West Anaheim Medical Center

“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: 26756 Based on interview and record review, the hospital failed to ensure nursing services were organized, supervised, and provided in accordance with hospital’s P&P, physician orders, and accepted standards of practice as evidenced by: The nursing staff failed to provide necessary care and services to Patient 1, including not administer antihypertensive medications and promptly notify the physician when the patient’s elevated SBP and change of condition, not calling the Stroke code as per the hospital’s P&P, not performing nurse to nurse report with the accepting facility, and not completing the required documentation for care and transfer. Cross reference to A395. The cumulative effect of these failures resulted in the hospital’s inability to provide safe and effective care to the patient and to meet the CoP for Nursing Services.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 38660 Based on interview and record review, the hospital failed to ensure its staff provided necessary care and services to one of eight sampled patients (Patient 1) as evidenced by: - Patient 1 was admitted to the ICU on 3/1/26, and intubated for acute shortness of breath. On 3/10/26, after extubation, Patient 1 required BiPAP with FiO2 at 100%. The physician gave a verbal order to adjust FiO2 to 70 %, but the RT did not enter the order in the patient’s medical record. Another RT changed the FiO2 without the physician’s order during the next shift and while preparing for transfer to a higher-level care facility. - The nursing staff failed to administer antihypertensive medication and timely inform the physician when Patient 1’s systolic blood pressure elevated to the 170s mmHg range. - The nurse staff failed to promptly notify the physician of the changes in Patient 1’s neurological status and failed to call the Code Stroke. Patient 1 experienced a large infarct in the left middle cerebral artery (MCA) territory with hemorrhage. The nursing staff did not document the Code Stroke procedures as per the hospital’s policy. - Patient 1 was transferred to the stroke center for a higher level of care. The hospital failed to ensure a physician-to-physician and nurse-to-nurse communications with the receiving hospital. The Patient Transfer Acknowledgement was not signed, and no copy of the transfer documents was retained in the HIM. These failures posed an increased risk of poor health outcomes to the patient. Findings: During a review of the hospital’s Plan For Provision of Patient Care dated July 2024, the hospital’s Plan For Provision of Patient Care showed the prime role of the Registered Nurse is the executive of the nursing process in prescribing the required care and evaluating effectiveness of the care given. The former is done via patient assessment, selection, individualization and professional modification of pre-developed standards of care and protocols. The latter is done via evaluation each shift in the nursing progress notes flowsheet to analyze patient response to the standard in terms of outcome achieved. Review of the hospital’s P&P titled Activation of Code Stroke dated 3/7/20, showed the following: * The hospital shall provide a Code Stroke procedure to help identify and determine timely response to a patient who is having stroke symptoms. * For Inpatient Code Stroke: Symptom Identification and Ongoing Assessment - Sudden dizziness/loss balance/ataxia - Cranial nerve palsies - Loss of sensation - Sudden confusion or trouble speaking/understanding/aphasia - Hemianopsia - Hemiparesis, sudden numbness or weakness - Dysarthria - Quadriparesis - Severe headache with above symptoms. CAT (Critical Assessment Team) is activated: speaks with the primary nurse to get the SBAR. - An accurate “Last Known Well” will be used to determine the assessed time of onset of symptoms and must be documented in the patient’s medical record. - Should the patient have significant deficit and the “Time of Last Known Well” be less than 4.5 hours, the attending physician will be notified for possible activation of code stroke. Dial 444 and tell the operator you have a Code Stroke in room #... During a review of the hospital’s P&P titled “BiPAP Non-Invasive Ventilation” dated 9/25, the P&P showed: * The hospital Non-invasive Ventilation will be initiated with a physician order. The therapy is intended to augment patient spontaneous breathing. * Indications for Non-invasive Ventilation include patients who develop post-extubation difficulties to prevent reintubation; patients with alveolar hypoventilation as reflected by elevated or rising PaCO2; patients with hypoxemia with supplemental oxygen FiO2 > 0.50 with PaO2 < 60 mmHg. * Verify physician order * Initial setting per physician order. May titrate to obtain desired tidal volume or SpO2 if indicated by physician. * Set alarms as appropriate. * Initial assessment when the patient is placed on BiPAP, reassessment at least every two hours. During a review of the hospital’s P&P titled “Prescribing - Ordering Medications - General Practices,” dated 12/19/24, the hospital’s P&P showed all orders for medications and treatment must be legible. All verbal/telephone orders shall be transcribed (recorded) in the metric system. Entered orders - all orders for treatment shall include the type of treatment, specific requirements of treatment (such as wet to dry dressings, etc.) and the frequency of treatment. Direct or telephone orders for medications - are entered immediately into the Hospital Information System (HIS) and signed with the name of the prescriber, the name of the transcriber, and the date and time received. May be taken by a Pharmacist, licensed nurse, Imaging/Radiology Technician, Nuclear Medicine Technician, Respiratory Therapist or Physician Therapist within the scope of their practice. Verbal orders must be cosigned by the physician ordering the medication within 48 hours. During a review of the hospital’s P&P titled “Transfer Policy: Other Facility,” dated 12/15/22, the P&P showed the discharge or transfer of hospital inpatient must comply with all applicable federal and state laws and regulations and stated reporting requirements. Inpatient or Emergent Transfers: * Transfer of a patient to another acute care hospital, with or without an emergency medical condition or whose emergency medical condition has been stabilized. * Transferring Physician Duties: - Informs the patient of the risks, benefits and alternatives of being transferred. - Secures a receiving physician and a receiving hospital that are appropriate to the medical needs of the patient and will accept responsibility for the patient’s medical treatment and hospital care. - Obtains and documents receiving physician’s consent to receive the patient. - Completes Physician Certification, Patient Transfer Acknowledgement for transfer. - Writes an order for transfer in the medical record. - Determines which mode is medically appropriate to safely transfer the patient, including-the type of transportation (ground or air), equipment and personnel required. - Reviews Transfer Medication Summary for completeness and accuracy, updates and signs prior to transfer. - Determines that the patient is medically fit and stable to be transferred and remains responsible for the patient during the transfer. - Dictates a Discharge (Transfer Summary, to be sent with the patient. * Nursing/Case Manager/Discharge Planner Duties: - Obtain written consent from patient after explanation to patient by physician. - (Patient Transfer Acknowledgement) Make two copies. Give the patient the original; keep a copy for the Medical Record, one in envelope with medical records going with the patient. - Complete Acute Inter-Facility Transfer Forms and document patient assessment at time of transfer. (Nursing). - Review Transfer Medication Summary for completeness and accuracy and physician signature. (Nursing). - Confirm the receiving facility acceptance of the patient and obtain room number as well as unit phone number to call report. (CM/Nursing). - Arrange transportation as ordered. (CM/Nursing). - Copy pertinent parts of patients medical record to send with patient including Completed Acute Interfacility Transfer Form (keep copy for medical record). - Call report to the Registered Nurse at receiving facility prior to patient transfer. * Note: retain copies of the medical record transfer documents, send original transfer forms with patient. Original medical records to be sent to Health Information Management. During a concurrent interview and review of Patient 1’s medical record on 5/13/26 at 1014 hours, with the CNO and the Director of PI, the medical record showed Patient 1 was admitted to the hospital on 3/1/26. During a review of the ED Provider Notes dated 3/1/26 at 1947 hours, showed Patient 1 came to the hospital with chief complaint of shortness of breath. The patient was alert and oriented. The patient’s neurological exam showed “Motor 5/5 & Symmetric Bilat, CN 2-12 grossly intact and symmetric bilat.” The patient had “Normal ROM UE’s and LE’s.” The patient was in moderate to severe respiratory distress. The patient intubated without complication and would be admitted to ICU. During a review of the Critical Care - Consult Note dated 3/1/26 at 2304 hours, the Critical Care - Consult Note showed Patient 1 with medical history of COPD presenting to the ER due to acute shortness of breath. The Physical Exam section showed the patient had bilateral round and reactive pupils; the patient’s ROM was intake and the patient’s strength was grossly intact. Patient 1 was intubated on ventilator and admitted to ICU. During a review of the Respiratory Therapy dated 3/10/26 at 1137 hours, the Respiratory Therapy showed Patient 1 was extubated and placed on 4 L NC without adverse effects, signs of shortness of breath or increased work of breathing. Patient 1 was stable and the nurse was notified. During a review of the Critical Care Progress Note dated 3/10/26 at 1516 hours, showed Patient 1 had bilateral round and reactive pupils. The patient’s strength was grossly intact. The patient was extubated and currently on NC. Review of the physician’s order dated 3/10/26 at 1707 hours, the physician’s order showed an order for routine CT head without contrast for Patient 1. 1. During a review of the Respiratory Therapy dated 3/10/26 at 1715 hours, the Respiratory Therapy showed Patient 1 increased work of breathing. Physician 1 was at the bedside and ordered to place the patient on BiPAP with IPAP 14, EPAP 8, BUR (Back-Up Rate) 20 and FiO2 100%. Patient 1 tolerated well and the nurse was notified. During a review of the physician’s order dated 3/10/26 at 1746 hours, the physician’s order showed to put Patient 1 on BiPAP with IPAP 14, EPAP 8, BUR 20, and FiO2 100%. During a review of the RT Note dated 3/10/26 at 1755 hours, the RT Note showed Patient 1’s ABG was drawn, results were reported to the physician, and FiO2 was reduced to 70%. During a review of the Flowsheet on 3/10/26, the Flowsheet showed Patient 1 was on BiPAP with the following settings: - At 1715 hours, IPAP 14, EPAP 8, BUR 20 and FiO2 100%. - At 1800 hours, the FiO2 was set 70%. - At 2000 hours, the FiO2 was set 60%. - At 2342 hours, IPAP 14, EPAP 8, BUR 20 and FiO2 40%. There was no documentation showing the physician’s verbal order for FiO2 70% was entered in Patient 1’s medical record. During an interview with RT 1 on 5/14/26 at 0917 hours, RT 1 in the presence of the CNO, the Manager of RT, and the Director of PI, RT 1 stated Patient 1 was intubated, then extubated by the resident physician and was placed on 4 L NC. Patient 1 tolerated well until 1715 hours, when Physician 1 at the bedside, noted Patient 1 in respiratory distress, and ordered BiPAP. During an interview with RT 1 on 5/19/26 at 1500 hours, RT 1 stated the resident physician verbally ordered the FiO2 to be reduced to 70%. RT 1 adjusted the BiPAP, documented the change in the flowsheet, and notified the next shift. RT 1 confirmed they did not record the physician’s verbal order in the medical record. The CNO, the Manager of RT, and the Director of PI verified the above settings for the BiPAP were changing without a written physician’s order for titration of the Fi02. 2. During a review of Patient 1’s Vital Signs flowsheet, the flowsheet showed on 3/10/26, Patient 1’s BP was as follows: - At 1800 hours, the BP was 154/89 mmHg - At 1830 hours, the BP was 176/94 mmHg - At 1930 hours, the BP was 179/80 mmHg - At 2000 hours, the BP was 171/92 mmHg - At 2030 hours, the BP was 190/87 mmHg - At 2100 hours, the BP was 186/87 mmHg - At 2130 hours, the BP was 157/90 mmHg During a review of the Neurological flowsheet dated 3/10/26, the Neurological flowsheet showed the following: - At 1600 hours, Patient 1 was alert, poor safety awareness, and unable to assess orientation level. Pupils were reactive, 3 mm bilaterally. Right and left hand grips were weak, and the Motor Response in all extremities showed normal flexion. - At 1945 hours, Patient 1 was drowsy, sleepy, unable to assess orientation level and unable to follow commands. Pupils were reactive, 2 mm bilaterally. Left grip was weak. The right hand grip was unable to be assessed. The RUE and RLE motor response were flaccid. The LUE responded to pain, and LLE moved to pain stimuli with non-purposeful movements. - At 2200 hours, Patient 1’s right pupil was sluggish and the pupil’s size was 5 mm; and left pupil was reactive with the size of 2 mm. - At 2345 hours, Patient 1 was drowsy, sleepy, unable to assess orientation level and unable to follow commands. Patient 1’s right pupil was sluggish with the size of 5 mm; and left pupil was reactive with the size of 2 mm. The left grip was weak, the right hand grip was unable to be assessed. The RUE and RLE motor response were flaccid. The LUE responded to pain, and LLE moved to pain stimuli with non-purposeful movements. During a review of the Nursing Note dated 3/10/26 at 2211 hours, the Nurse Note showed as follows: - At 1945 hours, an initial assessment was performed with a family member present; pupils were normal (2 mm, round, bilaterally reactive). - At 2031 hours, the Critical Care Resident Physician was informed of Patient 1’s elevated BP (190/87 mmHg). “Ok” to give the patient’s normal BP medications that were held in the morning. - At 2200 hours, a reassessment found unequal pupils. Right pupil was approximately 5 mm; and left pupil was approximately 2 mm. - At 2203 hours, the Critical Care Resident Physician was informed. - At 2250 hours (approximately), CT head was completed. The result was pending. The physician was notified regarding completion of CT head. Based on findings of CT, stroke protocol initiated. - On 3/11/26 approximately 0240 hours, RN 1 reported to ambulance personnel. At 0323 hours, Patient 1 was transferred to another acute care hospital. Patient 1’s SBP remained above 170 mmHg from 1830 to 2000 hours on 3/10/26, but RN 1 did not notify the physician or administered BP medication until 2031 hours, when the BP elevated to 190/87 mmHg. At 1945 hours, Patient 1’ experienced a change in neurological status with right upper and lower extremities flaccid, RN 1 did not notify the physician until 2203 hours, at which time Patient 1’s right pupil was sluggish and measured 5 mm and the left pupil remained reactive and measured 2 mm. During a review of the medical record, there was no documentation showing the CT Head ordered 3/10/26 at 1707 hours, was performed for Patient 1 as ordered. During a review of the physician’s order dated 3/10/26 at 2205 hours, the physician’s order showed an order for STAT (immediately) CT head without contrast. During a review of the Critical Care Resident Physician’s Significant Event date 3/10/26 at 2300 hours, the Significant Event showed the nurse notified the Critical Care Resident Physician that Patient 1’s right pupil was dilated. A CT head was ordered STAT. Bedside examination showed no light response in the right pupil, but the left pupil responded. Patient 1 was not able to squeeze the left and right hands; was unable to move both legs; and was unable to squeeze/close eyes. The House supervisor was informed that Patient 1 needed to transfer to a stroke center and neurosurgery center for higher level of care. During a review of the CT Head result showed the CT exam was begun on 3/10/26 at 2218 hours and ended on 3/10/26 at 2305 hours. The CT Head result showed Patient 1 had a large acute to subacute left MCA infarct with hemorrhagic conversion and a 7 mm rightward midline shift. During a review of the physician’s order dated 3/10/26 at 2324 hours, the physician’s order showed to discharge the patient to Hospital B for stroke. During a review of the Consults dated 3/11/26 at 1217 hours, showed the “Neuro Note.” Patient 1’s head CT showed “early ischemic change.” The patient had “Ischemic Stroke (Subacute).” The Plan section showed “Thrombolytic/Intervention: NOT IV Thrombolysis or IA Intervention candidate ... Thrombolytic Exclusion: > 4.5 hours.” During a review of the Orders date 3/11/26 at 0247 hours, showed to transfer the patient to higher level of care to Hospital B. During a review of the EMS Report dated 3/11/26 at 0200 hours, the report showed as follows: - At 0234 hours, the Unit at the bedside. - At 0235 hours, the report, paperwork, and imaging was received from the sending RN. The RN and EMS staff visually assessed all invasive lines/devices. The ventilator was set to CPAP with an FiO2 of 50%, pressure support of 14, and PEEP of 8. - At 0250 hours, Patient 1 was transferred to transport ventilator, but did not tolerate well. Sending RT was assisting the EMS RN with ventilator settings at the bedside. - At 0323 hours, Patient 1 moved to gurney by drawsheet with no issues. - 0327 hours, the Unit en route; assessments unchanged. - 0342 hours, the Unit arrived to the receiving hospital; assessments unchanged. During an interview with the CNO on 5/13/26 at 1205 hours, the CNO confirmed there was no documentation for the ambulance service transferring Patient 1, the type of ambulance provided (ACLS or BLS), discharge communication between the physician and the acceptance physician, nurse to nurse report, and Patient Transfer agreement. During an interview with the Director of Case Management on 5/13/26 at 1412 hours, the Director of Case Management stated for emergent transfers, to call the receiving hospital’s Transfer Center to secure a bed; the Transfer Request form was not required in emergencies, but the Transfer and Repatriation agreement must be completed. The EMS arrived within 30-60 minutes. The CM faxed the CT scans or progress reports, notified the patient’s family, requested imaging on CD and a link, and copied the medical record for the receiving hospital. The EMS arrangements would depend on insurance. CCT ambulances were used for the patients transferring to higher levels of care with the RN and RT. The BIPAP settings were communicated to EMS before arrival. The CM handled transfer arrangements during the day, and the House Supervisor arranged nighttime transfers. During an interview with the Manager of Respiratory and RT 2 on 5/14/26 at 0932 hours, the Manager of Respiratory stated the ambulance RT or RN would handle patient transfer from bedside. For BiPAP patients, the sending RT could assist moving the patient from bed to gurney at discharge if needed. RT 2 stated they could not recall whether he helped with the transfer. During an interview with the CNO and the Director of PI on 5/14/26 at 1100 and 1337 hours, the CNO and the Director of PI acknowledged RN 1 failed to administer high blood pressure medication and notify the patient promptly after elevated BP and neurological changes were observed. During an interview with the House Supervisor and the CNO on 5/18/26 at 1003 hours, the CNO and the House Supervisor stated the nurse informed them of a neurological change in the patient between approximately 2000 to 2100 hours. RN 1 was the primary nurse, the charge nurse communicated regarding the suspected stroke in the patient. A stroke code was initiated, and the resident physician was notified. A stat CT scan was performed, appropriate medications were administered, and the physician was present. The team awaited the CAT scan results. An accepting physician and a nurse-to-nurse report were required. The primary RN and the charge nurse coordinated transferring the patient properly to a higher level of care using an ACLS ambulance. The House Supervisor stated they did not arrange for the transfer, was not present when EMS arrived, and did not know the exact time of patient departure. This was considered a STAT transfer, dependent upon EMS availability and acuity; it needed to be completed within a reasonable timeframe, acceptable within an hour. The CNO confirmed there was no documentation of RRT or Code stroke being called as Patient 1 was in ICU, the ICU nurse cared of patient internally. During a telephone interview on 5/18/26 at 1034 hours, with RN 1 in the presence of the Director of PI, RN 1 stated the SBP in the 170s was not a concerning. At 1945 hours, when Patient 1’ neurological status changed, there was no clear baseline for comparing the right and left extremities weakness. Patient 1 was previously sedated and intubated, making assessment unclear, and RN 1 did not receive a thorough report. RN 1 stated when Patient 1’s right pupil was observed enlarged, RN 1 initiated stroke protocol, notified the physician, ordered a STAT CT head which confirmed ischemia, the physician obtained a tele neurology consult. Patient 1 required transfer to a higher level of care. RN 1 stated the charge nurse, the House Supervisor, or other nurse handled the patient transfer arrangements. RN 1 stayed with the patient and confirmed he did not give a report to the RN of the receiving hospital. When EMS arrived, RN 1 reported to their nurse and went outside documenting in the hallway. The RT stayed in room, managed BiPAP, and assisted transferring the patient with the EMS staff for about 45 minutes. During an interview on 5/18/26 at 1115 hours with Physician 1, Physician 1 stated the patient’s SBP in ICU should be maintained below 160 mmHg. Patient 1 might start having a stroke at 1600 hours, when the BP going high resulting from the body reacting to the infusion. Physician 1 stated he was not involved in peer-to-peer communication with the receiving hospital’s physician. An accepting facility, accepting physician required, but the process took long time, some cases were delayed even in emergent transfers. During an interview with the CNO and Director of PI on 5/19/26 at 1630 hours, the CNO and Director of PI acknowledged the verbal order to adjust FiO2 to 70% was not documented in the patient’s medical record. The RT adjusted FiO2 without a physician’s order during the subsequent shift and while preparing for transfer to a higher-level care facility. The nursing staff did not administer antihypertensive medication nor promptly notify the physician when Patient 1’s systolic BP increased and neurological status changed. The Code Stroke was not called, and Stroke protocol was not documented as per the hospital’s policy. Patient 1 was transferred to a stroke center for high level of care. The hospital did not ensure effective physician-to-physician and nurse-to-nurse communication with the receiving facility. Additionally, the Patient Transfer Acknowledgement was not signed, and no copy of transfer documents was retained in Health Information Management. Patient 1 required reintubation in the ED upon arrival at Hospital B.”

“IC PROFESSIONAL COMMUNICATION QAPI CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (iii) Communication and collaboration with the hospital’s QAPI program on infection prevention and control issues. This Standard is not met as evidenced by: 38660 Based on interview and record review, the hospital failed to ensure communication and collaboration occurred between the department, the infection control and quality programs to address, monitor, or improve current infection prevention activities, as the OR department failed to report the potential identified infection control issues in SPD to the Infection Preventionist and the QAPI program, creating the risk of spread of infections to patients obtaining services in the OR. Findings: During a review of the hospital’s Medical Staff By Laws, the Article VI: Corrective Action, showed each department shall conduct regular patient care reviews and studies of practice within the department in conformity with the Hospital’s general quality improvement plan and shall investigate complaints and practice-related incidents. During a review of the hospital’s P&P titled, “Infection Prevention and Control Performance Improvement” dated 9/18/25, the P&P showed each hospital IPCC has the authority to institute any surveillance, prevention or control measures or studies when there is reason to believe that any patient, staff member or visitor may be in danger. Develop and implement a preventive and corrective program to minimize infection hazards. - Monitor the effectiveness of the infection prevention and control program through the application of epidemiology and quality improvement processes. - Develop a system for identifying, reporting, and analyzing the incidence and cause of healthcare associated infections. During a review of the IC Dashboard for 2025, the IC Dashboard showed surgical site infection was included, but improper instrument sterilization and related incidents in SPD were not reported to Infection Preventionist. Records failed to show any plan or interventions by the Infection Prevention and Control and Quality Council Committee. During an interview on 3/16/26 at 1154 hours, with the Director of OR, the Director of PI, and the CNO, Director of OR and the Director of PI confirmed the wet instruments incident was not reported or entered to the hospital’s VERGE Risk system. IP and QAPI staff were unaware of the event.”

“IC PROFESSIONAL TRAINING CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (iv) Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of infection prevention and control guidelines, policies, and procedures. This Standard is not met as evidenced by: 38660 Based on interview and record review, the hospital failed to ensure that perioperative personnel received the required education and competency verification for instrument sterilization when the SPD Technician performed the sterilization process without completing training and competency for Steam Sterilizer Operations. As a result, the instruments were improperly sterilized, causing the patient to remain under anesthesia for over an hour. This failure placed the patient at risk for infection and a poor outcome. Findings: During a review of the hospital’s P&P titled, “Sterilization: Cleaning of Surgical Instruments” dated 9/25, the P&P showed to ensure the proper handling and processing of all surgical instruments. All instruments will be handled and cleaned according to the manufacturer’s instructions. The expected outcomes are that the patient is free from injury related to perioperative equipment, medical supplies, or instrumentation, and the patient is free from signs and symptoms of infection. Perioperative personnel who sterilize items for use in the perioperative setting will receive education and complete competency verification activities on the principles and processes pertinent to all methods of sterilization. During a review of the hospital’s guidelines titled, “Daily Procedure for Using Steam Sterilizers” with no date, the guidelines showed: * Run Bowie Dick test in each sterilizer using PREVAC 1 cycle. * Upon completion of the #1 cycle, check test results, initial test sheet and attach the appropriate page in the indicated logbook. * The first run load of instruments must be run with a Bio test. Any load containing an IMPLANTABLE item also must contain a Bio test. *All Bio test results must be read and entered into the proper area of the record book. * A list of all instrument packs and instruments in each load must be entered into the logbook prior to starting the sterilizer. During a review of the hospital’s guidelines titled, “Use of Steam Sterilizer Operations” with no date, the guidelines showed: * PREVAC 1 Bowie Dick only - temperature 270 degrees Fahrenheit - Sterilizer time 4 minutes - Dry time 1 minute - Total time 16 minutes. * PREVAC 2 small load - temperature 270 degrees Fahrenheit - Sterilizer time 4 minutes - Dry time 30 minutes - Total time 49 minutes. * PREVAC 3 heavy load - temperature 270 Fahrenheit - Sterilizer time 10 minutes - Dry time 40 minutes - Total time 67 minutes. * PREVAC 4 mini load - temperature 270 Fahrenheit - Sterilizer time 4 minutes - Dry time 20 minutes - Total time 37 minutes. On 3/12/26 at 1012 hours, during a concurrent interview and record review of the SPD logbook in the SPD room with SPD Technicians 1 and 2, the Director of OR and the Director of PI, the SPD logbook showed that on 12/29/25 at 0125 and 0756 hours, Loads 3 and 4 with orthopedic instruments and implants were sterilized for four minutes and dried for one minute. Later, Loads 5 and 6 with orthopedic instruments and implants were sterilized for four minutes and dried for 20 minutes in the autoclave at 1003 and 1214 hours. The Director of OR stated the SPD Technician 3 might have used the setting for the Bowie Dick test; instruments were wet, they were rewashed, rewrapped, and sterilized again. SPD Technician 1 explained the autoclave sterilization process using four buttons on the autoclave: PREVAC 1 for Bowie test: four minutes sterilization, 1 minute dry; PREVAC 2 for small load: four minutes sterilization, 30 minutes dry; PREVAC 3 for heavy load: 10 minutes sterilization, 40 minutes dry; PREVAC 4 for mini load: four minutes sterilization, 20 minutes dry. After sterilization, leave instruments in the autoclave for 10 minutes, then slightly open the door for five minutes to prevent condensation on the instruments. The Bowie cycle should not be used to sterilize the instruments. On 3/16/26 at 0900 hours, during a review of Patient 1’s medical record with the Director of OR, the Director of PI, and the CNO, Patient 1’s medical record showed Patient 1 was admitted to the hospital on 12/26/25 and had an open reduction internal fixation of the right distal femur on 12/29/25. During a review of the Anesthesia Record for Patient 1 dated 12/29/25, the Case Tracking Events showed as follows: * At 0833 hours, Anesthesia started; * At 0845 hours, Patient 1 was in OR; * At 0847 hours, Patient 1 was intubated; * At 0849 hours, Anesthesia was ready; * At 0912 hours, “implants found to be nonsterile, will take 45 minutes to reprocess”; * At 1024 hours, “implants re-sterilized and confirmed good to go, surgery proceeded.” During the review of the Intra-op Notes dated 12/29/25 for Patient 1, the Intra-op Notes showed the procedure started at 1036 hours and finished at 1236 hours. Five implants were used for Patient 1. During an interview on 3/12/26 at 1532 hours, with the Director of OR and the Director of IP, the Director of OR stated for 0rthopedic surgery, surgeons used specialized instruments provided by different vendors for each case. The Director of OR stated vendors brought their own limited sets of instruments, which were delivered the night before surgery. On 12/29/26, there were three ortho cases with two vendors using a total of 18 trays. SPD Technician 3 sterilized the trays overnight to prepare for morning surgeries, but SPD Technician 3 who was from the sister hospital, missed pressing the necessary buttons on the autoclave, causing all the trays to become wet. When the OR team brought the cases into the operating room, they found the instruments were still wet, leading them to reschedule the surgeries and reprocess the instruments. All trays were washed again in the decontamination room and then re-sterilized. On 3/16/26 at 1400 hours, during an interview with RN 1, RN 1 stated the patient was under anesthesia while the sterilized package was opened. RN 1 observed some instruments were found wet and others were dry. The surgical team decided to wait and reprocess the instruments. The implants came in sterilized packages and were ready for use, but the instruments were required to work with the implants. The patient remained in the operating room under anesthesia waiting for the instruments to reprocess. During a concurrent interview and review of employee files on 3/16/26 at 1415 hours, with the HR Manager, the Director of OR, and the Director of IP, the HR Manager stated staff were shared between the hospital and its sister facility. Employees from the sister hospital were required to demonstrate competency prior to beginning work at this location. The Director of OR stated the SPD Technician should have in-person autoclave training. The HR Manager and the Director of OR confirmed SPD Technician 3 did not have signed-off competencies for autoclave use in SPD following the incident on 12/29/2025. During a telephone interview on 3/16/26 at 1506 hours, with SPD Technician 3, SPD Technician 3 stated she worked at this hospital when help was needed. SPD Technician 3 stated she last worked at this hospital when SPD had no staff available. The autoclave setup and loads were different. SPD Technician 3 stated she had not received training before using the autoclave, and there was no documented training after the incident.”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to implement its grievance and complaint P&P for one of four sampled patients (Patient 1) when Patient 1’s grievance was not resolved within seven days, the patient was not notified that the hospital was still working to resolve the grievance, and the patient was not informed of the results of the grievance review or the date the investigation was completed. This failure posed a risk for delays in addressing patient concerns and not ensuring timely resolution of grievances. Findings: During a review of the hospital’s P&P titled, “Grievance/Complaint Process,” dated January 2023, the P&P showed “Patient Grievance is defined as a written or verbal concern (when verbal concern about patient care is not resolved at the time of the concern by staff present) by a patient, or the patient’s representative, regarding the patient’s care, abuse or neglect, issues related to the ... compliance with regulatory agencies ... The grievance review process will assure that the grievance is investigated and in a timely manner. ... On average, a time frame of 7 days for the response will be considered appropriate. The patient will be provided with a written notice of:... the results of the grievance process ... the date the investigation was completed ... If we are unable to resolve the issue on the spot, within seven (7) calendar days following the grievance receipt, the patient will be informed of this fact and of the anticipated length of the investigation ... The hospital should inform the patient or the patient’s representative in writing that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written final response, usually within 30 days.” On 9/10/25 at 1108 hours, medical record review for Patient 1 was initiated with the Director of PI. Patient 1’s medical record showed the patient was admitted to the hospital on 4/15/25 and discharged on 8/26/25. Review of the hospital’s Grievance Complaint Log 2025 showed the hospital received a grievance from Patient 1 on 7/23/25, and an acknowledgement letter was provided to the patient on 7/31/25. Review of the acknowledgement letter dated 7/31/25, showed it was hand-delivered to Patient 1. The letter indicated the hospital was currently investigating Patient 1’s concerns. During an interview on 9/10/25 with the Director of PI, the Director of PI verified the grievance had not been resolved within 7 days as per the hospital’s P&P. Additionally, the patient was not notified in writing that the hospital was continuing to investigate the grievance and would follow up with a final written response within 30 days. The patient was also not informed of the results of the grievance review or the date the investigation was completed, as required by the hospital’s P&P.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure that the plan of care for one of four sampled patients (Patient 3) was updated to reflect the use of restraints. This failure posed a risk of substandard outcomes for the patient. Findings: Review of the hospital’s P&P titled Restraints: Violent Behavior or Seclusion dated June 2023 showed the use of restraint or seclusion is in accordance with a written modification to the patient’s plan of care. Use available restraint flow sheets and order forms and narrative notes to document all pertinent information in the electronic medical record including but not limited to plan of care/treatment plan. During a concurrent interview and record review on 9/11/25 at 1100 hours, with the Director of PI and the ED Manager, Patient 3’s medical record was reviewed. Patient 3’s medical record showed the patient was admitted to the hospital on 8/27/25 and discharged on 8/28/25. During a review of the ED Notes dated 8/27/25 at 2136 hours, the ED Notes showed a Code Gray was called due to Patient 3 cursing at staff, attempting to elope, squaring up, posturing, and swinging at staff. Review of Patient 3’s Restraints Violent or Self-Destructive STAT order dated 8/27/25 at 2136 hours, showed to initiate 4-point locked restraints due to imminent risk of harm. During a review of Patient 3’s Violent or Self-Destructive Restraint Flowsheet, the Flowsheet showed the restraints were discontinued on 8/28/25 at 0550 hours. However, further review of Patient 3’s medical record did not show Patient 3’s plan of care was updated to reflect the use of restraints. On 9/11/25, the Director of PI and the ED Manager verified the findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure the nursing staff documented the initiation time, type, and location of the restraints for one of four sampled patients (Patient 3). This failure could create the risk of substandard outcomes for the patient. Findings: Review of the hospital’s P&P titled Restraints: Violent Behavior or Seclusion dated June 2023, showed to use available restraint flow sheets and order forms and narrative notes to document all pertinent information in the electronic medical record. During a concurrent interview and record review on 9/11/25 at 1100 hours, with the Director of PI and the ED Manager, Patient 3’s medical record was reviewed. Patient 3’s medical record showed the patient was admitted to the hospital on 8/27/25 and discharged on 8/28/25. During a review of the ED Notes dated 8/27/25 at 2136 hours, the ED Notes showed a Code Gray was called due to Patient 3 cursing at the staff, attempting to elope, squaring up, posturing, and swinging at the staff. Review of Patient 3’s Restraints Violent or Self-Destructive STAT order dated 8/27/25 at 2136 hours, showed to initiate 4-point locked restraints due to an imminent risk of harm. During a review of Patient 3’s Violent or Self-Destructive Restraint Flowsheet, the Flowsheet showed the restraints were discontinued on 8/28/25 at 0550 hours. An entry dated 8/27/25 at 2202 hours, documented the less restrictive alternatives attempted, the clinical justification for restraint use, and the criteria for discontinuation. However, there was no documentation indicating when the restraints were initiated, the type of restraints applied, or the specific location (e.g., bilateral wrists and ankles) to which the restraints were applied. On 9/11/25, the Director of PI and the ED Manager confirmed the findings. The ED Manager stated the nurse was expected to document the time of restraint initiation, the type of restraints applied, and the location on the patient’s body where the restraints were placed, such as bilateral wrists and ankles.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure the use of restraints for the management of violent or self-destructive behavior was renewed within four-hour for one of four sampled patients (Patient 3). This failure posed a risk of unnecessary restraint use and substandard outcomes for the patient. Findings: During a review of the hospital’s P&P titled Restraints: Violent Behavior or Seclusion dated June 2023, the P&P showed for the continuation of restraints or seclusion, all telephone or written orders are time limited as follows: 4 hours for adults. During a concurrent interview and record review on 9/11/25 at 1100 hours, with the Director of PI and the ED Manager, Patient 3’s medical record was reviewed. Patient 3’s medical record showed the patient was admitted to the hospital on 8/27/25 and discharged on 8/28/25. During a review of the ED Notes dated 8/27/25 at 2136 hours, the ED Notes showed a Code Gray was called due to Patient 3 cursing at the staff, attempting to elope, squaring up, posturing, and swinging at the staff. Review of Patient 3’s Restraints Violent or Self-Destructive STAT order dated 8/27/25 at 2136 hours, showed to initiate 4-point locked restraints due to an imminent risk of harm. Review of Patient 3’s physician orders showed that the next restraint order was not entered until 8/28/25 at 0215 hours, more than four hours after the initial order. Review of Patient 3’s Violent or Self-Destructive Restraint Flowsheet showed the restraints were discontinued on 8/28/25 at 0550 hours. During an interview on 9/11/25 with the Director of PI and the ED Manager, the Director of PI and the ED Manager confirmed that the continued use of restraints was not renewed within the required four-hours timeframe as per the hospital’s P&P.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure the nursing staff reassessed and monitored one of four sampled patients (Patient 3) while the patient was in restraints as per the hospital’s P&P. This failure had the potential to result in unsafe care for the patient. Findings: During a review of the hospital’s P&P titled Restraints: Violent Behavior or Seclusion dated June 2023, the P&P showed a staff who is trained and competent assesses the patient at the initiation of restraint or seclusion and periodically thereafter to include as appropriate to the type of restraint or seclusion and patient condition: - Every 15 minutes: assessment of psychological status/behavior, physical and psychological comfort, circulation, and continuous observation. - Every 2 hours: assessment of skin care and range of motion in the extremities, nutrition and hydration, hygiene and elimination, and vital signs. During a concurrent interview and record review on 9/11/25 at 1100 hours, with the Director of PI and the ED Manager, Patient 3’s medical record was reviewed. Patient 3’s medical record showed the patient was admitted to the hospital on 8/27/25 and discharged on 8/28/25. During a review of the ED Notes dated 8/27/25 at 2136 hours, the ED Notes showed a Code Gray was called due to Patient 3 cursing at the staff, attempting to elope, squaring up, posturing, and swinging at the staff. Review of Patient 3’s Restraints Violent or Self-Destructive STAT order dated 8/27/25 at 2136 hours, showed to initiate 4-point locked restraints due to an imminent risk of harm. Another restraint order was entered on 8/28/25 at 0215 hours. Review of Patient 3’s Violent or Self-Destructive Restraint Flowsheet showed the restraints were discontinued on 8/28/25 at 0550 hours. Review of the Flowsheet showed on 8/28/25 at 0330 hours, the patient was monitored for behavioral/psychological comfort, physical comfort, circulation, and continuous observation. However, further review of Patient 3’s medical record failed to show that nursing staff completed the required assessments and monitoring during the restraint episode from 8/27/25 at 2136 hours to 8/28/25 at 0550 hours. There was no documentation indicating that the nurse assessed and monitored the patient’s psychological status and behavior, physical and psychological comfort, circulation, and provided continuous observation every 15 minutes. In addition, there was no documented evidence the nursing staff assessed skin integrity, range of motion in the extremities, nutrition and hydration, hygiene and elimination, and vital signs every two hours, as required by the hospital’s P&P. During an interview on 9/11/25 with the Director of PI and the ED Manager, the Director of PI and the ED Manager verified the findings.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 35310 Based on observation, interview, and record review, the hospital failed to ensure the physical environment was maintained as evidenced by: 1. The hospital failed to ensure the storage of portable oxygen tanks was secure. Specifically, some tanks were strapped with cohesive wrap bandage instead of being secured with mounted oxygen tank holder brackets, which were broken. 2. The hospital did not have responsible leadership for identifying the elevators that were not functioning properly for patients, staff, and visitors. 3. The hospital did not develop or implement policies and procedures for safeguarding patients, employees, and visitors from improperly functioning elevators. 4. The hospital did not have contracted services for troubleshooting urgent calls for their elevators. 5. The hospital failed to ensure the cleaning of the elevators and did not clearly specify the responsibilities for elevator cleaning. These failures had the potential for substandard patient care. Findings: 1. Review of the hospital’s P&P titled Safety Medical Gas Cylinders dated 6/15/23, showed all tanks must be secured at all times. Acceptable safety systems include floor tank holders, tank racks, portable carts, or holders attached to wheelchairs or gurneys. On 7/17/25 at 1117 hours, an interview and concurrent observation were conducted with the Cardiac Pulmonary Services Manager and the CNO, in the Respiratory Department. The ventilators in the Respiratory Department were observed. Four ventilator carts (Ventilator 2, 4, 6, and 10) had oxygen cylinders strapped with cohesive wrap bandage. The Cardiac Pulmonary Services Manager stated the mounted secured strips to hold the oxygen cylinders were broken and that the oxygen cylinders should have been secured with mounted oxygen tank holder brackets. On 7/17/25 at 1335 hours, an interview was conducted with the Cardiac Pulmonary Services Manager. The Cardiac Pulmonary Services Manager stated the oxygen tank holder brackets had been broken since July last year, and the problem had not been reported yet, and he was in the process of finding new replacements. The Cardiac Pulmonary Services Manager stated there were five out of 19 ventilators with broken oxygen tank holder brackets. 22553 2. On 7/17/25 at 1047 hours, during a tour of the Telemetry unit, an interview and concurrent observation were conducted with RN 2. RN 2 stated she was aware of an incident on a weekday where the elevator alarm sounded loudly for 30 minutes, with a staff member trapped inside for the same duration. RN 2 stated the incident was not reported to the facility’s incident system. On 7/17/25 at 1517 hours, an interview with the PI Director was conducted. The PI Director stated if the elevators were not functioning properly, it was considered unsafe and should have been reported to the hospital. The PI Director stated it was every employee responsibility to report incidents when they occurred. On 7/17/25 at 1536 hours, an interview was conducted with RT 8. RT 8 stated on 7/12/25, RT 8, RN 3, and Patient 2 were trapped in an unidentified elevator for approximately one hour, on the 2nd floor, as the door would not open. RT 8 stated he reported the incident to the House Supervisor expecting the House Supervisor to file a report in the incident system. RT 8 stated if someone on the 1st floor needed the elevator, they would either have to run up the stairs to the 3rd floor to make it come down or call someone on the 3rd floor to push the button. The elevator frequently stopped on the 2nd floor. On 7/17/25 at 1601 hours, an interview with the House Supervisor was conducted. The House Supervisor stated she did not file an incident report about the elevator event on 7/12/25, because the patient was safe. The House Supervisor stated there was another episode where a family member, a patient, and a staff member were trapped in an elevator. On 7/18/25 at 1026 hours, an interview was conducted with RN 3. RN 3 confirmed the elevator incident on 7/12/25. RN 3 stated Patient 2 and RT 8 were in the elevator when it stopped for more than 20 minutes and released with assistance from engineers. RN 3 stated the House Supervisor was involved and it was House Supervisor’s responsibility to report the incident. On 7/18/25 at 1109 hours, a review of Patient 2’s medical record was conducted with the CNO. The medical records showed Patient 2 left the ED on 7/12/25 at 1247 hours and arrived at the med/surg unit at 1338 hours, indicating a 35-minute duration to travel from the 1st floor ED to the 2nd floor Med/Surg. On 7/18/25 at 1314 hours, an interview was conducted with the CNO. The CNO stated that documented events of employees being trapped in elevators were not found in the hospital system, but leadership was aware of these incidents. These events were reportedly discussed during daily huddles but were not formally documented. The hospital was not tracking or trending these occurrences. 3. On 7/18/25 at 1216 hours, when questioned about P&P for safeguarding the safety of patients, employees, and visitors for elevators rides, the Director of Plant Operations stated there was no existing policies or procedure specifically addressing scenarios where an elevator was not functioning properly. 4. On 7/18/25 at 0928 hours, the Director of Plant Operations stated that the hospital currently had a contracted services company on-site working on a new elevator. The PI Director also mentioned that this contractor assisted with troubleshooting urgency calls for their elevators. Review of the “Facility Services Agreement” did not include provisions for responding to urgency calls. Both the CNO and the Director of Plant Operations confirmed the findings. 5. On 7/17/25 at 1039 hours, the CNO accompanied riding hospital elevators. One elevator site was covered with a plastic seal, and the two other service elevators were in use. During the elevator ride, the CNO stated one of two service elevators had not been cleaned, noting visible matter on the ceiling’s clear panels. A note inside the elevator instructed passengers to “push the bottom to let the elevator to go to the first floor.” The CNO understood the instruction but was unsure of its purpose or each elevator’s identification number. On 7/18/25 at 0928 hours, during an interview with the Director of Plant Operations. The Director of Plant Operations stated that both Environmental Services and engineers were responsible for elevator cleaning. The Director of Plant Operations clarified that it would ultimately be the responsibility of the engineers. The Director of Plant Operations was unable to provide a cleaning schedule for the elevators.”

“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: 22553 Based on observation, interview, and record review, the nursing staff failed to ensure the visitor wore the PPE when visiting one of four sampled patients (Patient 2) as per the hospital’s P&P. This failure created the risk of spreading the infection in the hospital. Findings: Review of the hospital’s P&P titled Isolation: Transmission Based Precautions dated 9/21/23, showed the following: * Isolation or precaution techniques are to be used when patients have certain communicable or infectious disease. The techniques have the purpose of preventing the spread of the diseases to other patients, personnel and visitors. * In addition to Standard Precautions, use Transmission -based Precautions for patients with documented or suspected infection or colonization with highly transmissible or epidemiological-important pathogens for which additional precautions are needed to prevent transmission. The contact precautions: * Use of PPE: - Wear gloves whenever touching the patient’s intact skin or surfaces and articles on close proximity to the patient (e.g., medical equipment, bed rails) when anticipated, don gloves upon entry into the room if touching of anticipated. - Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. When anticipated, don gown upon entry into the room or cubicle. Remove gown and observe hand hygiene before leaving the patient-care environment. On 2/21/25 at 0910 hours, the ICU was toured with the PI Director and ICU Director. Patient 2 was observed in one of the ICU bays. RN 1 was observed at Patient 2’s bedside. A temporary notice of contact precaution was observed outside of the curtain of Patient 2’s bay. The second of the contact isolation sign was observed posted at the end of the patient’s bed. A visitor was observed wore on the street clothes, walked to the patient’s care area, talked to the patient, and hugged the patient. The visitor did not don the PPE. RN 1 was observed walked and talked to the visitor and advising the visitor the requirement of the PPE. The visitor was observed walked back the PPE box and donned a gown and gloves. There was no hand hygiene observed by the visitor before donned the PPE. During the concurrent interview with RN 1, RN 1 stated Patient 2 was admitted with colonized E. coli infection. RN 1 stated the visitor was the patient’s family and visited the patient yesterday. The PI Director and ICU Director confirmed the findings on 2/21/25 at 1600 hours.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 22553 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff clarified with the physician of the RASS target when administering propofol (sedative medication) to one of four sampled patients (Patient 2). This failure had the potential to result in poor health outcomes to the patient. Findings: Review of the hospital’s P&P tilted Medication Administration dated 3/21/24, showed medication management requires a system-based approach to evaluate and monitor the medication-use process providing safe and effective use of medications throughout the health system. Prior to administration, the practitioner will discuss any unresolved, significant concerns about the medication with the prescriber or physician covering the patient and/or relevant staff involved with the patient’s care, treatment, and services. Review of the hospital’s P&P tilted Propofol Infusion Guidelines for Ventilated Patient dated September 2024 showed the following: * The purpose is to provide safe and effective use of propofol infusion for patients receiving mechanical ventilation in a critical care setting. * All infusion orders must be complete and contain a titration goal. * The propofol infusion must be administered using an infusion pump and a physician’s order must relate a therapeutic goal (RASS Scale), sedation level or the desired level of sedation. For most patients, RASS target is 0 to -2; there are clinical exception to this range; however, a range must be specified in all orders. * The RASS score is range from - 5 to + 4. The RASS score of -2 indicates the patient has light sedation, was briefly awakens to voice which the eye opening or contact is less than 10 seconds. The RASS score of - 4 indicates the patient has deep sedation, no response to voice, but movement or eye opening to physical stimulation. On 2/21/25 at 0910 hours, the ICU was toured with the PI Director and ICU Director. Patient 2 was observed intubated and received the continuous propofol infusion. RN 1 was at Patient 2’s bedside. During the concurrent interview with RN 1, RN 1 stated revealed the physician ordered to administer the propofol infusion to the patient and the RASS goal was -4. The patient assessed and had the RASS score of -2. RN 1 stated the patient was slightly moving her head. The patient would be given the narcotic medication for pain. On 2/21/25 at 1244 hours, review of Patient 2’s medical record was conducted with the ICU Director. Patient 2’s medical record showed the patient arrived to the ED on 2/18/25 at 2100 hours. Review of the physician’s order dated 2/18/25 at 2239 hours, showed the propofol infusion order to be started on 2/18/25 at 2245 hours and the RASS target was less than - 4 (deep sedation). There was no range of the RASS score specified for Patient 2 as per the hospital’s P&P. Further review of Patient 2’s medical record showed on 2/21/25 at 1500 hours, the physician’s order for propofol infusion was modified; and the RASS Goal was - 2 to - 4. The ICU Director could not locate documented evidence to show the nursing staff verified with the provider/physician of the RASS target range from /18/24 at 2245 hours to 2/21/24 at 1453 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: 29798 Based on interview and record review, the hospital failed to ensure the nursing staff had initiated PET to release 5150 hold as per the hospital’s P&P related to the patients presenting to the ED on a 5150 hold for two of five sampled patients (Patients 1 and 2). This failure created the increased risk of poor health outcomes to the patients receiving services in the hospital. Findings: Review of the hospital’s P&P titled Admission-Criteria/Direct Admission Requirement dated December 2024 showed in part: * Purpose: to define criteria for admission according to severity of illness with a need for intensity of services. * Policy: Admission Criteria and Patients Served:...Patients have a Conservator/Public Guardian with rights to authorize mental health treatment, who is willing to consent to admission. - The Exclusion Criteria: (Each case is evaluated on an individual basis by a designated clinician). Patients that have been placed on a Lanterman-Petris-Short (LPS) hold (5150). Review of the hospital’s document titled Emergency Department Psychiatric Patient Process dated December 2023 showed for the psychiatric patient presents to the ED and medically clear and on Emergency Hold, call the Prime Orange County Call Center to initiate Psychiatric Evaluation Team (PET) if appropriate to release hold or determine bed availability and initiate transfer. 1. On 1/23/25 0900 hours, an interview with concurrent review of Patient 1’s closed medical record was conducted with the CNO and BHU Director. Review of Patient 1’s closed medical record showed the patient was presented to the ED on 12/17/24, with the chief complaint of aggressive behaviors. Review of the Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment dated 12/16/24 at 1550 hours, showed Patient 1 was placed on a 5150 hold. Review of the ED Provider Notes dated 12/17/24 at 2017 hours, showed Patient 1 was a DTS/DTO and placed on a 5150 hold on 12/16/24 at 1550 hours. Further review of Patient 1’s closed medical record showed on 12/18/24, the patient was presented with a document titled Voluntary Admission Behavioral Health by a BHU staff member. The Voluntary Admission Behavior Health form showed the patient’s signature on the form and the date/time was 12/18/24 at 0945 hours. The patient was admitted to the BHU on 12/18/24 at 1100 hours. However, further review of Patient 1’s closed medical record did not show if the patient’s conservator/legal guardian was contacted to consent for the psychiatric treatment of Patient A as per the hospital’s P&P. On 1/23/25 at 1330 hours, an interview with concurrent record review was conducted with the BHU Director. When asked, the BHU Director stated the PET located in another hospital. The PET could sometimes be delayed, they could break a hold. The BHU Director further stated the reason to break a hold was to minimize patient’s discomfort in the ED. When asked, the Director stated the hospital was a non-LPS facility and could ask patients to sign voluntarily. The social workers would handle the paperwork and would ensure the conservator makes the decision to treat the patient. On 1/23/25 at 1030 hours, an interview was conducted with RN 1. When asked, RN 1 stated RN 1 performed the psychiatric evaluation of the patient on a 5150 hold in the ED, and offered the patients voluntary form to sign for admission to the BHU. 2. Review of Patient 2’s closed medical record showed the patient was presented to the ED on 11/25/24 at 1409 hours, with chief complaint of aggressive behavior. Review of the Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment showed Patient 2 was placed on a 5150 hold on 11/25/24 at 1857 hours. Further review of Patient 2’s closed medical record showed the patient was presented with a document titled Voluntary Admission Behavioral Health on 11/27/24. The document showed the patient’s signature on the form and the date/time was 11/27/24 at 0930 hours. And the patient was admitted to the BHU on 11/27/24 at 1046 hours. However, Patient 2’s closed medical record did not show documented evidence the patient’s conservator/legal guardian was contacted regarding consent for psychiatric treatment of the patient as per the hospital’s P&P. On 1/23/25 at 1100 hours, an interview and concurrent closed medical record review was conducted with the BHU Director. When asked, the BHU Director stated patient presented to the ED on a 5150 hold were assessed and evaluated by the BHU Director or a designee/charge nurse. Patients were asked to sign the voluntary admission form for admission to the unit. The BHU Director further stated the patients admitted to the BHU were either conserved or voluntary admission. If a patient on a conservatorship and LPS, the nursing staff obtained a consent from the conservator/legal guardian regarding the patient’s mental health treatment. On 1/23/25 at 0945 hours, an interview and concurrent closed medical record review was conducted with the ED Director. The ED Director stated patients presented to the ED on a 5150 hold, the ED staff notified the BHU for further evaluation and treatment. When asked about the ED Psychiatric Patient Process algorithm dated December 2023, the ED Director stated he was not aware. On 1/27/25 at 0945 hours, an interview with concurrent closed medical record review was conducted with RN 2. When asked, RN 2 stated when a patient who was in the ED, on a 5150 hold, and medically stable, the BHU charge nurse or the unit director would assess and evaluate the patient for admission to the unit. On 1/23/25 at 1005 hours, during the interview with the CNO, the CNO stated the Emergency Department Psychiatric Patient Process algorithm dated December 2023 was posted in the ED and Geropsych unit. On 1/27/25 at 1330 hours, the above findings were verified by the CNO.”

“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: 36703 Based on interview and record review, the hospital failed to ensure the nursing staff carried out or clarified the physician’s orders for two of seven sampled patients (Patients 1 and 2) as evidenced by: 1. The nursing staff did not perform the EKG for Patient 1 as per the physician’s order and did not clarify with the physician when receiving two conflicting physician’s orders for Patient 1. 2. The nursing staff did not clarify with the physicians about the PWEP monitoring when the nursing staff could not perform the PWEP measurements for Patients 1 and 2. These failures created the risk of substandard outcomes for these patients. Findings: Review of the hospital’s Plan For Provision of Care dated July 2024 showed the RN will assume responsibility and accountability for executing therapeutic and diagnostic regimens prescribed by licensed physician and practitioners who by license are authorized to order these regimens. 1. On 1/6/25, review of Patient 1 closed medical record was initiated. Patient 1 was admitted to the hospital on 11/20/24. Review of the History and Physical Assessment - Internal Medicine dated 11/20/24 at 1640 hours, showed Patient 1 was admitted for NSTEMI. The Plan section showed to trend EKGs. Review of the physician’s order dated 11/20/24 at 1829 hours, showed to perform an ECG 12 Lead every six hours for two occurrences. The order remained active until it was discontinued on 11/24/24 at 1706 hours. Review of Patient 1’s medical record showed another physician’s order for EKG was written. Review of the physician’s order dated 11/20/24 at 1909 hours, showed to perform an ECG 12 Lead on Patient 1 once. Review of the EKG studies performed on Patient 1 were as follows for 11/20-11/21/24: - 11/20/24 at 1427 hours. - 11/21/24 at 0732 hours. An EKG was not performed every six hours for two occurrences after 1829 hours, nor after 1909 hours on 11/20/24. Additionally, the conflicting orders were not clarified by the nursing staff. 2. On 1/6/25, review of Patients 1 and 2’s closed medical records was initiated. a. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 11/20/24. Review of the Inpatient Consult - Cardiothoracic Surgery dated 11/21/24 at 1916 hours, showed MD 1 planned to perform a CABG on 11/23/24. Review of the Operative Report dated 11/23/24 at 1200 hours, showed MD 1 performed a coronary artery bypass grafting surgery to three vessels for Patient 1. At the conclusion of the surgery, Patient 1 was transferred to the ICU in stable condition and on a ventilator. Review of the physician’s order dated 11/23/24 at 1645 hours, showed the physician ordered to perform PWEP monitoring for Patient 1 on arrival, every two hours for four occurrences, then every four hours if Patient 1 was stable. The order remained active until it was discontinued on 12/1/24 at 2015 hours. However, review of Patient 1’s medical record failed to show documentation of the PWEP measurements according to the physician’s order. b. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 12/16/24, after arriving to the ED in cardiopulmonary arrest. Review of the Op Note dated 12/23/24 at 1200 hours, showed MD 1 performed a coronary artery bypass grafting surgery for Patient 2. Patient 2 was moved to the ICU in a stable hemodynamic and ventilatory status. Review of the physician’s order dated 12/23/24 at 1514 hours, showed the physician ordered to perform PWEP monitoring for Patient 2 on arrival, every two 2 hours for four occurrences, then every four hours if Patient 2 was stable. The order remained active until 1/2/25 at 2024 hours as an automatic discontinuation since the patient was discharged. Review of Patient 2’s medical record failed to show documentation of the PWEP measurements according to the physician’s order. On 1/7/24 at 1055 hours, an interview was conducted with the Director of ICU and Director of PI. The Director of ICU stated the PWEP measurements were not within the nursing scope of practice at the hospital and was only done by the physicians. The Director of ICU stated the ICU RN knew not to perform the PWEP measurement and released the order. The Director of ICU stated performing a PWEP measurement on the patient was very risky on a newly received cardiac bypass patient. When asked why the order was not clarified, the Director of ICU stated this was an ongoing issue with MD 1 and the OR for not clarifying the orders. The Director of PI stated that MD 1 stated the order was intended for the physicians or residents to perform the PWEP as necessary. The Director of PI acknowledged the physician’s order lacked clarification indicating it was for the physician’s exclusive use. On 1/7/25 at 1650 hours, the above findings were shared and acknowledged by the CNO and Director of PI.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure one of three sampled patients (Patient 1) received the oxygen therapy as per the physician’s plan. This failure had the potential to result in unsafe care and poor clinical outcomes to the patient. Findings: On 8/13/24, Patient 1’s closed medical record was reviewed. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 1/13/24, and discharged on 1/23/24. Review of the physician’s order dated 1/15/24 at 1312 hours, showed to administer oxygen via nasal cannula and titrate FiO2 to keep SpO2 > 88%. Review of the Pulmonary Critical Care Consultation dated 1/19/24 at 1307 hours, showed the following: * The pulmonary critical care was consulted for the developed chronic hypercapnia and altered mental status. * The Blood Gas section showed the patient’s pCO 2 was 36.3 mmHg (normal pCO2 in the blood is between 35 to 45 mmHg) on 1/14/24 at 1148 hours, 72.6 mmHg on 1/18/24 at 1455 hours, and 64.2 mmHg on 1/19/24 at 0421 hours. * The Plan section showed to continue supplemental oxygen, titrate to keep SpO2 between 89- 92%, and avoid excess oxygenation. Review of the Pulmonary Disease Progress Note dated 1/22/24 at 1718 hours and 1/23/24 at 2030 hours, showed the same plan as 1/19/24 at 1307 hours. Review of Patient 1’s SpO2 from 1/19/24 at 1500 hours to 1/23/24 at 1928 hours, showed Patient 1’s SpO2 was either equal or greater than 92 %. On 8/13/24 at 1401 hours, the CNO was interviewed. When asked, the CNO stated a physician placed an order so the nurses or other disciplinary department staff could follow the plan and orders. Further review of Patient 1’s medical record showed there was no physician’s order to carry out the physician’s plan to keep the patient’s SpO2 between 89 - 92 % and avoid excess oxygenation. On 8/13/24 at 1510 hours, the CNO and Director of Performance Improvement verified the above findings.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 39210 Based on interview and medical record review, the hospital failed to ensure the patient’s family was notified of the use of restraints as per the hospital’s P&P for one of nine sampled patients (Patient 2). This failure had the potential for depriving the family of the opportunity to participate in the decisions about the patient’s care. Findings: Review of the hospital’s P&P titled Restraints: Non-Violent Behavior dated 3/16/23, showed the patient and family are educated as possible as to the purpose for restraint use, criteria for termination, and monitoring and care that will be provided. Documentation includes pertinent information including physician and family notification. On 2/20/24 at 1037 hours, an interview and concurrent review of Patient 2’s medical record was conducted with the Director of Telemetry and DOU. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 2/13/24. Review of the nursing assessment dated 2/14/23 at 2000 hours, showed Patient 2 was confused but oriented to person. Review of the physician’s order dated 2/15/24 at 0112 hours, showed to apply the soft restraints to Patient 2’s right and left upper extremities. However, further review of Patient 2’ medical record failed to show documentation Patient 2’s family was informed of the use of restraints. On 2/20/24 at 1037 hours, an interview and concurrent medical record review was conducted with the Director of Telemetry and DOU. The Director of Telemetry and DOU was informed and acknowledged the findings.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 40483 Based on observation, interview, and record review, the hospital failed to ensure the Contract Employee Dialysis Nurse properly wore a gown when entering the patient’s room as per the hospital’s P&P for one of nine sampled patients (Patient 4). This failure created the risk of the spread of infection to the patients in the hospital. Findings: Review of hospital’s P&P titled Clostridium difficile (C. difficile) Prevention Bundle dated 9/21/23, showed all patients who are suspected of having CDI or confirmed as having active infection with C. difficile will be placed on contact plus precautions. The gown and gloves are required when entering the room. Review of Patient 4’s medical record was initiated on 2/20/24. Patient 4’s medical record showed Patient 4 was admitted to the hospital on 2/16/24. Review of the physician’s order dated 2/18/24 at 1958 hours, showed to place the patient on contact isolation to rule out C. difficile. The healthcare personnel caring for the patients on contact precaution wore a gown and gloves for all interactions that might involve contact with the patient or potentially contaminated areas in the patient environment and donning the PPE upon the room entry and discarding it before exiting the patient room is required. During a concurrent observation and interview on 2/20/24 at 1011 hours, with the CNO, the Contract Employee Dialysis Nurse was observed outside Patient 4’s room. A signage was observed posted outside of Patient 4’s room showing Contact Enteric Isolation and to wear gown and gloves. An isolation cart was observed containing available PPE, including yellow-colored gown and gloves. A yellow-colored gown was observed with two securing ties, one at the top for behind the neck and one at the waist. The Contract Employee Dialysis Nurse was observed being in the patient room and wearing the yellow-colored gown without the top tie secured behind the neck secured. The lower tie at the waist was observed to be tied and secured. The front of the yellow-colored gown was observed falling forward, exposing the underneath clothing/uniform of the Contract Employee Dialysis Nurse. On 2/20/24 at 1018 hours, an interview was conducted with the CNO. The CNO confirmed the observation of the Contract Employee Dialysis Nurse who wore a the yellow-colored gown with the unsecured top tie. The CNO stated the expectation was for all care providers including contract employees who entered a patient’s room with Contact Precaution signage were to don and doff the PPE correctly based on the signage posted outside the room. The CNO stated the hospital did not train the contract employees on donning and doffing the PPE but did expect the contract agency to train them. On 2/20/24 at 1028 hours, an interview was conducted with the Contract Employee Dialysis Nurse. The Contract Employee Dialysis Nurse verified she was providing the hemodialysis treatment to Patient 4 in the patient’s room. The Contract Employee Dialysis Nurse stated she was aware of the signage showing Contact Enteric Isolation. The Contract Employee Dialysis Nurse verified the Contract Employee Dialysis Nurse knew the PPE was required to don and doff when entering and exiting Patient 4’s room. The Contract Employee Dialysis Nurse stated she knew the yellow-colored gown needed to be tied and secured at both her neck and waist. The Contract Employee Dialysis Nurse stated the purpose of correctly donning PPE was for safety to both the patient and caregiver. Securing the yellow-colored gown at the top was done to prevent exposure of the caregiver’s clothes/uniform underneath. The Contract Employee Dialysis Nurse verified she had tied and secured the yellow-colored gown only at the waist and not the top tie for the neck. On 2/21/24 at 1308 hours, an interview was conducted with the Infection Preventionist. The Infection Preventionist stated the purpose of PPE was to protect the caregivers, staff, and patients from the spread of infection. The Infection Preventionist stated the PPE was expected to be donned correctly prior to entering a patient’s room based on the type of isolation. The Infection Preventionist stated the type of isolation signage was posted outside of the patient’s room. The Infection Preventionist stated the expectation for the caregivers was to don and wear the yellow-colored gowns with both ties affixed and secured at the neck and waist. The purpose for tying and securing both the top and waist ties on the yellow-colored gown was to protect the caregivers clothing beneath and prevent the spread of the organism. The Infection Preventionist stated the expectation applied to anyone who was entering an isolation room including the staff, contract employees, visitors, and family of the patients on isolation. On 2/23/24 at 1200 hours, the CNO was made aware of the findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 39210 Based on interview and record review, the hospital failed to ensure a physician’s order for the use of non-violent soft restraints was renewed as per the hospital’s P&P for one of nine sampled patient (Patient 2). This failure had the potential for unnecessary use of restraints. Findings: Review of the hospital’s P&P titled Restraints: Non-Violent Behavior dated 3/16/23, showed a written order based on an examination of the patient by the physician is entered into the patient’s medical record within 24 hours of the initiation of the restraints. Continued use of restraint beyond the first 24 hours is authorized by the physician after the examination of the patient and renewing the original order or issuing a new order. This is done no less than once each calendar day. On 2/20/24 at 1037 hours, an interview and concurrent review of Patient 2’s medical record was conducted with the Director of Telemetry and DOU. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 2/13/24. Review of the physician’s order dated 2/16/24 at 1132 hours, showed to apply the soft restraints to Patient 2’s right and left upper extremities. Further review of the physician’s order showed the duration should not exceed 24 hours or one day, and the orders must be renewed every calendar day or when discontinued. Review of Patient 2’s restraint flowsheet showed the soft restraints to the left and right wrists were continued for the patient from 2/17/24 1200 hours to 2/17/25 2200 hours. Review of the physician’s order dated 2/17/24 at 2205 hours, showed to apply the soft restraints to Patient 2’s right and left upper extremities. There was no documented evidence to show the physician’s order was obtained or renewed for the use of soft restraints for Patient 2 when it was exceeding 24 hours or every calendar day as per the hospital’s P&P. The Director of Telemetry and DOU was informed and acknowledged the findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 40483 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff monitored the use of non-violent restraints every two hours for one of nine sampled patients (Patient 5). This failure placed the patient at risk for not receiving the appropriate care to prevent possible medical complications. Findings: Review of hospital’s P&P titled Restraints: Non-Violent Behavior dated 3/16/23, showed a patient in restraints is to be monitored at least every two hours or more often as applicable to the patient. Monitoring is accomplished by observation and interaction with the patient or related direct examination of the patient by qualified staff. The care provided to the patients in restraints include toileting, positioning, circulation checks, range of motion and food/fluids to be offered. Documentation includes to use the restraint order form, electronic medical record restraint flowsheet, and narrative notes to document all pertinent information in the patient’s medical record, including assessments, care provided, and monitoring activities. During an observation on 2/20/24 at 1035 hours with the CNO, Patient 5 was observed on bilateral wrist restraints. Review of Patient 5’s medical record was initiated on 2/20/24. Patient 5’s medical record showed the patient was admitted to the hospital on 2/16/24. Review of the physician’s order dated 2/19/24 at 1853 hours, showed to apply the soft restraints to the patient’s bilateral wrists. The reason for the restraints was interference with the medical treatment. The patient pulled out his NGT and needed the restraints. Review of Patient 5’s restraint flowsheet showed Patient 5 was restrained on 2/19/24 at 1853 hours. Patient 5 was provided with care on 2/19/24 at 2000, 2200, and 2346 hours; and on 2/20/24 at 0800 hours. There was no documented evidence to show monitoring and nursing care were provided to Patient 5 at least every two hours from 2/19/24 at 2347 hours to 2/20/24) at 0759 hours (approximately 8 hours), as per the hospital’s P&P. On 2/20/24 at 1240 hours, an interview and concurrent review of Patient 5’s medical record was conducted with the CNO. The CNO reviewed and verified the hospital’s P&P titled Restraints: Non-violent Behavior applied to Patient 5’s care. The CNO stated the expectation was for the nursing staff to follow the hospital’s P&P to monitor and provide the nursing care at least every two hours to the patients who were restrained. The CNO stated the nurse was expected to monitor and offer care such as toileting, repositioning, checking the patient’s circulation, and offering nutrition and fluid to the patients who were restrained. The CNO stated the nurse was expected to document the care provided to the patients in the patients’ medical records. The CNO reviewed Patient 5’s medical record and verified there was no documentation to show Patient 5 was monitored or provided care from 2/19/24 at 2347 hours to 2/20/24 at 0759 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: 40483 Based on interview and record review, the hospital failed to ensure the nursing staff conducted the pain reassessment after administering the pain medication as per the hospital’s P&P for one of nine sampled patients (Patient 6). This failure had the potential to result in poor health outcomes to the patients. Findings: Review of hospital’s P&P titled Pain Management dated 06/29/21, showed the hospital places emphasis on pain management, including comfort, managing side effects, complications, and patient satisfaction. Patient participation in pain management is imperative and expected. The single most reliable indicator of existence and intensity of pain is the patient’s self-report. The section for Procedure showed to assess for pain using a pain scale with each new report of pain and after each pain management intervention once sufficient time has elapsed for treatment to reach peak effect. The goal is reassessment and documentation within one hour of intervention. Documentation should include patient’s response to the intervention. Review of Patient 6’s medical record was initiated on 2/20/24. Patient 6’s medical record showed the patient was admitted to the hospital on 2/19/24. Review of the Plan of Care dated 2/20/24 at 1010 hours, showed the patient’s problem was pain. The goal was for the patient’s pain to be manageable. The plan was to assess and monitor the patient’s pain levels using the appropriate pain scale, initiate the plan and interventions as ordered, re-assess the patient’s pain levels 30 to 60 minutes after the pain management intervention. Review of the physician’s order dated 2/19/24 at 2359 hours, showed to administer hydrocodone-acetaminophen 5-325 mg (an opioid pain medication) one tablet orally every six hours as needed for moderate pain (the pain level would be from four to six), and severe pain (the pain level would be from seven to 10). On 2/20/24 at 0938 hours, an interview was conducted with Patient 6. Patient 6 stated Patient 6 had been having pain in her arm and had told the nurse about the pain but had not received any pain medication. Review of Patient 6’s MAR showed hydrocodone-acetaminophen 5-325 mg was administered to the patient on 2/20/24 at 1201 hours. Review of Patient 6’s pain assessment showed on 2/20/24 at 1201 hours, Patient 6’s pain level was 10 out of 10. Further review of Patient 6’s pain assessment did not show the nursing staff had conducted any pain reassessment for Patient 6 on 2/20/24 at 1300 hours or 1400 hours. On 2/20/24 at 1420 hours, an interview and concurrent medical record review was conducted with the CNO. The CNO reviewed and verified the hospital’s P&P titled Pain Management applied to the care for Patient 6. The CNO stated the expectation was for the nursing staff to follow the hospital’s P&P to treat and reassess the patient’s pain. The CNO stated Patient 6 was assessed for pain using the 0 to 10 pain scale (with 0 = no pain and 10 = worst pain). The CNO stated the nursing staff was to reassess the patient’s pain in one hour to after providing the treatment to the patient. The rationale was to assess the effectiveness of the treatment. The CNO reviewed and verified Patient 6 was assessed for pain and treated with medication on 2/20/24 at 1201 hours. The CNO reviewed and verified on 2/20/24 at 1420 hours, Patient 6’s pain had not been reassessed for the treatment effectiveness.”