treatment was provided to the patient prior to transferring the patient to another a clinic, for one of 22 sample patients (Patient 22). This failure had the potential for the delay in treatment and for the patient’s condition to deteriorate.c Findings: On May 29, 2025, at 11:13 a.m., a concurrent interview and review of Patient 22’s record were conducted with Registered Nurse (RN) 1. A facility document titled, “Triage [a system for prioritizing patients for treatment],” dated March 31, 2025, at 7:22 a.m., was reviewed. The document indicated Patient 22 was seen at the facility for a chief complaint of abnormal laboratory (lab) results. The document indicated, “...Acuity [severity of patient’s illness]: 3 - Urgent...Vitals and Measurements...31-Mar-2025 [March 31, 2025] 07:25 [7:25 a.m.]...Temp [temperature]: 97 F [Fahrenheit, unit of measurement, normal is 97.7 - 99.0] (Forehead)...Resp [respiration, normal is 12-20 breaths per minute]:16...HR[heart rate, normal is 60-100 beats per minute (bpm)]: 86...BP [blood pressure, normal is 120/80] 1: 90/45...” A facility document titled, “Assessment Type: Daily,” dated March 31, 2025, 7:24 a.m., authored by Case Manager (CM) 1 was reviewed. The document indicated, “...Spoke with [name of Facility A Clinic Staff 1] at [Name of outpatient Facility A’s telephone number] to confirm pt’s [Patient 22] outpatient appointment. Per [Name of Internal Medicine Physician 1] to transfer pt from ER to her appointment in [Name of Facility A] Per [Facility Clinic Staff 1], pt has appointment on 4-1-25 [April 1, 2025] W [with] [Name of physician scheduled to see patient at the outpatient clinic], for pt to be there at 0945 [9:45 a.m.] for a 1045am [10:45 a.m.] procedure. Procedure will be done at [Name of Facility A] med [medical] ctr. [center] Comp. [Comprehensive] Digestive Disease Center, [address of outpatient clinic]. Pre procedure instructions received [name of Facility A Clinic Staff 1]. ALS [Advanced Life Support (lifesaving protocols, interventions airway management and cardiac monitoring] transport arranged w/ [Name of person who works at transportation company] for a 5am [5 a.m.] ETA [estimated time of arrival]...will call return transport back to [Name of facility] arranged w/ [Name of employee who works at transportation company]...” A facility document titled, “Emergency Department Record,” dated March 31, 2025, at 7:27 a.m., was reviewed. The document indicated, “...female presents to the ER [Emergency Room, ED] via [by way of] EMS [Emergency Medical Services, ambulance service] for evaluation of abnormal lab values [results]. Patient [Patient 22] reported to have a gallbladder surgery and was found to have a doubled white count [WBC, white blood cells, a component of the blood with high levels signifying possible infection, normal range is between 3.6-11.2] at [name of skilled nursing facility]...Past surgical history: Cholecystectomy [a surgery to remove the gallbladder], Biliary Stent Placement [a thin hollow tube inserted into the bile duct to keep it open]...Physical Examination...Abdomen...Purulent [with pus drainage from JP [Jackson-Pratt drain, a medical device used to drain fluid] drain...WBC 15.8...1232 [12: 32 p.m.] Patient will be admitted to Telemetry [unit where the patient will receive continuous remote monitoring of the heart rate and rhythm]...1257 [12:57 p.m.] [Name of Surgeon 1]...General Surgery, called back and states to try to send patients [sic] to [name of Facility A] instead...1330 [1:30 p.m.] [name of Facility A] unable to accept patient for transfer but patient can follow upas [sic] she has an appointment...1340 [1:40 p.m.]...Patient is appearing septic [a serious medical condition that occurs when body responds to an infection]. Heart rate is 115bpm with blood pressure at 89/49. Will give vanco [vancomycin, a medication to treat infections] and more fluids [fluids administered through the vein]...Disposition Time...12:32 [12:32 p.m.]...Condition: Critical...Diagnosis: Acute Intraabdominal Abscesses [collection of pus in the abdomen]...” A facility document titled, “Vitals,” dated March 31, 2025, at 7:50 a.m., through April 1, 2025, at 6:06 a.m., was reviewed. The document indicated Patient 22’s vital signs (HR, Resp, Temp, and BP) on the following dates and times: - on March 31, 2025, at 7:50 a.m., Temp 98.2 F...HR 86...Resp 14...BP 105/52; - on March 31, 2025, at 10 a.m., Temp 98.4 F...HR 94...Resp 14...BP 110/58; - on March 31, 2025, at 12 p.m., Temp 98.2 F...HR 102...Resp 16...BP 125/52; - on March 31, 2025, at 2 p.m., Temp 98.4 F...HR 108...Resp 16...BP 109/51; - on March 31, 2025, at 8 p.m., Temp 96 F...HR 114...Resp 20...BP 100/51; - on March 31, 2025, at 10 p.m., Temp 97.8 F...HR 116...Resp 22 ...BP 103/42; - on April 1, 2025, at 2 a.m., Temp 98 F...HR 102...Resp 19...BP 97/50; - on April 1, 2025, at 4 a.m., Temp 98.1...HR 104...Resp 21...BP 100/48; and - on April 1, 2024, at 6:06 a.m., Temp 98 F...HR 92 ...Resp 18...BP 123/42. A facility document titled, “Order Entry,” dated March 31, 2025, at 12:35 p.m., was reviewed. The document indicated, “...Admit to Inpatient Telemetry...Instructions...Intrabdominal Abscesses s/p [status post, after] recent Cholecystectomy under [Name of Internal Medicine Physician 1]...Reason/Indication: Epigastric pain...” A facility document titled, “Order Entry,” dated March 31, 2025, at 12:39 p.m., was reviewed. The document indicated, “...Admit To Inpatient - Telemetry...Discontinued...” (Four minutes after the initial admission order was given) A facility document titled, “TRANSFER SUMMARY AND CERTIFICATION,” dated March 31, 2025, at 4:54 p.m., authored by [Internal Medicine Physician] 1, was reviewed. The document indicated, “...Patient has been stabilized such that within medical probability, no material deterioration of the patient’s condition or the condition of the unborn child(ren) is likely to result from transfer...Time of Transfer...0606 [6:06 a.m.]...Vital Signs...BP 124/62; HR 92; RR 18; O2 sat 99; Temp 98.0...TRANSFER REQUIREMENTS...The receiving facility [Name of Facility A Digestive Disease Center] has available space and qualified personnel for treatment as acknowledged by [Facility A Clinic Staff 1]...The receiving physician has agreed to accept transfer and to provide appropriate medical treatment as acknowledged by...[Name of physician scheduled to see patient at the outpatient clinic]...Appropriate medical records of the examination and treatment of the patient are provided at the time of transfer as follows...Physician’s record; Lab Results; Diagnostics; EKG...The physician has determined that appropriate means of transportation for transfer which includes qualified personnel and transportation equipment as required...CCT [Critical Care Transport]...Provider Certification...Signature of Physician: [signed by Internal Medicine Physician 1]...” A facility document titled, “Assessment Type, Daily,” dated March 31, 2025, at 5:15 p.m., authored by RN 2 was reviewed. The document indicated, “...[Name of ED Physician] at bedside, assessing pt [Patient 22], Dr. [doctor] stated tht [sic, that] the pt appears septic. MD does nto [sic, not] want to call a cde [sic, code] sepsis [serious medical condition that occurs when body responds to an infection], he requested luids [sic, fluids] and antibiotics [medications to treat infections], pt is having a procedure tomorrow at [Name of Facility A], pt neds [sic, needs] to be at the appointment to have her stent [tiny tube placed in a hollow structure of the body] removed as it is cauing [sic, causing] an infection in her abdomen. MD made aware of pts low pbp [sic, blood pressure], he requested fluids until her bp improves. 2 [two] L [liters, unit of measurement] in so far...” A facility document titled, “Order Entry,” dated March 31, 2025, at 6:09 p.m., was reviewed. The document indicated, “...Discharge to Home...Instructions...Intraabdominal pain/ abscess...to [Name of Facility A] gi [gastrointestinal, pertaining to the stomach and intestines] lab...” A facility document titled, “Assessment Type Daily,” dated March 31, 2025, at 8 pm., was reviewed. The document indicated, “...patient had cholecystectomy 2 weeks ago then another surgery for stents placement, patient was discharged to [name of skilled nursing facility], patient had a JP to low right quadrant [an area o f the abdomen] with green discharge...bloodpressure [sic, blood pressure ] low withSBP [sic] [systolic blood pressure, top number in blood pressure reading that represents pressure in the artery when heart beats, normal is 120] in 90’s...at this time patient is pending transport to [Name of Facility A] for surgery to remove stents. NPO [nothing by mouth] after midnight...” A facility document titled, “Assessment Type Daily,” dated April 1, 2025, at 6:06 a.m., was reviewed. The document indicated, “...patient departed ED with medical transport, on monitor, with vanoc [sic, vancomycin] running at 125ml/hr [milliliter per hour, unit of measurement]...patient transferred to [Name of Facility A]...” There was no documented evidence the Internal Medicine Physician evaluated or assessed Patient 22. There was no documented evidence Patient 22 was assessed in accordance with the facility’s sepsis protocol. There was not documented evidence a Code Sepsis was called for Patient 22. On May 29, 2025, at 11:47 a.m., a concurrent interview and review of Patient 22’s record were conducted with RN 1. RN 1 stated the SIRS [systemic inflammatory response syndrome, a group of symptoms resulting from an inflammatory response in body] criteria [criteria for evaluating for sepsis] was not followed. RN 1 stated Patient 22 met the SIRS criteria due to increased heart rate, increased WBCs, and having a cholecystectomy two weeks ago. He further stated the sepsis protocol [set of guidelines designed to help healthcare providers to quickly identify and treat sepsis] should have been called. On May 29, 2025, at 12:02 p.m., a concurrent interview and review of Patient 22’s record were conducted with RN 2. RN 2 stated a code sepsis should have been called because Patient 22’s heart rate was 108, the blood pressure was low at 109/51, and the patient’s JP drain had light green drainage which would have been the source of sepsis. RN 2 further stated a code sepsis was not called even though the patient met criteria. On May 29, 2025, at 1:27 p.m., a concurrent interview and record review were conducted with CM 1. CM 1 stated she was told to transfer Patient 22 to an appointment that had been previously made before her hospitalization. CM 1 stated, “I did not give anyone report at the facility because the patient was going to an appointment.” She stated, “I set up transportation the day before.” CM 1 further stated there was no transfer order in the chart and there was an order to the patient to her home. CM 1 stated, as far as I knew, the patient was transferred to an outpatient appointment and was not transported to their home. On May 29, 2025, at 2:20 p.m., a concurrent interview and review of Patient 22’s record were conducted with ED Physician 1. ED Physician 1 stated, due to the patient’s blood pressure, Patient 22 could have met the sepsis criteria. ED physician 1 stated he did not order a lactic acid test (blood test to determine that cells are not getting enough oxygen due to serious infection because he felt Patient 22 was probably not septic. After reading his ED notes which indicated, “Patient is appearing septic...Condition: Critical...,” ED Physician 1 stated, “If it’s there then I wrote it.” ED Physician 1 stated he spoke with Internal Medicine Physician 1 and the general surgeon on call who both agreed Patient 22 needed to be transferred to [name of Facility A] to have the infected stent removed. ED Physician 1 stated a direct transfer to [name of Facility 2] was attempted but there were no beds available, and he was told [name of Facility 2] was closed to transfers. ED physician 1 stated Patient 22 was too sick to go back to a skilled nursing facility. The facility policy and procedure (P&P) titled, “VITAL SIGNS-STANDARD OF CARE,” dated September 2024, was reviewed. The policy indicated, “...Vital signs should be obtained on all patients ESI level 3 [three], 4 [four], and 5 [five], upon triage. Vital Signs should be repeated per patient condition and per interventions to assess response or at least every 2 hours...” A facility P&P titled, “ADULT SEPSIS SCREENING AND PHYSICIAN APPROVED NURSING SEPSIS,” dated May 2024, was reviewed. The policy indicated, “...This health system protocol applies to Registered Nurses (RNs) only and include the Emergency Department (ED) and inpatient populations >18 years of age...Systemic Inflammatory Response Syndrome (SIRS) = two (2) or more of the following....Temperature above 100.9F or less than 96.8 °F...Heart rate greater than 90 beats/min...Respiration rate is greater than 20 breaths/min or PaCO2 less than 32mmHg...WBC greater than 12,000 cells/mm3 or less than 4,000 cells/mm3, or greater than 10% bands...Sepsis = Two (2) or more SIRS criteria plus a suspected or confirmed infection...SEPSIS TEAM MEMBERS & RESPONSIBILITIES...Registered Nurse caring for the patient....Initiate code sepsis when sepsis, severe sepsis, or septic shock is recognized...Initiate and maintain the sepsis protocol as outlined under procedure ...Completing the Sepsis Worksheet and forwarding to appropriate department Leader when complete...Emergency Department Physician...Team Lead for ED code sepsis...Must work collaboratively with Charge Nurse & Registered Nurse...Must oversee completion of Sepsis Worksheet and confirm with print name...” A facility P&P titled, “EMTALA - DEFINITION AND GENERAL REQUIRMENTS,” dated April 2023, was reviewed. The policy indicated, “...To require, in conjunction with state-specific policies, that an acute care or specific hospital with an emergency department provide an appropriate medical screening examination and any necessary stabilizing treatment to ant individual, including every infant who id born alive, at any stage of development, who comes to the emergency Department and request such examination, as required by EMTALA and all Federal regulations and interpretive guidelines promulgated thereunder...Appropriate transfer occurs when...the transferring hospital provides medical treatment within its capacity that minimizes the risks of the individual’s health and, in the case of a woman in labor, the health and safety of the unborn child...the receiving facility has the available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate medical treatment...the transferring hospitals sends to the receiving hospital all medical records...related to the EMC for which the individual has presented, available at the time of transfer, including records related to the individual’s EMC, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of diagnostic studies or telephone reports of the studies, and the informed written consent for transfer or certification if applicable, name and address of any on-call physician who has refused or failed to appear within a reasonable and that any other records that are not readily available at the time of transfer are sent as soon as practicable after the transfer...the transfer is effected through qualified personnel, transportation and equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer...Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment of the transferred individual...Emergency Medical Treatment and Labor Act (“EMTALA”) refers to Sections 1866 and 1867 of the Social Security Act, 42 U.S.C. §§ 1395dd, which obligate hospitals to provide medical screening, treatment and transfer of individuals with EMCs or women in labor. It is also referred to as the “anti-dumping” statute and COBRA...Stabilized with respect to an EMC means that no material deterioration of the condition is likely within reasonable medical probability, to result from or occur during the transfer of the individual from the facility or in the case of a woman in labor, that the woman delivered the child and the placenta...Exception applicable to inpatient...If a hospital has screened an individual and found that the individual has an EMC and admits that individual as an inpatient in good faith in order to stabilize the EMC, the hospital has satisfied its responsibilities with respect to the individual under EMTALA...The hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer...””

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 50454 Based on interview and record review, the facility failed to ensure the patient rights were honored, for one of 35 sampled patients (Patient 37), in accordance with the facility’s policies and procedures (P&P), when Patient 37 requested a female registered nurse (RN) while on the intensive care unit (ICU, a specialized unit for critically ill patients), and was denied the request without adequate justification or documentation. In addition, Patient 37’s Foley catheter (a flexible plastic tube inserted into the bladder to drain urine) was removed by a male RN after Patient 37 requested for a female RN. This failure resulted in Patient 37’s Foley catheter being removed by a male nurse which caused Patient 37 to feel she was sexually assaulted by the male nurse and to feel her personal privacy had been violated. Findings: On May 29, 2025, at 10:49 a.m., a review of Patient 37’s record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, “History and Physical,” dated March 7, 2025, was reviewed and indicated Patient 37, a female, was admitted to the facility on March 7, 2025, and presented to the emergency room by ambulance for evaluation of an overdose. The document indicated, “...per EMS [emergency medical services, ambulance staff], about 30 min’s [sic, minutes] prior to their arrival on the scene patient was walking and talking but slowly began having erratic behavior...When EMS arrived on scene patient became more altered [change in behavior]. She was given Narcan [life-saving medication used to reverse opioid overdoses] and became more awake, agitated, and altered. Possible ingestion of pills about an hour prior to arriving in the ER [emergency room]...PHYSICAL EXAM...Constitution: sedated intubated on ventilation [a medical device that helps people breathe when they can’t do so on their own]...” On May 29, 2025, at 10:50 a.m., a review of Patient 37’s record was conducted with the PSC. A facility document titled, “Daily Focus Assessment Report,” dated March 7, 2025, at 7:54 p.m., was reviewed and indicated, “...Urinary Catheter Insertion...Catheter size: 16 french [unit of measurement]...Foley catheter: MD [medical doctor] order and indication for urinary catheter...” An untitled facility document, signed by RN 1, a male, dated May 9, 2025, at 5:30 a.m., was reviewed. The document indicated, “...Foley DC [discontinued] at 05:30 PER PT [Patient 37] complaints MD aware...” During an interview, on May 28, 2025, at 2:43 p.m., conducted with RN 1, RN 1 stated, Patient 37 “didn’t like me.” RN 1 stated towards the end of the shift, Patient 37 requested a female nurse and he informed the charge nurse. RN 1 stated the charge nurse informed him the other nurses had their own patients, and the assignment couldn’t be switched. RN 1 stated he was Patient 37’s admitting nurse that night, but there were at least two to three other female nurses present during that shift. RN 1 stated he did not remember if he made any notes in Patient 37’s record regarding request for a female RN. During an interview, on May 28, 2025, at 3:44 p.m., conducted with the ICU supervisor (ICU-S), the ICU-S stated arrangements should be made whenever a female patient is requesting for a female nurse. The ICU-S stated it should not have been an issue to make this type of accommodation since the unit has far more female nurses than male nurses. The ICU-S stated there were two other female RN’s working that night based on the staffing assignment sheet for May 7, 2025. The ICU-S stated this assignment could have easily been switched around. During an interview, on May 29, 2025, at 2:41 p.m., conducted with the Chief Quality Officer (CQO), the CQO stated, “That was a reasonable request and it should have been accommodated.” The facility P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES,” dated November 2022, was reviewed. The P&P indicated, “...The purpose of this policy is to establish the rights that each patient or patients [name of facility] facilities has pertaining to their care...All patients at [name of facility] have the right to: Considerate and respectful care, and to be made comfortable. They have the right to respect for their cultural, psychological, spiritual, personal values, beliefs, and preferences...Reasonable responses to any reasonable requests made for services...””

“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: 50454 Based on observation, interview, and record review, the facility failed to ensure care plans were initiated in accordance with the facility’s policies and procedures (P&P), for one of 35 sampled patients (Patient 37), when the care plan for the insertion of a Foley catheter (a flexible plastic tube inserted into the bladder to drain urine) was not initiated. This failure had the potential to compromise patient safety and cause a delay in treatment and interventions. Findings: On May 29, 2025, at 10:49 a.m., a review of Patient 37’s record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, “History and Physical,” dated March 7, 2025, was reviewed and indicated Patient 37, a female, was admitted to the facility on March 7, 2025, and presented to the emergency room by ambulance for evaluation of an overdose. The document indicated, “...per EMS [emergency medical services, ambulance staff], about 30 min’s [sic, minutes] prior to their arrival on the scene patient was walking and talking but slowly began having erratic behavior...When EMS arrived on scene patient became more altered [change in behavior]. She was given Narcan [life-saving medication used to reverse opioid overdoses] and became more awake, agitated, and altered. Possible ingestion of pills about an hour prior to arriving in the ER [emergency room]...PHYSICAL EXAM...Constitution: sedated intubated on ventilation [a medical device that helps people breathe when they can’t do so on their own]...” On May 29, 2025, at 10:50 a.m., a review of Patient 37’s record was conducted with the PSC. A facility document titled, “Daily Focus Assessment Report,” dated March 7, 2025, at 7:54 p.m., was reviewed and indicated, “...Urinary Catheter Insertion...Catheter size: 16 french [unit of measurement]...Foley catheter: MD [medical doctor] order and indication for urinary catheter...Unit where Urinary Catheter inserted: Emergency Department [ED]...” On May 29, 2025, at 10:55 a.m., a review of Patient 37’s record was conducted with the PSC. A facility document titled, “Admission Assessment Report,” dated March 7, 2025, at 8 p.m., was reviewed and indicated, “...Toileting: Urinary catheter...Foley catheter: Urinary Catheter secured...Urinary catheter care completed...Urinary catheter to gravity drainage...Urinary Catheter Indication...Critical-sedated...” There was no documented evidence a care plan was initiated for the insertion of the Foley catheter on Patient 37. During a concurrent interview with the PSC, she stated a care plan should have been initiated by the nurse who inserted the Foley catheter in the ED or by the admitting nurse when the patient arrived on the intensive care unit [ICU, unit for critically ill patients] within 24 hours of the Foley catheter insertion. The facility P&P titled, “INITIAL PATIENT ASSESSMENT AND REASSESSMENT AND PLAN OF CARE,” dated May 2024, was reviewed. The P&P indicated, “...Nursing assessments are performed, and care plans are developed by registered nurses. Care plans are focused on those patient problem/diagnosis requiring active treatment...TIMELINESS:...Care plans should be initiated within 24 hours...””

“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: 45431 Based on observation, interview, and record review, the facility failed to ensure patient care was delivered in accordance with the facility’s policy and procedure (P&P), for two of 35 sample patients (Patients 34 and 36), when: 1. For Patient 34, pain medication was not administered when Patient 34 was experiencing severe pain. This failure resulted in Patient 34’s pain to not be addressed timely; and 2. For Patient 36, medication reconciliation was not conducted during the admission process. These failures had the potential for delay in the patients’ treatment and recovery. Findings: 1. A review of Patient 34’s records was conducted on May 28, 2025, at 1:18 p.m., with the Intensive Care Unit Supervisor (ICU-S). A facility document titled, “History and Physical,” dated, May 3, 2025, was reviewed. The document indicated Patient 34 was admitted to the facility for left hip fracture (a break or a crack in the hip bone) due to a fall at home. A facility document titled, “Therapy Verification,” dated May 3, 2025, was reviewed. The document indicated, “...Order Information...Start: 05/03/2025 [May 3, 2025] 17:14 [5:14 p.m.]...Stop: 05/04/2025 [May 4, 2025] 11:36 [11:36 a.m.]...Route...intravenous [administered through a vein]...Frequency...every 4 [four] hours as needed...Drug: Hydromorphone [a pain medication]...Dose:0.5mg [milligram, unit of measurement]/0.5ml [milliliter, unit of measurement]...indication: severe pain...” A facility document titled, “Therapy Verification,” dated May 4, 2025, was reviewed. The document indicated, “...Order Information ...Start: 05/04/2025 11:36...Stop: 05/10/2025 [May 10, 2025] 16:01[4:01 p.m.]...Route...intravenous...Frequency...every 4 hours as needed...Drug: Hydromorphone...Dose: 1mg/1 ml...indication: severe pain...” An untitled facility document, dated May 4, 2025, was reviewed. The document indicated, “...10:49 a.m...Pain Score...hip left...8 [pain score, with a score of seven to 10 meaning severe pain]...” An untitled facility document, dated May 4, 2025, was reviewed. The document indicated, “...11:55 a.m...Pain score...hip left...9...” An undated facility document titled, “Med Admin - PRN [Pro re nata, as needed],” was reviewed. There was no documented evidence pain medication was administered to Patient 34 when Patient 34 experienced severe pain with a pain score of 8 and 9 on May 4, 2025, at 10:49 a.m., and at 11:55 a.m., respectively. An interview was conducted on May 28, 2025, at 2:30 p.m., with the ICU-S. The ICU-S stated that the policy was not followed when pain medication was not administerd to Patient 34 for severe pain. A review of the facility P&P titled, “Pain Management,” dated September 2024, was conducted. The P&P indicated, “...Treatment of Pain...inpatients shall receive treatment for any active pain issue...when intensity exceeds their acceptable level. Treatment shall be consistent with the patient’s clinical presentation and objective findings. The treatment modality selected shall be appropriate for the patient’s needs. Treatment is to be provided in a timely manner...Numeric Pain Tool...The patients rate their pain numerically...Physicians order pain medication related to...Severe pain...7-10...” 2. On May 29, 2025, at 10:49 a.m., a review of Patient 36’s record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, “History and Physical,” dated March 19, 2025, was reviewed and indicated Patient 36 was admitted to the facility on March 19, 2025, for abdominal pain, nausea, and vomiting for two weeks. The document indicated Patient 36 had a Port-a-Cath (a medical device placed under the skin, which provides easy access to a large vein for the administration of medications and fluids) on the left chest, a drain for the stomach on the right lower quadrant (an area of the stomach) and a drain for fluid in the lungs on the left lower quadrant (lower part of the left lung). The document indicated Patient 36 had a history of stomach cancer and liver cirrhosis (hardening of the liver decreasing its ability to function). During an interview, on May 29, 2025, at 10:49 a.m., was conducted with the PSC. The PSC stated there was no documentation a medication reconciliation for Patient 36 was conducted upon the patient’s admission to the facility. The PSC stated the only documentation the medication reconciliation was completed was during Patient 36’s discharge from the facility on May 23, 2025. The PSC further stated a medication reconciliation should always be conducted during a patient’s admission and discharge, especially for a patient undergoing cancer treatment. The facility P&P titled, “MEDICATION RECONCILIATION,” dated May 2024, was reviewed. The P&P indicated, “...[name of facility] will implement and maintain a process to obtain and document a complete list of a patients current medications upon admission...Medication reconciliation/verification will be performed...Upon admission/entry into the facility...Emergency Department...The nurse completing the admission assessment will obtain and document the patient’s current medications taken at home...physicians shall review the medication reconciliation in order to make decisions about drug therapy and to document the reason(s) to discontinue, change, and or hold medications...””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 42512 Based on observation, interview, and record review, the facility failed to ensure the facility’s physical environment was maintained and supplies were current when: 1. An expired box of moisture wicking fabric (a fabric used to keep skin folds dry and and help prevent infection) was observed readily available for patient use; 2. Mulitple expired laboratory vacutainers (blood collection tubes) were observed on the third floor Medical-Surgical-Telemetry Unit medication room, readily available for use; and 3. An acrylic box for holding the moisture-wicking fabric and a pair of scissors in the box holder were observed to have debris and grime. These failures had the potential to compromise patient safety, increase the risk of exposure to bacteria, increase the risk for infection, and may cause a delay in the patients’ treatment. Findings: 1. On May 27, 2025, at 10:15, am a tour of the facility was conducted with the Patient Advocate (PTA), the Local Chief Medical Officer (LCMO), the Chief Nursing Officer (CNO), and the Emergency Department Manager (EDM). On May 27, 2025, at 10:24 a.m., during a continued tour of the facility, in the clean utility closet, a box of antibacterial wicking sheets was observed. The box was observed to be labeled with an expiration date of October 2024. A concurrent interview was conducted with the EDM. The EDM stated expired products should not be available for patient use. She stated the box of antibacterial wicking sheets should have been removed and replaced with a new box. 2. On May 27, 2025, at 10:22 a.m., a tour of the third floor Medical-Surgical-Telemetry Unit was conducted with the Patient Safety Coordinator (PSC). On May 27, 2025, at 10:42 a.m., during a continued tour of the unit, the following were observed in a drawer in the medication room: - Two green top laboratory vacutainers, labeled with an expiration date of April 30, 2025; - Three clear top laboratory vacutainers, labeled with an expiration date of March 31, 2025; - Two yellow top laboratory vacutainers, labeled with an expiration date of January 1, 2025; - One lavender top laboratory vacutainer, labeled with an expiration date of December 1, 2024; and - 100 blue top laboratory vacutainers, labeled with an expiration date of April 30, 2024. On May 27, 2025, at 10:50 a.m., an interview was conducted with the PSC. The PSC verified the vacutainers listed above were expired and stated, “These should not be here.” The PSC further stated the expectation would be for the nurses to carefully check the supplies and discard any expired patient care supplies. A review of the facility’s policy and procedure (P&P) titled, “Central Supply-General Organization,” dated April 2024, was conducted. The P&P indicated, “...All supply items should be reviewed weekly and upon issuance in respect to expiration dates...All expired items should be immediately removed from the storage location and placed in a holding area until proper disposition can be made...” 3. On May 27, 2025, at 10:51 a.m., an observation was made of the moisture-wicking fabric box holder mounted on a wall in an alcove where clean supplies are stored. The box was observed to have grey debris and a white powdery substance in the holder. A pair of scissors was observed in the box holder with a thick buildup of black and brown colored sticky grime on its blades. The scissors holder was observed to have multiple clumps of grey fuzzy particles. An interview was conducted on May 27, 2025, at 10:55 a.m., with the PSC. The PSC stated the moisture wicking fabric is a material used to keep the patients’ skin folds (areas on the body where skin overlaps and rubs against itself) dry. The PSC stated the scissors are used to cut the moisture wicking fabric. The PSC stated the moisture wicking fabric box holder should be kept clean regularly. The PSC stated the scissors and the box holding the scissors were dirty and needed to be cleaned. The PSC further stated the pair of scissors should have been cleaned after each use. An interview was conducted on May 27, 2025, at 2:50 p.m., with the Medical-Surgical-Telemetry Unit Manager (MSTM) regarding the dirty wicking fabric box holder, scissors, and scissors holder found on her unit. The MSTM stated, “I know. I saw and they it should have been cleaned after every use.” A review of the facility P&P titled, “Material Resource Management,” dated May 2024, was conducted. The document indicated, “...It is the responsibility of the Materials Management Leader and the department’s personnel staff to ensure that proper rotation of all supply items is maintained...All supply items should be reviewed weekly and upon issuance in respect to expiration dates...All expired items will be immediately removed from the storage location...” A review of the facility P&P titled, “Equipment cleaning,” dated March 23, 2025, was conducted. The policy indicated, “...Equipment will be cleaned with a hospital approved disinfectant after each patient use, or if visibly soiled and on a regular schedule...””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 38479 Based on observation, interview, and record review, the facility’s governing body failed to ensure the facility’s operation was conducted in an effective, safe, and organized manner when: 1. A safe, orderly, and sanitary environment was not maintained (Refer to A 0700, A 0701, A 0709, A 0714, A 0722, and A 0724); 2. Nursing services and operations were not provided in a safe and effective manner that would meet the patients’ needs, for seven of 91 sample patients (Patients 8, 12, 26, 27, 28, 30, and 31) (Refer to A 0395, A 0397, and A 0398,); 3. Laboratory services and operations were not provided in a safe and effective manner that would meet the patients’ needs (Refer to A 0576, A 0582, A 0583, A 0584, and A 0701); and 4. Equipment, supplies, personnels, and resources were not adequate to meet patients’ needs (Refer to A 0049). The cumulative effect of these systemic problems resulted in the ICU (Intensive Care Unit, unit for critically ill patients) and the fifth floor to smell of sewer, the HVAC (Heating, Ventilation, and Air Conditioning) system supplying the Emergency Department to have a possible untreated Legionella bacteria (a type of bacteria which can cause lung infection) contamination, and patients on the second floor to not be monitored safely and for their needs to not be addressed timely. These failures resulted in the facility’s governing body to not ensure the patients were receiving quality care in a safe and effective manner.”

“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: 35056 Based on interview and record review, the facility failed to ensure patients were provided the care and treatment they needed, for seven of 91 sample patients (Patients 8, 12, 26, 27, 28, 30, 34), when 1. For Patients 12, 26, 27, 28, and 30, pain assessments and/or reassessments were not conducted (Refer to A395 and A398); 2. For Patient 26, assessment was not conducted after Patient 26 was transferred to a different nursing unit (Refer to A395); 3. For Patient 34, who was upgraded as an Intensive Care Unit (ICU, specialized unit that provides specialized care to critically ill patients) patient while on the Medical Surgical unit (unit care of the patient with a wide range of medical and surgical conditions), care was not provided by a qualified registered nurse (Refer to A 397). 4. For Patients 26 and 27 antiseptic (substances that prevent the growth of disease-causing microorganisms) baths were not completed (Refer A 398); 5. For Patient 26, assessment was not completed after the patient was transferred to a different nursing unit (Refer A 398); 6. For Patient 26 and 27, who needed assistance with repositioning, repositioning was not implemented (Refer A 398); 7. For Patient 8, a critical lab result was not reported to the provider (Refer A 398); and 8. For Patient 12, a Transthoracic Echocardiogram (a non-invasive imaging test that uses ultrasound to create detailed images of the heart) result was not reported to the provider (Refer A 398). The cumulative effects of these failures had the potential to impact the quality of care provided to the patients, inadequate pain management, delayed recognition of changes in the patients’ condition, and increased risk of pressure injury development. In addition, these failures had the potential for patients to not receive the appropriate care and monitoring which may result in injury and/or death for the patient.”

“LABORATORY SERVICES CFR(s): 482.27 The hospital must maintain, or have available, adequate laboratory services to meet the needs of its patients. The hospital must ensure that all laboratory services provided to its patients are performed in a facility certified in accordance with Part 493 of this chapter. This Condition is not met as evidenced by: 50122 Based on observations, interviews, and record reviews, the facility failed to ensure laboratory services were provided and maintained to meet the patients’ needs when: 1. Two out of the six freezers and refrigerators were not maintained in accordance with the manufacturer’s instructions for use (Refer to A 0582); 2. The standard laboratory procedure for storing specimens (a sample for medical testing) and reagents (any substance or mixture of substances used to perform a laboratory test) was not implemented (Refer to A 0582); 3. 18 out of 22 laboratory specimens for tests to be sent out for processing by another Laboratory were not completed in a timely manner, for 28 of 91 sample patients (Patients 51, 54 to 68, 70, and 71) (Refer to A 0582); 4. For Patients 51, 55, and 72, the laboratory specimens were not sent to Laboratory (Lab) 3 timely (Refer to A 0582); 5. For Patients 20, 52, and 53, the facility policy and procedure on laboratory services was not implemented (refer to A 0582); 6. For Patient 64, the laboratory test was not entered as ordered on the laboratory requisition form (Refer to A 0582); 7. For Patient 12, the laboratory specimens were not conducted as ordered by physician (Refer to A 0582); 8. For Patient 52, a Stat (an order to be completed immediately) order for Test 14 was not collected timely (Refer to A 0583); and 9. For Patient 53, a Stat order for Test 16 was not collected timely (Refer to A 0583); and 10. the facility’s medical staff were not informed of the change in laboratory (Lab) services for the facility from Lab 2 to Lab 3 (Refer to A0584). The cumulative effect of these failures resulted in a delay in obtaining the result of laboratory tests ordered for the patients and had the potential to produce erroneous laboratory results and cause a delay in the diagnosis and treatment of patients. 50304”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 50122 Based on observation, interview, and record review, the facility failed to ensure the facility’s physical environment was maintained when: 1. Ceiling tiles were observed with brownish stains in the storage and waiting rooms (Refer to A 00701); 2. Sewer smell was observed in ICU-A and in the dirty utility room and patient Rooms A, B, C, D, E, i, J, K, L, M, N, O, P, and Q (Refer to A 701); 3. For fourteen out of 91 sample patients (Patient 24, 36, 37, 38, 39, 40, 41, 42, 43, 44, 74, 75, 76, and 90), a system for use to call if assistance is needed and continuous telemetry (remote monitoring of the patients’ heart rates and rhythms) monitoring were not provided in accordance with the physician’s order (Refer to A 0701); 4. Four pharmaceutical (pertaining to medications)/sharps waste bins (containers for disposals of needles and other sharp items) in the Intensive care unit (ICU, a specialized unit that provides monitoring for patients with life-threatening conditions) were overfilled to the brim (Refer to A 0701); 5. Two out of seven freezers at the laboratory were not maintained in accordance with the manufacturer’s instructions for use. In addition, the condition of the alarm battery of the freezer was not maintained (Refer to A 701); 6. For Patient 73, who was on airborne isolation, the temporary plastic magnetic door in front of the patient’s room was not installed securely (Refer to A 0701); 7. Water retesting was not performed for the Mammoth cooling tower for the HVAC Systems supplying the heating and air-conditioning system to the Emergency Department, after the water tested positive for Legionella bacteria (a type of bacteria that could cause respiratory illness) on September 4, 2024 (Refer to A 0701); 8. The fire-release (a fire door that is designed to automatically close in response to a fire alarm or other emergency signal, preventing the spread of fire and smoke) double doors separating the Definitive Observation Unit (DOU, a unit which provides a high level of care for patients who don’t need intensive care) and Coronary Care Unit (CCU, a unit that treats patients with critical heart conditions) was obstructed (Refer to A 0709); 9. The Smith Cot (a piece of equipment used for evacuating non ambulatory patients) was not readily accessible for emergency use (Refer to A 0714); 10. The elevators cars (Cars 1, 2, 3, 4, 5, and 6) were not maintained in optimal working condition (Refer to A 0724); and 11. An acrylic box for holding the moisture-wicking fabric (fabric with antimicrobial to keep skin folds dry and reduce rubbing and help prevent infection) and a pair of scissors in the box holder were observed to have debris and grime (Refer to A 0724). The cumulative effects of these failures resulted in an unsafe environment, and had the potential for increased risk of exposure to harmful chemicals, viruses, and bacteria, which could potentially cause danger to the health, safety, and well-being of the already immunocompromised patients at the facility.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 38479 Based on interview and record review, the facility’s governing body failed to ensure the facility’s operation was conducted in an effective, safe, and organized manner when the Chief Nursing Officer (CNO) is also the Director of Operating Room and oversees the nursing education. This failure resulted in the facility to not have leadership personnel which could lead to patient needs to not be met timely, delayed treatment of patients, and injury to the patients. Findings: On March 3, 2025, at 11:10 a.m., the CNO was interviewed. The CNO stated she was away from the facility from December 14, 2024, through February 3, 2025, and it was the Chief Operating Officer (COO) who took over during her absence. The CNO stated, “It is important to have leadership because individual unit must have a present “boot [being physically present]” on the unit for chain of command.” The CNO stated, aside for being the CNO, she is also the Director of the Operating Room, and she also oversees the nurses’ education. The CNO stated the facility must delegate responsibilities appropriately, and the facility need to have a dedicated person assigned to each unit. The CNO stated, “Staff need the layer of support.” The CNO stated the facility must rebuild the facility’s leadership team to have more oversight and more cohesive individual units. The CNO stated she reports to the COO and the Chief Medical Officer (CMO) who were aware of the physical environment, laboratory, and provision of care issues in the hospital. On March 3, 2025, at 2:27 p.m., the COO was interviewed regarding leadership and chain of command. The COO stated, “Leadership is important.” The COO stated they have no dedicated person for infection prevention (IP) oversight and is concerned about the state and federal reporting elements for IP. On March 4, 2025, at 10:02 a.m., Governing Body Member (GBM) was interviewed. GBM stated leadership comes with accountability. GBM stated the COO was the person responsible for the operations in the facility. A review of the facility’s document, “CHIEF NURSING OFFICER”, dated January 2012 indicated, “POSITION SUMMARY...The Chief Nursing Officer is responsible for the direction of the hospital’s nursing services and participates as a member of the executive management team, sharing authority, accountability and responsibility with other executive managers to assure the provision of quality, cost efficient healthcare to patients presenting for services. The Chief Nursing Officer has the authority, accountability and responsibility to establish nursing policies and procedure, nursing standards of patient care, treatment, and services, and standards of nursing practice and nurse staffing plans for the organization. The incumbent has been empowered to perform the functions listed below and will be held accountable for them...Ensuring adequate and competent nursing staff service and nursing leadership at all levels...” A review of the facility’s document titled, “CHIEF OPERATING OFFICER,” dated November 2011, was conducted. The document indicated, “...POSITION SPECIFIC RESPONSIBILITIES...understand and behave positively toward the Corporate’s objective by maintaining current insight and knowledge of the social, economic and political climates in which the Corporate must compete for personnel, resources and capital and by ensuring that such environmental factors are appropriately considered and translated into the Corporate’s actions and objectives...Attends meetings of the Board of Directors and makes recommendations on administrative and budgetary matters...” A review of the facility’s bylaws titled, “AMENDED AND RESTATED BYLAWS OF KPC GLOBAL MEDICAL CENTERS, INC. [incorporated],” dated March 31, 2021, was conducted. The policy indicated, “...ARTICLE I DEFINITIONS...1.8 Medical Staff Bylaws means the set of written bylaws...set forth standards, criteria and processes for credentialing, disciplining and organizing the practitioners...ARTICLE II SCOPE AND PURPOSE...the Corporations purpose shall include (a) the operation of the Hospitals for the acute and continued care of the sick, injured and disabled, and the promotion of health...(c) doing any and all things necessary, advisable, appropriate or incidental to such purposes...””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50304 Based on interviews and record reviews, the facility failed to ensure patients’ rights were promoted when patients were not informed of the change in laboratory (lab) services for the facility from Lab 2 to Lab 3. This failure had prevented the patients to exercise their right to participate in their care. Findings: On February 24, 2025, at 9:33 a.m., an interview was conducted with the Director of Laboratory Services (DLS). The DLS stated Lab 2 terminated their contract with the facility on January 20, 2025. The DLS stated Lab 3 started picking up the facility’s specimens for testing on February 14, 2025. An untitled facility document, dated December 19, 2024, was reviewed. The document indicated, “...To: [Name of DLS]...The 30 day letter is going to be sent to the lab directors today and all are needing to understand that [Name of Lab 2] is giving 30 day notice to find another lab...[Name of Lab 2 Executive]...” An untitled facility document, dated January 25, 2025, was reviewed. The document indicated, “...This e-mail is final notification that services for the following accounts will be turned us [sic]...sic 5 PM [p.m.], PT [Pacific Time], Monday 01-20-24 [January 20, 2024, sic]...Breach of signed continuous Service Agreement on file...30 day termination letters overnighted as of 12 -19-24 [December 19, 2024], therefore [Name of Group], has had the opportunity to locate needed reference lab...” There was no documented evidence patients were informed of the change in lab services from Lab 2 to Lab 3 prior to February 24, 2025. On February 24, 2025, at 12:53 a.m., an interview with the Chief Quality Officer was conducted. The CQO stated they did not inform the patients about the changes in lab services from Lab 2 to Lab 3. The CQO stated the patients should have been informed of the changes in lab services from Lab 2 to Lab 3 when it happened, “It is patient’s rights.” A review of facility policy titled, “Patient Rights and Responsibilities,” dated April 2021 indicated, “...Patient’s Rights are part of the philosophy of the Health Group. In addition to assuring that patients are afforded their rights as set forth in the list of patient’s rights and responsibilities...” A review of an undated facility document titled, “Patient Rights,” indicated, “...You have the right to...Receive information about your health status, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in the development and implementation of your plan of care...””

“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: 50433 Based on interview and record review, the facility failed to ensure assessment was conducted, for five of 91 sample patients (Patients 26, 27, 28, and 30) when: 1. For Patients 12, 26, 27, 28, and 30, pain assessments and/or reassessments were not conducted; and 2. For Patient 26, assessment was not conducted after Patient 26 was transferred to a different nursing unit. These facility failures had the potential to impact the quality of care provided to the patients, inadequate pain management, and delayed recognition of changes in the patients’ condition. Findings: 1a. On February 26, 2025, at 11 a.m., a review of Patient 12’s record was conducted with Registered Nurse (RN) 6. A facility document titled, “History and Physical (H&P),” dated September 30, 2024, at 4:58 p.m., was reviewed. The document indicated Patient 12 was admitted to the facility for persistent disequilibrium (a feeling of imbalance or unsteadiness that lasts for most days), left sided facial droop, and acute right pontine infarction (a blood flow blockage to a part of the brain). The document indicated Patient 12 had a medical history of hypertension (high blood pressure), depression (a mood disorder) and benign prostatic hyperplasia (a condition in which the prostate gland enlarges). A facility document titled, “Order Inquiry,” for Patient 12, dated September 30, 2024, at 5:21 p.m., was reviewed and indicated, “...Acetaminophen (medication used for pain and/or fever)...Dose ...650 mg [milligrams, a unit of measurement]...Tablet...Frequency...as needed...Ord [Ordering] Phys [Physician]...[name of Medical Doctor [MD] 1...” A facility document titled, “Order Inquiry,” was reviewed. The document indicated acetaminophen 650 milligrams was administered to Patient 12 on October 1, 2024, at 6:47 a.m., for headache of seven out of 10 on a pain scale (a pain assessment tool, with 0 meaning no pain, and 10 meaning severe pain). There was no documented evidence Patient 12’s pain was reassessed after acetaminophen was administered on October 1, 2024, at 6:47 a.m. On February 26, 2025, at 12 p.m., an interview with Registered Nurse (RN) 6 was conducted. RN 6 stated there was no documentation a pain reassessment was conducted on Patient 12 after acetaminophen was administered for pain on October 1, 2024, at 6:47 a.m. RN 6 further stated, “It should have been done.” 1b. A review of Patient 26’s record was conducted on February 28, 2025, at 1:04 p.m., with the Stroke Coordinator Registered Nurse (SC). A facility document titled, “History and Physical [H&P],” was reviewed. The document indicated Patient 26 was admitted to the facility on February 23, 2025, for abdominal pain. A facility document titled, “Medication Administration Record,” was reviewed. The document indicated, “...Dilaudid [a pain medication]...1 [one] mg [milligram, a unit of measurement]...IV [intravenous, administered through the vein]...every 3 [three] hours, as needed for pain...” A facility document titled, “Med [Medication] Admin [Administration],” was reviewed. The document indicated on February 25, 2025, at 4:55 a.m., 1 mg of Dilaudid was administered to Patient 26. The document indicated Patient 26 had a pain scale level of eight of ten at the time of the Dilaudid administration. There was no documented evidence pain reassessment was conducted after the administration of Dilaudid on February 25, 2025, at 4:55 a.m. 1c. A review of Patient 27’s record was conducted on February 28, 2025, at 2:53 p.m., with the SC. A facility documented titled, “H&P,” was reviewed. The document indicated Patient 27 was admitted to the facility on February 17, 2025, for tremors. A facility document titled, “Medication Administration Record,” was reviewed. The document indicated, “...Morphine [a pain medication]...2 [two] mg...IV...every 4 [four] hours, as needed for pain...” A facility document titled, “Med Admin,” was reviewed. The document indicated on February 24, 2025, at 2:07 p.m., February 27, 2025, at 12:39 a.m., February 27, 2025, at 5:04 p.m., and on February 28, 2025, at 10:18 a.m., 2 mg of morphine was administered to Patient 27. A facility document titled, “Pain Assessment Flow Sheet,” was reviewed. The document indicated Patient 27’s pain level was assessed during the above-mentioned dates and times at eight of 10, 10 of 10, eight of 10, and eight of 10, respectively. There was no documented evidence pain was reassessed after morphine was administered to Patient 27 on the above-mentioned dates and times. 1d. A review of Patient 28’s record was conducted on March 3, 2025, at 9:45 a.m., with the SC. A facility documented titled, “H&P,” was reviewed. The document indicated Patient 28 was admitted to the facility on February 28, 2025, for shortness of breath. A facility document titled, “Medication Administration Record,” was reviewed. The document indicated, “...Acetaminophen...tablet oral [by mouth] every six hours as needed...for mild pain...650 mg...Tylenol [brand name of acetaminophen] ...” A facility document titled, “Med Admin,” was reviewed. The document indicated on February 28, 2025, at 10:40 p.m., March 1, 2025, at 9:33 a.m., March 2, 2025, at 10:05 a.m., and March 2, 2025, at 4:53 p.m., 650 mg of Tylenol was administered to Patient 28. A facility document titled, “Pain Assessment Flow Sheet,” was reviewed. There was no documented evidence Patient 28’s pain level was not assessed or reassessed on the above mentioned administration dates and times. 1e. A review of Patient 30’s record was conducted on March 3, 2025, at 10:10 a.m., with the SC. A facility documented titled, “H&P,” was reviewed. The document indicated Patient 30 was admitted to the facility on February 19, 2025, for shortness of breath. A facility document titled, “Medication Administration Record,” was reviewed. The document indicated, “...hydrocodone/acetaminophen [a pain medication] 5 [five]/325 mg ...Norco [brand name of hydrocodone/acetaminophen]...tablet...oral...PRN [as needed]...” A facility document titled, “Med Admin,” was reviewed. The document indicated on February 21, 2025, at 10:01 a.m., one tablet of Norco was administered to Patient 30. A facility document titled, “Pain Assessment Flow Sheet,” was reviewed. The document indicated Patient 30’s pain level was 10 of 10 on February 21, 2025, at 10:01 a.m. There was no documented evidence pain reassessment was conducted on Patient 30 after Norco was administered on February 21, 2025, at 10:01 a.m. An interview was conducted on March 3, 2025, at 10:45 a.m., with the SC. The SC stated it is important to assess and reassess patients pain levels to know if treatment is effective. The facility policy and procedure titled “Pain Management,” dated September 2024 was reviewed. The policy indicated, “...Routine Reassessment...Patient will be routinely reassessed for pain during the initial daily shift assessment...with new complaints, and as needed. At a minimum, this reassessment shall consist of noting the intensity of the patient’s pain...Reassessment Following Treatment for Pain...If a treatment intervention for pain is provided, the response to that intervention should be assessed. Reassessment is recommended to occur within 15 - 60 minutes following treatment...” 2. A review of Patient 26’s record was conducted on February 28, 2025, at 1:04 p.m., with the SC. A facility document titled, “H&P,” was reviewed. The document indicated Patient 26 was admitted to the facility on February 23, 2025, for abdominal pain. A facility document titled, “Daily Floor Census,” dated February 27, 2025, was reviewed and indicated Patient 26 was transferred from the ICU (intensive care unit, unit for patients with critical illnesses) to the telemetry unit (a unit for patients needing continuous remote heart rhythm monitoring) on February 27, 2025, at 7 p.m. A review of the facility flow sheet titled, “Daily,” was reviewed and indicated Patient 26 was assessed on Patient 26 on February 27, 2025, at 6 p.m., and then on February 28, 2025, at 8 a.m. There was no documented evidence Patient 26 was assessed after the patient was transferred to the telemetry unit on February 27, 2025, at 7 p.m., until February 28, 2025, at 8 a.m. An interview was conducted on February 28, 2025, at 1:15 p.m., with the SC. The SC stated there should have been an assessment overnight for Patient 26 from February 27, 2025, to February 28, 2025. An interview was conducted on March 3, 2025, at 10:45 a.m., with the SC. The SC stated patients should be assessed a minimum of once per shift. The SC further stated nurses should complete a transfer assessment when patients are transferred to another unit. The SC stated it is important for assessments of patients to be completed to monitor changes in conditions and report them back to the health care team. The facility policy and procedure titled, “Transferring of Patients (Including In-Unit Transfers,” dated September 2024, was reviewed. The policy indicated, “...A transfer assessment shall be completed by a registered nurse within eight (8) hours of transfer to the assigned unit/room...””

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 47071 Based on interview and record review the facility failed to ensure qualified staff provided care, for one of 91 sampled patients (Patient 34), who was upgraded as an Intensive Care Unit (ICU, specialized unit that provides specialized care to critically ill patients) patient while on the Medical Surgical unit (unit care of the patient with a wide range of medical and surgical conditions). This failure had the potential for Patient 34 to not receive the appropriate care and monitoring which may result in injury and/or death for the patient. Findings: A review of Patient 34’s record was conducted on March 3, 2025, at 10:53 a.m., with the Patient Safety Coordinator (PSC). A facility document titled, “History and Physical,” dated February 25, 2025, was reviewed. The document indicated Patient 34 was admitted to the facility on February 27, 2025, for generalized weakness and a history of hypertension (high blood pressure), hyperlipidemia (high levels of fat in the blood), and chronic kidney disease (a condition when the kidneys are not functioning well). A facility document titled, “Labs [laboratory],” dated March 1, 2025, at 8:27 a.m., was reviewed. The document indicated, “...Partial pressure of carbon dioxide [PCO2, amount of carbon dioxide in the blood]...65...H [High]...reference range...35-45...mmHg [millimeters of mercury, unit of measurement]...” A facility document titled, “Order Inquiry,” dated March 1, 2025, at 8:48 a.m., was reviewed. The document indicated, “...Transfer to Intensive Care Unit...start date: 3/1/2025 [March 1, 2025] 08:48 [8:48 a.m.]...priority...Stat [immediately]...possible intubation [inserting a tube in the windpipe to help with breathing]...” A facility document titled, “Labs,” dated March 1, 2025, at 9:50 a.m., was reviewed. The document indicated, “...Partial pressure of carbon dioxide...70...High [H]...reference range...35-45...mmHg...” A facility document titled, “Code Blue,” dated March 1, 2025, at 10:31 a.m., was reviewed. The document indicated, “...Code date 3/1/25...reason for code: abnormal ABG [arterial blood gas, test that measures levels of oxygen in the blood to evaluate breathing]. Planned intubation initiated...felt the patient required emergency intubation...” An undated facility document titled, “Progress Note,” was reviewed. The document indicated, “...3/1/2025 08:36 [8:36 a.m.]...called dr [medical doctor]...with abg...result dr wants pt [Patient 34] transferred to icu...rn [registered nurse] aware and will speak to icu...3/1/2025 09:23 [9:23 a.m.]...Dr...ordered transfer to ICU pH [measure the bodies acid-base balance , with normal value of 7.35-7.45 ] 7.23 pco2 [partial pressure of carbon dioxide] 62 refusing bipap [bilevel positive airway pressure, system that provides pressurized air to assist with breathing] last night...house sup [supervisor]...notified...3/1/2025 11:05 [11:05 a.m.]...unable to give fentanyl [drug used for pain medication and sedation] and versed [drug used for pain medication and sedation] on telemetry [unit where the patients’ heart rates and rhythms are continuously monitore remotely] floor, after code [Code Blue], doctors and staff qualified to give left, house supervisor...notified...stated that they would come in 20 minutes 20 minutes ago...3/1/2025 11:38 [11:38 a.m.]...called ccu [Critical Care Unit, unit for specialized care for patients with life threatening conditions] at 11:50 [11:50 a.m.] and said that we can’t give sedative on this floor, they said they would come down [to the floor where Patient 34 was]...” An undated facility document titled, “Encounter Management,” was reviewed. The document indicated Patient 34 was transferred to ICU Room H on March 1, 2025, at 12:18 p.m. A facility document titled “Acknowledgement of Employee Job description/Physical Requirements and Working Conditions Form,” dated July 26, 2022, was reviewed. The document indicated, “...Employee Name: RN 1 [Patient 34’s primary RN taking care of the patient on the medical surgical floor before and after Patient 34 was upgraded to be transferred to the ICU]...Date 7/26/22 [July 26, 2022]...Job Title...RN...Department...Med/Surg [Medical/Surgical]...” There was no documented evidence RN 1 has competency to care for an ICU patient. An interview was conducted on March 3, 2025, at 11:15 a.m., with the PSC. The PSC stated the patient should have been taken care of by a qualified ICU nurse on March 1, 2025, at 8:48 a.m., when the provider ordered the upgrade of Patient 34 to ICU. An interview was conducted on March 3, 2025, at 11:15 a.m., with the Nursing Supervisor Registered Nurse (NSRN). The NSRN stated the RN 1 was not qualified to take care of an ICU patient. The NSRN stated it was inappropriate for the Medical Surgical/Telemetry Unit to have the ICU patient in the unit. The NSRN stated the Charge Nurse from the ICU should have remained with Patient 34 and took over the patient care. An interview was conducted on March 4, 2025, at 8:45 a.m., with the Chief Nursing Officer (CNO). The CNO stated she was notified of the changes to Patient 34’s condition which required Patient 34 to be transferred to the ICU. The CNO stated she reinforced that Patient 34 was to be transferred to the ICU. The CNO stated she was made aware of the delay in transferring Patient 34 to the ICU. The CNO stated she was not aware RN 1 was providing care to Patient 34 and was not qualified to care for an ICU patient. The CNO stated it is not expected for a medical surgical nurse to provide care for an ICU patient. An interview was conducted on March 4, 2025, at 9:02 a.m., with the Corporate Quality Officer (CQO). The CQO stated nurses should be competent in the care providing to the patients. The facility was not able to provide a policy for Registered Nurse competencies. A facility policy and procedure titled, “Staffing Plan,” dated December 2023, was reviewed. The policy indicated, “...criteria and process for assigning patient care responsibilities in accordance with California Department of Public Health and Title 22 nurse...number of qualified RNs required for delivering nursing care to patients requiring a specific level of care...””

“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: 50433 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures were implemented, for six of 91 sampled patients (Patients 12, 26, 27, 28, and 30), when: 1. For Patients 12, 26, 27, 28, and 30 pain assessments and/or reassessments were not completed; 2. For Patients 26 and 27 antiseptic (substances that prevent the growth of disease-causing microorganisms) baths were not completed; 3. For Patient 26, assessment was not completed after the patient was transferred to a different nursing unit; 4. For Patient 26 and 27, who needed assistance with repositioning, repositioning was not implemented; 5. For Patient 8, a critical lab result was not reported to the provider; and 6. For Patient 12, a Transthoracic Echocardiogram (a non-invasive imaging test that uses ultrasound to create detailed images of the heart) result was not reported to the provider. These failures had the potential to compromise patient safety, result in inadequate pain management, increase the risk of infection, and increase the risk for pressure injuries (bedsores, injuries to skin and the tissue below the skin that are due to pressure on the skin for a long time). Findings: 1a. On February 26, 2025, at 11 a.m., a review of Patient 12’s record was conducted with Registered Nurse (RN) 6. A facility document titled, “History and Physical (H&P),” dated September 30, 2024, at 4:58 p.m., was reviewed. The document indicated Patient 12 was admitted to the facility for persistent disequilibrium (a feeling of imbalance or unsteadiness that lasts for most days), left sided facial droop, and acute right pontine infarction (a blood flow blockage to a part of the brain). The document indicated Patient 12 had a medical history of hypertension (high blood pressure), depression (a mood disorder) and benign prostatic hyperplasia (a condition in which the prostate gland enlarges). A facility document titled, “Order Inquiry,” dated September 30, 2024, at 5:21 p.m., was reviewed and indicated, “...Acetaminophen (medication used for pain and/or fever)...Dose ...650 mg [milligrams, a unit of measurement]...Tablet...Frequency...as needed...Ord [Ordering] Phys [Physician]...[name of Medical Doctor [MD] 1...” A facility document titled, “Order Inquiry,” was reviewed. The document indicated acetaminophen 650 milligrams was administered to Patient 12 on October 1, 2024, at 6:47 a.m., for headache of seven out of 10 on a pain scale (a pain assessment tool, with 0 meaning no pain, and 10 meaning severe pain). There was no documented evidence Patient 12’s pain was reassessed after acetaminophen was administered on October 1, 2024, at 6:47 a.m. On February 26, 2025, at 12 p.m., an interview with Registered Nurse (RN) 6 was conducted. RN 6 stated there was no documentation a pain reassessment was conducted on Patient 12 after acetaminophen was administered for pain on October 1, 2024, at 6:47 a.m. RN 6 further stated, “It should have been done.” 1b. A review of Patient 26’s record was conducted on February 28, 2025, at 1:04 p.m., with the Stroke Coordinator Registered Nurse (SC). A facility document titled, “History and Physical [H&P],” was reviewed. The document indicated Patient 26 was admitted to the facility on February 23, 2025, for abdominal pain. A facility document titled, “Medication Administration Record,” was reviewed. The document indicated, “...Dilaudid [a pain medication]...1 [one] mg [milligram, a unit of measurement]...IV [intravenous, administered through the vein]...every 3 [three] hours, as needed for pain...” A facility document titled, “Med [Medication] Admin [Administration],” was reviewed. The document indicated on February 25, 2025, at 4:55 a.m., 1 mg of Dilaudid was administered to Patient 26. The document indicated Patient 26 had a pain scale level of eight of ten at the time of the Dilaudid administration. There was no documented evidence pain reassessment was conducted after the administration of Dilaudid on February 25, 2025, at 4:55 a.m. 1c. A review of Patient 27’s record was conducted on February 28, 2025, at 2:53 p.m., with the SC. A facility documented titled, “H&P,” was reviewed. The document indicated Patient 27 was admitted to the facility on February 17, 2025, for tremors. A facility document titled, “Medication Administration Record,” was reviewed. The document indicated, “...Morphine [a pain medication]...2 [two] mg...IV...every 4 [four] hours, as needed for pain...” A facility document titled, “Med Admin,” was reviewed. The document indicated on February 24, 2025, at 2:07 p.m., February 27, 2025, at 12:39 a.m., February 27, 2025, at 5:04 p.m., and on February 28, 2025, at 10:18 a.m., 2 mg of morphine was administered to Patient 27. A facility document titled, “Pain Assessment Flow Sheet,” was reviewed. The document indicated Patient 27’s pain level was assessed during the above-mentioned dates and times at eight of 10, 10 of 10, eight of 10, and eight of 10, respectively. There was no documented evidence pain was reassessed after morphine was administered to Patient 27 on the above-mentioned dates and times. 1d. A review of Patient 28’s record was conducted on March 3, 2025, at 9:45 a.m., with the SC. A facility documented titled, “H&P,” was reviewed. The document indicated Patient 28 was admitted to the facility on February 28, 2025, for shortness of breath. A facility document titled, “Medication Administration Record,” was reviewed. The document indicated, “...Acetaminophen...tablet oral [by mouth] every six hours as needed...for mild pain...650 mg...Tylenol [brand name of acetaminophen] ...” A facility document titled, “Med Admin,” was reviewed. The document indicated on February 28, 2025, at 10:40 p.m., March 1, 2025, at 9:33 a.m., March 2, 2025, at 10:05 a.m., and March 2, 2025, at 4:53 p.m., 650 mg of Tylenol was administered to Patient 28. A facility document titled, “Pain Assessment Flow Sheet,” was reviewed. There was no documented evidence Patient 28’s pain level was not assessed or reassessed on the above mentioned administration dates and times. 1e. A review of Patient 30’s record was conducted on March 3, 2025, at 10:10 a.m., with the SC. A facility documented titled, “H&P,” was reviewed. The document indicated Patient 30 was admitted to the facility on February 19, 2025, for shortness of breath. A facility document titled, “Medication Administration Record,” was reviewed. The document indicated, “...hydrocodone/acetaminophen [a pain medication] 5 [five]/325 mg ...Norco [brand name of hydrocodone/acetaminophen]...tablet...oral...PRN [as needed]...” A facility document titled, “Med Admin,” was reviewed. The document indicated on February 21, 2025, at 10:01 a.m., one tablet of Norco was administered to Patient 30. A facility document titled, “Pain Assessment Flow Sheet,” was reviewed. The document indicated Patient 30’s pain level was 10 of 10 on February 21, 2025, at 10:01 a.m. There was no documented evidence pain reassessment was conducted on Patient 30 after Norco was administered on February 21, 2025, at 10:01 a.m. An interview was conducted on March 3, 2025, at 10:45 a.m., with the SC. The SC stated it is important to assess and reassess patients pain levels to know if treatment is effective. The facility policy and procedure titled “Pain Management,” dated September 2024 was reviewed. The policy indicated, “...Routine Reassessment...Patient will be routinely reassessed for pain during the initial daily shift assessment...with new complaints, and as needed. At a minimum, this reassessment shall consist of noting the intensity of the patient’s pain...Reassessment Following Treatment for Pain...If a treatment intervention for pain is provided, the response to that intervention should be assessed. Reassessment is recommended to occur within 15 - 60 minutes following treatment...” 2a. A review of Patient 26’s record was conducted on February 28, 2025, at 1:04 p.m., with the SC. A facility document titled, “History and Physical [H&P],” was reviewed. The document indicated Patient 26 was admitted to the facility on February 23, 2025, for abdominal pain. A review of the facility flow sheet, “I&O [intake and output, documentation fluid volumes taken in and out of the body],” was conducted. The document indicated Patient 26 had a foley catheter (a plastic tube inserted into the bladder to drain and collect the urine) placed since February 23, 2025. A review of the facility flow sheet, “Activities of Daily Living,” was conducted. The document indicated Patient 26 was provided with a chlorhexidine gluconate (CHG, an antiseptic solution to help reduce the bacteria on the skin) bath on February 23, 2025, February 24, 2025, February 25, 2025, and February 28, 2025. There was no documented evidence a CHG bath was provided to Patient 26 on February 26, 2025, and February 27, 2025. 2b. A review of Patient 27’s record was conducted on February 28, 2025, at 2:53 p.m., with the SC. A facility documented titled, “H&P,” was reviewed. The document indicated Patient 27 was admitted to the facility on February 17, 2025, for tremors. A review of the facility flow sheet, “I&O,” was conducted. The document indicated Patient 27 had a foley catheter inserted February 17, 2025, and remained in place until discharge. A review of the facility flow sheet, “Activities of Daily Living” was conducted. The document indicated Patient 27 was provided with a CHG bath on February 18, 2025, February 19, 2025, February 21, 2025, February 21, 2025, February 20, 2025, February 21, 2025, February 22, 2025, February 23, 2025, February 24, 2025, February 25, 2025, February 27, 2025, and February 28, 2025. The document further indicated Patient 27 refused a CHG bath on February 19, 2025. There was no documented evidence an CHG bath was provided to Patient 27 on February 26, 2025. 2c. A review of Patient 30’s record was conducted on March 3, 2025, at 10:10 a.m., with the SC. A facility documented titled, “H&P,” was reviewed. The document indicated Patient 30 was admitted to the facility on February 19, 2025, for shortness of breath. A review of the facility flow sheet, “I&O,” was conducted. The document indicated Patient 30 had a foley catheter inserted on February 23, 2025, and remained in place until February 28, 2025. A review of the facility flow sheet, “Activities of Daily Living,” was conducted. The documented indicated Patient 30 was provided with a CHG bath on February 23, 2025, February 24, 2025, February 25, 2025, and February 27, 2025. There was no documented evidence a CHG bath was provided to Patient 30 on February 26, 2025. An interview was conducted on March 3, 2025, at 10:45 a.m., with the SC. The SC stated CHG bath should be completed once per day for patients with foley catheters. The SC stated CHG baths are important to prevent hospital required infections. The facility policy and procedure titled, “Bathing with Hospital Approved Skin Antiseptic,” dated May 2024, was reviewed. The policy indicated, “...daily bathing with a hospital approved skin antiseptic will be performed...daily...on the following patients...have an indwelling urinary catheter...” 3a. A review of Patient 26’s record was conducted on February 28, 2025, at 1:04 p.m., with the SC. A facility document titled, “H&P,” was reviewed. The document indicated Patient 26 was admitted to the facility on February 23, 2025, for abdominal pain. A facility document titled, “Daily Floor Census,” dated February 27, 2025, was reviewed and indicated Patient 26 was transferred from the ICU (intensive care unit, unit for patients with critical illnesses) to the telemetry unit (a unit for patients needing continuous remote heart rhythm monitoring) on February 27, 2025, at 7 p.m. A review of the facility flow sheet titled, “Daily,” was reviewed and indicated Patient 26 was assessed on Patient 26 on February 27, 2025, at 6 p.m., and then on February 28, 2025, at 8 a.m. There was no documented evidence Patient 26 was assessed after the patient was transferred to the telemetry unit on February 27, 2025, at 7 p.m., until February 28, 2025, at 8 a.m. An interview was conducted on February 28, 2025, at 1:15 p.m., with the SC. The SC stated there should have been an assessment overnight for Patient 26 from February 27, 2025, to February 28, 2025. An interview was conducted on March 3, 2025, at 10:45 a.m., with the SC. The SC stated patients should be assessed a minimum of once per shift. The SC further stated nurses should complete a transfer assessment when patients are transferred to another unit. The SC stated it is important for assessments of patients to be completed to monitor changes in conditions and report them back to the health care team. The facility policy and procedure titled, “Transferring of Patients (Including In-Unit Transfers,” dated September 2024, was reviewed. The policy indicated, “...A transfer assessment shall be completed by a registered nurse within eight (8) hours of transfer to the assigned unit/room...” 4a. A review of Patient 26’s record was conducted on February 28, 2025, at 1:04 p.m., with the SC. A facility document titled, “H&P,” was reviewed. The document indicated Patient 26 was admitted to the facility on February 23, 2025, for abdominal pain. The facility flow sheet, “Activities of Daily Living,” was reviewed. The document indicated Patient 26 needed assistance to reposition. There was no documented evidence Patient 26 was repositioned every two hours on the following dates and times: - February 24, 2025, at 10 p.m.; - February 25, 2025, at 12 a.m.; 2 a.m., 4 a.m., and 6 a.m.; and - February 27, 2025, at 2 a.m.; 4 a.m., and 6 a.m. 4b. A review of Patient 27’s record was conducted on February 28, 2025, at 2:53 p.m., with the SC. A facility documented titled, “H&P,” was reviewed. The document indicated Patient 27 was admitted to the facility on February 17, 2025, for tremors. A facility document titled, “Wound Management,” was reviewed. The document, dated February 17, 2025, was reviewed and indicated, “...Large reddened area with small white area of macerated [occurs when skin is exposed to moisture for too long, causing it to soften, swell, and break down] skin.” The document, dated February 20, 2025, was reviewed and indicated, “...non-blanchable [discoloration of the skin that does not turn white when pressed] redness with small open area...” A facility document titled, “Progress Note,” dated February 24, 2025, at 10:54 a.m., was reviewed. the document it indicated, “...Stage 2 [a partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed] in the coccyx [tailbone]...” The facility flow sheet titled, “Activities of Daily Living,” was reviewed. The document indicated Patient 27 needed assistance to reposition. There was no documented evidence Patient 27 was repositioned every two hours on the following dates and times: - February 18, 2025, at 8 p.m. and 10 p.m.; and -February 19, 2025, at 12 a.m., 2 a.m., 4 a.m., and 6 a.m. An interview was conducted on March 3, 2025, at 10:45 a.m., with the SC. The SC stated, if patients need assistance, they should be repositioned every two hours to prevent pressure injuries, and offload pressure. The SC further stated if patients are not repositioned, it could result in pressure injuries. An interview and concurrent record review was conducted on March 3, 2025, at 2:35 p.m., with the SC. The SC confirmed Patient 26 had a Braden score (a pressure injury risk assessment tool with skin breakdoen risk categories of 19-23: no risk, 15-18: mild risk, 13-14: moderate risk, 10-12: high risk, and 9 and less: very high risk) of 15. The SC confirmed Patient 27 had a Braden score of 12. The SC stated Patient 26 and Patient 27 were at risk of skin breakdown. The facility policy and procedure titled, “Skin And Wound Care,” dated May 2024, was reviewed. The policy indicated, “...Risk factor for skin impairment: Braden Scale of eighteen (18) or less...Pressure injury skin bundle interventions include...Regular repositioning...For patients with intact skin, continue documentation to include interventions for prevention...” 5. On February 26, 2025, at 1:30 p.m., a review of Patient 8’s record was conducted with Registered Nurse (RN) 6. A facility document titled, “History and Physical [H&P],” dated February 23, 2025, at 12:49 a.m., was reviewed. The document indicated Patient 8 was admitted to the facility for altered mental status (a significant change in a person’s level of consciousness, awareness, cognition, or behavior). The document indicated Patient 8 had a history of end stage renal disease (condition where the kidneys are severely damaged) on hemodialysis (a procedure to filter and remove waste products from the blood using a machine), seizures (a sudden, temporary disruption in the brain’s electrical activity that can cause involuntary movements, changes in behavior, and/or loss of consciousness), diabetes (a condition with abnormal blood sugar levels), and hypertension (high blood pressure). The document indicated Patient 8 was admitted to Intensive Care Unit (ICU, a department of a hospital in which patients who are ill are kept under constant observation). A facility document titled, “Chemistry,” dated February 24, 2025, at 12:25 a.m., was reviewed. The document indicated, “...Calcium...14.1...H [high]...Reference Units...[8.6-10.3 mg/dl [milligrams per deciliter, unit of measurement]...” A facility document titled, “H&P,” dated February 24, 2025, at 12:49 a.m., was reviewed. The document did not indicate a critical calcium level. There was no documented evidence the physician was notified of Patient 8’s critical calcium level on February 24, 2025, at 12:25 a.m. On February 26, 2025, at 1 p.m., an interview was conducted with RN 6. RN 6 stated, “the critical calcium should have been reported to the doctor.” RN 6 stated there was no documentation anyone was notified of Patient 8’s critical calcium results or if any new orders for Patient 8 related to the critical calcium level was placed. RN 6 stated the facility’s policy was not followed. On February 26, 2025, a review of the policy titled, “Request for Laboratory Tests,” dated April 2021, was conducted. The policy indicated, “...Critical Values...All abnormal test results that appear to be in a range where immediate attention should be given to the patient will be phoned immediately to the appropriate caregiver within 60 minutes...” 6. On February 26, 2025, at 11 a.m., a review of Patient 12’s record was conducted with Registered Nurse (RN) 6. On February 26, 2025, at 11:05 a.m., Patient 12’ s record was reviewed with RN 6. A facility document titled, “History and Physical (H&P),” dated September 30, 2024, at 4:58 p.m., was reviewed. The document indicated Patient 12 was admitted to the facility for persistent disequilibrium (a feeling of imbalance or unsteadiness that lasts for most days), left sided facial droop acute right pontine infarction (a blood flow blockage to a part of the brain). The document indicated Patient 12 had a medical history of hypertension (high blood pressure), depression and benign prostatic hyperplasia (a condition in which the prostate gland enlarges). The document further indicated a plan for an echocardiogram (a test of the action of the heart using ultrasound waves to produce a visual display) for Patient 12. A facility document titled, “Order Inquiry,” dated October 1, 2024, at 8:01 a.m., was reviewed and indicated an echocardiogram was ordered by Medical Doctor (MD) 3. A facility document titled, “Transthoracic Echocardiogram Report [TTE],” dated October 2, 2024, at 12:14 p.m., was reviewed and indicated a TTE was completed on Patient 12. A facility document titled, “Discharge Summary,” dated October 2, 2024, at 4:54 p.m., authored by MD 2, was reviewed. The document indicated Patient 12 was discharged to home with home health (medical and nursing services provided in a patient’s residence instead of a hospital or other healthcare facility). The document indicated, “...TTE was done on October 2, 2024, patient wanted to leave and so was discharged shortly after TTE, primary team will follow up on result and inform patient...Disposition...follow up on TTE, PCP [primary care physician] appointment w/in [within] 1-2 [one to two weeks...” There was no documented evidence the physician and Patient 12 were notified of the results of Patient 12’s TTE procedure. On February 26, 2025, at 11:15 a.m., an interview was conducted with the Nursing Supervisor Registered Nurse (NSRN). The NSRN stated the physician who ordered the test should have been notified of the TTE results. The NSRN stated there was no documentation Patient 12 and MD 3, who ordered the TTE, were notified of the results of Patient 12’s TTE procedure. On February 26, 2025, a review of the facility policy titled, “Echocardiograms,” dated April 2021, was conducted. The policy indicated, “...Once an echocardiogram has been interpreted by the reading physician, the report will be filed in the patient’s chart, or sent to Medical Records if the patient is discharged...A second copy must be made of the original dictated report and placed in the patient’s cardiology folder...A copy of the report will be faxed to the dictating and referring physician upon verification of the report...””

“ADEQUACY OF LABORATORY SERVICES CFR(s): 482.27(a) The hospital must have laboratory services available, either directly or through a contractual agreement with a certified laboratory that meets the requirements of part 493 of this chapter. This Standard is not met as evidenced by: 50304 Based on observations, interviews, and record reviews, the facility failed to ensure laboratory services were provided and maintained to meet the patients’ needs when: 1. Two out of the six freezers and refrigerators and the freezer alarm battery were not maintained in accordance with the manufacturer’s instructions for use (IFU); 2. The standard laboratory procedure for storing specimens (a sample for medical testing) and reagents (any substance or mixture of substances used to perform a laboratory test) was not implemented; 3. 18 out of 22 laboratory specimens for tests to be sent out for processing to Laboratory 2 were not completed in a timely manner for Patients 20, 51, 54, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 70, and 71; 4. For three of 91 sample patients (Patients 51, 55, and 72), the laboratory specimens were not sent to Laboratory (Lab) 3 timely; 5. For three of 91 sample patients (Patients 20, 52, and 53), the facility policy and procedure on laboratory services was not implemented; 6. For one of 91 sample patients (Patient 64), the laboratory test was not entered as ordered on the laboratory requisition form; and 7. For one of 91 sample patients (Patient 12), the laboratory specimens were not conducted as ordered by physician. These failures resulted in a delay in obtaining the result of laboratory tests and had the potential to produce erroneous (wrong) laboratory results and cause a delay in the diagnosis and treatment of patients. Findings: 1.On February 24, 2025, at 5:30 p.m., an observation of the laboratory was conducted with the Director of Laboratory Services (DLS). 1a. During an inspection of Freezer 1 in the laboratory, an approximately two-inch thick white tiny ice crystals (frost) were observed in the compartments of Freezer 1. A review of the manufacturers’ Instruction For Use (IFU) for Freezer 1 was conducted with the DFM. The undated document titled, “Installation and Operation Manual [Name of Freezer 1],” was reviewed. The document indicated, “...defrost the freezer once a year or whenever the ice buildup exceeds 3/8” [inch, a unit of measurement]...” Based on record review, there was no documented evidence Freezer 1 was defrosted in the preventative maintenance (PM, the act of keeping a structure in its as-built condition) sheet provided by the facility. Based on record review, there was no documented evidence a work order was generated to defrost Freezer 1. On March 3, 2025, at 4:01 p.m., an interview with concurrent record review were conducted with the Director of Facility Maintenance (DFM). The DFM stated the PM for Freezer 1 did not contain documentation Freezer 1 was defrosted as directed by the IFU. The DFM stated it should have been defrosted. 1b. On February 24, 2025, at 5:30 p.m., an inspection of Refrigerator 1 in the laboratory was conducted with the DLS. An approximately two-inch white crystals were observed in the freezer compartment of Refrigerator 1. On February 24, 2025, at 5:30 p.m., an interview was conducted with the DLS. The DLS stated the two-inch frost was present in all the compartments of Freezer 1. The DLS stated there should not be frost in the freezer compartments in order “to maintain the stability and integrity of the controls (a sample with a known value that is tested alongside experimental samples) and specimens.” The DLS further stated, “We get bad results or erroneous results because of it.” A review of the manufacturer’s IFU for Refrigerator 1 was conducted with the DFM. The undated document titled, “Care and Cleaning,” was reviewed. The document indicated, “...defrost freezer compartment when frost becomes 1/4” to ½” thick in any area of the freezer...” Based on record review, there was no documented evidence Refrigerator 1 was defrosted in the PM sheet provided by the facility. Based on record review, there was no documented evidence a work order was generated to defrost Refrigerator 1. On March 3, 2025, at 4:01 p.m., an interview was conducted with the DFM. The DFM stated the PM sheet did not have documentation Refrigerator 1 was defrosted as directed by the manufacturer’s IFU. The DFM stated it should have been defrosted. 1c. On February 24, 2025, at 5:30 p.m., an observation of the laboratory with concurrent interview were conducted with the Director of Laboratory Services (DLS). The “Alarm battery low” light on the front of Freezer 1 was observed to be on. On February 24, 2025, at 5:30 p.m., during a concurrent interview, the DLS stated the alarm battery was low. The DLS stated it was time to change the alarm battery, but he has not submitted a work order yet. On February 25, 2025, at 1:48 p.m., an interview with concurrent record review were conducted with the DFM. A review of the PM for Freezer 1 was conducted with the DFM. The DFM stated there was no documentation on the PM sheet that a visual check was done on the battery for the alarm for Freezer 1. The DFM stated it should have been documented if the battery was checked. A review of the manufacturer’s IFU for the Freezer 1 was conducted with the DFM. An undated document titled, “Installation and Operation Manual [Name of Freezer 1],” was reviewed and indicated, “...Alarm Battery Maintenance check the condition of the alarm battery at least once a year...” Based on record review, there was no documented evidence a work order was generated to change Freezer 1’s alarm battery prior to February 24, 2025, at 5:30 p.m. There was no documented evidence the alarm battery on Freezer 1 was inspected prior to February 24, 2025. A review of the facility policy and procedure titled, “Temperature and Humidity Monitoring of General Lab and Lab equipment,” dated August 2024, was conducted. The policy indicated, “...it is the policy of [Name of Facility] to maintain proper temperature and humidity conditions for optimal instrument performance based on manufacturer’s guidelines and proper temperatures for all equipment (i.e., freezers, refrigerators, water baths, etc.) involving reagent and chemical storage...” 2. On February 24, 2025, at 5:30 p.m., an observation of the laboratory was conducted with the DLS. During an inspection of Freezer 1 in the laboratory, specimens and reagents were observed to have been stored together in the compartments. On February 25, 2025, at 9:47 a.m., an interview was conducted with the DLS. The DLS stated the specimens and reagents were mixed together in the same compartment. The DLS stated the specimens and reagents should have been stored in separate compartments. On February 25, 2025, at 10:15 a.m., an interview was conducted with the Chief Quality Officer (CQO). The CQO stated specimens and reagents cannot be stored mixed together in one compartment for infection control purposes. The CQO stated, “Specimens are dirty, and reagents are clean.” An undated document titled, “Can laboratory reagents be stored in a refrigerator that also contains medications or laboratory specimens,” was reviewed with the DLS. The document indicated, “...Laboratory reagents may be stored in the same refrigerator as laboratory specimens...there should be distinctly marked and separated areas in the refrigerator to minimize any risk of contamination from spills. Laboratory reagents should be stored on upper shelves with laboratory specimens on lower shelves...” 3. On February 24, 2025, at 9:33 am, an interview was conducted with the DLS. The DLS stated Lab 2 terminated their contract with the facility on January 20, 2025. The DLS stated Laboratory (Lab) 3 started picking up their specimens for testing on February 14, 2025. An untitled facility document dated December 19, 2024, was reviewed. The document indicated, “...To: [Name of DLS]...The 30 day letter is going to be sent to the lab directors today and all are needing to understand that [Name of Lab] is giving 30 day notice to find another lab...[Name of Lab 2 Executive]...” An untitled facility document dated January 25, 2025, was reviewed. The document indicated, “...This e-mail is final notification that services for the following accounts will be turned us [sic] off, [sic] 5 PM [p.m.], PT [Pacific Time], Monday 01-20-24 [January 20, 2024, sic]...Breach of signed continuous Service Agreement on file...30 day termination letters overnighted as of 12-19-24 [December 19, 2024], therefore, [Name of Group] has had the opportunity to locate needed reference lab...” On February 28, 2025, at 9:57 a.m. a review of laboratory tests completed with concurrent interview were conducted with the DLS and Technical Supervisor (TS): 3a. On February 28, 2025, at 10:07 a.m., a review of Patient 51’s record was conducted with the DLS. An untitled and undated facility document was reviewed and indicated Patient 51 was admitted to the facility on January 31, 2025, for septic shock (a severe infection). An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 51]...Ordered: [Name of Test 1...entered: 02/01/2025 [February 1, 2025]- 0010 [12:10 a.m.]...Reg Dr: [Name of Physician (MD 2)]...Coll [Collected]: 02/01/2025 - 0305 [3:05 a.m.]...Recv [Received]: 02/01/2025 - 0713 [7:13 a.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 51]...Received: 02/16/2025 [February 16, 2025]- 01:34 [1:34 a.m.]...Reported: 02/24/2025 [February 24, 2025]- 2323 [11:23 p.m.]...[Name of Test 1]...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility 23 days after the lab test was collected.) On February 28, 2025, at 10:07 a.m., an interview was conducted with the DLS. The DLS stated the lab test result for Test 1 for Patient 51 was late. The DLS stated, “It should have been resulted in three days.” 3b. On February 28, 2025, at 10:07 a.m., a review of Patient 54’s record was conducted with the DLS. An untitled and undated facility document was reviewed and indicated Patient 54 was admitted to the facility on January 11, 2025, for anemia (a condition in which the body does not have enough healthy red blood cells or hemoglobin). An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 54]...Ordered: [Name of Test 2]...entered: 02/15/2025 [February 15, 2025]- 2104 [9:04 p.m.]...Reg Dr: [Name of MD 16]...Coll: 02/16/2025 [February 16, 2025]- 0346 [3:36 a.m.]...Recv: 02/16/2025- 0403 [4:03 a.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 54]...Received: 02/18/2025 [February 18, 2025]- 0435 [4:35 a.m.]...Reported: 02/20/2025 [February 20, 2025]- 1824 [6:24 p.m.]...[Name of Test 2]...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility four days after the lab test was collected.) On February 28, 2025, at 10:07 a.m., an interview was conducted with the DLS. The DLS stated the lab test result for Test 2 for Patient 54 was late. The DLS stated, “It should have been done in one to three days.” 3c. On February 28, 2025, at 11:37 a.m., a review of Patient 56’s record was conducted with the DLS. An untitled and undated facility document was reviewed and indicated Patient 56 was admitted to the facility on February 6, 2025, for complicated urinary tact infection (UTI, a bladder infection). An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 56]...Ordered: [Name of Test 3]...entered: 02/06/2025 [February 6, 2025 ]- 0600 [6:00 a.m.]...Reg Dr: [Name of MD 4]...Coll: 02/06/2025 - 1140 [11:40 a.m.]...Recv: 02/06/2025 -1147 [11:47 a.m.]...Results are in as of 2/19/2025 (February 19, 2025)...” (The lab test result was received by the facility 13 days after the lab test was collected.) On February 28, 2025, at 11:37 a.m., an interview was conducted with the DLS. The DLS stated the lab test result for Test 3 for Patient 56 was late. The DLS stated, “It should have been resulted in one to three days.” 3d. On February 28, 2025, at 12:13 p.m., a review of Patient 57’s record was conducted with the DLS. An untitled and undated facility document was reviewed and indicated Patient 57 was admitted to the facility on February 7, 2025, for kidney stone. An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 57]...Ordered: [Name of Test 4]...entered: 02/07/2025 [February 7, 2025]-1000 [10:00 a.m.]...Reg Dr: [Name of MD 5]...Coll: 02/07/2025 - 1000 [10 a.m.]...Recv: 02/11/2025 -0904 [9:04 a.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 57]...Received: 02/15/2025- 1309 [1:09 p.m.]...Reported: 02/20/2025 [February 20, 2025]- 2141 [9:41p.m.]...[Name of Test 4]...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility 13 days after the lab test was collected.) On February 28, 2025, at 12:13 p.m., an interview was conducted with the DLS. The DLS stated the specimen was not received on time in their system. The DLS stated it should have been received right away. The DLS stated the lab test result for Test 4 for Patient 57 was late. The DLS stated, “It should have been done in nine days, but it took 13 days.” 3e. On February 28, 2025, at 12:34 p.m., a review of Patient 58’s record was conducted with the DLS. An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 58]...Admit Date/time: 02/19/2025- 11:38 [11:38 a.m.]...reason for visit: New Hire.” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 58]...Ordered: [Name of Test 5]...entered: 02/19/2025-1147 [11:47 a.m.]...Reg Dr: [Name of MD 6]...Coll: 02/19/2025 - 1147 [11:47 a.m.]...Recv: : 02/19/2025-1147 [11:47 a.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 58]...Received: 02/21/2025 [February 21, 2025 ]- 0511 [5:11 a.m.]...Reported: 02/23/2025 [February 23, 2025]- 0523 [5:23 a.m.]...[Name of Test 5]...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility four days after the lab test was collected.) On February 28, 2025, at 12:34 p.m., an interview was conducted with the DLS. The DLS stated the lab test result for Test 5 for Patient 58 was late. The DLS stated, “It should have been resulted in one to three days. It is one day late.” 3f. On February 28, 2025, at 1:03 p.m., a review of Patient 59’s record was conducted with the DLS. An untitled and undated facility document was reviewed and indicated Patient 59 was admitted to the facility on January 29, 2025, for hepatic encephalopathy (brain dysfunction due to liver dysfunction). An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 59]...Ordered: [Name of Test 6]...entered: 01/30/2025 [January 30, 2025] -1203 [12:03 p.m.]...Reg Dr: [Name of MD 7]...Coll: 01/30/2025 - 1435 [2:45 p.m.]...Recv: 01/30/2025 -1534 [3:34 p.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 59]...Received: 02/16/2025- 0151[1:51 a.m.]...Reported: 02/18/2025- 1728 [5:28 p.m.]...[Name of Test 6]...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility 17 days after the lab test was collected.) On February 28, 2025, at 1:03 p.m., an interview was conducted with the DLS. The DLS stated the lab test result for Test 6 for Patient 59 was late. The DLS stated, “It should have been resulted in one to three days. It was 15 days late.” 3g. On February 28, 2025, at 1:19 p.m., a review of Patient 60’s record was conducted with the DLS. An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 60]...Admit Date/time: 02/07/2025 [February 7, 2025]- 12:35 [12:35 a.m.]...reason for visit: New Hire.” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 60]...Ordered: [Name of Test 5]...entered: 02/07/2025 -1244 [12:44 p.m.]...Reg Dr: [Name of MD 6]...Coll: 02/07/2025 - 1301 [1:01 p.m.]...Recv: 02/07/2025-1335 [1:35 p.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 60]...Received: 02/17/2025 [February 17, 2025] -1830 [6:30 p.m.]...Reported: 02/19/2025- 2037 [8:37 p.m.]...[Name of Test 5]...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility 12 days after the lab test was collected.) On February 28, 2025, at 1:19 p.m., an interview was conducted with the DLS. The DLS stated the lab test result for Test 5 for Patient 60 was late. The DLS stated, “It should have been resulted in one to three days. It’s late nine days.” 3h. On February 28, 2025, at 1:25 p.m., a review of Patient 61’s record was conducted with the DLS. An untitled and undated facility document was reviewed and indicated Patient 61 was admitted to the facility on February 10, 2025, for sepsis secondary to UTI (a life-threatening condition). An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 61]...Ordered: [Name of Test 1]...entered: 02/10/2025 [February 10, 2025]- 1933 [7:33 p.m.]...Reg Dr: [Name of MD 8]...Coll: 02/12/2025 [February 12, 2025] -1953 [7:53p.m.]...Recv: 02/12/2025 -2028 [8:28 p.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 61]...Received: 02/17/2025- 1853 [6:53 p.m.]...Reported: 02/21/ 2025 [February 21, 2025]-1228 [12:28 p.m.]...[Name of Test 1]...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility nine days after the lab test was collected.) On February 28, 2025, at 1:25 p.m., an interview was conducted with the DLS. The DLS stated the lab test result for Test 1 for Patient 61 was late. The DLS stated, “It should have been resulted in two to four days. It’s late nine days.” 3i. On February 28, 2025, at 1:32 p.m., a review of Patient 62’s record was conducted with the DLS. An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 62]...Admit Date/time: 02/06/2025- 09:27 [9:27 a.m.]...reason for visit: New Hire.” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 62]...Ordered: [Name of Test 5]...entered: 02/06/2025- 0943 [9:43 a.m.]...Reg Dr: [Name of MD 6]...Coll: 02/06/2025 -0943 [9:43 a.m.]...Recv: 02/06/2025 -9:43 [9:43 a.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 62]...Received: 02/15/2025- 2220 [10:20 p.m.]...Reported: 02/19/2025-1931 [7:31 p.m.]...[Name of Test 5]...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility 13 days after the lab test was collected.) On February 28, 2025, at 1:32p.m., an interview was conducted with the DLS. The DLS stated the lab test result for Test 5 for Patient 62 was late. The DLS stated, “It should have been resulted in three days. It’s 10 days late.” 3j. On February 28, 2025, at 1:39 p.m., a review of Patient 63’s record was conducted with the Technical Supervisor (TS). An untitled and undated facility document was reviewed and indicated Patient 63 was admitted to the facility on February 7, 2025, for kidney stone. An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 63]...Ordered: [Name of Test 4]...entered: 02/07/2025- 1015 [12:10 a.m.]...Reg Dr: [Name of MD 9]...Coll: 02/07/2025 - 1015 [10:15 a.m.]...Recv: 02/11/2025- 0907 [9:07 a.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 63]...Received: 02/15/2025- 1307 [1:07 p.m.]...Reported: 02/20/2025- 2114 [9:14 p.m.]...[Name of Test 4]...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility 13 days after the lab test was collected.) On February 28, 2025, at 1:39 p.m., an interview was conducted with the TS. The TS stated the lab test result for Test 4 for Patient 63 was late. The TS stated, “It should have been resulted in six to nine days. It’s four days late.” 3k. On February 28, 2025, at 1:45 p.m., a review of Patient 64’s record was conducted with the TS. An untitled and undated facility document was reviewed and indicated Patient 64 was admitted to the facility on January 10, 2025, for diabetic ketoacidosis (a life-threatening complication of diabetes). An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 64]...Ordered: [Name of Test 8]...entered: 01/30/2025- 1106 [11:06 a.m.]...Reg Dr: [Name of MD 7]...Coll: 01/30/2025- 1800 [6 p.m.]...Recv: 01/30/2025 -1808 [6:08 p.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 64]...Received: 02/16/2025 [February 16, 2025]- 0533 [5:33 a.m.]...Reported: 02/21/2025- 2037 [8:37 p.m.]...[Name of Test 8]...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility 22 days after the lab test was collected.) On February 28, 2025, at 1:45 p.m., an interview was conducted with the TS. The TS stated the lab test result for Test 8 for Patient 64 was late. The TS stated, “It should have been resulted in five to ten days. It’s 11 days late.” 3l. On February 28, 2025, at 1:58 p.m., a review of Patient 65’s record was conducted with the TS. An untitled and undated facility document was reviewed and indicated Patient 65 was admitted to the facility on February 5, 2025, for hemoptysis (coughing up blood). An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 65]...Ordered: [Name of Test 9]...entered: 02/05/2025 [February 5, 2025]- 12:06 [12:06 a.m.]...Reg Dr: [Name of MD 10]...Coll: 02/06/2025 - 0940 [9:40 a.m.]...Recv: 02/06/2025-1024 [10:24 a.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 65]...Received: 02/15/2025- 2215 [10:15 p.m.]...Reported: 02/18/2025- 1728 [5:28 p.m.]...[Name of Test 9]...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility 12 days after the lab test was collected.) On February 28, 2025, at 1:58 p.m., an interview was conducted with the TS. The TS stated the lab test result for Test 9 for Patient 64 was late. The TS, “It should have been resulted in two to six days. It’s late seven days.” 3m. On February 28, 2025, at 2:04 p.m., a review of Patient 66’s record was conducted with the TS. An untitled and undated facility document was reviewed and indicated Patient 66 was admitted to the facility on February 3, 2025, for acute hyperglycemia (high blood sugar). An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 66]...Ordered: [Name of Test 6]...entered: 02/03/2025 [February 3, 2025]- 1032[10:32 a.m.]...Reg Dr: [Name of MD 7]...Coll: 02/03/2025 - 0209 [2:09 a.m.]...Recv: 02/05/2025 - 1535 [February 5, 2025, at 3:35 p.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 66]...Received: 02/15/2025- 2114 [9:14 p.m.]...Reported: 02/17/2025- 2014 [8:14 p.m.]...[Name of Test 6]...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility 14 days after the lab test was collected.) On February 28, 2025, at 2:04 p.m., an interview was conducted with the TS. The TS stated the lab test result for Test 6 for Patient 66 was late, “It should have been resulted in one to three days. It’s late 11 days.” 3n. On February 28, 2025, at 2:09 p.m., a review of Patient 67’s record was conducted with the TS. An untitled and undated facility document was reviewed and indicated Patient 67 was admitted to the facility on February 9, 2025, for nausea and vomiting. An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 67]...Ordered: [Name of Test 10]...entered: 02/09/2025- 0926 [9:26 a.m.]...Reg Dr: [Name of MD 11]...Coll: 02/09/2025 - 0926 [9:26 a.m.] ...Recv: 02/09/2025 - 0936 [9:36 a.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 67]...Received: 02/15/2025- 1022 [10:22 a.m.]...Reported: 02/21/2025- 1905 [7:05 p.m.]...[Name of Test 10]...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility 12 days after the lab test was collected.) On February 28, 2025, at 2:09 p.m., an interview was conducted with the TS. The TS stated the lab test result for Test 10 for Patient 67 was late. The TS stated, “It should have been resulted in two to five days. It’s seven days late.” 3o. On February 28, 2025, at 2:14 p.m., a review of Patient 68’s record was conducted with the TS. An untitled and undated facility document was reviewed and indicated Patient 68’s reason for visit for new hire assessment. An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 68]...Ordered: [Name of Test 5]...entered: 02/07/2025- 1220 [12:20 p.m.]...Reg Dr: [Name of MD 6]...Coll [Collected]: 02/07/2025 - 1227 [12:27 p.m.]...Recv: 02/07/2025-12:41 [12:41 p.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 68]...Received: 02/17/2025- 1849 [6:49 p.m.]...Reported: 02/19/2025- 2037 [8:37 p.m.]...[Name of Test 5] ...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility 12 days after the lab test was collected.) On February 28, 2025, at 2:14 p.m., an interview was conducted with the TS. The TS stated the lab test result for Test 5 for Patient 68 was late. The TS stated, “It should have been resulted in three days. It’s late nine days.” 3p. On February 28, 2025, at 2:22 p.m., a review of Patient 20’s record was conducted with the TS. An untitled and undated facility document was reviewed and indicated Patient 20 was admitted to the facility on February 11, 2025, for substance overdose. An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 20]...Ordered: [Name of Test 6]...entered: 02/12/2025- 1347 [1:47 a.m.]...Reg Dr [Registered Doctor]: [Name of MD 4]...Coll: 02/12/2025 -1750 [5:50 p.m.]...Received: 02/12/2025 -1758 [5:58 p.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 20]...Received: 02/17/2025- 1549 [at 3:49 p.m.]...Reported: 02/19/2025- 1658 [4:58 p.m.]...[Name of Test 6]...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility seven days after the lab test was collected.) On February 28, 2025, at 2:22 p.m., an interview was conducted with the TS. The TS stated the lab test result for Test 6 for Patient 20 was late. The TS stated, “It should have been reported in seven days. It’s late four days.” 3q. On February 28, 2025, at 2:29 p.m., a review of Patient 70’s record was conducted with the TS. An untitled and undated facility document was reviewed and indicated Patient 70 was admitted to the facility on February 6, 2025, for overdose ingestion. An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 70]...Ordered: [Name of Test 3]...entered 02/06/2025- 1457 [2:57 a.m.]...Reg Dr: [Name of MD 10]...Coll: 02/06 /2025 -2105 [9:05 p.m.]...Recv: 02/06/2025 -2111 [9:11 p.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 70]...Received: 02/15/2025- 2214 [10:14 p.m.]...Reported: 02/19/2025- 1618 [4:18 p.m.]...[Name of Test 3]...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility 13 days after the lab test was collected.) On February 28, 2025, at 2:29 p.m., an interview was conducted with the TS. The TS stated the lab test result for Test 6 for Patient 70 was late. The TS stated, “It should have been reported in one to three days. It’s late 10 days.” 3r. On February 28, 2025, at 2:46 p.m., a review of Patient 71’s record was conducted with the TS. An untitled and undated facility document was reviewed and indicated Patient 71 was admitted to the facility on February 10, 2025, for upper extremity pain. An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 71]...Ordered: [Name of Test 11]...entered: 02/10/2025- 1037 [10:37 a.m.]...Reg Dr: [Name of MD 12]...Coll: 02/10/2025 - 10:40 [10:40 a.m.]...Recv: 02/10/2025-1117 [11:17a.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 71]...Received: 02/18/2025- 04:46 [4:46 a.m.]...Reported: 02/18/2025 -1130 [11:30 a.m.] ...[Name of Test 11 ...Performing Laboratory information...[Name of Lab 3]...” (The lab test result was received by the facility eight days after the lab test was collected.) On February 28, 2025, at 2:46 p.m., an interview was conducted with the TS. The TS stated the lab test result for Test 6 for Patient 71 was late. The TS stated, “It should have been reported in two to four days. It’s late four days.” 4a. On February 28, 2025, at 10:07 a.m., a review of Patient 51’s record was conducted with the DLS. An untitled and undated facility document was reviewed and indicated Patient 51 was admitted to the facility on January 31, 2025, for septic shock. An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 51]...Ordered: [Name of Test 12]...entered: 02/01/2025- 1100 [11:00 a.m.]...Reg Dr: [Name of Physician (MD -Doctor of medicine 2)]...Coll: 02/01/2025 - 0305 [3:05 a.m.]...Recv: 02/01/2025 - 1309 [1:09 p.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 51]...Received: 02/15/2025- 11:18 [11:18 a.m.]...Reported: 02/17/2025- 1700 [5 p.m.]...Test not performed...The specimen exceeds stability for the test requested...[Name of Test 12]...Performing Laboratory information...[Name of Lab 3]...” On March 4, 2025, at 10:35 a.m., an interview was conducted with the DLS. The DLS stated the specimen for Test 12 for Patient 51 was expired because it exceeded Lab 3’s specimen storage time. The DLS further stated it was not sent to Lab 3 on time. b. On February 28, 2025, at 11:24 a.m., a review of Patient 55’s record was conducted with the DLS. An untitled and undated facility document was reviewed and indicated Patient 55 was admitted to the facility on January 27, 2025, for hypotension (low blood pressure). An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 55] ...Ordered: [Name of Test 2]...entered:...01/27/2025 [January 27, 2025] - 2155 [9:55 p.m.]...Reg Dr [Registered Doctor]: [Name of MD 1 ] ...Coll: 01/28/2025 [January 28, 2025] - 0927 [9:27 a.m.]...Received: 01/30/2025- 1040 [10:40 a.m.]...cancelled...Did not go out to [Name of Lab 2] cannot send to [Name of Lab 3] specimen stability is expired...” On March 4, 2025, at 10:41 a.m., an interview was conducted with the DLS. The DLS stated the specimen was expired for Test 2 for Patient 55 because it exceeded Lab 3’s specimen storage time. The DLS further stated it was not sent to Lab 3 on time because Lab 2 stopped their services for the facility on January 20, 2025, and Lab 3 began their services for the facility on February 14, 2025. c. On February 28, 2025, at 2:22 p.m., a review of Patient 72’s record was conducted with the DLS. An untitled and undated facility document was reviewed and indicated Patient 72 was admitted to the facility on January 31, 2025, for acute comminuted fracture (when bone shatters into multiple pieces). An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 72]...Ordered: [Name of Test 3]...01/31/2025 [January 31, 2025]- 2026 [8: 26 p.m.]...Reg Dr: [Name of MD 16]...Coll: 01/31/2025- 1750 [5:50 p.m.]...Received: 02/01/2025- 0733 [7:33 a.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 72]...Received: 02/16/2025- 01:34 [1:34 a.m.]...Reported: 02/24/2025 [February 25, 2025] - 2323 [11:23 p.m.]...[Name of Test 3]...not performed. The specimen exceeds stability for the test requested...Performing Laboratory information...[Name of Lab 3]...” On March 4, 2025, at 10:47 a.m., an interview was conducted with the DLS. The DLS stated the specimen was expired because it exceeded Lab 3’s specimen storage time. The DLS further stated it was not sent to the outside Lab on time because Lab 2 stopped their services for the facility on January 20, 2025, and Lab 3 began their services for the facility on February 14, 2025. The facility policy and procedure titled, “Specimen Collection,” dated February 2024, was reviewed. The document indicated, “...the laboratory has an ongoing mechanism for ensuring that acceptable criteria is established and followed for patient preparation, specimen collection, labeling, preservation and transportation of specimens for laboratory analysis...” The facility policy and procedure titled, “Collection and Transporting of Specimens,” dated February 2024, was reviewed. The document indicated, “...a test result is no better than the quality of the specimen received into the laboratory. A poor-quality specimen will probably produce an inaccurate and potentially dangerous result...the laboratory is responsible for the test result and therefore is obliged to take precautions to see that a valid good-quality sample is received...” 5a. On February 27, 2025, at 9:13 a.m., a review of Patient 52’s record was conducted with RN (registered nurse). An untitled and undated facility document was reviewed and indicated Patient 52 was admitted to the facility on February 25, 2025, for pneumonia (infection of the lung). An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 52]...Ordered: [Name of Test 14]...start date: 02/25/2025- 1037 [10:37 a.m.]...Ord Phys[Ordering Physician]: [Name of MD 13]...Coll [Collected]: 00/00/0000 a.m.]...Priority: STAT [immediately]...Collected by <None>...” There was no documented evidence the specimen for Test 14 for Patient 52 was collected prior to February 27, 2025. On February 27, 2025, at 9:13 a.m., an interview was conducted with RN. RN stated Test 14 for Patient 52 was ordered on February 25, 2027. RN stated the test has not yet been collected from February 25, 2025, to February 27, 2025. RN further stated it should have been done right away. RN stated it is important to do the test right away “to find out what bacteria and what antibiotic use.” 5b. On March 3, 2025, at 11:33 a.m., a review of Patient 53’s record was conducted with the Stroke Coordinator (SC). An untitled and undated facility document was reviewed and indicated Patient 53 was admitted to the facility on February 21, 2025, for dialysis (a procedure that removes waste and extra fluid from the blood when the kidneys are not working properly). An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 53]...Ordered: [Name of Test 16]...ordered by: [Name of MD 15]...Ordered for: 27-Feb-2025 [February 27, 2025]- 08:28 [8:28 a.m.]...Collected: 27-Feb-2025 - 10:00 [10 a.m.]...Priority: Stat...” There was no documented evidence the specimen for Test 16 for Patient 53 was collected prior to February 27, 2025, at 10 a.m. (one hour and 32 minutes from the time the order was given) On March 3, 2025, at 11:33 a.m., an interview was conducted with the SC. The SC stated the specimen was collected on February 27, 2025, at 10 a.m. The SC stated it should have been collected with ten to 15 minutes of order on February 27, 2025, at 8:28 a.m. The SC stated it is important to collect STAT orders on time “to trend patient’s lab and to treat abnormal results right away.” A review of the facility policy and procedure titled, “Request for Laboratory Tests,” dated April 2021, indicated, “... Priority of requests...the priority of the request, e.g. Routine, STAT, Timed, etc., should be indicated on all order requisitions...STAT: all requests for tests ordered as STAT will be collected within 10 to 15 minutes from the time they were ordered...NOTE: Remember that STAT orders must be called to the lab!...” 6. On February 28, 2025, at 1:45 p.m., a review of Patient 64’s record was conducted with the DLS. An untitled and undated facility document was reviewed and indicated Patient 64 was admitted to the facility on January 10, 2025, for DKA. An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 64]...Ordered: [Name of Test 8]...entered: 01/30/2025- 1106 [11:06 a.m.]...Reg Dr: [Name of MD 7]...Coll: 01/30/2025 - 1800 [6 p.m.]...Received: 01/30/2025 -1808 [6:08 p.m.]...” An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 64]...Received: 02/16/2025 - 0533 [5:33 a.m.]...Reported: 02/21/2025 - 2037 [8:37 p.m.]...[Name of Test 13]...Performing Laboratory information...[Name of Lab 3]...” On March 4, 2025, at 11:01 a.m., an interview was conducted with the DLS. The DLS stated the lab technician placed the wrong order in the manual requisition for Patient 64 (Test 13 was indicated on the requisition instead of Test 8 as ordered). The DLS further stated they had to correct it which delayed the process. The facility policy and procedure titled, “Specimen Collection,” dated February 2024, was reviewed. The policy indicated, “... the laboratory has an ongoing mechanism for ensuring that acceptable criteria is established and followed for patient preparation, specimen collection, labeling, preservation and transportation of specimens for laboratory analysis...” The facility policy and procedure titled, “Collection and Transporting of Specimens,” dated February 2024, was reviewed. The policy indicated, “... a test result is no better than the quality of the specimen received into the laboratory. A poor-quality specimen will probably produce an inaccurate and potentially dangerous result...the laboratory is responsible for the test result and therefore is obliged to take precautions to see that a valid good-quality sample is received...” 7. On February 26, 2025, at 12 p.m., Patient 12’s record was reviewed with Registered Nurse (RN) 6. A facility document titled, “History and Physical,” dated September 30, 2024, at 4:58 p.m., was reviewed. The document indicated Patient 12 was admitted to the facility for persistent disequilibrium (a feeling of imbalance or unsteadiness that lasts for most days), left sided facial droop acute right pontine infarction (a blood flow blockage to a part of the brain). The document indicated Patient 12 had a medical history of hypertension (high blood pressure), depression, and benign prostatic hyperplasia (a condition in which the prostate gland enlarges). A facility document titled, “Order Inquiry,” dated September 30, 2024, at 5:13 p.m., was reviewed. The document indicated a laboratory test for “Lipid panel (a blood test that measures the amount of fat in your blood)...priority...Routine...,” was ordered by Medical Doctor (MD) 1. A facility document titled, “Lab [laboratory] Specimen Internal Inquiry,” dated February 26, 2025, at 3:50 p.m., was reviewed. The document indicated the order for lipid panel for Patient 12, was auto cancelled (process of being cancelled by laboratory charting system) by the facility’s lab on October 2, 2024, at 12:05 a.m. There was no documented evidence the order for lipid panel for Patient 12 was cancelled by the physician. On February 26, 2025, at 4:15 p.m., an interview with the Director of Laboratory Services (DLS) was conducted. The DLS stated the order for lipid panel for Patient 12, entered as received by the lab on September 30, 2024, at 5:13 p.m., was cancelled by the lab. The DOL stated, “The lab was missed. It was their fault...” The DLS stated, “...the lab didn’t run and complete the lipid panel as ordered for Patient 12...” On February 28, 2025, at 12 p.m., an interview was conducted with the Chief Quality Officer (CQO). The CQO stated, “the physician is the only person who should be cancelling a lab, not the lab.” The CQO further stated the facility does not have a policy for cancellation of laboratory tests.”

“EMERGENCY LABORATORY SERVICES CFR(s): 482.27(a)(1) Emergency laboratory services must be available 24 hours a day. This Standard is not met as evidenced by: 50304 Based on interviews and record reviews, the facility failed to ensure emergency laboratory services were provided timely in accordance with the facility’s policy and procedure when: 1. For Patient 52, a Stat (an order to be completed immediately) order for Test 14 was not collected timely; and 2. For Patient 53, a Stat order for Test 16 was not collected timely. These failures resulted in delayed results of the laboratory tests sor Patients 52 and 53, and have the potential to delay the patients’ treatment. Findings: 1. On February 27, 2025, at 9:13 a.m., a review of Patient 52’s record was conducted with RN (Registered Nurse). An untitled and undated facility document was reviewed and indicated Patient 52 was admitted to the facility on February 25, 2025, for pneumonia (infection of the lung). An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 52]...Ordered: [Name of Test 14]...start date: 02/25/2025 [February 25, 2025] - 1037 [10:37 a.m.]...Ord Phys[Ordering Physician]: [Name of MD 13]...Coll [Collected]: 00/00/0000 a.m.]...Priority: Stat [immediately]...Collected by <None>...” Based on record review, there was no documented evidence the specimen for Test 14 for Patient 52 was collected prior to February 27, 2025. On February 27, 2025, at 9:13 a.m., an interview was conducted with the RN. The RN stated Test 14 for Patient 52 was ordered by the physician on February 25, 2025. The RN stated the specimen for Test 14 for Patient 52 was not collected from February 25, 2025 to February 27, 2025. The RN further stated it should have been done right away. RN stated it is important to do the test right away “to find out what bacteria and what antibiotic to use.” 2. On March 3, 2025, at 11:33 a.m., a review of Patient 53’s record was conducted with the Stroke Coordinator (SC). An untitled and undated facility document was reviewed and indicated Patient 53 was admitted to the facility on February 21, 2025, for dialysis (a procedure that removes waste and extra fluid from the blood when the kidneys are not working properly). An untitled and undated facility document was reviewed. The document indicated, “...[Name of Patient 53]...Ordered: [Name of Test 16]...ordered by: [Name of MD 15]...Ordered for: 27-Feb-2025 [February 27, 2025]-08:28 [8:28 a.m.]...Collected: 27-Feb-2025 - 10:00 [10 a.m.]...Priority: Stat...result name... results...” Based on record review, there was no documented evidence the specimen for Test 16 for Patient 53 was collected prior to February 27, 2025, at 10 a.m. On March 3, 2025, at 11:33 a.m., an interview was conducted with the SC. The SC stated the specimen was collected on February 27, 2025, at 10 a.m. The SC stated it should have been collected within 10 to 15 minutes of when it was ordered on February 27, 2025, at 8:28 a.m. The SC stated it is important to collect Stat orders on time “to trend patient’s lab and to treat abnormal results right away.” A review of the facility policy and procedure titled, “Request for Laboratory Tests,” dated April 2021, indicated, “...Priority of requests...the priority of the request, e.g. Routine, STAT, Timed, etc., should be indicated on all order requisitions...STAT: all requests for tests ordered as STAT will be collected within 10 to 15 minutes from the time they were ordered...NOTE: Remember that STAT orders must be called to the lab!...””

“WRITTEN DESCRIPTION OF SERVICES CFR(s): 482.27(a)(2) A written description of services provided must be available to the medical staff. This Standard is not met as evidenced by: 50304 Based on interviews and record reviews, the facility failed to ensure the facility’s medical staff were informed of the change in laboratory (Lab) services for the facility from Lab 2 to Lab 3. This failure had the potential to delay the diagnosis and treatment of patients. Findings: On February 24, 2025, at 9:33 a.m., an interview was conducted with the Director of Laboratory Services (DLS). The DLS stated Laboratory (Lab) 2 terminated their contract with the facility on January 20, 2025. The DLS stated Laboratory (Lab) 3 started picking up the facility’s specimens for testing on February 14, 2025. An untiled facility document dated December 19, 2024, was reviewed. The document indicated, “...To: [Name of DLS]...The 30 day letter is going to be sent to the lab directors today and all are needing to understand that [Name of Lab] is giving 30 day notice to find another lab...[Name of Lab 2 Executive]...” An untitled facility document dated January 25, 2025, was reviewed. The document indicated, “...This e-mail is final notification that services for the following accounts will be turned us off [sic]...5 PM [p.m.], PT [Pacific Time], Monday 01-20-24 [January 20, 2024, sic]...Breach of signed continuous Service Agreement on file...30 day termination letters overnighted as of 12-19-24 [December 19, 2024], therefore, [Name of Group] has had the opportunity to locate needed reference lab...” Based on record review, there was no documented evidence the medical staff were informed of the change in lab services from Lab 2 to Lab 3 prior to February 24, 2025. On February 24, 2025, at 12:53 p.m., an interview with the Chief Quality Officer was conducted. The CQO stated they did not inform the medical staff about the changes in lab services from Lab 2 to Lab 3. The CQO stated the medical staff should have been informed of the changes in lab services from Lab 2 to Lab 3 when it happened. On February 26, 2025, at 1:25 p.m., the facility policy on notification of medical staff about changes of laboratory services was requested from the Deputy Regional Director of Quality (DRDQ). The DRDQ stated the facility does not have a policy on notification of medical staff about changes of laboratory services.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 50304 Based on observation, interview, and record review, the facility failed to ensure the facility’s physical environment was maintained when: 1. Ceiling tiles were observed with brownish stains in the storage and waiting rooms; 2. Sewer smell was observed in ICU-A and in the dirty utility room and patient Rooms A, B, C, D, E, I, J, K, L, M, N, O, P, and Q; 3. For seven of 91 sample patients (Patient 24, 41, 42, 74, 75, 76, and 90), a system for use to call if assistance is needed and continuous telemetry (remote monitoring of the patients’ heart rates and rhythms) monitoring were not provided; 4. Four pharmaceutical (pertaining to medications)/sharps waste bins (containers for disposals of needles and other sharp items) in the Intensive care unit (ICU, a specialized unit that provides monitoring for patients with life-threatening conditions) were overfilled to the brim; 5. Two out of seven freezers containing vials of controls (a sample with a known value that is tested alongside experimental samples) at the laboratory were not maintained in accordance with the manufacturer’s instructions for use. In addition, the condition of the alarm battery of the freezer was not maintained; 6. For Patient 73, who was on airborne isolation, the temporary plastic magnetic door in front of the patient’s room was not installed securely; and 7. Water retesting was not performed for the Mammoth cooling tower for the HVAC (Heating, Ventilation, and Air Conditioning) Systems supplying the heating and air-conditioning system to the Emergency Department, after the water tested positive for Legionella bacteria (a type of bacteria that could cause respiratory illness) on September 4, 2024; and 8. The Smith Cot (a device used for evacuating non ambulatory patients) were readily accessible for emergency use. This failure had the potential to result in patient injury and/or death in case of fire when evacuation of patients is needed. These failures resulted in an unsafe environment, and had the potential for increased risk of exposure to harmful chemicals, viruses, and bacteria, which could potentially cause danger to the health, safety, and well-being of the already immunocompromised patients at the facility. Findings: 1. On February 27, 2025, at 1:49 p.m., a facility tour was conducted with the Chief Nursing Officer (CNO) and the Patient Advocate (PA). On February 27, 2025, at 2:18 p.m., a storage room was identified with brown staining on a ceiling tile. On February 27, 2025, at 3:14 p.m., the facility tour continued with the Director of Facilities Management (DFM). During the tour, an unoccupied patient room on [nursing unit] was identified with brown staining on two ceiling tiles. On February 28, 2025, at 9:58 a.m., a facility waiting room was identified with brown staining to three ceiling tiles. Engineer Tech (ET 2) was observed to arrive with a ladder and moved one of the ceiling tiles. During a concurrent interview, ET 2 stated a band (hose clamp) had broken on a pipe in the ceiling and it was leaking. On March 3, 2025, at 3:52 p.m., an interview was conducted with the DFM and the Deputy Regional Director of Quality (DRDQ). The DFM stated the brown staining on the ceiling tiles were caused by fluid. The DRDQ stated fluid damage could create health hazards. The facility policy and procedure titled, “Preventative Maintenance Program - Ensuring Operation Ability,” dated March 2021, was reviewed. The policy indicated, “...The Facilities Administrator is responsible for the proper and safe functioning of all equipment within the facility and the condition of the facility generally...” The facility policy and procedure titled, “Infection Control and Construction Safety,” dated March 2021 was reviewed. The policy indicated, “...Water damaged materials...Prevention of fungal [molds] growth is of increased importance after any type water damage [sic]...Acoustical tiles and porous materials...Wet acoustical ceiling tiles [tiles designed to absorb sound and lowering the noise level]...may produce fungal spores [microscopic particles which allow fungi to reproduce and disperse to new locations]...” 2. On February 24, 2025, at 8:56 a.m., a tour of the Intensive Care Unit (ICU, a specialized unit that provides monitoring for patients with life-threatening conditions) was conducted with the Chief Nursing Officer (CNO). On February 24, 2025, at 9:09 a.m., a tour of the medication room on the first floor ICU was conducted with CNO and the Nursing Supervisor (NSRN). A strong obnoxious foul smell of sewage odor was observed in the room. The CNO, and the NSRN stated they observed the foul sewer smell. On February 24, 2025, at 9:11 a.m., an interview with the NSRN was conducted. The NSRN stated she observed the strong smell which has been there for over a month. On February 24, 2025, at 9:11 a.m., an interview with the Director of Facility Maintenance (DFM) was conducted. The DRM stated the sewer vent in the wall between the medication room and the nutrition room is cracked which was causing the smell. The DRM stated they are unable to access the cracked pipe without tearing down the wall and that is a two-week process. The DRM stated the sewage smell was discovered one to two weeks ago. On February 24, 2025, at 9:20 a.m., a tour of the nutrition room and the soiled utility room on the first floor ICU A was conducted with the CNO and NSRN. A strong obnoxious smell of sewage odor was present in both rooms. The CNO and the NSRN stated they observed the sewer smell. The CNO stated she can smell the strong smell of sewer in the soiled utility room. On February 24, 2025, at 9:30 a.m., an interview with the CNO was conducted. The CNO stated she met with the DRM to discuss a plan to move the patients and close the ICU unit A and repair the pipes. The CNO stated they were waiting until March 2025 to begin the project. On February 24, 2025, at 9:36 a.m., a tour of the fifth floor telemetry (unit where patients’ heart rate and rhythm are continuously monitored remotely)/medical surgical (med surg, unit for patients with varied conditions not necessitating critical or telemetry monitoring) unit was conducted with the Patient Safety Coordinator (PSC) and the Nursing Supervisor Registered Nurse (NSRN). On February 24, 2025, at 9:45 a.m., a tour of the soiled utility room on the ICU B was conducted. A strong sewer smell was observed when opening the door. On February 24, 2025, at 10:10 a.m., a tour of the dirty utility room on the fifth floor was conducted with the PSC and the NSRN. A sewage odor was observed present in the room. An observation of the dirty utility room hopper sink (a special sink to empty stool and urine) was conducted with the PSC and the NSRN. Small black, worm-like moving insects were observed at the bottom of the hopper. On February 24, 2025, at 10:15 a.m., a tour of Rooms A, B, C, D, and E was conducted with the NSRN and the PSC. Sewer smell was observed in each of the rooms. On February 25, 2025, at 8:30 a.m., the facility work orders were reviewed. A facility document titled, “Work order #: 537992,” dated February 4, 2025, was reviewed. The document indicated, “...Area/project: [Unit B]...work order type #: Unscheduled, non-emergency...requested on: 2/4/25 [February 4, 2025]...service requested: replace waste lines in ceiling in break room...” A facility document titled, “Work Order 537993,” dated February 6, 2025, at 11:19 a.m., was reviewed. The document indicated, “...Facility...[name of facility]...Department...Nursing TWR [Tower] 2-5 [two to five]...Location...Nurse Station, Closets, Kitchen...Floor...5...sewer smell in office...” The document indicated, “...Notes...2’ [two inches] vent needs to be replaced on sink drain. Pipe is cracked. Pipe is currently under repair in ICU...2/06/25 [February 6, 2025]...” A facility document titled, “Work order#:538253” dated February 12, 2025, was reviewed. The document indicated, “...Department: Unit A...Work order type#: unscheduled, non-emergency...requested on 2/12/2025 [February 12, 2025]...service requested: Bad odor in med room...service notes...found cracked 2” cast iron vent from sink in Unit A kitchen. This will require removing cabinets and cutting wall open to replace vent...” A facility document titled, “Work order # [number]: 538171,” dated February 16, 2025, was reviewed. The document indicated, “...[Unit B]...work order type #: Unscheduled, Non-Emergency...Requested on...2/16/25 [February 16, 2025], service requested: room 1...notes: broken vent in wall, will work with clinical staff to shut room down...” A facility document titled, “Work order #: 538196” dated February 20, 2025, was reviewed. The document indicated, “...[Unit B]...Work order type#: Unscheduled, nonemergency...Requested on: 2/20/25 [February 20, 20205]...Service requested: plumbing repair on drain lines in different areas of [Unit A] and [Unit B]...Notes: need to order parts asap [as soon as possible]...” On February 25, 2025, at 9:46 a.m., a tour of [Unit A] and [Unit B] was conducted with Patient Safety Coordinator (PSC) and the CNO. A foul sewer odor was observed at the nurse’s station, the medication room, and the nutrition room of [Unit A]. Construction hammering and pounding sounds were observed to be in progress on the room to the left of the medication room. On February 25, 2025, at 9:50 a.m., a tour of the Rooms I, J, K, L, M, N, O, P, and Q was conducted with the CNO and the PSC. A sewer smell was observed in each of these rooms. On February 25, 2025, at 10:30 a.m., an interview was conducted with Anonymous (A) 3. A 3 stated the sewer odor had been observed in the fifth floor unit for at least a year. A 3 stated she was unsure if a work order was completed for the sewer smell issue. A 3 stated there have been gnats (drain flies) in the vicinity of room F, and throughout the Intensive Care Unit (ICU, unit for critically ill patients). A 3 stated the Environmental Services (EVS) has been putting cleaning solution in the sinks to help with the gnats. A 3 stated she was unsure what the issue was because the sewer smell remained after the facility repaired the staff breakroom. A 3 stated she has not been told anything related to what the sewer smell could be, but some of the staff, including her, have been complaining of dizziness and headaches since the odor has been observed. A 3 stated they were told it was a break in a sewer line. On February 25, 2025, at 10:45 p.m., an interview was conducted with A 4. A 4 stated she was told the sewer smell was from a broken sewer pipe. A 4 stated she had been feeling ill and had dizziness and headaches due to the sewer smell. A 4 stated she knew engineering was fixing a pipe in the breakroom, but the sewer smell never went away. A 4 stated the sewer smell had been there for a long time. On February 25, 2025, at 11:23 a.m., a tour of the fifth floor was conducted with the PSC and the NSRN. A sewer smell was observed when entering the fifth floor unit and in the hallway. When entering Rooms B and C, a smell of sewer was observed. During a concurrent interview, the NSRN stated she can smell the sewer odor and have been using fragrances to mask the smell. The NSRN stated she notified engineering regarding the sewer smell. On February 25, 2025, 3:45 p.m., an interview was conducted with the Director of Facility Maintenance (DFM) and the Corporate Quality Officer (CQO). The DFM stated he was first told about the sewer smell on the fifth floor about a month ago. The DFM stated they fixed a waste line leak on the first, second, third, and fourth floor of the facility. The DFM stated the problem is from a waste line (a pipe that carries wastewater from a unit in the facility to the sewer system) in the medication room in the ICU that needs repair. The DFM stated there had been no talk about possible contamination or environmental concerns outside or inside the facility to ensure there is no cross contamination of any possible infectious process and/or environmental concerns for patients and/or staff. The DFM stated the sewer smell follows the cavity/shaft (opening where pipes go through) from the bottom of the facility to the roof. The DFM further stated the sewer smell is traveling upward, and they have been trying to put fragrance in affected areas and assessed the exhaust fans. When shown photos of the small worm-like insects in the hopper taken during an observation on February 24, 2025, at 10:10 a.m., the DFM further stated the image of the black worm like insects in the fifth floor hopper “look like gnat larvae [immature worm-like stage of gnats] from the sewer.” The DFM stated the gnat larvae in the hopper could be related to the problem they possibly need to fix on the fifth floor. The CQO stated the Chief Nursing Officer (CNO) and DFM met to discuss the plan of repair for the ICU and the fifth floor. The DFM stated he had a meeting with the CNO, and the plan was to move patients to another area, but they anticipated a validation survey [a surveyof the facility to determine if the facility is complying with the regulations set by the Centers for Medicare and Medicaid (a fedral agency) and wanted to prep for that first prior to conducting the repairs to address the sewer smell. The CQO stated the Chief Operating Officer (COO) was aware of the problem. The CQO stated she was not aware and was not informed of the issue with the sewer smell. The CQO stated she should have been informed of the sewer smell in the ICU and the fifth floor. The CQO stated, if there was a concern about a possible sewer issue in the pipes and possible infection control concerns, she should have been informed because she is also in charge of Infection Prevention in the facility until the position is filled. The CQO stated the DFM should have given her the opportunity to evaluate the impact of the sewer smell to patient safety. The CQO further stated she was only informed of the situation of the sewer smell and possible broken sewer pipes during the ongoing survey of the facility. The CQO stated, “There should be no worms or bugs in any sink in the facility.” On February 25, 2025, at 4 p.m., an interview was conducted with the DFM. The DFM stated he was first notified of the ICU and fifth floor sewer smell two months ago. The DFM stated his department started to get reports about the sewer smell which traveled up and could be smelled on the sixth floor of the facility. On February 25, 2025, at 7:05 p.m., the survey team identified significant concerns in the facility. Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation with the potential to cause harm to the health and safety of the patients) was called in the presence of the facility’s Chief Nursing Officer (CNO), Chief Operating Officer (COO), Corporate Quality Officer (CQO), Deputy Regional Director of Quality (DRDQ), and the Director Facility Maintenance (DFM). They were notified regarding the concern of sewer smell in the Intensive Care Unit (ICU, unit for critically ill patients) and the fifth floor which was due to cracks on a four-inch sewer ventilation pipe located in the wall between medication room and computer room in the ICU A Nursing Station. The smell of sewer was noted by the facility since February 4, 2025, and was still observed in ICU A, ICU B, and on the fifth-floor telemetry (unit where patients’ heart rate and rhythms are continuously monitored remotely) and medical surgical unit (unit for patients with various illnesses not necessitating close monitoring) which may aggravate the pulmonary conditions of patients with lung diseases/conditions in the affected units by inhaling sewer gas which may contain toxic gases and cause symptoms ranging from eye irritation, coughing, fluid in the lungs, and loss of consciousness. On February 28, 2025, at 2:46 p.m., the facility provided a Corrective Action Plan (CAP) for the IJ. The CAP submitted by the facility indicated the following: - Immediately upon being notified of the IJ, members of the Governing Board and the MEC (Medical Executive Committee) were notified of the findings by the COO via an electronic memo; - The facility identified all patients and staff impacted/likely to be impacted by the deficiency and is committed to ensuring the deficiency is corrected immediately; - As soon as the facility was informed of the issuance of an IJ, the facility started developing and implementing this Removal Plan; - All elective surgeries (non-emergent surgeries) for February 26, 27, and 28, 2025 were cancelled to ensure the availability of Post Anesthesia Unit (PACU, unit where patients recover after a surgery) beds should they be needed to care for relocated ICU patients. Both the patients and surgeons were notified. Elective non emergent surgeries will be cancelled until the facility is able to use the ICU once the repair has been completed and the air quality has been verified to be safe for patients and staff based on testing results by the Industrial Hygienist/their accredited laboratories or an alternative acceptable location has been identified. The facility will continue to notify patients and surgeons of any pending cancellation. The facility will attempt to have these patients rescheduled as soon as it is feasible. The facility applied for a program flex (an approval to waive a regulation) with the California Department of Public Health (a state agency) to be able to use four beds in the Definitive Observation Unit (DOU, stepdown unit for patients who need close monitoring but less than critical care) as temporary ICU beds. The request is pending review. Once approved, the facility will not use PACU to hold ICU patients; - All ICU patients were evaluated for the appropriateness of safe downgrades. Any downgraded patients were moved to the appropriate level of care as per the MD order. The facility will continue to evaluate those patients that could be safely downgraded; - On February 25, 2025, and February 26, 2025, the facility Leadership relocated eight ICU patients to the Critical Care Unit (CCU, unit for patients with critical illnesses) and four patients to the PACU to minimize any further exposure. Patients will remain in these new locations until the repair has been completed and the air quality has been verified to be safe by the Industrial Hygienist (a professional who protects worker health and safety by identifying, evaluating, and controlling workplace hazards, such as chemicals, noise, and biological agents) and their contracted laboratories. All appropriate parties were notified of the relocation. ICUs A and B are currently temporarily closed and will remain closed until the repair is completed and the air quality is tested by the environmental hygienist and their accredited laboratories, and the results are deemed safe for both patients and staff. Currently there is one ICU hold in the Emergency Department. The patient is currently cared for by an ICU nurse and will be moved to the CCU by end of shift today; - On February 25, 2025, ICU B was sealed off and ventilated to the outside to minimize the risk of the gases traveling through the facility. The door is only open during business hours and while staff is present; - The COO approved additional labor and personnel to facilitate the prompt relocation of patients and repair of the pipe. - The facility started the repair of the pipe on February 26, 2025, at around 4 am. An additional vendor is currently onsite to help the staff with the repair. The vendor continues to be onsite; - On February 26, 2025, all patients on fifth floor were relocated to the second floor. The fifth floor will be vacated until the repair is complete and the air quality testing for sewer gases is performed by the industrial hygienist and their approved laboratory is back and verified to be safe for patients and staff; - On February 26, 2025, all providers (physicians) of the ICU patients were notified of the deficiency, relocation of ICU patients via a phone call and an electronic memo; - On February 26, 2025, the Leadership Team was educated by the CQO on the Centers for Medicare and Medicaid Conditions of Participations (sets of regulations applicable to the facility) related to Physical Environment using a power point presentation to read and sign. - On February 26, 2025, the facility-initiated education for Engineering Staff on Physical Environment CoPs. Employees will complete the education on by their first next scheduled shift; - On February 26, 2025, the Director of Plant Operations reviewed the hospital policy on building maintenance and found it acceptable; - On February 26, 2025, the ICU staff were informed of the potential sewer gas leak and the need to relocate patients via a memo; - On February 26, 2025, the facility-initiated patient/ family notification. All alert and oriented patients received a hand delivered letter. The facility continues the process of notifying representatives of patients who were unable to receive the notice (for example, patients who are confused); - On February 27, 2025, the facility contacted an industrial hygienist to perform the air quality test for the presence of sewer gases. The vendor collected samples for the wrong test. The facility contacted the vendor again to perform the air quality test for sewer gases. The new air quality test for sewer gases was performed on February 27, 2025, in the ICU and the fifth floor. Results are pending.; - On February 28, 2025, all providers were notified of the temporary decrease in the telemetry capacity at the hospital via an electronic memo; and - The CEO will continue to update the MEC, medical staff members, on the progress with the repair and the implementation of this Removal Plan. On February 28, 2025, at 3:55 p.m., the survey team found the CAP for IJ related to the sewer smell in the Intensive Care Unit acceptable and DRDQ, COO, and CQO were notified. On February 28, 2025, at 4:35 p.m., the IJ related to the sewer smell in the ICU was removed in the presence of the COO, after the CAP was verified onsite through observation, interviews, and record review as implemented. 3. On February 27, 2025, at 9 a.m., a tour of the second floor medical/surgical (med/surg, unit for patients with various illnesses not necessitating close monitoring)/telemetry (tele, unit where the patients’ heart rates and rhythm are contiously monitored remotely) unit was conducted with the Chief Nursing Officer (CNO) and the Patient Advocate (PA). On February 27, 2025, at 9:10 a.m., an interview of the CNO was conducted. The CNO stated the facility moved the patients from the fifth floor to the second floor on February 26, 2025, at approximately 3:30 p.m. The CNO stated 26 patients were moved to the second floor and five patients were downgraded to med/surg (when the physician orders the telemetry monitoring to be discontinued). The CNO stated the registered nurses caring for the patients are sitting near the rooms they are assigned to. The CNO stated they have runners and nurse assistants to assist in watching the cardiac monitors (a device that records the heart’s electrical activity) and the patients. The CNO stated all patients had been given a call bell (a device that summons attention by making a sound, alerting someone to a request for assistance) to request assistance from nursing when they were transferred to the second floor from the fifth floor. On February 27, 2025, at 9:18 a.m., an observation was conducted in Room G. Patient 24’s family member (FM 1) was present in the room. Patient 24 is on a telemetry monitor at the bed side. The heart rate monitor was facing toward the patient and away from the door behind the patient’s privacy curtains. The display on the monitor is not observed from the patient room’s door. On February 27, 2025, at 9:20 a.m. an interview was conducted with A 5. A 5 stated she has patients on telemetry and currently is unable to see the monitors from the door and must go all the way in the room. A 5 stated the patients in the B bed on the med/surg/tele unit on the second floor are not connected to the central telemetry monitoring system. A 5 stated the patients on the B are hooked to a bed side monitor. On February 27, 2025, at 11:15 a.m., an observation was conducted in Room G. Patient 24’s family member (FM 1) was present in the room and was concurrently interviewed. FM 1 stated Patient 24 needed pain medication on February 27, 2025, at approximately 12 a.m., and did not have access to a call light or a call bell on his bedside to call for assistance. FM 1 stated Patient 24 had to use his personal cell phone to call the facility’s operator to be transferred to the second floor nursing station. FM 1 stated Patient 24 did not receive pain medication for one hour after initially calling for assistance using his cell phone. FM 1 stated Patient 24 was instructed to use their cell phone to call the facility and notify the operator to transfer them to the nursing station on the second floor. On February 27, 2025, at 11:18 a.m., an interview of the Nursing Supervisor Registered Nurse (NSRN) was conducted. The NSRN stated patients on the second floor were given call bells (similar to desk bells which the patient could use to make a sound to call the attention of the staff) to call for help when they were transferred from the fifth floor to the second floor, but they found seven patients without one. The NSRN stated the room call lights that are hooked up to the door notification system were not functioning prior to moving patients from the fifth floor. On February 27, 2025, at 11:25 a.m., an interview with Patient 74 was conducted. Patient 74 stated he was not given a call bell or nor was he given instruction on how to call for a nurse when he was moved to the second floor. A call light was observed on Patient 74’s bedside. The light outside Patient 74’s room was observed to be lit prior to Patient 74 pressing the call light button. There was no audible sound observed when Patient 74 pressed the call light button. On February 27, 2025, at 11:28 a.m., an observation was conducted in Patients 75, 76, and 90’s room. There was a safety sitter (a staff observing the patients) observed sitting outside the room observing the three patients. The patients were observed to not have call bells to reach a nurse for assistance. On February 27, 2025, at 11:30 a.m., the NSRN was interviewed. The NSRN stated there were seven patients (Patient 24, 41, 42 74, 75, 76, and 90) who did not have a call bell at their bedside. On March 3, 2025, at 9 a.m., an interview was conducted with the DFM. The DFM stated the engineering department was aware of the nonfunctioning call light system on the second floor. On March 4, 2025, at 9:15 a.m., an interview was conducted with the Chief Quality Officer (CQO). The CQO stated, she was aware of the non-working call light system on the second floor and there was a program flex submitted requesting to waive the necessity of call lights. The CQO stated every patient should have had a means to contact the nurse staff. The CQO stated she had instructed staff to make sure every person had a call bell upon leaving the facility on February 26, 2025. On March 4, 2025, at 10 a.m., an interview was conducted with a member of the governing body (facility administration body who has ultimate oversight and decision-making authority) (GBM). The GBM stated she did not know about the nonfunctioning call light system on the second floor. The GBM further indicated the facility typically had no patients on the second floor due to lack of patient volume. The GBM stated the governing body should have been made aware of the situations prior to moving the patients during this investigation and it should have been reported to them. The facility policy and procedure titled, “Nurse Call System Failure,” dated April 2021, was reviewed. The policy indicated, “...Policy: To provide a method of communications for patients in the event the nurse call system fails. The nurse call system provides audible communication between patients and nursing staff for assistance in routine and emergency situations...In the event of a malfunction and/or failure of the nurse call system the following procedure will be followed...instruct staff members to set up an alternative method of communication...Identify the cause of the failure and attempt to repair...Notify House Supervisor...Record incident in [name of computer system of resporting]...Determine cause of failure and taken immediate steps to eliminate...Revise as necessary any tests, or changes in preventative maintenance to systems ...” On February 27, 2025, at 2:48 p.m., the survey team identified significant concerns in the facility. Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation with the potential to cause harm to the health and safety of the patients) was called in the presence of the facility’s CNO, COO, CQO, DRDQ, and the DFM. They were notified regarding the facility’s failure to ensure a safe environment to take care of medical surgical/ telemetry patients. The facility did not have a system in place to continuously monitor the patients’ heart rate and rhythm for patients transferred to the second floor and had orders for telemetry monitoring. 10 patients with telemetry orders did not have continuous monitoring of the cardiac rhythm and had a portable heart monitor at bed side which were not visibly seen upon entering the patients’ rooms and were not being continuously monitored. Seven of the patients did not have access to any assistive devise to call for help when needing assistance or in an emergency. One patient (Patient 24) had to use his personal cell phone to call the main hospital number to speak to the nurse on the second floor in order to request for pain medication which was administered one hour after the patient’s call was made. On February 28, 2025, at 12:12 p.m., the facility provided a Corrective Action Plan (CAP) for the IJ. The CAP submitted by the facility indicated the following: - The facility was unable to determine the impact of the deficiency on patients. However, no adverse effects or complications for any patient have been reported as a result of the use of portable bedside monitors; - On February 28, 2025, members of the Governing Board and the MEC were notified of the findings by the COO via an electronic memo; - The facility identified all patients impacted/likely to be impacted by the deficiency. - As soon as the facility was informed of the issuance of an IJ, the facility started developing and implementing this Removal Plan; - On February 27, 2025, all patients without a call light were provided with a bell and educated on the purpose of the call light and how to use it. On February 28, 2025, the CNO verified that all patients had bells; - On February 28, 2025, a letter was sent from the CNO to all the patients and staff on the second floor notifying them of the call light system malfunction and the use of the bells. - On February 27, 2025, the physicians for patients on telemetry were contacted to explore who can be downgraded safely with a physician order; - On February 27, 2025, the facility conducted an accurate account for all existing tele monitors, existing patients on tele, potential downgrades from tele and potential discharge from tele to efficiently utilize the system; and - On February 27, 2025, all patients on the second floor not connected to central tele monitoring (remote monitoring of patient’s heart rate and rhythm with one staff assigned to conitnuously watch the monitors) were either relocated to the third floor, safely downgraded or discharged in accordance with the physician orders. The second floor currently has only 16 tele patients who are all being centrally monitored. On February 28, 2025, at 12:53 p.m., the survey team found the CAP for the third IJ acceptable and the DRDQ was notified. On February 28, 2025, at 1:17 p.m., the third IJ regarding patients with telemetry orders and the patients who did not have access to any assistive devise to call for help, was removed in the presence of the COO, after the CAP implementation was verified onsite through observation, interviews, and record review as implemented. A facility policy and procedure titled, “Telemetry Monitoring,” dated April 20, 2024, was reviewed. The document indicated, “...Notify the Monitor observer [staff assigned to watch the monitor continuously] that the patient is on telemetry...Verify with the monitor observer that the rhythm [heart rhythm] is readable on the monitor...” 4. On February 24, 2025, at 8:52 a.m., a tour of the ICU was conducted with the Nursing Supervisor Registered Nurse (NSRN) and the Chief Nursing Officer (CNO). On February 24, 2025, at 8:59 a.m. an observation was made of the four grey/blue pharmaceutical/sharps containers which were observed to be full and/or overflowing in front of patients’ Rooms BB, Room CC, Room DD, Room EE, and Room I. A concurrent interview was conducted with NSRN. The NSRN stated the blue pharmaceutical/sharps containers are full with some with tubing sticking out. The NSRN stated the bins should have been emptied when they are filled to the 3/4 full fill line. Am interview was conducted on February 24, 2025, at 8:59 a.m., with the CNO. The CNO stated staff are to report the pharmaceutical/sharps container bins when they are at the full line as marked on the bins and Environmental Services (EVS) would come and replace the bins. The facility policy and procedure titled, “MEDICAL WASTE MANAGEMENT PLAN,” dated September 20, 2023, was reviewed. The policy indicated, “...provide guidelines for medical waste...management to facilitate a safe environment...Sharps disposal units, when three-fourths (3/4) full are exchanged by nursing personnel in nursing units...Used containers are secured closed and placed with other medical wastes to be transported by housekeeping...” 5a. On February 24, 2025, at 5:30 p.m., an observation of the laboratory with concurrent interview were conducted with the Director of Laboratory Services (DLS). a. During an inspection of Freezer 1 in the laboratory, an approximately two-inch thick white tiny ice crystals were observed in the compartments of Freezer 1. On February 24, 2025, at 5:30 p.m., an interview was conducted with the DLS. The DLS stated the two-inch frost was present in all the compartments of the Freezer 1. The DLS stated there should be no frost in the freezer compartments in order “to maintain the stability and integrity of the controls (a sample with a known value that is tested alongside experimental samples) and specimens.” He further stated, “we get bad results or erroneous results because of it.” A review of the manufacturer’s instructions for use for Freezer 1 was conducted with the DFM. The undated document titled, “Installation and Operation Manual [Name of Freezer 1],” was reviewed. The document indicated, “...defrost the freezer once or year or whenever the ice buildup exceeds 3/8” [inch, a unit of measurement]...” There was no documented evidence a work order was generated to defrost Freezer 1. There was no documented evidence Freezer 1 was defrosted in the preventive maintenance (PM, the practice of regularly servicing and inspecting equipment to prevent breakdowns) sheet provided by the facility. On March 3, 2025, at 4:01 p.m., an interview with concurrent record review were conducted with the Director of Facility Maintenance (DFM). The DFM stated the PM sheet for Freezer 1 did not contain documentation the BF was defrosted as directed by the manufacturer’s instructions for use. The DFM stated it should have been defrosted. b. An inspection of Refrigerator 1 in the laboratory was conducted with the DLS. An approximately two-inch white crystals were observed in the freezer compartment of Refrigerator 1. On February 24, 2025, at 5:30 p.m., during a concurrent interview with the DLS, the DLS stated the two-inch frost was present in the freezer compartments of Refrigerator 1. The DLS stated there should be no frost in the freezer compartments in order to maintain the stability and integrity of the controls and specimens which may cause errors in the results. A review of the manufacturer’s instructions for use for Refrigerator 1 was conducted with the DFM. The undated document titled, “Care and Cleaning,” was reviewed. The document indicated, “ ...defrost freezer compartment when frost becomes 1/4” to ½” thick in any area of the freezer ...” There was no documented evidence a work order was generated to defrost Refrigerator 1. There was no documented evidence Refrigerator 1 was defrosted in the PM sheet provided by the facility. On March 3, 2025, at 4:01 p.m., an interview with concurrent record review were conducted with the DFM. The DFM stated the PM sheet did not have a documentation Refrigerator 1 was defrosted as directed by the manufacturer’s instructions for use. The DFM stated it should have been defrosted. 5c. On February 24, 2025, at 5:30 p.m., an observation of the laboratory with concurrent interview were conducted with the Director of Laboratory Services (DLS). The “Alarm battery low” light on the front of Freezer 1 was observed to be on. On February 24, 2025, at 5:30 p.m., during a concurrent interview, the DLS stated the alarm battery was low. The DLS stated it was time to change the alarm battery, but he has not submitted a work order yet. On February 25,2025, at 1:48 p.m., an interview with concurrent review of the PM for Freezer 1 were conducted with the DFM. The DFM stated there was no documentation on the PM sheet a visual check was done on the battery for the alarm for Freezer 1. The DFM stated it should have been documented if the battery was checked. A review of the manufacturer’s instructions for use for the BF was conducted with the DFM. An undated document titled, “Installation and Operation Manual [Name of Freezer 1],” was reviewed and indicated, ...Alarm Battery Maintenance check the condition of the alarm battery at least once a year...” There was no documented evidence a work order was generated to change Freezer 1’s alarm battery prior to February 24, 2025, at 5:30 p.m. There was no documented evidence that the alarm battery was inspected prior to February 24, 2025. A review of the facility policy and procedure titled, “Temperature and Humidity Monitoring of General lab and Lab equipment,” was conducted. The policy indicated, “ ...it is the policy of [Name of Facility] to maintain proper temperature and humidity conditions for optimal instrument performance based on manufacturer’s guidelines and proper temperatures for all equipment (i.e., freezers, refrigerators, water baths, etc.) Involving reagent and chemical storage ...” 6. On February 25, 2025, at 11 a.m., a tour of the fifth floor was conducted with the Nursing Supervisor Registered Nurse (NSRN) and Patient Safety Coordinator (PSC). An observation was conducted of the temporary plastic door called “ZipWall Magnetic Door,” outside of Patient 73’s room. A plastic door was observed to be connected to the frame of the doorway with attachment at the top of the ZipWall door not affixed to the metal of the door frame, creating a gap between the ZipWall door and the door frame. On February 25, 2025, at 11:05 a.m., an interview was conducted with the NSRN and the PSC. They stated, “the door should not be like that. “ The NSRN and the PSC further stated they did not know why Patient 73 was in an isolation room(special hospital rooms that keep patients separate from other people while they receive medical care). On February 25, 2025, at 11:30 a.m., an interview was conducted with the Director of Facility Maintenance (DFM). The DFM stated when a person is under isolation, engineering will be called to put up the temporary door. The DFM stated throughout the use of the temporary door, nursing needs to report to his department if there is no contact . The DFM stated, “I would expect them to notify them of the issue.” On February 28, 2025, at 1:45 p.m., a review of Patient 73’s record and the manufacturer’s instructions for use (IFU) of the ZipWall® Magnetic Dust Barrier Door Kit was conducted was conducted with the Stroke Coordinator (SC). A review of the facility document titled, “History and Physical,” dated February 18, 2025, at 3:20 p.m., indicated Patient 73 was admitted to the facility for altered level of consciousness (the state of being less awake or alert than normal). The document indicated Patient 73 had a medical history of hypertension (high blood pressure). An undated facility document titled, “Assessment/Plan,” was conducted. The document indicated Patient 73 was on isolation precautions (a set of evidence-based practices designed to prevent the transmission of infectious diseases in healthcare and other settings) for COVID (a highly contagious virus) pneumonia (a type of lung infection). There was no documentation the ZipWall® Magnetic Dust Barrier Door Kit could be used in hospital rooms where a patient is on airborne isolation. On February 28, 2025, at 2 p.m., an interview was conducted with the SC. The SC stated, “[name of Patient 73] was on airborne isolation (infection control measures designed to prevent the transmission of infectious agents that spread through the air) for COVID pneumonia.” The SC stated patients are on airborne precautions until COVID is ruled out, and If the patient tests positive for COVID, the patient is placed on airborne isolation. The SC stated the physician is supposed to put in an order for isolation. The SC stated blue signs outside the patient’s room door would signify airborne isolation and the Facilities department will set the room up as a negative pressure room (room designed to maintain a lower air pressure than the surrounding environment prevents contaminated air from escaping into the surrounding areas). On March 4, 2025, at 9:40 a.m., an interview was conducted with the CQO. The CQO stated, “When a person is positive COVID, they are placed into airborne isolation.” The CQO stated the door of the room where a patient is on airborne isolation should be closed. The CQO stated they would follow up with facilities and the manufacturer to determine if the ZipWall® doors could be used for infectious disease and isolation of patients. The CQO further stated there is no policy for the ZipWall® doors when being used for COVID. On March 4, 2025, a review of the facility policy and procedure titled, “Infection Prevention and Control Practices When Caring For A Patient with Suspected or Confirmed COVID-19 Infection,” dated March 2021, was conducted. The policy indicated, “ ...If admitted, a patient with suspected or confirmed COVID-19 infection will be placed in a single-person room with the door closed ...” 7. On February 25, 2025, at 9:23 a.m., a tour of the Intensive Care Units (ICU, a specialized unit that provides monitoring for patients with life-threatening conditions) A & B and the Medical/Surgical Unit (Med/Surg, unit that provides care for patients with various medical and surgical conditions) was conducted with the Chief Nursing Officer (CNO) and the Patient Safety Coordinator (PS). On February 25, 2025, at 11:45 p.m. an interview with the Director of Facility Maintenance (DFM) was conducted. The DFM stated the water testing for the Mammoth cooling tower for the HVAC Systems supplying the heating and air-conditioning system to the Emergency Department in September 2024, indicated the presence of Legionnella bacteria. On February 25, 2025, at 2:42 p.m., an interview with the Corporate Quality Officer (CQO) was conducted. The CQO stated she spoke with the DFM who told her he knew of the positive Legionella bacteria results and performed a shock treatment to the condenser of the Mammoth cooling tower. The CQO further stated the facility has only tested the water for Legionella bacteria one time in 2024. The CQO stated the positive Legionella bacteria in the cooling tower water was not reported to the facility administration. The CQO stated they completed the treatment recommended but they did not perform a retest for Legionella bacteria within three to five days in accordance with the facility’s policy. The CQO stated at this time the facility does not know if the treatment performed on the water in the Mammoth cooling tower after it tested positive for the presence of Legionella bacteria in September 2024, was effective. On February 25, 2025, at 3:30 p.m., the facility records were reviewed. A facility document titled, “[Vendor 2] Service Report,” dated September 19, 2024, was reviewed. The document indicated, “...Central Plan-Cooling Tower & [and] Closed Loops...Opening Comment...Purpose of today’s visit: 1)Perform analysis of treated systems 2) check inventories, order chemicals or reagents as needed 3)Identify corrective actions, review with site engineers, initiate training opportunities...Higher than expected chemical residual could be that the chemical pump is pumping, and the cooling tower is not bleeding down and building excessive chemical in the basin....system requires more chemical treatment to be added, recommend that the system be checked for any possible reasons as to why the system continues to loss chemical and water...” A facility document titled, “[Vendor 1] Analytical Results Water Testing: Viable Legionella [bacteria] Bacteria-Quarter 3 Routine,” dated September 4, 2024, was reviewed. “...Attention DFM...re [regarding] Analytical Validation Water Testing-Viable Legionella Bacteria-Quarter 3...results that were sampled...on September 4, 2024...Water samples of inters were collected and analyzed for the presence of viable Legionella...legionella is detected at >1 [greater than or equal to] in the sample...for cooling towers, one (1) water sample showed detectable Legionella bacteria as indicated...Sample identification...Mammoth Cooling Tower...Legionella species...Total legionella 1470...” A facility document titled, “Equipment Data,” dated September 19, 2024, was reviewed. The document indicated, “...work order # [number]: 538274...manufacturer: Mammoth...Model AC-1 [air conditioner]...recommendations to shock condenser water...” A facility document titled, “Water Management Program Water Safety Plan,” dated 2024, was reviewed. The document indicated, “...Water safety plan is designed to control and manage microorganisms in the water systems...Cooling towers-Tower 1...System Name: Tower 1...Location:...ED [Emergency Department] Roof...Manufacturer...Mammoth...regular testing of microorganisms may include analysis for the following...legionella species...the goal is no detectable legionella bacteria...is Legionella detected?...yes...is legionella detected at >100 cfu/ml [colony forming unit per milliliter, a unit of measurement]...Resample for Legionella within 5 [five]-days of corrective actions...” On March 4, 2024, at 9:49 a.m., an interview was conducted with the Governing Body Member (GBM). The GBM stated the governing body was not notified the water in the Mammoth cooling system tested positive for Legionella bacteria in September 2024, and she was only notified during the ongoing survey. There was no documented evidence the water in the Mammoth cooling tower for the HVAC system supplying the ED was retested for Legionella bacteria. The facility policy and procedure titled, “Preventative Maintenance Program-Ensuring Operation Ability,” dated April 2021, was reviewed. The document indicated, “...The Facilities Administrator is responsible for the proper and safe functioning of all equipment within the facility and the condition of the facility generally...Failure of Water Distribution System...contamination of the potable water supply or an unscheduled shutdown of the main riser form more than one hour...” On February 25, 2025, at 7:08 p.m., the survey team identified significant concerns in the facility. Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation with the potential to cause harm to the health and safety of the patients) was called in the presence of the facility’s Chief Nursing Officer (CNO), Chief Operating Officer (COO), Corporate Quality Officer (CQO), Deputy Regional Director of Quality (DRDQ), and the Director Facility Maintenance. They were notified regarding the facility’s failure to ensure water retesting was performed for the Mammoth cooling tower for the Heating, Ventilation, and Air Conditioning (HVAC) System supplying the heating and air-conditioning system that supplies the Emergency Department and Cath lab (unit where heart related procedures are performed), after the water in the cooling tower tested positive for Legionella bacteria (a type of bacteria which can cause lung infection) on September 4, 2024. On February 27, 2025, at 12:23 p.m., the facility provided a Corrective Action Plan (CAP) for the IJ. The CAP submitted by the facility indicated the following: - Immediately upon being notified of the IJ, members of the Governing Board and the MEC were notified of the findings by the COO via an electronic memo; - The facility identified all patients and staff impacted/likely to be impacted by the deficiency and is committed to ensuring the deficiency is corrected immediately; - The facility was unable to determine the impact of the deficiency on patients. There have been no reports of any suspected or confirmed hospital acquired legionella cases. The facility will continue to trace all patients potentially impacted by any new reports of hospital acquired legionella; - As soon as the facility was informed of the issuance of an IJ, the facility started developing and implementing this Removal Plan. The facility verified that the Cath lab is not impacted by this deficiency. Please see the water management plan describing the service area of the Mammoth Cooling Tower; - On February 25,2025, the Mammoth Cooling Tower was shocked and treated then drained of water and kept on dry mode. The Mammoth Cooling Tower was then turned off to eliminate the risk of spreading any contaminated aerosols inside the ED; - On February 26, 2025, a certified vendor performed the Legionella test for the Mammoth Cooling Tower. The Mammoth Cooling Tower will remain off until the results of the testing are available and confirmed to be negative by the industrial hygienist/their contracted laboratory. The results are expected to be back in 7-10 days; - The facility rented portable AC units that are exhausting the hot air above the ceiling tiles while the potable AC units supply the ED with cool air while the Mammoth Cooling Tower is down. These AC portable units are not part of the internal HVAC system. The facility will continue to use the portable AC units until the Mammoth Cooling Tower has tested negative for Legionella and turned back on; - While the Mammoth Cooling Tower is off and the portable AC units are in use, the Facility will monitor the temp in the ED at least three times a day (once per shift) to ensure the portable AC units are maintaining acceptable temperature levels. Any issues with the temp readings will be addressed immediately; - On February 26, 2025, the Director of Plant Op reviewed the hospital policy on water management and found it acceptable; and - The CEO will continue to update the Medical Executive Committee (MEC) and the Governing Board (GB) on the testing results and any additional corrective actions needed to mitigate the risk and the implementation of this removal plan. On February 27, 2025, at 4 p.m., the survey team found the CAP for the IJ to be acceptable and the DRDQ was notified. On February 28, 2025, at 12 p.m., the IJ regarding the presence of Legionella bacteria in the Mammoth cooling tower was removed in the presence of the CQO, after the CAP implementation was verified onsite through observation, interviews, and record review was implemented. 8. On February 26, 2025, at 11:02 a.m., a tour of the fifth floor was conducted with the Nursing Supervisor Registered Nurse (NSRN) and the Deputy Regional Director of Quality (DRDQ). On February 24, 2025, at 8:59 a.m., an observation was made of the emergency Smith Cots which were locked in the maintenance closet outside the emergency stairwell. Am interview was conducted on February 26, 2025, at 12:35 p.m., with the NSRN. The NSRN stated the facility’s security department is responsible for the key to the maintenance closet. The NSRN stated the staff on the fifth floor medical/surgical unit do not have the key to unlock the maintenance closet to get the Smith Cots in case of emergency. An interview was conducted on February 26, 2025, at 2:15 p.m., with Corporate Quality Officer (CQO). The CQO stated the emergency evacuation devices should not be kept in a locked maintenance closet. The CQO stated the emergency devices should be readily available for staff to access in the event of an emergency. A facility policy and procedure titled, “Evacuation During Emergency,” dated April 21, 2025, was reviewed. The document indicated, “...Evacuations of Patients...Smith-cot devices for the evacuation of non-ambulatory patients are available and are maintained in a highly visible storage cart within the immediate area...” 50433”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 38479 Based on observation, interview, and record review, the facility failed to ensure fire-release (a fire door that is designed to automatically close in response to a fire alarm or other emergency signal, preventing the spread of fire and smoke) double doors separating the Definitive Observation Unit (DOU, a unit which provides a high level of care for patients who don’t need intensive care) and Coronary Care Unit (CCU, a unit that treats patients with critical heart conditions) was not obstructed. This failure had the potential to compromise patient safety during a fire emergency when the fire-release double doors placed to prevent fire migration are disabled. Findings: On February 26, 2025, at 12:07 p.m., the facility’s sixth floor was visited for tour and observation of CCU. The double doors separating the CCU and DOU was observed to be open. Upon closer inspection, a gurney (wheeled cot or a stretcher used to transport patients) was observed to be left in place by the double doors to keep the doors ajar. On February 26, 2025, at 12:19 p.m., the Nurse Supervisor Registered Nurse (NSRN) was interviewed. The NSRN stated a staff came to pick up a patient, brought the patient down on the patient’s bed, and left the gurney in the middle of the double doors. The NSRN stated it is a fire release door and supposed to be able to function by automatically closing the doors after passing through. The NSRN stated the gurney was blocking the fire door. A review of the facility policy and procedure titled, “MANAGEMENT RESPONSIBILITIES AND ENVIRONMENT OF CARE,” dated March 2021, was conducted. The policy indicated, “...PURPOSE: To ensure that guidelines are established for management that identifies their responsibilities with respect to the Environment of Care...PROCEDURES...Managers are responsible for the following...Safety...Participates in hazard surveillance...Models commitment to safety procedures and practices at the unit level...Fire Prevention/Life Safety...Understand the concept of smoke compartmentalization (e.g., a department may be used as a temporary smoke compartment as an area or refuge-the area is contained by smoke doors and smoke walls)...Ensures corridors are free for egress, and not used for storage...Enforces “no artificial doorstops”...Keeps exits and stairwells clear/clean...””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 38479 Based on observation, interview, and record review, the facility failed to ensure physical environment was maintained and kept in working order when: 1. The elevators cars (Cars 1, 2, 3, 4, 5, and 6) were not maintained in optimal working condition; and 2. An acrylic box for holding the moisture-wicking fabric (fabric with antimicrobial to keep skin folds dry and reduce rubbing and help prevent infection) and a pair of scissors in the box holder were observed to have debris and grime. This failure had the potential to compromise patient safety, increase the risk of exposure to bacteria, increased risk for infection, and may cause a delay in treatment. Findings: 1. On February 24, 2025, at 8:50 a.m., a tour and observation of the third floor were conducted with the Patient Advocate (PA) and the Director of Facility Maintenance (DFM). The light over the door of elevator Car 3 was observed to turn on when the elevator call button was pressed. Elevator Cars 1 and 2 were observed to take a while to transport patients, staff, and visitors. During a concurrent interview with the DFM, the DFM stated the facility has two building towers, with each tower having three elevators for patient, staff, and visitors use. The DFM stated Tower 1 has elevator Cars 1, 2, and 3, and Tower 2 has elevators Cars 4, 5, and 6. The DFM stated elevator Car 3 was decommissioned (make inoperative) and elevator Car 4 was always malfunctioning for the last two weeks. The DFM stated the two elevator cars on each tower were functional but slow. On February 24, 2025, at 1:25 p.m., the Life Safety Officer (LSO) was onsite to conduct a survey for issues regarding the facility elevator. The LSO stated elevator Car 4 had been malfunctioning and was inspected a week and a half ago and is requiring a new motor. On February 24, 2025, at 4:34 p.m., the LSO was interviewed. The LSO stated he conducted an investigation and had found elevator Car 4 door was “going bad” and waiting for repair. The LSO stated elevator Car 4 is not working well, and the other elevator car doors are connected and may affect all doors to slow down. On February 25, 2025, at 10:21 a.m., the Corporate Quality Officer (CQO) was interviewed regarding the facility’s physical environment and about the malfunctioning elevators. The CQO stated governing body is responsible for leadership of the hospital to ensure the facility environment is kept clean, sanitary, safe, and comfortable. The CQO stated the Governing Body is responsible in ensuring equipment and utilities are adequate and facility have structural integrity (a concept often used in engineering to produce items that will serve their designed purposes and remain functional for a desired service life). On February 26, 2025, at 11:56 a.m., an observation of the elevator was conducted with the Deputy Regional Director of Quality (DRDQ) on the way to observe the sixth floor. Elevator Car 6 was observed to be the only elevator car functioning. Elevator Cars 4 and 5 was observed to not be working. During a concurrent interview, the DRDQ stated she had not received report regarding the issue with elevator Car 5. On February 26, 2025, at 1:50 p.m., a walking tour was conducted with three Fire Department Officials, the DRDQ, the Director of Facility Maintenance (DFM), and the LSO, to conduct a floor to floor inspection of the basement up to the sixth floor. The elevator cars have been observed slow. There were patients, staff, and visitors observed waiting to ride in the elevator. The tour group had to utilize the stairs to get to each floor of the facility. On March 3, 2025, at 2:27 p.m., the Chief Operating Officer (COO) was interviewed regarding the outcome of slow-moving elevators. COO stated, “Result is delay in patient services.” On March 3, 2025, at 3:52 p.m., the DFM was interviewed regarding patient outcome for when the elevator is not working. The DFM stated there would be more wait time and patient services delay. A review of the facility policy and procedure titled, “ELEVATOR MAINTENANCE,” dated March 2021, was conducted. The policy indicated, “...POLICY...To assure safe and continued operation of all facility elevators...PROCEDURE...Maintain a complete service contract with an outside elevator company to include routine maintenance and repairs...Conduct inspections in compliance with State elevator codes and secure permits...Immediately respond to reports of elevator problems and call the elevator service vendor...” 47071 2.On February 25, 2025, at 9:46 a.m., a tour of the fifth floor was conducted with the Nursing Supervisor Registered Nurse (NSRN). On February 25, 2025, at 11 a.m., an observation was made of the moisture-wicking fabric box holder on the wall by the exit of the clean utility room. The box was observed to blackish debris and a white power substance in the holder and a pair of scissors with thick buildup of white and brown colored sticky grime were observed in the box. A interview was conducted on February 25, 2025, at 11:05 a.m., with the NSRN. The NSRN stated the moisture wicking fabric is used to keep the patients with skin folds (large amount of skin that overlaps or creases) dry. The NSRN stated the scissors are used to cut the moisture wicking fabric to the correct length for each patient. The NSRN stated the acrylic box that holds the scissors is dirty with debris. The NSRN stated the pair of scissors are dirty with thick buildup of white and brown colored sticky grime. The NSRN stated the moisture wicking fabric box should be kept clean and free of debris. The NSRN stated the pair of scissors should have been disinfected after each use. The NSRN stated the buildup of dirt in the scissors places the patients at risk for being exposed to bacteria. A facility policy and procedure titled, “Equipment cleaning ,” dated March 23, 2025, was reviewed. The policy indicated, “...Equipment will be cleaned with a hospital approved disinfectant after each patient use, of if visibly soiled and on a regular schedule...””

“IC PROFESSIONAL ADHERENCE TO POLICIES CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by hospital personnel. This Standard is not met as evidenced by: 47071 Based on observation, interview, and record review, the facility failed to ensure the facility’s policy and procedure for infection control was implemented when staff was observed not donning [putting on] personal protective equipment (PPE, protective gloves, mask and gown) when entering an isolation room. This failure has the potential for increased risk of spreading harmful bacteria to other patients. Findings: On February 25, 2025, at 10:18 a.m., a sign on Patient 30’s door was observed to indicate Patient 30 was in air borne isolation precautions (infection control measures designed to prevent the transmission of infectious agents that spread through the air). Charge Nurse (CN) 1 was observed to walk into Patient 30’s room without personal protective equipment on. CN 1 was observed exiting Patient 30’s room and took a mask, gloves, and a gown from the isolation cart that was located in front of Patient 30’s room. CN 1 was observed to don [put on] the mask, gloves, and gown and went back in Patient 30’s room. CN 1 was observed to not put an N95 mask on (a face mask designed to achieve a very close facial fit and very efficient filtration of airborne viruses and bacteria). An interview was conducted on February 25, 2025, at 10:19 a.m., with CN 1. CN 1 stated Patient 30 is in air borne isolation precautions. CN 1 stated he should have used hand sanitizer and put on the personal protective equipment (PPE) before going in Patient 30’s room. On February 25, 2025, at 10:22 a.m., Patient 30’s record was reviewed with Nursing Supervisor Registered Nurse (NSRN). A facility document titled, “History and Physical,” dated February 19, 2025, was reviewed. The document indicated Patient 30 was admitted to the facility on February 19, 2025, for shortness of breath and wheezing (high-pitched, whistling sound that occurs when air moves through narrowed airways in the lungs). A facility document titled, “Final Report Molecular Pathology Report,” dated February 21, 2025, was reviewed. The document indicated, “...[Patient 30’s name]...Summary of detected results...bacteria...pseudomonas aeruginosa [a type of bacteria]...detected...Staphylococcus epidemidis [type of bacteria in the urine]...detected...methicillin (oxacillin)-resistant Staphylococcus epidermidis [MRSE, type of bactria not easily treated with antibiotics]...Viruses...Ebstein-Barr [a type of contagious virus]...detected...Rhinovirus [virus that could cause respiratory illness]...detected...” An interview was conducted on February 25, 2025, at 10:25 a.m. with the Nurse Supervisor Registered Nurse (NSRN). The NSRN stated CN 1 should have put on PPE before entering the patient’s room. The facility policy and procedure (P&P) titled, “Standard and Transmission Based Precautions,” dated February 2024, was reviewed. The policy indicated, “...To prevent the exposure of patients...communicable and/or infectious diseases...Gloves...clean gloves must be worn when touching...body fluids...gown...must be worn to protect skin...during procedure...patient care activities...potential for splashes...body fluid...are expected...” The facility P&P titled, “Personal Protection Equipment (PPE) Program,” dated April 2021, was reviewed. The policy indicated, “...The procedure of donning (putting on) and removing PPE that will prevent skin or clothing contamination...””

“The following reflects the findings of the California Department of Public Health, Life Safety Code Section, during a Complaint Validation Survey authorized by the Centers for Medicare and Medicaid Services Region IX to investigate the following intakes: CA00947639, CA00947720, CA00948186, CA00948221, CA00948239, CA00948245, CA00948435, CA00948890, and CA00949043. Inspection was limited to the authorized Conditions of Participation [42 Code of Federal Regulations 482.41(b) Life Safety Code] reviewed for the specific intakes, and did not represent the findings of a full inspection of the facility. Three Life Safety Code tags, K161, K531, and K920, were written as a result of intakes CA00947639, CA00947720, CA00948186, CA00948221, CA00948239, CA00948245, CA00948435, CA00948890, and CA00949043. The average daily census was 106.”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 40597 Based on observation, record review, and interview, the facility failed to maintain the integrity of the building structure. This was evidenced by unsealed penetrations on the walls and ceilings. This could result in expedited spread of smoke to other areas of the facility. This could have affected 106 of 106 patients, staff, and visitors in Tower 2. NFPA 101, Life Safety Code, Edition 2012 4.2.2 Structural Integrity. Structural integrity shall be maintained for the time needed to evacuate, relocate, or defend in place occupants who are not intimate with the initial fire development. Findings: During a tour of the facility and interview with the Safety Officer, Chief Nursing Officer, and Patient Safety Coordinator on 2/24/25 through 2/28/25, the Tower 2 building construction was observed. 1. On 2/24/25 at 3:37 p.m., in the Intensive Care Unit (ICU) A, there was a penetration on the wall in the Soiled Linen storage closet. The penetration measured approximately one square foot. During a concurrent interview, the Safety Officer stated the facility’s plumber removed the drywall to locate a broken drain line. At 3:38 p.m., the Safety Officer provided a work order dated 2/22/25. The document indicated that drain lines need repair in different areas of ICU A and B. During concurrent interview, the Safety Officer stated that they are planning to start working in the ICU A and then continue with ICU B. 2. On 2/25/25 at 9:51 a.m., in the ICU B, there was a penetration on the wall in the technology storage closet located next to the Nurse Station. The penetration measured approximately one foot by seven feet. There was a cast iron four inch drain pipe behind the drywall. During a concurrent interview, the Chief Nursing Officer confirmed the finding and stated that the facility decided to repair the drain lines sooner than expected. 3. On 2/26/25 at 11:50 a.m., in the ICU B, there was a penetration on the wall next to Room 163. The penetration in the drywall measured approximately eight feet by one foot. During concurrent interview, the Safety Officer stated that they found a drain line that was broken and they had to remove the drywall. 4. On 2/26/25 at 11:57 a.m., in Room 163, the restroom wall had a penetration next to the toilet. The penetration measured approximately three square feet. During a concurrent interview, the Safety Officer confirmed the finding and stated that a drain line was repaired. 5. On 2/26/25 at 11:58 a.m., in Room 163, a ceiling tile was removed. The tile measured two square feet. During a concurrent interview, the Safety Officer stated that the plumber was removing ceiling tiles in order to locate the drain lines.”

“Elevators CFR(s): NFPA 101 Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter’s Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter’s Service Requirements of ASME/ANSI A17.3. (Includes firefighter’s service Phase I key recall and smoke detector automatic recall, firefighter’s service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3 This Standard is not met as evidenced by: 40597 Based on observation, record review, and interview, the facility failed to maintain the elevators. This was evidenced by the failure to provide elevators in a reliable operating condition, by an elevator fire sign that was not legible, and by the failure to complete corrections identified by a state agency. This could result in a delay to relocate the occupants with special needs during an emergency. This could have affected 106 of 106 patients, staff, and visitors in Tower 2. NFPA 101, Life Safety Code, Edition 2012 19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4. 9.4 Elevators, Escalators, and Conveyors. 9.4.2.2 Except as modified herein, existing elevators, escalators, dumbwaiters, and moving walks shall be in accordance with the requirements of ASME A17.3, Safety Code for Existing Elevators and Escalators. 9.4.2.4 For other than elevators used for occupant-controlled evacuation in accordance with Section 7.14 and other than existing elevators, the elevator corridor call station pictograph specified in 2.27.9 ofASMEA17.1/CSAB44, Safety Code for Elevators and Escalators, shall be provided at each elevator landing. 9.4.3.2 All existing elevators having a travel distance of 25 ft (7620 mm) or more above or below the level that best serves the needs of emergency personnel for fire-fighting or rescue purposes shall conform to the fire fighters’ emergency operations requirements of ASMEA17.3, Safety Code for Existing Elevators and Escalators. ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators 2.27.9 Elevator Corridor Call Station Pictograph. When the building code requires a sign be posted adjacent to hall call fixtures instructing occupants not to use the elevator in case of fire, the sign shown in Fig. 2.27.9 shall be provided. The sign shall include only the wording and graphics shown in Fig. 2.27.9. When the building code specifies a different design, 2.27.9 shall not apply. 8.6.1 General Requirements 8.6.1.1 Maintenance, Repair, and Replacement 8.6.1.1.1 Equipment covered within the scope of this Code shall be maintained in accordance with Section 8.6. 8.6.1.1.2 Maintenance, repairs, replacements, and tests shall conform to Section 8.6 and the applicable (a) Code at the time of the installation; and (b) Code requirements at the time of any alteration; and (c) ASME A17.3 if adopted by the authority having jurisdiction 8.6.2 Repairs. See 8.6.2.1 through 8.6.2.6 for general requirements for repairs. 8.6.2.1 Repair Parts. Repairs shall be made with parts of at least equivalent material, strength, and design (see 8.6.3.1). 8.6.3 Replacements 8.6.3.1 Replacement Parts. Replacements shall be made with parts of at least equivalent material, strength, and design. 8.6.4 Maintenance and Testing of Electric Elevators. The maintenance and testing of electric elevators shall conform to 8.6.1 through 8.6.4. 8.6.4.1 Suspension and Compensating Means 8.6.4.1.1 Suspension and compensating means shall be kept sufficiently clean so that they can be visually inspected. 8.6.4.7 Cleaning of Hoistways and Pits 8.6.4.7.1 Hoistways and pits shall be kept free of dirt and rubbish and shall not be used for storage purposes. Findings: During a tour of the facility, record review, and interview with the Safety Officer (SO), Security Staff 1, Deputy Regional Director of Quality, Chief Nursing Officer on 2/24/25 through 2/28/25, elevators #4, #5, and #6 were observed in Tower 2. 1. On 2/24/25 at 1:25 p.m., the facility failed to maintain Elevator #4 in Tower 2 in a reliable operating condition. During a concurrent interview, the SO stated that the Elevator #4 door operator stopped working a week ago due to age. A document titled, “Proposal,” dated 2/19/25 and with estimate #7663, indicated a proposal to install a new car door operator equipment. 2. On 2/26/25 at 12:09 p.m., the facility failed to maintain Elevator #5 in Tower 2 in a satisfactory operating condition. A document titled, “Work Order #466783,” dated 2/26/25, indicated that Elevator #5 was stuck on the 6th floor. During a concurrent interview, the SO stated that doors to Elevator 5 are bumped by accident and it causes the elevator to get stuck. On 2/26/25, from 12:09 p.m. to 12:14 p.m., a staff member and a patient were waiting in the lobby for the only functioning elevator at that time, Elevator #6. The staff was transferring the patient to a recovery room upstairs. After waiting for 5 minutes, the security staff had to be summoned to assist with recalling Elevator #6 by using the keyed firefighter’s recall switch. 3. On 2/26/25 at 12:20 p.m., the elevator fire sign observed in the first floor lobby of Tower 2 was not legible. The sign would have notified occupants to not use the elevators in case of a fire. During a concurrent interview, the SO confirmed the finding and stated that is was the original fire sign. 4. On 2/28/25 at 1:22 p.m., the preliminary order issued by the state agency responsible for permitting and inspecting elevators listed conditions in need of correction for multipe elevators. During a concurrent interview, the SO confirmed the listed conditions. The preliminary order indicated that the elevators in Tower 1, Tower 2, and in the Administration building had to be compliant by 3/31/25. Conditions were given to elevators with the following state numbers: 045801, 045802, 064018, 066278, 066276 (Elevator #4), 066277 (Elevator #5).”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 40597 Based on observation, record review, and interview, the facility failed to maintain the electrical equipment. This was evidenced by the failure to connect a refrigerator directly into a wall outlet without the use of an adapter. This could increase the risk of a shock hazard. This could have affected 106 of 106 patients, staff, and visitors in Tower 2. NFPA 99: Health Care Facilities Code, 2012 Edition 10.5.3 Servicing and Maintenance of Equipment. 10.5.3.1.2 Service manuals, instructions, and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment. Findings: During a tour of the facility and interview with the Safety Officer, Third Floor Unit Manager, and Chief Nursing Officer (CNO) on 2/24/25 through 2/28/25, the Tower 2 electrical equipment was observed, and the published service manual was reviewed. On 2/27/25 at 2:26 p.m., in the third floor Nutrition Room, a refrigerator was plugged directly into a Belkin power strip. The service manual indicated not to plug the appliance into an adapter. Failure to follow the instructions can result in electrical shock. During a concurrent interview, the CNO stated that the power strips were utilized during a power outage two weeks ago and the staff forgot to collect the power strips after the event.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure patient rights were provided for five of 32 sample patients, (Patients 2, 5, 13, 27, and 32), when: 1. For Patient 2, the patient or patient’s representative was not informed of their patient rights in advance prior to providing care (Refer to A-0117). 2. For Patient 5, the consent to transfer to another facility was not signed by the patient or patient representative (Refer to A-0131). 3. For Patients 13, 27, and 32, the consent to surgery or special procedure was not completed by the physician/s (Refer to A-0131). The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients seen at the facility, jeopardize their safety, and may cause delays in the provision of their care.”

“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: 42512 Based on interview, and record review, the facility failed to ensure the facility’s policies and procedures were implemented, for 12 of 32 sample patients (Patients 1, 2, 14, 15, 16, 17, 20, 22, 24, 25, 26, and 28), when: 1. For Patient 17, the Glucose (test used to indicate the amount of sugar in the blood) critical lab result was not reported to the physician (Refer to A-0398); 2. For Patients 1, 2, 14, 15, 16, 25, and 26, wound status and wound care provided were not assessed and documented as required (Refer to A-0398); 3. For Patient 14, Input and Output was not recorded at the end of the shift as required (Refer to A-0398); 4. For Patients 20, 22, 24, and 28, pain assessments and reassessments were not completed, pain medications were not administered, and pain management in the Emergency Room (ED) was not provided timely (Refer to A-0398). The cumulative effects of these systemic failures had the potential to impact the health, safety, and treatment of the patients, and may cause delays in the provision of patient care.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure the needs of patients in the Emergency Department were met in accordance with acceptable standards of practice when: 1. For Patient 10, staff did not provide a sepsis screening; and 2. For Patient 11, staff did not provide a triage examination in the Emergency Department (ED). These failures had the potential to cause a delay in patient care and an adverse patient outcome. Findings: On January 2, 2025, at 11:27 a.m., a review of Patient 10’s medical record and concurrent interview was conducted with the Registered Nurse Supervisor (RN Sup). A facility document titled, “Emergency Department Record,” dated November 10, 2024, 4:11 a.m., was reviewed and indicated Patient 10 presented to the ED for generalized weakness, persistent cough, and shortness of breath. The document further indicated Patient 10 had a white blood count [test to measure the white blood cells in blood to determine infection] of 15.8 [normal 3.6-11.2]. A facility document titled, “Emergency Department Record,” dated November 10, 2024, at 7:30 a.m., indicated, “...X-RAYS...CR Chest 1 View...Study Reason: Dyspnea...IMPRESSION...left upper consolidation with residual dense opacity concerning for residual pneumonia...Left lower lobe patchy opacities, may represent pneumonia and/or atelectasis...” The review of Patient 10’s record reflected no documented evidence Patient 10 received a sepsis screening. An interview was conducted on January 2, 2025, at 11:45 a.m., with the Corporate Quality Officer (CQO). The CQO stated all patients over the age of 18, should be screened for sepsis in the ED, and if admitted, on the unit every shift. An interview was conducted on January 2, 2025, at 11:55 a.m., with the RN Sup. The RN Sup stated there was no documented sepsis screenings in Patient 10’s medical record for the date of service of November 10, 2024. The RN Sup further stated sepsis screening was not done in triage or in the ED, and it should have been per facility policy. A review of the facility’s Policy and Procedure (P&P) titled, “ADULT SEPSIS SCREENING AND PHYSICAN APPROVED NURSING SEPSIS PROTOCOL,” dated May 2024, indicated, “...Registered Nurses to screen all adult patients...severe sepsis or septic shock and implement specified elements of the sepsis treatment bundle as indicated...All patients...will be screened for sepsis, severe sepsis, or septic shock in the Emergency Department, upon admission to all Inpatient units, every shift thereafter, and anytime there is a change in condition...” 2. On January 3, 2025, at 10:50 a.m., a review of Patient 11’s record was conducted with the Clinical Nurse Manager (CNM). The facility document titled, “ED Summary Report,” indicated Patient 11 was admitted to the ED on January 1, 2025, at 6:12 p.m. The document further indicated, “Chief Complaint: Abdominal pain...35-week G1P0 [Gravida 1, indicates total number of pregnancies, Para 0, indicates a woman has never given birth] accompanied by mother, states she felt fluid leak, does not know if bag is ruptured...” During review of Patient 11’s medical record there was no documented evidence of triage documentation. There was no documented evidence Patient 11 was triaged when arrived at the ED on January 1, 2025. On January 3, 2025, at 10:55 a.m., an interview was conducted with the Corporate Quality Officer (CQO). The CQO stated all patients seen in the ED should have a triage report in the electronic medical record. A review of the facility P&P titled “Triage and Assessments of Patient’s Using The Emergency Severity Index (ESI)”, dated April 2023, was conducted. The P&P indicated, “...All patients presenting to the ED requesting emergency care will be initially triaged by a qualified RN or ED physician in a timely manner to determine priority of medical screen and care based on physical, psychosocial, and social needs...””

“MEDICAL STAFF CFR(s): 482.12(a) The governing body must: This Standard is not met as evidenced by: 50304 Based on interview and record review, the facility failed to implement its medical staff bylaws, rules and regulations, for one of 32 patients reviewed (Patient 27) when the final report for Patient 27’s chest x-ray was not signed on time according to facility policy. This failure had the potential to cause a delay in Patient 27’s treatment. Findings: A review of Patient 27’s medical record was conducted on December 31, 2024, at 11:09 a.m., with the Registered Nurse Supervisor for Intensive Care Unit (RN Sup). The untitled facility document dated, December 28, 2024, was reviewed and indicated, “...DATE OF ADMISSION: 12/27/2024 [December 27, 2024]...CHIEF COMPLAINT: Abdominal pain...on hemodialysis [a medical treatment that filters waste and excess fluids from the blood when the kidneys are no longer able to do so.]...” An interview and concurrent record review were conducted with the Medical Director for Radiology (MDR) on January 6, 2025, at 8:59 a.m. The undated untitled facility document was reviewed with the MDR. The document indicated, “...CR Chest 1 view...Current Study Date and Time: 12/28/2024 10:59 a.m. [December 28, 2024, at 10:59 a.m.]... preliminary report dictated by Resident: [Name of Resident 1] on 12/28/2024 at 11:39 a.m [December 28, 2024, at 11:39 a.m]...final report signed by: MDR on 12/30/2024 8:59 a.m. [December 30, 2024, at 8:59 a.m.]...” The MDR stated the final report was not signed on time. He further stated the final report should have been signed on December 29, 2024. A review of facility’s Policy and Procedure (P&P) titled, “Graduate Medical Education Residency Program,” dated May 2018, indicated, “...exams will be dictated under the teaching attending on duty the following day, as designated by the attending schedule...” A review of the facility’s “Medical Staff Bylaws, and Rules and Regulation,” revised June 25, 2024, indicated, “...Basic Responsibilities of medical staff membership Except for the honorary Medical Staff, the ongoing responsibilities of each member of the Medical Staff, including those who exercise temporary clinical privileges, include...abiding by the Medical staff and Governing body bylaws and the Medical Staff Rules and Regulations and other established rules and policies of the hospital...””

“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: 42512 Based on interview and record review, the facility failed to ensure the patient or patient’s representative were informed of their patient rights prior to providing care, for one of 32 sampled patients (Patient 2). This failure resulted in Patient 2, and/or the patients’ representatives, to not be informed of their rights as a patient, which could have lead to Patients 2’s inability to effectively make decisions regarding their care and treatment. Findings: A review of Patient 2’s record was conducted on January 02, 2025, at 3:05 p.m., with the Corporate Quality Officer (CQO). A facility document titled, “H&P,” dated December 14, 2024, indicated Patient 2 was admitted to the facility on December 14, 2024, for wound debridement (a procedure that removes infected or dead tissue from a would to help it heal), and had a history of diabetes (disease where body cannot regulate blood sugar) and obesity. The Condition of Admission form was not signed, and indicated, “Pt [patient]unable to sign,” was handwritten on the form. There was no documentation in the record that additional efforts had been made to provide the information on patient’s rights to the patient, family, or surrogate. An interview was conducted with the CQO on January 02, 2025, at 3:15 p.m. The CQO stated it was the facility’s staff responsibility to provide the patients with the Conditions of Admission at the time of admission. The CQO further stated if the staff was not able to give the information on admission, the nurse should have made additional efforts to deliver the information during the patient’s stay at the hospital. After reviewing the records, the CQO stated the patient’s rights was not followed-up on after the initial admission process. A review of the facility’s policy and procedure titled, “CONDITIONS OF ADMISSION,” dated April 2021, was conducted. The document indicated “...To ensure that a Conditions of Admission is signed for every patient...as to why there is no Conditions of Admissions signature...A Conditions of Admission is to be signed for every patient...When a patient is registered in the Emergency Room, the ED Patient Access Representative will obtain the signature on the Conditions of Admission (COA). When the Main Admitting Office is closed, the ED Patient Access Representative will obtain the signature on all Direct Admissions/Transfers in to the facility as well...If a signature is not obtained...a note will be entered into the [name of electronic medical record (EMR)] Registration notes...A Patient Access Representative will be assigned each day to review the report, call the nursing unit the patient is assigned to and check on condition of patient. If patient is able to sign the rep will visit the bedside to obtain the signatures, provide admission paperwork and assure account is updated appropriately with Emergency Contact/Next of Kin information...””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for four of 32 sampled patients (Patients 5, 13, 27, and 32), when: 1. For Patient 5, the consent to transfer to another facility was not signed by the patient or patient representative. 2. For Patients 13, 27 and 32, the consent to surgery or special procedure was not completed by the physician. These failures had the potential to cause a delay of care or transfer for patients 5, 13, 27, and 32, and may have caused harm to the patients. Findings: 1. On January 3, 2025, at 11:05 a.m., an interview and concurrent record review of Patient 5’s record was conducted with the Corporate Quality Officer (CQO). A facility document titled, “Emergency Department Record,” dated December 26, 2024, indicated Patient 5 was seen in the Emergency Department (ED) for a mechanical fall and the patient was seven months pregnant. A facility document titled, “History and Physical,” dated, December 27, 2024, indicated Patient 5 was admitted to the facility for a right ankle fracture. The document further indicated Patient 5 was seven months pregnant. A facility document titled, “Consultation,” indicated “...The patient was being evaluated for an ankle fracture in the ED and seven months pregnant...in moderate to severe distress...Assessment...female with seven months pregnancy, waiting for ankle surgery. Due to staffing shortage in the OB department, I am advising the patient to be transferred to another facility because she will require continuous monitoring for the first six hours after surgery and thereafter NSTs (non-stress test) every four hours for the following 24 hours as well as tocolytics (drug to delay labor) for any possible contractions. Therefore, it is advisable that the patient be transferred to another facility that can monitor the baby continuously after surgery and NSTs prior to surgery for an hour...” A facility document titled, “Daily Focus Assessment Report,” dated December 27, 2024, at 11:31 a.m., indicated, “...Acute transfer order for ankle fracture repair for a 7 [seven] month gestation woman...Per house supervisor and COO, no OB service or staff available for pt’s [patient’s] needs pre and post surgery intervention; therefore, pt needs HLOC [higher level of care] for surgical intervention w [with]/OB services...Call made to [name of Doctor 1] to inquire on speaking to pt prior to CM [case management] obtaining transfer consent, no response, message left w/ [Name of Doctor 1] for further collab [collaboration] on transfer order...” A facility document titled, “Daily Focus Assessment Report,” dated December 27, 2024, at 5:30 p.m., indicated, “...pt [patient] accepted to [Hospital 2], by [Name of Doctor 2, IM (Internal Medicine)], [Name of Doctor 3, Ortho (Orthopedics)], [Name of Doctor 4, OB(Obstetrics)], [Name of Doctor 5, OB (Attending)]...” A facility document titled, “Discharge Summary,” dated December 28, 2024, indicated, “...Subsequently, we do not have OB department in full service here at our hospital. The patient (Patient 5) was transferred to [Hospital 2], which has OB and orthopedics. The patient was transferred there for further care and treatment...” A facility document titled, “PATIENT’S REQUEST/REFUSAL/CONSENT TO TRANSFER,” dated December 27, 2024, was reviewed. The document indicated, “...TRANSFER CONSENT...Signature of Patient or Legally Responsible Individual Signing on Patient’s Behalf...” There was no documented evidence the consent for transfer was signed by the patient or the patient’s representative...” A review of the facility’s Policy and Procedures titled, “EMTALA - TRANSFER POLICY,” dated May 2023, was conducted. The document indicated, “...To establish guidelines for...providing an appropriate transfer to another facility of an individual with an emergency medical condition...Any transfer of an individual with an EMC (emergency medical condition) must be initiated...by written request for transfer from the individual or the legally responsible person acting on the individual’s behalf...” 2a. On December 31, 2024, at 9:42 a.m., a review of Patient 13’s medical record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, “History and Physical,” dated December 17, 2024, indicated Patient 13 was admitted to the facility on December 17, 2024, for shortness of breath and abdominal pain. The facility document titled, “[Name of Facility] Consent to Surgery or Special Procedure,” dated December 20, 2024, was reviewed. The document indicated, “...Insertion of Right Chest Tube...December 20, 2024,...time...12:30 p.m....Telephone consent from...daughter...two witnesses...” There was no documented evidence the physician reviewed the History and Physical, signed, dated or timed the consent prior to the procedure. An interview was conducted on December 31, 2024, at 9:57 a.m., with the PSC. The PSC stated the physician should have signed the consent to surgery or special procedures. She further stated the physician can write in a provider note that the informed consent and risk and benefits were completed but he did not. An interview was conducted on December 31, 2024, at 10 a.m., with the Cooperate Quality Officer (CQO) and the PSC. The PSC stated if the physician did not sign the informed consent per the policy, they could have documented the informed consent in the physician progress notes, however the physician did not document it in the electronic medical record (EMR). Further review of Patient 13’s medical record, indicated there was no documented evidence the physician documented the informed consent and the risk and benefits in Patient 13’s electronic medical record. A review of the facility Policy and Procedure titled, “[Facility Name] Informed Consent,” dated September 2024, was conducted. The document indicated, “...In every case where informed consent is required, the physician must note in the patient’s medical record that informed consent was obtained...Informed Consent must be obtained prior to the procedure consent being signed, dated and timed by the patient...” 2b. A review of Patient 27’s medical record was conducted on December 31, 2024, at 11:09 a.m., with Registered Nurse Supervisor for Intensive Care Unit (RN Sup). The untitled facility document dated December 28, 2024, at 7:13 a.m., was reviewed. The document indicated Patient 27 was admitted to the facility on December 27, 2024, for abdominal pain and on hemodialysis [a medical treatment that filters waste and excess fluids from the blood when the kidneys are no longer able to do so] ...” The facility document titled, “Authorization for consent to surgery or special diagnostic or therapeutic procedure,” was reviewed with RN Sup. The document indicated, “... your physicians and/ or surgeons have recommended the following operation or procedure. Hemodialysis...Date...Time...Provider Signature...” There was no documented evidence the physician signed the hemodialysis consent prior to Patient 27’s procedure. There was no documented evidence the risks and benefits were explained to Patient 27 prior to the procedure. An interview with the Chief Quality Officer (CQO) was conducted on December 31, 2024, at 11:21 a.m. The CQO stated the physician should have signed the consent for hemodialysis prior to the procedure. An interview with RN Sup was conducted on December 31, 2024, at 11:23 a.m. The RN Sup stated there was no documentation on the chart that risks and benefits were explained by the physician to Patient 27. She further stated it was important to make sure the patient was aware of risks and benefits for any procedure. 2c. A review of Patient 32’s medical record was conducted on January 3, 2024, at 2:17 p.m., with the Stroke Coordinator (SC). The facility document titled, “History and Physical,” dated December 5, 2024, at 4:54 p.m., was reviewed. The document indicated Patient 32 was admitted to the facility on December 5, 2024, for ALOC [Altered level of consciousness (a change in a patient’s awareness and alertness)]. The facility document titled, “Authorization for consent to surgery or special diagnostic or therapeutic procedure was reviewed with the SC. The document indicated, “... your physicians and/ or surgeons have recommended the following operation or procedure. Hemodialysis...Date...Time...Provider Signature...” There was no documented evidence the physician signed the hemodialysis consent prior to Patient 32’s procedure. There was no documented evidence the risks and benefits were explained by the doctor to Patient 32 prior to the procedure. An interview with the SC was conducted on January 3, 2024, at 2:17 p.m. The SC stated there was no documentation on the physician notes or progress notes that risks and benefits were explained by the kidney doctor to the patient. The SC stated the kidney doctor should have explained the risks and benefits of hemodialysis to the patient. The SC stated it was important for the physician to explain the risks and benefits to the patient, “so they can receive informed care and make the proper decision.” A review of facility policy and procedure titled, “Informed Consent,” dated September 2024, was conducted with RN Sup and CQO. The policy indicated, “...The hospital is required to obtain documentation of consent to hospital services and to verify that the physician has obtained informed consent as appropriate...A procedural consent form, dated, timed and signed by the patient and witnesses by hospital staff are required for surgical invasive procedures/complex procedures as outlined in the Informed Consent section and for special procedures as listed under Informed consent Special Requirements...” 47071 50304”

“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: 42512 Based on interview, and record review, the facility failed to ensure the facility’s policies and procedures were implemented for 12 of 32 sampled patients (Patients 1, 2, 14, 15, 16, 17, 20, 22, 24, 25, 26, and 28), when: 1. For Patient 17, the Glucose (test used to indicate the amount of sugar in the blood) critical lab result was not reported to the physician (Refer to A-0398); 2. For Patients 1, 2, 14, 15, 16, 25, and 26, wound status and wound care provided were not assessed and documented as required (Refer to A-0398); 3. For Patient 14, Input and Output was not recorded at the end of the shift as required (Refer to A-0398); 4. For Patients 20, 22, 24, and 28, pain assessments and reassessments were not completed, pain medications were not administered, and pain management for patients in the Emergency Room (ED) was not provided timely (Refer to A-0398). These failures had the potential to impact the health, safety, and delay treatment of the patients. Findings: 1. On January 3, 2025, at 11:02 a.m., a review of Patient 17’s medical record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, “History and Physical,” dated November 11, 2024, indicated Patient 17 was admitted to the facility on November 11, 2024, for Diabetic Ketoacidosis (complication of diabetes which acid builds up in the blood to life threatening levels) and Sepsis (life threatening complication of infection). A facility document titled, “[Name of Facility] Order management,” dated November 14, 2024, at 12:37 a.m., was reviewed. The document indicated, “...comprehensive metabolic panel [a routine blood test that measures substances in the blood to provide information about the body’s chemical balance]...once...collected...” A facility document titled, “[Name of Facility] Results,” dated November 14, 2024, was reviewed. The document indicated, “...collected November 14, 2024, 04:45 [4:45 a.m.]...glucose 477...reference...70-110mg/dL [milligrams per deciliter-unit of measurement]...result called to RN[Registered Nurse]...at 0752 [7:52 a.m.] on 11/14/24 0725 [November 14, 2024 7:52 a.m.]...” During the review of Patient 17’s medical record, there was no documented evidence the RN reported Patient 17’s critical glucose lab result of 477 mg/dL to the physician. An interview was conducted on December 31, 2024, at 11:11 a.m., with the PSC. The PSC stated the nurse did not document the notification to the physician. The PSC further stated the nurse did not document the critical lab result in the critical lab section of the electronic medical record. A review of the facility’s Policy and Procedure (P&P) titled, “ [Facility Name] Critical Lab Values and Diagnostic Test Results Notification of,” dated September 2024, was conducted and indicated, “...The responsible physician...will be notified as soon as possible, but no later than, 60 minutes...glucose (fasting)...< (less than 40 mg/dl or (greater than) 400mg/dl...Document responsible physician notification of the critical laboratory or diagnostic test result in the medical record...” 2a. A review of Patient 1’s record was conducted on January 2, 2025, at 2:30 p.m., with the Corporate Quality Officer (CQO). A facility document titled, “History and Physical (H&P),” dated December 27, 2024, indicated Patient 1 was admitted to the facility on December 27, 2024, for coffee ground emesis (vomit indicative of internal bleeding that looks like coffee grounds), and melena (black tarry stool indicative of internal bleeding). Continued review of Patient 1’s medical record revealed an undated double sided facility document titled, “WOUND PROGRESS NOTES,” which indicated side one was used to assess a patient’s wound, and side two was used to place wound photos. There was no documentation on the form for wound assessment on side one. On side two, there were two photos of the wound which were blurry and did not clearly show Patient 1’s name, measuring device, anatomical location, patient identifier sticker, identification of site, wound measurement, and name of person taking the photo. There was no documented evidence the document was fully completed and that Patient 1’s wounds were properly assessed. An interview was conducted on January 3, 2025, at 2:44 p.m., with the CQO. The CQO stated the wound progress notes sheet should have been filled out in its entirety to document the wound and the photographs of the wound should have been clear so patient information could be read, indicating the date and time of when the photograph was taken, the size of the wound, the anatomical guide, and the signature of the nurse who took the photograph. The CQO further stated the registered nurse did not follow the facility’s policy and procedure. 2b. A review of Patient 2’s medical record was conducted on January 2, 2025, at 3:05 p.m., with the CQO. A facility document titled, “H&P,” dated December 14, 2024, indicated Patient 2 was admitted to the facility on December 14, 2024, for wound debridement (removal of dead tissue from a wound), and had a history of diabetes (disease where the body cannot regulate blood sugar) and obesity (overweight). A double-sided facility document titled, “WOUND PROGRESS NOTES,” located in Patient 2’s record and dated December 15, 2024, at 6:51 p.m., was reviewed. The document indicated side one was used to assess a patient’s wound and side two was used to place wound photos. There was no documentation for wound assessment on side one. On side two, there were two photos of the wound which were blurry and did not clearly show Patient 2’s name, measuring device, anatomical location, patient identifier sticker, identification of site, wound measurement, and name of person taking the photo. There was no documented evidence the document was fully completed and that Patient 2’s wounds were properly assessed. A double-sided facility document titled, “WOUND PROGRESS NOTES,” located in Patient 2’s record and dated December 15, 2024, at 6:38 p.m., was reviewed. The document indicated side one was used to assess a patient’s wound, and side two was used to place wound photos. There was no documentation for wound assessment on side one. On side two, there were two photos of the wound which were blurry and did not clearly show Patient 2’s name, measuring device, anatomical location, patient identifier sticker, identification of site, wound measurement and name of person taking the photo. There was no documented evidence the document was fully completed, and Patient 2’s wounds were properly assessed. A double-sided facility document titled, “WOUND PROGRESS NOTES,” located in patient 2’s record and dated December 26, 2024, at 4:53 a.m., was reviewed. The document indicated side one was used to assess a patient’s wound, side two was used to place wound photos. There was no documentation for wound assessment on side one. On side two, there were two photos of the wound which were blurry and did not clearly show Patient 2’s name, measuring device, patient identifier sticker, wound measurement and name of person taking the photo. There was no documented evidence the document was fully completed, and Patient 2’s wounds were properly assessed. A double-sided facility document titled, “WOUND PROGRESS NOTES,” located in Patient 2’s record and dated December 26, 2024, at 5:06 a.m., was reviewed. The document indicated side one was used to assess a patient’s wound, and side two was used to place wound photos. There was no documentation of wound assessment on side one. On side two, there were two photos of the wound, however there was no documentation to show the measuring device, wound measurement and name of person taking the photo. There was no documented evidence the document was fully completed, and that Patient 2’s wounds were properly assessed. An undated double-sided facility document titled, “WOUND PROGRESS NOTES,” located in Patient 2’s record was reviewed. The document indicated side one was used to assess a patient’s wound, and side two was used to place wound photos. There was no documentation of a wound assessment on side one. On side two, there were two photos of the wound which were blurry and did not clearly show Patient 2’s name, measuring device, patient identifier sticker, wound measurement and name of person taking the photo. There was no documented evidence the document was fully completed, and that Patient 2’s wounds were properly assessed. An interview was conducted on January 3, 2025, at 3:15 p.m., with the CQO. The CQO stated the wound progress notes sheet should have been filled out in its entirety to document the wound and the photographs of the wound should have been clear so patient information could be read, indicating the date and time of when the photograph was taken, the size of the wound, the anatomical guide, and the signature of the nurse who took the photograph. The CQO further stated the registered nurse did not follow the facility’s policy and procedure. 2c. On December 31, 2024, at 10:47 a.m., a review of Patient 14’s record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, “H&P,” dated December 8, 2024, indicated Patient 14 was admitted to the facility on December 8, 2024, for abdominal pain, localized numbness, tingling, weakness. An undated double sided facility document titled, “WOUND PROGRESS NOTES,” located in Patient 14’s record was reviewed. The document indicated side one was used to assess the patient’s wound, side two was used to place wound photos. On side one there is a signature that is not legible and does not identify if the signature is a registered nurse. On side two, there were two photos of the wound. The photo on top was dated December 19, 2024, at 2300 (11 p.m.) the photo was missing the measuring tool and the body alignment tool. The second picture was missing the date and time. There was no documented evidence the document was completed, and that Patient 14’s wounds were properly assessed. An undated double sided facility document titled, “WOUND PROGRESS NOTES,” located in Patient 14’s record was reviewed. The document indicated side one was used to assess the patient’s wound, side two was used to place wound photos. On side one there is a signature that is not legible and does not identify if the signature is a registered Nurse. On side two, there were two photos of wounds. The photo on top was dated December 19, 2024, at 11 p.m., and the photo was missing the measuring tool, and the body alignment tool. The second picture was missing the measuring tool, and the body alignment tool. There was no documented evidence the document was fully completed, and that Patient 14’s wounds were properly assessed. A double-sided facility document titled, “WOUND PROGRESS NOTES,” located in Patient 14’s record and dated December 26, 2024, was reviewed. The document indicated side one was used to assess a patient’s wound, side two was used to place wound photos. On side two, there was one photo of a wound. The patient sticker was blurry and did not clearly show the patients name and physician information. The wound measuring tool, identification of site, and wound measurement were also missing. There was no documented evidence the document was completed, and Patient 14’s wounds were properly assessed. A double-sided facility document titled, “”WOUND PROGRESS NOTES,” dated December 26, 2024, was reviewed. The document indicated side one was used to assess a patient’s wound, side two was used to place wound photos. On side two, there was three photos of different wounds. On each of the three pictures the wound measuring tool was missing. There was no documented evidence the document was fully completed, and Patient 14’s wounds were properly assessed. An interview was conducted on January 2, 2025, 11:34 a.m., with the PSC. The PSC stated the wound progress notes sheet should have been completed with the assessment of the wound and the photographs of the wound should have been clear, so patient information is legible, and indicated the date and time of when the photograph was taken, the size of the wound, the anatomical guide, and the signature of the nurse who took the photograph. The PSC further stated the registered nurse did not follow the facility’s policy for wound documentation. 2d. On January 2, 2024, at 10:47 a.m., a review of Patient 15’s medical record was conducted with the PSC. A facility document titled, “H&P,” dated December 3, 2024, indicated Patient 15 was admitted to the facility on December 3, 2024, for shortness of breath. A double-sided facility document titled, “WOUND PROGRESS NOTES,” located in patient 15’s record and dated December 27, 2024, was reviewed. The document indicated side one was used to assess a patient’s wound, side two was used to place wound photos. On side one there was a signature that was not legible and did not identify if the signature was a registered Nurse, and assessment of the wound was not documented. On side two, there was one photo of a wound. The photo was dated December 27, 2024, at 12:30 p.m., the photo was missing the measuring tool and the body alignment tool. There was no documented evidence the document was completed, and Patient 15’s wounds were properly assessed. A double-sided facility document titled, “WOUND PROGRESS NOTES,” located in patient 15’s record and dated December 27, 2024, was reviewed. The document indicated side one was used to assess a patient’s wound, side two was used to place wound photos. On side one there was a signature that was not legible and did not identify if the signature was a registered nurse, and assessment of the wound was not documented. On side two, there was one photo of a wound, dated December 27, 2024, at 12:37 p.m., the photo was missing the measuring tool. There was no documented evidence the document was completed, and Patient 15’s wounds were properly assessed. An interview was conducted on January 2, 2025, at 3:08 p.m., with the PSC. The PSC stated the wound progress notes sheet should have been completed with the assessment of the wound and the photographs of the wound should have been clear, so patient information is legible, the size of the wound, the anatomical guide, and the signature of the nurse who took the photograph. The PSC further stated the registered nurse did not follow the facility’s policy for wound documentation. 2e. On January 3, 2024, at 9:50 a.m., a review of Patient 16’s record was conducted with the PSC. A facility document titled, “H&P,” dated November 25, 2024, indicated Patient 16 was admitted to the facility on November 25, 2024, for shock, and acute hypoxic respiratory failure (AHRF, body fails to adequately oxygenate the blood). A double-sided facility document titled, “WOUND PROGRESS NOTES,” located in Patient 16’s record and dated December 19, (no year) was reviewed. The document indicated side one was used to assess a patient’s wound, side two was used to place wound photos. On side one the assessment was incomplete. On side two, there was one photo of a wound. The photo was not dated and timed and had no measurement tool. There was no documented evidence the document was completed, and Patient 16’s wounds were properly assessed. A review of the facility’s P&P titled, “Skin and Wound Care,” dated May 2024, was conducted. The document indicated, “...All patients admitted to the hospital will be assessed...for any skin impairment and pressure injury...Photographs...Wound photos should be included in the medical record to support documentation....All photographs of wounds...are to be posted on the on the Wound Progress Notes form...Labeling on the photo will include...Patient’s name and medical record number...Location or site...Date and time of photograph...Healthcare provider’s initials...Orientation Guide (Align to Body Stick figure)...measuring device or tools used within the photo...Documentation...Initial Nursing Assessment will include documentation of skin assessment, Braden Scale score, and any skin impairment or injuries upon admission, and every shift in the wound flowsheet...” 2f. A review of Patient 25’s medical record was conducted on December 31, 2024, at 9:40 a.m., with the Registered Nurse Supervisor for Intensive Care Unit (RN Sup). The facility document titled, “History and Physical,” dated December 26, 2024, at 8:52 p.m., indicated, “...Admission date: 12/26/2024 [December 26, 2024] ...Chief Complaint ... Intractable right foot pain ...History of present illness ...severe left lower extremity Peripheral Artery Disease (PAD) [a common condition in which narrowed arteries reduce blood flow to the arms or legs.], hypertension [HTN] (high blood pressure)...” A review of an untitled document dated December 27, 2024, at 8:00 p.m., indicated, “...12/27/2024 20:00 [December 27, 2024, at 8 p.m.]...Pts [Patient’s] right foot is swollen and red, a small ulcer [an open sore or lesion that develops on the skin or mucous membrane] on the right big toe that has been there for 1[one] month...” During the record review, there was no documented evidence of Patient 25’s wound assessments on December 28, 2024, and December 30, 2024. A review of Patient 25’s medical record and concurrent interview was conducted on December 31, 2024, at 9:40 a.m., with the RN Sup. The RN Sup stated there were no other wound assessments after the initial assessment on December 27, 2024. The RN Sup stated the nurses are supposed to be documenting wound assessments every shift. The RN Sup further stated it is important to do wound assessments “so we can monitor the wound and the progression of the wound.” 2g. A review of Patient 26’s medical record was conducted on December 31, 2024, at 10:28 a.m., with RN Sup. The facility document titled, “History and Physical,” dated December 28, 2024, indicated, “...Admission date/time: 12/28/2024 20:37 [December 28, 2024, at 8:37 p.m.]...chief Complaint...painful bump on neck...History of present illness...DM [diabetes mellitus] [a chronic disease that affects how the body regulates blood sugar levels], hypothyroidism [a condition where the thyroid gland doesn’t produce enough thyroid hormone]...” A review of a facility untitled document dated December 29, 2024, at 8 a.m., was conducted with the RN Sup. The document indicated, “...12/2/2024 08:00 [December 27, 2024, at 8 a.m.]...Abcess in the neck, dressing clean dry and intact...” During the review of Patient 26’s medical record there was no documented evidence of wound assessments on December 30, 2024. On December 31, 2024, at 10:28 a.m., a review of Patient 26’s medical record and a concurrent interview was conducted with the RN Sup. The RN Sup stated there were no wound assessments documented on December 30, 2024. The RN Sup stated the nurses are supposed to document wound assessments every shift. The RN Sup further stated it is important to do wound assessments “so we can monitor the wound and the progression of the wound.” A review of the facility policy titled, “Skin and wound care,” revised May 2024, was conducted. It indicated, “Documentation...Initial nursing assessment will include documentation of skin assessment, Braden scale score, and any skin impairment or injuries upon admission, and every shift in the wound flow sheet...” A review of the facility’s P&P titled, “Skin and Wound Care,” dated May 2024, was conducted. The document indicated, “...All patients admitted to the hospital will be assessed...for any skin impairment and pressure injury...Photographs...Wound photos should be included in the medical record to support documentation....All photographs of wounds...are to be posted on the on the Wound Progress Notes form...Labeling on the photo will include...Patient’s name and medical record number...Location or site...Date and time of photograph...Healthcare provider’s initials...Orientation Guide (Align to Body Stick figure)...measuring device or tools used within the photo...Documentation...Initial Nursing Assessment will include documentation of skin assessment, Braden Scale score, and any skin impairment or injuries upon admission, and every shift in the wound flowsheet...” 3. On December 31, 2024, at 10:47 a.m., a review of Patient 14’s record was conducted with Patient Safety Coordinator (PSC). A facility document titled, “History and Physical,” dated December 8, 2024, indicated Patient 14 was admitted to the facility on December 8, 2024, for abdominal pain, localized numbness, tingling, weakness. A facility document titled, “Order Management,” dated December 8, 2024, was reviewed. The document indicated, “...Intake and output [I&O, the measurement of fluids and food that enters and exits the body] every shift...Start 12/8/2024 [December 8, 2024]...Stop date 12/21/2024 [December 21, 2024]...” During a review of Patient 14’s medical record there was no documented evidence of I&O’s on December 26, 2024, for the p.m. shift (7a.m. to 7p.m.), December 28, 2024, for the p.m. shift, and December 30, 2024, for the p.m. shift. An interview was conducted on January 2, 2025, 11:34 p.m., with the PSC. The PSC stated the nursing staff did not document the output on the following dates; December 26, 2024, the p.m. shift, December 28, 2024, p.m. shift, and December 30, 2024, p.m. shift. The PSC further stated the nursing staff should have completed and documented the shift totals for the Input and Output for each day at the end of shift. A facility document titled, “Intake and Output (I&O) monitoring Policy,” dated December 2024, was reviewed. The document indicated, “...Intake and output documentation will be charted and recorded every shift and totaled at the end of the twenty-four (24) hours with in the Electronic Medical Record (EMR)...Accurately measure and record all fluid output, including urine, stool, vomitus and drainage from mounds...Document the time and type of fluid intake and output on the designated I&O chart...” 4a. On January 2, 2025, at 10:45 a.m., an interview and review of Patient 20’s record was conducted with Clinical Nurse Manager (CNM). The facility document titled, “Vital Sign Report,” dated December 29, 2024, through December 31, 2024, indicated, “...Assess Date/Time: 12/29/24 [December 29, 2024] 12:28 [p.m.]...Pain Score 4...” The facility document titled, “History and Physical,” dated December 29, 2024, at 2:30 p.m. indicated, “...patient presents to the ER for evaluation of right flank pain. Patient states...right flank pain since this morning...rates it from a 2-4/10 dull ache that comes and goes...Pain: scale: Numeric: 4...Assessment/Plan: #flank pain, right side...Tylenol 500mg prn [as needed] for pain...” An untitled facility document indicated “...Order Inquiry..ACETAMINOPHEN...start date 12/29/24 [December 29, 2024] 15:19 [3:19 p.m.] Q6HPRN [every six hours as needed]...” The facility document titled, “Medication Administration Record,” dated December 29, 2024, indicated “...ACETAMINOPHEN [500mg] Oral every 6 [six] hours as needed...indication: Pain...Last Administered...” The facility document titled, “Daily Assessment Inquiry,” dated December 29, 2024, through December 30, 2024, at 3:30 p.m., indicated, “...Pain Location...Pain Scale...Pain Score...” On January 2, 2025 at 11 a.m., the CNM stated the medication administration record indicated Tylenol as needed was ordered for Patient 20, however, was never given to the patient. The CNM stated Patient 20 verbalized pain four out of ten but did not receive any medication. The CNM stated Patient 20 was only assessed for pain the one time on December 29, 2024, at 12:28 p.m. and pain should have been reassessed daily. 4b. On January 2, 2025, at 2:15 p.m., an interview and review of Patient 22’s medical record was conducted with the CNM. An untitled facility document indicated “Pain Score...Abdomen generalized...12/30/24 0006 [December 30, 2024, at 12:06 a.m.] 10...0224 [2:24 a.m.] 10...0239 [2:39 a.m.] 4...0901 [9:01 a.m.] 9...1606 [4:06 p.m.] 8...2018 [8:18 p.m.] 8...” The facility document titled, “History and Physical,” dated December 30, 2024, at 5:39 a.m. indicated, “...came to ED for abdominal pain for the last 3 [three] days. The patient says the pain radiates to [their] back. She says nothing helps with the pain...Assessment/Plan: #Gallstone Pancreatitis [DEFINE]...Dilaudid and Ketorolac given in the ED...” An untitled facility document indicated, “...Med Admin PRN [as needed]...Hydromorphone... administration...12/30/24 [December 30, 2024]... 09:03 [9:03 a.m.]...1606 [4:06 p.m.]...2019 [8:19 p.m.]...12/31/24 [December 31, 2024] 00:54 [12:54 a.m.]...” An interview was conducted on January 2, 2025, at 2: 20 p.m., with the CNM. The CNM stated if pain medications are given, the expectation would be for pain to be reassessed within an hour for oral medications, and 15 minutes for IV medications. The CNM stated for a pain score of nine, the expectation would be to offer pain medications. The CNM stated Patient 22 received pain medication on December 30, 2024, at 9:03 a.m., but the pain was not reassessed according to the facility policy. The CNM further stated Patient 22 received pain medication again on December 30, 2024, at 4:06 p.m. but pain was not reassessed according to policy. 4c. On January 2, 2025, at 2:45 p.m., an interview and review of Patient 23’s medical record was conducted with CNM. The facility document titled, “History and Physical,” dated December 29, 2024, at 9:38 p.m. indicated, “...presents to ER for evaluation of abdominal distension...currently complaining of abdominal pain, shortness of breath, and back pain...” The facility document titled “Vital Sign Report,” indicated “...Pain Score Detail...12/29/24 [December 29, 2024] 21:30 [9:30 p.m.]...pain score: 9...23:37 [11:37 p.m.] Pain Score: 9...12/30/24 [December 30, 2024] 00:37 [12:37 a.m.] Pain Score: 7...14:21 [ 2:21 p.m.] Pain Score: 8...” The facility document titled, “Medication Administration History Report,” indicated “...Scheduled...Hydrocodone-Acetaminophen...once...admin Dt/Tm [date/time] 12/29/24 23:37 [December 29, 2024, at 11:37 p.m.]...PRN...Morphine...every 4 [four] hours as needed...intravenous...admin Dt/Tm 12/30/24 03:28 [December 30, 2024, at 3:28 a.m.]...admin Dt/Tm 12/30/24 14:21 [December 30, 2024, at 2:21 p.m.]...” An interview was conducted on January 2, 2025 at 2:50 p.m., with the CNM. The CNM stated the patient’s pain was not reassessed according to the facility’s policy. The CNM stated the patient was not given pain medication on December 30, 2024, until 2:21 p.m., despite having orders for IV morphine. 4d. A review of Patient 28’s medical record was conducted on January 3, 2025, at 10:15 a.m., with the Stroke Coordinator (SC). The untitled facility document, creation date, November 27, 2024, at 9:38 p.m., was reviewed. The document indicated, “...Arrival Date: 11/27/2024 [ November 27, 2024]...Chief Complaint: Assault...reports to the ER for the evaluation of an alleged assault. Patient states she was assaulted on Sunday. She was hit twice on the left side of her ribs...she states the rib pain has been getting progressively worse as time passes. Patient denies shortness of breath, nausea, vomiting, diarrhea, constipation, sick contact, and any other symptoms...” A review of facility document titled, “[Name of Facility] Triage Report,” dated November 27, 2024, at 8:29 p.m., was conducted with the SC. It indicated, “... pt [patient] brought in by ems [Emergency Medical Services] for c.o. [complaint of] left rib pain after she got hit on Sunday by a stick. Patient states pain is getting worse...Pain assessment Score:10...” The untitled facility document, creation date, November 27, 2024, at 9:38 p.m., was reviewed with the SC. The document indicated, “...Provider contact time: 11/27/2024 21:25...she states the rib pain has been getting progressively worse as time passes...Physical Exam Narrative...chest: + tenderness along the anterior aspect of the left side of the chest...Abdomen: soft, non-distended, non-tender. No guarding no rebound No masses...” At this time the SC stated MD1 did not order any pain medicine for Patient 28 right away. SC further stated there was no documentation that pain was referred to provider when patient did not get a pain medication order right away. A review of facility document titled, “Medication Administration History Report,” was conducted with the SC. The document indicated, “...Ordering Provider: [ Name of NP]...Start Date: 11/27/2024 22:37 [November 27, 2024, at 10:37 p.m.]... Ketorolac 60 mg/2 ml...order does:30 mg/1 ml Frequency: once Route: intramuscular...Admin Dt/tm [Administration Date/time]: 11/27/2024 22:42 [November 27, 2024, at 22:42 p.m.]...Verified by [ Name of Licensed Vocational Nurse]...” On January 3, 2024, at 11:05 a.m., an interview with the Emergency Room Manager (ERM) was conducted. The ERM stated Patient 28 should have received pain medicine within an hour of arrival to the ED. A review of facility’s policy and procedure (P&P) titled “Pain Management,” revised September 2024, indicated “...Patients have the right to main management...Treatment is to be provided in a timely manner...Patients will be routinely reassessed for pain during the initial daily shift assessment, upon change of condition, after procedures known to cause pain, with new complaints, and as needed...Inpatients shall receive treatment for any active pain issue...if a treatment intervention for pain is provided, the response to that intervention should be assessed. Reassessment is recommended to occur within 15- 60 minutes following treatment (depending on the type of intervention)...” 50304”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 42512 Based on interview and record review, the medical staff failed to be continuously responsible for the policies and procedures governing medical care provided to patients, when Emergency Department (ED) staff failed to document medical screening evaluations (MSE) in the Electronic Medical Record (EMR) for two of 32 patients reviewed (Patient 4 and 12). These failures had the potential to result in a delay of patient care and adverse outcomes. Findings: A. On January 3, 2025, at 10:30 a.m., Patient 4’s medical record was reviewed with the Corporate Quality Officer (CQO). A review of the facility document titled “[Name of Facility] Triage Report,” indicated Patient 4 arrived in the emergency room on December 17, 2024, at 1:52 p.m., for a chief complaint of uterine contractions. Patient 4’s delivery due date was February 10, 2025. A review of the facility document titled, “OB Department Daily Staffing Sheet,” dated December 17, 2024, morning shift 7 a.m. to 7 p.m., and night shift 7 p.m. to 7 a.m., indicated there was no post-partum [following childbirth] nurses scheduled. During further review of Patient 4’s medical record, the CQO stated when a pregnant person comes into the ED, they would be sent to the obstetrics (OB) department [a dedicated obstetrics unit for expected mothers] for evaluation, but at this moment the OB is short staffed due to pending closure of the unit and OB patients are being seen in the ED only. The CQO stated she could not locate any physician notes for Patient 4. She further stated any patient seen in the ED should be seen and evaluated by a physician. There was no documented evidence Patient 4 received a Medical Screening Evaluation (MSE). B. On January 3, 2025, at 11:24 a.m., a review of Patient 12’s medical record was conducted with the Clinical Nurse Manager (CNM). The facility document titled, “ED Summary Report,” indicated Patient 12 was admitted to the ED on January 1, 2025, at 6:22 p.m. The document further indicated “Chief Complaint: Miscarriage...BIBA [Brought in by ambulance] Patient CO [complained of] abd [abdominal] cramping and vag [vaginal] bleeding...” During the review of Patient 12’s medical record, there was no documented evidence of ED physician notes. There was no documented evidence Patient 12 received a Medical Screening Exam (MSE) while in the emergency room on January 1, 2025. A review of the facility’s Policy and Procedure titled, “EMTALA-MEDICAL SCREENING AND STABILIZATION POLICY,” dated April 2023, indicated, “...To establish guidelines for providing appropriate medical screening examinations (“MSE”) and any necessary stabilizing treatment or an appropriate transfer for the individual...A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department...to determine whether or not an EMC [Emergency Medical Condition] exists...to any individual, including pregnant woman having contractions...””

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 50122 Based on interview and record review the facility failed to provide an on-call physician (physicians who are scheduled to provide treatment and services including consultations to patients when needed) to provide services and consultation to the patients at the Emergency Department (ED) and/or Obstetrics (OB) department. This failure resulted in an on-call physician to not be available for consult and services in the ED and/or OB for a particular specialty. Findings: On December 26, 2024, at 9:05 a.m., an unannounced visit was conducted at the facility for an EMTALA survey. On December 26, 2024, at 10:25 a.m., the facility’s “Emergency Room Specialty Call Roster”, dated December 2024, was reviewed and indicated, “No coverage” for PEDS (pediatrics) on December 23, through December 25, 2024. On December 26, 2024, at 11:15 a.m., an interview with the Chief Operating Officer (COO) was conducted. The COO stated they did not have coverage on December 23, 24, or 25, for pediatrics. The COO stated, “...they made multiple attempts to get PEDS coverage from [local staffing agency (a staffing and recruiting agency that places physicians in temporary positions at healthcare facilities) used by the facility]...” The COO further indicated the patients that required PEDS services were transferred to other facilities for treatment. The COO further indicated they were placed on diversion per Chief Medical Officer (CMO). On December 26, 2024, at 12:47 p.m., Patient 8’s medical records were reviewed with the Nursing Supervisor (NS) and Director of Quality (DOQ). 1. Patient 8’s face sheet indicated Patient 8 presented to the ED on December 25, 2024, at 3:45 p.m., with complaints of abdominal pain/contractions. Patient 8’s “ ED Department Record,” dated December 25, 2024, at 3:20 p.m., indicated Patient 8 was examined by ED MD and “...OB/GYN nurse who recommended transfer due to concerns for contractions indicative for premature labor...” Patient 8’s “Transfer Summary and Certification”, dated December 25, 2024, at 6:10 p.m., indicated, “...Benefits of Transfer...physician specialties needed are not available...” On December 27, 2024, at 10:15 a.m., a concurrent record review and interview with the COO and DOQ was conducted. The COO provided emails pertaining to on-call coverage for PEDS. A review of an email dated November 27, 2024, at 1:59 p.m., indicated, the facility administration was aware of pending no coverage for PEDS on December 23, 24, and 25, 2024. The COO stated, “they were trying to obtain coverage through [name of staffing agency company] for the dates...” On December 27, 2024, at 10:20 a.m., review of an email received by the COO dated December 10, 2024, at 12:56 p.m., indicated CMO stated, “...they did speak to [Governing board], she stated the [name of staffing agency] would not be able to support the call stipend. I explained to her that the hospital was not in the position to take this on as well. We discussed the CMS potential implications, one of which would be losing our Deemed Status, esp [especially] since we have already been sited [sic] because of coverage issues. My plan is to discuss this with [Governing Board] tomorrow, letting him know the potential consequences of not having any coverage, hopefully he will provide some direction. I know how risky this will be if we have no coverage. Will get back to the group...” On December 27, 2024, at 10:30 a.m., a review of an email dated December 10, 2024, at 10:15 a.m., from [name of staffing agency], stated, “...we have not received any candidates that we would consider. [Governing board] had spoken with [CMO] regarding this yesterday morning as well. She informed him we will not be covering those dates...” On December 27, 2024, at 10:35 a.m., an interview with the DOQ was conducted. The DOQ stated Patient 8 was transferred out of the facility due to not having Pediatrician on-call coverage for the ED or OB. On December 27, 2024, at 3:00 p.m., a review of the facility policy and procedure titled, “EMTALA - Provision of On-Call Policy,” dated April 2023, indicated, “...The Hospital Administration in consultation with the Medical Executive Committee is responsible to develop an ED On-Call Schedule via a contractual relationship with the various specialists...provisions the hospital has made for situations where the on-call physician is not available or not able to respond due to circumstances beyond his or her control...” The policy further indicated, “...Back-up Plans and Transfers...The hospital shall have in place a written plan for transfer for situations in which a particular specialty is not available...” On December 27, 2024, at 3:15 p.m., a review of the facility policy and procedure titled, “No Physician On Call Policy,” dated April 2023, indicated, “...while conducting or following an appropriate medical screening of a patient with an emergency medical condition, attending Emergency Department physician determines that the patient’s medical condition requires the services of a specialist and no such specialist is present in the Emergency Department and there is no physician on call for the particular specialty...If an appropriate alternative specialist cannot be identified...the attending Emergency Department physician...shall initiate procedures to effect an appropriate transfer to another hospital...””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 50122 Based on interview and record review, the facility failed to provide, within the capabilities of the hospital’s emergency department (ED), an appropriate medical screening examination and emergent treatment for one of 20 sampled patients (Patient 15). This failure had the potential to compromise Patient 15’s health and safety when Patient 15’s parent decided to leave without being seen by a provider. Findings: On December 26, 2024, at 9:05 a.m., an unannounced visit was conducted at the facility for an EMTALA survey. On December 26, 2024, at 2 p.m., a review of Patient 15’s record was conducted with the Nursing Supervisor (NS) and Director of Quality (DOQ). A review of Patient 15’s face sheet dated November 30, 2024, at 9:04 p.m., indicated Patient 15 came into the ED with complaints of eye pain. On December 26, 2024, at 2 p.m., a review of the facility document titled, “EDM...Triage Report,” dated November 30, 2024, indicated Patient 15 arrived with his father to the facility ED. Registered Nurse (RN) 1 note indicated, “redness swelling with white drainage. dad when [sic] to urgent care earlier for medication and has been using medication and hot compress. infection drainage causing blurry vision but patient after blinking can see. dad said swelling went down he was concerned because of drainage. dad instructed to use medication as prescribed and instructed by urgent care provider but he is more than able to stay if he is concerned. He decided to leave...” On December 27, 2024, at 12:30 p.m., a review of the facility document titled, “EDM ...Triage Report,” dated November 30, 2024, indicated the patient was not informed of risks and benefits in leaving prior to an MSE, any offer of stabilizing treatment or medical examination by a provider, notification to a physician or provider, or indicate documentation of Refusal to Permit Medical Treatment or Refusal to sign Refusal to Permit Medical Treatment form. On December 27, 2024, at 12:40 p.m., an interview was conducted with the DOQ. The DOQ stated, “... the nurse should have explained the facility’s obligation for EMTALA, risks and benefits of leaving, and needed to document discussion of this in the medical record...” The DOQ stated, she did not see any of that on the patient’s record. On December 27, 2024, at 12:35 p.m., a review of the policy and procedure titled, “EMTALA -Definition and General Requirements,” dated April 2023, indicated, “...If an individual presents to the DED [dedicated emergency department] and requests services for a medical condition, is triaged and then indicates a desire to leave prior to the MSE [medical screening exam], the facility should use its best efforts to...offer the individual further medical examination and treatment as may be required to identify and stabilize an EMC [emergency medical condition] ...discuss with the individual the risks and benefits involved in leaving prior to the medical screening and document same...ask the patient to sign the Refusal to Permit Medical Treatment form...if the individual refuses to sign ...hospital personnel should document that the Refusal to Permit Treatment form provided to the individual refused to sign the form...describe in the medical record , the examination and treatment that was refused or the request for treatment was withdrawn...””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 48776 Based on interview and record review, the facility failed to ensure the facility had an effective Governing Body when: 1. There was insufficient staffing (number of nursing staff working in a unit) on the perinatal unit (unit designated for the care of patient in labor and of the mother and the infant during and after delivery, which includes the labor and delivery unit, the postpartum unit [unit where the mother is placed after delivery of the infant], and the nursery [unit where the infant is admitted after delivery]) and the facility was unable to care for two of 31 sample patients (Patients 2 and 31) and the Governing Body was not aware (Refer to A-0083); and 2. There was no pediatrician coverage (a physician specializing in treating children who is to be called and assigned to take care of a patient when the patient did not have his own pediatrician) scheduled for two shifts and the Governing Body was not aware (Refer to A-0084). The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients in the perinatal unit, and may cause delays in the provision of patient care.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48776 Based on interview and record review, the facility failed to ensure care is provided, for three of 31 sampled patients (Patients 2, 25, and 31) with obstetrical conditions (pertains to conditions related to pregnancy and childbirth), when: 1. There was insufficient staffing (number of nursing staff working in a unit) on the perinatal unit (unit designated for the care of patient in labor and of the mother and the infant during and after delivery, which includes the labor and delivery unit, the postpartum unit [unit where the mother is placed after delivery of the infant], and the nursery [unit where the infant is admitted after delivery]) and the facilitywas unable to care for two of 31 sample patients (Patients 2 and 31) (Refer to A-0144); 2. There was no pediatrician coverage (a physician specializing in treating children who is to be called and assigned to take care of a patient when the patient did not have his own pediatrician) scheduled for two shifts (Refer to A-0144); and 3. For Patient 25, a signed informed consent was not obtained prior to a the insertion of an epidural catheter (a thin flexible plastic tube inserted into the spinal cord for administration of pain medication) (Refer to A- 0131). The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients seen at the perinatal unit, jeopardize their safety and may cause delays in the provision of their care.”

“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: 48776 Based on interview and record review, the facility failed to ensure care was provided, for two of 31 sampled patients (Patients 2 and 31) with obstetrical conditions (pertains to conditions related to pregnancy and childbirth), when: 1. There was insufficient staffing (number of nursing staff working in a unit) on the perinatal unit (unit designated for the care of patient in labor and of the mother and the infant during and after delivery, which includes the labor and delivery unit, the postpartum unit [unit where the mother is placed after delivery of the infant], and the nursery [unit where the infant is admitted after delivery]) and the facility was unable to care for two of 31 sample patients (Patients 2 and 31) (Refer to A-0392); 2. Emergency equipment and supplies at the perinatal unit and the Emergency Department were not inspected, in accordance with the facility’s policy and procedure (Refer to A-0398). The cumulative effects of these systemic failures had the potential to impact the health, safety, and treatment of the patients, and may cause delays in the provision of patient care.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 48776 Based on interview and record review, the facility failed to ensure there is an effective Governing Body, when the staffing (number of nursing staff working in a unit) on the perinatal unit (unit designated for the care of patient in labor and of the mother and the infant during and after delivery) was insufficient to care for two of 31 sample patients (Patients 2 and 31) and the Governing Body was not aware. This failure resulted in Patients 2 and 31 to not receive the necessary care in the perinatal unit and had the potential to cause harm to the patients. Findings: On November 1, 2024, at 3 p.m., an interview was conducted with the Interim Chief Nursing Officer (ICNO). The ICNO stated the facility was on “OB [obstetrics, pertaining to the care of the mother during labor and delivery) diversion [when a department is too busy to safely treat more patients and must redirect ambulances to other hospitals]” on October 31, 2024, night shift (7 p.m. to 7 a.m.) because there was not enough nursing staff scheduled to work. On November 1, 2024, at 3 p.m., a review of the facility document titled, “OB Department Daily Staffing Sheet,” dated October 31, 2024, for the night shift, was conducted. The document indicated there was a sick call in the Labor and Delivery unit (OB unit). The document indicated, “Diversion.” A facility document titled, “OB Department Daily Staffing Sheet,” dated October 17, 2024, for the day shift, was reviewed. The document indicated there were two registered nurses (RN) scheduled to work in the Labor and Delivery and there was one sick call (when a staff is sick and unable to come to work). The document indicated, “ ...Diversion ...” a. On November 4, 2024, at 10:45 a.m., Patient 2’s record was reviewed with Supervisor 1. A facility document titled, “[Facility name] ED Summary Report,” dated October 31, 2024, was reviewed and indicated, “ ...Narrative...Pt [Patient 2] 40 weeks pregnant [a full-term pregnancy], says sent by Dr. [Physician 2]...” A facility document titled, “[Facility name] Daily Focus Assessment Report,” dated October 31, 2024, at 4:25 p.m., was reviewed. The document indicated, “ ...Category Note: On arrival, OB staff stated they are preparing to go on diversion. The patient [Patient 2] says that she was at Dr. [Physician 2] office and was sent here ‘to check the baby.’ Charge nurse made aware, patient was denying complaints, no SROM [spontaneous rupture of membranes, when the sac of fluid around the infant in the uterus breaks on its own] though she said in the office Dr. [name of Physician 2] wasn’t sure if she had ruptured. She says fetal movement [movement of the infant inside the uterus] has been normal, no pain other than chronic [long term] low back pain that she had the last few weeks of pregnancy. While in triage [area in emergency department where patients are categorized and prioritized based on the severity of their illness], the patient received a phone call by Dr. [Physician 2] telling her to go directly to [name of another acute care hospital]. Patient agreed to have MSE [medical screening exam, an examination conducted by the emergency department (ED) physician] here before leaving, [Name of ED physician] saw patient in triage and was preparing to discharge her when OB staff called and said Dr. [name of Physician 2] had contacted them and wanted ‘the baby checked due to the heart rate.’ Patient was taken immediately to OB...” A facility document titled, “Detail Notes Log,” dated October 31, 2024, at 6:11 p.m., was reviewed. The document indicated, “...Comment: [name of Physician 1] discussing condition and plan of mgmt [management] of care with patient and significant other who verbalized understanding and agreement. Physician certifies patient is not in labor, fetal heart rate stable, discharge to go to [name of another acute care hospital] for further evaluation/ plans for delivery d/t [due to] this unit not staffed adequately on pm [night] shift tonight to provide care for patient...” On November 5, 2024, at 11:05 a.m., an interview was conducted with Physician 1 (the physician who examined Patient 2 at the OB unit). Physician 1 stated Patient 2 was evaluated when she arrived at the facility on October 31, 2024. Physician 1 stated because the facility was going to be on diversion at 7 p.m., and Patient 2 was not in active labor, he advised Patient 2 to drive to another facility for continued care. On November 5, 2024, at 11:30 a.m., an interview was conducted with Physician 2. Physician 2 stated Patient 2 was sent to the facility on October 31, 2024, because of her concern about premature rupture of membranes (when the sac of fluid around the infant in the uterus breaks on its own earlier than expected) and low heart tones (infant’s heart rate). Physician 2 stated the facility was going to be on diversion starting at 7 p.m. on October 31, 2024, and wanted Patient 2 to be checked prior to driving to another facility because of the time it would take to drive to another facility. Physician 2 stated there was another incident of OB diversion on October 17, 2024, when Patient 31 was scheduled for a repeat Cesarean Section (C-section, a surgical procedure to deliver a baby through incision in the mother’s abdomen] on October 17, 2024. Physician 2 stated Patient 31 arrived at the facility but the OB department was on diversion and Patient 31 had to go to another facility for the C-section. On November 6, 2024, at 10 a.m., an interview was conducted with RN 2. RN 2 stated she worked on the OB unit on October 31, 2024, from 7 a.m., until 3 p.m. RN 2 stated the OB unit went on diversion for the night shift of October 31, 2024, due to not having enough nurses scheduled to work for the night shift. RN 2 stated the OB unit also went on diversion on the day shift (7 a.m. to 7 p.m.) on October 17, 2024, due to nursing staff shortage. b. On November 6, 2024, at 9:30 a.m., a concurrent interview and review of Patient 31’s record were conducted with Supervisor 1. Patient 31’s face sheet was reviewed and indicated Patient 31 came in on October 15, 2024, for “Service: LABS [laboratory] C SECTION # [number] 3 [three].” A facility document titled, “OR [operating room] Schedule by Room,” dated October 17, 2024, was reviewed. The document indicated, “09:30-11:00 [9:30 a.m. to 11 a.m.]...[name of Patient 31]...[name of Physician 2]...PREGNANCY AT 39 WEEKS [full term pregnancy] H/O [history of] C-SECTION X 2 (two times) REPEAT...CESAREAN SECTION #3 [third C-section]...” The document indicated a handwritten line across the page and the word, “CNL [canceled].” There were no documented evidence indicating Patient 31 was notified or that arrangements were made for the patient to have the procedure at another hospital. Supervisor 1 stated there was no record for Patient 31 for October 17, 2024, since she did not have her scheduled C-section at the facility. On November 6, 2024, at 11:15 a.m., an interview was conducted with the Chief Operating Officer (COO). The COO stated the OB unit was on diversion on October 17, 2024, day shift, due to not having enough nursing staff at the OB unit and arrangements were made for Patient 31 to go to another hospital for C-section. The COO stated the patient drove to another facility for the C-section. A review of the facility policy and procedure titled, “[Facility name] STAFFING PLAN,” dated December 2023 was conducted. The policy indicated, “Labor & Delivery suite of perinatal services...1:2 [one RN assigned to two patients] or fewer active labor patients at all times...Antepartum [period of time before childbirth] patients not in active labor...1:4 [one RN assigned to four patient] or fewer at all times...Perinatal services...1:4 mother-baby couplets [a mother and her newborn being cared for together in the same room after birth] or fewer at all times...In an effort to assure there are sufficient numbers of qualified staff available to specific units, systems are developed...””

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 48776 Based on interview and record review, the facility failed to ensure there is an effective Governing Body, when the facility did not have pediatrician coverage (a physician who specialized on treating children and is to be called and assigned to take care of a patient when the patient did not have his own pediatrician) for two shifts and the Governing Body was not aware. This failure had the potential to impact the health and treatment of the patients and cause delays in patient care and treatment. Findings: On November 5, 2024, at 12 p.m., a concurrent interview and record review were conducted with the Director of Medical Staff (DMS). A facility document titled, “[Name of facility] Emergency Room [ER] Specialty Call Roster November 2024,” was reviewed and indicated Physician 3 (a pediatrician) was scheduled on call on November 5, 2024, and November 6, 2024, for pediatrics (a branch of medicine specializing in the care of patients from birth to age 18). The DMS stated there were no lapses in pediatrician coverage for the months of October and November, 2024. On November 6, 2024, at 10 a.m., an interview with RN 2 was conducted. RN 2 stated she was informed by the night shift (7 p.m. to 7 a.m.) nursery nurse that Physician 3 was not on call for November 6, 2024, and was out of the country. RN 2 stated there was no one on call for pediatrics if a newborn was delivered at the facility on November 5, 2024, night shift or November 6, 2024, day shift (7 a.m. to 7 a.m.). On November 6, 2024, at 11:15 a.m., an interview with the COO was conducted. The COO stated she was informed on November 5, 2024, at 11 a.m., by nursing staff Physician 3 was not on call for pediatrics. The COO stated there was no pediatric coverage for November 5, 2024, night shift, and November 6, 2024, day shift. A facility document titled, “SECTION VI: EMERGENCY SERVICES,” from the medical staff’s Rules and Regulations was reviewed. The document indicated, “...Specialty Backup Coverage...ER Back Up Roster... Each clinical division shall establish an emergency room back up roster which is submitted to the Medical Staff Office by the fifteenth of the month prior to the month of call. The purpose of the back up (sic) roster is to provide a schedule of those physicians who, on a rotating basis, provide on call coverage in their respective specialties. Divisions may combine their call rosters if mutually agreeable with each Division and acceptable to the Medical Executive Committee...””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48776 Based on interview and record review, the facility failed to ensure an informed consent was signed by one of 30 sample patients (Patient 25) prior to the insertion of an epidural catheter (a thin flexible catheter inserted in the spinal cord for administration of pain medication), in accordance with the facility’s policy and procedure (P&P). This failure had the potential for Patient 25 to not understand the benefits and risks related to the procedure and may jeopardize the patient’s safety. Findings: On November 4, 2024, at 1:30 p.m., Patient 25’s record was reviewed with the Quality Analyst (QA). The face sheet, dated October 13, 2024, was reviewed and indicated Patient 25 was admitted to the facility’s obstetrical unit (unit where pregnant patients are monitored and treated, and infants are delivered) on October 13, 2024, for abdominal pain and being in active labor. A facility document titled, “Detail Notes Log,” dated October 13, 2024, at 2:09 a.m., authored by Certified Registered Nurse Anesthetist (CRNA) was reviewed. The document indicated Patient 25 had an epidural catheter inserted. There was no documented evidence Patient 25 signed an informed consent for the insertion of the epidural catheter. An interview was conducted on October 6, 2024, with RN 2. RN 2 stated, “Anesthesia [a department made up of physicians who specialized in pain management] gives informed consent and then the patient signs.” RN 2 stated an informed consent should have been signed by Patient 25 prior to the insertion of the epidural catheter procedure. A review of the facility’s P&P titled, “Informed Consent,” revised September 2024, was conducted. The policy indicated, “...the hospital is required to obtain documentation of consent to hospital services and to verify that the physician has obtained informed consent as appropriate...A procedural consent form, dated, timed, and signed by the patient and witnesses by hospital staff are required for surgical invasive procedures...””

“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: 50122 Based on interview and record review, the facility failed to ensure care is provided, for two of 31 sampled patients (Patients 2 and 31) with obstetrical conditions (pertains to conditions related to pregnancy and childbirth), when: 1. There was insufficient staffing (number of nursing staff working in a unit) on the perinatal unit (unit designated for the care of patient in labor and of the mother and the infant during and after delivery, which includes the labor and delivery unit, the postpartum unit [unit where the mother is placed after delivery of the infant], and the nursery [unit where the infant is admitted after delivery]) and was unable to care for two of 31 sample patients (Patients 2 and 31) (Refer to A-0083); and 2. There was no pediatrician coverage (a physician specializing in treating children who is to be called and assigned to take care of a patient when the patient did not have his own pediatrician) scheduled for two shifts (Refer to A-0084). These failures had the potential to impact the health and treatment of the patients admitted at the perinatal unit and may cause delays in providing patient care. Findings: 1. On November 1, 2024, at 3 p.m., an interview was conducted with the Interim Chief Nursing Officer (ICNO). The ICNO stated the facility was on “OB [obstetrics, pertaining to the care of the mother during labor and delivery) diversion [when a department is too busy to safely treat more patients and must redirect ambulances to other hospitals]” on October 31, 2024, night shift (7 p.m. to 7 a.m.) because there was not enough nursing staff scheduled to work. On November 1, 2024, at 3 p.m., a review of the facility document titled, “OB Department Daily Staffing Sheet,” dated October 31, 2024, for the night shift, was conducted. The document indicated there was a sick call in the Labor and Delivery unit (OB unit). The document indicated, “Diversion.” A facility document titled, “OB Department Daily Staffing Sheet,” dated October 17, 2024, for the day shift, was reviewed. The document indicated there were two registered nurses (RN) scheduled to work in the Labor and Delivery and there was one sick call (when a staff is sick and unable to come to work). The document indicated, “ ...Diversion ...” a. On November 4, 2024, at 10:45 a.m., Patient 2’s record was reviewed with Supervisor 1. A facility document titled, “[Facility name] ED Summary Report,” dated October 31, 2024, was reviewed and indicated, “ ...Narrative...Pt [Patient 2] 40 weeks pregnant [a full-term pregnancy], says sent by Dr. [name of Physician 2]...” A facility document titled, “[Facility name] Daily Focus Assessment Report,” dated October 31, 2024, at 4:25 p.m., was reviewed. The document indicated, “ ...Category Note: On arrival, OB staff stated they are preparing to go on diversion. The patient [Patient 2] says that she was at Dr. [Physician 2] office and was sent here ‘to check the baby.’ Charge nurse made aware, patient was denying complaints, no SROM [spontaneous rupture of membranes, when the sac of fluid around the infant in the uterus breaks on its own] though she said in the office Dr. [name of Physician 2] wasn’t sure if she had ruptured. She says fetal movement [movement of the infant inside the uterus] has been normal, no pain other than chronic [long term] low back pain that she had the last few weeks of pregnancy. While in triage [area in emergency department where patients are categorized and prioritized based on the severity of their illness], the patient received a phone call by Dr. [Physician 2] telling her to go directly to [name of another acute care hospital]. Patient agreed to have MSE [medical screening exam, an examination conducted by the emergency department (ED) physician] here before leaving, [Name of ED physician] saw patient in triage and was preparing to discharge her when OB staff called and said Dr. [name of Physician 2] had contacted them and wanted ‘the baby checked due to the heart rate.’ Patient was taken immediately to OB...” A facility document titled, “Detail Notes Log,” dated October 31, 2024, at 6:11 p.m., was reviewed. The document indicated, “...Comment: [name of Physician 1] discussing condition and plan of mgmt [management] of care with patient and significant other who verbalized understanding and agreement. Physician certifies patient is not in labor, fetal heart rate stable, discharge to go to [name of another acute care hospital] for further evaluation/ plans for delivery d/t [due to] this unit not staffed adequately on pm [night] shift tonight to provide care for patient...” On November 5, 2024, at 11:05 a.m., an interview was conducted with Physician 1 (the physician who examined Patient 2 at the OB unit). Physician 1 stated Patient 2 was evaluated when she arrived at the facility on October 31, 2024. Physician 1 stated because the facility was going to be on diversion at 7 p.m., and Patient 2 was not in active labor, he advised Patient 2 to drive to another facility for continued care. On November 5, 2024, at 11:30 a.m., an interview was conducted with Physician 2. Physician 2 stated Patient 2 was sent to the facility on October 31, 2024, because of her concern about premature rupture of membranes (when the sac of fluid around the infant in the uterus breaks on its own earlier than expected) and low heart tones (infant’s heart rate). Physician 2 stated the facility was going to be on diversion starting at 7 p.m. on October 31, 2024, and wanted Patient 2 to be checked prior to driving to another facility because of the time it would take to drive to another facility. Physician 2 stated there was another incident of OB diversion on October 17, 2024, when Patient 31 was scheduled for a repeat Cesarean Section (C-section, a surgical procedure to deliver a baby through incision in the mother’s abdomen] on October 17, 2024. Physician 2 stated Patient 31 arrived at the facility but the OB department was on diversion and Patient 31 had to go to another facility for the C-section. On November 6, 2024, at 10 a.m., an interview was conducted with RN 2. RN 2 stated she worked at the OB unit on October 31, 2024, from 7 a.m., until 3 p.m. RN 2 stated the OB unit went on diversion for the night shift of October 31, 2024, due to not having enough nurses scheduled to work for the night shift. RN 2 stated the OB unit also went on diversion on the day shift (7 a.m. to 7 p.m.) on October 17, 2024, due to nursing staff shortage. b. On November 6, 2024, at 9:30 a.m., a concurrent interview and review of Patient 31’s record were conducted with Supervisor 1. Patient 31’s face sheet was reviewed and indicated Patient 31 came in on October 15, 2024, for “Service: LABS [laboratory] C SECTION # [number] 3 [three].” A facility document titled, “OR [operating room] Schedule by Room,” dated October 17, 2024, was reviewed. The document indicated, “09:30-11:00 [9:30 a.m. to 11 a.m.]...[name of Patient 31]...[name of Physician 2]...PREGNANCY AT 39 WEEKS [full term pregnancy] H/O [history of] C-SECTION X 2 (two times) REPEAT...CESAREAN SECTION #3 [third C-section]...” The document indicated a handwritten line across the page and the word, “CNL [canceled].” There were no documented evidence indicating Patient 31 was notified or that arrangements were made for the patient to have the procedure at another hospital. Supervisor 1 stated there was no record for Patient 13 for October 17, 2024, since she did not have her scheduled C-section at the facility. On November 6, 2024, at 11:15 a.m., an interview was conducted with the Chief Operating Officer (COO). The COO stated the OB unit was on diversion on October 17, 2024, day shift, due to not having enough nursing staff at the OB unit and arrangements were made for Patient 31 to go to another hospital for C-section. The COO stated the patient drove to another facility for the C-section. A review of the facility policy and procedure titled, “[Facility name] STAFFING PLAN,” dated December 2023 was conducted. The policy indicated, “Labor & Delivery suite of perinatal services...1:2 [one RN assigned to two patients] or fewer active labor patients at all times...Antepartum [period of time before childbirth] patients not in active labor...1:4 [one RN assigned to four patient] or fewer at all times...Perinatal services...1:4 mother-baby couplets [a mother and her newborn being cared for together in the same room after birth] or fewer at all times...In an effort to assure there are sufficient numbers of qualified staff available to specific units, systems are developed...” 2. On November 5, 2024, at 12 p.m., a concurrent interview and record review were conducted with the Director of Medical Staff administration (DMS). A facility document titled, “[Name of facility] Emergency Room [ER] Specialty Call Roster November 2024,” was reviewed and indicated Physician 3 (a pediatrician) was on call on November 5, 2024, and November 6, 2024, for pediatrics (a branch of medicine specializing in the care of patients from birth to age 18). The DMS stated there were no lapses in pediatrician coverage for the months of October and November 2024. On November 6, 2024, at 10 a.m., an interview with RN 2 was conducted. RN 2 stated she was informed Physician 3 was not on call for November 6, 2024, and was out of the country. RN 2 stated there was no one on call for pediatrics if a newborn was delivered at the facility on November 5, 2024, night shift (7 p.m. to 7 a.m.) or November 6, 2024, day shift (7 a.m. to 7 a.m.). On November 6, 2024, at 11:15 a.m., an interview with the COO was conducted. The COO stated she was informed on November 5, 2024, at 11 a.m., by nursing staff Physician 3 was not on call for pediatrics. The COO stated there was no pediatric coverage for November 5, 2024, night shift, and November 6, 2024, day shift. A facility document titled, “SECTION VI: EMERGENCY SERVICES,” from the medical staff’s Rules and Regulations was reviewed. The document indicated, “...Specialty Backup Coverage...ER Back Up Roster... Each clinical division shall establish an emergency room back up roster which is submitted to the Medical Staff Office by the fifteenth of the month prior to the month of call. The purpose of the back up (sic) roster is to provide a schedule of those physicians who, on a rotating basis, provide on call coverage in their respective specialties. Divisions may combine their call rosters if mutually agreeable with each Division and acceptable to the Medical Executive Committee...””

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 50122 Based on interview and record review, the facility failed to ensure care is provided, for two of 31 sampled patients (Patients 2 and 31) with obstetrical conditions (pertains to conditions related to pregnancy and childbirth), when there was insufficient staffing (number of nursing staff working in a unit) on the perinatal unit (unit designated for the care of patient in labor and of the mother and the infant during and after delivery, which includes the labor and delivery unit, the postpartum unit [unit where the mother is placed after delivery of the infant], and the nursery [unit where the infant is admitted after delivery]). This failure resulted in Patients 2 and 31 to not receive the necessary care in the perinatal unit and had the potential to cause harm to the patients and delay in the provision of patient care. Findings: On November 1, 2024, at 3 p.m., an interview was conducted with the Interim Chief Nursing Officer (ICNO). The ICNO stated the facility was on “OB [obstetrics, pertaining to the care of the mother during labor and delivery) diversion [when a department is too busy to safely treat more patients and must redirect ambulances to other hospitals]” on October 31, 2024, night shift (7 p.m. to 7 a.m.) because there was not enough nursing staff scheduled to work. On November 1, 2024, at 3 p.m., a review of the facility document titled, “OB Department Daily Staffing Sheet,” dated October 31, 2024, for the night shift, was conducted. The document indicated there was a sick call in the Labor and Delivery unit (OB unit). The document indicated, “Diversion.” A facility document titled, “OB Department Daily Staffing Sheet,” dated October 17, 2024, for the day shift, was reviewed. The document indicated there were two registered nurses (RN) scheduled to work in the Labor and Delivery and there was one sick call (when a staff is sick and unable to come to work). The document indicated, “ ...Diversion ...” 1. On November 4, 2024, at 10:45 a.m., Patient 2’s record was reviewed with Supervisor 1. A facility document titled, “[Facility name] ED Summary Report,” dated October 31, 2024, was reviewed and indicated, “ ...Narrative...Pt [Patient 2] 40 weeks pregnant [a full-term pregnancy], says sent by Dr. [Physician 2]...” A facility document titled, “[Facility name] Daily Focus Assessment Report,” dated October 31, 2024, at 4:25 p.m., was reviewed. The document indicated, “ ...Category Note: On arrival, OB staff stated they are preparing to go on diversion. The patient [Patient 2] says that she was at Dr. [Physician 2] office and was sent here ‘to check the baby.’ Charge nurse made aware, patient was denying complaints, no SROM [spontaneous rupture of membranes, when the sac of fluid around the infant in the uterus breaks on its own] though she said in the office Dr. [name of Physician 2] wasn’t sure if she had ruptured. She says fetal movement [movement of the infant inside the uterus] has been normal, no pain other than chronic [long term] low back pain that she had the last few weeks of pregnancy. While in triage [area in emergency department where patients are categorized and prioritized based on the severity of their illness], the patient received a phone call by Dr. [Name of Physician 2] telling her to go directly to [name of another acute care hospital]. Patient agreed to have MSE [medical screening exam, an examination conducted by the emergency department (ED) physician] here before leaving, [Name of ED physician] saw patient in triage and was preparing to discharge her when OB staff called and said Dr. [name of Physician 2] had contacted them and wanted ‘the baby checked due to the heart rate.’ Patient was taken immediately to OB...” A facility document titled, “Detail Notes Log,” dated October 31, 2024, at 6:11 p.m., was reviewed. The document indicated, “...Comment: [name of Physician 1] discussing condition and plan of mgmt [management] of care with patient and significant other who verbalized understanding and agreement. Physician certifies patient is not in labor, fetal heart rate stable, discharge to go to [name of another acute care hospital] for further evaluation/ plans for delivery d/t [due to] this unit not staffed adequately on pm [night] shift tonight to provide care for patient...” On November 5, 2024, at 11:05 a.m., an interview was conducted with Physician 1 (the physician who examined Patient 2 at the OB unit). Physician 1 stated Patient 2 was evaluated when she arrived at the facility on October 31, 2024. Physician 1 stated because the facility was going to be on diversion at 7 p.m., and Patient 2 was not in active labor, he advised Patient 2 to drive to another facility for continued care. On November 5, 2024, at 11:30 a.m., an interview was conducted with Physician 2. Physician 2 stated Patient 2 was sent to the facility on October 31, 2024, because of a concern about premature rupture of membranes (when the sac of fluid around the infant in the uterus breaks on its own earlier than expected) and low heart tones (infant’s heart rate). Physician 2 stated the facility was going to be on diversion starting at 7 p.m. on October 31, 2024, and wanted Patient 2 to be checked prior to driving to another facility because of the time it would take to drive to another facility. Physician 2 stated there was another incident of OB diversion on October 17, 2024. Physician 2 stated Patient 31 was scheduled for a repeat Cesarean Section (C-section, a surgical procedure to deliver a baby through incision in the mother’s abdomen] on October 17, 2024, and arrived at the facility, but the OB department was on diversion and Patient 31 had to go to another facility for the C-section. On November 6, 2024, at 10 a.m., an interview was conducted with RN 2. RN 2 stated she worked at the OB unit on October 31, 2024, from 7 a.m., until 3 p.m. RN 2 stated the OB unit went on diversion for the night shift of October 31, 2024, due to not having enough nurses scheduled to work for the night shift. RN 2 stated the OB unit also went on diversion on the day shift (7 a.m. to 7 p.m.) on October 17, 2024, due to nursing staff shortage. 2. On November 6, 2024, at 9:30 a.m., a concurrent interview and review of Patient 31’s record were conducted with Supervisor 1. Patient 31’s face sheet was reviewed and indicated Patient 31 came in on October 15, 2024, for “Service: LABS [laboratory] C SECTION # [number] 3 [three].” A facility document titled, “OR [operating room] Schedule by Room,” dated October 17, 2024, was reviewed. The document indicated, “09:30-11:00 [9:30 a.m. to 11 a.m.]...[name of Patient 31]...[name of Physician 2]...PREGNANCY AT 39 WEEKS [full term pregnancy] H/O [history of] C-SECTION X 2 (two times) REPEAT...CESAREAN SECTION #3 [third C-section]...” The document indicated a handwritten line across the page and the word, “CNL [canceled].” There were no documented evidence indicating Patient 13 was notified or that arrangements were made for the patient to have the procedure at another hospital. Supervisor 1 stated there was no record for this patient for October 17, 2024, since she did not have her scheduled C-section at the facility. On November 6, 2024, at 11:15 a.m., an interview was conducted with the Chief Operating Officer (COO). The COO stated the OB unit was on diversion on October 17, 2024, day shift, due to not having enough nursing staff at the OB unit and arrangements were made for Patient 31 to go to another hospital for C-section. The COO stated the patient drove to another facility for the C-section. A review of the facility policy and procedure titled, “[Facility name] STAFFING PLAN,” dated December 2023 was conducted. The policy indicated, “Labor & Delivery suite of perinatal services...1:2 [one RN assigned to two patients] or fewer active labor patients at all times...Antepartum [period of time before childbirth] patients not in active labor...1:4 [one RN assigned to four patient] or fewer at all times...Perinatal services...1:4 mother-baby couplets [a mother and her newborn being cared for together in the same room after birth] or fewer at all times...In an effort to assure there are sufficient numbers of qualified staff available to specific units, systems are developed...””

“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: 48776 Based on interview and record review, the facility failed to ensure crash carts (a wheeled container for medicine and equipment used during emergencies), emergency equipment, and supply logs were inspected in accordance with the facility’s policy and procedure (P&P). This failure had the potential to jeopardize patient safety and may cause delay in the provision of treatment during an emergency. Findings: 1. On November 4, 2024, at 9:25 a.m., a tour of the Obstetrics Unit (unit where care and treatment are provided to pregnant patients during labor and delivery of infants) was conducted with Registered Nurse (RN)1. On November 4, 2024, at 9:30 a.m., a record review was conducted with RN 1. A facility document titled, “Daily Crash Cart Check,” dated November 2024, was reviewed. There was no documented evidence inspection of the following items listed on the document was conducted on November 2, 2024: if pharmacy drawer is sealed, defibrillator (an apparatus used to control heart fibrillation by the application of an electric current to the chest wall and the heart) was plugged in a red plug (an emergency backup power outlet which is used to power critical equipment during a power outage), if the battery charge is on, watt check (a test to ensure that the wattage testing dose on defibrillator machine is properly working, paper (paper used to print the heart rate and rhythm from the defibrillator) supply, if the board (a rigid board used during chest compressions when the heel of the palm is pushed towards the chest) is present, if the oxygen tank is half full, lead wires (essential devices used to connect the patient to a heart monitoring equipment), pads (equipment used to provide an electric shock to the heart), bag valve mask (BVM, equipment to establish airway to help in breathing) airway, and the first expiration date of medications. A facility document titled, “Nov [November] 2024 Preeclampsia [a potentially serious condition involving persistent high blood pressure and signs of liver or kidney damage which occurs during pregnancy or after giving birth] Box,” was reviewed. The document indicated, “ ...Diversion [when a department is too busy to safely treat more patients and must redirect ambulances to other hospitals] ...,” on November 2, 2024. There was no documented evidence the lock numbers and expiration date of the preeclampsia box were inspected on November 2, 2024. A facility document titled, “Nov 2024 Hemorrhage [loss of blood from a damaged blood vessel] Box,” was reviewed. The document indicated, “ ...Diversion ...,” on November 2, 2024. There was no documented evidence the lock number and expiration date of the hemorrhage box were inspected. A facility document titled, “[Facility Name] OB [a branch of medicine which specialize in the care of the pregnant patient before, during, and after the delivery of the infant] NORMAL QUALITY CONTROL LOG,” dated November 2024, was reviewed. The document indicated, “ ...Diversion ...,” on November 2, 2024. There was no documented evidence the daily quality control check for urine dipstick (a thin plastic strip with chemical patches that changes color when dipped into a urine sample to indicate the presence of certain substances) was conducted on November 2, 2024. A facility document titled, “Hemorrhage Cart Checklist,” dated November 2024, was reviewed. The document indicated, “ ...Diversion ...,” on November 2, 2024. There was no documented evidence the expiration date and lock number of the hemorrahge cart were inspected on November 2, 2024. A facility document titled, “Stop & [and] Drop Box [emergency medications used during an emergency during childbirth],” dated November 2024, was reviewed. The document indicated, “...Diversion...,” on November 2, 2024. There was no documented evidence the lock number and expiration date of the Stop and Drop box were inspected on November 2, 2024. A facility document titled, “Infant Warmer [an equipment used to maintain a newborn’s body temperature] Check ...LD [labor and delivery] # [number]1 [one],” dated November 2024, was reviewed. There was no documented evidence inspection of the following items was conducted on November 1, 2024, November 2, 2024, and November 3, 2024: regular and premature (infants born before 37 weeks of pregnancy) sized bag and mask (a handheld device used to assist in breathing and provide oxygen to a patient), oxygen connection and tubing, oxygen tank if full, stethoscope (a medical device used to listen to heart sounds), suction (an equipment used to remove solid and liquid substances from a patient), bulb syringe (a device used to suction liquid substances from a patient), and intubation (a procedure to establish an airway to allow a person to breathe by inserting a flexible plastic tube in the airway) tray. A facility document titled, “Infant Warmer Check...LD #2 [two],” dated November 2024, was reviewed. There was no documented evidence inspection of the following items was conducted on November 1, 2024, November 2, 2024, and November 3, 2024: regular and premature sized bag and mask, oxygen connection and tubing, oxygen tank if full, stethoscope, suction, bulb syringe, and intubation tray. A facility document titled, “Infant Warmer Check...LD #3 [three],” dated November 2024, was reviewed. There was no documented evidence inspection of the following items was conducted on November 1, 2024, November 2, 2024, and November 3, 2024: regular and premature sized bag and mask, oxygen connection and tubing, if oxygen tank was full, stethoscope, suction, bulb syringe, and intubation tray. 2. On November 4, 2024, at 9:50 a.m., a tour of the Emergency Department (ED) was conducted with RN 1. On November 5, 2024, at 9:50 a.m., a record review was conducted with RN 1. A facility document titled, “Infant Warmer Check...ED,” dated November 2024, was reviewed. There was no documented evidence inspection was conducted for the following items on November 1, 2024, November 2, 2024, and November 3, 2024: regular and premature sized bag and mask, oxygen connection and tubing, oxygen tank if full, stethoscope, suction, bulb syringe, and intubation tray. A facility document titled, “Infant Warmer Check...OR [Operating Room],” dated November 2024, was reviewed. There was no documented evidence inspection was conducted for the following items on November 1, 2024, November 2, 2024, and November 3, 2024: regular and premature sized bag and mask, oxygen connection and tubing, oxygen tank if full, stethoscope, suction, bulb syringe, and intubation tray. A facility document titled, “OB UNIT ORIENTATION,” was reviewed. The document indicated, “...Competency Requirements Returned to Supervisor Labor and Delivery...Area of Review...Tour of Labor & Delivery...crash cart open & review...Area of Review...Tour of Nursery & Mother/Baby Rooms...Infant Warmers...Neonatal [relating to newborn children] Crash Cart...Labor and Patient Management...Logbooks: Triage/Observation, Delivery, and Nursery...,” should be completed. A facility document titled, “Newborn Nursery Competency for Post-Partum [period after the infant was delivered by the patient] and Labor and Delivery,” was reviewed. The document indicated, “...the staff member must be able to demonstrate the knowledge and skills necessary to provide care based on physical, psychosocial, educational, safety, and related criteria appropriate to the age of the patients served in his/her assigned service area...Validation to be completed by co-worker with minimum of equivalent licensure and/or supervisor/manager...Demonstrates a working knowledge of emergency equipment and documents: 1. Is familiar with location & function of emergency supplies 2. Is able to set up intubation equipment 3. Checks emergency equipment and documents appropriately 4. Neonatal/Pediatric (relating to the branch of medicine dealing with children) & Adult Crash Carts...” An interview was conducted on November 4, 2024, at 9:20 a.m., with RN 1. RN 1 stated the daily logs are completed by any staff working on the unit for the day. RN 1 stated the signature on the log indicated inspection of the specific item or equipment that is marked on the log. RN 1 further indicated staff from a sister facility came to the facility to work due to the facility not having staff to work in the perinatal unit. RN stated the staff from the sister facility was not given orientation in the unit. RN 1 stated she did not know why some logs indicated “Diversion” on November 2, 2024. RN 1 stated, “The logs should have been completed and the equipment should have been inspected by the staff.” An interview was conducted on November 4, 2024, at 1:25 p.m., with the Chief Operating Officer (COO). The COO stated, “Logs should not say Diversion, we had staff. It was a mistake.” The COO further stated, “[Name of sister facility] staff that worked in the perinatal unit already had competencies but did not get orientation to the unit.” An interview was conducted on November 6, 2024, at 2:30 p.m., with RN 2. RN 2 stated, “Orientation packet states the check boxes and logs are listed there and the staff sign that they are completed.” RN 2 stated the charge nurse is ultimately responsible for the completion of the logs. She stated the reason the logs were not completed on November 2, 2024, is because the staff who worked in the unit on that date was from another facility and was not given orientation to the perinatal unit. A facility P&P titled, “...Policy and Procedure...Crash Cart,” was reviewed. The P&P indicated, “...Verification of the contents of the crash cart is to be checked according to the following...All twenty-four (24) hour nursing units are to do crash cart checks once a day by Licensed Nurse or designated licensed personnel ...Verification of completing the crash cart checklist will be documented on the Crash Cart Check form...” A facility P&P titled, “...Policy and Procedure Resuscitation [the process of reviving someone from unconsciousness or apparent death] of the Newborn At Deliver [sic],” was reviewed. The P&P indicated, “...Appropriate staff and equipment for resuscitation will be provided at all births...The Nursery Nurse is responsible for ensuring completeness of the neonatal crash cart...The neonatal crash cart and resuscitation equipment will be checked for presence at infant resuscitation warmer and proper functioning at the beginning of every 12 hour shift and prior to each delivery. This equipment check will be documented on the Neonatal Crash Cart Checklist daily and the neonatal resuscitation warmer supply list every shift...””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 34933 Based on interview and record review, the facility failed to ensure the facility had an effecttive Governing Body, when Normal Saline (a type of fluid) with 20 milliequivalents (unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, during a rapid response (a hospital code when a group of healthcare professionals are called to a patient’s bedside to provide immediate care when a patient’s condition is unstable or they are critically ill) for one of 30 sample patients (Patient 13), for Patient 13’s high potassium level, and the Governing Body was not aware of the medication error (Refer to A-0083). The cumulative effect of this deficient practice resulted in Patient 13 to have more elevated potassium levels and may have resulted in delay of Patient 13’s recovery and could have contributed to the deterioration of Patient 13’s medical condition and subsequent death.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure medication was given as ordered, for one of 30 sample patients (Patient 13), when Normal Saline (a type of fluid) with 20 milliequivalents (unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, during a rapid response (a hospital code when a group of healthcare professionals are called to a patient’s bedside to provide immediate care when a patient’s condition is unstable or they are critically ill) for Patient 13’s high potassium level (Refer to A-0144). The cumulative effect of this failure resulted in Patient 13 to have more elevated potassium levels and may have resulted in delay of Patient 13’s recovery and could have contributed to the deterioration of Patient 13’s medical condition and subsequent death.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 35056 Based on interview and record review, the facility failed to ensure there is a functioning Quality Assessment and Performance Improvement process, when Normal Saline (a type of fluid) with 20 milliequivalents (mEq, unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, during a rapid response (a hospital code when a group of healthcare professionals are called to a patient’s bedside to provide immediate care when a patient’s condition is unstable or they are critically ill), for one of 30 sample patients (Patient 13), for Patient 13’s high potassium level, and this incident was not reported to and tracked by the facility (Refer to A-0286). The cumulative effect of this deficient practice resulted in Patient 13 to have more elevated potassium levels and may have resulted in delay of Patient 13’s recovery and could have contributed to the deterioration of Patient 13’s medical condition and subsequent death, and may negatively affect the treatment and safety of the patients in the facility.”

“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: 42512 Based on interview and record review, the facility failed to ensure patient care is provided to warrant the safety and well-being of the patients when: 1. Licensed Vocational Nurse (LVN) 1 was not supervised by a registered nurse (RN) when performing initial assessments of wounds and staging pressure injuries (wounds caused by pressure on body areas), for two of 30 sampled patients (Patients 26 and 30) (Refer A0395); 2. For Patients 1, 2, 18, 19, and 24, pain assessment was not completed before and after pain medication administration. In addition (Refer A 0398); 3. For Patients 1 and 30, wound assessments and photographs were not completed (Refer A 0398); 4. For Patients 17 and 28, the assessment for the patient’s intake and output (I&O, the measurement of the fluids that enter the body and the fluids leave the body in a 24-hour period) were not completed (Refer A 0398); and 5. For Patient 13, IV fluid medication was not given as ordered, for one of 30 sample patients (Patient 13), when Normal Saline (a type of fluid) with 20 milliequivalents (mEq, unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, during a rapid response (a hospital code when a group of healthcare professionals are called to a patient’s bedside to provide immediate care when a patient’s condition is unstable or they are critically ill) for Patient 13’s high potassium level (Refer A 405). The cumulative effect of these facility failures had the potential for the patients’ safety and well-being to be at risk, inadequate pain management, and increase the risk for pressure injuries, and may have contributed in delay in recovery and deteriorating of medical condition and subsequent death of Patient 13.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 42512 Based on observation, interview, and record review, the facility failed to ensure the environment was maintained in such a manner that the safety and well-being of patients are assured, when: 1. The equipment in the kitchen area was observed to have black grime build-up, grease, food particles, and thick yellow/gray matter in the grease container (a metal compartment that holds grease from grill) of a gas range (Refer to A-0701); 2. Multiple medical equipment used for patients on Unit A were observed to be broken, unavailable for patients’ use, and not sent for repairs (Refer to A-0701); and, 3. Empty food containers and recyclables were observed stored under the sink in the nutrition/medication room on Unit B (Refer to A-0701). The cumulative effect of these facility failures had the potential for the safety and well-being of the patients adittd at the facility to be at risk and had the potential to cause a kitchen fire and/or provide harborage for rodents, which could contaminate the food and cause food-borne illness to medically compromised patients who received food from the kitchen, and for equipment to not be available for patient’s use.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 35056 Based on interview and record review, the facility failed to ensure there is a functioning Quality Assessment and Performance Improvement process, when Normal Saline (a type of fluid) with 20 milliequivalents (mEq, unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, for one of 30 sample patients (Patient 13), and this incident was not reported to and tracked by the Quality Department and the Governing Body was not aware of the medication error. This failure resulted in Patient 13 to have more elevated potassium levels and may have resulted in delay of Patient 13’s recovery and could have contributed to the deterioration of Patient 13’s medical condition and subsequent death, and had the potential for further medication errors to occur, and may negatively affect the treatment and safety of the patients in the facility. Findings: On October 23, 2024, at 1:45 p.m., a review of Patient 13’s record was conducted with the Stroke Coordinator (SC). The facility document titled, “History and Physical,” dated September 30, 2024, at 5:34 a.m., was reviewed and indicated Patient 13 was admitted to the facility on September 29, 2024, with diagnoses which included abdominal pain, nausea, vomiting, and diarrhea with blood in the stool. The document indicated Patient 13’s potassium level was 4.7 mEq/L (milliequivalent per liter, unit of measurement, normal value 3.5-5.1 mEq/L). A facility document titled, “Progress Notes Report,” dated October 1, 2024, at 12:55 p.m., was reviewed and indicated, “...received call from lab [laboratory] around 11 am that pt’s [Patient 13] glucose [blood sugar level] was 10 [normal is 70 to 100 milligrams per deciliter, mg/dL, unit of measurement]...did another finger poke test on both fingers. Reading was too low foor [sic] glucometer [a handheld device which measures blood sugar level] to read. Called primary [physician] who ordered d50 [dextrose 50%, a type of IV fluid] push [a process of introducing a medication or fluid substance directly into the bloodstream via the venous system] and d10 [sic] at 60ml/hr [milliliter per hour, rate at which a drug is administered, unit of measurement]. called a rapid response [when a group of health care professionals are called to a patient’s bedside to assess and treat a patient who is showing signs of clinical decline], team arrived, see mar [medication administration record] and rapid [response] sheet for meds medication] given. Pt moved to ICU [intensive care unit, unit for critically ill patients]...” A facility document titled, “RAPID RESPONSE TEAM RECORD,” dated October 1, 2024, at 11:17 a.m., was reviewed. The document indicated, “...REASON FOR CALL...LOW GLUCOSE...10 PER LAB...MEDICATIONS...IV NS BOLUS [a type of fluid administered rapidly] 250 [milliliter]...OUTCOME...TRANSFERRED TO ICU...SITUATION...BS [blood sugar] 10 [mg/dl, milligrams per deciliter, unit of measurement, normal is 70 to 110 mg/dl]- D50 given blood sugar accucheck [point of care determination of blood sugar] still says 52 and pt [Patient 13] was unresponsive...” A facility document titled, “[Name of facility] Discharge Summary Report,” was reviewed and indicated, “...Date Oct 1 [October 1, 2024]...Time 1000 [10 a.m.] Potassium 6.6...H [high]...Reference Range...3.5-5.1...meg/L [unit of measurement]...Date Oct 1...Time 1342 [1:42 p.m.]...Potassium 5.9...H...Date Oct 1...Time 2030 [8:30 p.m.]...Potassium 6.4...H...” The document also indicated on October 1, 2024, Patient 13’s glucose were as follows on the following times: - at 10:55 a.m., < [less than] 10...Reference Units 70-110 MG/DL; - at 11:01 a.m., < 10 MG/DL; - at 11:09 a.m., < 10 MG/DL; - at 11:12 a.m., <10 MG/DL; - at 11:17 a.m., 103 MG/DL; - at 11:28 a.m., 92 MG/DL; - at 12:45 p.m., 47 MG/DL; - at 1:06 p.m., 163 MG/DL; - at 1:41 p.m., 121 MG/DL and, - at 8:07 p.m., 42 MG/DL; A facility document titled, “Medication Administration History Report,” dated September 9, 2024, at 12 a.m., through October 2, 2024, at 11:59 p.m., was reviewed. The document indicated the following: - “...Medication: DEXTROSE 50% IN WATER (D50W) 25GM [gram, unit of measurement]/50 ML...Order Dose 25 GM/50ML...Frequency: ONCE...Route: INTRAVENOUS...Indications: Hypoglycemia [low blood sugar]...Sched Dt/TM [Scheduled Date/Time] 10/01/2024 [October 1, 2024] 11:08 [a.m.] Admin Dt/Tm [Administered Date/Time] 10/01/2024 11:08 a.m...Charted Dt/Tm [Date/Time] 12:54 [p.m.] Adm [Administered] Dose 25 GM/50 ML...Route INTRAVENOUS...Note: glucose 10; - ...IV Dextrose 10% WATER D-10%...Order Dose: 1000 ML...Route...Intravenous...Rate 60 ML/HR...Start Date: 10/01/2024 12:00 [p.m.]; - “...Medication: DEXTROSE 50% IN WATER (D50W) 25GM/50 ML...Order Dose 25 GM/50ML...Frequency: AS NEEDED...Route: INTRAVENOUS...Start Date: 10/01/24...Indications: Hypoglycemia...Admin Dt/Tm 10/01/2024 20:52 [8:52 p.m.]...Charted Dt/Tm (Date/Time) 10/01/2024 20:52 [8:52 p.m.] Adm Dose 25 GM...Route INTRAVENOUS...” A facility document titled, “Name of Facility CODE BLUE [a hospital code for a person needing to be revived] RECORD,” dated October 2, 2024, at 9:25 a.m., was reviewed. The document indicated, “...REASON CODE [code blue] INITATED...Lost Pulses...0925 [9:25 a.m.]...Code Started...0935 [9:35 a.m.]...Compressions Stopped...” A facility document titled, “All Discrepancies Report,” dated October 24, 2024, at 12:04 p.m., indicated, “...[Unit B]...IV DEXTROSE 10% WATER 1000 ML...Beg [beginning] 1...End...2...Transaction Type...Count Inventory...[Unit B]...10/1/24 23:32 [11:32 p.m.]...IV NACL [sodium chloride, salt] 0.9 % w/ KCL 20 MEQ/L 1000 ML (POTASSIUM CHLORIDE IN 0.9%NACL)(1000 mL)...Beg...5 [five]...End...4 [four]...Transaction Type...Count Inventory...” [There was an extra bag of D10W and one IV bag of NS with 20 mEq/l of potassium was removed from the Pyxis.] There was no documented evidence D10 Water was scanned [process of scanning the patient’s identification bracelet and the medication label using a handheld device prior to administering the medication to the patient) as administered to Patient 13. There was no documented evidence of medication Dextrose 10% at 60 ml/hr was administered to Patient 13 on October 1, 2024, during the rapid response on October 1, 2024, at 11:17 a.m. During a concurrent interview with the SC, the SC stated the D50 25gm.50 ml IV fluid was taken from the Pyxis (an automated medication dispensing system) on October 1, 2024, for an emergent low blood sugar. The SC stated this IV fluid was an override (a process which allows staff to dispense medication without a pharmacist reviewing the order, usually in an emergency). The SC stated D10 Water was not scanned as administered for Patient 13. He further stated the policy is to scan the medication prior to administration to ensure the right medication is being administered. He stated if the medication was given during a rapid code or code blue and not scanned due to emergency, the staff would have documented the medication on the code sheet, and it was not. He stated the staff did not follow policy. The SC stated Patient 13 expired during the code blue on October 2, 2024, at 9:35 a.m. He further stated the low glucose at 8:07 p.m., was an indication patient was not receiving D10 per physician’s orders. The SC stated Patient 13’s low blood sugar on October 1, 2024, at 8:52 p.m., could have been due to the administration of the wrong IV fluid. On October 23, 2024, at 3:56 p.m., an interview was conducted with Nursing Supervisor (NS) 1. NS 1 stated, on October 2, 2024, Staff 4 reported to her that D10 was not hung and administered to Patient 13 in accordance with the physician’s orders and instead “Normal Saline with something else” was administered during the rapid response on October 1, 2024, but she (NS 1) did not try to find the IV bag. NS 1 stated Staff 4 reported the IV fluid with “something else” had a pink sticker labeled with D10. On October 23, 2024, at 4:15 p.m., an interview was conducted with Staff 1. Staff 1 stated, on October 1, 2024, the laboratory called to report a blood sugar of 10 for Patient 13. Staff 1 stated a rapid response code was called on October 1, 2024. Staff 1 stated the physician was called and he ordered D50 to be administered by IV push and D10 at a slow rate to maintain Patient 13’s blood sugar. Staff 1 stated NS 1 assisted in hanging fluids which were administered during the rapid response. Staff 1 stated the normal process is to label any fluid being hung with a pink sticker identifying the type of IV fluid, the date and time it was hung, and the name of the staff who hung the medication. Staff 1 stated he could not recall who hung the NS with 20 mEq/l of potassium IV fluid during the rapid response on Patient 13. Staff 1 stated the Pyxis does not require staff to scan a medication after it is taken out of the machine. He stated a medication was only scanned at the patients’ bedside after scanning the patients arm band. Staff 1 stated the facility did not inform him of any medication error (wrong IV fluid administered to Patient 13) prior to this interview. On October 23, 2024, at 4:45 p.m., an interview was conducted with NS 1. NS 1 stated after a report of a medication error, an investigation would be started. NS 1 stated she spoke to Staff 1 and Staff 5. She stated she was not able to pinpoint who administered the NS with 20 mEq/l of potassium IV fluid during a rapid response code on October 1, 2024. NS 1 stated the Pyxis did not require staff to scan the medication after it is pulled from the Pyxis machine. She stated she was not aware medications could be scanned at the Pyxis. NS 1 stated she did not report the incident of the wrong IV fluid administered to Patient 13 to the Quality department or to the Risk department. She stated the medication error would be considered an adverse or an unusual event and she was not aware if it had been reported to California Department of Public Health (CDPH, a state agency). On October 23, 2024, at 5:02 p.m., an interview was conducted with Staff 3. Staff 3 stated pharmacy staff scans the medications when loading them into the Pyxis. She stated the Pyxis has the capability to require medications be scanned after being removed from the machine prior to closing the drawer but this feature has not been activated at this facility. Staff 3 stated D10 was not scanned at the Pyxis nor when it was to be administered to Patient 13. Staff 3 stated the pharmacy department completed an inventory of the fluids on Unit B and the inventory indicated the Pyxis on Unit B was short one bag of NS with 20 mEq of potassium with one extra bag of D10. Staff 3 stated when the wrong medication was pulled there would be a discrepancy of both medications, with one missing and one having an extra bag. Staff 3 stated during the Code Blue, Patient 13’s blood sugar was 47 which would have indicated D10 was not actually being given. Staff 3 stated she was not told of the medication error but was alerted through the internal reporting system. Staff 3 stated she did not report the incident to anyone and she just answered the internal reporting system [a facility system filled out by the facility staff to report medication error]. On October 23, 2024, at 5:34 p.m., an interview was conducted with Staff 4. Staff 4 stated he received report from a day shift nurse and was told Patient 13 had a rapid response on Unit B and was on D10 at 60 ml/hr. Staff 4 stated at about 8 p.m., he entered Patient 13’s room and observed an IV fluid running at 60 ml/hr. He stated he followed the IV line and observed the line going to a medication fluid bag with a handwritten pink label which indicated D10, but noted that the IV medication bag read NS+20K (Normal Saline with 20 mEq of potassium). Staff 4 stated he stopped the medication but the bag was half empty, with about 500 ml left in the IV bag. Staff 4 stated he called Physician (P) 2 to inform him of the medication error. Staff 4 stated he completed a blood sugar check and Patient 13’s blood sugar was low. He stated P 2 ordered D50 and D10. Staff 4 stated labs were drawn, and Patient 13’s potassium level was now 6.4 [mEq/l]. Staff 4 stated he reported the medication error to the charge nurse, through the internal reporting system, and to NS 1. Staff 4 stated he informed NS 1 the IV bag of NS with 20 mEq/l of potassium was outside of the room in the blue bin. Staff 4 stated he offered to look for it, but NS 1 told him no. Staff 4 stated NS 1 did not attempt to look for the medication bag. On October 24, 2024, at 11:26 a.m., an interview was conducted with Staff 5. Staff 5 stated the process for receiving a new patient into the ICU was to receive report, verify the IV fluids that are being administered to the patient, and verify the medications the patient came with. Staff 5 stated he was told Patient 13 had D10 running at 60 ml/hr from the rapid response. He further stated he did see a pink sticker labeled D10. He stated the patient’s IVs were not working. He stated after Patient 13 arrived, the lab called, and a code sepsis [a life-threatening infection] was called. Staff 5 stated this was when code blue was called and Patient 13 was intubated [when a flexible tube is inserted in the airway to assist in breathing], and this was why the fluids had not been verified. Staff 5 stated he spoke to Staff 4 regarding the medication error. He stated they discussed the elevated potassium lab draw and was informed the IV bag labelled D10 was actually NS with 20 mEq of potassium. He stated if the patient would have received the D10 as ordered it would have helped with the low blood sugar and the high potassium. Staff 5 stated he had spoken to pharmacy staff regarding the Pyxis having the capability to scan medications when removing them but was told the facility does not pay for that functionality. On October 24, 2024, at 1:20 p.m., an interview was conducted with Staff 6. Staff 6 stated Patient 13 was transferred to the ICU with a bag of fluids with a pink label indicating D10 from the rapid response but did not verify what the content of the IV medication bag was. On October 24, 2024, at 2:27 p.m., an interview was conducted with P 1 who stated he ordered D10 for a low blood sugar. He stated he ordered Kayexalate (a medication to help bring potassium levels down) to bring down patient potassium as it was high. P1 stated Patient 13 was not able to take medication orally. He stated the purpose of the D10 was for low blood sugar and high potassium. He stated, “maybe during the rapid [response], they screwed up” and gave her NS +20K and not the D10. P1 stated he was informed of the medication error after the code blue. P1 stated he informed family of the code [blue] but did not inform family of the medication error. A review of the policy and procedure (P&P) titled, “MEDICATION ERROR REPORTING,” dated August 2021, was conducted. The P&P indicated, “...To describe the procedures for reporting a medication error and the mechanism for multi-disciplinary review to allow appropriate follow-up, education and continuous quality improvement to promote a medication error-free environment and prevent the reoccurrence of the same error...Medication errors are captured through many mechanisms...review of adverse drug reactions, review of abnormal lab values...All medication errors that resulted in the patient receiving the medication shall be reported immediately to the prescribing or primary physician and appropriate actions, documentations and reporting completed...The patient and/or family, as appropriate, shall be notified following the hospital disclosure policy...As soon as possible but no more than five business days from the event, an investigation and review of the medication error shall be done by the appropriate department...when a medication error occurs and the event reached the patient...An entry of the medication given, any adverse effects observed and actions taken are recorded appropriately in the patient’s medical record...The patient and/or family are notified according to the hospital disclosure policy...The event is reported via the Safety & Risk Management (SRM) Reporting System...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed...Upon notification of the error, the pharmacist will investigate the error...The Director of Pharmacy shall discuss with the individual who made the error the ramifications of such mistake and develop an action plan to help prevent future occurrence...” A review of the P&P titled, “ADVERSE EVENT/SENTINEL EVENT REPORTING AND ROOT CAUSE ANALYSIS,” dated January, 2022 indicated, “...A Sentinel Event...is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, severe harm...or permanent harm...A patient death or serious disability associated with a medication error, including, but not limited to, an error involving the wrong drug...An adverse event...that cause the death or serious disability of a patient...The facility shall inform the patient or the party responsible for the patient of the adverse event by the time the report is made...The department shall review Section 7073 of Title 22 of the California Code of Regulations requiring hospitals to report “unusual occurrences”...defines incidents as any event, occurrence or circumstance that is not consistent with the routine care and expected course of treatment...Reporting of...CDPH reportable occurrences will be completed electronically...will notify California Department of Public Health within 5 days of a non-emergency/non-urgent event and within 24 hours if the event is ongoing urgent/emergent threat to the welfare, health or safety of patients...” A review of the P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES,” dated November 2022, indicated, “...to establish the rights that each patient...has pertaining to their care...Receive information about their health status...course of treatment...including unanticipated outcomes...Receive care in a safe setting...” A review of the P&P titled, “MEDICATION ERROR REPORTING,” dated May 2018, indicated, “...definition of a medication error is “any preventable medication-related event that my cause or lead to inappropriate use or patient harm while the medication is in the control of the healthcare professional...All medication errors that resulted in the patient receiving the medication shall be reported immediately...and reporting completed...As soon as possible, but no more than (five) business days from the event, an investigation and review of the medication error shall be done. By the appropriate department...For medication errors...that resulted or have the potential for resulting in serious consequences, methods such as a Root Cause Analysis...shall be used to gain insight into the actual/potential error in an effort to reduce future occurrence within the hospital...The patient and/or family is notified...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed...” A review of the P&P titled, “PYXIS ENTERPRISE SERVER (ES) GUIDELINES FOR USE,” dated May 2024, indicated, “...To establish best practices for the utilization of the Pyxis Enterprise Server (ES) medical devices as a medication storage, security, dispensing and charging system approved medications and controlled substances; to establish quality controls to assure proper usage of both hardware and software components...the patient can be selected by searching under ‘All Available Patients’ or ‘My Patients’...After selecting the patient, select “Remove”, which will display medications Due Now...Select the medication...from the list to remove, follow any required prompts...remove the medication, then close the pocket and drawer...” A review of the P&P titled, “HAND-OFF COMMUNICATION,” dated September 2024, indicated, “...’Handoff’ communication will take place whenever there is a change in the patient’s...caregivers. Caregivers include all clinical staff and physicians...communication shall include...Situation...Vital signs...Background...History...Assessement...labs...medciations...When physicians and nurses are transferring patients/clients/residents to another level of care within or outside of the organization...Caregivers shall give a “Bedside Shift Report”...using SBAR format...in a clean and concise manner...Information provided during hand-off communications will include...Summary of the patient’s...current physical...health condition including...Current medications...IVs present...Recent...changes in the patient’s...condition...””

“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: 42512 Based on interview and record review, the facility failed to ensure medication was given as ordered, for one of 30 sample patients (Patient 13), when Normal Saline (a type of fluid) with 20 milliequivalents (unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, during a rapid response (a hospital code when a group of healthcare professionals are called to a patient’s bedside to provide immediate care when a patient’s condition is unstable or they are critically ill) for Patient 13’s high potassium level. This failure resulted in Patient 13 to have more elevated potassium levels and may have resulted in delay of Patient 13’s recovery and could have contributed to the deterioration of Patient 13’s medical condition and subsequent death, and had the potential for further medication errors to occur, and may negatively affect the treatment and safety of the patients in the facility. Findings: On October 23, 2024, at 1:45 p.m., a review of Patient 13’s record was conducted with the Stroke Coordinator (SC). The facility document titled, “History and Physical,” dated September 30, 2024, at 5:34 a.m., was reviewed and indicated Patient 13 was admitted to the facility on September 29, 2024, with diagnoses which included abdominal pain, nausea, vomiting, and diarrhea with blood in the stool. The document indicated Patient 13’s potassium level was 4.7 mEq/L (milliequivalent per liter, unit of measurement, normal value 3.5-5.1 mEq/L). A facility document titled, “Progress Notes Report,” dated October 1, 2024, at 12:55 p.m., was reviewed and indicated, “...received call from lab [laboratory] around 11 am that pt’s [Patient 13] glucose [blood sugar level] was 10 [normal is 70 to 100 milligrams per deciliter, mg/dL, unit of measurement]...did another finger poke test on both fingers. Reading was too low foor [sic] glucometer [a handheld device which measures blood sugar level] to read. Called primary [physician] who ordered d50 [dextrose 50%, a type of IV fluid] push [a process of introducing a medication or fluid substance directly into the bloodstream via the venous system] and d10 [sic] at 60ml/hr [milliliter per hour, rate at which a drug is administered, unit of measurement]. called a rapid response [when a group of health care professionals are called to a patient’s bedside to assess and treat a patient who is showing signs of clinical decline], team arrived, see mar [medication administration record] and rapid [response] sheet for meds medication] given. Pt moved to ICU [intensive care unit, unit for critically ill patients]...” A facility document titled, “RAPID RESPONSE TEAM RECORD,” dated October 1, 2024, at 11:17 a.m., was reviewed. The document indicated, “...REASON FOR CALL...LOW GLUCOSE...10 PER LAB...MEDICATIONS...IV NS BOLUS [a type of fluid administered rapidly] 250 [milliliter]...OUTCOME...TRANSFERRED TO ICU...SITUATION...BS [blood sugar] 10 [mg/dl, milligrams per deciliter, unit of measurement, normal is 70 to 110 mg/dl]- D50 given blood sugar accucheck [point of care determination of blood sugar] still says 52 and pt [Patient 13] was unresponsive...” A facility document titled, “[Name of facility] Discharge Summary Report,” was reviewed and indicated, “...Date Oct 1 [October 1, 2024]...Time 1000 [10 a.m.] Potassium 6.6...H [high]...Reference Range...3.5-5.1...meg/L [unit of measurement]...Date Oct 1...Time 1342 [1:42 p.m.]...Potassium 5.9...H...Date Oct 1...Time 2030 [8:30 p.m.]...Potassium 6.4...H...” The document also indicated on October 1, 2024, Patient 13’s glucose were as follows on the following times: - at 10:55 a.m., < [less than] 10...Reference Units 70-110 MG/DL; - at 11:01 a.m., < 10 MG/DL; - at 11:09 a.m., < 10 MG/DL; - at 11:12 a.m., <10 MG/DL; - at 11:17 a.m., 103 MG/DL; - at 11:28 a.m., 92 MG/DL; - at 12:45 p.m., 47 MG/DL; - at 1:06 p.m., 163 MG/DL; - at 1:41 p.m., 121 MG/DL and, - at 8:07 p.m., 42 MG/DL; A facility document titled, “Medication Administration History Report,” dated September 9, 2024, at 12 a.m., through October 2, 2024, at 11:59 p.m., was reviewed. The document indicated the following: - “...Medication: DEXTROSE 50% IN WATER (D50W) 25GM [gram, unit of measurement]/50 ML...Order Dose 25 GM/50ML...Frequency: ONCE...Route: INTRAVENOUS...Indications: Hypoglycemia [low blood sugar]...Sched Dt/TM [Scheduled Date/Time] 10/01/2024 [October 1, 2024] 11:08 [a.m.] Admin Dt/Tm [Administered Date/Time] 10/01/2024 11:08 a.m...Charted Dt/Tm [Date/Time] 12:54 [p.m.] Adm [Administered] Dose 25 GM/50 ML...Route INTRAVENOUS...Note: glucose 10; - ...IV Dextrose 10% WATER D-10%...Order Dose: 1000 ML...Route...Intravenous...Rate 60 ML/HR...Start Date: 10/01/2024 12:00 [p.m.]; - “...Medication: DEXTROSE 50% IN WATER (D50W) 25GM/50 ML...Order Dose 25 GM/50ML...Frequency: AS NEEDED...Route: INTRAVENOUS...Start Date: 10/01/24...Indications: Hypoglycemia...Admin Dt/Tm 10/01/2024 20:52 [8:52 p.m.]...Charted Dt/Tm (Date/Time) 10/01/2024 20:52 [8:52 p.m.] Adm Dose 25 GM...Route INTRAVENOUS...” A facility document titled, “Name of Facility CODE BLUE [a hospital code for a person needing to be revived] RECORD,” dated October 2, 2024, at 9:25 a.m., was reviewed. The document indicated, “...REASON CODE [code blue] INITATED...Lost Pulses...0925 [9:25 a.m.]...Code Started...0935 [9:35 a.m.]...Compressions Stopped...” A facility document titled, “All Discrepancies Report,” dated October 24, 2024, at 12:04 p.m., indicated, “...[Unit B]...IV DEXTROSE 10% WATER 1000 ML...Beg [beginning] 1...End...2...Transaction Type...Count Inventory...[Unit B]...10/1/24 23:32 [11:32 p.m.]...IV NACL [sodium chloride, salt] 0.9 % w/ KCL 20 MEQ/L 1000 ML (POTASSIUM CHLORIDE IN 0.9%NACL)(1000 mL)...Beg...5 [five]...End...4 [four]...Transaction Type...Count Inventory...” [There was an extra bag of D10W and one IV bag of NS with 20 mEq/l of potassium was removed from the Pyxis.] There was no documented evidence D10 Water was scanned [process of scanning the patient’s identification bracelet and the medication label using a handheld device prior to administering the medication to the patient) as administered to Patient 13. There was no documented evidence of medication Dextrose 10% at 60 ml/hr was administered to Patient 13 on October 1, 2024, during the rapid response on October 1, 2024, at 11:17 a.m. During a concurrent interview with the SC, the SC stated the D50 25gm.50 ml IV fluid was taken from the Pyxis (an automated medication dispensing system) on October 1, 2024, for an emergent low blood sugar. The SC stated this IV fluid was an override (a process which allows staff to dispense medication without a pharmacist reviewing the order, usually in an emergency). The SC stated D10 Water was not scanned as administered for Patient 13. He further stated the policy is to scan the medication prior to administration to ensure the right medication is being administered. He stated if the medication was given during a rapid code or code blue and not scanned due to emergency, the staff would have documented the medication on the code sheet, and it was not. He stated the staff did not follow policy. The SC stated Patient 13 expired during the code blue on October 2, 2024, at 9:35 a.m. He further stated the low glucose at 8:07 p.m., was an indication patient was not receiving D10 per physician’s orders. The SC stated Patient 13’s low blood sugar on October 1, 2024, at 8:52 p.m., could have been due to the administration of the wrong IV fluid. On October 23, 2024, at 3:56 p.m., an interview was conducted with Nursing Supervisor (NS) 1. NS 1 stated, on October 2, 2024, Staff 4 reported to her that D10 was not hung and administered to Patient 13 in accordance with the physician’s orders and instead “Normal Saline with something else” was administered during the rapid response on October 1, 2024, but she (NS 1) did not try to find the IV bag. NS 1 stated Staff 4 reported the IV fluid with “something else” had a pink sticker labeled with D10. On October 23, 2024, at 4:15 p.m., an interview was conducted with Staff 1. Staff 1 stated, on October 1, 2024, the laboratory called to report a blood sugar of 10 for Patient 13. Staff 1 stated a rapid response code was called on October 1, 2024. Staff 1 stated the physician was called and he ordered D50 to be administered by IV push and D10 at a slow rate to maintain Patient 13’s blood sugar. Staff 1 stated NS 1 assisted in hanging fluids which were administered during the rapid response. Staff 1 stated the normal process is to label any fluid being hung with a pink sticker identifying the type of IV fluid, the date and time it was hung, and the name of the staff who hung the medication. Staff 1 stated he could not recall who hung the NS with 20 mEq/l of potassium IV fluid during the rapid response on Patient 13. Staff 1 stated the Pyxis does not require staff to scan a medication after it is taken out of the machine. He stated a medication was only scanned at the patients’ bedside after scanning the patients arm band. Staff 1 stated the facility did not inform him of any medication error (wrong IV fluid administered to Patient 13) prior to this interview. On October 23, 2024, at 4:45 p.m., an interview was conducted with NS 1. NS 1 stated after a report of a medication error, an investigation would be started. NS 1 stated she spoke to Staff 1 and Staff 5. She stated she was not able to pinpoint who administered the NS with 20 mEq/l of potassium IV fluid during a rapid response code on October 1, 2024. NS 1 stated the Pyxis did not require staff to scan the medication after it is pulled from the Pyxis machine. She stated she was not aware medications could be scanned at the Pyxis. NS 1 stated she did not report the incident of the wrong IV fluid administered to Patient 13 to the Quality department or to the Risk department. She stated the medication error would be considered an adverse or an unusual event and she was not aware if it had been reported to California Department of Public Health (CDPH, a state agency). On October 23, 2024, at 5:02 p.m., an interview was conducted with Staff 3. Staff 3 stated pharmacy staff scans the medications when loading them into the Pyxis. She stated the Pyxis has the capability to require medications be scanned after being removed from the machine prior to closing the drawer but this feature has not been activated at this facility. Staff 3 stated D10 was not scanned at the Pyxis nor when it was to be administered to Patient 13. Staff 3 stated the pharmacy department completed an inventory of the fluids on Unit B and the inventory indicated the Pyxis on Unit B was short one bag of NS with 20 mEq of potassium with one extra bag of D10. Staff 3 stated when the wrong medication was pulled there would be a discrepancy of both medications, with one missing and one having an extra bag. Staff 3 stated during the Code Blue, Patient 13’s blood sugar was 47 which would have indicated D10 was not actually being given. Staff 3 stated she was not told of the medication error but was alerted through the internal reporting system. Staff 3 stated she did not report the incident to anyone and she just answered the internal reporting system [a facility system filled out by the facility staff to report medication error]. On October 23, 2024, at 5:34 p.m., an interview was conducted with Staff 4. Staff 4 stated he received report from a day shift nurse and was told Patient 13 had a rapid response on Unit B and was on D10 at 60 ml/hr. Staff 4 stated at about 8 p.m., he entered Patient 13’s room and observed an IV fluid running at 60 ml/hr. He stated he followed the IV line and observed the line going to a medication fluid bag with a handwritten pink label which indicated D10, but noted that the IV medication bag read NS+20K (Normal Saline with 20 mEq of potassium). Staff 4 stated he stopped the medication but the bag was half empty, with about 500 ml left in the IV bag. Staff 4 stated he called Physician (P) 2 to inform him of the medication error. Staff 4 stated he completed a blood sugar check and Patient 13’s blood sugar was low. He stated P 2 ordered D50 and D10. Staff 4 stated labs were drawn, and Patient 13’s potassium level was now 6.4 [mEq/l]. Staff 4 stated he reported the medication error to the charge nurse, through the internal reporting system, and to NS 1. Staff 4 stated he informed NS 1 the IV bag of NS with 20 mEq/l of potassium was outside of the room in the blue bin. Staff 4 stated he offered to look for it, but NS 1 told him no. Staff 4 stated NS 1 did not attempt to look for the medication bag. On October 24, 2024, at 11:26 a.m., an interview was conducted with Staff 5. Staff 5 stated the process for receiving a new patient into the ICU was to receive report, verify the IV fluids that are being administered to the patient, and verify the medications the patient came with. Staff 5 stated he was told Patient 13 had D10 running at 60 ml/hr from the rapid response. He further stated he did see a pink sticker labeled D10. He stated the patient’s IVs were not working. He stated after Patient 13 arrived, the lab called, and a code sepsis [a life-threatening infection] was called. Staff 5 stated this was when code blue was called and Patient 13 was intubated [when a flexible tube is inserted in the airway to assist in breathing], and this was why the fluids had not been verified. Staff 5 stated he spoke to Staff 4 regarding the medication error. He stated they discussed the elevated potassium lab draw and was informed the IV bag labelled D10 was actually NS with 20 mEq of potassium. He stated if the patient would have received the D10 as ordered it would have helped with the low blood sugar and the high potassium. Staff 5 stated he had spoken to pharmacy staff regarding the Pyxis having the capability to scan medications when removing them but was told the facility does not pay for that functionality. On October 24, 2024, at 1:20 p.m., an interview was conducted with Staff 6. Staff 6 stated Patient 13 was transferred to the ICU with a bag of fluids with a pink label indicating D10 from the rapid response but did not verify what the content of the IV medication bag was. On October 24, 2024, at 2:27 p.m., an interview was conducted with P 1 who stated he ordered D10 for a low blood sugar. He stated he ordered Kayexalate (a medication to help bring potassium levels down) to bring down patient potassium as it was high. P1 stated Patient 13 was not able to take medication orally. He stated the purpose of the D10 was for low blood sugar and high potassium. He stated, “maybe during the rapid [response], they screwed up” and gave her NS +20K and not the D10. P1 stated he was informed of the medication error after the code blue. P1 stated he informed family of the code [blue] but did not inform family of the medication error. A review of the policy and procedure (P&P) titled, “MEDICATION ERROR REPORTING,” dated August 2021, was conducted. The P&P indicated, “...To describe the procedures for reporting a medication error and the mechanism for multi-disciplinary review to allow appropriate follow-up, education and continuous quality improvement to promote a medication error-free environment and prevent the reoccurrence of the same error...Medication errors are captured through many mechanisms...review of adverse drug reactions, review of abnormal lab values...All medication errors that resulted in the patient receiving the medication shall be reported immediately to the prescribing or primary physician and appropriate actions, documentations and reporting completed...The patient and/or family, as appropriate, shall be notified following the hospital disclosure policy...As soon as possible but no more than five business days from the event, an investigation and review of the medication error shall be done by the appropriate department...when a medication error occurs and the event reached the patient...An entry of the medication given, any adverse effects observed and actions taken are recorded appropriately in the patient’s medical record...The patient and/or family are notified according to the hospital disclosure policy...The event is reported via the Safety & Risk Management (SRM) Reporting System...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed...Upon notification of the error, the pharmacist will investigate the error...The Director of Pharmacy shall discuss with the individual who made the error the ramifications of such mistake and develop an action plan to help prevent future occurrence...” A review of the P&P titled, “ADVERSE EVENT/SENTINEL EVENT REPORTING AND ROOT CAUSE ANALYSIS,” dated January, 2022 indicated, “...A Sentinel Event...is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, severe harm...or permanent harm...A patient death or serious disability associated with a medication error, including, but not limited to, an error involving the wrong drug...An adverse event...that cause the death or serious disability of a patient...The facility shall inform the patient or the party responsible for the patient of the adverse event by the time the report is made...The department shall review Section 7073 of Title 22 of the California Code of Regulations requiring hospitals to report “unusual occurrences”...defines incidents as any event, occurrence or circumstance that is not consistent with the routine care and expected course of treatment...Reporting of...CDPH reportable occurrences will be completed electronically...will notify California Department of Public Health within 5 days of a non-emergency/non-urgent event and within 24 hours if the event is ongoing urgent/emergent threat to the welfare, health or safety of patients...” A review of the P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES,” dated November 2022, indicated, “...to establish the rights that each patient...has pertaining to their care...Receive information about their health status...course of treatment...including unanticipated outcomes...Receive care in a safe setting...” A review of the P&P titled, “MEDICATION ERROR REPORTING,” dated May 2018, indicated, “...definition of a medication error is “any preventable medication-related event that my cause or lead to inappropriate use or patient harm while the medication is in the control of the healthcare professional...All medication errors that resulted in the patient receiving the medication shall be reported immediately...and reporting completed...As soon as possible, but no more than (five) business days from the event, an investigation and review of the medication error shall be done. By the appropriate department...For medication errors...that resulted or have the potential for resulting in serious consequences, methods such as a Root Cause Analysis...shall be used to gain insight into the actual/potential error in an effort to reduce future occurrence within the hospital...The patient and/or family is notified...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed...” A review of the P&P titled, “PYXIS ENTERPRISE SERVER (ES) GUIDELINES FOR USE,” dated May 2024, indicated, “...To establish best practices for the utilization of the Pyxis Enterprise Server (ES) medical devices as a medication storage, security, dispensing and charging system approved medications and controlled substances; to establish quality controls to assure proper usage of both hardware and software components...the patient can be selected by searching under ‘All Available Patients’ or ‘My Patients’...After selecting the patient, select “Remove”, which will display medications Due Now...Select the medication...from the list to remove, follow any required prompts...remove the medication, then close the pocket and drawer...” A review of the P&P titled, “HAND-OFF COMMUNICATION,” dated September 2024, indicated, “...’Handoff’ communication will take place whenever there is a change in the patient’s...caregivers. Caregivers include all clinical staff and physicians...communication shall include...Situation...Vital signs...Background...History...Assessement...labs...medciations...When physicians and nurses are transferring patients/clients/residents to another level of care within or outside of the organization...Caregivers shall give a “Bedside Shift Report”...using SBAR format...in a clean and concise manner...Information provided during hand-off communications will include...Summary of the patient’s...current physical...health condition including...Current medications...IVs present...Recent...changes in the patient’s...condition...””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 35056 Based on interview and record review, the facility failed to ensure there is a functioning Quality Assessment and Performance Improvement process, when Normal Saline (a type of fluid) with 20 milliequivalents (mEq, unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, during a rapid response (a hospital code when a group of healthcare professionals are called to a patient’s bedside to provide immediate care when a patient’s condition is unstable or they are critically ill), for one of 30 sample patients (Patient 13), for Patient 13’s high potassium level, and this incident was not reported to and tracked by the facility. This failure resulted in Patient 13 to have more elevated potassium levels and may have resulted in delay of Patient 13’s recovery and could have contributed to the deterioration of Patient 13’s medical condition and subsequent death, and had the potential for further medication errors to occur, and may negatively affect the treatment and safety of the patients in the facility. Findings: On October 23, 2024, at 1:45 p.m., a review of Patient 13’s record was conducted with the Stroke Coordinator (SC). The facility document titled, “History and Physical,” dated September 30, 2024, at 5:34 a.m., was reviewed and indicated Patient 13 was admitted to the facility on September 29, 2024, with diagnoses which included abdominal pain, nausea, vomiting, and diarrhea with blood in the stool. The document indicated Patient 13’s potassium level was 4.7 mEq/L (milliequivalent per liter, unit of measurement, normal value 3.5-5.1 mEq/L). A facility document titled, “Progress Notes Report,” dated October 1, 2024, at 12:55 p.m., was reviewed and indicated, “...received call from lab [laboratory] around 11 am that pt’s [Patient 13] glucose [blood sugar level] was 10 [normal is 70 to 100 milligrams per deciliter, mg/dL, unit of measurement]...did another finger poke test on both fingers. Reading was too low foor [sic] glucometer [a handheld device which measures blood sugar level] to read. Called primary [physician] who ordered d50 [dextrose 50%, a type of IV fluid] push [a process of introducing a medication or fluid substance directly into the bloodstream via the venous system] and d10 [sic] at 60ml/hr [milliliter per hour, rate at which a drug is administered, unit of measurement]. called a rapid response [when a group of health care professionals are called to a patient’s bedside to assess and treat a patient who is showing signs of clinical decline], team arrived, see mar [medication administration record] and rapid [response] sheet for meds medication] given. Pt moved to ICU [intensive care unit, unit for critically ill patients]...” A facility document titled, “RAPID RESPONSE TEAM RECORD,” dated October 1, 2024, at 11:17 a.m., was reviewed. The document indicated, “...REASON FOR CALL...LOW GLUCOSE...10 PER LAB...MEDICATIONS...IV NS BOLUS [a type of fluid administered rapidly] 250 [milliliter]...OUTCOME...TRANSFERRED TO ICU...SITUATION...BS [blood sugar] 10 [mg/dl, milligrams per deciliter, unit of measurement, normal is 70 to 110 mg/dl]- D50 given blood sugar accucheck [point of care determination of blood sugar] still says 52 and pt [Patient 13] was unresponsive...” A facility document titled, “[Name of facility] Discharge Summary Report,” was reviewed and indicated, “...Date Oct 1 [October 1, 2024]...Time 1000 [10 a.m.] Potassium 6.6...H [high]...Reference Range...3.5-5.1...meg/L [unit of measurement]...Date Oct 1...Time 1342 [1:42 p.m.]...Potassium 5.9...H...Date Oct 1...Time 2030 [8:30 p.m.]...Potassium 6.4...H...” The document also indicated on October 1, 2024, Patient 13’s glucose were as follows on the following times: - at 10:55 a.m., < [less than] 10...Reference Units 70-110 MG/DL; - at 11:01 a.m., < 10 MG/DL; - at 11:09 a.m., < 10 MG/DL; - at 11:12 a.m., <10 MG/DL; - at 11:17 a.m., 103 MG/DL; - at 11:28 a.m., 92 MG/DL; - at 12:45 p.m., 47 MG/DL; - at 1:06 p.m., 163 MG/DL; - at 1:41 p.m., 121 MG/DL and, - at 8:07 p.m., 42 MG/DL; A facility document titled, “Medication Administration History Report,” dated September 9, 2024, at 12 a.m., through October 2, 2024, at 11:59 p.m., was reviewed. The document indicated the following: - “...Medication: DEXTROSE 50% IN WATER (D50W) 25GM [gram, unit of measurement]/50 ML...Order Dose 25 GM/50ML...Frequency: ONCE...Route: INTRAVENOUS...Indications: Hypoglycemia [low blood sugar]...Sched Dt/TM [Scheduled Date/Time] 10/01/2024 [October 1, 2024] 11:08 [a.m.] Admin Dt/Tm [Administered Date/Time] 10/01/2024 11:08 a.m...Charted Dt/Tm [Date/Time] 12:54 [p.m.] Adm [Administered] Dose 25 GM/50 ML...Route INTRAVENOUS...Note: glucose 10; - ...IV Dextrose 10% WATER D-10%...Order Dose: 1000 ML...Route...Intravenous...Rate 60 ML/HR...Start Date: 10/01/2024 12:00 [p.m.]; - “...Medication: DEXTROSE 50% IN WATER (D50W) 25GM/50 ML...Order Dose 25 GM/50ML...Frequency: AS NEEDED...Route: INTRAVENOUS...Start Date: 10/01/24...Indications: Hypoglycemia...Admin Dt/Tm 10/01/2024 20:52 [8:52 p.m.]...Charted Dt/Tm (Date/Time) 10/01/2024 20:52 [8:52 p.m.] Adm Dose 25 GM...Route INTRAVENOUS...” A facility document titled, “Name of Facility CODE BLUE [a hospital code for a person needing to be revived] RECORD,” dated October 2, 2024, at 9:25 a.m., was reviewed. The document indicated, “...REASON CODE [code blue] INITATED...Lost Pulses...0925 [9:25 a.m.]...Code Started...0935 [9:35 a.m.]...Compressions Stopped...” A facility document titled, “All Discrepancies Report,” dated October 24, 2024, at 12:04 p.m., indicated, “...[Unit B]...IV DEXTROSE 10% WATER 1000 ML...Beg [beginning] 1...End...2...Transaction Type...Count Inventory...[Unit B]...10/1/24 23:32 [11:32 p.m.]...IV NACL [sodium chloride, salt] 0.9 % w/ KCL 20 MEQ/L 1000 ML (POTASSIUM CHLORIDE IN 0.9%NACL)(1000 mL)...Beg...5 [five]...End...4 [four]...Transaction Type...Count Inventory...” [There was an extra bag of D10W and one IV bag of NS with 20 mEq/l of potassium was removed from the Pyxis.] There was no documented evidence D10 Water was scanned [process of scanning the patient’s identification bracelet and the medication label using a handheld device prior to administering the medication to the patient) as administered to Patient 13. There was no documented evidence of medication Dextrose 10% at 60 ml/hr was administered to Patient 13 on October 1, 2024, during the rapid response on October 1, 2024, at 11:17 a.m. During a concurrent interview with the SC, the SC stated the D50 25gm 50 ml IV fluid was taken from the Pyxis (an automated medication dispensing system) on October 1, 2024, for an emergent low blood sugar. The SC stated this IV fluid was an override (a process which allows staff to dispense medication without a pharmacist reviewing the order, usually in an emergency). The SC stated D10 Water was not scanned as administered for Patient 13. He further stated the policy is to scan the medication prior to administration to ensure the right medication is being administered. He stated if the medication was given during a rapid code or code blue and not scanned due to emergency, the staff would have documented the medication on the code sheet, and it was not. He stated the staff did not follow policy. The SC stated Patient 13 expired during the code blue on October 2, 2024, at 9:35 a.m. He further stated the low glucose at 8:07 p.m., was an indication patient was not receiving D10 per physician’s orders. The SC stated Patient 13’s low blood sugar on October 1, 2024, at 8:52 p.m., could have been due to the administration of the wrong IV fluid. On October 23, 2024, at 3:56 p.m., an interview was conducted with Nursing Supervisor (NS) 1. NS 1 stated, on October 2, 2024, Staff 4 reported to her that D10 was not hung and administered to Patient 13 in accordance with the physician’s orders and instead “Normal Saline with something else” was administered during the rapid response on October 1, 2024, but she (NS 1) did not try to find the IV bag. NS 1 stated Staff 4 reported the IV fluid with “something else” had a pink sticker labeled with D10. On October 23, 2024, at 4:15 p.m., an interview was conducted with Staff 1. Staff 1 stated, on October 1, 2024, the laboratory called to report a blood sugar of 10 for Patient 13. Staff 1 stated a rapid response code was called on October 1, 2024. Staff 1 stated the physician was called and he ordered D50 to be administered by IV push and D10 at a slow rate to maintain Patient 13’s blood sugar. Staff 1 stated NS 1 assisted in hanging fluids which were administered during the rapid response. Staff 1 stated the normal process is to label any fluid being hung with a pink sticker identifying the type of IV fluid, the date and time it was hung, and the name of the staff who hung the medication. Staff 1 stated he could not recall who hung the NS with 20 mEq/l of potassium IV fluid during the rapid response on Patient 13. Staff 1 stated the Pyxis does not require staff to scan a medication after it is taken out of the machine. He stated a medication was only scanned at the patients’ bedside after scanning the patients arm band. Staff 1 stated the facility did not inform him of any medication error (wrong IV fluid administered to Patient 13) prior to this interview. On October 23, 2024, at 4:45 p.m., an interview was conducted with NS 1. NS 1 stated after a report of a medication error, an investigation would be started. NS 1 stated she spoke to Staff 1 and Staff 5. She stated she was not able to pinpoint who administered the NS with 20 mEq/l of potassium IV fluid during a rapid response code on October 1, 2024. NS 1 stated the Pyxis did not require staff to scan the medication after it is pulled from the Pyxis machine. She stated she was not aware medications could be scanned at the Pyxis. NS 1 stated she did not report the incident of the wrong IV fluid administered to Patient 13 to the Quality department or to the Risk department. She stated the medication error would be considered an adverse or an unusual event and she was not aware if it had been reported to California Department of Public Health (CDPH, a state agency). On October 23, 2024, at 5:02 p.m., an interview was conducted with Staff 3. Staff 3 stated pharmacy staff scans the medications when loading them into the Pyxis. She stated the Pyxis has the capability to require medications be scanned after being removed from the machine prior to closing the drawer but this feature has not been activated at this facility. Staff 3 stated D10 was not scanned at the Pyxis nor when it was to be administered to Patient 13. Staff 3 stated the pharmacy department completed an inventory of the fluids on Unit B and the inventory indicated the Pyxis on Unit B was short one bag of NS with 20 mEq of potassium with one extra bag of D10. Staff 3 stated when the wrong medication was pulled there would be a discrepancy of both medications, with one missing and one having an extra bag. Staff 3 stated during the Code Blue, Patient 13’s blood sugar was 47 which would have indicated D10 was not actually being given. Staff 3 stated she was not told of the medication error but was alerted through the internal reporting system. Staff 3 stated she did not report the incident to anyone and she just answered the internal reporting system [a facility system filled out by the facility staff to report medication error]. On October 23, 2024, at 5:34 p.m., an interview was conducted with Staff 4. Staff 4 stated he received report from a day shift nurse and was told Patient 13 had a rapid response on Unit B and was on D10 at 60 ml/hr. Staff 4 stated at about 8 p.m., he entered Patient 13’s room and observed an IV fluid running at 60 ml/hr. He stated he followed the IV line and observed the line going to a medication fluid bag with a handwritten pink label which indicated D10, but noted that the IV medication bag read NS+20K (Normal Saline with 20 mEq of potassium). Staff 4 stated he stopped the medication but the bag was half empty, with about 500 ml left in the IV bag. Staff 4 stated he called Physician (P) 2 to inform him of the medication error. Staff 4 stated he completed a blood sugar check and Patient 13’s blood sugar was low. He stated P 2 ordered D50 and D10. Staff 4 stated labs were drawn, and Patient 13’s potassium level was now 6.4 [mEq/l]. Staff 4 stated he reported the medication error to the charge nurse, through the internal reporting system, and to NS 1. Staff 4 stated he informed NS 1 the IV bag of NS with 20 mEq/l of potassium was outside of the room in the blue bin. Staff 4 stated he offered to look for it, but NS 1 told him no. Staff 4 stated NS 1 did not attempt to look for the medication bag. On October 24, 2024, at 11:26 a.m., an interview was conducted with Staff 5. Staff 5 stated the process for receiving a new patient into the ICU was to receive report, verify the IV fluids that are being administered to the patient, and verify the medications the patient came with. Staff 5 stated he was told Patient 13 had D10 running at 60 ml/hr from the rapid response. He further stated he did see a pink sticker labeled D10. He stated the patient’s IVs were not working. He stated after Patient 13 arrived, the lab called, and a code sepsis [a life-threatening infection] was called. Staff 5 stated this was when code blue was called and Patient 13 was intubated [when a flexible tube is inserted in the airway to assist in breathing], and this was why the fluids had not been verified. Staff 5 stated he spoke to Staff 4 regarding the medication error. He stated they discussed the elevated potassium lab draw and was informed the IV bag labelled D10 was actually NS with 20 mEq of potassium. He stated if the patient would have received the D10 as ordered it would have helped with the low blood sugar and the high potassium. Staff 5 stated he had spoken to pharmacy staff regarding the Pyxis having the capability to scan medications when removing them but was told the facility does not pay for that functionality. On October 24, 2024, at 1:20 p.m., an interview was conducted with Staff 6. Staff 6 stated Patient 13 was transferred to the ICU with a bag of fluids with a pink label indicating D10 from the rapid response but did not verify what the content of the IV medication bag was. On October 24, 2024, at 2:27 p.m., an interview was conducted with P 1 who stated he ordered D10 for a low blood sugar. He stated he ordered Kayexalate (a medication to help bring potassium levels down) to bring down patient potassium as it was high. P1 stated Patient 13 was not able to take medication orally. He stated the purpose of the D10 was for low blood sugar and high potassium. He stated, “maybe during the rapid [response], they screwed up” and gave her NS +20K and not the D10. P1 stated he was informed of the medication error after the code blue. P1 stated he informed family of the code [blue] but did not inform family of the medication error. On October 24, 2024, at 4:45 p.m., an interview was conducted with the Deputy Regional Director for Quality (DRDQ) and the Chief Quality and Patient Safety Officer (CQO). The RDQ stated when there is an incident which resulted to or had the potential to result to major harm, the incident should be reported to the clinical leaders who make the decision if they should be reported to the Quality Department. She stated NS 1 told the Quality Department that the incident was not reportable. She stated she was not aware that NS 1 had knowledge of the NS with 20 mEq potassium IV bag was in the blue bin (bin where discarded medications are placed for the pharmacy to dispense of) which could have been retrieved to determine if a medication error did occur. She stated the CQO and the Chief Medical Officer were not aware that an investigation of the medication error incident was not conducted by NS 1. She stated a root cause analysis about the medication error incident has not been done and it has not been reported to the Governing Body and the Medical Executive Committee. She stated the Chief of Staff was not notified of the incident. A review of the policy and procedure (P&P) titled, “MEDICATION ERROR REPORTING,” dated August 2021, was conducted. The P&P indicated, “...To describe the procedures for reporting a medication error and the mechanism for multi-disciplinary review to allow appropriate follow-up, education and continuous quality improvement to promote a medication error-free environment and prevent the reoccurrence of the same error...Medication errors are captured through many mechanisms...review of adverse drug reactions, review of abnormal lab values...All medication errors that resulted in the patient receiving the medication shall be reported immediately to the prescribing or primary physician and appropriate actions, documentations and reporting completed...The patient and/or family, as appropriate, shall be notified following the hospital disclosure policy...As soon as possible but no more than five business days from the event, an investigation and review of the medication error shall be done by the appropriate department...when a medication error occurs and the event reached the patient...An entry of the medication given, any adverse effects observed and actions taken are recorded appropriately in the patient’s medical record...The patient and/or family are notified according to the hospital disclosure policy...The event is reported via the Safety & Risk Management (SRM) Reporting System...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed...Upon notification of the error, the pharmacist will investigate the error...The Director of Pharmacy shall discuss with the individual who made the error the ramifications of such mistake and develop an action plan to help prevent future occurrence...” A review of the P&P titled, “ADVERSE EVENT/SENTINEL EVENT REPORTING AND ROOT CAUSE ANALYSIS,” dated January, 2022 indicated, “...A Sentinel Event...is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, severe harm...or permanent harm...A patient death or serious disability associated with a medication error, including, but not limited to, an error involving the wrong drug...An adverse event...that cause the death or serious disability of a patient...The facility shall inform the patient or the party responsible for the patient of the adverse event by the time the report is made...The department shall review Section 7073 of Title 22 of the California Code of Regulations requiring hospitals to report “unusual occurrences”...defines incidents as any event, occurrence or circumstance that is not consistent with the routine care and expected course of treatment...Reporting of...CDPH reportable occurrences will be completed electronically...will notify California Department of Public Health within 5 days of a non-emergency/non-urgent event and within 24 hours if the event is ongoing urgent/emergent threat to the welfare, health or safety of patients...” A review of the P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES,” dated November 2022, indicated, “...to establish the rights that each patient...has pertaining to their care...Receive information about their health status...course of treatment...including unanticipated outcomes...Receive care in a safe setting...” A review of the P&P titled, “MEDICATION ERROR REPORTING,” dated May 2018, indicated, “...definition of a medication error is “any preventable medication-related event that my cause or lead to inappropriate use or patient harm while the medication is in the control of the healthcare professional...All medication errors that resulted in the patient receiving the medication shall be reported immediately...and reporting completed...As soon as possible, but no more than (five) business days from the event, an investigation and review of the medication error shall be done. By the appropriate department...For medication errors...that resulted or have the potential for resulting in serious consequences, methods such as a Root Cause Analysis...shall be used to gain insight into the actual/potential error in an effort to reduce future occurrence within the hospital...The patient and/or family is notified...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed...” A review of the P&P titled, “PYXIS ENTERPRISE SERVER (ES) GUIDELINES FOR USE,” dated May 2024, indicated, “...To establish best practices for the utilization of the Pyxis Enterprise Server (ES) medical devices as a medication storage, security, dispensing and charging system approved medications and controlled substances; to establish quality controls to assure proper usage of both hardware and software components...the patient can be selected by searching under ‘All Available Patients’ or ‘My Patients’...After selecting the patient, select “Remove”, which will display medications Due Now...Select the medication...from the list to remove, follow any required prompts...remove the medication, then close the pocket and drawer...” A review of the P&P titled, “HAND-OFF COMMUNICATION,” dated September 2024, indicated, “...’Handoff’ communication will take place whenever there is a change in the patient’s...caregivers. Caregivers include all clinical staff and physicians...communication shall include...Situation...Vital signs...Background...History...Assessement...labs...medciations...When physicians and nurses are transferring patients/clients/residents to another level of care within or outside of the organization...Caregivers shall give a “Bedside Shift Report”...using SBAR format...in a clean and concise manner...Information provided during hand-off communications will include...Summary of the patient’s...current physical...health condition including...Current medications...IVs present...Recent...changes in the patient’s...condition...””

“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: 44871 Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 was supervised by a registered nurse (RN) when performing initial assessments of wounds and staging pressure injuries (wounds caused by pressure on body areas), for two of 30 sampled patients (Patients 26 and 30). This failure may impact the quality of care provided to patients. Findings: On October 24, 2024, at 10:30 a.m., the record review was conducted with the Patient Safety (PS). a. The record of Patient 26 was reviewed. A facility document titled, “[Name of facility] History and Physical [H&P],” dated March 29, 2024, was reviewed. The document indicated Patient 26 was admitted to the facility on March 29, 2024, for heart attack, diabetes (elevated levels of blood glucose), and a sacral (the area above the tailbone) decubitus ulcer (pressure injury wound). A facility document titled, “Order Inquiry,” dated March 31, 2024, was reviewed. The document indicated, “...Wound Care Nurse Notification...,” was ordered for Patient 26. A facility document titled, “Wound Care Note,” dated April 1, 2024, was reviewed. The document indicated, “...LOCATION...Coccyx [tailbone area] extending to bilateral [both]buttock....WOUND TYPE...Unstageable pressure injury [a full-thickness skin and tissue loss where the stage of the injury is unclear]...MEASUREMENT...10 [ten] x [by] 9 [nine] x 0.1cm [centimeter, a unit of measurement of length]...WOUND BED [open area or base of the wound]...100% [percentage, a rate, number, or amount in each hundred] slough [yellow/white material in the wound bed]...DRAINAGE...scant serosanguineous [a combination of blood and serum, the liquid part of blood, that’s usually light pink to red in color]...PERIWOUND [area around the wound]...non blanchable [discoloration of the skin that does not turn white when pressed] redness...RECOMMENDATIONS...Cleanse with NS [normal saline, a type of fluid], pat dry, apply hydrogel [a gel dressing] followed by silver impregnated [a type of dressing] and cover with foam dressing q3days [every 3 days] and PRN [as needed] if soiled or dislodged. Offload patient, turn from side to side frequently as tolerated to redistribute pressure. Keep HOB [head of bed] at 30 degrees [a unit of measure of angles] or lower to reduce pressure to the coccyx area...Entered by...[name of LVN 1]...” b. The record of Patient 30 was reviewed. A facility document titled, “H&P,” dated October 2, 2024, was reviewed. The document indicated Patient 30 was admitted to the facility on October 2, 2024, for congested heart failure (condition when the heart is not pumping properly). A facility document titled, “Order,” dated October 2, 2024, was reviewed, the document indicated, “...Wound Care Nurse Notification...,” was ordered for Patient 30. A facility document titled, “Wound Care Note,” dated September 22, 2024, was reviewed. The document indicated, “...LOCATION...Right lower extremity...WOUND TYPE...Venus ulcer [a wound on the legs caused by damaged veins]...MEASUREMENT...5 [five] x1 [one] x 0.1cm...WOUND BED...100% red viable [capable of living] tissue...DRAINAGE...scant serosanguineous, odor free...PERIWOUND...dry, intact, pink, scar tissue...RECOMMENDATIONS...Cleanse with NS, pat dry, apply xeroform [a gauze dressing impregnated with petrolatum] to open areas only, cover with non adherent [sic] dressing, wrap with kerlix [gauze dressing] followed by ACE [a brand of an elastic bandage] wrap every other day or PRN if soiled or dislodged...Entered by...[name of LVN 1]...” The facility document titled, “WOUND MANAGEMENT RN - ACUTE CARE,” dated September 2017, was reviewed. The document indicated, “...Uses knowledge of physiology, pathophysiology, pharmacology and health assessment in assessing and intervening in complex health care problems; selecting, using and/or evaluating products and equipment appropriate to the clinical area of practice; improving and promoting health care outcomes; developing and facilitating related staff education and in mentoring nursing staff. Under the direction of the Director of Inpatient Services, is responsible for assessing, analyzing, planning, and implementing patient care measures related to wound management...Education...Possession of Associate Degree in Nursing or successful completion of an accredited Registered Nursing Program...Knowledge of...Hospital established policies quality assurance program, safety, environmental and infection control policies and procedures and Nursing Practice Act of the State of California....Federal, State, and local laws and regulations governing professional aspects of nursing...Manage emergency or crisis situations; requires judgment/action...” The facility document titled, “WOUND CARE COORDINATOR,” dated August 2018, was reviewed. The document indicated, “...ACKNOWLEDGE OF EMPLOYEE JOB DESCRIPTION/PHYSICAL REQUIRMENTS AND WORKING CONDITIONS FORM...[signed by LVN 1]...Dated...December 9, 2020...JOB Title...LVN wound care...” There was no documented evidence LVN 1 was supervised by a RN when the initial assessments and staging of the pressure injuries were conducted for Patients 26 and 30. On October 24, 2024, at 11:49 a.m., an interview and record review were conducted with LVN 1. LVN 1 stated she had been the wound nurse for four years and she had been assessing the wounds, staging pressure injuries, and giving recommendations for wound care treatment. LVN 1 stated the assessments were not cosigned by an RN. On October 24, 2024, at 11:30 a.m., an interview and record review were conducted with the Chief Quality Officer (CQO). The CQO stated an LVN should not be performing initial assessments of these wounds and staging pressure injuries. The CQO stated the facility policy was not followed. According to an article published by the California Board of Registered Nursing titled, “Understanding the Role of the Registered Nurse and Interim Permittee,” an RN “...is accountable for an ongoing comprehensive assessment that includes data collection, analysis, and drawing conclusions/making judgments...LVN is not prepared by formal education to make RN level nursing judgments that include independent analysis, synthesis, and decision-making...” According to the Board of Vocational Nursing and Psychiatric Technician, a licensed vocational nurse is “...An entry-level health care provider who is responsible for rendering basic nursing care. A vocational nurse practices under the direction of physician or registered nurse. The licensee is not an independent practitioner...” The facility document policy and procedure (P&P) titled, “SKIN AND WOUND CARE,” dated May 2024, was reviewed. The document indicated, “...To assess and document skin and wound condition, Braden Scale, and risk factors...” The facility document P&P titled, “PRESSURE INJURIES,” dated May 20, 2024, was reviewed. The document indicated, “...[Name of facility] guidelines for risk for wounds shall initiate if appropriate for patients identified as “at risk” per physician’s order or as indicated by the Braden Scale [a risk assessment tool that predicts the likelihood of pressure ulcers in adult patients]. Wound care consultation shall be considered for high risk [sic] patients based on utilization of the Braden score...Wound care consultation is ordered by entering a wound care consult...The RN shall initiate prevention measures, when appropriate, for at risk patients with no skin integrity issues...The Wound RN can be a resource in determining advanced in support surfaces...””

“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: 42512 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures were implemented, for eight of 30 sample patients (Patients 1, 2, 17, 18, 19, 24, 28, and 30), when: 1. For Patients 1, 2, 18, 19, and 24, pain assessment was not completed before and after pain medication administration; 2. For Patients 1 and 30, wound assessments and photographs were not completed; and 3. For Patients 14 and 28, the assessment for the patient’s intake and output (I&O, the measurement of the fluids that enter the body and the fluids leave the body in a 24-hour period) were not completed. These failures had the potential to compromise patient safety, result in inadequate pain management, and increase the risk for pressure injuries. Findings: 1a. A review of Patient 1’s record was conducted on October 23, 2024, at 9:40 a.m., with the Nursing Supervisor (NS). A facility document titled, “[Name of Facility] History and Physical (H&P),” was reviewed and indicated Patient 1 was admitted to the facility on August 21, 2024, for hypotension (low blood pressure) and generalized weakness. A facility document titled, “Medication Administration Record,” was reviewed. The document indicated, “...Acetaminophen [pain medication]...Tablet oral [by mouth] every four hours as needed...for mild pain...650 mg [milligrams, unit of measurement]...Tylenol [brand name of acetaminophen]...Start 08/22/24 [August 22, 2024]...” A facility document titled, “Med [Medication] Admin [Administration]- PRN [as needed],” was reviewed. The document indicated the following: - On August 26, 2024, at 2:47 a.m., Tylenol (a pain medication) 650 mg (milligrams, unit of measurement) was administered and the patient’s pain level (a pain scale measuring 10 as highest level of pain and zero the lowest) prior to the administration of Tylenol was not assessed; - On August 26, 2024, at 9 a.m., Tylenol 650 mg was administered for a pain level of eight out of 10; and -On August 28, 2024, at 7:24 p.m., Tylenol 650 mg was administered, and the pain level was not assessed prior to administration. An interview was conducted on October 23, 2024, at 2 p.m., with the NS. The NS verified pain assessment was not conducted August 26, 2024, at 2:47 a.m., before Tylenol was administered to Patient 1. The NS verified Patient 1’s pain was not reassessed after Tylenol was administered on August 26, 2024, at 9 a.m. The NS verified Patient 1’as pain level was not assessed before and after Tylenol was administered on August 28, 2024, at 7:24 p.m. The NS stated the pain level should be assessed prior to medication administration and the pain level should be reassessed one hour after medication administration. 1b. A review of Patient 2’s record was conducted on October 23, 2024, at 2:30 p.m., with the NS. A facility document titled, “H&P,” was reviewed and indicated Patient 2 was admitted to the facility on October 20, 2024, for left flank (the area between the ribs and lower back) pain. An untitled facility document was reviewed and indicated the following: - On October 20, 2024, at 7:03 p.m., Patient 2’s pain level was eight out of 10; - On October 20, 2024, at 11:30 p.m., Patient 2’s pain level was 10 out of 10; and - On October 21, 2024, at 5:02 a.m., Patient 2’s pain level was 10 out of 10. A facility document titled, “Med Admin- PRN,” was reviewed. The document indicated, “...Morphine [pain medication]...1 [one] MG...Intravenous [IV, administered through the vein]...SeverePpain...” The document indicated the following: - On October 20, 2024, at 7:04 p.m., morphine one mg intravenous for severe pain was administered; - On October 20, 2024, at 11:32 p.m., morphine one mg IV for severe pain was administered; and - On October 21, 2024, at 5:02 a.m., morphine one mg IV for severe pain was administered. There was no documented evidence pain assessment was conducted after morphine was administered on the dates and times above. An interview was conducted on October 23, 2024, at 2:30 p.m., with the NS. The NS verified Patient 2’s pain was not assessed on the dates and times above. The NS stated the pain reassessments should have been done one hour after pain medication administration. 1c. A review of Patient 18’s record was conducted on October 24, 2024, at 4:22 p.m., with the Stroke Coordinator (SC). A facility document titled, “H&P,” dated October 21, 2024, at 5:53 p.m., was reviewed and indicated Patient 18 was admitted to the facility on October 20, 2024, for chest pain. A facility document titled, “Order Inquiry,” dated October 21, 2024, at 11:51 p.m., was reviewed and indicated, “HYDROmorphone [a pain medication]...DILAUDID...EVERY 4 [four] HOURS AS NEEDED...FOR SEVERE PAIN...INTRAVENOUS...0.5 MG/0.5 ML [milliliter, unit of measurement]...” A facility document titled, “Pain Assessment Flow Sheet,” was reviewed and indicated, “...10/22/2024 [October 22, 2024]...at 03:31 [3:31 a.m.] pain 10/10 ...” A facility document titled, “Pain Assessment Flow Sheet,” was reviewed. The document indicated “...Dilaudid 0.5mg/0.5ml was administered on October 22, 2024 at 3:37 a.m.” There was no documented evidence pain was reassessed after Dilaudid was administered to Patient 18 on October 22, 2024, at 3:37 a.m. On October 24, 2024, at 4:22 p.m., an interview was conducted with the Chief Quality Officer (CQO). The CQO stated the expectation is for the patient’s pain level to be reassessed one hour after the administration of pain medication. 1d. A review of Patient 19’s medical record was conducted on October 24, 2024, at 4:36 p.m., with the SC. A facility document titled, “H&P,” dated October 8, 2024, was reviewed and indicated Patient 19 was admitted to the facility on October 8, 2024, for abdominal pain, nausea, vomiting, and a missed dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). A facility document titled, “Order Inquiry,” dated October 08, 2024, at 7:55 p.m., was reviewed and indicated, “...HYDROmorphone...DILAUDID...EVERY 4 [four] HOURS AS NEEDED...FOR SEVERE PAIN...INTRAVENOUS...1 MG/1 ML...” A facility document titled, “Pain Assessment Flow Sheet,” dated October 15, 2024, was reviewed. The document indicated Patient 19’s pain level on October 15, 2024, at 8:54 a.m., was 10/10. A facility document titled, “MAR,” was reviewed. The document indicated Dilaudid 1mg/1ml was administered to Patient 19 on October 15, 2024, at 8:55 a.m. There was no documented evidence Patient 19’s pain level was reassessed after Dilaudid was administered on October 15, 2024, at 8:55 a.m. 1e. A review of Patient 24’s record was conducted on October 23, 2024, at 1:01 p.m., with the Patient Safety (PS). A facility document titled, “H&P,” indicated Patient 24 was admitted to the facility on October 23, 2024, for a urinary tract infection (a bacterial infection that affects the urinary tract, which includes the bladder, kidneys, and urethra) and a malfunctioning urinary catheter (a plastic tube placed in the body to drain and collect urine from the bladder). A facility document titled, “MAR,” was reviewed. The document indicated Morphine 2 mg IV was administered to Patient 19 on October 22, 2024, at 8:34 p.m. There was no documented evidence a pain reassessment was completed after morphine was administered to Patient 24 on October 22, 2024, at 8:34 p.m. An interview was conducted on October 23, 2024, at 1:52 p.m., with the PS. The PS stated pain reassessments should have been done one hour after pain medication was administered. The PS stated there was no documentation this was done for Patient 24 in accordance with the facility’s policy. A review of the facility’s P&P titled, “Pain Management,” revised September 2024, was conducted. The P&P indicated, “...If a treatment intervention for pain is provided, the response to that intervention should be assessed. Reassessment is recommended to occur within 15-60 minutes following treatment...the expectation for documentation is as soon as possible after completion of the reassessment...” 2a. A review of Patient 1’s record was conducted October 23, 2024, at 9:40 a.m., with the PS. A facility document titled, “H&P,” dated August 21, 2024, was reviewed and indicated Patient 1 was admitted to the facility on August 21, 2024, for hypotension (low blood pressure), generalized weakness, and a pressure injury to the left buttocks. An undated facility document titled, “WOUND PROGRESS NOTES,” was reviewed. The document indicated, “...Date...Length...Width...Depth...Undermining [the destruction of tissue or ulcer extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface]...Tunneling [a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound]...Sinus Tract [a narrow passageway extending from a wound]...Necrotic Tissue [premature death of body tissue]...Eschar [dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like, usually firmly attached to the base, sides and/or edges of the wound and over time falls off]...Stage [classification of wound severity]...DRAINAGE...Purulent...Serosanguineous [watery light red or pink colored Fluid]...None...ODOR...Foul...Mild...None...Exposed Tendon...Bone Exposed...GRANULATION TISSUE [red bumpy tissue]/QUANTITY AND COLOR...None...Base Only...Half Filled...Completely Filled...Covered w/ [with] Epithelium [thin tissue forming outer layer of the body]...Pale Gray...Pink...Red...Date MD notified 1st [first]...Re-evaluation & [and] notify of change date...C & S [culture and sensitivity, a laboratory test for infection and appropriate antibiotics] date...Treatment...Comments...Signatures...” There was no documented evidence the document was completed and Patient 1’s wounds was assessed. A facility document titled, “Photo Sheet,” was reviewed. The document was labeled “Left buttocks.” The document did not indicate the date and time when the photograph was taken, and nor the name or signature of the nurse who took the photograph. A facility document titled, “Photo Sheet,” was reviewed. The document was labeled “right.” The document did not indicate the time and date when the photograph was taken, a description of the wound, nor the name or signature of the nurse who took the photograph. An interview was conducted on October 23, 2024, at 9:40 a.m., with the PS. The PS stated the wound progress notes sheet should have been filled out in its entirety to document the wound and the photographs of the wound should have indicated the date and time of when the photograph was taken, the size of the wound, and the signature of the nurse who took the photograph in accordance with the facility’s policy. 2b. A review of Patient 30’s record was conducted October 24, 2024, at 1:15 p.m., with the PS. A facility document titled, “H&P,” dated October 2, 2024, indicated Patient 30 was admitted to the facility on October 2, 2024, for congested heart failure (condition when the heart is not pumping properly) and bilateral stasis ulcers (a wound on the legs caused by damaged veins). An undated facility document titled, “Wound Progress Notes,” was reviewed. There was no documented evidence Patient 30’s wound was assessed on October 7, 2024, through October 10, 2024. An interview was conducted on October 24, 2024, at 1:37 p.m., with the PS. The PS stated the facility document titled, “Wound Progress Notes,” should have been filled out for the days listed above to document the wound. The PS stated the documents for October 7 to October 10, 2024, were all blank. An interview was conducted on October 24, 2024, at 1:40 p.m., with the Chief Quality Officer (CQO). The CQO stated the facility document titled, “Wound Progress Notes,” should be filled out in accordance with the facility’s policy. The CQO further stated the policy was not followed. A review of the facility’s P&P titled, “PRESSURE INJURIES,” dated May 20, 2024, was conducted. The document indicated, “...pressure Injury care evaluation by the RN will be completed on the Wound Progress Note Form and placed in patient’s medical record under the Wound Care section...” 3a. A review of Patient 14’s record was conducted on October 24, 2024, at 4 p.m., with the SC. A facility’s document titled, “H&P,” dated September 30, 2024, was reviewed. The document indicated Patient 14 was admitted to the facility on September 30, 2024, for hip pain. A facility documents titled, “I&O,” from October 4, 2024, through October 11, 2024, were reviewed. The documents indicated Patient 14’s I&Os were not completed on the following dates: -October 4, 2024, at breakfast or dinner; -October 5, 2024, at lunch or dinner; -October 7, 2024, at breakfast, lunch or dinner; -October 8, 2024, at dinner; -October 9, 2024, at dinner; -October 10, 2024, at breakfast, lunch, or dinner; and -October 11, 2024, at lunch and dinner. A concurrent interview with the SC was conducted. He stated the day shift nursing staff should have documented the patient’s I&O during breakfast and lunch. He further stated the patient’s I&O during dinner may have been documented by the day shift or the night shift staff depending on when the patient had their dinner. He stated all meals should have been documented. 3b. A review of Patient 28’s record was conducted on October 24, 2024, at 1:27 p.m., with the PS. A facility’s document titled, “H&P,” dated March 31, 2024, was reviewed. The document indicated Patient 28 was admitted to the facility on March 31, 2024, for atrial fibrillation (irregular heartbeat) and diabetes mellitus (high blood levels). A facility document titled, “I&O,” was reviewed. There was no documented evidence Patient 28’s I&O were completed on the following days: -April 1, 2024; and -April 2, 2024, night shift. An interview was conducted on October 24, 2024, at 1:47 p.m., with the PS. The PS stated the nurse did not document the I&O’s for April 1, 2024, and on the night shift of April 2, 2024. The PS stated the facility did not have a policy for monitoring and recording I&O’s.”

“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: 42512 Based on interview and record review, the facility failed to ensure medication was given as ordered, for one of 30 sample patients (Patient 13), when Normal Saline (a type of fluid) with 20 milliequivalents (unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, during a rapid response (a hospital code when a group of healthcare professionals are called to a patient’s bedside to provide immediate care when a patient’s condition is unstable or they are critically ill) for Patient 13’s high potassium level. This failure resulted in Patient 13 to have more elevated potassium levels and may have resulted in delay of Patient 13’s recovery and could have contributed to the deterioration of Patient 13’s medical condition and subsequent death, and had the potential for further medication errors to occur, and may negatively affect the treatment and safety of the patients in the facility. Findings: On October 23, 2024, at 1:45 p.m., a review of Patient 13’s record was conducted with the Stroke Coordinator (SC). The facility document titled, “History and Physical,” dated September 30, 2024, at 5:34 a.m., was reviewed and indicated Patient 13 was admitted to the facility on September 29, 2024, with diagnoses which included abdominal pain, nausea, vomiting, and diarrhea with blood in the stool. The document indicated Patient 13’s potassium level was 4.7 mEq/L (milliequivalent per liter, unit of measurement, normal value 3.5-5.1 mEq/L). A facility document titled, “Progress Notes Report,” dated October 1, 2024, at 12:55 p.m., was reviewed and indicated, “...received call from lab [laboratory] around 11 am that pt’s [Patient 13] glucose [blood sugar level] was 10 [normal is 70 to 100 milligrams per deciliter, mg/dL, unit of measurement]...did another finger poke test on both fingers. Reading was too low foor [sic] glucometer [a handheld device which measures blood sugar level] to read. Called primary [physician] who ordered d50 [dextrose 50%, a type of IV fluid] push [a process of introducing a medication or fluid substance directly into the bloodstream via the venous system] and d10 [sic] at 60ml/hr [milliliter per hour, rate at which a drug is administered, unit of measurement]. called a rapid response [when a group of health care professionals are called to a patient’s bedside to assess and treat a patient who is showing signs of clinical decline], team arrived, see mar [medication administration record] and rapid [response] sheet for meds medication] given. Pt moved to ICU [intensive care unit, unit for critically ill patients]...” A facility document titled, “RAPID RESPONSE TEAM RECORD,” dated October 1, 2024, at 11:17 a.m., was reviewed. The document indicated, “...REASON FOR CALL...LOW GLUCOSE...10 PER LAB...MEDICATIONS...IV NS BOLUS [a type of fluid administered rapidly] 250 [milliliter]...OUTCOME...TRANSFERRED TO ICU...SITUATION...BS [blood sugar] 10 [mg/dl, milligrams per deciliter, unit of measurement, normal is 70 to 110 mg/dl]- D50 given blood sugar accucheck [point of care determination of blood sugar] still says 52 and pt [Patient 13] was unresponsive...” A facility document titled, “[Name of facility] Discharge Summary Report,” was reviewed and indicated, “...Date Oct 1 [October 1, 2024]...Time 1000 [10 a.m.] Potassium 6.6...H [high]...Reference Range...3.5-5.1...meg/L [unit of measurement]...Date Oct 1...Time 1342 [1:42 p.m.]...Potassium 5.9...H...Date Oct 1...Time 2030 [8:30 p.m.]...Potassium 6.4...H...” The document also indicated on October 1, 2024, Patient 13’s glucose were as follows on the following times: - at 10:55 a.m., < [less than] 10...Reference Units 70-110 MG/DL; - at 11:01 a.m., < 10 MG/DL; - at 11:09 a.m., < 10 MG/DL; - at 11:12 a.m., <10 MG/DL; - at 11:17 a.m., 103 MG/DL; - at 11:28 a.m., 92 MG/DL; - at 12:45 p.m., 47 MG/DL; - at 1:06 p.m., 163 MG/DL; - at 1:41 p.m., 121 MG/DL and, - at 8:07 p.m., 42 MG/DL; A facility document titled, “Medication Administration History Report,” dated September 9, 2024, at 12 a.m., through October 2, 2024, at 11:59 p.m., was reviewed. The document indicated the following: - “...Medication: DEXTROSE 50% IN WATER (D50W) 25GM [gram, unit of measurement]/50 ML...Order Dose 25 GM/50ML...Frequency: ONCE...Route: INTRAVENOUS...Indications: Hypoglycemia [low blood sugar]...Sched Dt/TM [Scheduled Date/Time] 10/01/2024 [October 1, 2024] 11:08 [a.m.] Admin Dt/Tm [Administered Date/Time] 10/01/2024 11:08 a.m...Charted Dt/Tm [Date/Time] 12:54 [p.m.] Adm [Administered] Dose 25 GM/50 ML...Route INTRAVENOUS...Note: glucose 10; - ...IV Dextrose 10% WATER D-10%...Order Dose: 1000 ML...Route...Intravenous...Rate 60 ML/HR...Start Date: 10/01/2024 12:00 [p.m.]; - “...Medication: DEXTROSE 50% IN WATER (D50W) 25GM/50 ML...Order Dose 25 GM/50ML...Frequency: AS NEEDED...Route: INTRAVENOUS...Start Date: 10/01/24...Indications: Hypoglycemia...Admin Dt/Tm 10/01/2024 20:52 [8:52 p.m.]...Charted Dt/Tm (Date/Time) 10/01/2024 20:52 [8:52 p.m.] Adm Dose 25 GM...Route INTRAVENOUS...” A facility document titled, “Name of Facility CODE BLUE [a hospital code for a person needing to be revived] RECORD,” dated October 2, 2024, at 9:25 a.m., was reviewed. The document indicated, “...REASON CODE [code blue] INITATED...Lost Pulses...0925 [9:25 a.m.]...Code Started...0935 [9:35 a.m.]...Compressions Stopped...” A facility document titled, “All Discrepancies Report,” dated October 24, 2024, at 12:04 p.m., indicated, “...[Unit B]...IV DEXTROSE 10% WATER 1000 ML...Beg [beginning] 1...End...2...Transaction Type...Count Inventory...[Unit B]...10/1/24 23:32 [11:32 p.m.]...IV NACL [sodium chloride, salt] 0.9 % w/ KCL 20 MEQ/L 1000 ML (POTASSIUM CHLORIDE IN 0.9%NACL)(1000 mL)...Beg...5 [five]...End...4 [four]...Transaction Type...Count Inventory...” [There was an extra bag of D10W and one IV bag of NS with 20 mEq/l of potassium was removed from the Pyxis.] There was no documented evidence D10 Water was scanned [process of scanning the patient’s identification bracelet and the medication label using a handheld device prior to administering the medication to the patient) as administered to Patient 13. There was no documented evidence of medication Dextrose 10% at 60 ml/hr was administered to Patient 13 on October 1, 2024, during the rapid response on October 1, 2024, at 11:17 a.m. During a concurrent interview with the SC, the SC stated the D50 25gm.50 ml IV fluid was taken from the Pyxis (an automated medication dispensing system) on October 1, 2024, for an emergent low blood sugar. The SC stated this IV fluid was an override (a process which allows staff to dispense medication without a pharmacist reviewing the order, usually in an emergency). The SC stated D10 Water was not scanned as administered for Patient 13. He further stated the policy is to scan the medication prior to administration to ensure the right medication is being administered. He stated if the medication was given during a rapid code or code blue and not scanned due to emergency, the staff would have documented the medication on the code sheet, and it was not. He stated the staff did not follow policy. The SC stated Patient 13 expired during the code blue on October 2, 2024, at 9:35 a.m. He further stated the low glucose at 8:07 p.m., was an indication patient was not receiving D10 per physician’s orders. The SC stated Patient 13’s low blood sugar on October 1, 2024, at 8:52 p.m., could have been due to the administration of the wrong IV fluid. On October 23, 2024, at 3:56 p.m., an interview was conducted with Nursing Supervisor (NS) 1. NS 1 stated, on October 2, 2024, Staff 4 reported to her that D10 was not hung and administered to Patient 13 in accordance with the physician’s orders and instead “Normal Saline with something else” was administered during the rapid response on October 1, 2024, but she (NS 1) did not try to find the IV bag. NS 1 stated Staff 4 reported the IV fluid with “something else” had a pink sticker labeled with D10. On October 23, 2024, at 4:15 p.m., an interview was conducted with Staff 1. Staff 1 stated, on October 1, 2024, the laboratory called to report a blood sugar of 10 for Patient 13. Staff 1 stated a rapid response code was called on October 1, 2024. Staff 1 stated the physician was called and he ordered D50 to be administered by IV push and D10 at a slow rate to maintain Patient 13’s blood sugar. Staff 1 stated NS 1 assisted in hanging fluids which were administered during the rapid response. Staff 1 stated the normal process is to label any fluid being hung with a pink sticker identifying the type of IV fluid, the date and time it was hung, and the name of the staff who hung the medication. Staff 1 stated he could not recall who hung the NS with 20 mEq/l of potassium IV fluid during the rapid response on Patient 13. Staff 1 stated the Pyxis does not require staff to scan a medication after it is taken out of the machine. He stated a medication was only scanned at the patients’ bedside after scanning the patients arm band. Staff 1 stated the facility did not inform him of any medication error (wrong IV fluid administered to Patient 13) prior to this interview. On October 23, 2024, at 4:45 p.m., an interview was conducted with NS 1. NS 1 stated after a report of a medication error, an investigation would be started. NS 1 stated she spoke to Staff 1 and Staff 5. She stated she was not able to pinpoint who administered the NS with 20 mEq/l of potassium IV fluid during a rapid response code on October 1, 2024. NS 1 stated the Pyxis did not require staff to scan the medication after it is pulled from the Pyxis machine. She stated she was not aware medications could be scanned at the Pyxis. NS 1 stated she did not report the incident of the wrong IV fluid administered to Patient 13 to the Quality department or to the Risk department. She stated the medication error would be considered an adverse or an unusual event and she was not aware if it had been reported to California Department of Public Health (CDPH, a state agency). On October 23, 2024, at 5:02 p.m., an interview was conducted with Staff 3. Staff 3 stated pharmacy staff scans the medications when loading them into the Pyxis. She stated the Pyxis has the capability to require medications be scanned after being removed from the machine prior to closing the drawer but this feature has not been activated at this facility. Staff 3 stated D10 was not scanned at the Pyxis nor when it was to be administered to Patient 13. Staff 3 stated the pharmacy department completed an inventory of the fluids on Unit B and the inventory indicated the Pyxis on Unit B was short one bag of NS with 20 mEq of potassium with one extra bag of D10. Staff 3 stated when the wrong medication was pulled there would be a discrepancy of both medications, with one missing and one having an extra bag. Staff 3 stated during the Code Blue, Patient 13’s blood sugar was 47 which would have indicated D10 was not actually being given. Staff 3 stated she was not told of the medication error but was alerted through the internal reporting system. Staff 3 stated she did not report the incident to anyone and she just answered the internal reporting system [a facility system filled out by the facility staff to report medication error]. On October 23, 2024, at 5:34 p.m., an interview was conducted with Staff 4. Staff 4 stated he received report from a day shift nurse and was told Patient 13 had a rapid response on Unit B and was on D10 at 60 ml/hr. Staff 4 stated at about 8 p.m., he entered Patient 13’s room and observed an IV fluid running at 60 ml/hr. He stated he followed the IV line and observed the line going to a medication fluid bag with a handwritten pink label which indicated D10, but noted that the IV medication bag read NS+20K (Normal Saline with 20 mEq of potassium). Staff 4 stated he stopped the medication but the bag was half empty, with about 500 ml left in the IV bag. Staff 4 stated he called Physician (P) 2 to inform him of the medication error. Staff 4 stated he completed a blood sugar check and Patient 13’s blood sugar was low. He stated P 2 ordered D50 and D10. Staff 4 stated labs were drawn, and Patient 13’s potassium level was now 6.4 [mEq/l]. Staff 4 stated he reported the medication error to the charge nurse, through the internal reporting system, and to NS 1. Staff 4 stated he informed NS 1 the IV bag of NS with 20 mEq/l of potassium was outside of the room in the blue bin. Staff 4 stated he offered to look for it, but NS 1 told him no. Staff 4 stated NS 1 did not attempt to look for the medication bag. On October 24, 2024, at 11:26 a.m., an interview was conducted with Staff 5. Staff 5 stated the process for receiving a new patient into the ICU was to receive report, verify the IV fluids that are being administered to the patient, and verify the medications the patient came with. Staff 5 stated he was told Patient 13 had D10 running at 60 ml/hr from the rapid response. He further stated he did see a pink sticker labeled D10. He stated the patient’s IVs were not working. He stated after Patient 13 arrived, the lab called, and a code sepsis [a life-threatening infection] was called. Staff 5 stated this was when code blue was called and Patient 13 was intubated [when a flexible tube is inserted in the airway to assist in breathing], and this was why the fluids had not been verified. Staff 5 stated he spoke to Staff 4 regarding the medication error. He stated they discussed the elevated potassium lab draw and was informed the IV bag labelled D10 was actually NS with 20 mEq of potassium. He stated if the patient would have received the D10 as ordered it would have helped with the low blood sugar and the high potassium. Staff 5 stated he had spoken to pharmacy staff regarding the Pyxis having the capability to scan medications when removing them but was told the facility does not pay for that functionality. On October 24, 2024, at 1:20 p.m., an interview was conducted with Staff 6. Staff 6 stated Patient 13 was transferred to the ICU with a bag of fluids with a pink label indicating D10 from the rapid response but did not verify what the content of the IV medication bag was. On October 24, 2024, at 2:27 p.m., an interview was conducted with P 1 who stated he ordered D10 for a low blood sugar. He stated he ordered Kayexalate (a medication to help bring potassium levels down) to bring down patient potassium as it was high. P1 stated Patient 13 was not able to take medication orally. He stated the purpose of the D10 was for low blood sugar and high potassium. He stated, “maybe during the rapid [response], they screwed up” and gave her NS +20K and not the D10. P1 stated he was informed of the medication error after the code blue. P1 stated he informed family of the code [blue] but did not inform family of the medication error. A review of the policy and procedure (P&P) titled, “MEDICATION ERROR REPORTING,” dated August 2021, was conducted. The P&P indicated, “...To describe the procedures for reporting a medication error and the mechanism for multi-disciplinary review to allow appropriate follow-up, education and continuous quality improvement to promote a medication error-free environment and prevent the reoccurrence of the same error...Medication errors are captured through many mechanisms...review of adverse drug reactions, review of abnormal lab values...All medication errors that resulted in the patient receiving the medication shall be reported immediately to the prescribing or primary physician and appropriate actions, documentations and reporting completed...The patient and/or family, as appropriate, shall be notified following the hospital disclosure policy...As soon as possible but no more than five business days from the event, an investigation and review of the medication error shall be done by the appropriate department...when a medication error occurs and the event reached the patient...An entry of the medication given, any adverse effects observed and actions taken are recorded appropriately in the patient’s medical record...The patient and/or family are notified according to the hospital disclosure policy...The event is reported via the Safety & Risk Management (SRM) Reporting System...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed...Upon notification of the error, the pharmacist will investigate the error...The Director of Pharmacy shall discuss with the individual who made the error the ramifications of such mistake and develop an action plan to help prevent future occurrence...” A review of the P&P titled, “ADVERSE EVENT/SENTINEL EVENT REPORTING AND ROOT CAUSE ANALYSIS,” dated January, 2022 indicated, “...A Sentinel Event...is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, severe harm...or permanent harm...A patient death or serious disability associated with a medication error, including, but not limited to, an error involving the wrong drug...An adverse event...that cause the death or serious disability of a patient...The facility shall inform the patient or the party responsible for the patient of the adverse event by the time the report is made...The department shall review Section 7073 of Title 22 of the California Code of Regulations requiring hospitals to report “unusual occurrences”...defines incidents as any event, occurrence or circumstance that is not consistent with the routine care and expected course of treatment...Reporting of...CDPH reportable occurrences will be completed electronically...will notify California Department of Public Health within 5 days of a non-emergency/non-urgent event and within 24 hours if the event is ongoing urgent/emergent threat to the welfare, health or safety of patients...” A review of the P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES,” dated November 2022, indicated, “...to establish the rights that each patient...has pertaining to their care...Receive information about their health status...course of treatment...including unanticipated outcomes...Receive care in a safe setting...” A review of the P&P titled, “MEDICATION ERROR REPORTING,” dated May 2018, indicated, “...definition of a medication error is “any preventable medication-related event that my cause or lead to inappropriate use or patient harm while the medication is in the control of the healthcare professional...All medication errors that resulted in the patient receiving the medication shall be reported immediately...and reporting completed...As soon as possible, but no more than (five) business days from the event, an investigation and review of the medication error shall be done. By the appropriate department...For medication errors...that resulted or have the potential for resulting in serious consequences, methods such as a Root Cause Analysis...shall be used to gain insight into the actual/potential error in an effort to reduce future occurrence within the hospital...The patient and/or family is notified...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed...” A review of the P&P titled, “PYXIS ENTERPRISE SERVER (ES) GUIDELINES FOR USE,” dated May 2024, indicated, “...To establish best practices for the utilization of the Pyxis Enterprise Server (ES) medical devices as a medication storage, security, dispensing and charging system approved medications and controlled substances; to establish quality controls to assure proper usage of both hardware and software components...the patient can be selected by searching under ‘All Available Patients’ or ‘My Patients’...After selecting the patient, select “Remove”, which will display medications Due Now...Select the medication...from the list to remove, follow any required prompts...remove the medication, then close the pocket and drawer...” A review of the P&P titled, “HAND-OFF COMMUNICATION,” dated September 2024, indicated, “...’Handoff’ communication will take place whenever there is a change in the patient’s...caregivers. Caregivers include all clinical staff and physicians...communication shall include...Situation...Vital signs...Background...History...Assessement...labs...medciations...When physicians and nurses are transferring patients/clients/residents to another level of care within or outside of the organization...Caregivers shall give a “Bedside Shift Report”...using SBAR format...in a clean and concise manner...Information provided during hand-off communications will include...Summary of the patient’s...current physical...health condition including...Current medications...IVs present...Recent...changes in the patient’s...condition...””

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 42512 Based on observation, interview, and record review, the facility failed to ensure the environment was maintained in such a manner that the safety and well-being of patients are assured, when: 1. The equipment in the kitchen area was observed to have black grime build-up, grease, food particles, and thick yellow/gray matter in the grease container (a metal compartment that holds grease from grill) of a gas range; 2. Multiple medical equipment used for patients on Unit A were observed to be broken, unavailable for patients’ use, and not sent for repairs; and, 3. Empty food containers and recyclables were observed stored under the sink in the nutrition/medication room on Unit B. These failures had the potential to cause a kitchen fire and/or provide harborage for rodents, which could contaminate food and cause food-borne illness for medically compromised patients who are admitted to the facility and who received food from the kitchen, and for equipment to not be available for patient’s use. Findings: 1. On October 21, 2023, at 1:47 p.m., a concurrent observation and interview were conducted in the kitchen with the Director of Food and Nutrition Services (DFNS). A build-up of black grime, grease, food particles, and thick yellow/gray matter were observed inside a grease container (compartment which holds grease) under the stainless-steel gas range stovetop. The DFNS stated the grease container was dirty. The DFNS stated there were no cleaning logs which indicate the grease container was part of the routine cleaning. The DFNS stated there was no policy or process for cleaning the stove. On October 23, 2024, at 1:30 p.m., a record review was conducted with the DFNS. A facility document titled, “FNS CLEANING AND SANITATION PROGRAM,” dated May 2024, was reviewed. The document indicated, “...To maintain a clean and safe environment of care and to prevent the transmission of food borne illnesses...A copy of the Employee Cleaning Schedules with identified cleaning frequencies can be found on the following pages as well as the Cleaning Procedures for specific pieces of equipment...” A facility document titled, “[Name of Manufacturer for stovetop in the kitchen], Installation and Operation Manual,” dated February 29, 2008, was reviewed. The document indicated, “...Griddle...to keep the griddle clean and operating at peak performance, follow these simple instructions...After Each Use...Clean griddle thoroughly with a grill scraper or spatula. Wipe off any excess debris left from cooking process...Once A Day...Clean griddle surface with a grill brick and grill pad. Remove grease container and clean thoroughly in same manner as any ordinary cooking utensil...” During a concurrent interview on October 23, 2024, at 1:30 p.m., conducted with the DFNS, the DFNS stated he read the operation manual and there should be daily cleaning of the grease container. 2. On October 21, 2023, at 10 a.m., an observation was conducted in the storage room on Unit A storage room with the Patient Advocate (PA), Stroke Coordinator (SC), and the Director of Facilities (DF). The following medical equipment were observed to be broken, not available for patient use, and not sent to be repaired: - One vital signs machine (a machine used to take patient’s blood pressure, heart rate, oxygen saturation [level of oxygen in the blood], and temperature). A facility document titled, “Safety Concern,” was observed taped on the vital signs machine. The document was reviewed and indicated, “...Name of person reporting machine...unit...type of machine...REMARKS...machine missing charging cord...ENGINEERING DEPARTMENT WAS NOTIFIED OF THIS REPAIR NEEDED BY TELEPHONE...10/16/2024 [October 24, 2024]...A WORK ORDER WAS INITATED TO ENSURE THE REPAIR OF THIS...” - One vital signs machine. A facility document titled, “Safety Concern,” was observed taped on the vital signs machine. The document indicated, “Safety Concern,” was reviewed and indicated, “No Oximeter.” The document did not indicate the name of the person who reported the broken machine, and if the department or engineering had been notified. A facility document titled, “Work Order,” taped on the vital signs machine was also reviewed. The document indicated, “...Request Details...VITALS MACHINE NOT WORKING...Needed by...09/24/2024 [September 24, 2024]...” - One television remote controller. A facility document titled, “Safety Concern,” was observed taped on the vital signs machine. The document indicated, “...Cable Exposed...ENGINEERING DEPARTMENT WAS NOTIFIED OF THIS REPAIR NEED BY TELEPHONE...10/16/24 [October 16, 2024]...” The document did not indicate the name of the person who reported the broken equipment. There was no work order observed attached to the broken remote control. During a concurrent interview conducted with the Director of Facilities (DF) on October 21, 2024, at 10 a.m., the DF stated once an equipment was found to be broken, the staff should have tagged it, then called for the repair. The DFS stated once the equipment was called for repair, the equipment should have been picked up by SPD (Sterile Processing Department), then cleaned, disinfected, and taken to engineering for repair. He further stated the broken equipment should not be on the unit, and especially not since September 2024 (a month ago). A review of the facility’s policy and procedure titled, “MAINTENANCE OF MEDICAL EQUIPMENT - NON LIFE SUPPORT,” dated April 2021, was conducted. The policy indicated, “...Each piece or type of equipment is to be measured for performance standards based on user experience and manufacturer’s recommendations...Operational reliability is critical, and to promote the operational reliability, the non-life support medical equipment is required to be preventatively maintained...At the beginning of the month, the scheduled maintenance work orders are issued...Maintenance is performed in accordance with the instructions included in the work order. The maintenance shall be documented, including any pertinent observations, on the work order...” 3. A tour was conducted on Unit B on October 21, 2024 at 11:30 a.m., with the Nursing Supervisor (NS) and the Chief Nursing Officer (CNO). The nutrition/medication room on Unit B was observed to have two medium sized food containers with smeared white particles stacked underneath the sink, along with a large plastic bag filled with empty beverage cans. An interview was conducted on October 21, 2024, at 11:30 a.m., with Registered Nurse (RN) 1. RN 1 stated the cabinet underneath the sink should not have any items and it should have remained locked. RN 1 stated staff belongings should not be stored in the nutrition/medication room. A review of an undated facility’s policy and procedure titled, “Cleaning Procedures,” was conducted. The policy indicated, “...cleaning of key areas to ensure they appear neat and tidy until thorough cleaning can occur...Everyone in the Housekeeping Department is responsible for keeping the hospital areas sparkling and free of debris...””

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 42512 Based on observation, interview, and record review, the facility failed to ensure the overall hospital environment was maintained to warrant the safety and well-being of the patients, when: 1. The call light was not working and some of the beds were missing in 17 out of 18 rooms at the second floor (Rooms 2A, 2B, 2C, 2D, 2E, 2F, 2G, 2H, 2I, 2J, 2K, 2L, 2M, 2N, 2O, 2P, and 2Q) and in 10 out of 19 rooms at the third floor (Rooms 3A, 3B, 3C, 3D, 3E, 3F, 3G, 3H, 3I, and 3J) (Refer to A 701); 2. The call light was not working and some of the beds were missing in eight of nine rooms at the sixth floor Critical Care Unit (CCU, a unit for critically ill patients) (Rooms 6A, 6B, 6C, 6D, 6E, 6F, 6G, and 6H)(Refer to A 701); and 3. Three of four pharmaceutical (pertaining to medications and intravenous fluids) waste bins at the Intensive Care Unit (ICU, a unit for critically ill patients) (Bins 1, 3, and 4) were not emptied timely and were over filled (Refer to A 701). The cumulative effect of these facility failures had the potential for the patients’ safety and well-being to be at risk.”

“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: 42512 Based on interview and record review, the facility failed to ensure the patient or the patient’s representative’s rights were protected, for four of 30 sampled patients (Patients 2, 20, 21, and 23), in accordance with the facility’s policy and procedure (P&P), when 1. For Patients 20, 21, and 23, there was no documented evidence the Important Message from Medicare form was provided to and signed by the patients nor the patients’ representatives; and 2. For Patient 2, the informed consent was not completed appropriately. These failures had the potential to result in the patients or patients’ representatives to not be informed of their rights to appeal their discharge. Findings: 1.a. On August 13, 2024, at 1:10 p.m., a concurrent interview and review of Patients 20, 21, and 23’s records were conducted with the Patient Safety Coordinator (PSC). a. The facility document titled, “History and Physical,” dated July 10, 2024, at 9:23 p.m., indicated Patient 20 was admitted to the facility for frequent episodes of falls. A facility document titled, “Important Message from Medicare (IMM),” indicated, “...Please sign below to indicate you received and understood this notice...” The signature line indicated, “...Verbal obtained...” There was no documented evidence the IMM was provided to and signed by Patient 20. b. A review of Patient 21’s record was conducted. The facility document titled, “History and Physical,” dated July 23, 2024, at 3:13 p.m., indicated Patient 21 was admitted to the facility for shortness of breath. A facility document titled, “Important Message from Medicare,” indicated, “...Please sign below to indicate you received and understood this notice...” The signature line indicated, “...Verbal...” There was no documented evidence the IMM was provided to and signed by Patient 21. c. A review of Patient 23’s record was conducted. The facility document titled, “History and Physical,” dated June 26, 2024, at 11:05 p.m., indicated Patient 23 was admitted to the facility for a rash to the left lower extremity (leg and foot) and a recent history of scabies (a contagious skin disorder). A facility document titled, “Important Message from Medicare,” indicated, “...Please sign below to indicate you received and understood this notice...” The signature line indicated, “...Unable to sign...” There was no documented evidence that the Important Message from Medicare (IMM) was given and signed by Patient 23. The PSC stated, if staff were not able to obtain a patient signature, the document should have indicated who received the form. She further stated the form should have also been signed by two staff to acknowledge the verbal signature. On August 14, 2024, at 10:10 a.m., an interview was conducted with the Case Manager (CM). The CM stated the IMM form should have been signed by the patient or the patient’s representative. The CM stated, if the case manager could not obtain a signature, the case manager needed to indicate the name of the patient or the patient’s representative to whom the form was provided, and the case manager and the registered nurse would need to both sign the form. On August 14, 2024, at 10:15 a.m., an interview was conducted with the Director of Case Management (DCM). The DCM stated, if the patient could not sign the IMM form, the case manager would then reach out to the family to have them sign the form. She further stated if a verbal signature was obtained over the phone, two facility staff would need to acknowledge and sign the form. She further stated the form’s signature should have been more specific as to who obtained the information and who signed the form. A review of the facility P&P titled, “IMPORTANT MESSAGE FROM MEDICARE IMM FORM,” dated April, 2021, indicated, “...All inpatients who are Medicare beneficiaries, including those enrolled in Medicare Advantage Plans...and those who have Medicare as a secondary payor, will be notified about their discharge rights...The Important Message from Medicare (IMM) will be given to all applicable patients by Patient Access staff within 2 days of admission...The Patient Access Rep (PAR) will explain the IMM to the patient...The patient will be asked to sign, date, and time the form...” 2. On August 13, 2024, at 9:20 a.m., a concurrent interview and review of Patient 2’s record were conducted with the Nursing Supervisor (NS). A review of Patient 2’s record was conducted. The facility document titled, “History and Physical,” dated August 6, 2024, at 7:37 p.m., indicated Patient 2 was admitted to the facility for shortness of breath for three days while on oxygen, abdominal distension (measurably swollen beyond its normal size), and right leg swelling. A facility document titled, “CONSENT TO SURGERY OR SPECIAL PRODEDURE,” showed any of the boxes for History and Physical Reviewed: No changes and Changes noted, updated record was not checked. The document showed the lines for Physician Signature and Anesthesiologist Signature, and the respective lines for the date and time of the signature were left blank. A facility document titled, “(Name of Facility)...Bedside Procedures,” was indicated, “...Procedure Date 08/09/2024 [August 8, 2024]...Start Time/Date...6:00 P.M. 8/9/24...” On August 14, 2024, at 9:15 a.m., an interview was conducted with the NS. The NS stated the consent should have been signed, and the date and time should have been indicated before the insertion of a central line (a thin, flexible tube that’s inserted into a large vein in the body to provide fluids, medication, blood, or nutrition). The NS stated the physician did not follow the facility’s policy and procedure. A facility document titled, “Medical Staff Rules & Regulation,” was reviewed and indicated, “...2.7 Dated/Timed...All clinical entries in the patient’s medical record shall be accurately dated, timed, and authenticated...” The facility P&P titled, “INFORMED CONSENT,” dated May, 2024, indicated, “...A physician has both a legal and ethical duty to obtain the patient’s consent or the consent of the legal representative prior to treatment...The hospital is required to obtain documentation of consent to hospital services and to verify that the physician has obtained informed consent as appropriate...Informed Consent must be obtained prior to the procedure consent being signed, dated and timed by the patient...””

“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: 42512 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for three of 30 patients (Patients 10, 16, and 23), when: 1. For Patient 16, the physician was not notified of the patient’s high blood pressure; 2. For Patient 10, the physician was not notified of the the patient’s critical laboratory result; and 3. For Patient 23, the physician was not notified of the patient’s fall. These failures had the potential to delay patient care and may cause harm or death to the patients. Findings: 1. On August 13, 2024, at 10:31 a.m., a concurrent interview and review of Patient 16’s record were conducted with the Patient Safety Coordinator (PSC). A facility document titled, “History and Physical,” dated August 8, 2024, indicated Patient 16 was admitted to the facility for shortness of breath. The document further indicated Patient 16 has a past medical history of diabetes mellitus (elevated blood sugar). A facility document titled, “Blood Sugar Check Order,” dated August 11, 2024, indicated, “...Accu -Check [tool to check blood sugar] AC [morning] & HS [night]...” A facility document titled, “Insulin Orders,” dated August 10, 2024, at 9:31 p.m., indicated, “...INSULIN REGULAR HUMAN...ACHS PRN [as needed]...” An untitled facility document indicated, “...Insulin Regular Human...Give if Blood Sugar Greater Than 400...Before Meals and at Bedtime as Needed...Start Date 08/10/2024 [August 10, 2024] 2131...” A facility document titled, “Critical Value (Glucose 423),” dated August 12, 2024, indicated, “...Result Name...GLUCOSE POC...423...Reference Range...70-110 mg/dL [milligrams per deciliter, unit of measurement]...” A facility document titled, “Sliding Scale,” dated August 12, 2024, indicated, “...Blood Glucose 351-400...Insulin 8 [eight] units...> [greater than] 400 call physician...” There was no documented evidence insulin was administered to Patient 16 as ordered and the physician was notified of the patient’s blood sugar of 423 mg/L. On August 13, 2024, at 11 a.m., an interview was conducted with the PSC. The PSC stated the expectation for all registered nurses would be to call and inform the physician of a patient’s high blood sugar and obtain new orders. On August 14, 2024, at 5 p.m., an interview was conducted with the Unit Supervisor (US). The US stated the registered nurse should have called the physician to report the high blood sugar and then carry out the physician’s new order. 2. On August 14, 2024, at 3 p.m., a concurrent interview and review of Patient 10’s record were conducted with the Deputy Regional Director of Quality (DRDQ). A facility document titled, “History and Physical,” dated August 6, 2024, indicated Patient 10 was admitted to the facility for complications of a fall at home. The document further indicated Patient 10 has a history of end stage emphysema (a lung disease causing shortness of breath), cardiomyopathy (a disorder affecting the heart muscle), and atrial fibrillation (irregular heart rhythm). A facility document titled, “Hematology,” dated August 11, 2024, indicated, “...Aug [August]10 [2024]...0510 [5:10 a.m.]...HGB [hemoglobin, a component of the red blood cell that carries oxygen to the body]...5.5 (h) * [critical] L [low]...References Units...12.5-16.3g/dl (grams per deciliter, units of measurement)...called at 0611 [6:11 a.m.] on 8/10/24 [August 10, 2024]...” A facility document titled, “Progress Notes Report,” dated August 10, 2024, at 7:49 a.m., indicated, “...Received call from lab [laboratory] this AM [morning] for critical HGB of 5.5 Hgb downwards trending since 08/06 [August 6, 2024]. Notified [name of physician]...Orders n place to transfer to DOU [direct observation unit; unit where patient’s need more extensive monitoring]...” (The physician notification was conducted one hour and 38 minutes after notification of the critical laboratory result was called in to the unit) On August 14, 2024, at 3 p.m., an interview was conducted with the DRDQ. The DRDQ stated the registered nurse (RN) should have called the physician to report the critical hemoglobin within 60 mins. The DRDQ stated the RN was 38 minutes late in notifying the physician based on the facility’s policy. A review of the facility P&P titled, “PHYSICIAN NOTIFICATION,” dated May 2024, was conducted. The P&P indicated, “...Purpose: To outline the process by which physician notification occurs when warranted by a change in the patient condition...It is the policy of this facility that all changes in patient condition will be communicated to the physician...Any sudden or serious change in patient’s condition...will be communicated to the physician at once...If unable to contact the attending physician or alternate physician TIMELY, initiate the Chain of Command policy...” A review of facility P&P titled, “Critical Lab Values and Diagnostic Tests Results; Notification of,” dated May 2021, was conducted. The P&P indicated, “...The responsible physician ...will be notified as soon as possible, but no later than, 60 min...” A review of P&P titled, “Critical Values,” dated February 2024, was conducted. The P&P indicated, “...critical values are defined as...Test...Results...Hematology Section...Hemoglobin...< (less than) 7gm/dl...” 3. On August 14, 2024, at 10:22 a.m., a concurrent interview and review of Patient 23’s record were conducted with the Patient Safety Coordinator (PSC). A facility document titled, “History and Physical,” dated June 26, 2024, indicated Patient 23 was admitted to the facility for a rash. The document further indicated Patient 23 has a past medical history of scabies (a contagious skin disorder. A facility document titled, “Diagnostic Imaging Department,” dated June 28, 2024, at 10:24 a.m., indicated, “...Procedure: CT [computerized tomography, an imaging procedure] Brain w/o [without] contrast...Study date and Requested Time: 6/28/2024 [June 28, 2024] 10:24 AM [a.m.]...Study Reason: unwitnessed fall...” A facility document titled, “Daily Focus Assessment Report,” indicated, “...Assessment Date 6/28/2024 08:00 [8 a.m.] Safety Interventions...Entry Date 06/28/2024 10:48 [a.m.]...” An untitled facility document indicated, “...Order Code...Sitter Required, Patient Disoriented...Start Date 06/28/2024 [June 28, 2024]...” A facility document titled, “Progress Notes Report,” dated June 26, 2024, at 12:07 p.m., indicated, “...Neurochecks/vitals done and at baseline for patient [Patient 23]. Patient was transpoorted [sic] to CT scan. Patient’s [family member] notified of fall, sitter watching patient per MD [medical doctor] order...” There was no documentation about Patient 23’s fall on June 28, 2024. There was no documented evidence Patient 23’s physician was notified of Patient 23’s fall on June 28, 2024. On August 14, 2024, at 10:34 a.m., an interview was conducted with the Patient Safety Coordinator (PSC). The PSC stated there was no documentation of the fall in the patient’s record. The facility P&P titled, “Physician Notification,” dated May 2024, indicated, “...It is the policy of this facility that all changes in patient condition will be communicated to the physician...Any sudden or serious change in a patient’s condition...will be communicated to the physician at once. This communication must be documented in the patient’s medical record. The facility P&P titled, “FALL ASSESSMENT, PREVENTION AND REDUCTION PROGRAM,” dated April 2024, indicated “...If fall occurs, assess patient for presence of injury and document in medical record...Notify physician(s) actively involved in the care of the patient...””

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 42512 Based on observation, interview, and record review, the facility failed to ensure the overall hospital environment was maintained to warrant the safety and well-being of the patients, when: 1. The call light was not working and some of the beds were missing in 17 out of 18 rooms at the second floor (Rooms 2A, 2B, 2C, 2D, 2E, 2F, 2G, 2H, 2I, 2J, 2K, 2L, 2M, 2N, 2O, 2P, and 2Q) and in 10 out of 19 rooms at the third floor (Rooms 3A, 3B, 3C, 3D, 3E, 3F, 3G, 3H, 3I, and 3J); 2. The call light was not working and some of the beds were missing in eight of nine rooms at the sixth floor Critical Care Unit (CCU, a unit for critically ill patients) (Rooms 6A, 6B, 6C, 6D, 6E, 6F, 6G, and 6H); and 3. Three of four pharmaceutical (pertaining to medications and intravenous fluids) waste bins at the Intensive Care Unit (ICU, a unit for critically ill patients) (Bins 1, 3, and 4) were not emptied timely and were over filled. These failures had the potential to affect the patients’ health and safety by not providing a means to contact the facility staff, which may contribute to a patient’s needs to not be addressed timely and may lead to episodes of falls or death. Findings: 1a. On August 13, 2024, at 9:36 a.m., a facility tour was conducted with the Interim Chief Nursing Officer (ICNO). During the tour of the second floor, the following were observed: - in Room 2A- a negative pressure room (a type of hospital room that keeps patients with infectious illnesses, or patients who are susceptible to infections from others, away from other patients) with a part of a sewer pipe broken; - in Room 2B- Bed 1 was present with a working call light, and Bed 2 and the call light remote control were not available; - in Room 2C- Bed 1 was missing and the call lights were activated and did not function; - in Room 2D- Bed 2 was missing and the call lights were activated and did not function; - in Room 2E- Bed 2 was missing and the call lights were activated and did not function; - in Room 2F- Bed 1 was missing and the call lights were activated and did not function; - in Room 2G- Bed 1 was missing and the call lights were activated and did not function; - in Room 2H- there were no beds observed in the room and the call lights were activated and did not function; - in Room 2I- there were no beds observed in the room and the call lights were activated and did not function; - in Room 2J- there were no beds observed in the room and the call lights were activated and did not function; - in Room 2K- the call lights for Beds and 2 were were activated and did not function; - in Room 2L- there were no beds observed in the room and the call lights were activated and did not function; - in Room 2M- Bed 1 was missing and the call lights for both Beds 1 and 2 were activated and did not function; - in Room 2N - the call lights for both Beds 1 and 2 were activated and did not function; - in Room 2O- there were no beds observed in the room, the sink was out of service, and the call lights for both Beds 1 and 2 were activated and did not function; - in Room 2P - there were no beds observed in the room and the call lights for both Beds 1 and 2 were activated and did not function; and - in Room 2Q - there were no beds observed in the room and the room was full of mobile computers. During a concurrent interview with the ICNO, she stated the mobile computers were being updated due to the software crashing incident a few weeks back. She stated the rooms on the second floor were medical-surgical rooms and were not ready for patient use. She stated there has not been a patient placed on the second floor for many years. She stated the call lights system on this floor was not in working order. b. On August 13, 2024, at 10 a.m., a tour of the facility’s third floor was conducted with the Interim Chief Nursing Officer. During the tour of the third floor the following were observed: - in Room 3A- there was no call light remote available for Bed 1. There was a patient in Bed 2 and the call light was activated and did not function; - in Room 3B- there were patients using Beds 1 and 2 and the call lights were activated and did not function for both beds; A cow bell was observed by Bed 1; - in Room 3C- there were patients using Beds 1 and 2 and the call lights for both beds were activated and did not function; - in Room 3D - Bed 1 was missing and the call lights for Beds 1 and 2 were activated and did not function; - in Room 3E- a contact isolation room (room where patients with contagious diseases are placed and infetion prevention precautions are exercised). Bed 1 was missing. There was a patient in Bed 2 but the call lights for Beds 1 and 2 were activated and did not function; - in Room 3F- the call light for Bed 1 was activated and did not function and the call light for Bed 2 did not have a call light remote control; - in Room 3G- there was a patient in Bed 1 and the call lights for Beds 1 and 2 were activated and did not function; - in Room 3H - there was a patient in Bed 1 and the call lights for Beds 1 and 2 were activated and did not function; - in Room 3I- the call lights for both Beds 1 and 2 were activated and did not function; and - in Room 3J- there was no call light remote control for Bed 2. During a concurrent interview with the ICNO, she stated the call light system was important for patient safety. She stated in the event the call light system went down, cow bells would be distributed to the patients. She stated the cow bells had not been distributed to the patients on the third floor. On August 14, 2024, at 2:25 p.m. an interview with the Director of Facilities (DOF) was conducted. He stated the call lights on the second floor have been broken for a very long time. He stated he obtained a quote to fix those call lights but the cost was over two hundred thousand dollars and would need authorization from corporate. The DOF stated the call light system on the third floor has been broken since March of 2024. He stated the company was supposed to come fix the call light system on August 13, 2024, but they didn’t. A review of the facility document titled, “Falls last 3 [three] months 2024,” indicated six out of 21 falls occured on the third floor unit. 2. On August 13, 2024, at 12:15 p.m., a facility tour was conducted with the Nursing Supervisor (NS) and Patient Advocate (PA). During the tour of the sixth floor CCU unit the following were observed: - in Room 6A- there was no room number signage on the door, the bed was missing, and the call light did not stay on but only worked when the button is held down; - in Room 6B- there were no beds in the room; - in Room 6C- there were no beds in the room, the call lights were activated and did not function, and there were no call light remote controls available; - in Room 6D- there were no beds in the room, the call lights were activated and did not function, and there were no call light remote controls available; - in Room 6E- there were no beds in the room, the call lights were activated and did not function, the wall unit headboard was broken, and there was exposed wiring observed; - in Room 6F- there were no beds in the room, the call lights were activated and did not function, and there were no call light remote controls available; - in Room 6G- the call lights were activated and did not function; and - in Room 6H- the call lights were activated and did not function and there were no call light remote controls available. During a concurrent interview with the NS, she stated the call lights are not working and the rooms did not have beds because the unit is closed and have not been used since 2020. When asked if the unit was officially closed and if they had sent the information to the California Department of Public Health, the NS stated, “No, it is not official.” A review of the facility policy and procedure (P&P) titled, “NURSE CALL SYSTEM FAILURE,” dated April 2021, was conducted. The P&P indicated, “...To provide a method of communication for patients in the event the nurse calls system fails...The nurse call system provides audible communication between patients and nursing staff for assistance in routine or emergency situations...In the event of a malfunction and/or failure of the nurse call system the following procedures will be followed...Identify the cause of the failure and attempt to repair...If the nurse call system has been disabled and the problem is not remedied immediately, notify nurse call system vendor to dispatch immediate emergency service technician...Determine cause of failure and taken immediate steps to eliminate...Revise as necessary any tests, or changes in preventive maintenance to systems...” 3. On August 13, 2024, at 9:36 a.m., a facility tour was conducted with the Nursing Supervisor (NS). During the tour of the ICU, the following pharmaceutical bins were observed: - Outside ICU Room A, Bin 1 was observed to have intravenous fluids (fluids administered through a vein) bags sticking out of the opening of at the top; and - Outside ICU Room B, Bins 3 and 4 were observed to have intravenous fluids bags sticking out of the opening of at the top. During a concurrent interview with the NS, On August 13, 2024, at 9:36 a.m., she stated the bins should not have the intravenous fluid bags sticking out of the top. The NS stated the bins should have been emptied by housekeeping. A review of the facility P&P titled, “Medical waste management Plan,” dated July 2021, was conducted. The P&P indicated, “...TYPES OF MEDICAL WASTE GENERATED...PHARMACEUTICAL WASTE...Sharps disposal units, when three-fourths (3/4) full, are exchanged by nursing personnel in the nursing units...Sharps containers shall be considered “full” when they reach 2/3 capacity or the manufacturer’s full line...””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure full medical examination and treatment was provided timely, for one of 22 sampled patients (Patients 22). This failure had the potential to affect the patients’ health and safety and may result in a delay in treatment. Findings: On August 6, 2024, at 1:45 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated he heard a five year old female child (Patient 22) came in with a respiratory infection and was discharged possibly four to five months ago. He stated the day following the Patient 22’s discharge, the patient was brought back into the Emergency Department (ED) in full arrest (condition when a patient stopped breathing and the heart stopped beating). He stated cardiopulmonary resuscitation (CPR, chest compressions to attempt to revive a person) was performed but Patient 22 expired. On August 6, 2024, at 2 p.m., an interview was conducted with Physician 1. Physician 1 stated he clearly remembered Patient 22 as he was the physician who ran the code (code blue, a hospital code for a patient who is needing to be revived) when Patient 22 came in. He stated Nurse Practitioner (NP) 1 saw Patient 22 in the Rapid Medical Exam (RME, area of the ED for patients who need to be examined) area on the first time the patient was brought to the ED. He stated he could not recall Patient 22’s name, but the incident occurred between January to March of 2024. On August 6, 2024, at 3 p.m., a concurrent interview and review of Patient 22’s record were conducted with the Quality Manager (QM). A facility document titled, “...Emergency Department Record- Pediatric- Scribe to Mid-Level,” dated February 24, 2024, authored by NP 1, indicated, “...Patient [Patient 22] is a 5 [five] year old...broguht in...for evaluation of fever, congestion, runny nose, cough x 2-3 [two to three] days ago. Patient reporting chest pain and dysuria [difficulty in urination]...ED Course/Medical Decision Making...Orders placed for urine [laboratory test] and...Chest [chest xray, an imaging procedure] 2 [two] View...Patient administered Tylenol [a pain and fever reducing medication] 325/mg [milligram, unit of measurement] 10.15 mL [milliliter, unit of measurement] PO [by mouth] and Ibuprofen [a pain and fever reducing medication] 340 mg/17 mL PO. Will continue to monitor...2311 [11:11 p.m.]: Nurse reports repeat temp [temperature, normal temperature in children is 97.6 to 99.3 F] is 102.7 [degrees Fahrenheit, F, a unit of measurement] after patient received meds [medications] 40 minutes ago...2337 [11:37 p.m.]: Nurse reported that repeat temp is 103 [F]. Patient given ice packs...0020 [12:20 a.m.]...Repeat temperature is 101.8 [F]...” A facility document titled, “ED Summary Report,” dated February 24, 2024, indicated, “...Vital Signs...02/24/2024 [February 24, 2024] 21:36 [9:36 p.m.]...Temp 101.1 F...BP [blood pressure] [no entry indicated]...Pulse [heart rate] 160 [beats per minute, bpm; normal heart rate in children is 80-140 bpm]...Resp [respirations] 20...O2 sat [oxygen saturation, level of oxygen in the blood] 98%...23:13 [11:13 p.m.] Temp 102.7 F...[no entries were documented for the BP, pulse, respiration, O2 sat]...02/25/2024...00:17 [12:17 a.m.]...Temp 102.1 F...no entries were documented for the BP, pulse, respiration, O2 sat]...” A facility document titled, “Medication Administration Record,” dated February 24, 2024, indicated, “...Scheduled Meds...Acetaminophen [a fever reducing medication]-STAT [to administer immediately]...325 MG/10.15ML...Admin [administered] 02/24 [February 24, 2024] 22:49 [10:49 p.m.]...Ibuprofen-STAT...100 MG/5ML...Admin...02/24...22:39 [10:39 p.m.]...” A facility document titled, “Diagnostic Imaging Department,” dated February 24, 2024, at 11:49 p.m., indicated, “...Impression...Right middle lobe pneumonia [a lung infection]...” A facility document titled, “Discharge Assessment/Summary Report,” indicated, “...Patient [Patient 22] departed from the ED Date and Time 02/25/2024 [February 25, 2024] 12:24 a.m...” A facility document titled, “...Emergency Department Record Pediatric- Scribe to Physician,” indicated, “15:55 [3:55 p.m.]: Patient brought in by [family member]...No pulses were felt. CPR began immediately. Code Blue initiated...Time of death pronounced at 1645 [4:45 p.m.]...” There was no documented evidence a complete set of vital signs which included pulse, BP, respirations, O2 sat, and pain were taken for Patient 22 during her first visit to the ED on February 24, 2024, until she was discharged on February 25, 2024, at 12:24 a.m. There was no documented evidence Patient 22’s vitals were taken prior to being discharged. There was no documented evidence laboratory tests aside from chest x-ray and urinalysis were done for Patient 22. The QM stated Patient 22’s acuity Emergency Severity Index (ESI, a tool used in the ED to determine which patient needs urgent attention with level 1 meaning immediate medical care is needed, patients classified as level 2 and 3 means care is needed within 15 minutes, and those classified as level 4 and 5 means care is needed within 30 minutes) level was a three. On August 6, 2024, at 4:26 p.m. a concurrent interview and review of Patient 22’s record were conducted with Physician 1. Physician 1 stated vital signs should be taken when patient comes in and prior to discharging the patient to ensure the patient is stable. Physician 1 stated the cause of cardiac arrest (when the heart stopped beating) for Patient 22 could have been possible pneumonia leading to sepsis (a life threatening infection in the blood). He further stated vital signs and laboratory tests would indicate if a patient has sepsis. On August 6, 2024, at 4:56 p.m., an interview was conducted with NP 1. NP 1 stated vitals should have been taken at discharge. She further stated she requested vitals prior to discharginf Patient 22 but she was not sure what they were if they were not documented. A review of the policy and procedure (P&P) titled, “Discharge From Emergency Department,” dated August 2019, was conducted. The P&P indicated, “...After being evaluated in the Emergency Department (ED) by a Licensed Independent Practitioner (LIP) and/or MD, appropriate discharge planning for a patient includes completing a medical record, making a plan for follow-up care suitable to the individual patient’s needs...Documentation appropriate for the patient will occur within the Discharge Tab in EMR...A discharge assessment shall be completed prior to leaving the ED...” A review of the P&P titled, “Triage And Assessments Of Patients Using The Emergency Severity Index (ESI),” dated, April, 2023, was conducted. The P&P indicated, “...To ensure that every patient receives efficient and appropriate medical care based on his/her Emergency Severirty Index (ESI)...Complete a triage to determine the patient’s condition...This initial triage should include...An assessment of the patient’s vital signs...ESI LEvel 3: Urgent; Stable iwth multiple types of resources needed to investigate or treat (such sa lab tests and x-ray imaging)...The patient presents with a condition that could progress to a serious problem requireing emergency interventions...The vital signs of a Level 3 patient may or may not be outside of normal limits (danger zone)...””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 42512 Based on observation interview, and record review, the facility failed to ensure care and treatment were provided in a safe environment, for one of 30 sampled patients (Patient 5), when: 1. Medical staff was not held accountable to the governing body for the quality of care provided patients (Refer to A-0049); and 2. Services were not provided in a safe and effective manner (Refer to A-0083). The cumulative effect of these systemic failures resulted in the patients to not be provided safe and quality care to meet the patient needs and had the potential to delay the provision of care and treatment of the patients.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 42512 Based on interview and record review, the facility failed to develop, implement, and maintain an effective, ongoing, hospital-wide data driven quality program for the use of restraints (Refer to A0286). This failure had the potential to cause harm or death to the patients. The cumulative effect of these systemic failures resulted in the patients to not be provided safe and quality care to meet the patient needs and had the potential to delay provision of care and treatment.”

“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: 42512 Based on observation, interview and record review, the facility failed to ensure the facility’s policy and procedures were implemented, for 22 of 30 sampled patients (Patients 1, 2, 3, 5, 6, 7, 8, 9, 14, 15, 16, 17, 18, 19, 22, 23, 24, 25, 26, 27, 28 and 29), when: 1. The facility failed to ensure an individualized plan of care was completed, for four of 30 sampled patients (Patient 22, 25, 26, and 27) (Refer to A0396); 2. For Patient 1, a physician’s order for the application of restraints (any manual or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body) was not obtained. This failure had the potential to result in injury or unnecessary use of restraints (Refer to A0398); 3. For Patient 24, repositioning was not done every two hours, weekly photographs of the patient’s wounds were not taken, and documentation of the wounds was not completed, in accordance with the facility’s policy and procedure (Refer to A0398); 4. For Patients 16, 18, and 27, screening for Methicillin Resistant Staphylococcus Aureus (MRSA, a bacterial infection that is difficult to treat) was not completed (Refer to A 0398); 5. For Patients 3, 6, 7, 8, 9, 14, 15, 16, 17, 22, 23, 24, 25, 26, 27, and 28, Chlorhexidine Gluconate (CHG, bathing product that kills germs and reduces the spread infection in hospitals) baths were not provided (Refer to A0398); 6. For Patient 14, two intravenous (IV, administered through the veins) medications observed hanging by the bedside were not labeled (Refer to A0398); 7. For Patients 6, 7, 8, and 29, pain was not reassessed after pain medication administration (Refer to A0398); 8. For Patients 2, 7, 14, 22, 23, and 24, a 12 lead EKG (electrocardiogram, a procedure to record heart rate and rhythm) was not completed in accordance with the facility’s policy and procedure (Refer to A0398); 9. For Patient 27, pain was not addressed (Refer to A0398); 10. For Patient 27, critical blood pressure was not reported to the physician (Refer to A0398); 11. For Patients 25 and 27, medication reconciliation was not completed on admission (Refer to A0398); 12. For Patients 22 and 23, the telemetry (recording or remotely monitored heart rate and rhythm) strips were not printed, analyzed, signed, and documented in the patients’ record every four hours, in accordance with the facility’s policy and procedure (Refer to A0398); 13. For Patient 5, the facility did not ensure time sensitive medications were given timely in accordance with physician order (Refer to A0405); 14. For Patient 27, the facility failed to ensure the informed consent was completed by the physician prior to the surgical procedure (Refer to A0466); 15. Two different types of medium contrast (an internally administered substance used in imaging procedures)were not stored in accordance with the manufacturer’s recommendation and were readily available for use (Refer to A0505); and 16. Expired supplies were found in the respiratory supply cart, and preventative and maintenance per manufacture recommendations for the endoscope drying and storage cabinet were not performed timely (Refer to A0724). The cumulative effect of these systemic failures resulted in the patients to not be provided safe and quality care to meet the patient needs and had the potential to delay provision of care and treatment.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 42512 Based on interview and record review, the hospital failed to ensure the facility’s policy and procedures were implemented, for 15 of 30 sampled patients (Patients 6, 7, 8, 9, 15, 16, 17, 18, 21, 24, 25, 26, 27, 28, and 29), when: 1. For Patients 6, 7, 8, 9, 16, 18, 24, and 27, a pre-surgery (before the surgery) checklist (a list of items that need to be completed prior to surgery) was not completed (Refer to A-0951); 2. For Patients 25 and 29, the necessary documentations were not completed prior to surgery (Refer to A-0952); and 3. For Patients 15, 16, 17, 26, 28, and 29, a comprehensive operative report was not completed immediately after a surgery (Refer to A-0959). The cumulative effect of these systemic failures resulted in the patients to not be provided safe and quality care to meet the patient needs and had the potential to delay provision of care and treatment.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure the medical staff is accountable to the governing body for the quality of care provided patients, for one of 30 patients (Patient 5). This failure had the potential to result in patient harm or death. Findings: On April 11, 2024, at 9 a.m., a concurrent interview and record review with the Chief Quality Officer (CQO) and the Patient Safety Coordinator PSC were conducted. The facility document titled, “History and Physical,” dated March 22, 2024, indicated Patient 5 was admitted to the facility on March 22, 2024, for low blood pressure. The facility document titled, “Consent to Surgery Or Special Procedure,” dated April 2, 2024, was reviewed. The document indicated Patient 5 was to have a percutaneous endoscopic gastrostomy (PEG, a procedure in which a tube is passed into a patient’s stomach though a small incision on the abdominal wall for feeding) and a surgical tracheostomy (surgically created hole in a windpipe that provides an alternative way of breathing) on April 2, 2024. The facility document titled, “IntraOperative Case Report,” dated April 3, 2024, at 1:02 a.m., indicated, “...Emergent: No...Anes [Anesthesia] Start 04/02/2024 [April 2, 2024] 16:57 [4:57 p.m.]...Anesthesia: General anesthesia...Anes Stop 04/02/2024 23:10 [11:10 p.m.]...Case Note: Tracheostomy And Percutaneous Endoscopic Gastrostomy Insertion Turned Into Open Gastrostomy...” The CQO stated there was an incident in the operating room (OR) where the surgeon requested Registered Nurse (RN) 2 to administer local anesthesia and to make an incision into Patient 5. On April 16, 2024, at 5:05 p.m., an interview was conducted with the Governing Board Member (GBM) 2. She stated there are only three members on the governing board. She stated the members were GBM 1, GBM 2, and GBM 3. She stated she was not aware why there were no members of the community in the governing board. GBM 1 stated she did not know how she was appointed to the board. She stated she was not informed about the unusual event for Patient 5. The facility document titled, “AMENDED AND RESTATED BYLAWS OF (NAME OF FACILITY) INCLUDES GOVERNING BODY BYLAWS,” dated March 31, 2021, were reviewed. The documented indicated, “...The approved Medical Staff Bylaws and rules and regulations...shall create an effective administrative unit to discharge the functions and responsibilities assigned to the Medical Staff by the BOARD, and shall be upheld by Board...Board Responsibility. The Medical Staff shall be responsible to the Board for the general quality of medical care provided in the hospital and the ethical and professional standards of the members of the Medical Staff. The Board shall assure that specific review and evaluation activities are undertaken in order to assess, preserve and improve the overall quality and efficiency of patient care in the hospital...(c) Accountability to the Board. The Medical Staff and the other health care personnel providing patient care services at the hospital shall conduct and be accountable to the Board for conducting acitivities that contribute to the preservation and improvement of the quality and efficacy of patient care provided in the hospital...Documentation. The Board shall require, receive, consider and act upon the findings and recommendations emanating from the activities required by sub-section (c) above...””

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure the facility provided services in a safe and effective manner, for one of 30 sampled patients (Patient 5). This failure could have resulted in patient harm or death. Findings: On April 8, 2024, at 1 p.m., an unannounced visit was conducted at the facility to investigate a complaint. On April 9, 2024, at 4:10 p.m., an interview was conducted with the Director of Surgical Services (DSS). She stated she was called by the Certified Registered Nurse Anesthetist (CRNA, an RN who specialized in the administration of anesthesia [medications for sedation and pain]) who told her a “bad event” occurred in the operating room (OR). She stated the CRNA told her the surgeon had told RN 2 to administer a local anesthesia on Patient 5’s abdominal skin and to make an incision (surgical cut) on the patient’s skin. She further stated the Surgical Tech (ST) 1 was asked by the surgeon to pull the guidewire harder and this caused the PEG tube to come out of Patient 5’s abdomen. The DSS stated this incident caused the patient to then have an open gastrostomy (placement of a tube placement into the stomach using a surgical procedure where the abdomen is cut open duirng the surgery). The DSS stated she received a call from RN 2 who told her, “I know I shouldn’t have done it, I was stressed, the surgeon was yelling and cussing, I felt pressured.” On April 10, 2024, at 3 p.m., an interview was conducted with Surgical Tech (ST) 2. She stated the Surgical Charge Nurse (SCN) assigned her to this case. ST 2 stated she told the SCN she did not know how to assist in a PEG surgery. ST 2 stated S 1 instructed RN 2 and ST 1 to put on sterile gloves. ST 2 states S 1 then told RN 2 to administer local anesthesia to Patient 5’s abdomen and then to insert the needle into Patient 5’s abdomen into the stomach. ST 2 stated S 1 then instructed ST 1 to pull the guide wire out of Patient 5’s stomach, and when ST 1 felt resistance S 1 told her to keep pulling. ST 1 stated the PEG tube then came out of Patient 5’s abdomen. ST 2 stated S 1 became angry and started cursing and told them they needed to convert to an open surgery. On April 10, 2024, at 3:38 p.m., an interview with the SCN was conducted. The SCN stated she assigned ST 1 and ST 2 to Patient 5’s PEG procedure. She stated ST 1 and ST 2 stated they were unfamiliar with the PEG part of the case. She stated a practice kit was pulled out and ST 1 was inserviced (trained) using the practice kit. SCN stated the in-service only instructed ST 1 on the procedures she could do, which was hold the scope for the surgeon and hand him instruments. She further stated ST 2 was not in-serviced. The SCN stated the expectation of the charge nurse is to find staff that is comfortable with the procedure. The SCN stated she did not find anyone else because they were not available. She further stated she did not reach out to the Director of Surgical Services for help. On April 11, 2024, at 9 a.m., a concurrent interview and record review were conducted with the Chief Quality Officer (CQO) and the Patient Safety Coordinator (PSC). The facility document titled, “History and Physical,” dated March 22, 2024, indicated Patient 5 was admitted to the facility on March 22, 2024, for low blood pressure. The facility document titled, “Consent to Surgery Or Special Procedure,” dated April 2, 2024, was reviewed. The document indicated Patient 5 was to have a percutaneous endoscopic gastrostomy (PEG, a procedure in which a tube is passed into a patient’s stomach though a small incision on an abdominal wall for feeding) and a surgical tracheostomy (surgically created hole in a windpipe that provides an alternative way of breathing) on April 2, 2024. The facility document titled, “IntraOperative Case Report,” dated April 3, 2024, at 1:02 a.m., indicated, “...Emergent: No...Anes [Anesthesia] Start 04/02/2024 [April 2, 2024] 16:57 [4:57 p.m.]...Anesthesia: General anesthesia...Anes Stop 04/02/2024 23:10 [11:10 p.m., 6 hours and 13 minutes]...Case Note: Tracheostomy And Percutaneous Endoscopic Gastrostomy Insertion Turned Into Open Gastrostomy...” The CQO stated there was an incident in the operating room (OR) where the surgeon requested Registered Nurse (RN) 2 to administer local anesthesia and to make an incision into Patient 5. On April 11, 2024, at 10 a.m., an interview with ST 1 was conducted. ST 1 stated, at the start of Patient 5’s PEG procedure, the staff could not get the scope to work properly. She stated S 1 had said, “Who is going to do the peg since I’m going to run the scope,” in which she (ST 1) responded that they were there to help S 1. ST 1 stated S 1 then told RN 2 to administer the local anesthesia to Patient 5’s abdomen. ST 1 stated S 1 had said, “Anyone can do the local, just grab it and do the local!” ST 1 stated S 1 then instructed RN 2 to do the incision into Patient 5’s abdomen then instructed ST 1 to pull the guidewire back through the abdomen. ST 1 stated she felt resistance and stopped pulling but S1 became angry and told her to keep pulling. ST 1 stated when she pulled a second time per S 1 instructions, the PEG tube came out of Patient 5’s abdomen. ST 1 stated S 1 became very angry and yelled, “What the [expletive] happened,” and she (ST 1) responded that she told him (S 1) she was in, but he insisted on her pulling more. ST 1 stated S 1 then told the staff that he would have to open the patient up. ST 1 stated S 1 apologized to her and said he should have never asked her to pull the wire and that it was his (S 1’s) fault. On April 11, 2024, at 11 a.m., an interview was conducted with the CRNA. The CRNA stated S 1 didn’t seem like he was experienced in this type of case. The CRNA stated at the beginning of Patient 5’s PEG procedure, the staff could not get the scope to work. He states S 1 was yelling at all the staff being condescending and belittling them. The CRNA stated the PEG tube placement was not an emergent case and could have waited till the next day when the proper equipment and knowledgeable staff was available. The CRNA stated both RN 2 and ST 1 had sterile gloves on during the procedure. The CRNA stated the surgeon performing a PEG procedure usually hands the scope over to the OR technician then scrubs in and administers local anesthesia, inserts the needle into the abdomen, and makes the abdominal cut. The CRNA stated a surgical tech had to assist S 1 place the peg tube onto the guidewire as S 1 was not doing it right. The CRNA stated S 1 then instructed ST 1 to pull the guidewire through the stomach and when ST 1 felt it was in place, S 1 very sarcastically told ST 1 to keep pulling and this was when the PEG tube came out of Patient 5’s abdomen. On April 11, 2024, at 12:30 p.m., an interview with Surgeon (S 2) was conducted. S 2 stated, during a PEG procedure, the nurses take care of monitoring the patient and the surgical techs are in charge of handing him instruments and hold the scope once it is in place. S 2 stated it is not in the scope of the RN’s or the ST’s practice to administer local anesthesia, insert a needle into the abdomen, or make any surgical cuts. S 2 stated he would not ask an RN to do any of those things. On April 11, 2024, at 2 p.m., an interview was conducted with RN 2 and S1. RN 2 stated Surgeon 1(S 1) was having difficulty with the scope that would be used for Patient 5’s PEG procedure. RN 2 stated he did not have much experience using PEG scopes at all. RN 2 stated S 1 was very upset and was yelling that he needed to do this case. RN 2 stated S 1 explained that S 1 would be doing the camera part of the procedure, and ST 1 would have to do the rest. RN 2 stated S 1 told RN 2 and ST 1 to don sterile gloves. RN 2 stated S 1 instructed him to administer topical anesthesia and insert the needle into Patient 5’s abdomen. RN 2 stated he didn’t feel comfortable doing it but with S 1 being angry, yelling, and cussing he felt pressured. RN 2 further stated S 1 told him to make a small incision into Patient 5’s abdomen and unfortunately he did make that small incision. RN 2 stated S 1 then instructed ST 1 to pull the guidewire out of Patient 5’s abdomen and ST 1 pulled the guidewire until ST 1 felt resistance but S 1 told ST 1 to continue pulling. RN 2 stated ST 1 pulled like instructed by S1 and the PEG tube completely came out of Patient 5’s abdominal wall. RN 2 stated S 1 then became very angry and yelled at ST 1 while saying he now had to do an open surgery on Patient 5’s abdomen. RN 2 stated he had never been trained to administer local anesthesia, to insert a needle into a patient stomach, or to make incision (cut) on a patient’s skin and S 1 did not ask him (RN 2) if he was trained in these procedures. S 1 stated he was not an employee of the facility. He stated he was contracted through (name of Company). S 1 stated he had only performed 10 endoscopic PEG tube placements in the past six years. S 1 stated there was a scope in the OR but it was not working, and that he did not know how to fix it. S 1 stated this surgery is a two-person procedure, one person has to do the scope and one person has to do the sterile portion. S 1 stated he asked the RN 2 to create a skin wheel with the dermal injection because the RN 2 was scrubbed and sterile. S 1 stated he asked RN 2 to advance a needle through the skin into the stomach and advance the guidewire through the needle into the stomach. S 1 stated he asked RN 2 to make a cut in the abdomen so the PEG tube could come out. S 1 stated ST 1 pulled the guide wire back out of the abdomen, guiding the PEG tube through. S 1 stated the PEG tube was seeded (in the right place) but it just popped out. S 1 stated he was not aware of RN 2’s and ST 1’s scopes of practice in (name of state). S 1 stated the local anesthesia administration, needle insertion, and the abdominal incision should be done by someone who is trained. S 1 stated he asked ST 1 to pull the guide wire even after she stated she met resistance. S 1 stated if he knew RN 2 was not supposed to do those procedures, he would not have asked RN 2 to do them. S 1 stated he supervised the staff the entire time and they did what he asked. On April 12, 2024, at 1:45 p.m., an interview was conducted with the Chief of Surgery (COS). The COS stated it is not normal for a surgeon to ask a nurse to make an incision on a patient. The COS stated during a surgical residency, everyone’s scope of practice is reviewed. The COS stated, “Why would a surgeon give a scalpel to someone who is not a surgeon?” On April 12, 2024, at 2:10 p.m., an interview was conducted with the Medical Staff Director (MSD). The MSD stated this would be considered an unusual event. She further stated S 1 did not report the incident to the MSD and a written statement was not requested from S 1. MSD stated it was unusual for S 1 not to need to make a statement. On April 16, 2024, at 4 p.m., an interview was conducted with the Chief Medical Officer and Chief of Clinical Operations (CMOCCO). The CMOCCO stated this event was an unusual event. The CMOCCO stated the surgeon should not have asked the OR staff “To do anesthesia, needle into the abdomen, cut.” The CMOCCO stated a statement outside of the operative report was not obtained from S 1. The CMOCCO stated S 1 has completed his stay and will not be coming back. The CMOCCO stated, “There is a reason why he isn’t coming back.” The CMOCCO stated this event had not been reported to the state agency. The CMOCCO stated the responsibility is with the surgeon. The CMOCCO stated, “Clearly the RN practiced outside his scope. I have looked at competencies of our department staff and being asked to work outside of the scope is the person’s responsibility.” The CMOCCO stated it is not a normal practice to have anyone other than the surgeon cut into the patient. He further stated the surgeon should not have asked the staff to do what he did. A review of the facility document titled, “Staff Registered Nurse- OR [operating room],” dated October 2023, was reviewed. The document indicated, “...Position Description...Under the supervision...to perform professional nursing duties in the care and services to patients and their families in an acute care...to assist physicians and carry out their orders...Knowledge & [and] Abilities...Federal, State, and local laws and regulations governing professional aspects of nursing...requires judgement/action which could result in undesirable patient outcome...” A review of the policy and procedure (P&P) titled, “Scope of Services- Surgical Services,” dated April 2021, was conducted. The P&P indicated, “...The Surgical Services Department...provides a safe and comfortable environment for both patients and staff in order to provide optimum assistance to the surgeon...The basic staffing plan for each Operating Room Suite is 1RN(s) and 1 scrub tech(s)...Qualifications Of Staff...An ongoing program of inservice education and periodic clinical skills evaluation for all staff members is maintained...Standards Of Practice and Methods UsedTo Meet Patient Care Needs...AORN [Association of periOperative Registered Nurses, a nationally recognized organization], ASPAN [American Society of PeriAnesthesia Nurses, a nationally recognized organization], Association of the Advancement of Medical Instrumentation (AAMI, a nationally recognized organization), the Center for Disease Control (CDC, a nationally recognized agency) and Public Health Department standards are references used in the formulation and review of policies, procedures and standards of practice in the Surgical Services Department, as well as collaborative input from the knowledgeable and expertise of the surgical staff...To assist in meeting patient care needs, support is readily available from all equipment and instrument manufactures...””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to develop, implement, and maintain an effective, ongoing, hospital-wide data driven quality program for the use of restraints. This failure had the potential to cause harm or death to the patients. Findings: On April 8, 2024, at 2 p.m., during the facility tour, an observation and concurrent interview was conducted with the Unit Supervisor (US). Patient 1 was observed to have bilateral (both left and right) soft wrist restraints and bilateral oversized mittens on his hands. The US stated the restraints were placed due to the patient attempting to pull out his intravenous catheter (IV, a long thin flexible tube that enters the body through a vein) and his Foley catheter (a device that drains urine from the bladder into a collection bag). On April 9, 2024, at 3:30 p.m., a review of Patient 1’s record was conducted. The “History and Physical,” dated April 6, 2024, indicated Patient 1 was admitted to the facility on April 6, 2024, at 2:13 p.m., with diagnoses of low blood pressure of 50/47, atrial fibrillation (abnormal heart rhythm), and dementia (condition with confusion). The facility document titled, “Order Inquiry,” dated April 8, 2024, at 1:10 a.m., was reviewed. The document indicated, “...Restraint Soft Limb Wrist - Bilateral [both wrists]...Frequency q 24h (every 24 hours)...” There was no documented evidence a physician’s order was obtained for Patient 1’s mitten restraints on April 8, 2024. The facility document titled, “Assessment Type Daily,” dated April 8, 2024, through April 9, 2024, was reviewed. The document indicated Patient 1 had mittens on from 12 a.m. through 6 a.m., and from 8 p.m. through 10 p.m. on April 8, 2024. The document further indicated Patient 1 had mittens on from 12 a.m., through 5 a.m. on April 9, 2024. On April 9, 2024, at 2:27 p.m., an interview was conducted with the Chief Quality Officer (CQO). The CQO stated bulky hand mittens are considered a form of restraint and there should be a separate physician order for the mitten restraints. She further stated Patient 1 should not have mitten restraints without a physician’s order for them. On April 9, 2024, at 4:24 p.m., an interview was conducted with Registered Nurse (RN) 3. She stated she did not know mittens were a form of restraint. She stated Patient 1 did have bilateral mittens on April 8, 2024. RN 3 stated she did not document mittens under the assessment because she didn’t know they were considered restraints. On April 9, 2024, at 4:30 p.m., an interview was conducted with the US. She stated she was not aware that mittens were a form of restraint. She stated she did not know a physician’s order was needed for mittens. On April 16, 2024, at 10 a.m., the Quality Assurance and Performance Improvement (QAPI) minutes for January 2024, were reviewed. The QAPI minutes indicated the facility did not meet the measured goals for documentation and necessary physician orders for mitten restraints. On April 16, 2024, at 4:50 p.m., an interview was conducted with the Deputy Regional Director of Quality (DRDQ). The DRDQ stated she did not know mittens were a form of restraint and that a physician’s order for its application was needed. A review of the facility P&P titled, “Restraints and Seclusion,” dated April 2021, was conducted. The P&P indicated, “...Restraint...any manual method, physical or mechanical device...that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely...Each episode of restraint shall be initiated...Upon the order of a licensed independent practitioner who is responsible for the patient...” A review of the facility P&P titled, “Restraint and Seclusion - Documentation Standards,” dated April, 2021, was conducted. The P&P indicated, “...Examples of Physical Restraint...Mittens...Patient cannot flex fingers or does not have access to his/her body...” A review of the facility’s document titled, “AMENDED AND RESTATED BYLAWS OF (NAME OF THE FACILITY) INCLUDES GOVERNING BODY BYLAWS,” dated March 31, 2021, was conducted. The document indicated, “...The QM (Quality Management) Committees shall receive reports from all quality improvement/management activities throughout the Hospitals, as applicable, and shall annually assess the effectiveness of the existing quality improvement programs. The QM Committees shall objectively and systematically monitor and evaluate the quality and appropriateness of patient care, pursue opportunities to improve patient care, and resolve identified problems. The QM Committees shall meet as necessary and no less than quarterly, and shall make recommendations to the full Board with respect to improving the quality of care throughout the Hospitals, as applicable...Report regularly to the Board on the performance of the Hospitals’ functions such as financial matters, staffing and employment issues, quality of care issues and risk management issues. Cooperation and liaison with the Medical Staffs of the Hospitals, and with all other individuals rendering professional services to patients, with the objective of assuring a high quality of services rendered to patients...Assure that the requirements of the Hospitals’, as applicable, Quality Improvement and Management System are carried out on a regular and ongoing basis, and implement such collective actions and preventive activities as are deemed necessary...””

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 42512 Based on interview and record review the hospital failed to ensure the Medical Staff Bylaws and Rules and Regulations were received and reviewed by a medical staff (Surgeon 1). This failure had the potential to cause harm to the patients. Findings: An interview was conducted on April 11, 2024, at 2 p.m., with Surgeon 1 (S 1.) S 1 stated, “I do not know if I received the Rules, Regs [regulations] and Bylaws when I was onboarding. S 1 further stated, “No, I can’t say that I did.” An interview was conducted on April 11, 2024, at 4 p.m., with the Chief Medical Officer and Chief of Clinical Operations (CMOCCO). The CMOCCO stated the contracted surgeons are onboarded and the Medical Staff (MS) plays a large role in this piece and provides the Rules, Regs, and the Bylaws at onboarding. An interview was conducted on April 16, 2024, at 2:20 p.m., with the Director of Medical Staff (DMS). The DMS stated part of the application packet goes out to the medical staff, and in an attempt to be quick, that is one of the items that she did not follow up on. The DMS further stated he would have received this in his initial onboarding application, but he did not receive it. A review of the facility document titled, “[Name of the facility] Medical Staff Bylaws,” dated February 20, 2024, was reviewed. The document indicated, “...An acknowledgement that the applicant has received and read the Medical Staff Bylaws, Rules and Regulations, and that the practitioners agrees to be bound by the term thereof, as they may be amended from time to time, if the practitioner is granted membership or clinical privileges and to be bound by the terms thereof without regard to whether or not the practitioner is granted membership and/or clinical privileges in all matters relating to consideration of the application...””

“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: 47071 Based on interview and record review, the facility failed to ensure an individualized plan of care was completed, for four of 30 sampled patients (Patient 22, 25, 26, and 27). These failures had the potential to delay patient care and services or cause patient harm. Findings: 1. A condurrent interview and review of Patient 22’s record was conducted on April 12, 2024, at 11 a.m., with the Deputy Regional Director Quality (DRDQ). The facility document titled, “History and Physical [H&P],” indicated Patient 22 was admitted to the facility on March 27, 2024, for pain and swelling in the right knee after a fall with a diagnosis of right patella (kneecap) fracture (a break in the bone). There was no documented evidence an individualized patient care plan was completed related to Patient 22’s infection risk, and skin integrity. The DRDQ stated there should have been more to the care plans based on the patient’s needs. She stated that since the patient had a surgical procedure, infection risk and skin integrity should have been included in the patient’s care plan. 2. On April 15, 2024, at 3:30 p.m., a concurrent interview and review of Patient 25’s record were conducted with the Nurse Educator Special Projects Administrator (NESPA). The facility document titled, “History and Physical [H&P],” indicated Patient 25 was admitted to the facility on April 3, 2024, for pain in the left knee leading to a left knee total arthroplasty (left knee replacement). There was no documented evidence an individualized patient care plan related to Patient 25’s risk for infection and impaired skin integrity was completed. The NESPA stated there should have been more to the care plans based on the patient’s needs. The NESPA stated Patient 25’s care plan is not complete and should have included the high risk for infection and skin integrity based on the patient’s needs after having had a surgical procedure. 3. On April 16, 2024, at 10:05 a.m., a concurrent interview and review of Patient 26’s record were conducted with DRDQ. The facility document titled, “History and Physical [H&P],” indicated Patient 26 was admitted to the facility on May 27, 2024, for wounds on both feet. Patient 26’s record indicated Patient 26 had lower extremity cellulitis (deep infection of the skin) and had a right foot irrigation (procedure of flushing the wound with a solution) with debridement (procedure to remove the damaged tissue) and partial second toe amputation to the proximal phalanax (toe bone closest to the foot), and the infectious disease specialist was consulted on the wounds. The records indicated Patient 26 was identified as a fall risk. There was no documented evidence an individualized patient care plan completed for impaired skin integrity and risk for fall. The CQO stated a care plan based on the assessment was not completed. The CQO stated Patient 26 should have a care plan for skin integrity based on the surgical procedure and a fall risk care plan should have been completed. 4. On April 16, 2024, at 10:18 a.m., a review of Patient 27’s record was conducted with the CQO. The facility document titled, “History and Physical [H&P],” indicated Patient 27 was admitted to the facility on April 3, 2024, for hip discomfort after a fall at home. The record indicated Patient 27 had a diagnosis of hip fractured and underwent a right hip nailing (pin placement) surgical procedure. There was no documented evidence an individualized patient care plan for risk for infection and impaired skin integrity was completed. An interview was conducted with the CQO on April 16, 2024, at 11:33 a.m. The CQO stated a care plan based on the assessment of Patient 27’s needs for high risk for infection and impaired skin integrity related to the surgical wound should have been completed. The facility policy and procedure (P&P) titled, “Initial Patient Assessment And Reassessment and Plan of Care,” dated April 12, 2024, was reviewed. The P&P indicated,”...Each patient...shall receive a completed head-to-toe assessment...so that a plan of care can de developed to best meet the needs of the patient...Upon completion of the initial admission assessment, an individualized prioritized plan of care will be developed...””

“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: 42512 Based on observation, interview and record review, the facility failed to ensure, for 21 of 30 sampled patients (Patients 1, 2, 3, 6, 7, 8, 9, 14, 15, 16, 17, 18, 19, 22, 23, 24, 25, 26, 27, 28 and 29), 1. For Patient 1, a physician’s order for the application of restraints (any manual or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body) was obtained. This failure had the potential to result in injury or unnecessary use of restraints; 2. For Patient 24, repositioning was done every two hours, weekly photographs of the patient’s wounds were taken and documentation of the wounds were completed, in accordance with the facility’s policy and procedure (P&P); 3. For Patients 16, 18, and 27, screening for Methicillin Resistant Staphylococcus Aureus (MRSA, a bacterial infection that is difficult to treat) was completed; 4. For Patients 3, 6, 7, 8, 9, 14, 15, 16, 17, 19, 22, 23, 24, 25, 26, 27, and 28, Chlorhexidine Gluconate (CHG, bathing product that kills germs and reduces the spread infection in hospitals) bath was provided; 5. For Patient 14, two intravenous (IV, administered through the veins) medications found hanging by the bedside were labeled; 6. For Patients 6, 7, 8, and 29, pain was reassessed after medication administration; 7. For Patients 2, 7, 14, 22, 23, and 24, the 12 lead EKG (electrocardiogram, a procedure to record heart rate and rhythm) was completed in accordance with the facility’s P&P; 8. For Patient 27, pain was addressed; 9. For Patient 27, critical blood pressure was reported to the physician 10. For Patients 25 and 27, medication reconciliation was completed on admission; and 11. For Patients 22 and 23, the telemetry (recording or remotely monitored heart rate and rhythm) strips were printed, analyzed, signed, and documented in the patients’ record every four hours, in accordance with the facility’s P&P. These failures had the potential to delay patient care, increase the risk for infection, and/or cause harm to the patients. Findings: 1. On April 8, 2024, at 2 p.m., during the facility tour, an observation and concurrent interview was made with the Unit Supervisor (US). Patient 1 was observed to have bilateral (both left and right) soft wrist restraints and bilateral oversized mittens on his hands. The US stated the restraints were placed due to the patient attempting to pull out his IV (intravenous catheter, a long thin flexible tube that enters the body through a vein) and his Foley catheter (a device that drains urine from the bladder into a collection bag). On April 9, 2024, at 3:30 p.m., a review of Patient 1’s record was conducted. The “History and Physical,” dated April 6, 2024, indicated Patient 1 was admitted to the facility on April 6, 2024, at 2:13 p.m., with diagnoses of low blood pressure of 50/47, atrial fibrillation (abnormal heart rhythm), and dementia (condition with confusion). The facility document titled, “Order Inquiry,” dated April 8, 2024, at 1:10 a.m., was reviewed. The document indicated, “...Restraint Soft Limb Wrist - Bilateral...Frequency q 24h (every 24 hours)...” There was no documented evidence a physician’s order was obtained for Patient 1’s mitten restraints on April 8, 2024. The facility document titled, “Assessment Type Daily,” dated April 8, 2024, through April 9, 2024, was reviewed. The document indicated Patient 1 had mittens on from 12 a.m. through 6 a.m., and from 8 p.m. through 10 p.m. on April 8, 2024. The document further indicated Patient 1 had mittens on from 12 a.m., through 5 a.m. on April 9, 2024. On April 9, 2024, at 2:27 p.m., an interview was conducted with the Chief Quality Officer (CQO). The CQO stated bulky hand mittens are considered a form of restraint and there should be a separate physician order for the mitten restraints. She further stated Patient 1 should not have mitten restraints without a physician’s order for them. On April 9, 2024, at 4:24 p.m., an interview was conducted with Registered Nurse (RN) 3. She stated she did not know mittens were a form of restraint. She stated Patient 1 did have bilateral mittens on April 8, 2024. RN 3 stated she did not document mittens under the assessment because she didn’t know they were considered restraints. On April 9, 2024, at 4:30 p.m., an interview was conducted with the US. She states she was not aware that mittens were a form of restraint. She stated she did not know a physician’s order was needed for mittens. A review of the facility P&P titled, “Restraints and Seclusion,” dated April 2021, was conducted. The P&P indicated, “...Restraint...any manual method, physical or mechanical device...that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely...Each episode of restraint shall be initiated...Upon the order of a licensed independent practitioner who is responsible for the patient...” A review of the facility P&P titled, “Restraint and Seclusion - Documentation Standards,” dated April, 2021, was conducted. The P&P indicated, “...Examples of Physical Restraint...Mittens...Patient cannot flex fingers or does not have access to his/her body...” 2a. On April 15, 2024, at 10 a.m., a review of Patient 24’s record was conducted with the CQO and the US. The facility document titled, “History and Physical,” indicated Patient 24 was admitted to the facility on March 19, 2024, with diagnoses which included chronic ventilatory insufficiency (inefficient breathing) due to anoxic brain injury (caused by a complete lack of oxygen to the brain) for a scheduled tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck). The facility document titled, “Flow Sheet,” was reviewed. There was no documented evidence Patient 24 was turned or repositioned every two hours on the following dates and times: - On March 20, 2024, from 8 a.m., to 6 p.m. (10 hours); - On March 21, 2024, from 8 a.m., to 4 p.m. (8 hours); - On March 22, 2024, from 9 a.m., to 3 p.m. (6 hours); - On March 24, 2024, from 2 a.m., to 6 a.m. (4 hours); - On March 24, 2024, from 6 p.m., to 10 p.m. (4 hours); - On March 25, 2024, from 12 a.m., to 6 a.m. (6 hours); - On March 25, 2024, from 6 p.m., to 10 p.m. (4 hours); - On March 26, 2024, from 10 a.m., to 6 p.m. (8 hours); - On March 29, 2024, from at 10 p.m., to March 30, 2024, at 6 p.m. (11 hours); - On March 31, 2024, from 10 a.m., to April 1, 2024, at 6 a.m. (20 hours); - On April 5, 2024, from 8 a.m., to 6 p.m. (10 hours); - On April 6, 2024, from 12 a.m., to 4 a.m. (4 hours); - On April 6, 2024, from 12 p.m., to 8 p.m. (8 hours); - On April 9, 2024, from 8 a.m., to 2 p.m. ( 6 hours); - On April 10, 2024, from 6 a.m., to 2 p.m. (8 hours); and - On April 11, 2024, from 8 a.m., to 8 p.m. (12 hours). An interview and record review was conducted with the US on April 12, 2024, at 3:05 p.m. The US stated the expectation was the patient should be turned every two hours and the RN should have documented the turning every two hours. The US stated the RN did not turn Patient 24 every two hours in accordance with the facility’s policy. 2b. The facility documents titled, “Wound Progress Notes,” were reviewed. There is no documented evidence Patient 24’s wounds on the left upper extremity, the left elbow, the left extremity, the right shoulder and clavicle, and on the right extremity with dimpling of the skin and dark brown patches on the right extremity, on the neck and chin, and the sacrum (tailbone) were photographed, dated, and signed, on March 23, 2024, April 4, 2024, and April 11, 2024, in accordance with the facility P&P. A concurrent interview and record review were conducted with the US on April 15, 2024, at 12:15 p.m. The US stated photos of the patient’s wounds are to be taken weekly and the wound assessment should be completed, dated, and signed. The facility P&P titled, “SKIN AND WOUND CARE,” dated April 21, was reviewed. The P&P indicated, “...Photographs ... For wounds present on admission and/or discovery, and on the day of discharge...Additional photos will be retaken on Thursday, during any scheduled dressing changes and with any change of condition...Photographs include the patient’s last name and first initial, measuring device, anatomical location, and head/toe reference guide (Stickman). The photograph is placed on the photograph form and includes patient identification sticker, time date, identification of site, wound measurements, and printed name of the...Measurements taken on admission or whenever a wound is identified, and weekly thereafter or when there is significant change in the wound. Measure the wounds using the longest length (head to toe direction) by the longest width (side to side). Depth is measured by gentle insertion of a cotton-tipped applicator to the point that it meets skin level, then removed and held alongside a ruler to determine depth measurement in centimeters...Regular repositioning. Avoid direct pressure to at-risk body surfaces. Off-load heels with off-loading boots or pillows for patients at high risk for potential injury to heels...” 3. The records of Patients 16, 18, and 27 were reviewed with the US on April 15, 2024, at 9:25 a.m. a. For Patient 16, the facility document titled, “History and Physical,” indicated Patient 16 was admitted to the facility on April 2, 2024, for sepsis (a serious infection), fracture of the right ulna (broken arm bone). The facility document, titled, “...Order Report,” indicated, “...Decision to Admit...Start Date...4/2/2024 [April 2, 2024]...” The facility document titled, “...Orders Report,” was reviewed. The document indicated, “...MRSA Screen....Start Date...4/3/2024 [April 3, 2024]...” An untitled facility document indicated the order for MRSA screening for Patient 16 was placed on April 3, 2024, at 9:54 a.m. and the MRSA screening was collected on April 4, 2024, at 7:36 p.m. The facility document titled, “[Name of facility] Operative Report,” dated April 8, 2024, indicated, “...right hand dog bites; ulnar styloid fracture [break in the wrist bone]...” There was no documented evidence Patient 16 MRSA screening was done within 24 hours of being admitted to the facility. An interview and record review were conducted on April 15, 2024, at 10:11 a.m., with the US. The US stated the patient was admitted April 2, 20224, and the MRSA screening was ordered April 3, 2024, but was not collected until April 4, 2024. The US stated the screening was collected 48 hours after the patient was admitted. The US further stated the facility policy indicates a patient needs to be screened for MRSA within 24 hours of being admitted. b. For Patient 18, the facility document titled, “History and Physical,” indicated Patient 18 was admitted to the facility on April 5, 2024, for an infected sacral decubitus (infection to wound on the tailbone which was due to pressure over a bony area). Patient 18’s record indicate he was admitted from a skilled nursing facility (a facility which provides nursing care). The facility document titled, “[Name of facility] Operative Report,” dated April 7, 2024, at 2:53 p.m., indicated, “...Preoperative diagnosis: sacral decubitus ulceration with underlying abscess [infection] extending over the left gluteus [thigh] complex and left perianal [area in the buttocks] region...Postoperative diagnosis: same...Procedure: normal saline lavage and VAC [vacuum assisted closure, a device for wound treatment] wound dressing drainage...” There was no documented evidence MRSA screening was done for Patient 18 within 24 hours of being admitted to the facility. There was no documented evidence MRSA screening was done for Patient 18 during his hospitalization, despite meeting the criteria for MRSA screening. An interview and record review were conducted on April 15, 2024, at 9:54 a.m., with the US. The US stated MRSA screening should have been done for Patient 18 within 24 hours of admission due to the patient coming from a skilled nursing facility and having had a surgery. The US further stated there was no documented evidence a MRSA screening order was placed and completed. c. For Patient 27, the facility document titled, “History and Physical,” indicated Patient 27 was admitted to the facility on April 3, 2024, for hip discomfort after a fall. Patient 27’s record indicated he had a right hip nailing (pin placed in the hip). The facility document titled, “[Name of Facility] Discharge Assessment/Summary Report,” dated April 5, 2024, at 6:23 p.m., indicated, “...If patient did not meet the above indication, do not perform MRSA screening, culture not indicated...” There was no documented evidence MRSA screening was done on Patient 27 within 24 hours of being admitted to the facility. An interview with was conducted with Chief Quality Officer (CQO) on April 15, 2024, at 10:36 a.m. The CQO stated Patient 27 had a surgical procedure and what the patient had is considered an implant. The CQO stated Patient 27 should not have been excluded from the MRSA screening. The facility’s P&P titled, “Active Surveillance Cultures (ASC) - MRSA,” dated September 2021, was reviewed and indicated, “...MRSA screening is performed as outlined by SB 1058 in accordance with the policy...Nursing staff are responsible for carrying out all pertinent orders and for initiation and daily implementation of proper precautions as indicated by clinical and laboratory findings...The following patients must be screened within 24 hours of admission...The patient being admitted/transferred to the intensive care unit (ICU, CCU)...The patient is being transferred from a skilled nursing facility...Patients with scheduled orthopedic...” 4. The review of the records of Patients 3, 6, 7, 8, 9, 14, 15, 16, 17, 19, 22, 23, 24, 25, 26, 27, and 28, and concurrent interview were conducted with the Patient Safety Coordinator (PSC) on April 10, 2024, at 9 a.m. a. For Patient 3, the facility document titled, “History and Physical,” indicated Patient 3 was admitted to the facility on April 2, 2024, for respiratory failure (inefficient breathing). There was no documented evidence Patient 3 was provided a CHG bath while admitted to the facility. The PSC stated Patient 3 had a PICC (peripherally inserted central catheter, when a type of catheter is inserted to access large veins in the chest) line placed on April 3, 2024. The PSC stated Patient 3 should have had a daily CHG bath while hospitalized. b. For Patient 6, the facility document titled, “History and Physical,” indicated Patient 6 was admitted to the facility on March 31, 2024, for abdominal pain. There was no documented evidence Patient 6 received a CHG bath while admitted to the hospital. The PSC stated Patient 6 had a hernia repair surgery on April 4, 2024. The PSC stated Patient 6 should have had a CHG bath prior to surgery. c. For Patient 7, the facility document titled, “History and Physical,” indicated Patient 7 was admitted to the facility on April 1, 2024, for abdominal pain, associated nausea, and two episodes of vomiting with small dots of suspected blood. There was no documented evidence Patient 7 received a CHG bath while admitted to the facility. The PSC stated Patient 7 had a Magnetic Resonance Cholangiopancreatography (MRCP, an imaging procedure) on April 4, 2024. The PSC stated Patient 7 should have had a CHG bath prior to the MRCP. d. For Patient 8, the facility document titled, “History and Physical,” indicated Patient 8 was admitted to the facility on April 3, 2024, for a mechanical fall and injury to the left leg. There was no documented evidence Patient 8 received a CHG bath while admitted to the hospital. The PSC stated Patient 8 had a left tibial-fibular fracture (broken leg bones) and had left tibia intramedullary nailing (placement of pins on the bones) on April 5, 2024. The PSC stated Patient 8 should have had a CHG bath prior to the surgery. e. For Patient 9, the facility document titled, “History and Physical,” indicated Patient 9 was admitted to the facility on April 7, 2024, for a fall. The document indicated Patient 9 had a prior medical history of diabetes (abnormal blood sugar levels), high blood pressure, and frequent fractures (breaks in the bone). There was no documented evidence Patient 9 received a CHG bath while admitted to the hospital. The PSC stated Patient 9 had an open reduction internal fixation (ORIF, surgical procedure to fix broken bones) surgery on April 8, 2024. The PSC stated Patient 9 should have had a CHG bath prior to the surgery. f. For Patient 14, the facility document titled, “History and Physical,” indicated Patient 14 was admitted to the facility on April 6, 2024, for acute respiratory failure (inefficient breathing) and lung disease. The facility document titled, “Genitourinary Assessment,” dated April 6, 2024, indicated, “...Urinary catheter insertion...April 6, 2024, at 10:34 p.m...” There was no documented evidence Patient 14 received a CHG bath on April 8, 9, 10, and 11, 2024, while a foley catheter was in place. On April 12, 2024, at 9:45 a.m. a concurrent interview and record review were conducted with the US. The US stated there is no documentation Patient 14 was provided with a daily CHG bath on April 8, 9, 10, and 11, 2024. The US stated Patient 14 had a foley catheter and per the facility’s policy, the patient was supposed to be provided a daily CHG bath. g. For Patient 15, the facility document titled, “History and Physical,” indicated Patient 15 was admitted to the facility on March 29, 2024, for hyperglycemia (high blood sugar) and osteomyelitis (bone infection). There was no documented evidence Patient 15 received a CHG bath while admitted at the facility. On April 12,2024, at 10:30 a.m, an interview and concurrent record review were conducted with the US. The US stated Patient 15 had a left foot irrigation (procedure to clean an infection) and debridement (by removing infected parts and dead tissues) treatment for wound down to the bone on April 2, 2024. The US further stated there is no documentation Patient 15 received a CHG before and on the day of his surgery. The US stated the patient should have had a CHG bath 24 hours before surgery which would have been April 1, 2024, and on day of surgery per the facility’s policy. h. For Patient 16, the facility document titled, “History and Physical,” indicated Patient 16 was admitted to the facility on April 2, 2024, for sepsis (a serious infection), cellulitis (skin redness and irritation), and fracture of the right ulnar (broken bone in the arm). There was no documented evidence Patient 16 received a CHG bath while admitted to the hospital. On April 12, 2024, at 1:45 p.m., an interview and a concurrent record review were conducted with the US. The US stated the patient had a right-hand incision and drainage (procedure to treat an infection) on April 2, 2024. The US stated the patient should have had a CHG bath before the day of the surgery. The US further stated there is no documentation Patient 16 was provided a CHG bath before the day of the surgery. i. For Patient 17, the facility document titled, “History and Physical,” indicated Patient 17 was admitted to the facility on April 3, 2024, for a fall. There was no documented evidence Patient 17 received a CHG bath while admitted to the hospital. On April 15, 2024, at 11:07 a.m., a interview and a concurrent record review were conducted with the US. The US stated the patient had a right ankle ORIF surgery on April 4, 2024. The US further stated there is no documentation Patient17 was provided a CHG bath before and on the day of his surgery. The US stated Patient 17 should have had a CHG bath 24 hours before surgery which would have been April 3, 2024, and on day of surgery per the facility’s policy. j. For Patient 19, the facility document titled, “History and Physical,” indicated Patient 19 was admitted to the facility on April 2, 2024, for an appendicitis (when the appendix becomes inflamed and painful). There was no documented evidence Patient 19 received a CHG bath while admitted to the hospital. On April 15, 2024, at 11:20 a.m., an interview and a concurrent record review were conducted with the US. The US stated the patient had an appendectomy (removal of the appendix) on April 3, 2024. The US stated there is no documentation Patient 19 was provided a CHG bath before and on the day of his surgery. The US stated the patient should have had a CHG bath 24 hours before surgery which would have been April 2, 2024, and on the day of the surgery per the facility policy. k. For Patient 22, the facility document titled, “History and Physical,” indicated Patient 22 was admitted to the facility on March 27, 2024, for right patella fracture (a break in the knee cap). Patient 22’s record indicated the patient had an open reduction internal fixation (surgical procedure to fix fractures) of the right patella. There was no documented evidence Patient 22 received a CHG bath while admitted to the hospital. An interview and concurrent record review were conducted with Deputy Regional Director of Quality (DRDQ) on April 12, 2024, at 11:05 a.m. The DRDQ stated that she is not able to find any documentation that CHG baths have been given. The DRDQ stated Patient 22 should have had a CHG bath daily per the facility policy. l. For Patient 23, the facility document titled, “History and Physical,” indicated Patient 23 was admitted to the facility on April 2, 2024, for left radical nephrectomy (surgical removal of a kidney). There was no documented evidence Patient 23 received a CHG bath while admitted to the hospital. An interview and concurrent record review were conducted with DRDQ on April 12, 2024, at 1:30 p.m. The DRDQ stated the patient was in the ICU and should have had the baths daily. m. For Patient 24, the facility document titled, “History and Physical,” indicated Patient 24 was admitted to the facility on March 19, 2024, with diagnoses which included chronic ventilatory insufficiency (inefficient breathing) due to anoxic brain injury (caused by a complete lack of oxygen to the brain) for a scheduled tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck). There was no documented evidence Patient 24 was provided a CHG bath on the following dates: March 23, 2024, March 27, 2024, March 28, 2024, April 2, 2024, April 3, 2024, April 4, 2024, and April 6, 2024, while admitted to the facility. An interview and concurrent record review were conducted with US on April 12, 2024, at 3:30 p.m. The US stated she cannot find that a CHG bath was documented on Patient 24’s record. The US stated Patient 24 should have been given a CHG bath daily. n. For Patient 25, the facility document titled, “History and Physical,” indicated Patient 25 was admitted to the facility on April 3, 2024, with a diagnosis of left knee pain and had a left knee total arthroplasty (joint replacement). There was no documented evidence Patient 25 received a CHG bath while admitted to the hospital. An interview and concurrent record review were conducted with the DRDQ on April 15, 2024, at 12 p.m. The DRDQ stated there is no documentation Patient 25 was provided a CHG bath was daily. The DRDQ stated the nurse should have given the CHG bath daily per the facility policy. o. For Patient 26, the facility document titled, “History and Physical,” indicated Patient 26 was admitted to the facility on March 27, 2024, with a diagnosis of wounds on both feet. The record indicated Patient 26 had lower extremity cellulitis (deep infection of the skin) and had a right foot irrigation (solution to the wound to flush) with debridement (removal of damaged tissue) and partial second toe amputation to the proximal phalanx (surgical removal of the toe bone closest to the foot). There was no documented evidence Patient 26 was provided a CHG bath 24 hours before the surgical procedure, on the day of the procedure, and while admitted to the hospital. An interview and concurrent record review were conducted with the DRDQ on April 16, 2024, at 9:41 a.m. The DRDQ stated Patient 26 was not provided a CHG bath. DRDQ stated the nurse should have given the CHG bath daily per the facility policy. p. For Patient 27, the facility document titled, “History and Physical,” indicated Patient 27 was admitted to the facility on April 3, 2024, for hip discomfort after a fall. The record indicated Patient 27 had a right hip nailing. There was no documented evidence CHG bath 24 hours before the surgical procedure, on the day of the procedure, and while admitted to the hospital. An interview and concurrent record review were conducted with the Chief Quality Officer (CQO) on April 16, 2024, at 10:30 a.m. The CQO stated Patient 27 was not provided a CHG bath 24 hours prior to the surgical procedure and on the day of the procedure. The CQO stated the patient should have had the CHG baths while in the hospital and prior to the procedure. q. For Patient 28, the facility document titled, “History and Physical,” indicated Patient 28 was admitted to the facility on April 5, 2024, for a cystoscopy (examination of the lining of the bladder) with insertion of left ureteral (tubes that carry urine) doubled j-stent (tube to drain urine). There was no documented evidence CHG bath 24 hours before the surgical procedure and on the day of the procedure. An interview and concurrent record review were conducted with the CQO on April 16, 2024, at 11:46 a.m. The CQO stated the patient should have had a CHG bath because he was a surgical patient. The COO stated the nurse documented “NA [not applicable]” on the check list for CHG bath. The CQO stated the patient should have had the CHG bath the day of the procedure. A review of the facility’s P&P titled, “Bathing With Hospital Approved Skin Antiseptic,” dated April 2021, was conducted and indicated, “...the steps for all healthcare workers assigned to provide bedside bathing to patients...Daily bathing with a hospital approved skin antiseptic will be performed upon admission and daily thereafter on the following patients...admitted to ICU [intensive care unit, unit for critically ill patients], CCU [cardiac critical unit, unit for critically ill patients with heart conditions], or DOU [definitive observaion unit, a step down unit for patients with conditions not necessitating critical care]...history of multi-drug resistant organism (MRDO) [a type of infection that is hard to treat] or Clostridium difficile infection (CDI) [a bacterial infection]...have a central line [insertion of a plactic tube in the large blood vessels] (CVC [central venous catheter], PICC, Hemodialysis [procedure of removal of toxin from the body using a machine] catheter)...Have an indwelling urinary catheter....all surgical patients...document the type of bathing performed in the patient’s medical record...All surgical patients...Surgical patients will be bathed the evening before and the morning of surgery....” 5. A tour of the Intensive Care Unit (ICU) was conducted on April 8, 2024, at 3 p.m. with CQO. During an observation conducted in Patient 14’s room, two IV bags were observed hanging on the IV pole. The IV bags were observed to not have the date and time it was hung documented on the label. An interview was conducted on April 8, 2024, at 3:15 p.m., with Registered Nurse (RN) 1. RN 1 stated the two hanging IV bags in Patient 14’s room were not dated, timed, or labeled per facility policy. On April 8, 2024, at 3:37 p.m., Patient 14’s record was reviewed with US. The facility document titled, “[Name of facility] History and Physical,” dated April 6, 2024, at 10:06 p.m., indicated, Patient 14 had a diagnosis of “...AHRF 2/2 COPD [acute hypoxemic respiratory failure secondary to chronic obstructive pulmonary disease, a lung disease]...Sepsis [a serious infection]...” The facility document titled, “Medication Administration Record,” dated April 7, 2024, indicated, “...IV D5W [dextrose 5% (percent) in water, a type of IV fluid] 0.45 % NACL [sodium chloride, a type of IV fluid]...SOLUTION 50 ML [milliliter, a measure of volume]/HR [per hour] Intravenously...1,000 ML...” The facility document titled, “Medication Administration Record,” with a start date of April 7, 2024, and a stop date of April 8, 2024, was reviewed. The document indicated, “...Vancomycin [an antibiotic] 500 MG [unit measurement] INJECTABLE IVPB [IV piggyback, administered with another IV medication] EVERY 8 [eight] HOURS...Additives: IV NACL 0.9% WATER [a type of IV fluid]...” An interview was conducted on April 10, 2024, at 10 a.m., with the CQO. The CQO stated there were two IV bags of fluids in Patient 14’s room which lacked the patient identifier, date, and time when the fluid was hung, which was not in accordance with the facility policy. The CQO stated any medication or fluid hung must have the patient identifier, date, and time. The CQO further stated if the fluid contains an additive the additive needs to be labeled as well. The CQO stated the IV medications that were found at Patient 14’s bedside were not labeled correctly in accordance with the facility’s policy. A review of the facility’s P&P titled, “MEDICATION MANAGEMENT,” dated December 2018, indicated, “...Label Contents: At a minimum, medications will be labeled with the following...Inpatient...Drug name, strength and amount/concentration...Bar code label...Expiration Date and Lot number...Any applicable cautionary or auxiliary labels...IV/Irrigation/TPN solutions, in addition to the above...type, concentration and amount of additive(s)...type and volume of solution...Date prepared...” 6a. On April 15, 2024, at 9 a.m., a concurrent interview and record review with the Patient Safety Coordinator (PSC) was conducted. - A review of Patient 6’s record was conducted. The “History and Physical,” dated March 31, 2024, indicated Patient 6 was admitted to the facility on March 31, 2024, for abdominal pain. The facility document titled, “Order Inquiry,” dated April 2, 2024, at 9 p.m., indicated, “...KETOROLAC [a medication for pain]...EVERY 8 [eight] HOURS...INTRAVENOUS [IV, administer through the vein]...DOSE...15MG[milligram, a unit of measurement]/0.5ML [millilitter, a unit of measurement]...STRENGTH...30MG/ML...” The facility document titled, “Medical Administration Record,” indicated Patient 6 was administered Ketorolac on the following dates: -April 2, 2024, at 9:10 p.m.; -April 3, 2024, at 3:14 a.m.; and -April 3, 2024, at 8:40 a.m. There was no documented evidence Patient 6’s pain was reassessed after the pain medication Ketorolac was administered. The PSC stated the registered nurses must assess pain after pain medication administration to assess if the pain medication was effective. - A review of Patient 7’s record was conducted. The facility document titled, “History and Physical,” dated April 1, 2024, indicated Patient 7 was admitted to the facility on April 1, 2024, for abdominal pain. The facility document titled, “Medication Administration Record,” dated April 8, 2024, was reviewed. The documented indicated, “...HYDROmorphone 0.5 MG/0.5ML [a pain medication]...EVERY 4 [four] HOURS AS NEEDED...INTRAVENOUS...” The document indicated Patient 7 was administered hydromorphone on April 5, 2024, at 3:29 a.m. There was no documented evidence Patient 7’s pain was reassessed after hydromorphone was administered. The PSC stated the registered nurses must assess pain after medication administration to assess if the pain medication was effective. - A review of Patient 8’s record was conducted. The facility document titled, “History and Physical,” dated April 3, 2024, indicated Patient 8 was admitted to the facility on April 3, 2024, for a fall with left tibial-fibular fracture (a break in the bones of the lower leg). The facility document titled, “Medication Administration Record,” dated April 7 2024, was reviewed. The documented indicated, “...HYDROmorphone (PF) 1MG/ML...EVERY 4 HOURS AS NEEDED...INTRAVENOUS...” The document indicated hydromorphone was administered to Patient 8 on the following dates: - April 5, 2024, at 10:45 a.m.; - April 5, 2024, at 2:43 p.m.; - April 5, 2024, at 10:12 p.m.; - April 6, 2024, at 2:27 a.m.; and - April 6, 2024, at 1:37 p.m. There was no documented evidence Patient 8’s pain was reassessed after hydromorphone was administered on these dates. The PSC stated the registered nurses must assess pain after medication administration to ensure the pain medication was effective. b. On April 7, 2024, at 9 a.m., a concurrent interview and record review with the Unit Supervisor (US) were conducted. - A review of Patient 29’s record was conducted. The facility document titled, “History and Physical,” dated April 2, 2024, indicated Patient 29 was admitted to the facility on April 8, 2024, for a left knee replacement (a surgical procedure). The facility document titled, “Medication Administration Record,” dated April 8, 2024, was reviewed. The document indicated, “...KETOROLAC...AS NEEDED...INTRAVENOUS...dose...15MG/0.5 ML...strength 30 MG/ML...comment FOR PAIN...” The document indicated ketorolac was administered to Patient 29 on the following dates: - April 10, 2024, at 11:54 a.m.; and - April 10, 2024, at 1:02 a.m. There was no documented evidence Patient 29’s pain was reassessed after ketorolac was administered on these dates. The US stated the patient should have been reassessed for pain 30 min after the medication was given. A review of the P&P titled, “PAIN MANAGEMENT,” dated January 2021, was conducted. The P&P indicated, “...To assure that patients receive an assessment and management of their pain...Patients have the right to pain management...An appropriate assessment and/or reassessment of a patient’s pain should be conducted...Inpatients will be routinely reassessed for pain...If a treatment intervention for pain is provided, the response to that intervention should be assessed. Reassessment is recommended to occur within 15-60 minutes following treatment...Time frames for reassessment: 60 minutes after PO medication administration, 30 minutes after IM medication administration, and 15 minutes after IV medication administration...” 7. a. On April 10, 2024, at 9 a.m., a concurrent interview and review of Patient 2’s record were conducted with the Patient Safety Coordinator (PSC). The facility document titled, “History and Physical,” indicated Patient 2 was admitted to the facility on March 23, 2023, for vomiting of blood. The record indicated Patient 2 was admitted in the telemetry unit (unit where the patients’ heart rates and rhythm are continously monitored remotely). There was no documented evidence an EKG was conducted on Patient 2 every shift on the following dates: - March 23, 2024, through March 24, 2024; - March 27, 2024, through March 31, 2024; and - April 1, 2024, through April 8, 2024. The PSC stated the facility’s policy indicates a 12 lead EKG was to be completed every shift when a patient was on telemetry monitoring. b. On April 15, 2024, at 9 a.m., a concurrent interview and review of Patient 7’s record were conducted with the PSC. The facility document titled, “History and Physical,” indicated Patient 7 was admitted to the facility on April 1, 2024, for abdominal pain. The record indicated Patient 7 was admitted to the telemetry unit. There was no documented evidence Patient 7 had an EKG every shift on the following dates: - April 3, 2024; and - April 5, 2024, through April 8, 2024. The PSC stated the facility’s policy indicated a 12 lead EKG was to be completed every shift when a patient was on telemetry monitoring. c. On April 12, 2024, at 10:10 a.m., a concurrent interview and review of Patient 14 record were conducted with the Unit Supervisor (US). The facility document titled, “History and Physical,” indicated Patient 14 was admitted to the facility on April 6, 2024, for acute hypoxemic respiratory failure (low oxygen level in the blood due to inefficient breathing). The record indicated Patient 14 was admitted to the Intensive Care Unit (ICU, unit for critically ill patients). There was no documented evidence the 12 leads EKG were completed on Patient 14 on the following days: - March 7, 2024, day shift (7a.m. to 7 p.m.) and night shift (7 p.m. to 7 a.m.); - March 8, 2024, night shift; - March 9, 2024, day shift and night shift; - March 10, 2024, day shift and night shift; and - March 11, 2024, day shift and night shift. An interview and record review were conducted on April 12, 2024, at 1:45 p.m., with the US. The US stated the was no documentation the 12 lead EKGs were done on Patient 14 on the days listed above. The US stated the 12 leads should have be done within 15 minutes of patient arriving to the floor, every shift, and patient transferring to another unit. The US further stated the facility policy for the 12 lead EKG was not followed. d. On April 10, 2024, at 3:50 p.m., a concurrent interview and review of Patient 22’s record were conducted with the DRDQ. The facility document titled, “History and Physical,” indicated Patient 22 was admitted to the facility on March 27, 2024, for pain in the right knee and swelling after falling. The record indicated Patient 22 had a diagnosis of right patella fracture and was admitted to the telemetry unit. There was no documented evidence the 12 lead EKG’s were completed on the following dates: - March 27.2024, day shift (7a.m. to 7 p.m.) and night shift (7 p.m. to 7 a.m.); - March 28, 2024, day shift and night shift; - March 29, 2024, day shift and night shift; - March 30, 2024, day shift and night shift; - March 31, 2024, day shift and night shift; - April 1, 2024, day shift and night shift; - April 2, 2024, day shift and night shift; - April 3, 2024, day shift and night shift; - April 4, 2024, day shift and night shift; - April 5, 2024, day shift and night shift; and - April 6, 2024, day shift and night shift. An interview and record review were conducted with the DRDQ on April 12, 2024, at 3:38 p.m. The DRDQ stated the staff should have completed the 12 lead EKG’s on Patient 22 on the above listed dates. The DRDQ further said the 12 lead EKG per shift was not completed per the facility’s policy. e. On April 12, 2024, at 12:46 p.m., a concurrent interview and review Patient 23’s record were conducted with the DRDQ. The facility document titled, “History and Physical,” indicated Patient 23 was admitted to the facility on April 2, 2024, for a left radical nephrectomy (surgical removal of a kidney). The record indicated Patient 23 was admitted to the ICU. There was no documented evidence the admission 12 lead EKG on April 2, 2024, at 1:59 p.m. There was no documented evidence a 12 lead EKG was conducted on Patient 23 on the following dates: - April 2, 2024, day shift (7 a.m. to 7 p.m.) and night shift (7 p.m. to 7 a.m.); -April 3, 2024, day shift and or night shift; - April 4, 2024, day shift and or night shift; - April 5, 2024, day shift and or night shift; - April 6, 2024, day shift and or night shift; - April 7, 2024, day shift and or night shift; - April 8, 2024, day shift and or night shift; - April 9, 2024, day shift and or night shift; - April 10, 2024, day shift and or night shift; and - April 11, 2024, day shift and or night shift. The DRDQ stated the staff should have completed the 12 lead EKG’s on Patient 23 on the above listed dates. The DRDQ further said the 12 lead EKG per shift was not completed per facility policy. f. On April 15, 2024, at 10 a.m., a concurrent interview and review of Patient 24’s record were conducted with the CQO and the US. The facility document titled, “History and Physical,” indicated Patient 24 was admitted to the facility on March 19, 2024, for a scheduled tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) related to chronic ventilatory insufficiency (inefficient breathin) due to anoxic brain injury (brain injury due to lack of oxygen). The record indicated Patient 24 was admitted to the ICU. There was no documented evidence a 12 lead EKG was completed on Patient 24’s admission on March 19, 2024. There was no documented evidence a12 lead EKG was completed on the following dates: - March 19, 2024, day shift (7 a.m. to 7 p.m.) or night shift (7 p.m. to 7 a.m.); - March 20, 2024, night shift; - March 21, 2024, night shift; - March 22, 2024, day shift and night shift; - March 23, 2024, day shift and night shift; - March 24, 2024, day shift and night shift; - March 25, 2024, day shift and night shift; - March 26, 2024, day shift and night shift; - March 27, 2024, day shift and night shift; - March 28, 2024, day shift and night shift; - March 29, 2024, day shift and night shift; - March 30, 2024, day shift and night shift; - March 31, 2024, day shift and night shift; - April 1, 2024, day shift and night shift; - April 2, 2024, day shift and night shift; - April 3, 2024, day shift and night shift; - April 4, 2024, night shift; - April 5, 2024, day shift and night shift; - April 6, 2024, day shift and night shift; - April 7, 2024, day shift and night shift; - April 8, 2024, day shift and night shift; - April 9, 2024, day shift and night shift; - April 10, 2024, day shift and night shift; - April 11, 2024, night shift; - April 12, 2024, day shift and night shift; - April 13, 2024, day shift and night shift; - April 14, 2024, day shift and night shift; and - April 15, 2024, day shift and night shift. The CQO stated Patient 24’s record is missing the admission 12 lead EKG and the 12 lead EKGs for the dates listed above. The CQO stated she “does not see a 12 lead EKG at all in the EMR [electronic medical record].” The facility Policy and Procedure (P&P) titled, “INITIATING AND DISCONTINUING TELEMETRY MONITORING,” dated April 2021, was reviewed. The document indicated, “...Initiating Telemetry Monitoring...The patient will be placed on telemetry monitoring and an initial EKG strip will be run within fifteen (15) minutes of the patient’s arrival on the nursing unit...A 12 lead EKG will be run by the Monitor observer at the beginning of each shift...” 8. A concurrent interview and review of Patient 27’s record were conducted with CQO on April 16, 2024, at 11:22 a.m. The facility document titled, “History and Physical,” indicated Patient 27 was admitted to the facility on April 3, 2024, due to hip discomfort after a fall. The record indicated Patient 27 had a right hip nailing (procedure with placement of a pin in the broken bone). A facility document titled, “[Facility Name] Medication Administration Record,” dated April 3, 2024, indicated “ ...MORPHINE [pain mendication]-STAT [administer immediately]...4 [four] MG/ML...INJECTABLE...INTRAVENOUS ONCE...SEVERE PAIN...Admin (administered)...April 3, 2024, at 16:17 [4:16 p.m.]... ACETAMINOPHEN [medication for pain]...(325)...TABLET...ORAL [by mouth] EVERY 6 [six] HOURS...AS NEEDED...[2X325 MG PER DOSE]...indication...Mild pain...indication...Headache...Last Administered...April 4, 2024...16:35 [4:35 p.m.]... HYDROCODONE-ACETAMINOPHEN [a pain medication]...10-325MG...TABLET...ORAL EVERY 6 HOURS AS NEEDED...Last Administered... KETOROLAC [30 MG/ML]...INJECTABLE...INTRAVENOUS EVERY 6 HOURS AS NEEDED...Indication...EFFUSION [accumulation of fluid]...RIGHT HIP...Last Administered ...April 5, 2024, 14:02 [2:02 p.m.]...” The facility document titled, “[Facility Name] Vital sign Report,” dated April 6, 2024, indicated the pain was assessed on the following dates: - April 3, 2024, at 11:10 a.m., pain 7/10 (seven out of 10, with ten being worst pain on the pain scale); - April 3, 2024, at 8:01 p.m. pain 5/10 (five out of 10); and - April 3, 2024, at 12:14 p.m. pain 9/10 (nine out of 10. There was no documented evidence Patient 27 was administered pain medications on the dates above. The CQO stated the patient was not given pain medication. The CQO stated she was unable to find when the pain medication was given. The CQO further stated the patient should have been given the pain medication that was ordered. A review of the facility’s P&P titled, “PAIN MANAGEMENT,” dated January 2021, indicated, “...Policy...an appropriate assessment and/or reassessment of a patient’s pain should be conducted that is consistent with the scope of care, treatment and service provided in the specific care setting...Post-Procedure Assessment ...assessment following the operative or invasive procedure to determine the presence of any pain that may have resulted from the procedure...the intensity of pain using age or condition appropriate assessment...location and nature of pain...Treatment of pain...patients shall receive treatment for acute pain...Treatment is to be provided in a timely manner...” 9. On April 16, 2024, at 11 a.m., a review of Patient 27’s record was conducted with the CQO. The facility document titled, “History and Physical,” indicated Patient 27 was admitted to the facility on April 3, 2024, due to hip discomfort after a fall. The record indicated Patient 27 had a right hip nailing. A facility document titled, “[Facility Name] Vital Sign Report,” indicated Patient 27’s critical vitals were the following: - On April 3, 2024, at 6 p.m., blood pressure (BP) was 164/78; - On April 3, 2024, at 8:10 p.m., BP was 172/86; - On April 3, 2024, at 11:10 a.m., BP was 197/73; - On April 3, 2024, at 12 p.m., BP was 189/57; - On April 3, 2024, at 2 p.m., BP was 185/54; and - On April 3, 2024, at 4 p.m., BP was 189/50. There was no documented evidence the physician was notified of Patient 27’s critical blood pressure readings on the dates and times listed above. A review of the facility’s P&P titled, “PHYSICIAN NOTIFICATION,” dated April 2021, was conducted and indicated, “...The attending physician and/or if indicated the consulting physician should be notified in a timely manner by the primary care nurse of any significant changes in the patient’s condition...” 10. On April 15, 2024, at 12:15 p.m., a concurrent interview and review of Patient 25’s record were conducted with the CQO. a. The facility document titled, “History and Physical,” indicated Patient 25 was admitted to the facility on April 3, 2024, with a diagnosis of left knee pain and had a left knee total arthroplasty (joint replacement procedure). There was no documented evidence a medication reconciliation was completed when Patient 25 was admitted to the hospital. A concurrent interview and record review were conducted with CQO on April 15, 2024, at 12:24 p.m. The CQO stated that a medication reconciliation was not completed upon Patient 25’s admission. The CQO stated the staff should have completed the medication reconciliation per the facility policy. b. The facility document titled, “History and Physical,” indicated Patient 27 was admitted to the facility on April 3, 2024, due to hip discomfort after a fall. The record indicated Patient 27 had a right hip nailing (pin placed). There was no documented evidence a medication reconciliation was completed when Patient 27 was admitted to the hospital. There was no documented evidence the facility titled, “[Facility Name] Combined Home Medication and Inpatient Medication reconciliation Order Form,” dated April 3, 2024, was completed upon Patient 27’s admission. A concurrent interview and record review were conducted with CQO on April 16, 2024, at 11:10 a.m. The CQO stated the medication reconciliation was not completed for Patient 27. The CQO further stated there should have been a medication reconciliation completed for the patient upon admission to the hospital. A review of the facility’s P&P titled, “MEDICATION RECONCILIATION,” dated March 2020, was conducted and indicated, “...Medication reconciliation is a multidisciplinary process between Nursing, the Pharmacist and the physician with patient/family involvement...Medication reconciliation/verification will be performe...Upon admission/entry in to the facility...Emergency Department, Surgery, Direct Admits...The nurse completing the admissions assessment will obtain and document the patient’s current medications taken at home. These medications will be listed on the Medication Reconciliation...” 11a. On April 12, 2024, at 9:30 a.m., a record review were conducted with the Deputy Regional Director of Quality (DRDQ) and Chief Quality Officer (CQO). A review of Patient 22’s record was conducted. The facility document titled, “History and Physical,” indicated Patient 22 was admitted to the facility on March 27, 2024, for pain in the right knee and swelling after falling, with a diagnosis of a right patellar (knee cap) fracture (a break in the bone) and was admitted to the telemetry unit (unit where the patients’ heart rate and rhythm are remotely monitored continuously). There was no documented evidence telemetery strips were printed on the folowing dates: - March 27, 2024, at 4p.m., 8 p.m.; and - March 28, 2024, at 12 a.m., 4 a.m. There was no documented evidence a rhythm strip was signed every four hours by the telemetry monitor observer (staff who monitors and analyzes the patients’ heart rate and rhythm as recorded on the telemetry hythm strips). An interview and record review were conducted with the Emergency Room Manager (EDM) and CQO on April 12, 2024, at 3:38 p.m. The EDM stated the patient was on the telemetry monitor in the emergency department (ED) and was monitored every four hours. The EDM stated the telemetry strips for Patient 22 were not printed and placed in the patient’s record on the above listed dates and times. The CQO stated the ED staff is to complete the telemetry monitoring every four hours and is to print, sign the strips, and place them in the patient’s record. The CQO stated there was no separate ER policy. The CQO further stated Patient 22’s record did not include the telemetry strips from March 27, 2024, at admission, up to March 28, 2024, at 8:30 a.m. b. On April 12, 2024, at 12:46 p.m., a record review was conducted with the DRDQ. A review of Patient 23’s record was conducted. The facility document titled, “History and Physical,” indicated Patient 23 was admitted to the facility on April 2, 2024, for a left radical nephrectomy (surgical removal of a kidney). The record indicated Patient 23 was admitted to the Intensive Care Unit (ICU, a unit for critically ill patients). There was no documented evidence Patient 23’s telemetry rhythm strips printed and placed on the patient’s record from April 2, 2024, to April 8, 2024. There was no documented evidence a telemetry rhythm strip was signed every four hours by the monitor observer from April 8, 2024, to April 11, 2024, when the patient was discharged. An interview and record review were conducted with the DRDQ on April 12, 2024, at 2:45 p.m. The DRDQ stated the telemetry rhythm strips for Patient 23 were not printed and placed on the patient’s record from April 2, 2024, to April 8, 2024. The DRDQ stated each of the telemetry rhythm strips printed from April 8, 2024, to April 11, 2024, were not signed. An interview and concurrent review of Patient 23’s record were conducted with the CQO on April 12, 2024, at 2:45 p.m. The CQO stated the patient was in the ICU Unit and it was required to complete, print, sign, and place the telemetry strips in the patient’s file every four hours. The CQO stated this would be under the telemetry P&P. The facility P&P titled, “TELEMETRY MONITORING STATION,” dated April 2021, was reviewed. The P&P indicated, “...Charge Nurse/Monitor Technician will monitor and respond to the central monitor alarms...Alarms...set specifically to each patient’s age and clinical condition...One (1) rhythm strip per (4) [four] hours will be printed and documented in the patient’s medical record...Signature of the monitor observer who analyzed rhythm strip...A rhythm strip will be placed in the patient’s medical records...””

“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: 42512 Based on interview and record review, the facility failed to ensure time sensitive medications were given timely, in accordance with physician order and the facility policy and procedure, for one of 30 patients reviewed (Patient 5). This failure had the potential to adversely affect Patient 5’s healing and medical outcome. Findings: On April 11, 2024, at 9:15 a.m., a concurrent interview and record review with the Patient Safety Coordinator (PSC) were conducted. The PSC stated antibiotics are considered timed medication (medications which should be administered within a certain time period). She stated all timed medications should be given on time. She further stated a timed medication could be given one hour prior or one hour after the scheduled time but anything outside of that parameter would be considered administered too early or too late. The facility document titled, “CPOE Orders Report,” dated March 27, 2024, was reviewed. The document indicated, “...Cefepime [an antibiotic] 2 [two] grams [unit of measurement] intravenously [administered theough the vein] every 8 [eight] hours...Start date 03/27/2024 [March 27, 2024] 14:00 [2 p.m.]...Stop date 04/03/2024 [April 3, 2024]...” A review of Patient 5’s medication administration record was reviewed with the PSC. Patient 5’s medication record indicated Cefepime was administered on the following dates and times: - March 28, 2024, at12:37 p.m., (1 hr 23 minutes early); - March 28, 2024, at 8:47 p.m., (1 hour 13 minutes early); - March 30, 2024, at 4:17 p.m., (2 hours 17 minutes late); - March 31, 2024, at 11:39 a.m., (2 hours 21 minutes early) and; - April 3, 2024, at 12:45 p.m., (1 hour 15 minutes early). During a concurrent interview, the PSC stated the antibiotic was due at 6 a.m., 2 p.m., and at 10 p.m. She stated the registered nurses administered the antibiotic either too early or too late. A review of the policy and procedure (P&P) titled, “Medication Management,” dated December 2018, was conducted. The P&P indicated, “...Medication Management is a critical component in the safe treatment of patients...The organization is committed to the implementation of an effective program that addresses the critical process of...preparing/dispensing, administration, and monitoring...Staff who administers medications is responsible for...Administering medications in accordance with the regulations...Medications are safely and accurately administered...Accuracy In Medication Administration: All licensed personnel who administer medication will Follow...right time...Medication Schedules...Medications will be dosed on a scheduled dosing time...Time-critical scheduled medications - the following medications...are considered to be time-critical because delay in administration can have a negative affect or outcome. Thus, they must be administered within a 1 hour of the scheduled dosing time...Antibiotics...””

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 42512 Based on interview and record review the facility failed to ensure the informed consent was completed by the physician prior to the surgical procedure, for one of 30 sampled patients (Patient 27), in accordance with the facility’s policy and procedure (P&P). This failure had the potential to delay patient care and services or cause harm to the patient. Findings On April 15, 2024, at 3:45 p.m. an interview and concurrent review of Patient 27’s record were conducted with the Chief Quality Officer (CQO) and the Unit Supervisor (US). The facility document titled, “History and Physical,” dated April 3, 2024, indicated Patient 27 was admitted to the facility on April 3, 2024, for hip discomfort after a fall. The record indicated Patient 27 had a right hip nailing (placement of a pin in the bone). A facility document titled, “CONSENT TO SURGERY OR SPECIAL PROCEDURE,” dated April 4, 2024, was reviewed. The consent did not include the date and time Surgeon 6 (S 6) completed the consent.. The CQO stated the physician did not indicated date and time the surgical consent was completed prior to the surgical procedure. The CQO further stated the consent was incomplete and S 6 should have indicated the date and time on the consent form prior to Patient 27’s surgery. A review of the P&P titled, “INFORMED CONSENT,” dated June 2021, was conducted. The P&P indicated, “...A procedural consent form, dated, timed, and signed...are required for surgical invasive procedures/complex prodedures...If the consent for is completed in the doctor’s office prior to the patient’s admission to the hospital for an elective procedure, a person other than the doctor shall serve as the witness and the original signed form shell be submitted to the hospital for inclusion in the patient’s record...If the consent is form is completed in the hospital, a hospital staff member shall serve as the witness...””

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 44871 Based on observation and interview, the facility failed to ensure two different types of medium contrast (an internally administered substance used in imaging procedures) were stored in accordance with the manufacturer’s recommendation, readily available for use. This failure placed the patient’s medical safety at risk. Findings: A tour of the Radiology Department was conducted on April 9, 2024, at 1:15 p.m., with the Director of Surgical Services (DSS), and the Chief Quality Officer (CQO), and the Unit Supervisor (US). The following were observed inside the Pyxis (an automated dispensing cabinet for medications and supplies): - Six 300 milliliter (ml, unit of measurement) bottles labeled, “Cystografin Diatrizoate Meglumine [a type of contrast medium], Injection USP 30% [percent]...” A green sticker labeled “PROTECT FROM LIGHT” was observed on the plastic container of the contrast which was not observed to have a dark pocket cover (used to keep a medication/contrast from direct light exposure); - Seven bottles of “Optiray 350 Loversol Injection 74%) 350 mg/ml Organically Bound Iodine...” A green sticker labeled “PROTECT FROM LIGHT” was observed on the plastic container of the contrast which was not observed to have a dark pocket cover. The two contrast media were observed stored in the Pyxis and exposed to direct light. An interview was conducted om April 9, 2024, at 1:47 p.m., with the Director of Radiology (DOR) who stated she did not know they were supposed to be protected from the light. An interview was conducted on April 10, 2024, at 10:30 a.m., with the CQO. The CQO stated the contrasts should have been protected from direct light and the contrasts were not. The CQO further stated for the two different contrast media, the manufacture instruction instructions indicated the items should be protected from light. The CQO stated the contrast media were not stored properly and the manufacturer’s instructions for storing and the facility policy were not followed. An interview was conducted on April 16, 2024, at 3: 28 p.m., with the Director of Pharmacy (DOP). The DOP stated the contrast media were not stored per the manufacturer’s recommendations. The DOP further stated this medium contrast should have been stored in a dark plastic cover to protect them from light. A review of the facility’s policy and procedure titled, “STORAGE OF MEDICATIONS,” dated September 2023, indicated, “...The medications will be stored according to the manufacturing’s recommendations or in the absence of such recommendations, according to a pharmacist instructions...Prepackaging...Prepackaged medications will be in light-resistant containers to ensure their stability...””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 44871 Based on observation, interview, and record review, the hospital failed to ensure available supplies and equipment were ready for patient use, when: 1. Expired supplies were found in the respiratory supply cart; and 2. Preventative maintenance per manufacture recommendations for the endoscope drying and storage cabinet were not performed timely. These failures had the potential to delay patient care and services or cause patient harm. Findings: 1. A tour of the Emergency Department was conducted on April 8, 2024, at 2:23 p.m., with the Chief Quality Officer (CQO), the Deputy Regional Director of Quality (DRDQ), and the Emergency Department Manager (EDM). During the tour an observation was made of the respiratory supply cart and the following expired supplies were observed inside the cart: - Aircare Endotracheal Tube, labeled with an expiration date of March 28, 2024; and - GlideScope Single Use Stylets, labeled with an expiration date of April 2, 2023.. An interview was conducted on April 8, 2024, at 2:32 p.m., with the Respiratory Therapist (RT). The RT stated the items found in the respiratory cart were expired. The RT stated the cart is checked weekly but there is no log to document it. The RT further stated the items should have been discarded. An interview was conducted on April 10, 2024, at 10:24 a.m., with the CQO. The CQO stated it is against hospital policy to have expired items in patient care areas and the respiratory cart in the Emergency Department is a care area. The CQO verified the above items were expired and should have been discarded. A review of the facility’s policy and procedure (P&P) titled, “STOCK ROTATION AND EXPIRATION,” dated April 2024, was conducted and indicated, “...Expired products and devices shall not be made available for patient use. All stock will be rotated and expiration dates on products should be checked...Expiration dates must be monitored on a regular basis so those items nearing expiration date can be identified and used properly if possible...Expired stock is not to be used under any circumstances...” 2. A tour of the Radiology Department was conducted on April 9, 2024, at 11:40 a.m., with the Director of Surgical Services (DSS) and the CQO. A sticker was observed on the endoscope drying and storage cabinet which indicated the last preventative maintenance was performed in March of 2022. An interview was conducted on April 10, 2024, at 10:04 a.m., with Director of Facilities (DOF). The DOF stated the preventative maintenance for the endoscope drying and storage cabinet was missed. The DOF further stated the preventative maintenance should be done every six months according to the facility’s policy and this was not done for the endoscope drying and storage cabinet. An interview was conducted on April 10, 2024, at 2:09 p.m., with the CQO. The CQO stated this endoscope cabinet was last serviced in March of 2022. The CQO stated preventative maintenance should have been done on the cabinet every six months, and this was not done. A review of the facility’s policy and procedure (P&P) titled, “Preventative Maintenance Program -Ensuring Operation Ability,” dated April 2021, was conducted and indicated, “...Each component within a system must be evaluated to determine the content and frequently of testing procedures, inspections, calibrations, and the services and replacement of parts. In the development of preventive maintenance programs, a review is made from various sources of information, such as manufactures’ recommendations, codes, standards, and federal, state, and local laws and regulations. The basic sources of information are invaluable as start-up aids, however, over time it is essential that local operating experience be factored in to modify the program. Though this process, initial levels of risk are maintained or reduced...” A review of the facility’s P&P titled, “Medical Equipment Management Plan, “dated January 2023, was conducted and indicated, “...Maintaining, Inspecting, and Testing Activities...The Biomedical Manager identifies in writing the activities used for maintaining, inspecting, and testing all of the medical equipment in the inventory used for the diagnosis, care, treatment, and monitoring, of patients thus assuring safety and maximum useful life...Predictive maintenance based on manufacture’s recommendations...Reliability-centered maintenance based on equipment history, Interval-based inspections based on specific intervals between tests, inspections, or maintenance activity...Corrective maintenance based on a request for service or failure of the equipment to pass internal self-tests (Such equipment is subject to an initial test on receipt, and asset management)...””

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 42512 Based on interview and record review, the hospital failed to ensure a pre-surgery (before the surgery) checklist (a list of items that need to be completed prior to surgery) was completed, for eight of 30 sampled patients (Patients 6, 7, 8, 9, 16, 18, 24, and 27) in accordance with the facility’s policy and procedure (P&P). This failure had the potential to cause harm or death to these patients. Findings: 1. On April 15, 2024, at 9 a.m., an interview and concurrent record review was conducted with the Patient Safety Coordinator (PSC). a. A review of Patient 6’s record was conducted. The facility document titled, “History and Physical,” dated March 31, 2024, indicated Patient 6 was admitted to the facility on March 31, 2024, for abdominal pain. The record indicated Patient 6 had surgery for hernia repair on April 2, 2024. There was no documented evidence the facility completed the pre-surgery checklist prior to Patient 6’s surgery. The PSC stated the pre-surgery checklist was missing from Patient 6’s Electronic Medical Record (EMR). She further stated if its not in the EMR then the pre-surgery check list was not done. The PSC stated a pre-surgery check list should have been completed prior to any patient who had surgery. b. A review of Patient 7’s record was conducted. The facility document titled, “History and Physical,” dated April 1, 2024, indicated Patient 7 was admitted to the facility on April 1, 2024, for abdominal pain. The record indicated Patient 7 had surgery for a laparoscopic cholecystectomy (surgical removal of gall stones with the use of a camera) on April 4, 2024. There was no documented evidence the facility completed the pre-surgery check list prior to Patient 7’s surgery. The PSC stated the pre-surgery check list was missing from Patient 7’s EMR. She further stated if it’s not in the EMR, then the pre-surgery check list was not done. The PSC stated a pre-surgery check list should have been completed prior to any patient who had surgery. c. A review of Patient 8’s record was conducted. The facility document titled, “History and Physical,” dated April 3, 2024, indicated Patient 8 was admitted to the facility on April 3, 2024, for a left tibia fracture (a break in a leg bone). The record indicated Patient 8 had surgery to repair the left tibia fracture on April 5, 2024. There was no documented evidence the facility completed the pre-surgery check list prior to Patient 8’s surgery. The PSC stated the pre-surgery check list was missing from the EMR. She further stated if it’s not in the EMR then the pre-surgery check list was not done. The PSC stated a pre-surgery checklist should have been completed prior to any patient who had surgery. d. A review of Patient 9’s record was conducted. The facility document titled, “History and Physical,” dated April 7, 2024, indicated Patient 9 was admitted to the facility on April 7, 2024, for a left ankle fracture due to a fall. The record indicated Patient 9 had surgery to repair the left ankle fracture on April 8, 2024. There was no documented evidence the facility completed the pre-surgery check list prior to Patient 9’s surgery. The PSC stated the pre-surgery check list was missing from Patient 9’s EMR. She further stated if it’s not in the EMR, then the pre-surgery check list was not done. The PSC stated a pre-surgery check list should have been completed prior to the surgery for any patient who had surgery. 2. On April 15, 2024, at 9:07 a.m. an interview and concurrent review Patients 16’s and 18’s records were conducted the Unit Supervisor (US). a. A review of Patient 16’s record was conducted with the US. The facility document titled, “History and Physical,” dated April 2, 2024, indicated Patient 16 was admitted to the facility on April 2, 2024, for sepsis (a serious infection), cellulitis (skin redness and irritation), and fracture to the right ulnar (a break in a bone of the arm). The record indicated Patient 16 had an incision and drainage procedure (procedure to drain an infection) to his right hand on April 2, 2024. There was no documented evidence the facility completed the pre-surgical checklist prior to Patient 16’s surgery. The US stated the pre-surgery checklist was not found in Patient 16’s EMR. The US further stated it does not look like a pre-surgery checklist was completed for Patient 16. The US stated the presurgery checklist is required before the patient is sent down to surgery per the facility policy. b. A review of Patient 18’s record was conducted with the US. The facility document titled, “History and Physical,” dated April 5, 2024, indicated Patient 18 was admitted to the facility on April 5, 2024, for septic sacral decubitus (infection to a wound caused by pressure on an area). The record indicated Patient 18 had surgery to his sacral (tailbone) area, normal saline lavage (flushing of the wound area with a salt solution), and wound vac (vacuum assisted closure, a device for wound treatment) dressing application on April 7, 2024. There was no documented evidence the facility completed the pre-surgical checklist prior to Patient 18’s surgery. The US stated the pre-surgery checklist was not found in Patient 18’s EMR. The US further stated it does not look like the pre-surgery checklist was completed for Patient 18, and this check list is required before the patient is sent down to surgery per the facility’s policy. 3. A concurrent interview and record review was conducted with Deputy Regional Director Quality (DRDQ) on April 15, 2024, at 10 a.m. Patient 24’s record was reviewed. The facility document titled, “History and Physical,” indicated Patient 24 was admitted to the facility on March 19, 2024, with diagnoses which included chronic ventilatory insufficiency (inefficient breathing) due to anoxic brain injury (caused by a complete lack of oxygen to the brain) for a scheduled tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck). The record indicated Patient 24 had surgery procedure for tracheostomy. There was no documented evidence the facility completed the pre-surgical checklist prior to Patient 24’s surgery. The DRDQ stated the pre-surgery checklist was not found in Patient 24’s EMR. The DRDQ stated the checklist is a requirement prior to a surgical procedure per the policy. 4. A concurrent interview and review of Patient 27’s record were conducted with the CQO on April 15, 2024, at 10:30 a.m. The facility document titled, “History and Physical,” indicated Patient 27 was admitted to the facility on April 3, 2024, for hip discomfort after a fall. The record indicated Patient 27 had a right hip nailing (surgery for placement of a pin in the bone). There was no documented evidence the facility completed the pre-surgical checklist prior to Patient 27’s surgery. The CQO stated the pre-surgery check list was not found in Patient 27’s EMR. The CQO stated it is the facility’s responsibility to ensure the checklist is completed before surgery. A review of the policy and procedure (P&P) titled, “UNIVERSAL PROTOCOL FOR PREVENTING WRONG PERSON, WRONG SITE, WRONG PROCEDURE, WRONG SURGERY,” dated June 2021, was conducted. The P&P indicated, “...This protocol is an organization-wide policy. It applies to all medical staff and hospital personnel performing applicable operative or invasive procedures...to ensure patient safety by...PROCEDURE FOR PRE-OPERATIVE SCHEDULINE/INVASIVE PROCESURE VERIFICATION...Start pre-procedure check list [sic] in EHR [electronic health record]...””

“HISTORY AND PHYSICAL CFR(s): 482.51(b)(1) Prior to surgery or a procedure requiring anesthesia services and except in the case of emergencies: (i) A medical history and physical examination must be completed and documented no more than 30 days before or 24 hours after admission or registration, and except as provided under paragraph (b)(1)(iii) of this section. This Standard is not met as evidenced by: 42512 Based on interview and record review the facility failed to ensure the necessary documentations were completed prior to surgery, for two of 30 sampled patients (Patients 25 and 29). This failure had the potential to delay patient care and services or cause harm to the patient. Findings 1. On April 15, 2024, at 3:45 p.m., an interview and concurrent record review was conducted with the Chief Quality Officer (CQO) and the Unit Supervisor (US). A review of Patient 25’s record was conducted. The facesheet indicated Patient 25 was admitted to the facility on April 3, 2024, for pain in the left knee for which Patient 25 underwent a left knee total arthroplasty (a surgical procedure to resurface a knee damaged by arthritis). A review of the facility document titled, “[Name of facility] Orthopedics,” completed by Surgeon 5 on April 2, 2024, in the orthopedics office was conducted. The document indicated the facility document titled, “History and Physical (H&P),” was completed by Surgeon 5 on April 2, 2024, in the orthopedics office. There was no documented evidence the H&P was updated prior to Patient 25’s surgical procedure. The CQO stated the H&P for Patient 25 was completed on April 3, 2024, and needed to have had an update prior to the procedure. The CQO stated there was no documentation the up-date was completed as required by the facility’s policy. 2. On April 16, 2024, at 3:45 p.m., an interview and concurrent record review was conducted with the CQO and the US. A review of Patient 29’s was conducted. The “History and Physical,” dated April 2, 2024, indicated Patient 29 was admitted to the facility on April 8, 2024, for a left knee replacement. A review of the facility document titled, “SHORT STAY RECORD CHART SUMMARY [Name of facility],” was conducted. The document indicated the H&P for Patient 29 was started by Surgeon 6 on April 3, 2024, but was not completed. An interview and record review were conducted with the CQO. The CQO stated the H&P for Patient 29 started on April 3, 2024, needed to have had an update prior to the procedure. The CQO stated there was no documentation the update was completed as required by policy nor is there documentation staff contacted the surgeon to complete the document prior to Patient 29’s surgery. The facility policy and procedure (P&P) titled, “History and Physical,” dated February 2024, was reviewed. The document indicated, “...When an H&P is performed prior to admission, an updated H&P, including any changes in the patient’s condition, must be completed and documented by a licensed practitioner who is credentialed and privileged by the hospital’s medical staff to perform an H&P, within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration...If the licensed practitioner finds no change in the patient’s condition since the H&P was completed, he/she shall indicate in the patient’s medical record that the H&P was reviewed, the patient was examined, and that “no change” has occurred in the H&P was completed...history and physical examination includes indications for procedures, pertinent medical history, medications being taken, allergies and vital signs. Additionally, evaluation of heart and lungs is to be recorded prior to any outpatient procedure...””

“OPERATIVE REPORT CFR(s): 482.51(b)(6) An operative report describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon. This Standard is not met as evidenced by: 42512 Based on interview and record review the facility failed to ensure a comprehensive operative report was completed immediately after a surgery in accordance with the facility’s policy and procedure (P&P), for six of 30 sampled patients (15, 16, 17, 26, 28, 29). This failure had the potential for delay of treatment for patients. Findings: 1. On April 12, 2024, at 8:40 a.m., an interview and concurrent record review was conducted with the Chief Quality Officer (CQO) and the Unit Supervisor (US). a. A review of Patient 15’s record was conducted. The facility document titled, “History and Physical,” indicated Patient 15 was admitted to the facility on March 29, 2024, for hyperglycemia (high blood sugar) and osteomyelitis (bone infection). The record indicated Patient 15 had incision and drainage (procedure to drain an infection) to the first toe of his left foot on April 2, 2024. A facility document titled, “[Name of facility] Brief Post-Operative Progress Note,” dated April 2, 2024, was reviewed. There was no entry on the sections under Findings and Specimen Disposition. There was no documented evidence a comprehensive operative report was completed immediately after Patient 15’s surgery on April 2, 2024. A facility document titled, “[Name of facility] Operative Report,” dated April 8, 2024 (six days after Patient 15’s surgery on April 2, 2024), was reviewed. There was no entry on the sections under Findings, Specimen Removed, and Specimen Disposition. An interview and record review were conducted with the US. The US stated the surgeon (Surgeon 3) completed the operative report on April 8, 2024, at 2:27 p.m. The US stated this should have been done immediately per the facility’s policy. The US further stated the brief note was completed on April 2, 2024, but the brief note was incomplete, and the operative note written on April 8, 2024, was also incomplete. An interview and record review were conducted with the CQO. The CQO stated the April 2, 2024, note for Patient 15 was incomplete and was missing the Findings and Specimen disposition. The CQO further stated the note written on April 8, 2024, was also incomplete and was missing entries for the Findings, Specimen Removed, and Specimen Disposition. b. A review of Patient 16’s record was conducted. The facility document titled, “History and Physical,” indicated Patient 16 was admitted to the facility on April 2, 2024, for sepsis (a serious infection) and fracture of the right ulna (a break in the arm bone). The record indicated Patient 16 had incision and drainage (procedure to drain the infection) to his right hand with the application of ulnar gutter splint (a type of an arm splint for immobilization) on April 2, 2024. A review of the facility document titled, “[Name of facility] Brief Post-Operative Progress Note,” dated April 2, 2024, was conducted. There was no entry on the sections under Findings, Anesthesia, Specimen Removed, and Specimen Disposition. A review of the facility document titled, “[Name of facility] Operative Report,” dated April 8, 2024 (six days after Patient 15’s surgery on April 2, 2024), was reviewed. There was no entry on the sections under Findings, Specimen Removed, Specimen Disposition, and Post operative diagnosis. During a concurrent interview, the CQO stated the operative reports for Patient 16, dated April 2, 2024, and April 8, 2024, were both incomplete and missing many required items. c. A review of Patient 17’s record was conducted. The facility document titled, “History and Physical,” indicated Patient 17 was admitted to the facility on April 3, 2024, for a fall. The record indicated Patient 17 had an open reduction and internal fixation (ORIF, type of surgery to fix broken bones) surgery to her right ankle on April 4, 2024. A review of the facility document titled, “[Name of facility] Brief Post-Operative Progress Note,” dated April 2, 2024, was conducted. There was no entry on the sections under Findings, Descriptions of the Procedure, Specimen Removed, and Specimen. A review of the facility document titled, “[Name of facility] Operative Report,” dated April 10, 2024, was conducted (eight days after Patient 17’s surgery on April 4, 2024). There was no entry on the sections under Specimen Removed and Specimen Disposition. During a concurrent interview, the CQO stated the operative reports for Patient 17, dated April 2, 2024, and April 10, 2024, were both incomplete and missing many required items. 2. On April 15, 2024, at 3:45 p.m., an interview and concurrent record review was conducted with the CQO, the Unit Supervisor (US), and Nurse Educator Special Projects Administrator (NESPA). A review of Patient 26’s record was conducted. The facility document titled, “History and Physical,” indicated Patient 26 was admitted to the facility on March 27, 2024, with a diagnosis of wounds on both feet. The document indicated Patient 26 had lower extremity (legs) cellulitis (deep infection of the skin) and underwent a right foot irrigation (procedure of flushing the wound with a solution) with debridement (removal of damaged tissue) and partial second toe amputation to the proximal phalanx (surgical removal of the toe bone closest to the foot) on April 4, 2024. A review of the facility document titled, “[Name of facility] Brief Post-Operative Progress Note,” dated April 4, 2024, was conducted. There was no entry on the sections under Post-operative diagnosis, Urine output, IV (intravenous, through the vein) fluids, Findings, Anesthesia, Specimen removed, and Specimen Disposition. A review of the facility document titled, “[Name of facility] Operative Report,” dated April 6, 2024 (two days after Patient 26’s surgery on April 4, 2024), was conducted. There was no entry on the sections under the Specimens removed and Specimen Disposition, Estimated blood loss, and Findings. During a concurrent interview, the CQO stated the operative reports for Patient 26, dated April 4, 2024, and April 6, 2024, were both incomplete and missing many required items. 3. On April 16, 2024, at 11:45 a.m., an interview and concurrent record review was conducted with the CQO, US, and NESPA. a. A review of Patient 28’s record was conducted. The facility document titled, “History and Physical,” indicated Patients 28 was admitted to the facility on April 5, 2024, for a cystoscopy (examination of the lining of the bladder) with insertion of left ureteral (tubes that carry urine) doubled j-stent (a type of tube to drain urine) on April 5, 2024. A review of the facility document titled, “[Name of facility] Operative Report,” dated April 5, 2024, was conducted. There was no entry on the sections under Specimens Removed, Specimen Disposition, and Estimated blood loss. During a concurrent interview, the CQO stated the operative report written for Patient 28’s surgery on April 5, 2024, was incomplete and missing many of the required items. b. A review of Patient 29’s record was conducted. The facility document titled, “History and Physical,” dated April 2, 2024, indicated Patient 29 was admitted to the facility on April 8, 2024, for a left knee replacement (procedure to replace parts of an injured knee) which was completed on April 8, 2024. A review of the facility document titled, “[Name of facility] Operative Report,” dated April 8, 2024, was conducted. There was no entry on the sections under Specimens Removed and Specimen Disposition. An interview and record review were conducted with the CQO. The CQO stated the operative report written for Patient 29’s surgery on April 8, 2024, was incomplete and missing the required items. A review of an undated facility document titled, “[Name of the facility] GENERAL RULES AND REGULATIONS,” was conducted. The document indicated, “...A post-operative note must be written immediately following surgery to provide information to those caring for the patient in the immediate post-operative phase. The note must include: date/time; surgeon; assistant; procedure performed; post operative diagnosis; findings; description of procedure; estimated blood loss and specimen(s) removed...Operative reports shall include a detailed account of the findings at surgery as well as detailed of the surgical technique. Operative reports shall be written (or dictated) immediately following surgery for outpatients as well as in patients, the report promptly signed by the surgeon and made part of the patient’s current medical record...” A review of the facility’s policy and procedure (P&P) titled, “DOCUMENTATION OF OPERATIVE AND OTHER HIGH-RISK PROCEDURES,” dated February 2024, indicated, “...Reports of operative and other high-risk procedures will be written or dictated for inclusion in the medical record immediately after the operative or other high-risk procedure and before the patient is transferred to the next level of care. The comprehensive operative report must contain: Preoperative diagnosis...Procedure(s) performed; Description of the procedure(s); Clinical findings; Any specimens removed; Disposition of the specimen, Estimated blood loss, Postoperative diagnosis; Name of the primary surgeon, assistants and the anesthesist, if anesthesia was provided...””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 38479 Based on interview and record review, the facility failed to ensure Medical Screening Examinations (MSE) were conducted by a qualified emergency services personnel, when a Registered Nurse (RN) provided MSE’s for two Obstetrics (OB/pregnant women) patients (Patient 11 and 17). This failure had the potential to compromise the patient’s health and safety if an emergency medical condition was not identified and addressed during their Emergency Department (ED) visit. Findings: On March 26, 2024, at 9:00 a.m., an unannounced visit was conducted at the facility. On March 26, 2024, at 1:15 p.m., a concurrent interview and record review was conducted with the Chief Quality Officer (CQO). The CQO indicated patients who are 20 weeks pregnant will receive a quick triage in the Emergency Room (ER) and will then be transferred to the OB Labor and Delivery Department. The CQO stated OB MSE is provided by RNs who have the qualifications according to their policy. A review of the facility’s document titled, “Triage Report” dated March 14, 2024, at 5:57 p.m. and authored by RN 1, was reviewed. It indicated Patient 11 arrived at the facility on March 14, 2024, at 5:57 p.m., with complaints of vaginal pressure and pain. A review of the facility’s document titled, “Triage Report”, dated March 13, 2024, at 3:32 a.m. and authored by RN 2, was reviewed. It indicated Patient 17 arrived at the facility on March 13, 2024, at 3:32 a.m., with complaints of uterine contractions (tightening of uterine muscle fibers) and pain every two minutes. On March 27, 2024, at 2 p.m., an interview was conducted with the CQO. The CQO stated there was no documented evidence that RN 1 and RN 2, who conducted the OB MSE on Patient’s 11 and 17, had been approved by the board of governing body in the hospital. The CQO stated the nurses had to pass a competency validation that includes Advance Fetal Monitoring, at least one year of experience as a labor nurse, and three MSE’s previously performed in the last 12 months. The CQO stated both are not qualified to conduct MSE on their own. On March 27, 2024, at 2:14 p.m., a concurrent interview and record review was conducted with RN 1. RN 1 stated she cared for Patient 11 on March 14, 2024, and had conducted Patient 11’s MSE. RN 1 stated she had not been signed off, nor “hit” one year of labor and delivery experience, and was not qualified to conduct the MSE. RN 1 stated Patient 11 should have been seen by an OB doctor or that a qualified person should have conducted the MSE. On March 27, 2024, at 2:57 p.m., an interview with RN 2 was conducted. RN 2 stated she cared for Patient 17 on March 12, 2024, and conducted Patient 17’s MSE. RN 2 stated she was not qualified to conduct an MSE per the facility’s policy. A review of the facility policy and procedure titled, EMTALA - MEDICAL SCREENING EXAMINATION AND STABILIZATION POLICY”, dated April 27, 2023, indicated, “PURPOSE...To establish guidelines for providing appropriate medical screening examinations (“MSE”) and any necessary stabilizing treatment or an appropriate transfer for the individual...D...Who May Perform the MSE...1. Only the following individuals may perform an MSE...A qualified physician with appropriate privileges...Other qualified licensed independent practitioner (LIP) with appropriate competencies and privileges...or...A qualified staff member who is qualified to conduct such an examination through appropriate privileging and demonstrated competencies; ii. Is functioning within the scope of his or her license and in compliance with the state law and applicable practice acts (e.g., Medical or Nurse Practice Acts); iii. Is performing the screening examination based on medical staff approved guidelines, protocols or algorithms; and iv. Is approved by the facility’s governing board as set forth in a document such as the hospital bylaws or medical staff rules and regulations, which document has been approved by the facility’s governing body and medical staff. It is not acceptable for the facility to allow informal personnel appointments that could change frequently...” A review of the facility obstetrics policy and procedure titled, “(sic) STANDORDIZED PROCEDURE: MEDICAL SCREENING EXAMINATION” dated April 2021 indicated, “PURPOSE: To define the standardized procedure providing a medical screening exam (MSE) for an OB patient. During the performance of this exam, the qualified RN may perform identified assessments that alternatively would require a physician’s order. The purpose of this procedure is also to define who is competent to perform an MSE...3. Definitions...d. A qualified RN is a Registered Nurse who is certified to perform emergency medical examinations as defined in the OB Department Rules and Regulations who meet the following requirement. Experience, training and/or education and evaluation of competency: Initial Competency. I. Demonstration of competence in skills and knowledge for evaluation and care of the woman in labor via Competency Validation Tool (refer to Appendix A). II. At least one year of experience as a labor nurse. III. Demonstrated competency in AWHONN Advance Fetal Monitoring. IV. Successful completion of written examination for performance of Medical Screening Examination. V. Successful completion of observed/precepted Medical Screening Examination with three (3) MSE’s performed. Ongoing Competency. VI. Three previous MSE’s performed in the last 12 months without any identified opportunity for improvement (refer to Appendix A). VII. Annual review of Policy/Procedure for Medical Screening Examination during Skills Day...””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 45431 Based on interview and record review, the facility failed to ensure stabilizing treatment and to provide safety and security relevant to the psychiatric emergency medical condition (EMC) for one of 21 sampled patients (Patient # 1) when Patient #1 was admitted on a psychiatric hold (5150 - when a person is deemed a danger to self, others, or gravely disabled, could be involuntary detained for 72 hours). This failure resulted in Patient #1 to elope (patient leaving the hospital before discharged) from the Emergency department (ED) and running out of the ED, into the middle of the street, then jumping inside a moving vehicle, where he sustained life threatening injuries when forcefully ejected when the vehicle suddenly stopped. Findings: On March 26, 2024, an unannounced visit was conducted at the facility for an EMTALA survey. A review of Patient 1’s medical record was conducted. Review of a document, titled “ED [Emergency Department] [Name of Hospital] Triage Report”, dated March 21, 2024, indicated, “...Acuity 2...Chief Complaint...Suicidal: 5150 HOLD...Triage D/T [date/time]: 03/21/2024 [March 21, 2024] 15:06 [3:06 p.m.]...Patient Narrative...Pt [patient-Patient #1] BIBA [brought in by ambulance] for DTS [delirium tremens - the most severe form of alcohol withdrawal]. Pt told PD [police department] that he wants a car to hit him...” A review of the facility’s document for Patient 1 titled, “PHH Emergency Department Record (Scribe to Physician)”, dated, March 21, 2024, was conducted. It indicated, “Provider Contact time...03/21/2024 [March 21, 2024] 1505 [3:05 p.m.] ...Chief Complaint...suicidal Ideation...Narrative...present to the ED for evaluation of suicidal ideation. As per police, patient was found walking...in and out of traffic. Patient then told police he wanted to die, and therefore PD placed him on a 5150 hold...” A review of the facility’s document titled, “[Name of Facility] CPOE [ Computerized Provider Order Entry] Orders Report” dated March 21, 2024, was conducted. It indicated “...1503 [3:03 p.m.], Suicide Precaution...” A review of Patient 1’s “Daily Focus Assessment Report”, dated March 21, 2024 was conducted. It indicated, “...Suicide Risk...Interventions 1:1 observation...” A review of the document titled, “Application for 72-hour Detention for Evaluation and Treatment”, dated March 21, 2024, was conducted. It indicated, “Subject (Patient 1) stated he wants to die and wanted a vehicle to hit him ...Based upon the above information it appears there is a probable cause to believe that said person is, as a result of mental disorder: [box checked] a danger to himself/herself.” A review of the facility’s video footage was conducted on March 26, 2024, at 1:35 p.m., with the Director of Facilities (DOF), Chief Nurse Officer (CNO) and Chief Quality Officer (CQO). The video footage dated March 21, 2024 indicated, a. Video 1 - At 2:47 p.m. observed Patient 1 arriving via ambulance, Emergency Medical Staff (EMS) at the bedside. b. Video 2 - At 3:04 p.m. observed Patient 1 arriving in Bay #1 with EMS. Did not observed any ED staff at bedside. c. Video 2 - At 3:08 p.m. observed Registered Nurse 1(RN1) talking to EMS. DOF stated RN1 was receiving report from EMS. d. Video 3 - At 4:00 p.m. observed Patient 1 being moved to Bay#2. Observed Patient Sitter 2 (Sitter 2) and Sitter 3 sitting in the hallway across from Bay #2. The DOF stated Sitter 3 was the sitter assigned to Patient 1 and Sitter 2 was assigned to another patient in the hallway (Patient 21). At 4:08 p.m. observed Patient 1 approaching the doorway while Sitter 2 stood up and approached Patient 1. During a concurrent interview, the DOF stated Patient 1 was asking for assistance to go to the restroom because he felt dizzy. A few seconds later observed Patient 1 pushing Sitter 2 and Patient 1 started running. e. Video 4 - At 4:12 p.m. Patient 1 was observed running towards the door with Sitter 2 following him. f. Video 5 - At 4:12 p.m. Patient 1 was observed running across the parking lot without any hospital staff chasing him. During a concurrent interview, the DOF stated a call was already made to the security staff and it is their practice not to follow the patient, so the patient can concentrate on where he/she is going and reduce further accident. The DOF further stated, at that time the security guard patrolling the south side of the hospital had already been informed. g. Video 6 - Patient 1 was observed in the middle of a busy street. During a concurrent interview, the DOF stated at this time a security guard had already responded, however, he is not seen on the video because view was obstructed by a structure. There was no documented evidence the “Sitter Observation Documentation” was initiated until Patient 1 was moved to Bay#2 at 4:00 p.m. There was no documented evidence the “Environmental Checklist for Psychiatric Patients” was initiated when Patient 1 was moved to Bay#2. An interview on March 27, 2024, at 10:56 a.m., with the Safety Officer 1 (SO1), was conducted. The SO1 stated he responded to the call of a patient eloping. He stated he saw Patient 1 in the middle of the street trying to talk to the drivers passing by. He stated he was at the sidewalk coaching Patient 1 to safety however, he wasn’t sure if Patient 1 could hear him, or if he was ignoring him. The SO1 further stated Patient 1 jumped inside an open window of a moving vehicle and was forcefully ejected when the vehicle suddenly stopped. An interview and record review was conducted on March 27, 2024, at 10:31 a.m., with Sitter 3. Sitter 3 stated, Sitter 2 who was assigned another 5150 patient was helping her watch Patient 1 because he had more experience with 5150 patients than she did. An interview was conducted on March 27, 2024, at 1:16 p.m., with Sitter 2. Sitter 2 stated, “I was assigned as a 1:1 sitter for a patient (Patient 21) in the hallway but I was also helping (name of Sitter 3), so technically I was watching two patients.” On March 27, 2024, at 1:34 p.m., video 3 dated March 21, 2024, was reviewed with the Director of Facilities (DOF), Chief Nurse Officer (CNO) and Chief Quality Officer (CQO). The video indicated Sitter 3 seated across Bay #2 was engaged in a conversation with a staff member while Sitter 2 was across Bay #2 watching Patient 1. At this time, the CQO stated Sitter 3 was not watching/observing Patient 1 as she should. She further stated the 1:1 observation should have started when Patient 1 arrived in the ED. During continued interview, the CNO stated, Sitter 3 was not watching any patients, and that no one was watching Patient 21 or documenting the every 15-minute observations. The CNO further stated her expectation for 1:1 observation is for one (1) sitter to be assigned one (1) patient and for them to perform the assigned task e.g., environmental checklist, and every 15 minutes observations. A review of the facility’s policy and procedures (P&P), titled, “ Behavioral Health Management (ED)” dated August 2019, was conducted. It indicated, “Purpose: To appropriately manage patients in the ED with an acute psychiatric condition...Definition: 5150 custodial hold: is authorized under the LPS Act as a process for holding persons involuntarily for evaluation and treatment...One to one observation is the process where a patient is observed on a one to one staff patient ratio by trained staff. The patient is in line of sight by the staff at all times...””