Mercy Medical Center

“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: 49884 The following reflects the findings of the California Department of Public Health during a CMS authorized EMTALA survey, CA00983201. The inspection was limited to EMTALA violations and does not reflect the findings of a full inspection of the hospital. The department was able to substantiate the following EMTALA violations which represent substantial non-compliance: CFR 489.20 - A 2400 EMTALA CFR 489.20 (q) Posting of Signs - A 2402”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 45929 Based on observation, interview and record review, the hospital failed to post the required signage at the walk-in obstetrics (OB, medical specialty focusing on pregnancy and childbirth) triage area (where staff quickly assess patients for the severity of their condition), specifying the rights of individuals to examination and treatment for emergency medical conditions and for women in labor. This failure prevented patients seeking care in the walk-in OB triage and/or their representatives from viewing and understanding their rights and had the potential to result in those rights not being protected and upheld. Findings: During a concurrent observation and interview on 1/6/26 at 9:44 a.m. in the OB Triage area with the Family Birthing Clinical Manager (FBCM) and the Chief Nursing Officer (CNO), the FBCM stated pregnant patients were able to bypass the Emergency Department (ED) and come directly to the OB triage area for assessment of their condition. The Emergency Medical Treatment and Active Labor Act (EMTALA) required signage informing patients of their right to examination and treatment for emergency medical conditions and for women in labor was not seen posted in the OB triage area. The FBCM and CNO could not locate the EMTALA signage in the OB triage area. When asked if there should be EMTALA signage in the OB triage area, the CNO stated, “ ... I’m assuming there should be ...”. During an interview on 1/8/26 at 11:29 a.m. with the CNO, the CNO stated if pregnant patients come directly to the OB triage area and bypass the ED, where EMTALA signage was posted, then EMTALA signage should be also posted in the OB triage area. During a review of the hospital’s policy and procedure (P&P) titled, “EMTALA Governance Policy”, dated 12/11/24, the P&P indicated, “ ... POLICY ... to comply with the Emergency Medical Care and Labor Act (EMTALA) obligations. These regulations are mandated by Section 1867 of the Social Security Act ... and adopted by the Centers for Medicare and Medicaid Services (CMS) ... SCOPE OF EMERGENCY MEDICAL CARE/EMTALA OBLIGATIONS ... This Policy applies to anyone who requests or requires care who presents on hospital property specifically including the main Emergency Department (ED), Labor and Delivery/Obstetrical Units (Labor and Delivery Departments), on-campus or off-campus DEDs [Dedicated Emergency Departments] ... GENRAL POLICIES ... A. Signage. The hospital will post required EMTALA signage to be seen by all individuals entering the Emergency and Labor and Delivery Departments. Signage will be posted in each DED and Labor and Delivery Departments ...”.”

“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: 47888 Based on observation, interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA for two of 22 patients (Patient 1 and Patient 15) when: 1. Stabilizing measures were not provided to Patient 1. Patient 1 was brought to the ED on 11/13/23 for throat swelling and pain. He was assessed as having an acute upper respiratory obstruction (an Emergency Medical Condition, EMC- health condition with acute symptoms of sufficient severity, including severe pain, that without immediate medical attention could result in placing a person’s health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ ) due to an abscess (a confined pocket of pus that collects in tissues, organs, or spaces inside the body in the throat). The Emergency Medical Condition (EMC) was identified by the Emergency Department (ED) Medical Doctor and consulted with the on-call ENT (Ear, Nose and Throat) surgeon at 6:44 a.m. The surgeon indicated he would be in but was delayed approximately 5 hours from the time consulted and did not meet the timely 1-hour expected arrival time in accordance with facility policy and procedure or Medical Staff bylaws. Upon arrival the ENT surgeon assessed the need to perform an incision and drainage (I&D-medical procedure to drain pus or fluid) of the throat abscess and rather than determine the availability of a suitable operating room, performed the procedure in the ED exam room. The procedure immediately had complications with uncontrolled hemorrhage (bleeding), the inability to control the bleeding and keep the airway patent and Patient 1 coded (medical emergency, requiring immediate resuscitation and medical attention by a trained hospital team) in the Emergency Department. 2. Patient 15 did not receive an appropriate medical screen exam (MSE) or stabilizing measures when Patient 15 came to the ED due to chest pain for four days, with a pain score of 7/10 in the chest and neck area. She received an EKG (Electrocardiogram- test that records the heart’s electrical activity to show how fast it’s beating and if the rhythm is regular) due to the hospital chest pain protocol within 10 minutes, but there was no record of the EKG being read by a physician within the 10-minute timeframe, nor did she see a physician. Patient 15 left the ED after being there for 1 hour and 8 minutes without being seen by a physician. The nurse that triaged her did not follow hospital policy and procedures and did not contact a physician to let them know she was leaving. Patient 15 was not provided a MSE, nor stabilizing treatment for her Emergency Medical Condition (EMC) and a physician was not notified that she left. The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare in a safe and responsible manner.”

“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: 47888 Based on interview and record review, the hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [EMC] exists) within the capability of the hospital’s emergency department (ED) for one of 22 patients (Patient 15), when Patient 15 was seen in the ED on 5/2/25 at 12:14 p.m. for a chief complaint of chest pain for four days with a pain score of 7/10 in the chest and neck area and no physician was notified to conduct a physical evaluation of Patient 15. The triage nurse (RN 6) determined an ESI (Emergency Severity Index- is a standardized tool used in emergency departments to classify patients based on the urgency of their medical condition and the resources they require) of 3, obtained an EKG Electrocardiogram- test that records the heart’s electrical activity to show how fast it’s beating and if the rhythm is regular) and then had Patient 15 wait in the lobby. The results of the EKG were not read by the physician within 10 minutes in accordance with hospital policy and procedures and RN 6 did not notify the ED physician of the symptoms or vital signs of Patient 15. These failures resulted in Patient 15 waiting 1 hour and 4 minutes in the ED without an appropriate MSE, promoting Patient 15 to notify the nurse of leaving, the nurse did not take the opportunity to notify the physician of Patient 15 leaving and denying Patient 15 of the benefit of a physician providing a physical examination and diagnosis for the chest pain and an EMC was not ruled out. The hospital did not follow up with Patient 15 after the patient left the ED per the electronic medical record. Findings: During a review of Patient 15’s “Triage Assessment (TA)”, dated 5/2/25 at 12:14 p.m., the TA indicated, “ ... Triage ... Chief Complaint: Chest pain ...ED [Emergency Department] Check-in Time: 5/2/25, 12:14 p.m. Arrived by: [not filled in]... Subjective Nursing Assessment: left sided chest and neck pain x 4 days ... Tracking Acuity: 3- Urgent [ESI- Emergency Severity Index It is a standardized tool used in emergency departments to classify patients based on the urgency of their medical condition and the resources they require] ...”. During a review of Patient 15’s “Vital Signs (VS)”, dated 5/2/25 at 12:22 p.m., the VS indicated, temperature 36.6 Celsius (C- a unit of measurement for body temperature), heart rate 88 (HR- number of times the heart beats per minute), blood pressure BP-force exerted by the blood on the walls of the blood vessels as it circulates) 148/83, Respiration Rate (RR- how many breaths are taken in one minute) 20, Pulse oximetry (SPO2-oxygen saturation or percentage of hemoglobin in blood carrying oxygen) on room air 98%, pain score 7 out of 10. During a review of Patient 15’s “Order Summary (OS)”, dated 5/2/25, the OS indicated, “ ... Summary of All Orders ... EKG [Electrocardiogram- test that records the heart’s electrical activity to show how fast it’s beating and if the rhythm is regular] 12 lead ... [Ordering Physician] 5/2/25 at 12:16 p.m., Chest Pain ...”. During a review of Patient 15’s “Patient Summary Report (PSR)”, dated 5/2/25, the PSR indicated, “ ... [Patient 15] ... Age: 50 years ... Sex: F [Female] ... Encounter Information: ... Visit Reason: Chest Pain ... Discharge Date: 5/2/25 at 1:18 p.m. ... Discharge Disposition: ED- Left before medical screening exam ... Arrive: 5/2/25 at 12:14 p.m. ... Triage Start: 12:14 p.m. ... EKG Complete 5/2/25 at 12:16 p.m. ...”. During a review of Patient 15’s “ED Nursing Note (NN)”, dated 5/2/25 at 1:20 p.m., the NN indicated, “ ... Source of Report: [Registered Nurse] RN 2 ... Patient unable to wait to be triaged and be seen by a provider, stated will see her provider or else will go to another ED. [Patient 15] was advised to come back if symptoms get worst ...”. During a review of Patient 15’s “EKG”, dated 5/2/25, the EKG indicated, “ ...rate 91 ... electronically signed 5/3/25 at 5:40 p.m. by [telecardiologist] ...”. During a concurrent interview and record review on 9/23/25 at 9:15 a.m., with the Emergency Department Nurse Shift Manager (EDSM), Patient 15’s “Electronic Medical Record (EMR)” dated 5/2/25 was reviewed. The EMR indicated Patient 15 was triaged for chest pain, she did not see a provider and Registered Nurse (RN) 3 did not notify a physician when she left. The EDSM stated Patient 15 did not have a medical screening exam (MSE- initial examinations by a qualified medical professional in a hospital emergency department (ED) to determine if a patient has an emergency medical condition (EMC), an urgent condition that could jeopardize the patient’s health without immediate attention) and she should have seen a provider. The EDSM stated there was no record of a provider reviewing any part of Patient 15’s visit, including her EKG. The EDSM stated when someone comes in for chest pain and has a pain score of 7/10, an EKG was to be reviewed by a physician within 10 minutes of patient presentation to the ED. The EDSM stated Patient 15 could have had a “negative outcome”, such as an acute myocardial infarction (MI- heart attack) or another “adverse (unfavorable or harmful)” cardiac issue. During a concurrent interview and record review on 9/23/25 at 4:30 p.m., with RN 6, Patient 15’s EMR dated 5/2/25 was reviewed. The EMR indicated RN 6 was Patient 15’s nurse that day she came to the hospital. RN 6 stated it was “really important” for Patient 15 to have seen a provider and complete an MSE. RN 6 stated it was a safety risk to Patient 15 that an MSE was not done and she did not contact a provider before Patient 15 left the ED. RN 6 stated a provider would have “at least” reviewed the vital signs, the EKG and explained the risk and benefits of elopement to her. During an interview on 9/24/25 at 10:30 a.m., with the ED RN Clinical Manager (RNCM), the RNCM stated the expectation after Patient 15 was seen by the RN during triage, would be to “advocate” for the patient to see a physician and get an MSE. The RNCM stated the ED had an “obligation” to have completed Patient 15’s care and they did not. The RNCM stated that ED policy and procedures were not followed. The RNCM stated because there was no provider notification before Patient 15 left, she could have been “negatively” affected. During an interview on 9/24/25 at 11:10 a.m., with the ED Director (EDD), the EDD stated the expectation would have been to have Patient 15 be seen by a provider and do an MSE before she left and that did not happen. The EDD stated it was a “safety concern” for Patient 15 that an MSE did not take place. The EDD stated hospital policy and procedures were not followed for what occurred with Patient 15. During an interview on 9/24/25 at 1:15 p.m., with the Chief Nursing Officer (CNO), the CNO stated that Patient 15 should have had an MSE “immediately” for the chest pain she came into the ED with. The CNO stated because this was not done, Patient 15 could have had a “bad outcome” up to death. The CNO stated she would have expected the EKG to be read by a physician within 10 minutes of triage and that be documented in the EMR. The CNO stated ED policy and procedures were not followed. During a review of the facility’s policy and procedure (P&P) titled, “Emergency Services Nursing Standards of Practice,” dated September 2025, the P&P indicated, “ ...The Standards of Practice for the Emergency Department (ED) serve as guidelines for the provision of nursing care and professional performance expectations. These standards are based upon the 3rd edition of the American Nurses Association (ANA) and the Emergency Nurses Association (ENA, 3rd edition) Scope and Standards of Practice ... Affected Areas or Departments: Emergency Departments ... Standard 2- Diagnosis: The ED nurse analyzes assessment data to determine actual or potential diagnosis, problems and issues in a manner that facilitates the development of the expected outcomes and collaborative plan. 1. Medical Screening Exam: At triage, patients are evaluated using the ESI criteria. At minimum, patients who meet ESI level 1 criteria are roomed immediately and care is initiated emergently. All patients receive a Medical Screening Exam (MSE) by a qualified medical provider ... 1. The nurse will review the medical screening examination (MSE) that is completed by a physician/ authorized Licensed Practitioner (LP) responsible for the patient’s care or an MSE qualified nurse ... The emergency registered nurse implements the identified plan: 1. Uses critical thinking to implement the nursing process to collect, measure, record, retrieve, trend, and analyze data and information to enhance outcomes and nursing practice. 2. Coordinating care delivery with the interdisciplinary team and advocates for delivery of person-centered care ... 4. Documents implementation ... of the identified plan ... Consulting with the health care team to influence the plan of care ... 6. Delegates after considering the circumstance, person, task, direction or communication, supervision, and evaluation including the state nurse practice act regulations, institution and regulatory entities, while maintaining accountability for the care ...”. During a review of the facility’s P&P titled, “Chest Pain- Acute Coronary Syndrome”, dated February 2024, the P&P indicated, “ ... Indications: All patients presenting with chest pain or for whom an acute coronary syndrome is suspected, will be cared for in accordance with the American Heart Association Basic Life Support (BLS) or Advance Cardiac Life Support (ACLS) guidelines ... All patients presenting with suspected ACS symptoms will be placed on cardiac and pulse oximetry monitoring immediately ... Twelve (12) lead ECG is completed within ten (10) minutes of patient’s complaints of chest pain. a. ECG is provided directly to the physician who will read/interpret it ... A physician will evaluate patients exhibiting these symptoms as soon as possible ...”. During a review of the facility’s P&P titled, “Patient Elopement”, dated December 2024, the P&P indicated, “ ...Emergency Department: Once it is expected that a patient has eloped the staff shall ... Depart Disposition: ... b. Left prior to MSE (LWBS- left without being seen) ... 3. The primary nurse should confer with the provider to determine what information should be shared with the patient ...”.”

“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: 51059 Based on interview and record review, the facility failed to provide stabilizing measures within the capacity and capability of the facility for one of twenty two patients when Patient 1, a 50-year- old male, came into the facility on 11/13/23 at 6:31 a.m. with a three-day history of throat swelling and pain and was assessed as having an acute upper respiratory obstruction (an Emergency Medical Condition, EMC- health condition with acute symptoms of sufficient severity, including severe pain, that without immediate medical attention could result in placing a person’s health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ ) due to an abscess (a confined pocket of pus that collects in tissues, organs, or spaces inside the body in the throat). The EMC was identified by the Emergency Department Medical Doctor (ED MD) 1 and consulted with the on-call ENT surgeon (ENT MD) at 6:44 a.m. The surgeon indicated he would be in but was delayed approximately 5 hours from the time consulted, at 6:44 a.m., and did not meet the timely 1-hour expected arrival time in accordance with facility policy and procedure or Medical Staff bylaws. Upon arrival the ENT surgeon assessed the need to perform an incision and drainage (I&D-medical procedure to drain pus or fluid) of the throat abscess and rather than determine the availability of a suitable operating room, performed the procedure in the ED exam room. The procedure immediately had complications with uncontrolled hemorrhage (bleeding), the inability to control the bleeding and keep the airway patent and Patient 1 coded (medical emergency, requiring immediate resuscitation and medical attention by a trained hospital team) in the Emergency Department. These failures resulted in delayed efforts to stabilize due to the 5-hour delay of the ENT surgeon, not anticipating the benefit of performing the incision and drainage in a controlled setting of an operating room, not having a trained anesthetist immediately available to intubate and support Pt 1, required a possibly avoidable tracheostomy, possible avoidable admission to the ICU and prolonged convalescence, and death on 11/17/23. Findings: During a concurrent interview and record review on 9/17/25 at 3:04 p.m. with the Emergency Department Registered Nurse Clinical Manager (RNCM), Patient 1’s “Medical Record (MR),” dated 9/17/25 was reviewed. The “MR” indicated Patient 1, a 50-year-old male accompanied by a family member, arrived ambulatory to the Emergency Department (ED) on 11/13/23 at 6:31 a.m. and was seen by Advanced Practice Provider (APP) 1 with a chief complaint of throat swelling, a sore throat and an abscess to the back of the throat for three days. Patient 1 was triaged at 6:36 a.m. by Registered Nurse (RN) 4.The “MR” indicated Patient 1’s vital signs were: temperature 36.5 Celsius (C- a unit of measurement for body temperature), Blood Pressure (BP-force exerted by the blood on the walls of the blood vessels as it circulates) 166/97, Heart Rate (HR- number of times the heart beats per minute) 85, Respiration Rate (RR- how many breaths are taken in one minute) 22, Pulse oximetry (SPO2-oxygen saturation or percentage of hemoglobin in blood carrying oxygen) on room air 98%, pain score 8 out of 10. The “MR” indicated RN 4’s ED triage assessment indicated, Patient 1 had difficulty breathing at rest and an Emergency Severity Index (ESI) score 3- urgent assigned. The “MR” indicated Emergency Department Medical Doctor (ED MD) 1 initiated the Medical Screening Exam (MSE- required examination in a hospital emergency department to determine if a patient has an Emergency Medical Condition (EMC), such as acute symptoms that could lead to serious harm) at 6: 36 a.m. The “MR” indicated ED MD 1 completed an assessment and documented Patient 1 was in general severe distress, had respiratory shortness of breath, and endorsed difficulty breathing and talking which worsened with speaking and had worsened since arrival to the ED. The “MR” indicated ED MD 1 requested by phone call an Ear, Nose, and Throat (ENT) consult from ENT MD at 6:44 a.m. and ENT MD agreed to consult Patient 1 with a recommendation for possible admission for observation. The “MR” did not indicate an agreed upon time for ENT MD assessment to occur. The “MR” indicated at 6:47 a.m. APP 1 placed orders for laboratory and blood testing. The “MR” indicated at 7:14 a.m. ED MD 1 placed orders for breathing treatment medications, antibiotic and supportive intravenous fluids and a Computed Tomography Soft Tissue Neck with Contrast (CT- medical imaging technique that uses X-rays to create detailed cross-sectional images of the body. These images can help doctors diagnose and monitor). The “MR” indicated Patient 1’s vital signs were repeated at 7:48 a.m. and were: HR 74, RR 22, SPO2 99% on room air, BP 127/79, temperature and pain score were not repeated. The “MR” indicated Patient 1’s vital signs were repeated at 9:58 a.m. and were: HR 85, RR 22, SPO2 97% on room air, BP 130/85, temperature and pain score were not repeated. The “MR” indicated Patient 1’s vital signs were repeated at 10:00 a.m. and were: HR 78, RR 20, SPO2 98% on room air, BP 127/78, temperature and pain score were not repeated. The “MR” indicated Patient 1’s vital signs were repeated at 11:00 a.m. and were: HR 93, SPO2 97% on room air, BP 151/99, respiratory rate, temperature and pain score were not repeated. The “MR” did not indicate what time laboratory and blood testing were completed, but showed a white blood cell count of 27,000 cells per microliter of blood (WBC- part of the immune system that fight infection and disease, normal range 4,500 to 11, 000 cells per microliter of blood). The” MR” indicated the CT was completed at 9:00 a.m. The “MR” indicated at 9:49 a.m. RN 5 prepared and placed ENT MD’s assessment supplies at Patient 1’s bedside. The “MR” indicated Patient 1’s CT was transcribed at 10:21 a.m. and an attending physician could not be reached to discuss CT results. The “MR” indicated ENT MD arrived to the ED between 11:30 a.m. and 11:45 a.m. and reviewed Patient 1’s diagnostic results and assessed Patient 1. The “MR” indicated ENT MD noted an elevated WBC of 27,000 and CT reading of left greater than right tonsil swelling with a possible peritonsillar abscess (a collection of pus that forms behind the tonsil). The “MR” indicated ENT MD documented Patient 1 had a “ ...somewhat compromised airway in the upper pharyngeal airway at that time ...was having some difficulty sitting still and felt like he was not breathing well enough though his oxygen saturation was 97-98% ... it seemed like that pharyngeal mass was partially in the way ... reviewed his past medical history, but it was difficult because he was not able to give it to me, his wife gave me some ...” The “MR” indicated ENT MD determined Patient 1 had a left peritonsillar abscess and an incision and drainage (I&D) needed to be performed. The “MR” indicated there was no informed consent obtained from Patient 1 or his family member at bedside. The “MR” indicated ENT MD prepped for the I&D by applying hurricane spray ( a topical oral anesthetic for relief of minor irritation and pain) and injecting lidocaine with epinephrine (a combination of two medication used to numb and vasoconstrict [ constrict blood vessels]) into the left anterior tonsil pillar (the fold of mucous membrane and tissue located just in front of the tonsil) and the left palate (roof of the mouth). The “MR” indicated ENT MD documented, “ ...he seemed to have more difficulty breathing during this time ...” an 18- gauge needle was placed into the left superior peritonsillar region and no blood return was noted, the needle was removed and “ ...there was quite a bit of blood drainage and his airway got worse ...this made me wonder is this was a peritonsillar hematoma, not an abscess ...at this point, his airway was becoming more compromised ...” The “MR” indicated at 11:48 a.m. RN 5 notified respiratory therapy, ED MD 1, and anesthesia that Patient 1 was tachypneic (increased respiratory rate), anxious, tripoding (positioning to try to breathe better) and bleeding profusely from the mouth. The “MR “ indicated ENT MD left Patient 1’s ED room to prepare the Operating Room (OR) for an emergency I&D of the peritonsillar abscess. The “MR” indicated at 12:00 p.m. Patient 1’s vital signs were HR 81, SPO2 47% on room air, and BP 178/114. The “MR” indicated temperature, respiratory rate or pain score was not recorded. The “MR” indicated at 12:01 p.m. a code blue was called for Patient 1 when he lost his pulse and airway. The “MR” indicated Patient 1’s HR was established at 12:05 p.m. and an LARYNGEAL Mask Airway (LMA-medical device used to secure and maintain a patient’s airway) was established at 12:10 p.m. The “MR” indicated ENT MD returned to Patient ‘s ED room during code blue events. The “MR” indicated ENT MD brought Patient 1 to the OR with anesthesia to perform an emergency tracheostomy, left tonsillectomy and direct laryngoscopy, diagnostic. The “MR” indicated ENT MD obtained informed consent prior to the OR procedure. The “MR” indicated during the OR procedure ENT MD re-reviewed the CT from the morning and documented “ ...I see some evidence of supraglottic swelling, not so much the epiglottis, but the arytenoid area and the area with the aryepiglottic folds on the CT this morning, and of course, he went hours after that before we did our procedure...” The “MR” indicated Patient 1’s tonsil was removed, and a tracheostomy was placed by ENT MD. The “MR” indicated Patient 1 was admitted to the facility at 12:30 p.m. for further care evaluation and transferred from the OR to the Intensive Care Unit (ICU). The” MR” indicated at 1:26 p.m. transcribed CT results were read back to APP 1. The CT results indicated Patient 1 had a complex multifocal left peritonsillar abscess (a severe infection with multiple pockets of pus located on the left side of the throat) extending from C1 caudally to C6 (segment of the spinal cord from the top of the neck to the lower half of the neck) and measured 6 x2 centimeters (cm- a unit of measurement), as well as a right small tonsillar abscess measuring 1.2 x 1.6 cm, with a noted airway deviated to the right secondary to edema (swelling) on the left side . The “MR” indicated on 11/17/23 Patient 1’s family decided to withdraw care and Patient 1 expired. The RNCM stated ED providers contacted specialty consult providers, such as ENT consult providers, when more advanced assessments were required to complete MSE’s. The RNCM stated MSE’s were an ongoing process that involved laboratory, diagnostics and specialty consults to rule in or rule out EMC’s. The RNCM stated ED MD 1 contacted ENT MD for a specialty consultation, as Patient 1’s chief complaint involved the throat, and was ENT MD’s specialty. The RNCM stated the purpose of specialty consultants were to provide specialized treatment and stabilization outside the scope of the ED provider. The RNCM stated the facility did not have a designated on call ENT provider. The RNCM stated ENT MD provided his specialty consults on a voluntary or courtesy basis, but did not provide the facility with a set schedule for on call. The RNCM stated ENT MD was responsible to adhere to all facility policy and procedures, medical by laws and regulations when agreeing to consult. The RNCM stated when specialty consults agreed to provide a consult they were required to respond in person within one hour, per expectation of policy and procedure and medical staff bylaws. The RNCM stated it was expected if consults could not arrive within a timely timeframe another consult should be contacted by the primary ED provider for consult or a transfer initiated to ensure timely completion of MSE’s. During a concurrent interview and record review on 9/18/25 at 10:05 a.m. with Medical Doctor (MD) 3, Patient 1’s “MR”, dated 9/18/25 was reviewed. MD 3 stated he was the admitting internal medicine and hospitalist provider for Patient 1 on 11/13/23 at 12:30 p.m. MD 3 stated he was not involved in Patient 1’s care until he was admitted. MD 3 stated specialty consults were utilized by ED providers for a higher level of assessment, treatment, and stabilization in a specialty area, such as the throat. MD 3 stated it was expected all consults arrived in person within one hour to assess and review the patients condition to assist in completing the MSE and rule out an EMC. MD 3 stated all conversations between ED providers and consult providers were expected to be documented, per policy and procedure and medical staff bylaws to ensure requested consult time was agreed upon and recorded in the medical record. MD 3 stated the “MR” indicated ED MD contacted ENT MD for a specialty consult and ENT MD did not arrive until approximately 5 hours after agreeing to consult. MD 3 stated ENT MD provided his consults on a voluntary or courtesy basis and did not provide the ED with an on call schedule. MD 3 stated if ENT MD could not respond or accept the consult he would expect documentation in the medical record. MD 3 stated if ED MD and ENT MD agreed the consult would not occur until 5 hours after agreeing he would expect documentation in the medical record. MD 3 stated if timely consults could not be provided it was expected the ED MD would initiate a transfer to another facility where specialty services could be provided. MD 3 stated I&D’s were a procedure and required informed consent prior to performing the procedure. MD 3 stated if an EMC was present per facility policy informed consent could be bypassed to complete a procedure. MD 3 stated if Patient 1 was not having an EMC it would be expected to have a documented informed consent within the “MR” prior to the I&D. MD 3 stated if Patient 1 was having an EMC no consent would be documented within the “MR” prior to the I&D. MD 3 stated he could not determine based on Patient 1’s “MR” documentation if Patient 1 was having an EMC. During a concurrent interview and record review on 9/18/25 at 2:43 p.m. with RN 5, Patient 1’s “MR” dated 9/18/25 for the date of11/13/23 was reviewed. RN 5 stated Patient 1 had an assigned ESI of 3-urgent which indicated the patient needed to be seen quickly by a qualified medical professional to complete an MSE and required prioritization of ongoing care. RN 5 stated Patient 1 was placed into an ED room on 11/13/23 at 7:46 a.m. and she became his primary RN. RN 5 stated Patient 1 had a family member at bedside with him but could not recall their relation status. RN 5 could not recall Patient 1’s clinical presentation on memory. RN 5 stated she was responsible for all vital signs after she assumed care. RN 5 could not state why complete set of vital signs were not taken at 7:48 a.m., 9:58 a.m., 10:00 a.m., 11:00 a.m. and 12:00 p.m. RN 5 stated it was important to ensure all vitals signs were obtained and recorded in the “MR” for assessment. RN 5 stated the “MR” indicted she prepared ENT MD’s assessment supplies at Patient 1’s bedside at 9:49 a.m. RN 5 stated the “MR” indicated ENT MD did not arrive until 11:30 a.m. to assess Patient 1. RN 5 stated consult providers were responsible to arrive and consult in person within one hour. RN 5 stated the ED provider was responsible to ensure timely consults and if a consult could not be provided an outside consult or transfer could be initiated to provide the service. RN 5 stated informed consents were the responsibility of the provider performing the procedure. RN 5 stated I&D’s required informed consent. RN 5 stated the “MR” indicated informed consent was not obtained prior to ENT MD’s I&D. RN 5 stated she could not recall if she assisted ENT MD with the bedside I&D. RN 5 stated the “MR” indicated Patient 1 began to decline during the I&D and bleed from the mouth. RN 5 stated ENT MD directed her to contact respiratory therapy, ED MD 1 and anesthesia. RN 5 stated she exited Patient 1’s room to retrieve ED MD 1 and when she returned to Patient 1’s room he had lost his pulse and airway which resulted in a code blue. During an interview on 9/19/25 at 9:13 a.m. with the Quality Director (QD), the QD stated ED MD 1 and ENT MD refused to interview or patriciate in EMTALA survey. During an interview on 9/19/25 at 10:59 a.m. with MD 4, MD 4 stated he was a board-certified family medicine physician, full time ED attending and served on the facility’s peer review committee and medical executive committee. MD 4 stated documentation was important and if it was not documented it did not happen .MD 4 stated if patient care was not documented it would be difficult to determine if care or treatment occurred. MD 4 stated documentation was expected to reflect the exact condition of the patient. MD 4 stated it was important that all vital signs were obtained and documented to ensure an ongoing assessment of the patient’s condition. MD 4 stated both vital signs and physical assessment were required to determine a patient’s condition and monitor for an EMC. MD 4 stated he first became aware of Patient 1 in 1/2024 when it was presented to the peer review committee. MD 4 stated ED providers seek specialty consults when care is beyond their scope of practice, expertise and specialty training. MD 4 stated it was expected when an ED provider contacted a specialty consult an agreeable time was documented as to when the specialty consult would arrive in person. MD 4 stated a documented agreeable timeframe was important to ensure timely treatment, stabilization and patient safety. MD 4 stated it was the responsibility of the ED provider to determine if specialty consult timeframe was appropriate based on patients condition and seek other consults or transfers if required. MD 4 stated voluntary, or courtesy on-call providers were required to adhere to all facility policy and procedures, medical staff bylaws and expectations when agreeing to consult. MD 4 stated on -call providers were expected to respond in person within one hour, unless a different time frame was agreed upon and documented. MD 4 stated timely on-call specialty consults were important in the global assessment of the patient to determine a formal diagnosis and rule out an EMC, as well as to design a plan of action to determine if the consultant or facility could provide the care needed or if the patient needed to be transferred to a higher level of care. MD 4 stated Patient 1 could have been at risk for an EMC due to a delay for an in person specialty consult if it was not agreed upon. During a concurrent interview and record review on 9/19/25 at 2:57 p.m. with the Interim Medical Staff Director (MSD), ENT MD’s job duty contract titled, “Hospital Response Agreement (individual), dated 12/1/21 and signed by ENT MD on 12/3/21, was reviewed. The MSD stated ENT MD acted as a voluntary or courtesy on call ENT specialty consultant for the hospital. The MSD stated ENT MD did not provide the facility with an on-call schedule, instead providers knew they could call him, and he would respond for a consultation. The MSD stated ENT MD had an addendum within his facility job contract, exempting him from on-call schedule requirements. The contract indicated, ENT MD had a specialty in Otolaryngology (medical and surgical specialty focused on treating diseases of the ears, nose, throat, and related structures of the head and neck). The contract addendum indicated, “ ...provide professional consultation and treatment of patients in need of emergency specialty medical care who present to the ED ...physician shall comply with all provisions of this agreement and shall be available to provide specialty medical care to patients as set forth herein ...physician shall be available to the ED physicians via telephone for consultation regarding patients. Physician shall respond in person, if necessary ....to requests from the ED physician to personally provide consultation and/or treatment in the ED or provide post-admissions follow-up care to patients admitted through the ED at the request of the ED physician. Physician provisions of services shall be subject to physician being available ...physician shall, on a periodic basis, prospectively inform hospital of his/her availability to provide services during the specified period (e.g., monthly, quarterly, etc.). physician shall make reasonable efforts to adjust his/her schedule if requested by hospital in order to meet hospital’s need for services ...” The MSD stated ENT MD’s job contract exempted him from having to respond if he declined, however once he agreed to respond he was responsible to adhere to all facility policy and procedures, medical staff bylaws and expectations. During an interview on 9/24/25 at 12:21 p.m. with the QD, the QD stated ED MD 1 and ENT MD refused to interview or participate in EMTALA survey. LM stated APP 1 was unable to participate in interview or EMTALA survey. During an interview on 9/24/25 at 11:11 a.m. with the Emergency Department Director of Emergency and Trauma Services (EDD), the EDD stated it was important QMP’s completed MSE timely to treat and stabilize patients. The EDD stated an MSE was an ongoing process and was not completed until all laboratory, imaging and consultations were completed to determine if an EMC was present. The EDD stated the purpose of a specialty consultation was to assist in treating and stabilizing a patient. The EDD stated the facility was responsible to stabilize and treat Patient 1 in a timely manner. The EDD stated, per documentation, ENT MD agreed to provide consultation on 11/13/23 at 6:44 a.m. and did not arrive in person until 11:30 a.m. to 11:45 a.m. The EDD stated Patient 1 was at risk for decompensation which could lead to a serious medical condition when ENT MD did not arrive in person for approximately 5 hours to provide treatment. The EDD stated all providers were responsible to adhere to facility policy and procedures, medical staff bylaws, and expectations. The EDD stated all Medical Record documentation was expected to be accurate and reflect all conversations which concerned the patient’s care, treatment and timeline of events. The EDD stated facility policy and procedure, medical staff bylaws and expectations were not followed when ENT MD took 5 hours to respond in person to an agreed upon consult, ED MD 1 did not ensure timely ENT MD response or document agreed upon consultation timeframe, Patient 1’s vital signs were not repeated in entirety throughout the ED course and informed consent was not obtained prior to the bedside I&D procedure. The EDD stated when the facility did not follow policy and procedures, medical staff bylaws and expectations Patient 1 was placed at risk for delayed treatment and stabilization. During an interview on 9/24/25 at 12:47 p.m. with ED MD 2, ED MD 2 stated the facility had limited access to specialty services, which included ENT services. ED MD 2 stated specialty consults, such as ENT MD, provided services on a voluntary or courtesy basis when requested by ED providers. ED MD 2 stated ED providers contacted ENT MD when treatment to be provided was outside of their medical scope. ED MD 2 stated all on-call providers were expected to provide an on-call schedule to assist in timely contacts of the appropriate resource. ED MD 2 stated if no on call service was available for a specialty the ED provider could attempt a transfer or telephone consult from a provider in the required specialty. ED MD 2 stated when an on call provider agreed to consult a patient they assumed responsibility of the patient and were responsible to adhere to all facility policies and procedures, medical staff bylaws and expectations. ED MD 2 stated a specialty consult was a continuation of the MSE to determine if an EMC was present from the standpoint of the expert in the specialty. ED MD 2 stated specialty consults were important during the MSE process to determine treatment and stabilization that the ED provider could not provide within their scope of practice. ED MD 2 stated it was important to complete specialty consults timely to ensure timely treatment and stabilization of a patient. ED MD 2 stated if an ED provider was agreeable to a delayed consult based on the patient’s condition it was required to be documented. ED MD 2 stated specialty consultants were responsible to perform their own assessment from an expertise standpoint and determine if an EMC was present timely. ED MD 2 stated patients who received delayed specialty consults were at risk for a delay in treatment and could lead to worsening of their condition and negative patient outcomes. During an interview on 9/24/25 at 1:15 p.m. with the Chief Nursing Officer (CNO), the CNO stated specialty consults were part of the MSE and were responsible in determining advanced treatment and stabilization of a patient. The CNO stated when a provider agreed to consult a patient they were required to abide by all facility policy and procedures, medical staff bylaws and expectations. The CNO stated when a provider was consulted they were required to respond in person within one hour, per facility policy and procedure. The CNO stated when the ED provider requested a specialty consult they were required to document an agreed upon timeframe for in person consult if the one hour timeframe could not be provided, per medical staff bylaws. The CNO stated the facility was responsible to adhere to all EMTALA regulations, which included timely treatment and stabilization of all patients. The CNO stated when the ENT MD did not respond in person within one hour after agreeing to consult and ED MD 1 did not specify a documented timeframe for ENT MD to respond in person the threshold of timely treatment and stabilization had not been met for Patient 1, and facility policy and procedure and medical staff bylaws had not been followed. The CNO stated an EMC could not be ruled out until a specialty consult was completed. The CNO stated Patient 1 was at risk for an EMC and deterioration when a specialty consult was not completed timely to initiate treatment. During an interview on 9/24/25 at 1:42 p.m. with the Chief Medical Officer (CMO), the CMO stated MSE’s were required to be completed on patients in a timely manner after arrival to the ED to assess level of care or if care needed to be escalated to another physician assessment, such as a specialty consult. The CMO stated an EMC could be identified clinically without laboratory, imaging or diagnostic workup results and specialty consults, however an EMC could not be ruled out until laboratory, imaging, or diagnostic workup and specialty consults were completed. The CMO stated specialty consults provided advanced and focused assessments of an area of concern outside of the ED providers scope of practice. The CMO stated on-call providers were required to respond in person timely to ensure treatment and stabilization occurred. The CMO stated documentation was required to accurately detail the timeline of events, conversations between providers and agreed upon timeframes for consults in all medical records. The CMO stated informed consent was required prior to an I&D to ensure the patient was informed of all the risks and benefits, alternative treatments or refusal options. During a review of the facility’s policy and procedure (P&P), titled “Emergency Medical Treatment and Labor Act (EMTALA)”, dated 12/11/24, the facility stated the P&P was in place 11/2023, the P&P indicated, “ ...all individuals who come to the DED [Dedicated Emergency Department] and all individuals who present on Hospital Property requesting or requiring examination or treatment of an Emergency Medical Condition (EMC) shall receive an appropriate Medical Screening Examination (MSE) ...the scope of the MSE must be tailored to the presenting complaint and the medical history of the individual. The process may range from a simple examination ...to a complex examination that may include laboratory tests, diagnostic imaging, lumbar punctures, other diagnostic tests and procedures and the use of on-call physician specialists ...The MSE must include all services within the capability of the hospital, which, in the judgement of the emergency physician, Qualified Medical Person (QMP), or other treating provider, are necessary to screen or stabilize an individual with an EMC. These services include the use, when necessary, of on-call specialty physicians identified on the On-Call List ...EMC means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain ...) ...MSEs necessarily depend on the individual’s presenting symptoms but involve an ongoing process that may include vital signs, history and physical examination of affected or potentially affected symptoms, consideration of known chronic conditions, or testing needed to determine the presence of an EMC ...” During a review of the facility’s P&P titled, “Emergency Services Department Consultation & Referrals, EMALA (MS-19),” dated 2/2023, the P&P indicated, “ ...When the Emergency Department physician determines that a consultation or specialized treatment beyond the capability of the Emergency Department Licensed Practitioner is needed to provide necessary stabilizing treatment to a patient with an emergency medical condition, the Emergency Licensed Practitioner shall arrange for the services of a member of the Medical Staff to come to the Hospital ...If the patient requests a specific Licensed Practitioner, who must be a member of the Medical Staff and qualified to provide the specialized services, the Emergency Licensed Practitioner shall attempt to contract that Licensed Practitioner. If the Licensed Practitioner requested by the patient is not available or cannot come to the Emergency Department within a reasonable period of time, then the Emergency Licensed Practitioner shall contact the Licensed Practitioner on call in the needed specialty ...Members of the on-call panel must respond by phone within thirty (30) minutes of when they are called by the Emergency Department for consultation and must respond in person if requested to do so within sixty (60) minutes ...The Emergency Licensed Practitioner will document attempts and time of contact for on call Licensed Practitioner or the Licensed Practitioner requested by the patient, in the patient’s medical record ...If on call Licensed Practitioner refuses to come to the Emergency Department or fails to respond within a reasonable period of time. The Emergency Licensed Practitioner shall also report the refusal or failure to the Department chair or his/her designee Department. If the Department Chair or his/her designee cannot be contacted, the Chief of Staff or his/her designee will be informed of the event and will be responsible for the resolution of the problem ...definitions ...Emergency Medical Condition - A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychic disturbances and or symptoms of substance abuse) such that the absence of immediate medication attention could reasonably be expected to result in either: 1. Placing the health of the individual ... in serious jeopardy ...2. Serious impairment to bodily functions ...3. Serious dysfunction to any bodily organ or part ... Consultation - Rendering an opinion, giving advice, or prescribing treatment by telephone and, when determined to medically necessary jointly by the emergency physician and the specialty physician(s), includes a review of the patient’s medical record, and examination and treatment of the patient in person by a specialty who is qualified to give an opinion or render the necessary treatment in order to stabilize the patient ...” During a review of the facility’s P&P titled, “Consent for Treatment/Informed Consent (RI-02),” dated 2/2023, the P&P indicated, “ ...Every competent adult has the fundamental right of self-determination over his person and property. All patients must give consent for treatment, surgery, diagnostic procedures and therapeutic procedures. The only time it is appropriate to administer treatments or procedures without the patient’s consent are when the attending licensed independent practitioner/provider (LIP) declares that an emergency situation exists and a delay of care or treatment to obtain a written or verbal consent would be detrimental to the patient ...Consent to Surgery or Special Procedure The concept of “Informed Consent” holds that the patient or person authorized to consent has the right to be informed of the following: a. The proposed care, treatment, service, medication, interventions or procedures ...b. The risk, complications and expected benefits or effects of such treatment, including potential recuperation problems, and likelihood of achieving desired outcomes ...c. Any reasonable alternatives to the procedure, their risks and benefits including refusing care and possible results of not receiving care, treatment or services ...d. When indicated, any limitations on the confidentiality of information learned from or about the patient ...” During a review of the facility’s P&P titled, “Standards of Practice (ED-69),” dated 2/2022, the P&P indicated, “ ... The emergency registered nurse collects pertinent data and information relative to the patient’s health or situation ...Vital signs, including blood pressure for patients over the age of two, heart rate, respirations, pulse oximetry and applicable method of pain assessment per age and/or condition ...Assessments and supportive data are documented in a retrievable format accessible to the interprofessional team ...Collaborates with other team members to reassess patients already triaged in waiting or holding areas according to hospital policy and acuity ...All care is performed in a safe and timely manner in compliance with policy, procedure and guidelines of the medical facility ...” During a review of the facility’s medical by-laws titled, “Medical Staff Rules and Regulations”, dated 2/27/20, the medical by-laws indicated, “ ...It is the policy of Mercy Medical Center Merced to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) ... EMTALA requires that any patient who presents to the emergency department seeking or in need of an examination for a medical condition must receive an appropriate medical screening examination to determine if the patient has an emergency medical condition. If so, the patient must receive further examination and treatment within the capability of the Emergency Department, as necessary to stability the emergency medical condition ... The medical screening exam shall include the use of appropriate resources routinely available to the emergency department, including specialized tests or consultations ... All members of the Emergency Department on-call/back-up panel are expected to abide by the rules and regulations of this service as well as by-laws, general rules and regulations of the facility, and the current federal and state regulations inclusive of EMTALA ... The good conduct of medical practice includes the proper and timely use of consultation. Except in an emergency, it is the responsibility of the attending physician to order all consultations. Judgment as to the serious nature of the illness and the question of doubt as to diagnosis and treatment generally rests with the attending practitioner. Physician-to-physician communication is required for all consultations either in writing or by phone. In the case of urgent or emergent consultations, the attending should document the extent of the verbal or written communications with the consulting physician... During the physician to physician communication, a timeframe should be stablished for when the specialist will see the patient. If the timeframe is not aggregable to both parties, consultation of another specialist should occur. .. Except in an emergency, when time does not permit, consultation is required in the following situations: ... In unusually complicated situations where specific skills of other practitioners may be needed ...””

“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: 42321 Based on interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA for two of 21 patients (Pt 14 and 16) when the hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP for the purpose of determining whether an emergency medical condition [EMC] exists) within the capability of the hospital’s emergency department (ED) when: 1. Pt 14 arrived to the ED via car on 2/3/25 at 3:47 p.m. for chief complaint of chest pain and shortness of breath (SOB) and was not appropriately triaged according to the hospital’s policies and procedures (P&P). (Refer to A2406, Finding 1) 2. Pt 16 arrived to the ED via car on 2/9/25 at 12:47 a.m. for chief complaint of abdominal pain and the QMP did not document a face-to-face assessment and hospital staff did not attempt to locate Pt 16 according to the hospital’s P&P. Thess failures resulted in Pt 16 leaving the hospital after an hour and a half and an incomplete MSE. Pt 16 was not called three times in the lobby and did not have a follow-up phone call. (Refer to A2406, Finding 2) The cumulative effect of these systemic problems resulted in the inabiity of the hospital to meet the statutory EMTALA obligation.”

“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: 49538 Based on interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA for two of 21 patients (Pt 14 and 16) when the hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP for the purpose of determining whether an emergency medical condition [EMC] exists) within the capability of the hospital’s emergency department (ED) when: 1. Pt 14 arrived to the ED via car on 2/3/25 at 3:47 p.m. for chief complaint of chest pain and shortness of breath (SOB) and was not appropriately triaged according to the hospital’s policies and procedures (P&P). This failure resulted in Pt 14 leaving the hospital after one hour and 48 minutes and a Medical Screening Exam (MSE) was not started. 2. Pt 16 arrived to the ED via car on 2/9/25 at 12:47 a.m. for chief complaint of abdominal pain and the QMP did not document a face-to-face assessment and hospital staff did not attempt to locate Pt 16 according to the hospital’s P&P. Thess failures resulted in Pt 16 leaving the hospital after an hour and a half and an incomplete MSE. Pt 16 was not called three times in the lobby and did not have a follow-up phone call. Findings: 1. During a concurrent interview and record review on 5/8/25 at 10:15 a.m. with Registered Nurse (RN) 2, Pt 14’s “Electronic Medical Record (EMR),” was reviewed for the ED visit on 2/3/25. The “EMR” indicated, Pt 14 arrived in the ED on 2/3/25 at 3:47 p.m. via car with a chief complaint of chest pain and shortness of breath (SOB). The “EMR” indicated, Pt 14 had an electrocardiogram (EKG/ECG- a diagnostic test that records the electrical activity of the heart) completed at 3:52 p.m. and Pt 14 had a “Normal ECG.” The “EMR” indicated, initial vital signs at 3:57 p.m. were blood pressure (BP) was 103/68 millimeters of mercury (mmHg-unit of measure; normal 120/80 mmHg), respiratory rate (RR) 20 breaths per minute (normal 12-18 breaths per minute), heart rate (HR) 102 beats per minute (bpm; normal 60-100 bpm), temperature 36.9 degrees Fahrenheit (normal 97-99 degrees Fahrenheit), oxygen saturation 95% on room air (normal 95-100%), and a pain score of 5 (0 being no pain and 10 being the most severe pain). The “EMR” indicated Pt 14 was not triaged and left prior to triage. RN 2 stated the last documented contact time with Pt 14 was at 3:57 p.m. when vital signs were taken by Emergency Department Technician (EDT) 1. RN 2 stated a chief complaint of chest pain was a priority with an EKG to be completed. RN 2 stated she could not locate Pt 14’s printed and signed EKG results in the EMR. RN 2 stated after an EKG was completed, the results would be printed and taken directly to an ED physician to be reviewed to be signed and dated. RN 2 stated this process had to be completed in under 10 minutes. RN 2 stated Pt 14 should have been placed in a hallway chair in the triage area after the EKG was completed and a triage nurse should have completed the triage for Pt 14. RN 2 stated she could not tell where Pt 14 was placed after the EKG was completed. RN 2 stated a chief complaint of chest pain should have been at the top of the stack for the patient to be seen first. RN 2 stated “it seems odd to me” that Pt 14 was not immediately triaged after the EKG was completed. RN 2 stated Pt 14 should have been triaged with an Emergency Severity Index (ESI-a 5 level scale used by triage nurses to indicate the seriousness of the patient’s condition and the resources needed, ESI 1 being the most serious) of 2 in which vital signs would have been taken hourly and frequent assessments. RN 2 stated Pt 14 had no other orders. RN 2 stated more orders would be placed after triage when the provider saw the patient and completed an assessment. The “EMR” indicated Pt 14 was called at 5:35 p.m., 5:52 p.m., and 6:33 p.m. RN 2 stated the process was to call the patient three times, 15 minutes apart in the lobby and check the surrounding areas like the hallways, bathroom, and parking lot before discharging the patient from the system. RN 2 stated after the third call, a phone call to the patient should be completed. RN 2 stated if the patient did not answer, a phone call to the patient’s emergency contact should be completed. RN 2 stated there was no phone call to the patient or the patient’s emergency contact on the same day the patient was in the ED. RN 2 stated it was important to contact the patient to ensure the patient’s well-being. RN 2 stated it was important to contact Pt 14 the same day because a heart attack could not be ruled out. RN 2 stated a phone call was made on 2/5/25 at 8:36 p.m. (2 days after Pt 14’s ED visit). During a telephone interview on 5/8/25 at 2:30 p.m. with EDT 1, EDT 1 stated her duties in triage included responding to EKG requests and completing vital signs for patients in the lobby. EDT 1 stated a patient with chest pain would have vital signs completed and placed in the hallway chair to be seen by the triage nurse. EDT 1 stated she would let the triage nurse know the patient was in the hallway after vital signs were completed. EDT 1 stated she does not stay with the patient until the triage nurse comes and does not keep track of when the patient is seen by the triage nurse. EDT 1 stated a patient with chest pain would be placed at the top of the file to be seen next by the triage nurse. During a telephone interview on 5/8/25 at 3:02 p.m. with Physician Assistant (PA) 1, PA 1 stated she worked as a provider in the triage area. PA 1 stated when a patient came in with chest pain, the provider would be notified and then would place an order for an EKG. PA 1 stated the EKG would be handed to an ED physician to be reviewed and signed. PA 1 stated the EKG would be attached to the patient’s face sheet to be reviewed when the patient was assessed in triage. PA 1 stated a patient who presented to the ED with chest pain would be high priority and placed next to be triaged. During an interview on 5/9/25 at 9:55 a.m. with RN 2, RN 2 stated an EKG should be completed and read within 10 minutes of a patient’s arrival with complaints of chest pain because “time is tissue.” RN 2 stated it was important to get the patient’s baseline to reference with future EKG. RN 2 stated it was important to note abnormalities from the EKG and treat it as fast as possible. During an interview on 5/9/25 at 11:01 a.m. with the Director of Emergency Department (DED), the DED stated he expected a patient with chest pain to be brought to the back and have an EKG completed then be “triaged right then and there.” The DED stated the process was to have the printed EKG results handed to the physician to be reviewed, signed and timed. The DED stated the printed EKG results with the physician’s signature was placed in the patient’s paper chart and then scanned into the medical record after the patient was discharged. The DED stated at times, the paper chart “gets lost in translation” and those initial documents get lost. During a telephone interview on 5/15/25 at 3:57 p.m. with Pt 14, Pt 14 stated she left the hospital ED because it took too long for her to be seen. Pt 14 stated she had an EKG completed but no one explained the results to her. Pt 14 stated after the EKG, she had her vital signs taken then was placed back into the lobby. Pt 14 stated it took her a few days to recover and did not return to the ED. During a review of the hospital’s P&P titled, “Triage in the Emergency Department (ED-68),” dated 3/2024, the P&P indicated, “ ... All Patients presenting to the ED will receive a triage assessment by a Registered Nurse (RN) who has demonstrated competency in the principles of triage ... The triage nurse will obtain information needed to prioritize each patient’s care needs. Information includes, but is not limited to: chief complaint, signs/symptoms, and vital signs ... Triage should occur within 15 minutes of arrival ... The triage nurse will categorize according to the Emergency Severity Index scoring system ... Emergent (Level 2) - Major Injury or Illness; High Risk: The ED provider should be notified of all patients meeting the criteria. Except in extraordinary circumstances, ANY Level 2 should have bed placement as soon as possible, if no bed is available, the patient shall be placed in chair within sight of qualified RN/[Charge] RN/[Nurse Shift Manager] and should have applicable nursing protocols initiated as soon as possible ... Emergency conditions may include, but are not limited to: ... Active chest pain, suspicious for coronary syndrome, but does not require an immediate life-saving intervention, stable ...” During a review of the hospital’s P&P titled, “Patient Elopement (Code Green) (PC-512),” dated 10/2024, the P&P indicated, “ ... POLICY: ... When a patient is found missing, measures shall be implemented to attempt to locate the patient, notify the appropriate parties, and ensure that efforts continue until the patient is located or all efforts have been exhausted ... PROCEDURE: ... Emergency Department: 1. Once it is expected that a patient has eloped the staff shall: a. Call the patient’s name in the waiting room on three separate occasions. b. If the patient cannot be located, the following shall be documented in the EHR [electronic health record]: 1) Time left the department if observed 2) Times called for the patient in the waiting room. If the patient is called three times with no answer, depart the patient using the first no answer date and time. 3) Depart disposition a) Left prior to triage b) Left prior to MSE [Left without being seen] c) Left after MSE (eloped) d) Left AMA (with signature) 2. If the patient is unable to be located, the primary nurse should make every effort to contact the patient or next of kin. 3. The primary nurse should confer with the provider to determine what information should be shared with the patient if they are able to be contacted by phone. Examples: lab values, follow up, education on condition, request return to ED. 4. The following shall be documented in the EHR: a. Efforts made to contact patient including names of persons spoken to b. Information on instructions shared with patient and next of kin listed in the EHR ...” 2. During a concurrent interview and record review on 5/8/25 at 11:30 a.m. with Registered Nurse (RN) 2, Pt 16’s “Electronic Medical Record (EMR),” was reviewed for the ED visit on 2/9/25. The “EMR” indicated, Pt 16 arrived to the ED on 2/9/25 at 12:47 a.m. via car with a chief complaint of abdominal pain. The “EMR” indicated, Pt 16 was triaged at 2:10 a.m. and ESI of 3 was assigned. Initial vital signs at 1:30 a.m. indicated Pt 16’s BP was 168/92 mmHg, RR 16 breaths per minute, HR 104 bpm, temperature 36.0 degrees Fahrenheit, oxygen saturation 99% on room air, and a pain score of 0. The document titled “ED Triage,” dated 2/9/25 at 2:10 a.m. indicated, “ ... pt [complaining of] lower [abdominal] cramping since yesterday (denies vaginal bleeding) and lower back pain for 2 weeks. denies taking pain meds [past] 24 hours. denies urinary [signs and symptoms], no blood in [urine]. [last menstrual period]: 08/28/2024. [gravida-the number of times a woman has been pregnant, regardless of the outcome of the pregnancy] 3 [para-total number of babies that a female has carried past 20 weeks] 1, 1x miscarriage. [complaining of] rash that is itchy to back ...” The “EMR” indicated another set of vital signs was completed at 2:10 a.m. with BP was 158/89 mmHg, RR 16 breaths per minute, HR 104 bpm, temperature 35.6 degrees Fahrenheit, oxygen saturation 99% on room air, and a pain score of 0. The “EMR” indicated, Pt 16 was seen by the provider at 2:19 a.m. The document titled “ED Physician Notes,” dated 2/25/25 indicated, “ ... Encounter info: ... Emergency, 02/09/2025 ... Time seen: Provider Initial Contact Time 02/09/2025 [2:19 a.m.] ... Medical Decision Making. Differential Diagnosis: Abdominal pain, electrolyte imbalance, viral syndrome. Rationale: ... Patient remained stable during ED evaluation and treatment ... MDM-Patient ELOPED before work-up and complete evaluation. Plan-ELOPED ...” RN 2 stated Pt 16 was evaluated by Physician Assistant (PA) 2 at 2:19 a.m. RN 3 stated the process was for the provider to see the patient in triage, complete an assessment, and discuss with patient the plan of care. RN 2 stated a patient would go back to the lobby if no urgent issues were identified after the provider saw the patient. The “EMR” indicated Pt 16 was discharged from the system at 3 a.m. RN 2 stated she could not find any documentation indicating Pt 16 was called three times before being discharged from the system. RN 2 stated Pt 16 should have been called three times before being discharged. RN 2 stated she could not find any documentation Pt 16 was contacted on the phone and a phone call to the patient should have occurred. During a concurrent interview and record review on 5/9/25 at 9:20 a.m. with RN 3, Pt 16’s “EMR” dated 2/9/25 was reviewed. RN 3 stated he was the triage nurse for Pt 16 on 2/9/25. RN 3 stated Pt 16 came to the ED for abdominal pain and cramping. RN 3 reviewed “ED Provider Note” and stated Pt 16’s history, problems, and medications were documented by PA 2. RN 3 stated the “ED Provider Note” did not indicate the plan for Pt 16. RN 3 stated a provider would assess a patient in triage, discuss with the patient the plan of care, then go document the plan and enter orders. RN 3 stated there were no orders placed for Pt 16. During a concurrent interview and record review on 5/9/25 at 10 a.m. with RN 4, Pt 16’s “EMR,” dated 2/9/25 was reviewed. RN 4 stated she was the nurse who discharged Pt 16 from the system. RN 4 stated she thought the patient had went to Family Birth Center since Pt 16 informed staff she was pregnant. RN 4 reviewed Pt 16’s “EMR” and stated she did not document the patient was called three times before discharging Pt 16. RN 4 stated she could not recall what occurred that day. RN 4 stated Pt 16 should have been called three times before being discharged. RN 4 stated she could not find Pt 16 was contacted via phone after leaving the hospital. RN 4 stated the process was to call the patient to return to the ED for evaluation. RN 4 stated it was important to contact the patient to know the hospital did everything to ensure the patient was not in danger. During an interview on 5/9/25 at 11:01 a.m. with the Director of Emergency Department (DED), the DED stated a patient should be called three times in the lobby before being discharged and required documentation of when the patient was called. During an interview on 5/9/25 at 11:55 a.m. with the Regulatory Compliance Manager (RCM), the RCM stated an ED physician note should be completed and filed within 24 hours. During a telephone interview on 5/9/25 at 12 p.m. with PA 2, PA 2 stated a physician note was started as soon as a patient came into triage. PA 2 stated he would triage the patient with the triage nurse and ask additional clarifying questions when appropriate to determine the next steps for the patient. PA 2 stated orders would be entered quickly but it depended on how busy he was. PA 2 stated he could not recall the specifics of Pt 16’s ED encounter. PA 2 stated a note should be filed if the patient eloped. PA 2 stated when a patient eloped and the note was not filed, he would receive a notification seven to ten days later to complete the note. PA 2 could not recall why the note was not filed within 24 hours. During a review of the hospital’s P&P titled, “Patient Elopement (Code Green) (PC-512),” dated 10/2024, the P&P indicated, “ ... POLICY: ... When a patient is found missing, measures shall be implemented to attempt to locate the patient, notify the appropriate parties, and ensure that efforts continue until the patient is located or all efforts have been exhausted ... PROCEDURE: ... Emergency Department: 1. Once it is expected that a patient has eloped the staff shall: a. Call the patient’s name in the waiting room on three separate occasions. b. If the patient cannot be located, the following shall be documented in the EHR [electronic health record]: 1) Time left the department if observed 2) Times called for the patient in the waiting room. If the patient is called three times with no answer, depart the patient using the first no answer date and time. 3) Depart disposition a) Left prior to triage b) Left prior to MSE [Left without being seen] c) Left after MSE (eloped) d) Left AMA (with signature) 2. If the patient is unable to be located, the primary nurse should make every effort to contact the patient or next of kin. 3. The primary nurse should confer with the provider to determine what information should be shared with the patient if they are able to be contacted by phone. Examples: lab values, follow up, education on condition, request return to ED. 4. The following shall be documented in the EHR: a. Efforts made to contact patient including names of persons spoken to b. Information on instructions shared with patient and next of kin listed in the EHR ...” During a review of the facility’s policy and procedure (P&P) titled, “Medical Staff Rules & Regulations”, with a board approval date 2/27/2025, the P&P indicated, “ ... The emergency department physician specialist shall complete 100% of their records for all patients seen and/or cared for within 24 hours. Emergency department medical records not completed within 24 hours will result in medical records suspension ...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49884 Based on observation interview and record review the facility failed to protect and promote each patient’s rights when: 1. The hospital failed to inform one of nine patients (Pt 31) in advance of care decisions when interpreter services were not used to communicate, from 10/15/24 to 10/20/24 in a language Pt 31 could understand according to the hospital’s policy and procedure (P&P) titled, “Limited English-Proficiency (LEP): Language Access for Patient and Companions” (Refer to A-117). 2. Discharge instructions were not in a language the patient (Pt 24) could understand and an interpreter was not used to review the discharge instructions according to the hospital’s P&P titled, “Limited English-Proficiency (LEP): Language Access for Patient and Companions” (Refer to A-131). 3. The hospital failed to ensure one of 25 patients (Patient 1) was provided information about advance directives according to the hospital’s P&P, “Advance Directives / Patient Self-Determination” (Advance Directives -Legal document that states a person’s wishes for medical care if they are unable to communicate their preferences) (Refer to A-132). 4. The hospital failed to ensure patients were free from restraints (chemical, physical, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely), and to ensure restraints were discontinued at the earliest possible time. Licensed Nurses (LNs) did not complete restraint assessment monitoring every two-hours, for one of three patients (Pt 31) to ensure Pt 31 remained free from injury, and to determine if the restraints could be released in accordance with hospital policy and procedure (P&P) (Refer to A-154). The cumulative effect of these systemic problems resulted in failure to ensure patients were cared for in a safe and effective manner, and their rights were protected and promoted at all times.”

“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: 49884 Based on observation, interview and record review, the facility failed to have a well-organized and effective nursing service when: 1. The hospital failed to develop and keep a current nursing care plan for three of 34 patients, Patient (Pt) 9, Pt 22 and Pt 23, when Licensed Nurses (LN) did not assess and develop an individualized care plan for pain and post-operative surgery in accordance with hospital policy and procedure (P&P), “Core Nursing Standards of Practice” (Refer to A-396). 2. A cardiopulmonary resuscitation (CPR, a lifesaving procedure performed when the heart stops beating) backboard (a flat, rigid board used to support the patient during CPR) was missing from Crash Cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) #2 on the seventh floor and Crash Cart #2 was not maintained and checked in accordance with hospital P&P (Refer to A-398 Finding 1). 3. Licensed Nurses (LN) in the Emergency Department (ED) did not assess temperatures with every vital sign assessment for two of three sampled patients (Pt 25 and Pt 26), in accordance with hospital P&P, “Core Standards of Practice” (Refer to A-398 Finding 2). 4. Medication reconciliation (the process of comparing a patient’s medication orders to all of the medications that the patient has been taking) was not completed for three of eight patients (Pt 22, Pt 24 and Pt 29) in accordance with hospital P&P, “Medication Reconciliation” (Refer to A-398 Finding 3). 5. Licensed Nurses (LN) for two of six patients (Pt 1 and Pt 31), did not assess pain or reassess pain after administration of pain medications in accordance with hospital P&P, “Pain, Assessment and Management of” (Refer to A-398 Finding 4). 6. Licensed Nurses (LN) did not document a chest pain assessment and/or notification to the physician of a change in condition related to chest pain or abdominal pain for one of 10 patients (Pt 1), in accordance with hospital P&P “Core Nursing Standards of Practice” (Refer to A-398 Finding 5). 7. Nursing staff administered blood products not in accordance with the hospitals policy and procedures (P&P) titled “Blood Products Transfusion”, for one of one patient (Patient 9). (Refer to A-410). The cumulative effect of these system problems resulted in the hospital’s inability to provide nursing services in a safe setting.”

“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: 49884 Based on observation, interview and record review, the hospital failed to inform one of nine patients (Pt 31) in advance of care decisions when interpreter services were not used to communicate, from 10/15/24 to 10/20/24 in a language Pt 31 could understand according to the hospitals policy and procedure (P&P) titled, “Limited English-Proficiency (LEP): Language Access for Patient and Companions.” This failure denied Pt 31 their right to make informed decisions about, participate in their daily care and had the potentially to affect all non-English speaking patients treated at the hospital. Findings: During a concurrent interview and record review on 11/12/24 at 3:23 p.m. with Registered Nurse (RN) 7 and the Director of Nursing (DON) Pt 31’s “History & Physical [H&P- an assessment from physician including medical history and exam],” and “Face Sheet [FS- a document that contains a summary of a patients’ personal information],” dated 10/11/24, were reviewed. The “H&P” indicated, Pt 31 was admitted to the hospital on 10/11/24 at 4:42 p.m. for sepsis (a life-threatening blood infection), and acute kidney injury (AKI- A sudden and often reversible decline in kidney function) after a laminectomy (a surgical cut into the backbone to get access to the structures in the spinal cord). RN 7 stated the “FS” indicated, Pt 31’s preferred language was Spanish. During a concurrent interview and record review on 11/13/24 at 11:03 a.m. with Shift Manager (SM) 3, Pt 31’s “Interpreter Services Flowsheet (ISF),” dated 10/11/24 to 11/13/24, were reviewed. SM 3 stated no Licensed Nursing (LN) documentation was present on the “ISF” to indicate a Spanish medical interpreter was used during Pt 31’s admission to the Medical Surgical (MS) Unit. SM 3 stated a Spanish medical interpreter should have been used for Pt 31’s admission questions. SM 3 stated Pt 31’s “ISF” indicated, no Spanish medical interpreter was used to communicate with Pt 31 or his family on 10/15/24 through 10/20/24. SM 3 stated medical interpreters (CMI) should be used to communicate patient education, medications, plan of care, procedures, treatments, and care options. SM 3 stated LNs could access a medical interpreter via computer tablet, telephone, or use an in-person interpreter. SM 3 stated LNs should use medical interpreters for non-English speaking patients and their caregivers/families to ensure the plan of care was understood. SM 3 stated Pt 31’s wife also was non-English speaking. SM 3 stated Pt 31 was “often confused” and did not always have family at bedside so, speaking in a language he understood was important. SM 3 stated speaking to Pt 31 in his preferred language could help to prevent Pt 31 from being scared and give him a sense of what was happening to him. SM 3 stated her expectation was for LNs to document use of medical interpreters in the “ISF” according to P&P. During a concurrent observation and interview on 11/14/24 at 3:45 p.m. with the In-house Spanish Interpreter (ISI), Family Member (FM) 2 and Registered Nurse (RN) 8, in Pt 31’s hospital room, Pt 31 was observed lying in his hospital bed at a 90-degree angle with his eyes open. Pt 31’s right and left wrist were in soft restraints (padding attached around a limb attached to bedframe that limits a person’s movement). Pt 31 had a foley catheter (a flexible tube that drains urine from the bladder into a collection bag). Pt 31’s primary RN (RN 8) was in the room at bedside attempting to get a finger-stick blood sugar (poking finger with needle to test blood sugar levels) and vital signs (VS) from Pt 31. RN 8 was speaking to Pt 31 in English. Pt 31’s wife (FM 2) was at bedside. FM 2 stated through the ISI that neither Pt 31 nor FM 2 spoke English. Pt 31 stated they only spoke Spanish. FM 2 stated her husband was often confused, because of his illness. FM 2 stated she was not always updated of Pt 31’s change in status. FM 2 stated medical interpreters were used sometimes to communicate with her. FM 2 stated she appreciated when medical interpreters were used because she felt better informed in Pt 31’s care and treatment. During an interview on 11/14/24 at 3:53 p.m. with RN 8, RN 8 stated using medical interpreters for non-English speaking patients and their families was important to help them understand the plan of care. RN 8 stated he should have used a medical interpreter to inform FM 2 about Pt 31’s change of condition and any new treatment plans. During an interview on 11/15/24 at 10:12 a.m. with Clinical Manager (CM) 6, CM 6 stated her expectation was, if patients were non-English speaking LNs should use a medical interpreter. CM 6 stated Pt 31’s LNs should use a medical interpreter to communicate with him and his family to explain any new plans of care or treatments. CM 6 stated her expectation was for LNs to document when a medical interpreter was used, what was communicated to the patient, and the interpreter’s name and/or ID number. During an interview on 11/15/24 at 3:25 p.m. with the Chief Nursing Officer (CNO), the CNO stated, Medical Interpreter Services should be used when LNs were communicating with patients about plans of care, changes in or new medications, instructions, and treatments. The CNO stated employees who were native speakers of the patient’s preferred language could be used as interpreters when asking patients about toileting, fluids, bathing, or nutrition. The CNO stated her expectation was for LNs to follow the P&P and document what was information was interpreted, the interpreter’s name, and ID number information. The CNO stated LNs need to use a medical interpreter in the patient’s preferred language so patients could understand and ask questions if clarification was needed. The CNO stated interpretation was important so patients could understand their plan of care. During a review of the hospital’s P&P titled, “Limited English Proficiency (LEP): Language Access for Patients and Companions,” dated 4/2/23, indicated, “ ... utilization of interpreter services. ... Considerations for determining the appropriate model for the delivery of interpreter services will include the patient’s preferences, the nature of the clinical interaction, the availability of qualified in-person medical interpreters and the availability of the technology to allow for telephonic or video-conference interpreters ... Providing Interpreter Services for Meaningful Access ... Interpreter services will be provided for any patient who has Limited English Proficiency. ... Interpreter services, including a Qualified Medical interpreter when needed to provide meaningful, equitable access to the Facility’s services, are required for patient assessment, consent, education and discharge ... Determining a patient’s history or description of ailment [illness] or injury ... Obtaining informed consent or permission for treatment ... Explaining diagnosis or prognosis [likely course of disease or illness] of ailments or injuries ... Explaining procedures, tests, treatment, treatment options or surgery ... Explaining the administration and side effects of medications, including side effects and food or drug interactions [a change in the way a drug acts in the body when taken with other drugs] ... Explaining follow-up treatment, test results, or recovery ... The documentation of the provision [supplying for use] of interpreter services shall be recorded in the patient medical record and shall include ... Name of requestor ... Date and time of interpretation ... Name of [hospital Name] Qualified Medical interpreter or vendor company name and interpreter name, or telephonic interpreter ID number, as applicable; and a ... Brief description of content interpreted ... For limited communications about basic activities of daily living (ADL), such as a request for water or to use the bathroom, employees who are native speakers of the patient’s preferred language may communicate with an LEP patient without the use of a Qualified Medical interpreter, but it is recommended that tools such as picture communication boards be available to allow patients to express their needs ...”. During a review of professional reference titled, “Clinicians’ Obligations to Use Qualified Medical interpreters When Caring for Patients with Limited English Proficiency,” dated 3/2017, (retrieved from https://journalofethics.ama-assn.org/article/clinicians-obligations-use-qualified-medical-interpreters-when-caring-patients-limited-english/2017-03) indicated, “ ... Access to language services is a required and foundational component of care for patients with limited English proficiency (LEP) ... In the United States, patients with LEP have a legal right to access health care in their preferred language ...”.”

“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: 49884 Based on observation, interview and record review, the hospital failed to inform one of nine patients (Pt 31) in advance of care decisions when interpreter services were not used to communicate, from 10/15/24 to 10/20/24 in a language Pt 31 could understand according to the hospitals policy and procedure (P&P) titled, “Limited English-Proficiency (LEP): Language Access for Patient and Companions.” This failure denied Pt 31 their right to make informed decisions about, participate in their daily care and had the potentially to affect all non-English speaking patients treated at the hospital. Findings: During a concurrent interview and record review on 11/12/24 at 3:23 p.m. with Registered Nurse (RN) 7 and the Director of Nursing (DON) Pt 31’s “History & Physical [H&P- an assessment from physician including medical history and exam],” and “Face Sheet [FS- a document that contains a summary of a patients’ personal information],” dated 10/11/24, were reviewed. The “H&P” indicated, Pt 31 was admitted to the hospital on 10/11/24 at 4:42 p.m. for sepsis (a life-threatening blood infection), and acute kidney injury (AKI- A sudden and often reversible decline in kidney function) after a laminectomy (a surgical cut into the backbone to get access to the structures in the spinal cord). RN 7 stated the “FS” indicated, Pt 31’s preferred language was Spanish. During a concurrent interview and record review on 11/13/24 at 11:03 a.m. with Shift Manager (SM) 3, Pt 31’s “Interpreter Services Flowsheet (ISF),” dated 10/11/24 to 11/13/24, were reviewed. SM 3 stated no Licensed Nursing (LN) documentation was present on the “ISF” to indicate a Spanish medical interpreter was used during Pt 31’s admission to the Medical Surgical (MS) Unit. SM 3 stated a Spanish medical interpreter should have been used for Pt 31’s admission questions. SM 3 stated Pt 31’s “ISF” indicated, no Spanish medical interpreter was used to communicate with Pt 31 or his family on 10/15/24 through 10/20/24. SM 3 stated medical interpreters (CMI) should be used to communicate patient education, medications, plan of care, procedures, treatments, and care options. SM 3 stated LNs could access a medical interpreter via computer tablet, telephone, or use an in-person interpreter. SM 3 stated LNs should use medical interpreters for non-English speaking patients and their caregivers/families to ensure the plan of care was understood. SM 3 stated Pt 31’s wife also was non-English speaking. SM 3 stated Pt 31 was “often confused” and did not always have family at bedside so, speaking in a language he understood was important. SM 3 stated speaking to Pt 31 in his preferred language could help to prevent Pt 31 from being scared and give him a sense of what was happening to him. SM 3 stated her expectation was for LNs to document use of medical interpreters in the “ISF” according to P&P. During a concurrent observation and interview on 11/14/24 at 3:45 p.m. with the In-house Spanish Interpreter (ISI), Family Member (FM) 2 and Registered Nurse (RN) 8, in Pt 31’s hospital room, Pt 31 was observed lying in his hospital bed at a 90-degree angle with his eyes open. Pt 31’s right and left wrist were in soft restraints (padding attached around a limb attached to bedframe that limits a person’s movement). Pt 31 had a foley catheter (a flexible tube that drains urine from the bladder into a collection bag). Pt 31’s primary RN (RN 8) was in the room at bedside attempting to get a finger-stick blood sugar (poking finger with needle to test blood sugar levels) and vital signs (VS) from Pt 31. RN 8 was speaking to Pt 31 in English. Pt 31’s wife (FM 2) was at bedside. FM 2 stated through the ISI that neither Pt 31 nor FM 2 spoke English. Pt 31 stated they only spoke Spanish. FM 2 stated her husband was often confused, because of his illness. FM 2 stated she was not always updated of Pt 31’s change in status. FM 2 stated medical interpreters were used sometimes to communicate with her. FM 2 stated she appreciated when medical interpreters were used because she felt better informed in Pt 31’s care and treatment. During an interview on 11/14/24 at 3:53 p.m. with RN 8, RN 8 stated using medical interpreters for non-English speaking patients and their families was important to help them understand the plan of care. RN 8 stated he should have used a medical interpreter to inform FM 2 about Pt 31’s change of condition and any new treatment plans. During an interview on 11/15/24 at 10:12 a.m. with Clinical Manager (CM) 6, CM 6 stated her expectation was, if patients were non-English speaking LNs should use a medical interpreter. CM 6 stated Pt 31’s LNs should use a medical interpreter to communicate with him and his family to explain any new plans of care or treatments. CM 6 stated her expectation was for LNs to document when a medical interpreter was used, what was communicated to the patient, and the interpreter’s name and/or ID number. During an interview on 11/15/24 at 3:25 p.m. with the Chief Nursing Officer (CNO), the CNO stated, Medical Interpreter Services should be used when LNs were communicating with patients about plans of care, changes in or new medications, instructions, and treatments. The CNO stated employees who were native speakers of the patient’s preferred language could be used as interpreters when asking patients about toileting, fluids, bathing, or nutrition. The CNO stated her expectation was for LNs to follow the P&P and document what was information was interpreted, the interpreter’s name, and ID number information. The CNO stated LNs need to use a medical interpreter in the patient’s preferred language so patients could understand and ask questions if clarification was needed. The CNO stated interpretation was important so patients could understand their plan of care. During a review of the hospital’s P&P titled, “Limited English Proficiency (LEP): Language Access for Patients and Companions,” dated 4/2/23, indicated, “ ... utilization of interpreter services. ... Considerations for determining the appropriate model for the delivery of interpreter services will include the patient’s preferences, the nature of the clinical interaction, the availability of qualified in-person medical interpreters and the availability of the technology to allow for telephonic or video-conference interpreters ... Providing Interpreter Services for Meaningful Access ... Interpreter services will be provided for any patient who has Limited English Proficiency. ... Interpreter services, including a Qualified Medical interpreter when needed to provide meaningful, equitable access to the Facility’s services, are required for patient assessment, consent, education and discharge ... Determining a patient’s history or description of ailment [illness] or injury ... Obtaining informed consent or permission for treatment ... Explaining diagnosis or prognosis [likely course of disease or illness] of ailments or injuries ... Explaining procedures, tests, treatment, treatment options or surgery ... Explaining the administration and side effects of medications, including side effects and food or drug interactions [a change in the way a drug acts in the body when taken with other drugs] ... Explaining follow-up treatment, test results, or recovery ... The documentation of the provision [supplying for use] of interpreter services shall be recorded in the patient medical record and shall include ... Name of requestor ... Date and time of interpretation ... Name of [hospital Name] Qualified Medical interpreter or vendor company name and interpreter name, or telephonic interpreter ID number, as applicable; and a ... Brief description of content interpreted ... For limited communications about basic activities of daily living (ADL), such as a request for water or to use the bathroom, employees who are native speakers of the patient’s preferred language may communicate with an LEP patient without the use of a Qualified Medical interpreter, but it is recommended that tools such as picture communication boards be available to allow patients to express their needs ...”. During a review of professional reference titled, “Clinicians’ Obligations to Use Qualified Medical interpreters When Caring for Patients with Limited English Proficiency,” dated 3/2017, (retrieved from https://journalofethics.ama-assn.org/article/clinicians-obligations-use-qualified-medical-interpreters-when-caring-patients-limited-english/2017-03) indicated, “ ... Access to language services is a required and foundational component of care for patients with limited English proficiency (LEP) ... In the United States, patients with LEP have a legal right to access health care in their preferred language ...”.”

“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: 49884 Based on interview and record review the hospital failed to ensure patient’s right to make informed decisions about care for one of two patients (Pt 24) when discharge instructions were not in a language the patient (Pt 24) could understand and an interpreter was not used to review the discharge instructions according to the facility’s policy and procedure (P&P) titled, “Limited English-Proficiency (LEP): Language Access for Patient and Companions.” This failure denied Pt 24 their right to make informed decisions about, participate in their discharge care and had the potentially to affect all non-English speaking patients discharge at the hospital. Findings: During a review of Pt 24’s “Face Sheet (FS-a list of a patient’s information that provides quick access for healthcare providers),” undated, the FS indicated Pt 24’s preferred language was Spanish. During a concurrent interview and record review on 11/13/24 at 1:49 p.m. with Registered Nurse (RN) 7 and Nurse Educator (NE) 3, Pt 24’s “Discharge Instructions (DI),” dated 11/13/24 was reviewed. RN 7 stated the DI was written in English. During a concurrent interview and record review on 11/13/24 at 1:55 p.m. with RN 7 and NE 3, Pt 24’s “Interpreter Flowsheet (IF),” dated 11/13/24 and “Nursing Discharge Summary (NDS),” dated 11/13/24 were reviewed. RN 7 stated the “IF” indicated no interpreter was used to give discharge instructions to Pt 24. RN 7 stated the “NDS” indicated no interpreter was used to give discharge instructions to Pt 24. RN 7 stated it was important to provide discharge instructions and education in Pt 24’s primary language to ensure Pt 24 understood the information and Pt 24’s questions were answered at the time of discharge. During an interview on 11/14/24 at 3:25 p.m. with Clinical Manager (CM) 5, CM 5 stated Licensed Nurses (LN) are expected to provide discharge instructions in Spanish when the patient’s preferred language is Spanish. CM 5 stated LNs are expected to use a qualified translator to provide discharge instructions to patients who have a different preferred language. CM 5 stated LNs are expected to document the use of a translator in the patient’s electronic medical record (EMR- a digital version of a patient’s medical history). During an interview on 11/15/24 at 3:13 p.m. with the Chief Nursing Officer (CNO), the CNO stated LNs are expected to use a certified interpreter in the patient’s primary language to ensure the patient understands the education and to ask questions if needed. During a review of the facility’s P&P titled, “Limited English-Proficiency (LEP): Language Access for Patient and Companions,” revised 3/2023, the P&P indicated, “ ...It is the policy of [Name of Hospital] that patients or surrogate decisionmakers (hereafter patients) who are Limited English Proficient (LEP), will have services provided to them in their primary language during the delivery of all significant healthcare services. Interpreter services will be available within a reasonable time during all hours of operation, at no cost to patients ... Patients and companions who are Limited English Proficient (LEP) shall have information and services provided to them in their primary language while receiving healthcare services at all [Name of Hospital] ... Interpreter services, including a Qualified Medical Interpreter when needed to provide meaningful, equitable access to the Facility’s services, are required for patient assessment, consent, education and discharge, including but not limited to the following topics ... Providing discharge instructions or discussing plans ... Language Accessible Vital Documents ... a. All Vital Documents shall be printed in the Threshold Languages. Only a qualified translation company that certifies the accuracy of its documents shall be used for written translation for any document that affects a patient’s health care. b. Vital Documents that are not produced in a written translation shall be verbally translated to the patient by a Qualified Medical Interpreter. The provision of oral translation of all Vital Documents to patients shall be documented in the medical record ...” During a review of the facility’s P&P titled, “Discharge of the Adult Inpatient,” reviewed 6/2022, the P&P indicated, “ ...Discharge Packets (Plans and Written Instructions) ... Will be in a form the patient, family and/or caregiver(s) can understand ... The nurse will review the Discharge Instruction Packet with the patient, family and/or appropriate caregivers in order to educate them regarding the anticipated needs for continued care, treatment, and services following discharge ...””

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 49884 Based on interview, and record review, the hospital failed to ensure one of 25 patients (Patient 1) was provided information about advance directives in accordance with the Policy and Procedure, “Advance Directives / Patient Self-Determination” (Advance Directives -Legal document that states a person’s wishes for medical care if they are unable to communicate their preferences.) This failure resulted in Patient (Pt) 1’s rights and wishes to go unidentified in the event of an emergency. Findings: During a concurrent interview and record review on 11/13/24 at 3:13 p.m. with Shift Manager (SM) 3, Pt 1’s “History and Physical [H&P- an assessment from physician including medical history and exam]” dated 9/4/24, were reviewed. The “H&P” indicated, Pt 1 was admitted as an inpatient on 9/4/24 at 5:47 p.m. During a concurrent interview and record review on 11/13/24 at 3:17 p.m. with SM 3, Pt 1’s “Condition of Admission and Treatment (COA), and “Advance Directive and POLST [physician order for life sustaining treatment] Tracking [ADPT]” dated 9/4/24, were reviewed. SM 3 stated page 5 of the “COA” asked patients questions about Advance Directives. SM 3 stated the “COA” page five was completed by registration staff when patients were admitted. SM 3 stated page five of Pt 1’s “COA” did not have any of the advanced directive questions completed by hospital staff. The “COA” indicated, hospital staff must check a box on the form to indicate if the patient had an advanced directive or did not have an advanced directive. The “COA” had additional boxes for hospital staff to check if patients indicated they did or did not want information about advanced directives. The “COA” had a line for hospital staff to sign and date when the form was completed and was signed and dated. SM 3 stated Pt 1’s “COA” should have had the boxes checked if Pt 1 received information or declined information about advanced directives. SM 3 stated Pt 1 should have been asked the questions on the “COA” and the “COA” should have been completed. SM 3 stated Pt 1 should have been given information about advanced directives for her to decide if she wanted one. SM 3 stated Pt 1’s “ADPT” form was completed by a nurse. SM 3 stated Pt 1’s “ADPT” indicated Pt 1 answered no to having an advanced directive. SM 3 stated the “ADPT” had a question on the form to prompt nurses to ask patients if they wanted a visit to complete, change or discuss an Advance Directive. SM 3 stated the area in Pt 1’s form was blank. SM 3 stated her expectation was for nurses to complete all admission questions on the “ADPT” form. During an interview on 11/15/24 at 2:52 p.m. with the Director of Patient Access (DPA), the DPA stated the Patient Access Registration (PAR) staff ask patients about Advanced Directives after admission. The DPA stated if patient’s say they have an Advanced Directive the PAR staff request a copy from the patient. The DPA stated when patients do not have an Advanced Directive the PAR staff asked patients if they wanted information. During a record review of the hospital’s policy and procedure titled, “Advance Directives / Patient Self-Determination RI-51), dated 2/23, indicated, “ ... The front page of the Advance Directive Statement will be completed ... to document each patient’s Advance Directive status by the staff member who initiates the admission process ... Planned admission via Registration Department: Done by the Registration Clerk during the hours the Department is open and by the ER Registration Clerk after hours. ... Direct admission to a patient care unit: Done by the Registration Clerk at the bedside during the hours that the Registration Department is open and by the Nursing staff on the inpatient unit after hours ... Pre-registration of a surgical patient: Done by the Registration Clerk. ... Emergency Department (ED) patient who is admitted: Done by the ED Registration staff when the decision to admit an ED patient is made ...The form is reviewed with the patient and/or his/her legal representative. The appropriate box (es) and space(s) are completed to indicate the current Advance Directive status ... Patients requesting an advance directive document to read and/or prepare are given a blank copy of this document ... Nursing Assessment/Healthcare Team Follow-Up Process ... The nurse who admits the patient will ... Review the front page of the Advance Directive Statement to ascertain the Advance Directive status of the patient ... Completes the Advance Directive section of the Nursing Admission Assessment ... Follow up appropriately ...”.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 49884 Based on interview, and record review, the hospital failed to ensure one of 25 patients (Patient 1) was provided information about advance directives in accordance with the Policy and Procedure, “Advance Directives / Patient Self-Determination” (Advance Directives -Legal document that states a person’s wishes for medical care if they are unable to communicate their preferences.) This failure resulted in Patient (Pt) 1’s rights and wishes to go unidentified in the event of an emergency. Findings: During a concurrent interview and record review on 11/13/24 at 3:13 p.m. with Shift Manager (SM) 3, Pt 1’s “History and Physical [H&P- an assessment from physician including medical history and exam]” dated 9/4/24, were reviewed. The “H&P” indicated, Pt 1 was admitted as an inpatient on 9/4/24 at 5:47 p.m. During a concurrent interview and record review on 11/13/24 at 3:17 p.m. with SM 3, Pt 1’s “Condition of Admission and Treatment (COA), and “Advance Directive and POLST [physician order for life sustaining treatment] Tracking [ADPT]” dated 9/4/24, were reviewed. SM 3 stated page 5 of the “COA” asked patients questions about Advance Directives. SM 3 stated the “COA” page five was completed by registration staff when patients were admitted. SM 3 stated page five of Pt 1’s “COA” did not have any of the advanced directive questions completed by hospital staff. The “COA” indicated, hospital staff must check a box on the form to indicate if the patient had an advanced directive or did not have an advanced directive. The “COA” had additional boxes for hospital staff to check if patients indicated they did or did not want information about advanced directives. The “COA” had a line for hospital staff to sign and date when the form was completed and was signed and dated. SM 3 stated Pt 1’s “COA” should have had the boxes checked if Pt 1 received information or declined information about advanced directives. SM 3 stated Pt 1 should have been asked the questions on the “COA” and the “COA” should have been completed. SM 3 stated Pt 1 should have been given information about advanced directives for her to decide if she wanted one. SM 3 stated Pt 1’s “ADPT” form was completed by a nurse. SM 3 stated Pt 1’s “ADPT” indicated Pt 1 answered no to having an advanced directive. SM 3 stated the “ADPT” had a question on the form to prompt nurses to ask patients if they wanted a visit to complete, change or discuss an Advance Directive. SM 3 stated the area in Pt 1’s form was blank. SM 3 stated her expectation was for nurses to complete all admission questions on the “ADPT” form. During an interview on 11/15/24 at 2:52 p.m. with the Director of Patient Access (DPA), the DPA stated the Patient Access Registration (PAR) staff ask patients about Advanced Directives after admission. The DPA stated if patient’s say they have an Advanced Directive the PAR staff request a copy from the patient. The DPA stated when patients do not have an Advanced Directive the PAR staff asked patients if they wanted information. During a record review of the hospital’s policy and procedure titled, “Advance Directives / Patient Self-Determination RI-51), dated 2/23, indicated, “ ... The front page of the Advance Directive Statement will be completed ... to document each patient’s Advance Directive status by the staff member who initiates the admission process ... Planned admission via Registration Department: Done by the Registration Clerk during the hours the Department is open and by the ER Registration Clerk after hours. ... Direct admission to a patient care unit: Done by the Registration Clerk at the bedside during the hours that the Registration Department is open and by the Nursing staff on the inpatient unit after hours ... Pre-registration of a surgical patient: Done by the Registration Clerk. ... Emergency Department (ED) patient who is admitted: Done by the ED Registration staff when the decision to admit an ED patient is made ...The form is reviewed with the patient and/or his/her legal representative. The appropriate box (es) and space(s) are completed to indicate the current Advance Directive status ... Patients requesting an advance directive document to read and/or prepare are given a blank copy of this document ... Nursing Assessment/Healthcare Team Follow-Up Process ... The nurse who admits the patient will ... Review the front page of the Advance Directive Statement to ascertain the Advance Directive status of the patient ... Completes the Advance Directive section of the Nursing Admission Assessment ... Follow up appropriately ...”.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 49884 Based on observation, interview and record review, the hospital failed to ensure patients were free from restraints (chemical, physical, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) and to ensure restraints were discontinued at the earliest possible time, when nurses did not complete restraint assessment monitoring every two-hours for one of three patients (Pt 31) to ensure Pt 31 remained free from injury and to determine if the restraints could be released , in accordance with hospital policy and procedure (P&P). These failures resulted in Pt 31 to go without restraint monitoring, violated Pt 31’s right to be released from restraints at the earliest possible time, and had the potential to cause injury from restraints. Findings: During a concurrent interview and record review on 11/12/24 at 3:23 p.m. with Registered Nurse (RN) 7 and the Director of Nursing (DON) Pt 31’s “History & Physical [H&P- an assessment from physician including medical history and exam],” dated 10/11/24, was reviewed. The “H&P” indicated, Pt 31 was admitted to the hospital on 10/11/24 at 4:42 p.m. for sepsis (a life-threatening blood infection), and acute kidney injury (AKI- A sudden and often reversible decline in kidney function) after a laminectomy (a surgical cut into the backbone to get access to the structures in the spinal cord). During a concurrent interview and record review on 11/13/24 at 11:30 a.m. with Shift Manager (SM) 3, Pt 31’s “Restraint Monitoring Flowsheet (RMF),” dated 10/16/24 to 11/13/24 were reviewed. The “RMF” indicated Pt 31 was on two-point (a mechanical restraint that restricts a patient’s wrist movement) soft limb (soft materials for arm or leg) restraints on 10/25/24. SM 3 stated Pt 31’s LN was supposed to document monitoring assessments for Pt 31 every two hours. SM 3 stated Pt 31’s “RMF” had no restraint monitoring documentation on 10/25/24 at 6 a.m., and on 10/30/24 at 4 a.m. SM 3 stated Pt 31’s “RMF” indicated on 10/28/24 at 6 a.m. and on 10/30/24 at 6 a.m. LNs did not document a complete restraint monitoring assessment. SM 3 stated LNs were supposed to document in the “RMF” a complete restraint monitoring assessment every two hours. SM 3 stated, restraint monitoring assessments included, visual or safety observation, skin, circulation, level of consciousness, toileting, flids or nourishment offered, and response to interventions. SM 3 stated monitoring documentation was absent from Pt 31’s “RMF”. SM 3 stated monitoring patients in restraints was important to ensure patient’s safety and patients were not being injured while in restraints. During a concurrent interview and record review on 11/13/24 at 11:40 a.m. with SM 3, Pt 31’s “Physician Orders (PO)” dated 10/25/24, was reviewed. The “PO” indicated, “ ... Restraints-Non Violent/Non Destructive ... 10/25/24 10:00:00 [10 a.m.] ... [every two hours] (interval) ... Soft Limb, Bilateral Wrists, Climbing out of bed/chair risking safety: Pulling at lines, Tubes or Dressings ...Order Comments: RENEW RESTRAINTS DAILY ...”. SM 3 stated, every two hours on the “PO” meant to monitor the patient every two hours. During a concurrent observation and interview on 11/14/24 at 3:45 p.m. with the Spanish Interpreter (SI), and Family Member (FM) 2 in Pt 31’s hospital room, Pt 31 was observed lying in his hospital bed at a 90-degree angle with his eyes open. Pt 31’s right and left wrist were in soft restraints (padding attached around a limb [wrist] attached to bedframe, that limits a person’s movement). During an interview on 11/15/24 at 10:05 a.m. with Clinical Manager (CM) 6, CM 6 stated LNs should monitor and document restraint assessments every two hours and once per shift to determine if patients needed to remain on restraints. CM 6 stated, at least every two hours LNs should, reposition the patient, offer food or drinks and check circulation (flow of blood) to limbs (arm or leg). CM 6 stated when LNs assess restraints it should be documented. During an interview on 11/15/24 at 3:43 p.m. with the Chief Nursing Officer (CNO), the CNO stated, her expectation was for LNs to monitor and document non-violent restraints every two hours according to hospital P&P. The CNO stated LNs should, assess for skin breakdown (skin damage), offer food, water, and toileting, and determine if patients could be released from restraints. The CNO stated an assessment of a patient in restraints should happen at least every two hours, to determine if a patient has a compromised (impaired or unable to function) limb, skin breakdown, agitation (tense, irritable, or confused), or a decline in mental status. The CNO stated LNs should assess patients in restraints to determine the earliest time the restraints can be removed. During a review of the hospital’s P&P titled, “Restraint Seclusion (PC-37)”, dated 1/24/19, indicated, “ ... PATIENT ASSESSMENT AND DOCUMENTATION OF THE NEED FOR NONVIOLENT/NON-SELF-DESTRUCTIVE RESTRAINTS: ... The RN must document the assessment in the EHR at the initiation of restraints ... Patient evaluation will be completed every TWO (2) hours on the even hour throughout the shift and will include but is not limited to ... Perform and Provide ... Vital signs with emphasis on cardiac and respiratory status ... Skin integrity ... Signs of any injury associated with restraint application ... CSM - circulation, sensation, range of motion ... LOC - level of consciousness ... Comfort (response to restraints - restless, calm, agitation) ... Provide nutrition and hydration ... Provide hygiene ... Provide for elimination ... Maintain safe environmental, dignity and safety ... Assess for readiness for discontinuation of restraint or behavior necessitating the continuation of restrains ... Non Violent/Non Self Destructive Restraint orders will not exceed one (1) calendar day ...”. During a review of professional reference titled, Patient Restraint and Seclusion,” dated 11/14/22, (retrieved from https://www.ncbi.nlm.nih.gov/books/NBK565873/ f (nih.gov) indicated, “ ... Healthcare workers should know that restraint and seclusion can have significant adverse implications on patients and should be deemed a last resort. Healthcare professionals must follow the 4 basic ethical healthcare principles: autonomy [make decisions and act independently without interference from others], justice, beneficence [the doing of good, promoting the well-being of others], and non-maleficence [doing no harm]. Per beneficence - the act of doing good - and non-maleficence - do no harm; healthcare providers must ensure the administration of restraint is implemented as a last resort ... Healthcare workers must also be sure to appropriately monitor the patient following restraint and seclusion to avoid deleterious [causing harm] effects such as pressure ulcers [localized area of damaged skin or tissue that occurs when pressure is applied to skin for a long time], skin breakdown, abrasions [scraping or wearing away] , asphyxia [body deprived of oxygen, suffocation], strangulation, incontinence [involuntary loss of bladder control], depression, social isolation, and drug overdose or interaction ...Document appropriate clinical indications and prepare a standardized checklist for staff to monitor and supply patient needs effectively. Numerous deaths and adverse patient outcomes have been reported due to inappropriate restraint placement and negligent [failing to take proper care] monitoring. After restraint placement, patients should be reevaluated every hour and moved regularly ... Once it is safe, the patient should also be evaluated for medical causes of agitation ...”.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 49884 Based on observation, interview and record review, the hospital failed to ensure patients were free from restraints (chemical, physical, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) and to ensure restraints were discontinued at the earliest possible time, when nurses did not complete restraint assessment monitoring every two-hours for one of three patients (Pt 31) to ensure Pt 31 remained free from injury and to determine if the restraints could be released , in accordance with hospital policy and procedure (P&P). These failures resulted in Pt 31 to go without restraint monitoring, violated Pt 31’s right to be released from restraints at the earliest possible time, and had the potential to cause injury from restraints. Findings: During a concurrent interview and record review on 11/12/24 at 3:23 p.m. with Registered Nurse (RN) 7 and the Director of Nursing (DON) Pt 31’s “History & Physical [H&P- an assessment from physician including medical history and exam],” dated 10/11/24, was reviewed. The “H&P” indicated, Pt 31 was admitted to the hospital on 10/11/24 at 4:42 p.m. for sepsis (a life-threatening blood infection), and acute kidney injury (AKI- A sudden and often reversible decline in kidney function) after a laminectomy (a surgical cut into the backbone to get access to the structures in the spinal cord). During a concurrent interview and record review on 11/13/24 at 11:30 a.m. with Shift Manager (SM) 3, Pt 31’s “Restraint Monitoring Flowsheet (RMF),” dated 10/16/24 to 11/13/24 were reviewed. The “RMF” indicated Pt 31 was on two-point (a mechanical restraint that restricts a patient’s wrist movement) soft limb (soft materials for arm or leg) restraints on 10/25/24. SM 3 stated Pt 31’s LN was supposed to document monitoring assessments for Pt 31 every two hours. SM 3 stated Pt 31’s “RMF” had no restraint monitoring documentation on 10/25/24 at 6 a.m., and on 10/30/24 at 4 a.m. SM 3 stated Pt 31’s “RMF” indicated on 10/28/24 at 6 a.m. and on 10/30/24 at 6 a.m. LNs did not document a complete restraint monitoring assessment. SM 3 stated LNs were supposed to document in the “RMF” a complete restraint monitoring assessment every two hours. SM 3 stated, restraint monitoring assessments included, visual or safety observation, skin, circulation, level of consciousness, toileting, flids or nourishment offered, and response to interventions. SM 3 stated monitoring documentation was absent from Pt 31’s “RMF”. SM 3 stated monitoring patients in restraints was important to ensure patient’s safety and patients were not being injured while in restraints. During a concurrent interview and record review on 11/13/24 at 11:40 a.m. with SM 3, Pt 31’s “Physician Orders (PO)” dated 10/25/24, was reviewed. The “PO” indicated, “ ... Restraints-Non Violent/Non Destructive ... 10/25/24 10:00:00 [10 a.m.] ... [every two hours] (interval) ... Soft Limb, Bilateral Wrists, Climbing out of bed/chair risking safety: Pulling at lines, Tubes or Dressings ...Order Comments: RENEW RESTRAINTS DAILY ...”. SM 3 stated, every two hours on the “PO” meant to monitor the patient every two hours. During a concurrent observation and interview on 11/14/24 at 3:45 p.m. with the Spanish Interpreter (SI), and Family Member (FM) 2 in Pt 31’s hospital room, Pt 31 was observed lying in his hospital bed at a 90-degree angle with his eyes open. Pt 31’s right and left wrist were in soft restraints (padding attached around a limb [wrist] attached to bedframe, that limits a person’s movement). During an interview on 11/15/24 at 10:05 a.m. with Clinical Manager (CM) 6, CM 6 stated LNs should monitor and document restraint assessments every two hours and once per shift to determine if patients needed to remain on restraints. CM 6 stated, at least every two hours LNs should, reposition the patient, offer food or drinks and check circulation (flow of blood) to limbs (arm or leg). CM 6 stated when LNs assess restraints it should be documented. During an interview on 11/15/24 at 3:43 p.m. with the Chief Nursing Officer (CNO), the CNO stated, her expectation was for LNs to monitor and document non-violent restraints every two hours according to hospital P&P. The CNO stated LNs should, assess for skin breakdown (skin damage), offer food, water, and toileting, and determine if patients could be released from restraints. The CNO stated an assessment of a patient in restraints should happen at least every two hours, to determine if a patient has a compromised (impaired or unable to function) limb, skin breakdown, agitation (tense, irritable, or confused), or a decline in mental status. The CNO stated LNs should assess patients in restraints to determine the earliest time the restraints can be removed. During a review of the hospital’s P&P titled, “Restraint Seclusion (PC-37)”, dated 1/24/19, indicated, “ ... PATIENT ASSESSMENT AND DOCUMENTATION OF THE NEED FOR NONVIOLENT/NON-SELF-DESTRUCTIVE RESTRAINTS: ... The RN must document the assessment in the EHR at the initiation of restraints ... Patient evaluation will be completed every TWO (2) hours on the even hour throughout the shift and will include but is not limited to ... Perform and Provide ... Vital signs with emphasis on cardiac and respiratory status ... Skin integrity ... Signs of any injury associated with restraint application ... CSM - circulation, sensation, range of motion ... LOC - level of consciousness ... Comfort (response to restraints - restless, calm, agitation) ... Provide nutrition and hydration ... Provide hygiene ... Provide for elimination ... Maintain safe environmental, dignity and safety ... Assess for readiness for discontinuation of restraint or behavior necessitating the continuation of restrains ... Non Violent/Non Self Destructive Restraint orders will not exceed one (1) calendar day ...”. During a review of professional reference titled, Patient Restraint and Seclusion,” dated 11/14/22, (retrieved from https://www.ncbi.nlm.nih.gov/books/NBK565873/ f (nih.gov) indicated, “ ... Healthcare workers should know that restraint and seclusion can have significant adverse implications on patients and should be deemed a last resort. Healthcare professionals must follow the 4 basic ethical healthcare principles: autonomy [make decisions and act independently without interference from others], justice, beneficence [the doing of good, promoting the well-being of others], and non-maleficence [doing no harm]. Per beneficence - the act of doing good - and non-maleficence - do no harm; healthcare providers must ensure the administration of restraint is implemented as a last resort ... Healthcare workers must also be sure to appropriately monitor the patient following restraint and seclusion to avoid deleterious [causing harm] effects such as pressure ulcers [localized area of damaged skin or tissue that occurs when pressure is applied to skin for a long time], skin breakdown, abrasions [scraping or wearing away] , asphyxia [body deprived of oxygen, suffocation], strangulation, incontinence [involuntary loss of bladder control], depression, social isolation, and drug overdose or interaction ...Document appropriate clinical indications and prepare a standardized checklist for staff to monitor and supply patient needs effectively. Numerous deaths and adverse patient outcomes have been reported due to inappropriate restraint placement and negligent [failing to take proper care] monitoring. After restraint placement, patients should be reevaluated every hour and moved regularly ... Once it is safe, the patient should also be evaluated for medical causes of agitation ...”.”

“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: 45977 Based on interview and record review, the hospital failed to develop and keep current a nursing care plan for three of 34, Patient (Pt) 9, Pt 22 and Pt 23, when Licensed Nurses (LN) did not assess and develop an individualized care plan for pain and post-operative surgery in accordance with their policy and procedure titled “Core Nursing Standards of Practice”. This failure had the potential to result in Patients’ care needs going unmet and could possibly lead to a decline in health status. Findings: During a concurrent interview and record review on 11/13/24, at 11:06 a.m., with Registered Nurse (RN) 1 and Educator Manager (EM), Pt 9’s electronic health record (EHR- digital collection of medical information) was reviewed. Pt 9’s “History and Physical (H&P -- the formal document that physicians produce through interview with the patient, physical exam, and summary of laboratory testing)”, dated 11/2/2024 at 3:20 a.m. and “Document in Plan [Nursing Care Plan]”, dated 11/2/2024, were reviewed. Pt 9’s H&P indicated Pt 9 was brought to the hospital for lethargy (general state of fatigue) and pain with a history of congestive heart failure (a chronic condition that occurs when the heart can not pump enough blood to the body), chronic obstructive pulmonary disorder (a common lung disease that makes it hard to breath), and chronic alcohol use. Pt 9 had been admitted to primarily treat hepatic encephalopathy (a serious but potentially reversible brain disorder that occurs when the liver is unable to filter toxins from the blood), pain, urinary tract infection and sepsis (a serious condition in which the body responds to a blood infection). Pt 9’s “Nursing Care Plan” indicated, “...Confusion...Impaired Mobility...Nutrition...Risk for Falls... Fluid Volume Excess...Infection...Risk for Impaired Skin Integrity...[Alcohol] Abuse ... “ as the focused care problems for nursing interventions. RN 1 stated, the care plan did not address one of the main reasons for the admission, pain. RN 1 stated, there should be a focus in the nursing care plan that addresses the patient’s pain. RN 1 stated nurses are expected to develop a care plan to align with the needs of the patient. During a review of Pt 22’s “History and Physical (H&P-an assessment from physician including medical history and exam),” dated 10/21/24, the H&P indicated Pt 22 was a 24-year-old male who came to the facility for an outpatient procedure for excision (a medical procedure involving the removal of tissue through a surgical incision) of a right neck mass. During a concurrent interview and record review on 11/13/24 at 9:41 a.m. with the post-anesthesia care unit (PACU-a specialized unit for the care of patients after surgery and the patient’s vital signs are closely observed, pain management begins, and fluids are given) Clinical Manager (CM) 3, Pt 22’s “Orders/Plans,” dated 11/12/24 was reviewed. CM 3 stated Pt 22’s care plan in the PACU addressed issues of anxiety. CM 3 stated a care plan for pain management was not initiated in the PACU and should have been. CM 3 stated care plans were initiated for patients to help guide Licensed Nurses (LN) on an individualized plan for patient care. During a review of Pt 23’s “H&P,” dated 10/31/24, the H&P indicated “...71 year old male with a [past medical history] of chronic HFrEF (heart failure with reduced ejection fraction-the amount of blood, as a percentage, that is pumped out of a filled ventricle with each heartbeat), chronic atrial fibrillation (irregular and often very rapid heart rhythm) with RVR (rapid ventricular response-when the rapid contractions of the atria make the ventricles beat too quickly), hypertension (high blood pressure) ...” . During a review of Pt 23’s “Progress Note (PN),” dated 11/12/24, the PN indicated, “...patient to undergo cardiac catheterization (a long, thin, flexible tube called a catheter is put into a blood vessel in the arm, groin or upper thigh, or neck. The catheter is then threaded through the blood vessels to the heart) ...” During a concurrent interview and record review on 11/13/24 at 11:13 a.m. with CM 3 and Nurse Educator (NE) 3, Pt 23’s “Orders/Plans,” dated 11/12/24 was reviewed. CM 3 stated Pt 23’s care plan in the PACU addressed issues for fall. CM 3 stated a care plan for pain management was not initiated in the PACU and should have been initiated. NE 3 stated a care plan to address discharge plan should have also been initiated for Pt 23. During an interview on 11/14/24 at 3:32 p.m. with CM 3, CM 3 stated LNs are expected to initiate care plans for patients in PACU. CM 3 stated LNs should follow the policy. During a concurrent interview and record review with the Chief Nursing Officer (CNO), on 11/15/24, at 3:15 p.m., the CNO stated the nursing care plan should have addressed Pt 9’s primary needs for the admission, and it was not. The CNO stated a nursing care plan for Pt 9’s pain was not developed and implemented. The CNO stated LNs are expected to initiate a care plan addressing pain for patients in the PACU. The CNO stated, nurses are expected to follow the policy to develop, document and update the care plan to meet the patient’s care needs. During a review of the facility P&P titled, “Core Nursing Standards of Practice”, dated 6/2022, the P&P indicated, “ 2. Nursing Diagnosis - The registered nurse analyzes assessment data to determine actual or potential nursing diagnoses, patient problems and issues. The registered nurse: ... a. Identifies actual or potential risks to the patient’s health and safety or barriers to health, which may include but are not limited to interpersonal, systematic, cultural or environmental circumstances. ... b. Uses assessment data, standardized classification systems, technology, and clinical decision support tools to articulate actual or potential nursing diagnoses, patient problems, and issues. ... c. Verifies the nursing diagnoses, patient problems and issues with the patient, family, and interprofessional colleagues. ... d. Prioritizes nursing diagnoses, patient problems, and issues based on mutually established goals to meet the needs of the patients across the health-illness continuum. ... e. Documents nursing diagnoses, patient problems, and issues in a manner that facilitates the determination of the expected outcomes and plan (ANA [American Nurses Association], 2015). ... 4. Plan of Care - The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes. The registered nurse: ... a. Partners with the patient to implement the plan in a safe, effective, efficient, timely, patient-centered, and equitable manner. ... “ The “Lippincott Manual of Nursing Practice 10th Edition,” dated 2014, page 16-17 indicated, “ Standards of practice General Principles... 1. The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable ...b. These standards provide patients with a means of measuring the quality of care they receive ...5. A deviation from the protocol should be documented in the patient’s chart with clear, concise statements of the nurse’s decisions, actions, and reasons for the care provided, including any apparent deviation ... Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record ... Failure to formulate or follow the nursing care plan ...””

“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: 49884 Based on observation, interview, and record review, the facility failed to follow their policies and procedures when: 1. A cardiopulmonary resuscitation (CPR, a lifesaving procedure performed when the heart stops beating) backboard (a flat, rigid board used to support the patient during CPR) was missing from Crash Cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) #2 on the seventh floor and Crash Cart #2 was not maintained and checked in accordance with hospital policies and procedures. This failure had the potential to put patients at risk of not having their needs met if the crash cart was needed in an emergent situation. 2. Nursing Staff in the Emergency Department (ED) did not assess temperatures with every vital sign assessment for two of three sampled patients (Pt 25 and Pt 26), in accordance with hospital policy and procedure titled, “Core Standards of Practice”. These failures had the potential to result in missing a change in condition in patients and a possible delay in implementing interventions to address the clinical needs of patients. 3. Medication reconciliation (the process of comparing a patient’s medication orders to all the medications that the patient has been taking) was not completed for three of eight patients (Pt 22, Pt 24 and Pt 29) according to the hospital policy and procedure titled, “Medication Reconciliation.” This failure resulted medication reconciliation not being performed and had the potential to cause harm to Pt 22, Pt, 24 and Pt 29. 4. For two of six patients (Pt 1 and Pt 31) Licensed Nurses (LN) did not complete a pain assessment, did not reassess pain after administration of pain medications and did not complete a level of sedation assessment after opioid (a class of drug used to treat moderate to severe pain) administration in accordance with hospital policy and procedure (P&P), “Pain, Assessment and Management of (PC-56 B)”. These failures had the potential to for Pt 1 and Pt 31 to receive inadequate pain management, or oversedation (greater than the desired therapeutic level of a relaxed, calm, sleepy state caused by medication) , and had the potential for LNs to miss change in conditions of Pt 1 and Pt 31. 5. LNs did not document chest pain assessment and notification to the physician of a change in condition related to chest pain and abdominal pain for one of ten patients (Pt 1) in accordance with hospital policy and procedure, titled, “Core Nursing Standards of Practice”. This failure resulted in no documentation of coordinating care for Pt 1 and had the potential to result in a possible delay of needed treatment and services for Pt 1. Findings: 1. During a concurrent observation and interview on 11/12/24 at 10:34 a.m. on the seventh floor medical/surgical (M/S) unit with Registered Nurse (RN) 2, Crash Cart #2 did not have a backboard on the cart. RN 2 stated the backboard should have been hanging on the back of the Crash Cart but it was not there. During a review of the facility’s policy and procedure titled, “Crash Cart Management (CCM)”, dated 6/2023, the “CCM” indicated, “ ... All Crash Carts will be maintained with age appropriate emergency equipment, supplies, and medications for the patient population being served. Crash Carts ... are located throughout the patient care areas to provide timely .... response to code [the heart stops beating] situations ... The Crash Cart ‘Content List’, which is laminated and available on the cart, describes the exact location (e.g. drawers or top of the cart) of all items (supplies and medications) contained on the Crash Cart. This list is standardized in all nursing units ... the content list serves as a guide and verification tool for the daily and monthly cart checks ... Guidelines ... Crash Cart Check Process ... Designated Registered Nurses will check the Crash Cart each shift and document their findings on the Crash Cart Checklist ... Replacement of missing equipment and other content will be immediately handled by the designee ... Crash Cart Contents ... The code Blue Committee is responsible for reviewing and updating the Crash Cart Contents List per American Heart Association Guidelines ... References ... American Heart Association ...”. During a review of the facility’s “Adult Crash Cart Content List (CL)”, dated 3/29/22, the “CL” indicated, “ ... Top of Cart Contents ... 1 EA [each] ... Adult Backboard ...”. During a concurrent interview and record review on 11/15/24 at 3:15 p.m. with the Chief Nursing Officer (CNO), the facility’s “7th Floor Crash Cart Checklist #2 (CCC)”, dated 11/2024, was reviewed. The “CCC” indicated, the crash cart had been checked each shift from 11/1/24 to 11/15/24. The CNO stated the crash cart should be checked each shift for all the supplies and items located on the cart. During the review of a professional reference titled, “Unleashing the potential of CPR boards: Enhance life-saving techniques and ensure workplace safety (UP)”, dated 2024, “UP” indicated, “ ... CPR boards play a vital role in providing stability, proper positioning, and support during resuscitation procedures ... One of the essential CPR boards is the standard adult CPR board, which offers a sturdy surface for performing CPR on adult patients. It ensures proper alignment of the head, neck, and torso, facilitating effective compressions [pushing of the chest bone to pump the heart] and ventilations [providing respirations] ... CPR boards are an essential piece of equipment for emergency response situations ... By having CPR boards readily available in emergency response kits or medical facilities, responders can quickly access the necessary equipment to initiate life-saving interventions. These boards contribute to improving the quality of CPR and increasing the chances of a successful resuscitation outcome during critical moments ...”. 2. During a review of Pt 25’s “Emergency Department Physician Note (EDPN),” dated 11/10/24, the EDPN indicated, “ ...85 year old female, with a [past medical history] of HTN [hypertension- high blood pressure], Alzheimer disease [a brain disorder that gradually destroys memory and thinking skills], and dementia [a condition that causes loss of memory and the ability to think clearly] ... BIBA [brought in by ambulance] from ... retirement homes after experiencing an unwitnessed fall from her wheelchair ...” During a concurrent interview and record review on 11/14/24 at 11:04 a.m. with Registered Nurse (RN) 5, Pt 25’s “Vital Signs Summary (VSS)” dated 11/10/24 was reviewed. RN 5 stated the VSS indicated Pt 25 had a temperature assessed at 8 p.m. and no other temperature was assessed with a vital sign assessment during Pt 25’s visit to the ED. RN 5 stated a temperature assessment should be completed with every vital sign assessment. During a review of Pt 26’s “EDPN,” dated 11/1/24, the EDPN indicated, “ ...73 year old female with [past medical history] of DM [diabetes mellitus- a condition that happens when your blood sugar (glucose) is too high] ... kidney disease [a condition where the kidneys are damaged and cannot filter blood properly], ... GERD [gastroesophageal reflux disease-a chronic condition that occurs when stomach contents leak back into the esophagus], HTN ... BIBA ... for altered mental status [a change in how well your brain is working] ...” During a concurrent interview and record review on 11/14/24 at 11:41 a.m. with RN 5, Pt 26’s VSS, dated 11/1/24 and 11/2/24 were reviewed. The VSS indicated Pt 26 had a temperature assessed at 5:06 p.m. and no other temperature was assessed with a vital sign assessment during Pt 26’s visit to the ED. During an interview on 11/14/24 at 3:41 p.m. with the Emergency Department Clinical Manager (CM) 4, CM 4 stated LNs are expected to assess and document a temperature with every vital sign assessment. During an interview on 11/15/24 at 3:13 p.m. with the Chief Nursing Officer (CNO), the CNO stated a temperature should be taken with every vital sign to recognize changes in a patient’s condition. During a review of the facility’s P&P titled, “Core Standards of Practice,” reviewed 6/2020, the Policy and procedure (P&P) indicated, “ ...Vital signs include temperature, heart rate, respiratory rate, blood pressure, and pulse oximetry ...” 3. During a review of Pt 22’s “History and Physical (H&P-an assessment from physician including medical history and exam),” dated 10/21/24, the H&P indicated Pt 22 was a 24-year-old male who came to the facility for an outpatient procedure for excision (a medical procedure involving the removal of tissue through a surgical incision) of a right neck mass. During a concurrent interview and record review on 11/13/24 at 9:25 a.m. with Clinical Manager (CM) 3, Pt 22’s “Medication Reconciliation (MR)” tab, undated, was reviewed. CM 3 stated the “MR” indicated the last documented date was on 11/5/24. CM 3 stated Pt 22’s medication history was not completed when Pt 22 arrived in the preoperative (before a surgical operation) area of the Post-Anesthesia Care Unit (PACU- a specialized unit where the patient’s vital signs are closely observed, pain management begins, and fluids are given). CM 3 stated LNs are expected to complete the patient’s medication history to ensure the medication list is the most current. CM 3 stated it was important to know the patient’s medication history because it could cause interactions with anesthesia (a medical intervention that uses drugs to temporarily induce a state of controlled loss of awareness or sensation), and it was to prevent an adverse effect from occurring. During an interview on 11/14/24 at 3:32 p.m. with CM 3, CM 3 stated pre-admission completes a medication history when the patient registered for the procedure. CM 3 stated LNs in the preoperative area are expected to review the patient’s medication history on the day of the procedure. CM 3 stated it was important for LNs to review the patient’s medication history on the day of the procedure to make sure a medication was not missed or changed since the last review. During a review of Pt 24’s “H&P,” dated 11/4/24, the H&P indicated Pt 24 was a 69-year-old male with benign prostatic hyperplasia (BPH-a condition in which the prostate gland grows larger than normal) who came to the facility for a transurethral resection of the prostate (TURP-a surgery to remove the inside part of the prostate gland) procedure. During a concurrent interview and record review on 11/13/24 at 1:49 p.m. with Registered Nurse (RN) 7 and Nurse Educator (NE) 3, Pt 24’s “MR” tab, undated, was reviewed. RN 7 stated the “MR” indicated a medication reconciliation was not completed at discharge for Pt 24. RN 7 stated the medication reconciliation should have been completed before discharge to determine new medication and medications to continue at home and how often to take them. During a review of Pt 29’s “H&P,” dated 11/7/24, the H&P indicated Pt 29 was an 81-year-old male with a past medical history of Chronic Obstructive Pulmonary Disease [COPD-a common lung disease that makes it difficult to breathe], Congestive Heart Failure [CHF-a chronic condition that occurs when the heart can’t pump enough blood to meet the body’s needs], and atrial fibrillation [an abnormal heartbeat] who came to the Emergency Department (ED) for shortness of breath and dry cough for a couple of days. During a concurrent interview and record review on 11/14/24 at 9:43 a.m. with Registered Nurse (RN) 1, Pt 29’s “MR” tab, undated, was reviewed. RN 1 stated the “MR” indicated a medication reconciliation was not completed at admission for Pt 29. RN 1 stated it should have been completed when Pt 29 was admitted to determine if there were medication changes at discharge. RN 1 stated an adverse effect could cause harm to the patient when medication reconciliation was not completed. During an interview on 11/14/24 at 3:25 p.m. with CM 5, CM 5 stated Licensed Nurses (LN) are expected to complete a medication reconciliation when a patient is admitted to the unit. CM 5 stated LNs are expected to complete a medication reconciliation when a patient is discharged. CM 5 stated LNs are responsible to review the patient’s medication history and the physician would then review and sign the medication reconciliation. During an interview on 11/15/24 at 3:13 p.m. with the Chief Nursing Officer (CNO), the CNO stated LNs are expected to make every effort to have an accurate medication list collected so the physician can finalize and reconcile the patient’s medications. The CNO stated it was important to make sure patients are receiving the appropriate medications. During a review of the facility’s P&P titled, “Medication Reconciliation,” reviewed 6/2023, the P&P indicated, “ ...POLICY: [Name of Hospital] nursing and medical staff ensures that each patient’s medication profile is reconciled on admission to the hospital, at the time of transfer to a different level of care, and on discharge from the hospital and its various outpatient locations ... GUIDELINES: ... Inpatient ... Upon Admission: a. Registered nurse staff is responsible for obtaining an accurate and complete medication history including prescription medications, over the counter medications as well as herbal therapies. b. Included in the history is the medication name, dosage, frequency of administration, and the date and time of last dosage taken. c. The medication history is to be documented on the admission assessment database in the electronic health record (EHR). d. LIP [Licensed Independent Practitioner] will review the medications on the Admission Medication History and reconcile the list through the EHR ... Upon discharge from the hospital: a. LIP will review the Discharge Medication Reconciliation Section in the EHR and identify the medications they want the patient to: 1) Continue taking at home. 2) Discontinue on discharge 3) Change the dosage, route, or frequency of the medications before they go home ... Outpatient ... All Outpatient locations administering medication will: a. Obtain a current medication list from the patient, family member(s) and/or LIP. b. Upon discharge from the outpatient location the current medication list will be reconciled and any changes to the patient’s current medications will be noted ...” 4. During a concurrent interview and record review on 11/12/24 at 3:23 p.m. with Registered Nurse (RN) 7 and the Director of Nursing (DON) Pt 31’s “History & Physical [H&P- an assessment from physician including medical history and exam],” dated 10/11/24, was reviewed. The “H&P” indicated, Pt 31 was admitted to the hospital on 10/11/24 at 4:42 p.m. for sepsis (a life-threatening blood infection), and acute kidney injury (AKI- A sudden and often reversible decline in kidney function) after a laminectomy (a surgical cut into the backbone to get access to the structures in the spinal cord). During a review of Pt 31’s “Medication Order (MO)”, dated 11/6/24 at 11:13 a.m., the “MO” indicated, “ ... morphine (medication used to treat moderate to severe pain) ... 4 [milligrams] (a unit of measurement), IV (intravenous, into vein) Push (medication pushed into vein by syringe through IV line), [injection]- (use of a syringe to push medication into body)], [every 4 hours] ... [as needed] Reason: Pain Severe (7-10) ...”. During a concurrent interview and record review on 11/13/24 at 2:30 p.m. with Shift Manager (SM) 3, Pt 31’s “Pain Monitoring Flowsheet (PMF),” and “Medication Administration Record (MAR- a record of drugs administered to a patient),” dated 11/8/24, were reviewed. Pt 31’s “PMF” indicated, on 11/8/24 at 12:23 p.m. a numeric pain scale with a pain intensity of 10 (10/10 pain indicating worst possible pain). SM 3 stated no additional pain assessment information was documented. SM 3 stated a pain score of seven to 10 was severe pain. Pt 31’s “MAR” indicated, on 11/8/24 at 12:25 p.m. LNs administered 4 milligrams morphine IV. SM 3 stated Pt 31’s “PMF” indicated, on 11/8/24 at 12:40 p.m. a continued pain intensity of 10, with an acceptable pain (level of pain considered tolerable enough to allow someone to carry out their normal daily activities) intensity score of 4. SM 3 stated Pt 31’s “PAF” indicated LNs did not document a sedation scale after administration of morphine. SM 3 stated LNs should have documented a sedation scale. SM 3 stated LNs documented, “Effective-Pain Goal Met”. SM 3 stated LNs only documented the pain intensity and the pain scale prior to administration of medication. SM 3 stated LNs should have contacted the physician when Pt 31 continued to have a pain intensity of 10. SM 3 stated Pt 31’s “PMF” indicated a numeric score of four was an acceptable level of pain, and LNs documented pain medication was effective when Pt 31 continued to report a pain level of 10. SM 3 stated a score of 10 was not Pt 31’s reported acceptable level of pain. SM 3 stated if pain medication was not effective and patients continued to complain of pain, the patient should be assessed, and the physician should be contacted. SM 3 stated each time Pt 31 was assessed for pain LNs should have documented the location of pain, pain intensity, the pain scale used, and patient’s acceptable level of pain. During an interview on 11/15/24 at 10:05 with Clinical Manager (CM) 6, CM 6 stated pain assessments should be done once per shift, with vital signs and whenever patients complain of pain. CM 6 stated LNs should reassess patients after pain medications were administered to ensure (make certain) pain was well controlled or if there was anything else LNs could do for the patient to help alleviate pain. During a concurrent interview and record review on 11/13/24 at 3:12 p.m. with SM 3, Pt 1’s “H&P,” dated 9/4/24, were reviewed. The “H&P” indicated, Pt 1 was brought in by ambulance to the Emergency Department (ED) on 9/4/24 at 1:25 p.m. with moderate-to severe widespread abdominal pain radiating (spread from one area of body to another) to the left lower quadrant (LLQ- left lower section of abdomen) pain, nausea, and vomiting. Pt 1 had a past medical history (PMH) of hypertension (HTN-high blood pressure) and colitis (swelling of the large intestine). The “H&P” indicated, Pt 1 was admitted for abdominal pain, and acute renal failure (when the kidneys suddenly can’t filter waste products from the blood). Pt 1 was admitted as an inpatient on 9/4/24 at 5:47 p.m. During a concurrent interview and record review on 11/13/24 at 3:18 p.m. with SM 3 Pt 1’s “Medication Order (MO)”, dated 9/7/24 at 3:39 p.m., was reviewed. The “MO” indicated, ...Order: morphine ... 4 milligrams [mg-a unit of measurement], IV Push (pushed into IV line) ... [injection] ... [one time dose] Priority: STAT (immediately) .... During a concurrent interview and record review on 11/13/24 at 3:22 p.m. with SM 3, Pt 1’s “PMF,” and “MAR,” dated 9/4/24 to 9/7/24, were reviewed. The “Pain Monitoring Flowsheet” indicated on 9/4/2024 at 1:25 p.m. a reported numeric pain intensity score of 8. SM 3 stated Pt 1’s “PMF” indicated no additional LN pain assessment information was documented. SM 3 stated Pt 1’s “MAR” indicated no medications were administered. SM 3 stated LNs should have documented the location, duration, type, and acceptable level of pain. The “PMF” indicated on 9/4/2024 at 3:47 p.m. a numeric pain intensity score of 2 (mild pain). SM 3 stated no additional pain assessment information was documented. SM 3 stated Pt 1’s “MAR” indicated no pain medications were administered. Pt 1’s “PMF” indicated on 9/4/24 at 4:46 p.m. a numeric pain intensity score of seven (severe pain), and the Pasero Opioid (class of drug used to treat moderate to severe pain) Sedation Scale (POSS - a valid reliable tool used to assess sedation when administering opioids) were completed. SM 3 stated no additional pain assessment information was documented. SM 3 stated Pt 1’s “MAR” indicated on 9/4/2024 4:46 p.m. LNs administered 4 mg morphine IV. SM 3 stated a pain reassessment should have been completed by 5:16 p.m. The “PMF” indicated Pt 1’s pain was not reassessed until 7:40 p.m. SM 3 stated Pt 1’s pain should have been reassessed to determine if medication was effective. SM 3 stated Pt 1’s “PMF” indicated, LNs did not document Pt 1’s location of pain during any pain assessment. SM 3 stated LNs should have completed pain assessments according to hospitals P&P. SM 3 stated LNs needed to determine where Pt 1’s pain was originating from. SM 3 stated LNs needed to ensure pain was being treated, and following up with patients to ensure pain wasn’t worsening or changing. SM 3 stated “assessments drive our care (information collected from assessments determine patient care)”. SM 3 stated LNs need to determine where pain is located to determine what information to give the physician about what could be causing the pain. During an interview on 11/15/24 at 10:17 a.m. with CM 5, CM 5 stated LNs were expected to assess and document pain location, pain intensity, number, what was being done about the pain, and what pain medication was being administered. CM 5 stated, LNs should contact the physician if pain medications were not effective. During an interview on 11/15/24 at 3:40 p.m. with the Chief Nursing Officer (CNO), the CNO stated pain assessments should include, numerical value, duration (how long pain), intensity (how strong), and location (where pain was located) of the pain. The CNO stated when LNs do not complete a pain assessment a patient’s pain may go untreated. The CNO stated when LNs do not complete a full pain assessment LNs could miss a change in condition (a significant worsening in health). The CNO stated incomplete pain assessments could be detrimental (causing harm) in a patient’s healing. The CNO stated anytime a pain medication was given LNs were expected to reassess and document pain according to hospital P&P. During a review of the hospital’s P&P titled, “Pain, Assessment and Management of (PC-56-B)”, dated 2/23, indicated, “ ... Assessment parameters include, but are not limited to: ... Nature of pain, location, duration, type, intensity, factors that exacerbate pain, any pain relief methods that have proven effective or ineffective, and the patient’s desire for pain control (i.e. complete pain relief, etc.) ... Age, developmental status, physical condition, cultural, spiritual, ethnic and personal belief systems ... Information will be obtained from family, significant others and/or non-verbal ... cues for those patients who are unable to communicate verbally ... Numeric Rating Scale: (zero to ten with zero being pain free and ten (10) the worst pain imaginable) verbally communicated - older children and adults ... Pasero Opioid Sedation Scale (POSS) is a validated, standardized scale used in multiple populations for assessment of opioid sedation ... Use POSS to monitor sedation in patients receiving any form of opioids (oral, topical, IV, rectal) ... Notify MD for patients that are having levels in three to four (3-4) range and review medications ... The patient’s self-report of pain is obtained and recorded on the Vital Sign Flow Sheet ... Using the appropriate tool ... Each and every time Vital Signs are taken ... Or at least once per shift ... At a reasonable interval, after every pain intervention to determine effectiveness ... No more than thirty (30) minutes after IV analgesic ... No more than sixty (60) minutes after PO analgesic ... If the patient is sleeping, “S” is documented ... A pain rating of three (3) or more, or greater than the patient’s goal, will be reported and assessed by a Registered Nurse ... Additional pain management interventions will be performed, as needed, to obtain an acceptable outcome ... Care providers will communicate and collaborate regarding effective pain management for an individual patient, when appropriate ... All assessments, reassessments and interventions for pain management are to be documented appropriately in electronic medical record ...”. During a review of the hospital’s P&P titled, “Core Nursing Standards of Practice (PC-460),” dated 6/9/22, indicated, “ ... Assessment ... The registered nurse performs and/or oversees the collection of pertinent data and information relative to the patient’s health or the situation. Data will be obtained by interview, observation, physical exam and review of the patient record. Priority of data collection is determined by the patient’s immediate health care needs ... Care Delivery - The registered nurse performs and/or oversees delivers care according to the patient’s need, LP [licensed provider] orders, and the plan of care to achieve identified outcomes ... Comfort and Sedation ... Pain is assessed by location, intensity and exacerbating and relieving characteristics using the appropriate pain scale on admission, a minimum of every shift, and PRN ... A pain assessment and reassessment is performed and documented before and after each intervention for pain ... During a professional reference review titled, “Acute Pain Management Pearls: A Focused Review for the Hospital Clinician [health care professional],” dated 12/22/22, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9818465/) indicated, “ ... Uncontrolled pain worsens patient outcomes ... Uncontrolled acute pain triggers a complex neurohormonal cascade [a series of coordinated responses where hormones produced by neurons [make up brain and nervous system] that are released in succession to body responses] that is toxic to nearly every organ system, as evidenced by increased rates of renal [kidney] and gastrointestinal [stomach and intestine] dysfunction, infection, cardiopulmonary [heart and lungs] and thrombotic [blood clot] complications, impaired wound healing, adverse psychological effects, and poorer functional recovery and quality of life ... Acute pain management in hospitalized patients should therefore be a clinician and institutional [facility] priority as a key driver of patient outcomes ...”. 5. During a concurrent interview and record review on 11/13/24 at 3:12 p.m. with SM 3, Pt 1’s “H&P,” dated 9/4/24, were reviewed. The “H&P” indicated, Pt 1 was brought in by ambulance to the ED on 9/4/24 at 1:25 p.m. with moderate-to severe abdominal pain radiating to the left lower quadrant (LLQ- left lower section of abdomen) pain, nausea, and vomiting. Pt 1 had a past medical history (PMH - a record of a patient’s health before the current problem) hypertension (HTN- high blood pressure), and colitis (swelling of the large intestine [long tube inside abdomen that turns food waste into stool]) The “H&P” indicated, Pt 1 was admitted for abdominal pain, and acute renal failure (when the kidneys suddenly can’t filter waste products from the blood). Pt 1 was admitted as an inpatient on 9/4/24 at 5:47 p.m. During a concurrent interview and record review on 11/14/24 at 9:40 a.m. with SM 3, Pt 1’s “PMF” dated 9/7/24 was reviewed. The “PMF” indicated on 9/7/24 at 8 a.m. Pt 1 reported pain intensity as zero. SM 3 stated Pt 1’s next pain score was documented until 2:59 p.m. SM 3 stated Pt 1’s “PMF” indicated on 9/7/24 at 2:59 p.m. a pain intensity score of 7. SM 3 stated Pt 1’s “PMF” had no documentation of a pain assessment associated with chest pain on 9/7/24. During an interview on 11/14/24 at 2:05 p.m. with Shift Manager (SM) 4, SM 4 stated on 9/7/24 she was the Charge Nurse (Shift Manager) on the Pt 1’s unit from 6:30 a.m. to 7 p.m. SM 4 stated her role as a Charge Nurse was a resource (answer questions, help with care) for the LNs on the unit. SM 4 stated she recalled in the morning of 9/7/24 around 8:30 a.m. Pt 1 reported chest pain to one of the LNs. SM 4 stated she thought Pt 1’s primary nurse (RN 14) called Pt 1’s physician. SM 4 stated she later found out that RN 14 did not document the call to physician. SM 4 stated LNs should document communication with physicians, so the care team has a record of when the physicians were contacted. During an interview on 11/14/24 at 2:40 p.m. with RN 13, RN 13 stated she was working on Pt 1’s unit on 9/7/24 from 7 a.m. to 7:30 p.m. and was assigned to a different patient in the same room as Pt 1. RN 13 stated she was caring for her assigned patient and heard Pt 1 moaning and calling out for help, over the curtain in the room. RN 13 stated Pt 1 was complaining of chest pain and was saying “somebody help me”. RN 13 stated she informed Pt 1’s primary nurse (RN 14), and the Charge Nurse (SM 4) about Pt 1’s pain. RN 13 stated she did not contact Pt 1’s physician. RN 13 stated she did not document in Pt 1’s medical record because she was not Pt 1’s primary nurse. RN 13 stated she should have documented any care she provided in Pt 1’s medical record. During an interview on 11/14/24 at 3:17 p.m. with Medical Doctor (MD) 1, MD 1 stated he was Pt 1’s primary admitting hospitalist (a dedicated in-patient physician who works exclusively in a hospital). MD 1 stated on 9/7/24 he assessed Pt 1 after LNs contacted him about abdominal pain, and Pt 1 appeared to be in distress. MD 1 stated Pt 1’s reported pain was a change in her baseline pain level (initial measurement taken about a patient’s health condition). MD 1 stated he ordered a CT scan (computed tomography - medical imaging procedure that uses X-rays to create detailed cross-sectional images of the body, used to diagnose disease, or plan treatment) of Pt 1’s abdomen. During an interview on 11/15/24 at 10:17 p.m. with Clinical Manager (CM) 5, CM 5 stated anytime LNs contacted the physician the information should be documented in the medical record. During an interview on 11/15/24 at 10:47 a.m. with the Manager of Patient Safety (MPS), the MPS stated Pt 1’s daytime primary nurse (RN 14) from 9/7/24 no longer works at the hospital. During an interview on 11/15/24 at 11:13 a.m. with the MPS, the MPS stated any LNs who provided care to or contacted the physician for Pt 1 should have documented in Pt 1’s medical record. The MPS stated Pt 1’s medical record was lacking documentation. The MPS stated when Pt 1’s medical record was reviewed by the Chief Medical Officer (CMO) he discovered no chest pain assessment was documented. The MPS stated LNs failed to document Pt 1’s chest pain assessment, notification to the physician for chest pain or abdominal pain, and what the physician was doing for the chest pain or abdominal pain. During an interview on 11/15/24 at 10:47 a.m. with the MPS, the MPS stated Pt 1’s family requested a meeting with the care team a week after Pt 1’s death. The MPS stated in preparation of the meeting Pt 1’s medical record was reviewed by the Chief Medical Officer (CMO). The MPS stated a lack of LN documentation for a chest pain assessment was identified. The MPS stated the CMO was reviewing the physician’s care of Pt 1 and did not investigate lack of LN documentation in Pt’s 1 medical chart. During an interview on 11/15/24 at 11:24 a.m. with RN 9, RN 9 stated he was working on the Medical Surgical (MS-a hospital unit where patients are treated for a variety of medical conditions) Unit during the dayshift on 9/7/24. RN 9 stated he was not Pt 1’s primary nurse. RN 9 stated he answered Pt 1’s call light and Pt 1’s family were requesting to speak to MD 1. RN 9 stated he then called MD 1 to report Pt 1’s family wanted an update. RN 9 stated MD 1 came to the MS unit to assess Pt 1 shortly after. RN 9 stated he did not document contacting MD 1 in Pt 1’s medical record. RN 9 stated he “probably should have”. RN 9 stated he was not sure if he could access the medical record because Pt 1 was not “his patient (he was not Pt 1’s primary nurse)”. During an interview on 11/15/24 at 1:58 p.m. with the Chief Nursing Officer (CNO), the Manager of Patient Services (MPS), and the Accreditation Regulation Manager (ARM), the CNO stated further review of Pt 1’s medical record was complete by nursing management. The CNO stated a review of Pt 1’s medical record and interviews of Pt 1’s LN care team were completed prior to a “CANDOR [Communication and Optimal Resolution- process that healthcare institutions and practitioners can use to respond in a timely, through and just way when an unexpected event occurs]” meeting with Pt 1’s family. The CNO stated a lack of LN documentation was identified during nursing management review of Pt 1’s medical record. The CNO stated some of the LNs interviewed about failure to document care reported not documenting because, Pt 1 was not “their patient” meaning, LNs were not assigned the patient as the primary nurse. The CNO stated anytime LNs “touch the patient (provide care)” documentation should be completed in the patient’s medical record. During an interview on 11/15/24 at 3:35 p.m. with the CNO, the CNO stated her expectation was anytime LNs communicated with a physician the information should be documented. The CNO stated, documentation of physician notifications was important, for the patient’s care team to be informed of what each physician had been informed of and, what interventions each physician wanted done for the patient. During a review of the hospital’s policy and procedure (P&P) titled, “Core Nursing Standards of Practice (PC-460),” dated 6/9/22, indicated, “ ... Assessment ... The registered nurse performs and/or oversees the collection of pertinent data and information relative to the patient’s health or the situation. Data will be obtained by interview, observation, physical exam and review of the patient record. Priority of data collection is determined by the patient’s immediate health care needs ... Care Delivery - The registered nurse performs and/or oversees delivers care according to the patient’s need, LP [licensed provider] orders, and the plan of care to achieve identified outcomes ... Comfort and Sedation ... Pain is assessed by location, intensity and exacerbating and relieving characteristics using the appropriate pain scale on admission, a minimum of every shift, and PRN ... A pain assessment and reassessment is performed and documented before and after each intervention for pain ... STANDARD 2: DOCUMENTATION EXPECTATIONS ... Documentation is considered a communication tool. As such, nursing documentation should reflect the nursing assessment process, admission data, patient and family education, discharge planning, plan of care and any treatment, interventions and associated outcomes including the patient’s response. As a communication tool, documentation should inform the care team succinctly of the patient’s status ... Document in chronological order: ... Pertinent, factual, objective data ... Selected subjective data that validates or clarifies ... Nursing actions taken ... Documentation should be entered into the electronic health record (EHR) using the fields provided ... When clarification is required or in the event of an unexpected outcome, a note should be entered by the nurse providing detail and summarization. Additional nursing notes may be entered per the nurse’s discretion to clearly document patient care issues and interventions ... Nurses notes are entered for the following instances ... Admission ... Shift summary ... LP notification ... Rapid response ... Documentation should be done as close to time of assessment, treatment, and response as possible to keep the record current and ensure availability of the most recent information for all caregivers using the record ...” During a review of a professional reference titled, “Health professionals’ routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study,” dated 2/16/23, the professional article indicated, “ ... Documentation is a standard way of keeping ongoing patient care information. It is the relevant facts of routine health information and patient care plans, such as professionals’ evaluation and judgement about the patients, evaluation charts, tests, reports, subjective notes or professionals’ reflections ... Documenting routine practices is essential for the continuity of patient care, ... communication among healthcare professionals and better patient diagnoses and treatments ... it should be patient-focused, accurate, relevant, clear, permanent, confidential and timely ... Poor documentation practice affects patient management, continuity of patient care and medicolegal issues, which arise from incomplete and inadequate documentation, lack of accuracy and poor quality. It leads to adverse patient outcomes, medication errors and patient deaths. Distorted health information may influence health professionals’ decision-making capabilities due to inappropriate and misleading documentation practices ...”.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 11090 Based on interview and record review, the hospital failed to ensure the nursing staff administered blood products according to their policy and procedures (P&P) titled “Blood Products Transfusion”, for one of one patient (Patient 9) when documentation was missing for the completion of administration of a blood product, vital signs (measurements of the body’s basic functions, such as breathing rate, temperature, pulse, and blood pressure), and a nursing assessment. This failure had the potential to place Pt 9 at risk for overlooking a possible reaction to the administration of a blood product and negative health outcomes. Findings: During a concurrent interview and record review on 11/13/24, at 11:06 a.m., with the Registered Nurse (RN) 1 and Educator Manager (EM), Pt 9’s electronic health record (EHR- digital collection of medical information) was reviewed. Pt 9’s “History and Physical (H&P -- the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending)”, dated 11/2/2024 at 3:20 a.m. and “Blood Transfusion [Flowsheet]”, dated 11/3/2024 and 11/4/24, were reviewed. Pt 9’s H&P indicated Pt 9 was brought to the hospital for lethargy and pain with a history of congestive heart failure (a chronic condition that occurs when the heart cannot pump enough blood to the body), chronic obstructive pulmonary disorder (a common lung disease that makes it hard to breath), and chronic alcohol use. Pt 9 was admitted to primarily treat hepatic encephalopathy (a serious but potentially reversible brain disorder that occurs when the liver is unable to filter toxins from the blood), pain, urinary tract infection and severe sepsis (a serious condition in which the body responds improperly to an infection). RN 1 stated, on 11/3/2024, the provider had ordered a total of three units of fresh frozen plasma (FFP) (blood product that contains clotting factors to help patients with a risk of bleeding) and one unit of packed red blood cells (used for treating patients with a low blood count). RN 1 stated, the last unit of FFP was started on 11/4/2024 at 5:03 a.m. RN 1 stated, the nurse did not document the time the FFP had been completed and it should have been documented. RN 1 stated, the nurse should have documented the time of the completion of the FFP, vital signs and if the patient had any adverse effects from the blood product. During an interview on 11/15/24 at 3:12 p.m., with the Chief Nursing Officer (CNO), the CNO stated she was aware of the case for Pt 9 and her expectations of nurses were to follow the P&P for blood transfusions. The CNO stated it was important to ensure that nurses document per the hospitals policy for the safety of the patient and not miss a possible adverse reaction. During a review of the hospital’s P&P titled, “Blood and/or Blood Products Transfusion (PC-78)”, dated 7/24, the P&P stated, “ ... 2. The patient’s baseline vital signs are to be taken and recorded on the Blood Transfusion Record ... a. Pre transfusion ...b. Within fifteen (15) minutes of starting transfusion ... c. Thirty (30) minutes of starting transfusion ... d. Once when infusion is complete ... e. One (1) hour after infusion is completed....””

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 45977 Based on interview and record review, the hospital failed to ensure the nursing staff administered blood products according to their policy and procedures (P&P) titled “Blood Products Transfusion”, for one of one patient (Patient 9) when documentation was missing for the completion of administration of a blood product, vital signs (measurements of the body’s basic functions, such as breathing rate, temperature, pulse, and blood pressure), and a nursing assessment. This failure had the potential to place Pt 9 at risk for overlooking a possible reaction to the administration of a blood product and negative health outcomes. Findings: During a concurrent interview and record review on 11/13/24, at 11:06 a.m., with the Registered Nurse (RN) 1 and Educator Manager (EM), Pt 9’s electronic health record (EHR- digital collection of medical information) was reviewed. Pt 9’s “History and Physical (H&P -- the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending)”, dated 11/2/2024 at 3:20 a.m. and “Blood Transfusion [Flowsheet]”, dated 11/3/2024 and 11/4/24, were reviewed. Pt 9’s H&P indicated Pt 9 was brought to the hospital for lethargy and pain with a history of congestive heart failure (a chronic condition that occurs when the heart cannot pump enough blood to the body), chronic obstructive pulmonary disorder (a common lung disease that makes it hard to breath), and chronic alcohol use. Pt 9 was admitted to primarily treat hepatic encephalopathy (a serious but potentially reversible brain disorder that occurs when the liver is unable to filter toxins from the blood), pain, urinary tract infection and severe sepsis (a serious condition in which the body responds improperly to an infection). RN 1 stated, on 11/3/2024, the provider had ordered a total of three units of fresh frozen plasma (FFP) (blood product that contains clotting factors to help patients with a risk of bleeding) and one unit of packed red blood cells (used for treating patients with a low blood count). RN 1 stated, the last unit of FFP was started on 11/4/2024 at 5:03 a.m. RN 1 stated, the nurse did not document the time the FFP had been completed and it should have been documented. RN 1 stated, the nurse should have documented the time of the completion of the FFP, vital signs and if the patient had any adverse effects from the blood product. During an interview on 11/15/24 at 3:12 p.m., with the Chief Nursing Officer (CNO), the CNO stated she was aware of the case for Pt 9 and her expectations of nurses were to follow the P&P for blood transfusions. The CNO stated it was important to ensure that nurses document per the hospitals policy for the safety of the patient and not miss a possible adverse reaction. During a review of the hospital’s P&P titled, “Blood and/or Blood Products Transfusion (PC-78)”, dated 7/24, the P&P stated, “ ... 2. The patient’s baseline vital signs are to be taken and recorded on the Blood Transfusion Record ... a. Pre transfusion ...b. Within fifteen (15) minutes of starting transfusion ... c. Thirty (30) minutes of starting transfusion ... d. Once when infusion is complete ... e. One (1) hour after infusion is completed....””

“ACCESS TO LOCKED AREAS CFR(s): 482.25(b)(2)(iii) Only authorized personnel may have access to locked areas. This Standard is not met as evidenced by: 11090 Based on observation, interviews, and record review, the facility failed to maintain secure access to locked medication rooms when Registered Nurse (RN) 1 shouted the medication room door lock code across the hall on the 7th floor medical/surgical (M/S) unit. This failure had the potential to result in unauthorized patients, staff and visitors access to medications in the locked medication room. Findings: During a concurrent observation and interview on 11/12/24 at 10:30 a.m. on the 7th floor at the medication room door with Registered Nurse (RN) 2, RN 2 stated the medication room door code had recently been changed throughout the hospital and she could not remember it. RN 2 called out to RN 1 and asked RN 1 to come to the medication room and give her the code, RN 1, who was not visible, yelled the code number to open the medication room door. RN 1 was observed across the next hallway on the other side of the nursing station. When asked if the method of yelling the code was common practice, RN 2 stated, “ ... that’s why I asked him to come over here ...”. During an interview on 11/12/24 at 10:40 a.m. with RN 1, RN 1 stated it was wrong to yell the medication room door code and there was a risk of visitors hearing the code. RN 1 stated a visitor could then access the medication room. During an interview on 11/15/24 at 3:15 p.m. with the Chief Nursing Officer (CNO), the CNO stated yelling the medication code out in the hall could lead to unauthorized individuals’ access to medications. During a review of the facility’s policy and procedure titled, “Medication Storage and Security (MSS)”, dated 4/20/24, the “MSS” indicated, “ ... Medications outside the Pharmacy Department will be handled and stored ... maintaining adequate and appropriate security at all times ... Safety and security ... all medications will be maintained in a secure storage area insuring accessibility by authorized individuals only ... Definitions ... Secure--Medications are considered ‘secure’ when locked or under constant surveillance ...”. During the review of a professional reference titled, “Hospital Medication Security: A guide to protecting controlled substances (HMS)”, dated 9/26/24, the “HMS” indicated, “ ... Without medication access control systems and surveillance, medications can be stolen or tampered with, leading to potential overdoses, medication errors, or the use of unsafe drugs ...”.”

“ACCESS TO LOCKED AREAS CFR(s): 482.25(b)(2)(iii) Only authorized personnel may have access to locked areas. This Standard is not met as evidenced by: 45929 Based on observation, interviews, and record review, the facility failed to maintain secure access to locked medication rooms when Registered Nurse (RN) 1 shouted the medication room door lock code across the hall on the 7th floor medical/surgical (M/S) unit. This failure had the potential to result in unauthorized patients, staff and visitors access to medications in the locked medication room. Findings: During a concurrent observation and interview on 11/12/24 at 10:30 a.m. on the 7th floor at the medication room door with Registered Nurse (RN) 2, RN 2 stated the medication room door code had recently been changed throughout the hospital and she could not remember it. RN 2 called out to RN 1 and asked RN 1 to come to the medication room and give her the code, RN 1, who was not visible, yelled the code number to open the medication room door. RN 1 was observed across the next hallway on the other side of the nursing station. When asked if the method of yelling the code was common practice, RN 2 stated, “ ... that’s why I asked him to come over here ...”. During an interview on 11/12/24 at 10:40 a.m. with RN 1, RN 1 stated it was wrong to yell the medication room door code and there was a risk of visitors hearing the code. RN 1 stated a visitor could then access the medication room. During an interview on 11/15/24 at 3:15 p.m. with the Chief Nursing Officer (CNO), the CNO stated yelling the medication code out in the hall could lead to unauthorized individuals’ access to medications. During a review of the facility’s policy and procedure titled, “Medication Storage and Security (MSS)”, dated 4/20/24, the “MSS” indicated, “ ... Medications outside the Pharmacy Department will be handled and stored ... maintaining adequate and appropriate security at all times ... Safety and security ... all medications will be maintained in a secure storage area insuring accessibility by authorized individuals only ... Definitions ... Secure--Medications are considered ‘secure’ when locked or under constant surveillance ...”. During the review of a professional reference titled, “Hospital Medication Security: A guide to protecting controlled substances (HMS)”, dated 9/26/24, the “HMS” indicated, “ ... Without medication access control systems and surveillance, medications can be stolen or tampered with, leading to potential overdoses, medication errors, or the use of unsafe drugs ...”.”

“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: 11090 Based on observation, interviews, and record review, the facility failed to ensure unusable medications were not available for patient use when an intravenous (IV, in the vein) fluid bag was out of its protective overwrap against professional standards in the storage room on the 6th floor. This failure had the potential for patients to receive altered, ineffective, and contaminated medications. Findings: During a concurrent observation and interview on 11/12/24 at 11:00 a.m. in the 6th floor storage room with Registered Nurse (RN) 3, an IV fluid bag missing its protective overwrap was in the stock of IV fluids available for patient use. RN 3 stated an IV fluid bag that did not have a protective overwrap could not be used for a patient. RN 3 stated the IV fluid bag could have been tampered with or fluid could have evaporated for the bag once the overwrap had been removed. RN 3 stated the exposed IV bag needed to be disposed of. During a review of a professional reference titled, “Working up a sweat (WUS)”, dated 10/2002, the “WUS” indicated, “ ... The purpose of the overwrap [for IV bags] is to improve shelf life and to stabilize the drug concentration. What happens then if a bag is removed from its overwrap and remains unused for days or weeks? Over time, the fluid volume inside the bag decreases and the drug concentration per milliliter [ml, a unit of measure] increases ... Don’t remove the overwrap from any I.V. bag stored in your unit until you’re ready to use the solution ...”. During a review of a professional reference titled, “Expiration dates and removal of i.v. bag overwrap (EDR)”, dated 9/1/95, the “EDR” indicated, “ ... The overwrap protects against evaporation of the solution, desiccation [removal of moisture] of the container, drug oxidation [common way of degrading a drug], and photochemical [with light] inactivation of the drug. Without a barrier, substantial moisture loss may occur, increasing the drug concentration ... Manufacturers of these products recommend ... removing the overwrap just before the drug or solution is administered ...”.”

“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: 45929 Based on observation, interviews, and record review, the facility failed to ensure unusable medications were not available for patient use when an intravenous (IV, in the vein) fluid bag was out of its protective overwrap against professional standards in the storage room on the 6th floor. This failure had the potential for patients to receive altered, ineffective, and contaminated medications. Findings: During a concurrent observation and interview on 11/12/24 at 11:00 a.m. in the 6th floor storage room with Registered Nurse (RN) 3, an IV fluid bag missing its protective overwrap was in the stock of IV fluids available for patient use. RN 3 stated an IV fluid bag that did not have a protective overwrap could not be used for a patient. RN 3 stated the IV fluid bag could have been tampered with or fluid could have evaporated for the bag once the overwrap had been removed. RN 3 stated the exposed IV bag needed to be disposed of. During a review of a professional reference titled, “Working up a sweat (WUS)”, dated 10/2002, the “WUS” indicated, “ ... The purpose of the overwrap [for IV bags] is to improve shelf life and to stabilize the drug concentration. What happens then if a bag is removed from its overwrap and remains unused for days or weeks? Over time, the fluid volume inside the bag decreases and the drug concentration per milliliter [ml, a unit of measure] increases ... Don’t remove the overwrap from any I.V. bag stored in your unit until you’re ready to use the solution ...”. During a review of a professional reference titled, “Expiration dates and removal of i.v. bag overwrap (EDR)”, dated 9/1/95, the “EDR” indicated, “ ... The overwrap protects against evaporation of the solution, desiccation [removal of moisture] of the container, drug oxidation [common way of degrading a drug], and photochemical [with light] inactivation of the drug. Without a barrier, substantial moisture loss may occur, increasing the drug concentration ... Manufacturers of these products recommend ... removing the overwrap just before the drug or solution is administered ...”.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 11090 Based on observation, interview, and record review, the hospital failed to maintain a clean and sanitary environment when: 1. Two boxes of N-95 masks (a disposable face mask that covers the user’s nose and mouth which offers protection from small solid or liquid droplets found in the air) and a spill kit (spill-response tools and equipment worn by an employee for protection against infectious materials) were stored in the soiled utility room (a room designated to store waste products and dirty surgical instrument carts) of the Emergency Department (ED) not in accordance with hospital’s policy and professional standards. 2. An intravenous (IV-tube inserted in the vein) filtered extension set (tubing with a small micron solution filter in the drip chamber or attached to the tubing) was observed to be opened and placed back into the clean supplies in the Emergency Department (ED) medication room not in accordance with professional standards. 3. An expired Y-connector (port used to administer secondary and IV push medications) was observed in the clean supplies and stored for use in the ED medication room not in accordance with professional standards. 4. A normal saline fluid (fluid used to replace water and electrolyte) bag was not labeled with the expiration date in the warmer in the Post-Anesthesia Care Unit (PACU-specialized unit where the patient’s vital signs are closely observed) clean utility room (a?room used to store clean medical equipment and supplies) not in accordance with the hospital’s policy and procedure titled, “Fluid Warming.” These failures had the potential to place patients at risk for cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and the spread of infection. Findings: 1. During a concurrent observation and interview on 11/12/24 at 10:30 a.m. with the Emergency Department Clinical Manager (CM) 4, in the Emergency Department Soiled Utility room, a cabinet containing two boxes of N-95 masks (a disposable face mask that covers the user’s nose and mouth which offers protection from small solid or liquid droplets found in the air) and a spill kit (spill-response tools and equipment worn by an employee for protection against infectious materials) was observed. CM 4 stated clean items should not be stored in the soiled utility room. CM 4 stated all things in the soiled utility room was considered dirty and should not be used. CM 4 stated when clean items stored in a soiled utility room was used, it could be an infection control issue for patients. During an interview on 11/15/24 at 9:05 a.m. with the Infection Preventionist Manager (IP), the IP stated clean items should not be stored in the soiled utility room. The IP stated it was important not to store clean items in the soiled utility room due to cross-contamination to patients or staff. During an interview on 11/15/24 at 3:14 p.m. with the Chief Nursing Officer (CNO), the CNO stated soiled utility room were considered dirty. The CNO stated clean supplies should not be stored in the soiled utility room. During a review of the facility’s P&P titled, “Medical Waste Management Plan,” revised 3/2024, the P&P indicated, “Waste containing discarded materials contaminated with excretion, exudate, or secretions from patients that are required to be isolated to protect others from highly communicable diseases employee orientation shall include, but not be limited to: 1. Definitions of Medical Wastes 2. Containment, transportation, and storage of medical waste.” During a review of a professional reference titled, “Infection Control and Prevention (ICP),” undated, by the Agency for Healthcare Research and Quality (AHRQ), (found at https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/infectioncontrol.pdf), the “ICP” indicated, “ ...There is a clear separation of clean and dirty work areas. Clean areas are used for storage and preparation of medications and unused supplies; dirty work areas are used for contaminated equipment.” 2. During a concurrent observation and interview on 11/12/24 at 10:25 a.m., with the Emergency Department Clinical Manager (CM) 4, in the ED Medication Room, an opened filtered extension set package was observed in the clean supply cabinet. CM 4 verified the filtered extension set package was opened. CM 4 stated the opened filtered extension set should have been thrown away and not placed back in the clean supplies. CM 4 stated the seal was broken and should not be used on patients, because it was an infection control concern . During an interview on 11/15/24 at 9:05 a.m. with the Infection Prevention Manager (IP), the IP stated after a filtered extension package was opened, it should not be placed back into the clean supply. The IP stated the opened filtered extension should have been thrown away. The IP stated infection control was a concern when supplies that had been previously opened were used on different patients. During an interview on 11/15/24 at 3:14 p.m. with the Chief Nursing Officer (CNO), the CNO stated supplies with packaging that has been breached should be discarded. During a review of a professional reference titled, “Quick Safety: Managing packaged sterile supplies and devices (QS),” dated June 2022, (found at https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-65/#:~:text=Managing%20commercially%20prepared%20sterile%20supplies,on%20or%20with%20their%20devices.), the QS indicated, “ ...In order to protect patients from infection and other potential harm from expired or compromised supplies and devices, organizations must identify the best location to store the supplies so that staff can readily access them, ensure the supplies are being stocked to the most optimal par levels, and that items have not passed their expiration dates. Additionally, the storage area must be maintained so that supplies are stored safely, in a manner where they are kept in good condition while protecting them from contamination. The purpose of this Quick Safety is to provide guidance for managing and storing packaged sterile supplies within your facility with the goal to keep patients safe from infection and other potential harm from expired or compromised supplies and devices ... CMS [Centers for Medicare and Medicaid Services] requires that sterile packages are stored so that sterility is not compromised, and sterile items are inspected for integrity before use ...” 3. During a concurrent observation and interview on 11/12/24 at 10:30 a.m., with Emergency Department Clinical Manager (CM) 4, in the ED medication room, a Y-connector with an expiration date of 7/12/24 was observed. CM 4 verified the expiration date as 7/12/24 on the Y-connector package and stated the package was compromised once expired and should have been thrown away. During an interview on 11/15/24 at 9:05 a.m. with the Infection Prevention Manager (IP), the IP stated expired supplies should be removed and disposed. The IP stated the integrity of the contents could not be verified if expiration date had passed. During an interview on 11/15/24 at 3:14 p.m. with the Chief Nursing Officer (CNO), the CNO stated an expired supply should be discarded. During a review of a professional reference titled, “Quick Safety: Managing packaged sterile supplies and devices (QS),” dated June 2022, (found at https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-65/#:~:text=Managing%20commercially%20prepared%20sterile%20supplies,on%20or%20with%20their%20devices.), the QS indicated, “ ...In order to protect patients from infection and other potential harm from expired or compromised supplies and devices, organizations must identify the best location to store the supplies so that staff can readily access them, ensure the supplies are being stocked to the most optimal par levels, and that items have not passed their expiration dates. The purpose of this Quick Safety is to provide guidance for managing and storing packaged sterile supplies within your facility with the goal to keep patients safe from infection and other potential harm from expired or compromised supplies and devices ...” 4. During a concurrent observation and interview on 11/12/24 at 11:43 a.m. with the Director of Surgical Services (DSS) in the Post-Anesthesia Care Unit (PACU -specialized unit where the patient’s vital signs are closely observed) clean utility room, a 3000 milliliter (mL-unit of measure) bag of normal saline solution without a label of the expiration date was found in the warmer. The DSS stated the normal saline solution bag should have been labeled with an expiration date when placed in the warmer. The DSS stated fluid bags should not be in the warmer for longer than 14 days. The DSS stated it was important to label the fluid bags with an expiration date. The DSS stated this was based on the manufacturer’s recommendation. The DSS stated there could be changes to the chemicals in the solution if the fluid was warmed too long. The DSS stated all staff who place new fluid bags in the warmer should place a label with the expiration date on it. During an interview on 11/15/24 at 9:05 a.m. with the Infection Prevention Manager (IP), the IP stated the process for labeling the fluid bag should have been followed. The IP stated if the fluid is warmed too long it can become contaminated with the risk of organism (a microbe, like bacteria, virus, fungus, or parasite, that has the potential to cause an infection) build-up within the fluid. The IP stated the integrity of the fluid would be questionable. During an interview on 11/15/24 at 3:14 p.m. with the Chief Nursing Officer (CNO), the CNO stated fluid bags should be dated to keep from using fluids that are contaminated. During a review of the facility’s P&P titled “Fluid Warming,” reviewed 3/2023, the P&P indicated, “ ...Each flexible bag (pouch) or semi rigid pour bottle will be labeled with the date that it expires indicating removal from the warmer ... IV and Irrigation Fluids ... Warming recommendations for Large (150 ml or greater) Volume Intravenous (IV) a. Solution in plastic bags: 1) not to exceed 40 °C (104°F) and for a period no longer than fourteen (14) days ...””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 49538 Based on observation, interview, and record review, the hospital failed to maintain a clean and sanitary environment when: 1. Two boxes of N-95 masks (a disposable face mask that covers the user’s nose and mouth which offers protection from small solid or liquid droplets found in the air) and a spill kit (spill-response tools and equipment worn by an employee for protection against infectious materials) were stored in the soiled utility room (a room designated to store waste products and dirty surgical instrument carts) of the Emergency Department (ED) not in accordance with hospital’s policy and professional standards. 2. An intravenous (IV-tube inserted in the vein) filtered extension set (tubing with a small micron solution filter in the drip chamber or attached to the tubing) was observed to be opened and placed back into the clean supplies in the Emergency Department (ED) medication room not in accordance with professional standards. 3. An expired Y-connector (port used to administer secondary and IV push medications) was observed in the clean supplies and stored for use in the ED medication room not in accordance with professional standards. 4. A normal saline fluid (fluid used to replace water and electrolyte) bag was not labeled with the expiration date in the warmer in the Post-Anesthesia Care Unit (PACU-specialized unit where the patient’s vital signs are closely observed) clean utility room (a?room used to store clean medical equipment and supplies) not in accordance with the hospital’s policy and procedure titled, “Fluid Warming.” These failures had the potential to place patients at risk for cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and the spread of infection. Findings: 1. During a concurrent observation and interview on 11/12/24 at 10:30 a.m. with the Emergency Department Clinical Manager (CM) 4, in the Emergency Department Soiled Utility room, a cabinet containing two boxes of N-95 masks (a disposable face mask that covers the user’s nose and mouth which offers protection from small solid or liquid droplets found in the air) and a spill kit (spill-response tools and equipment worn by an employee for protection against infectious materials) was observed. CM 4 stated clean items should not be stored in the soiled utility room. CM 4 stated all things in the soiled utility room was considered dirty and should not be used. CM 4 stated when clean items stored in a soiled utility room was used, it could be an infection control issue for patients. During an interview on 11/15/24 at 9:05 a.m. with the Infection Preventionist Manager (IP), the IP stated clean items should not be stored in the soiled utility room. The IP stated it was important not to store clean items in the soiled utility room due to cross-contamination to patients or staff. During an interview on 11/15/24 at 3:14 p.m. with the Chief Nursing Officer (CNO), the CNO stated soiled utility room were considered dirty. The CNO stated clean supplies should not be stored in the soiled utility room. During a review of the facility’s P&P titled, “Medical Waste Management Plan,” revised 3/2024, the P&P indicated, “Waste containing discarded materials contaminated with excretion, exudate, or secretions from patients that are required to be isolated to protect others from highly communicable diseases employee orientation shall include, but not be limited to: 1. Definitions of Medical Wastes 2. Containment, transportation, and storage of medical waste.” During a review of a professional reference titled, “Infection Control and Prevention (ICP),” undated, by the Agency for Healthcare Research and Quality (AHRQ), (found at https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/infectioncontrol.pdf), the “ICP” indicated, “ ...There is a clear separation of clean and dirty work areas. Clean areas are used for storage and preparation of medications and unused supplies; dirty work areas are used for contaminated equipment.” 2. During a concurrent observation and interview on 11/12/24 at 10:25 a.m., with the Emergency Department Clinical Manager (CM) 4, in the ED Medication Room, an opened filtered extension set package was observed in the clean supply cabinet. CM 4 verified the filtered extension set package was opened. CM 4 stated the opened filtered extension set should have been thrown away and not placed back in the clean supplies. CM 4 stated the seal was broken and should not be used on patients, because it was an infection control concern . During an interview on 11/15/24 at 9:05 a.m. with the Infection Prevention Manager (IP), the IP stated after a filtered extension package was opened, it should not be placed back into the clean supply. The IP stated the opened filtered extension should have been thrown away. The IP stated infection control was a concern when supplies that had been previously opened were used on different patients. During an interview on 11/15/24 at 3:14 p.m. with the Chief Nursing Officer (CNO), the CNO stated supplies with packaging that has been breached should be discarded. During a review of a professional reference titled, “Quick Safety: Managing packaged sterile supplies and devices (QS),” dated June 2022, (found at https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-65/#:~:text=Managing%20commercially%20prepared%20sterile%20supplies,on%20or%20with%20their%20devices.), the QS indicated, “ ...In order to protect patients from infection and other potential harm from expired or compromised supplies and devices, organizations must identify the best location to store the supplies so that staff can readily access them, ensure the supplies are being stocked to the most optimal par levels, and that items have not passed their expiration dates. Additionally, the storage area must be maintained so that supplies are stored safely, in a manner where they are kept in good condition while protecting them from contamination. The purpose of this Quick Safety is to provide guidance for managing and storing packaged sterile supplies within your facility with the goal to keep patients safe from infection and other potential harm from expired or compromised supplies and devices ... CMS [Centers for Medicare and Medicaid Services] requires that sterile packages are stored so that sterility is not compromised, and sterile items are inspected for integrity before use ...” 3. During a concurrent observation and interview on 11/12/24 at 10:30 a.m., with Emergency Department Clinical Manager (CM) 4, in the ED medication room, a Y-connector with an expiration date of 7/12/24 was observed. CM 4 verified the expiration date as 7/12/24 on the Y-connector package and stated the package was compromised once expired and should have been thrown away. During an interview on 11/15/24 at 9:05 a.m. with the Infection Prevention Manager (IP), the IP stated expired supplies should be removed and disposed. The IP stated the integrity of the contents could not be verified if expiration date had passed. During an interview on 11/15/24 at 3:14 p.m. with the Chief Nursing Officer (CNO), the CNO stated an expired supply should be discarded. During a review of a professional reference titled, “Quick Safety: Managing packaged sterile supplies and devices (QS),” dated June 2022, (found at https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-65/#:~:text=Managing%20commercially%20prepared%20sterile%20supplies,on%20or%20with%20their%20devices.), the QS indicated, “ ...In order to protect patients from infection and other potential harm from expired or compromised supplies and devices, organizations must identify the best location to store the supplies so that staff can readily access them, ensure the supplies are being stocked to the most optimal par levels, and that items have not passed their expiration dates. The purpose of this Quick Safety is to provide guidance for managing and storing packaged sterile supplies within your facility with the goal to keep patients safe from infection and other potential harm from expired or compromised supplies and devices ...” 4. During a concurrent observation and interview on 11/12/24 at 11:43 a.m. with the Director of Surgical Services (DSS) in the Post-Anesthesia Care Unit (PACU -specialized unit where the patient’s vital signs are closely observed) clean utility room, a 3000 milliliter (mL-unit of measure) bag of normal saline solution without a label of the expiration date was found in the warmer. The DSS stated the normal saline solution bag should have been labeled with an expiration date when placed in the warmer. The DSS stated fluid bags should not be in the warmer for longer than 14 days. The DSS stated it was important to label the fluid bags with an expiration date. The DSS stated this was based on the manufacturer’s recommendation. The DSS stated there could be changes to the chemicals in the solution if the fluid was warmed too long. The DSS stated all staff who place new fluid bags in the warmer should place a label with the expiration date on it. During an interview on 11/15/24 at 9:05 a.m. with the Infection Prevention Manager (IP), the IP stated the process for labeling the fluid bag should have been followed. The IP stated if the fluid is warmed too long it can become contaminated with the risk of organism (a microbe, like bacteria, virus, fungus, or parasite, that has the potential to cause an infection) build-up within the fluid. The IP stated the integrity of the fluid would be questionable. During an interview on 11/15/24 at 3:14 p.m. with the Chief Nursing Officer (CNO), the CNO stated fluid bags should be dated to keep from using fluids that are contaminated. During a review of the facility’s P&P titled “Fluid Warming,” reviewed 3/2023, the P&P indicated, “ ...Each flexible bag (pouch) or semi rigid pour bottle will be labeled with the date that it expires indicating removal from the warmer ... IV and Irrigation Fluids ... Warming recommendations for Large (150 ml or greater) Volume Intravenous (IV) a. Solution in plastic bags: 1) not to exceed 40 °C (104°F) and for a period no longer than fourteen (14) days ...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42321 Based on observations, interviews and record reviews the hospital failed to protect and promote Patient 1’s rights when: The hospital failed to ensure patients received care in a safe setting for one of three patients, Patient (Pt) 1, when Pt 1 was brought in by ambulance on 8/26/24 to the hospital’s Emergency Department (ED) with a chief complaint of a ground level fall at home with a large bruise to the forehead and after being evaluated, treated and stabilized, was discharged to the nearest bus stop and not provided a safe transport home. Pt 1 was elderly, non-English speaking and had a history of dementia and determined to be ready for discharge on 8/26/24 at 10:43 p.m. Pt 1’s clinical record documented she was discharged to the bus stop. Staff where aware buses did not run at that time of night. Pt 1 spent the night in the hospital lobby. The following morning 8/27/24 Pt 1 was escorted to the nearest bus stop and family was not contacted. Hospital social services was not consulted and utilized to evaluate safe transport home after discharge. (Refer to A-0144) The cumulative effects of these systemic problems resulted in the hospitals inability to ensure care in a safe and effective manner for Pt 1 in accordance with the statutory-mandated Condition of Participation for Patient Rights.”

“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: 47888 Based on interview and record review, the facility failed to have a well-organized and effective nursing service when: 1. Licensed Nurses failed to meet the needs for Patient (Pt) 3 and 4 when the nursing care plans (goals of treatment for safe nursing care) did not include nursing interventions (actions that were performed to help patients reach their goals of care) corresponding to the primary diagnoses and treatments of each patient (Refer to A396). 2. Licensed Nurses did not follow physician orders for high risk/high-alert titratable (continuous intravenous medication that can be changed to a higher or lower dose based off of physician order parameters) medications (Medications that have a heightened risk of causing significant patient harm when they are used in error) according to the facility’s P&P “”Medication “High Alert, Administration of ...” (Refer A398). 3. Patient 13 was administered the incorrect amount of high-risk/high-alert medications 14 different times (Medications that have a heightened risk of causing significant patient harm when they are used in error) and Patient 14 was administered medication ordered for moderate pain (pain that interferes with daily living activities and can be ignored for a period of time) eight separate times, when the pain score (a tool that helps people describe how much pain they are feeling, and is used by medical professionals to assess and manage pain) was documented as severe (disabling or intense pain that prevents someone from doing their daily living activities completely) (Refer 405). The cumulative effect of these deficient practices resulted in the facility’s inability to provide care in a safe and effective manner.”

“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: 42321 Based on interview and record review, the hospital failed to ensure patients received care in a safe setting for one of three patients, Patient (Pt) 1, when Pt 1 was brought in by ambulance on 8/26/24 to the hospital’s Emergency Department (ED) with a chief complaint of a ground level fall at home with a large bruise to the forehead and after being evaluated, treated and stabilized, was discharged to the nearest bus stop and not provided a safe transport home. Pt 1 was elderly, non-English speaking and had a history of dementia and determined to be ready for discharge on 8/26/24 at 10:43 p.m. Pt 1 was not provided safe transport home and clinical record documented provided bus stop. Staff where aware buses did not run at that time of night. Pt 1 apparently spent the night in the hospital lobby. The following morning 8/27/24 Pt 1 was escorted to the nearest bus stop and family was not contacted to provide a safe transport home. Hospital social services was not consulted and utilized to evaluate safe transport home after discharge. These failures resulted in the hospital not ensuring a safe environment of care upon discharge, not treating Pt 1 with dignity and respect, and resulted in Pt 1 staying in an unknown area of the hospital overnight and wandering the streets of a local rural town approximately 10 miles from the hospital. Pt 1 was not found until the morning of 8/27/24 and experienced the night and early morning without food, water, shelter, and comfort. These failures resulted in extreme worry and mental anguish for family members of Pt 1. Findings: During an interview on 8/28/24, at 9:39 a.m., with Pt 1’s Daughter (Dtr), the Dtr stated Pt 1 went by ambulance to the hospital on 8/26/24 for a fall with laceration to her forehead and was expecting the hospital to call when Pt 1 was ready to be discharged and she never received a call. Dtr stated she reached out to the hospital in the morning when she had no missed calls and was informed that Pt 1 was discharged by bus at 10:43 p.m. on 8/26/24. Dtr stated she asked for clarification and was told staff would not know more until the shift that discharged her came back in tonight because they could not locate any notes to indicate how Pt 1 left except by bus at 10:43 p.m. Dtr also stated that hospital staff told her the cameras for the ED were down and she could file a missing person request with the police department. Dtr stated on Pt 1’s previous visit on 7/30/24 Pt 1 had a diagnosis of underlying dementia. Dtr stated the hospital was able to set up transport home for her last ED visit on 7/30/24. Pt 1 does not drive. Dtr stated she was never notified of her discharge on 8/26/24. Dtr stated on 8/27/24 around 3:13 p.m. Pt 1 was found by the police wandering around a rural town about 10 miles from the hospital. During a review of Pt 1’s face sheet (provides demographic information to include name, date of birth, contact information, insurance information, etc.), dated 8/26/24, indicated Pt 1 was admitted on 8/26/24 at 5:34 p.m., no discharge time or date noted, 74 year old female, primary language is Spanish and an interpreter is needed; chief complaint: Ground Level Fall (GLF) Hematoma (bruise) on forehead; contact person Daughter (Dtr). During a review of Pt 1’s ED Note titled “Final Report” dated 8/26/24, at 8:27 p.m., indicated, Pt 1 arrived by ambulance at 6:03 p.m. for a ground level fall (GLF) and presented with a large hematoma to forehead, alert and oriented times 4, denied any loss of consciousness. Pt 1 has past medical history (PMH) of Hypertension (elevated blood pressure), arthritis (inflammation in joints causing pain and stiffness), depression (mental disorder that can affect a person’s feelings, thoughts, behaviors, and sense of well-being). On physical exam Pt 1 is in “No acute distress, alert and oriented x 3 ... forehead hematoma, partially obstructing the right eye”. At 9:44 p.m. per treating provider reexamination/reevaluation “discussed all results, diagnosis, treatment plan, prescriptions, and discharge home. The patient verbalized understanding and agrees to be discharged at this time. They [referring to Pt 1] understand to return to the ED for worsening of symptoms or concerns for their safety.” Final diagnosis this visit: Traumatic hematoma of forehead and GLF both discharged at 9:47 p.m. to home or self-care, condition stable. During a review of Pt 1’s ED Physician Notes titled, “Final Report,” dated 7/30/24, at 12:34 p.m., indicated Pt 1 came into the ED by ambulance on 7/30/24 at 11:50 a.m. for chief complaint of 5150 hold (a legal term for the involuntary psychiatric hospitalization of an adult who is experiencing a mental health crisis) for mental health evaluation “Per daughter PT [Pt 1] having Hallucinations”. On physical exam Pt 1 presents as “agitated”. Reexamination/Reevaluation done at 1:44 p.m. indicated, “Patient is medically clear for psychiatric evaluation”. Medical Decision Making ED Course: “ ... Patient denies any suicidal homicidal ideation has no neurodeficit has a history of dementia ...”. Final diagnosis this visit: Acute psychosis (symptoms include hallucinations, delusions, disorganized thoughts, or behaviors, last about a month; causes brain damage, diseases, or substance abuse); elevated blood pressure; hypokalemia (low potassium level); dehydration (loss of fluids in body can cause increased thirst, tiredness, decreased urine output, dizziness, headaches, and confusion); medical clearance for psychiatric evaluation. Condition Stable. Review of document titled, “Neurology/Stroke Note,” dated 7/30/24 at 5:15 p.m., indicated, “ ... Recommendations ... Discharge ... Impression Hallucinations ? (questionable) underlying dementia ... recommendations ... Outpatient neurology consultation ...” During a concurrent interview and record review on 8/28/24, at 10:04 a.m. with ED Registered Nurse (RN) 13 Informaticist, Pt 1’s electronic Health records (EHR) for ED visits on 8/26/24 and 7/30/24 were reviewed. Pt 1’s EHR indicated on 8/26/24 Pt 1 arrived at 5:34 p.m. by ambulance for a ground level fall with large hematoma to forehead and was discharged to a bus on 8/26/24 at 10:43 p.m. RN 13 confirmed the bus does not run that late in this area but Pt 1’s EHR does not indicate any other form of transportation used nor any family contacted about the discharge plan. RN 13 stated the EHR for Pt 1’s ED visit on 8/26/24 does not indicate that Pt 1 has a diagnosis of dementia. RN 13 stated when patients who are confused or have dementia are discharged family is contacted and patient is placed in a secure area where they can be monitored until family arrives or transport is arranged for them to go back to their home. RN 13 stated the EHR for Pt 1’s ED visit on 8/26/24 did not show that family was called for discharge of Pt 1. RN 13 stated Pt 1’s EHR for ED visit on 7/30/24 indicated Pt 1 was brought in by ambulance as a 5150 gravely disabled patient and a psych evaluation was done that indicated Impression “Hallucinations ? (questionable) underlying dementia”. RN 13 confirmed Pt 1 was discharged home on 7/31/24 by transport set up by social worker (SW). During an interview on 8/28/24, at 12:18 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he started his shift in ED on 8/27/24 and around 7:30 a.m. he saw Pt 1 come to the registration window asking for assistance in Spanish and registration asked me to help because I speak and understand Spanish. LVN 1 stated Pt 1 wanted a taxi but did not have her wallet with her because she needed to go home. LVN 1 stated he tried to explain to Pt 1 where the bus stop was, but she asked for someone to show her instead. LVN 1 stated Pt 1 had her belongings with her, and he walked her to the bus stop but once outside the hospital Pt 1 stated, “I feel like I am drunk”. LVN 1 stated Pt 1 told me she has a daughter, but she is pregnant and does not have family that can come and get her. LVN 1 stated he asked Pt 1 if she knew where she was going on the bus and she stated she lived near the airplanes and a clinic was across the street, LVN 1 stated he provided the name of the clinic and she agreed and told me she needed to go to a rural town about 10 miles from the hospital. LVN 1 stated he left Pt 1 at the bus stop after he pushed the button that informs the bus driver there is a passenger waiting for the bus. LVN 1 stated Pt 1 had told him that she had attempted to call her family earlier and did not know the results of that phone call. LVN 1 stated he knew Pt 1 was discharged the night before on 8/26/24 and did see her discharge paperwork. LVN 1 stated Pt 1 was answering questions appropriately. During a concurrent interview and video review on 8/28/24, at 2:26 p.m. with Security Supervisor (SS), SS was able to bring up the video of the ED department on 8/27/24 at 7:45 a.m. and it showed Pt 1 and LVN 1 leaving the ED walking across the bridge Pt 1 was seen using the rail on the left side of the bridge for support while walking and once she let it go she appeared to be unsteady while walking. The SS stated the night shift Security Lead reviewed the video overnight and did not see Pt 1 leave the ED the night of 8/26/24. The SS confirmed some of the cameras have been down in the ED department and they are currently being worked on, so they had limited view in the ED itself. During an interview on 8/29/24, at 7:45 a.m., with LVN 2, LVN 2 stated she works in the ED, and she was working on 8/26/24 from 7 p.m. to 7:30 a.m. LVN 2 stated she does recall discharging Pt 1 on 8/26/24. LVN 2 stated Pt 1 spoke Spanish and an interpreter was used. LVN 2 stated Pt 1 had told them that she did not know how to get ahold of her family. LVN 2 advised Pt 1 to speak with registration they would have her contact numbers and they can call for a ride for her. LVN 2 stated Pt 1 had informed them that her family works nights, and she did not have anyone to call until the morning, so she stayed in the lobby all night. LVN 2 stated she remembers seeing Pt 1 throughout the night when she brought other patients back into the ED. Pt 1 was still waiting in the ED lobby by the time she got off work at 7:30 a.m. on 8/27/24. LVN 2 stated when a patient has dementia and is being discharged, we have them wait in a more secure area in the back of the ED where we have access to them. LVN 2 stated she was not aware that Pt 1 had dementia. LVN 2 stated she did not investigate Pt 1’s previous visits and only looked at her current visits. LVN 2 stated for those with dementia we make sure they are discharged with a family member, and she makes sure to document it in her notes. LVN 2 states we have needed to schedule transport for patients that need it before. During an interview on 8/29/24, at 3:20 p.m. with EKG technician (TECH 1), TECH 1 stated he spoke with Pt 1’s Dtr on 8/27/24. TECH 1 stated he noticed the Dtr seemed anxious and was loud and informed him that her mother, Pt 1, was discharged last night, and the hospital does not know where she is, and she mentioned Pt 1 had dementia. TECH 1 stated he remembered who Pt 1 was because she had a goose egg (large bruise) on her face. TECH 1 stated he went into the back of the ED and looked at the inter-facility log and noticed he could not find Pt 1’s name on it and asked around about Pt 1. TECH 1 stated he looked up Pt 1 and saw she was discharged last night and noticed her visit did not mention Pt 1 had dementia. TECH 1 stated the Dtr was on the phone and then asked me what she should do, and I told her “I would call the police department and make a missing person report”. TECH 1 said the Dtr was upset and was on the phone with Adult Protective Services (APS). TECH 1 stated he was going to see if he could find more information for her but when he came back the Dtr was gone. During an interview on 8/29/24, at 4:18 p.m., with the Patient Relations Specialist (PRS), PRS stated Pt 1’s Dtr came in at 11:50 a.m. on 8/27/24 and security called me to come speak with her. PRS stated the Dtr informed her that Pt 1 was missing and that she had already filed a missing person report and filled me in on how this had happened, provided a picture of her mom, and left her contact information. PRS stated she began looking into what happened to Pt 1 after her discharge and did multiple interviews and had staff look all inside of the facility and outside the surrounding of the facility and they were not able to locate her. PRS stated she let her own manager know what was going on and the footage from the cameras was reviewed. PRS stated she called the Dtr the following day and Pt 1 had been found in a rural town about 10 miles from the hospital. During an interview on 8/30/24, at 12:55 p.m., with the Chief Nursing Officer (CNO), CNO stated the ED does not have a social worker (SW) on at night time. CNO stated if a patient needs a referral the face sheet is copied and placed on the SW desk with a message of what is needed for the patient and is addressed by the SW who comes in the next morning. The CNO stated she interviewed the staff that cared for Pt 1 on 8/26/24 and based on her interviews staff felt Pt 1 was alert and oriented. The CNO stated staff did not think it unusual for Pt 1 not to remember her contact numbers, none of her staff felt Pt 1 was in any danger or risk discharging her at night to herself. The CNO stated based on how Pt 1 presented the night of 8/26/24 her staff did what was appropriate for this patient. The CNO stated only issue is the documentation in Pt 1’s chart for her discharge on 8/26/24 time 10:44 p.m. transportation type as bus and she understood the bus does not run that late at night. During an interview on 8/3/24, at 10 a.m. with the Accreditation Regulatory Compliance Manager (ARM), ARM stated the facility did not have a separate discharge policy for the ED, so the “Discharge of the Adult Inpatient (PC 92)” is what is used. During a review of the facility’s policy titled, “Discharge of the Adult Inpatient (PC 92)” reviewed last on 6/22, indicated, “DEPARTMENTS: Hospital-wide POLICY: ... Discharge planning is to begin when the patient is admitted to the facility and is to be an ongoing planning process throughout their hospital stay. The patient, family and health care provider(s) from appropriate care disciplines are responsible or planning and coordination of the discharge ... GUIDELINES: A. The patient’s Registered Nurse (RN) and Care Coordination will coordinate discharge-planning needs for the patient... 2. Staff will assist the patient, family and/or caregiver(s) in arranging, obtaining, or offering information appropriate to their discharge needs. 3. The patient will be assisted in contacting their family and/or caregiver(s) informing them of the impending discharge so timely preparation and transportation arrangements can be made. B. On Admission in Preparation for Discharge: 1. The admitting RN will document in Cerner: a. The patient contact information. B. Verify the patient primary care physician (PCP), transportation and preferred pharmacy ... d. Identify potential barriers to discharge (i.e. lack of insurance, transportation issues, homelessness, etc.) and notify Care Coordination. E. Verify transportation available for discharge ... D. Discharge Documentation in Cerner: 1. In Nursing Communication: for nursing units 4 through 7, ICU and ED in their appropriate sections ... E. Verify the Discharge Plan with and Document ... 3. Transportation Plan ... 9. The patient is escorted via wheelchair, or other appropriate mode of transport, and released to a responsible individual. During a review of the facility’s policy titled, “Patient’s Right and Responsibilities (RI-01)”, effective dated 1/24/19, indicated, “ ... These rights and responsibilities are identified in the ‘Patient Rights and Responsibilities’ booklet ... Patients are informed of their rights and responsibilities upon admission to an inpatient setting, or upon initial presentation to an outpatient setting ...” Review of “Patient Rights and Responsibilities” dated 9/2017, indicated, “[name of hospital] complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity ... Each patient is entitled to compassionate and professionally competent care delivered with respect for each individual ... to be made comfortable ... 2. Have a family member (or other representative of your choosing) and you own physician notified promptly of your admission to the hospital ... 14. Receive care in a safe setting, free from mental, physical, sexual, or verbal abuse and neglect, exploitation, or harassment ... 17. ... You have the right to be involved in the development and implementation of your discharge plan. Upon your request, a friend or family member may be provided this information also ... 19. Designate a support person as well as a visitor or your choosing, if you have decision making capacity ...””

“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: 11090 Based on interview and record review, the hospital failed to develop and keep current care plans for two of five patients in accordance with the policy “ Plan of Care Development (PC-59)”. The primary care needs related to Patient 3 and Patient 4 were not assessed and developed and not documented in the patients’ care plans. This failure had the potential to result in Patient 3 and Patient 4 care needs to go unmet. Findings: During a concurrent observation tour and interview on 8/27/24 at 2:00 p.m. with Nurse Manager (RNM4), on the 6th Floor Medical Surgical Unit , Patient 3 was observed lying in bed, in a designated isolation room. The Nursing Manager (RNM6) stated Patient 3 had been admitted on 8/24/24 at 3:56 a.m. with diagnoses of COVID and pneumonia. During a concurrent interview and record view on 8/28/24 at 2:00 p.m., with RNM4, Pt 3’s electronic health record (digital collection of medical information) “History and Physical (H&P-the formal document that physicians produce through interview with the patient, physical exam, and the summary of testing either obtained or pending)”, dated 8/24/24 at 4:03 a.m. was reviewed. Pt 3’s H&P indicated Pt 3 “was admitted on 8/24/24 with a previous complex medical history including anemia, asthma who continues to smoke cigarettes, coronary artery disease status post MI (myocardial infarction), pulmonary hypertension (type of high blood pressure that affects the right side of the heart), type 2 diabetes (a chronic disease characterized by elevated blood sugars), hypothyroidism (deficiency of thyroid hormone that can disrupt heart rate, body temperature and all aspects of metabolism), GERD (gastro esophageal reflux syndrome), end stage renal disease (kidney function failure) receiving hemodialysis (a treatment that filters blood to remove waste and fluids when the kidneys are not working), generalized weakness and shortness of breath.” The “H&P” assessment plan identified current treatment needs as: “Severe sepsis related to COVID-pneumonia, COVID pneumonia, End-Stage Renal Disease on hemodialysis, Diabetes to be treated with [insulin] sliding scale. Hyperthyroidism (a condition when the thyroid gland produces too much thyroid hormone) and coronary artery disease (heart disease that affects the main blood vessels that supply blood to the heart).” On 8/28/24 at 2:00 p.m., four days after Pt 3 was admitted, Pt 3’s Care Plan only listed two areas of need: Pain and Shortness of breath. RNM4 stated the “Care Plan was incomplete and should have at a minimum added care plans for dialysis, diabetes, fluid balance, hypertension and falls precautions.” RNM4 stated staff “did not follow the hospital’s Plan of Care Development policy and procedure.” During a concurrent interview and record review on 8/28/24 at 2:30 p.m. with RNM4, Pt 4’s electronic health record (digital collection of medical information) was reviewed. Pt 4’s admission “History and Physical (H&P-the formal document that physicians produce through interview with the patient, physical exam, and the summary of testing either obtained or pending)”, dated 8/21/24 at 10:00 p.m., was reviewed. Pt 4’s H&P indicated Pt 4 was admitted on 8/21/24 with “worsening nausea and vomiting over the past 2 days.” The H&P indicated that Pt 4 was 81 years of age and lives alone. Pt 4 has a “past medical history of hypertension, seizure disorder and Type 2 Diabetes.” The H&P Assessment plan in the 8/21/24 H&P identified the following medical issues: Fever of unknown origin (possibly due to aspiration), Hyponatremia (low sodium levels), Hypokalemia (low potassium levels), Intractable nausea and vomiting, Abdominal pain, Hypertension (high blood pressure), and Seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and level of consciousness).” Physician Note dated 8/27/24 8:00 p.m. indicated Pt 4 “has been experiencing break-through seizures (seizures occurring regardless of medication treatment) since admission” and a new diagnosis of chronic kidney disease. A review of Pt 4’s Care Plan listed the following areas of need as: Nutrition -not eating, fluid volume excess (when the body has too much fluid), Risk for Infection, electrolyte imbalance (when certain minerals in your body become too high or too low), and fall risk. RNM4 stated that the care plans should also have included seizure activity, diabetes, pain and at risk for aspiration (when material enters a person’s airway and lungs by accident). RNM4 stated “staff did not follow the hospital’s Plan of Care Development policy and procedure”. During a review of the facility’s policy and procedure (P&P) titled, “Plan of Care Development (PC-59)” dated 5/2022, indicated, “ ...POLICY, Guidelines ...Developing a Plan of Care ...After completion of the admission assessment, the registered nurse (RN) initiates the Plan of Care by selecting a Care Plan that addresses the admitting, supplemental diagnoses and or identified problems of the patient ...Individualizing the Plan of Care ...Once the necessary standardized Plan of Care has been chose, the RN may modify the interventions based on the patients unique needs ...Revising the Plan of Care ...Revision to the Care Plan is made when changes occur in the patient’s status or clinical condition ...When needed ...Adding new diagnoses or problems.”

“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: 47888 Based on interview and record review, the facility failed to complete and document independent double checks at shift change for two of two sampled patients (Patient 13, Patient 14), on high risk/high-alert titratable (continuous intravenous medication that can be changed to a higher or lower dose based off of physician order parameters) medications (Medications that have a heightened risk of causing significant patient harm when they are used in error). This failure resulted in the potential for harm for both patients due to the lack of adherence to safeguards prior to drug administration and not following the hospital policy and procedure “Medication “High Alert, Administration of ...”. Findings: During a review of Patient (Pt) 13’s “History and Physical (H&P)”, dated 8/26/24, the H&P indicated, Pt 13 was diagnosed with acute respiratory distress (a serious lung condition that can be life-threatening where patient has difficulty breathing), COPD (Chronic Obstructive Pulmonary Disease- a common lung disease causing restricted airflow and breathing problems) exacerbation (sudden worsening of symptoms), history of smoking and hyperglycemia (elevated blood sugar). The H&P indicated Pt 13 was intubated (a process where a healthcare provider inserts a tube through a person’s mouth or nose that delivers air or oxygen into a person’s lungs) and transferred to the Intensive Care Unit (ICU- a specialized hospital unit that provides critical care and life support to patients who are very ill or injured). During a review of Pt 14’s “H&P”, dated 8/25/24, the H&P indicated, Pt 14 was diagnosed with DKA (Diabetic Ketoacidosis- a serious life-threatening condition when a patient’s blood sugar becomes dangerously high) and severe sepsis (serious condition from harmful bacteria in the blood that can lead to malfunctions of organs). Pt 14 was transferred to the ICU and put on an insulin titratable drip (continuous medication administration intravenously). During a concurrent interview and record review on 8/29/24 at 11:45 a.m., with the Intensive Care Unit (ICU) Nurse Shift Manger (NSM), Patient (Pt) 14’s “Medication Details (MD)”, dated 8/26/24 (1) and 8/27/24 (2) was reviewed. The MD 1 indicated, “ ... Route: IV (intravenous) ... Insulin (a medication to control a patient’s blood sugar) regular ... Given on August 26, 2024, 7 p.m. ... Action List: ... Perform by Registered Nurse (RN) 6 on 8/26/24, 7:21 p.m. ... VERIFY by RN 6 on 8/26/24, 7:21 p.m. ...”. The MD 2 indicated, “ ... Route: IV (intravenous) ... Insulin regular ... Given on August 27, 2024, 7 p.m. ... Action List: ... Perform by RN 6 on 8/27/24, 7:56 p.m. ... VERIFY by RN 6 on 8/27/24, 7:56 p.m. ...”. The ICU NSM verified there was no two licensed nurse hand-off communication (two licensed nurses verify and document medication is delivered at a set rate that is ordered) between nurses at shift change for Pt 14’s the insulin drip. ICU NSM verified there was only one licensed nurse documented on Pt 14’s hand-off, RN 6. During a concurrent interview and record review on 8/29/24 at 12:15 p.m., with the ICU NSM, Pt 13’s Electronic Medical Record (EMR), dated 8/26/24 to 8/29/24 was reviewed. The EMR indicated Pt 13 did not have an independent double check (two licensed nurses document and independently check the rate the medication infusion was running while verifying that with the physician order). Pt 13’s EMR indicated there was not a two licensed nurse hand-off documented for norepinephrine (medication to rapidly elevate blood pressure) and fentanyl (powerful medication used for pain relief) titratable drip medications for shift changes on shifts 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m. . The ICU NSM stated that the lack of an independent double check was a safety issue for Pt 13. The ICU NSM stated the nursing staff did not follow hospital policy for administration of high alert medications. During an interview on 8/29/24 at 7:40 a.m., with RN 3, RN 3 stated she was the nurse for Pt 13 8/26/24 through 8/28/24. RN 3 stated she never knew nursing staff was required to document a hand-off communication for a patient’s titratable drips. RN 3 stated the staff did not know the policy “Medication “High Alert” Administration” ever “existed”. RN 3 stated that by not completing this two-nurse verification for the “High Alert” medications, that it put Pt 13’s safety at risk. During an interview on 8/29/24 at 10:40 a.m., with RN 4, RN 4 stated she was responsible for Pt 13’s care 8/27/24 and 8/28/24. RN 4 stated staff should have verified and documented the drip titration rates for norepinephrine and fentanyl at shift change and they did not. RN 4 stated it was important to complete this check to make sure the patient had the right dose of high alert titratable drips and make sure the drip rate was appropriate at that time. During an interview on 8/29/24 at 4:40 p.m., with the ICU Clinical Manager (ICM), the ICU CM stated nurses should be “signing off (two different license nurse independent check)” the titratable drips with the oncoming shift. The ICU CM stated the nurses should have done this for Pt 13’s and Pt 14’s safety, “bottom line” and they could have harmed the patient. The ICU CM stated nursing staff did not follow hospital policy and procedure. During an interview on 9/3/24 at 12:30 p.m. with the Chief Nursing Officer (CNO), the CNO stated that two licensed nurses should have communicated and documented what Pt 14’s insulin and Pt 13’s, norepinephrine and fentanyl rates were at shift change. The CNO stated that this was a patient safety issue and the patients could have potentially had negative outcomes. The CNO stated the nurses did not follow the policy and procedure, “Medication “High Alert” Administration”. During a review of the facility’s policy and procedure (P&P) titled, “Medication “High Alert, Administration of ...’”, dated 1/22 was reviewed. The P&P indicated, “ ...High-Alert medications are those medications involved in a high percentage of errors and/or sentinel (event that results in death or permanent harm) events as well as medications that carry a higher risk for abuse or other adverse outcomes. To promote safe management of High-Alert medications ... require specific safeguards prior to administration to reduce the risk of harm to patients ...Medications to be considered “High Alert” are ... 2. Insulin (drips only)- IV only. 3. Narcotic drips ... 6. Vasopressor (medication that raises a patient’s blood pressure) Drips (e.g. (for example) Norepinephrine ... All “High Alert” medications will have an independent double check performed and documented prior to initial administration, during dosage adjustment, and “hand off” communication/shift change (for continuous drip medications). This will be carried out by two (2) licensed nurses ... c. Each nurse independently verifies that the correct dose ... e. Each nurse independently documents in the e-MAR (electronic Medication Administration Record) ...”.”

“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: 47888 Based on interview and record review, the facility failed to ensure nursing staff followed physician medication orders for two of two sampled patients (Patient 13 and Patient 14) when: 1. Patient 13 was administered the incorrect amount of high-risk/high-alert medications 14 different times (Medications that have a heightened risk of causing significant patient harm when they are used in error). 2. Patient 14 was administered the medication ordered for moderate pain (pain that interferes with daily living activities but can be ignored) eight separate times, when the pain score (a tool that helps people describe how much pain they are feeling, and is used by medical professionals to assess and manage pain) was documented as severe (disabling or intense pain that prevents someone from doing their daily living activities completely). These failures placed Patient 13 and Patient 14 at risk for not receiving the desired patient therapeutic medication goals (meaningful outcome for patients). Findings: 1. During a review of Patient (Pt) 13’s “History and Physical (H&P)”, dated 8/26/24, the H&P indicated, Pt 13 was diagnosed with acute respiratory distress (a serious lung condition that can be life-threatening where patient has difficulty breathing), COPD (Chronic Obstructive Pulmonary Disease- a common lung disease causing restricted airflow and breathing problems) exacerbation (sudden worsening of symptoms), history of smoking and hyperglycemia (elevated blood sugar). The H&P indicated Pt 13 was intubated (a process where a healthcare provider inserts a tube through a person’s mouth or nose that delivers air or oxygen into a person’s lungs) and transferred to the Intensive Care Unit (ICU- a specialized hospital unit that provides critical care and life support to patients who are very ill or injured). During an observation on 8/27/24 at 11:45 a.m., in the ICU, Pt 13 was on a ventilator with his eyes closed in a medically induced coma (use of medications to put the patient in a reversible state of unconsciousness that doctors use to protect the brain from damage and allow the body to heal). Pt 13’s titratable medications, fentanyl (a potent medication for pain relief), propofol (potent medication to rapidly sedate and put someone to sleep) and norepinephrine (potent medication to treat life-threatening low blood pressure) were actively being administered by an IV medication pump. During a review of Pt 13’s “Order Information (OI)”, dated 8/26/24, the OI indicated, “ ...Order information ... Fentanyl additive 2,500 mcg (microgram- unit of measurement)/50 mL (milliliters- unit of measurement) ... Volume dose: 250 mL ... Route of administration: IV (intravenous) ... Titration Range: 0 - 300 mcg/hr (hour) ... Titrate Instructions: Titrate by 25 mcg/hr as often as every 15 minutes, to achieve CPOT (Critical Care Pain Observation Tool- pain assessment tool for intubated patients based off of non-verbal cues) ... less than 3; if PRN (as-needed) fentanyl is available, only titrate infusion after two PRN doses have been administered and COPT remains 3 or greater ...”. During a review of Pt 13’s “Order Sheet (OS)”, dated 8/27/24, the OS indicated, “ ... Norepinephrine 14mcg/minute ... IV... 52.5 mL/hr ... Titration Range: 0 - 50 mcg/min, Titrate by 2 mcg/min as often as every minute to max 50 mcg/min. MAP (Mean Arterial Pressure- a measurement of how well blood is pumped throughout the body and is important for ensuring organs receive enough oxygen and nutrients) greater than 65, if MAP less than 50, than increase to 20 mcg/min and then resume titration ... Start: 8/26/24 @ 11:22 p.m., ... Start Dose based on systolic (point at which a person’s blood pressure is highest when the heart beats, pumping the blood) blood pressure (SBP): SBP greater than 90: 4 mcg/min, SBP 80-89: 6 mcg/min, SBP: 70 - 79: 10 mcg/min, SBP less than 70: 15 mcg/min ...”. During a review of Pt 13’s “Norepinephrine Titrations and Vital Signs (NT VS)” dated 8/26/24 to 8/28/24, the NT VS indicated, “ ... Date/Time: 8/27/24 @ 8:35 a.m. VS BP- 136/68 mmHg, (Titration) 28 mcg/min ... VS BP-136 (systolic) mmHg (unit of measurement)/68 (diastolic) mmHg, No MAP recorded ... Date/Time: 8/27/24 at 8:37 a.m. (Titration) 30 mcg/min ... No VS at this time ... (Drip was titrated up- per order need a MAP below 65 for titration) ... Date/Time: 8/27/24 at 9 a.m. VS BP- 73/50 mmHg, MAP- 58 (no titration- per order there should have been a titration) ... Date/Time: 8/27/24 at 9:05 a.m. VS BP- 71/47 mmHg, No MAP recorded (no titration- per order there should have been a titration) ... Date/Time: 8/27/24 at 9:08 a.m. VS BP- 90/62 mmHg, No MAP, (Titration) 32 mcg/min ... (Drip was titrated up- per order need a MAP below 65 for titration) ... Date/Time: 8/27/24 at 9:15 a.m. VS BP- 142/87 mmHg, No MAP, (Titration) 34 mcg/min (Drip was titrated up- per order need a MAP below 65 for titration) ... Date/Time: 8/27/24 at 10 a.m. VS BP- 135/75 mmHg, MAP 99, (Titration) 36 mcg/min (Drip was titrated up- per order need a MAP below 65 for titration) ... Date/Time: 8/27/24 at 10:15 a.m. VS BP- 96/63 mmHg, No MAP, (Titration) 38 mcg/min (Drip was titrated up- per order need a MAP below 65 for titration) ... Date/Time: 8/27/24 at 10:26 a.m. VS BP- 87/51 mmHg, MAP 64, (Titration) 38 mcg/min (Drip was titrated down- per order need a MAP below 65 titration should have been up) ...”. During a concurrent interview and record review on 9/3/23 at 11:50 a.m. with the Manager of Education (MOE) Pt 13’s “Fentanyl Titrations and CPOT Scores (FT CS)” dated 8/26/24 to 8/28/24 was reviewed. The MOE validated edits had been made to the “FT CS” after initial review. The FT CS notes indicated, “ ... Date/Time: 8/27/24 at 7:59 a.m. CPOT score 8, no titration (per order should have been titrated up by 25 mcg/hr) ... Date/Time: 8/27/24 at 8:45 a.m. CPOT score (not recorded), titration of 25 mcg/hr from 150 mcg/hr to 175 mcg/hr (per order should not have been a titration due to not having a CPOT score) ... Date/Time: 8/27/24 at 11:06 a.m. CPOT score 4, no titration (per order should have been titrated up by 25 mcg/hr) ... Date/Time: 8/27/24 at 12:03 p.m. CPOT score 4, titration went down 25 mcg/hr from 225 mcg/hr to 200 mcg/hr (per order should have been titrated up by 25 mcg/hr) ... Date/Time: 8/27/24 at 3:02 p.m. CPOT score 2, titration went up by 25 mcg/hr from 150 mcg/hr to 175 mcg/hr (per order Pt 13 was at goal and a titration up was not warranted) ...”. During an interview on 8/28/24 at 2:30 p.m. with Registered Nurse (RN) 1, RN 1 stated she was Pt 13’s nurse on 8/27/24 and 8/28/24. RN 1 stated she was an orientee (1-month on the unit) and had a preceptor (RN 4- an experienced practitioner who provides supervision during clinical practice) with her at all times. RN 1 stated she did not follow the physician orders for the titratable drips because “the preceptor told me too”. RN 1 stated physician orders are there for the safety and continuity of Pt 13’s care. RN 1 stated that ultimately the physicians orders were not followed. During an interview on 8/29/24 at 10:40 a.m., with RN 4, RN 4 stated she was RN 1’s preceptor and responsible for Pt 13’s care. RN 4 stated she told RN 1 when to titrate the drips and watched her input the titrations into the electronic medical record (EMR). RN 4 stated after review of the EMR, it appears physician orders were not followed and the drips were not titrated appropriately. RN 4 stated nurses are expected to follow the physician orders and they did not. RN 4 stated these errors put Pt 13’s safety at-risk. During an interview on 8/29/24 at 12:15 p.m., with ICU Nurse Shift Manager (ICU NSM), the ICU NSM stated the expectation for ICU nurses was to follow the physician’s orders and they were not. The ICU NSM stated Pt 13 would be negatively affected by orders not being followed. The ICU NSM stated norepinephrine and fentanyl were “High Alert” medications. During an interview on 8/29/24 at 4:40 p.m., with the ICU Clinical Manager (ICM), the ICU CM stated nurses need to follow the physician’s orders as that is the “guide for a plan of care”. The ICU CM stated Pt 13’s physician orders were not followed. The ICU CM stated norepinephrine and fentanyl are high-risk medications and the nurses put the patient’s safety at-risk. The ICU CM stated nursing staff did not follow hospital policy and procedure. During an interview on 9/3/24 at 12:30 p.m. with the Chief Nursing Officer (CNO), the CNO stated staff should follow physician orders. The CNO stated that this was a patient safety issue and the patients could have potentially had negative outcomes. The nurses did not follow the policy and procedure, “Adult Critical Care Nursing Standards of Practice”. During a review of the facility’s policy and procedure (P&P) titled, “Adult Critical Care Nursing Standards of Practice”, dated 11/2023 was reviewed. The P&P indicated, “ ... the standards of practice for adult critical care units serve as guidelines for the provision of nursing care and professional performance expectations. These standards are based upon ... the American Nurses Association scope and standards of practice and the American Association of Critical Care Nurses. They are used in conjunction with ... authorized licensed practitioners (LP) responsible for patient care orders. These standards of practice ... represent minimal, safe standards ... STANDARDS OF CARE: ... 5. Implementation ... c. Care Delivery- the registered nurse performs and/or overseas delivery of care according to the patient need, licensed practitioner orders and the plan of care to achieve identified outcomes ... 9. Medication Administration. A) medication should be administered according to the six rights of medication safety, licensed practitioner orders, and hospital policies ...”. Review of Registered Nursing.org Professional Reference titled, “Does a Nurse Always Have to follow a Doctor’s Orders?” dated 1/30/23, (found at https://www.registerednursing.org/does-nurse-always-follow-doctors-orders/) indicated, “ ...nurses cannot just randomly decide which order to follow and which not to follow. Unless there is a safety concern (I.E., medication not indicated for patient and/or task conflicts with facility policy/protocol) or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed “neglect.” 2. During a review of Pt 14’s “H&P”, dated 8/25/24, the H&P indicated, Pt 14 was diagnosed with DKA (Diabetic Ketoacidosis- a serious life-threatening condition where a patient’s blood sugar was dangerously high) abdominal pain and severe sepsis (serious condition from harmful bacteria in the blood that can lead to malfunctions of organs). Pt 14 was transferred to the ICU and put on an insulin titratable drip (continuous medication administration intravenously). During a review of Pt 14’s “Morphine Order (MO)”, dated 8/25/24 to 9/24/24, the MO indicated, “ ...Morphine (a medication used to treat severe pain) 2mg ... IV Push ... Q4hr (Every 4 hours) ... PRN (as needed) reason: Pain Moderate (4-6) ... Comment: ... IV Push Rate: 2 mg/min ... “. During a review of Pt 14’s “Pain Flowsheet (PF)”, dated 8/25/24 to 8/30/24, the PF indicated, “ ... Date/Time: 8/26/24 at 11:08 a.m., (Medication given) Morphine 2 mg (milligram- unit of measurement), Pain intensity: 10, Pain scale used: Numeric rating (0 to 10- with 10 being most severe) ... Date/Time: 8/26/24 at 3:22 p.m., (Medication given) Morphine 2 mg, Pain intensity: 10, Pain scale used: Numeric rating ... Date/Time: 8/26/24 at 8:10 p.m., (Medication given) Morphine 2 mg, Pain intensity: 9, Pain scale used: Numeric rating ... Date/Time: 8/27/24 at 1:06 a.m., (Medication given) Morphine 2 mg, Pain intensity: 9, Pain scale used: Numeric rating ... Date/Time: 8/27/24 at 5:37 a.m., (Medication given) Morphine 2 mg, Pain intensity: 7, Pain scale used: Numeric rating ... Date/Time: 8/27/24 at 9:32 p.m., Medication given) Morphine 2 mg, Pain intensity: 8, Pain scale used: Numeric rating ... Date/Time: 8/28/24 at 1:29 a.m., Medication given) Morphine 2 mg, Pain intensity: 8, Pain scale used: Numeric rating ... Date/Time: 8/28/24 at 5:43 a.m., Medication given) Morphine 2 mg, Pain intensity: 8, Pain scale used: Numeric rating ...”. Phone interview was attempted for Pt 14 to talk about her pain experience, but phone calls were never returned. During an interview on 9/3/24 at 10:50 a.m., with the ICU Clinical Manager (ICM), the ICU CM stated nurses should have read the physician orders and gave the correct pain medications. The ICU CM stated Pt 14’s pain was not adequately addressed and she could potentially have had a negative outcome because of that. The ICU CM stated staff put Pt 14’s safety at risk. The ICU CM stated nursing staff did not follow hospital policy and procedure. During an interview on 9/3/24 at 11:15 a.m., with RN 4, RN 4 stated she was responsible for Pt 14’s care. RN 4 stated she should have given the medication for severe pain based off of the Pt 14’s reported pain score. RN 4 stated “it was an oversight” that she gave the medication for moderate pain. RN 4 stated Pt 14 was “screaming like hell for pain medications”. RN 4 stated the physician’s order was not followed and she gave the wrong medication. RN 4 stated pain control would not be effective because she gave the lesser pain medication. RN 4 stated this was a patient safety issue due to not treating Pt 14’s pain adequately and she did not follow the hospital policy and procedure for pain management. During an interview on 9/3/24 at 12:30 p.m. with the Chief Nursing Officer (CNO), the CNO stated the nurse should have followed the physicians orders in regard to pain management. The CNO stated that this was a patient safety issue and Pt 14 could have potentially had a negative outcome. The nurses “absolutely” did not follow the policy and procedure, “Pain, Assessment and Management of”. During an interview on 9/3/24 at 1 p.m., with RN 6, RN 6 stated she was responsible for Pt 14. RN 6 stated she “didn’t really look at the order” when she gave her the pain medication for moderate pain when Pt 14 told her, her pain was severe. RN 6 stated that if Pt 14’s pain was not treated “appropriately” than she was not “going to get better and have a longer hospital stay”. RN 6 stated giving the lesser pain medication was a patient safety concern and a “med-error if overlooked”. RN 6 stated she did not follow the hospital policy and procedure in regard to pain management. During a review of the facility’s policy and procedure (P&P) titled, “Pain, Assessment and Management of”, dated 2/2023 was reviewed. The P&P indicated, “ ... patients have the right to attentive pain management and that the single most reliable indicator of the existence and intensity of pain is the patient’s self-report ... staff is to provide careful assessment of pain levels, timely and appropriate interventions, accurate evaluation of those interventions, communication of the effectiveness of interventions ... pain management goals are to be mutually set by the care providers and patient ... E. Appropriate pain control interventions are initiated as indicated ... 1. Medications administered for the control or relief of pain ... F. Patient ... regarding effective pain management will include ... 1. The right to attentive pain management 2. The use of pharmacologic ... methods ... 5. The concept that effective pain relief is an important part of treatment and that health professionals will respond to reports of pain ... G. All assessments, reassessments and interventions for pain management are to be documented appropriately in the electronic medical record ...”. Review of Registered Nursing.org Professional Reference titled, “Does a Nurse Always Have to follow a Doctor’s Orders?” dated 1/30/23, (found at https://www.registerednursing.org/does-nurse-always-follow-doctors-orders/) indicated, “ ...nurses cannot just randomly decide which order to follow and which not to follow. Unless there is a safety concern (I.E., medication not indicated for patient and/or task conflicts with facility policy/protocol) or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed “neglect.” Review of Nursing World.org Professional Reference titled, “The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition”, dated July 2015, (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf) indicated, “ ...Standards of Practice The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse’s decision-making ... Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer’s health or the situation ...”.”

“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: 45929 Based on interview and record review, the facility failed to have a well-organized and effective nursing service when: 1. Licensed Nurses failed to meet the needs for Patient (Pt) 23 when the nursing care plans (goals of treatment for safe nursing care) did not include nursing interventions (actions that were performed to help patients reach their goals of care) corresponding to the primary diagnoses and treatments of each patient. (Refer to A396) 2. Licensed Nurses did not monitor, assess and follow caesarean (a surgical procedure to remove a baby through a cut in the abdomen) guidelines for two of two patients (Patient 1, Patient 2) according to the facility’s P&P “Fetal Monitoring and Caesarean Section Guidelines” (Refer A398). 3. The norepinephrine (a medication used to control blood pressure) was not administered in accordance to the physician order for one of one patients. (Refer to A405). The cumulative effect of these deficient practices resulted in the facility’s inability to provide care in a safe and effective manner.”

“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: 45977 Based on interview and record review, the hospital failed to develop and keep current a nursing care plan for one of 34 patients, Patient (Pt) 23, when nurses did not assess and develop a care plan for pain and history of uncontrolled diabetes in accordance with their policy and procedure titled “Core Nursing Standards of Practice”. This failure had the potential to result in pain not being treated and the patient’s diabetes not being controlled. Findings: During a concurrent interview and record review on 7/11/24, at 2:40 p.m., with the Nurse Manager of Medical Surgical Unit (RNM 4), and Quality Management Specialist (QM 1), Pt 23’s electronic health record (EHR- digital collection of medical information) was reviewed. Pt 23’s “History and Physical (H&P - the formal document that physicians produce through interview with the patient, physical exam, and the summary of testing either obtained or pending)”, dated 2/26/24, “Document in Plan”, undated and “Flow Sheet”, undated, were reviewed. Pt 23’s H&P indicated Pt 23 was a admitted on 2/26/24 with a history of uncontrolled diabetes [a chronic disease characterized by elevated blood sugars], Diabetic neuropathy [a long-term complication of diabetes that occurs when high blood sugar and high levels of fats damage nerves in the body], seizures, blindness secondary to diabetic neuropathy presents to the ED [Emergency Department] on account of gangrene [death of body tissue] of the fourth/fifth fingers of his right hand. Pt 23 was prepared for surgical amputation of the fingers on his right hand. RNM 4 stated, Pt 23’s nursing care plan addressed issues for blood glucose levels, impaired skin integrity, risk for fluid and electrolyte imbalance, risk for infection, knowledge deficit, fluid volume deficit and risk for impaired metabolic function. RNM 4 stated, pain management and the patient’s history of non-compliance were not addressed in the care plan. RNM 4 stated, nothing was included in the chart to address the refusal of care during his hospital stay. RNM 4 stated, there should have been a nursing care plan that addressed Pt 23’s pain and his non-compliance with medical and nursing care in regards to control of diabetes. . RNM 4 stated, nurses are expected to develop a care plan that matches and guides the care needs of the patient. During a concurrent interview and record review with the Chief Nursing Officer (CNO), on 7/12/24, at 12:30 p.m., Pt 23’s care was reviewed. The CNO stated the nursing care plan should have been updated to address Pt 23’s needs, and it was not. The CNO stated a nursing care plan for pain was not developed and implemented. The CNO stated a nursing care plan for diabetes control was not developed and implemented. The CNO stated, nurses are expected to follow the policy to develop, document and update the care plan to meet the patient’s care needs. During a review of the facility P&P titled, “Core Nursing Standards of Practice”, dated 6/2022, the P&P indicated, “ 2. Nursing Diagnosis - The registered nurse analyzes assessment data to determine actual or potential nursing diagnoses, patient problems and issues. The registered nurse: ... a. Identifies actual or potential risks to the patient’s health and safety or barriers to health, which may include but are not limited to interpersonal, systematic, cultural or environmental circumstances. ... b. Uses assessment data, standardized classification systems, technology, and clinical decision support tools to articulate actual or potential nursing diagnoses, patient problems, and issues. ... c. Verifies the nursing diagnoses, patient problems and issues with the patient, family, and interprofessional colleagues. ... d. Prioritizes nursing diagnoses, patient problems, and issues based on mutually established goals to meet the needs of the patients across the health-illness continuum. ... e. Documents nursing diagnoses, patient problems, and issues in a manner that facilitates the determination of the expected outcomes and plan (ANA [American Nurses Association], 2015). ... 4. Plan of Care - The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes. The registered nurse: ... a. Partners with the patient to implement the plan in a safe, effective, efficient, timely, patient-centered, and equitable manner. ... “ During a review of a professional reference titled, “Lippincott Manual of Nursing Practice 10th Edition,” dated 2014, page 16-17 indicated, “ Standards of practice General Principles... 1. The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable ...b. These standards provide patients with a means of measuring the quality of care they receive ...5. A deviation from the protocol should be documented in the patient’s chart with clear, concise statements of the nurse’s decisions, actions, and reasons for the care provided, including any apparent deviation ... Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record ... Failure to formulate or follow the nursing care plan ...””

“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: 49538 Based on interview and record review, the hospital failed to ensure nurses followed hospital policies and procedures (P&P) “Intrapartum Fetal Monitoring” and the P&P titled, “Cesarean Section Guidelines (FBC-195), for two of two sampled patients Patient (Patient 1 -mom) 1 and Patient 2 (baby of Patient 1), when licensed nurses did not document the status of Patient 2, including episodic and periodic patterns; did not complete electronic fetal monitoring assessment intervals, did not notify the provider regarding abnormalities of Patient 1 and Patient 2; and did not follow criteria to perform a cesarean section within 30 minutes of making the decision to perform the procedure; and fetal heart tones for Patient 2 were not obtained in the operating room in accordance with hospital policies and procedures. These failures resulted in delay in treatment of Patient 1’s pregnancy; and resulted in inadequate fetal monitoring of Patient 2, and an incomplete clinical assessment which led to a decline in oxygenation and may have possibly contributed to the death of Patient 2. Findings: During a review of Patient 1’s “Electronic Medical Record (EMR),” dated 5/24/24 to 5/27/24, the EMR indicated Patient 1 was a 25-year-old female, gravida (the total number of confirmed pregnancies) 5, para (the number of live births) 0, 38 weeks and 3 days pregnant. The EMR indicated Patient 1 was admitted to Labor and Delivery (L&D) on 5/24/24 at 5:45 a.m. for induction of labor (IOL-when a medical provider starts labor). Patient 1 delivered Patient 2 (baby) on 5/27/24 at 11:09 p.m., total time in labor was 89 hours and 24 minutes. Patient 1’s EMR indicated Patient 1 was first assessed on 5/24/24 at 5:57 a.m. Patient 2’s EMR indicated the Fetal Heart Rate (FHR) was “Category 1/Normal Tracings” (baseline FHR 110-160 beats per minute and moderate FHR variability). Patient 1’s EMR indicated she was assessed on 5/24/24 at 2:43 p.m. and had no cervical change. Patient 1 was not administered the next physician ordered two doses of misoprostol a (medication used to for IOL) on 5/24/24 at 8 p.m. and 5/25/24 at 12 a.m. due to Patient 1 contracting too often (when the muscles of your uterus get tight and then relax). Patient 1’s EMR indicated her medication for IOL was changed 5/25/24 at 6:52 a.m. Patients 1’s EMR indicated she had had progressed to 1 centimeter (cm unit of measurement) dilated and the medication had “fell out”. Patient 1’s EMR indicated Medical Doctor (MD) 4 changed Patient 1’s IOL medication on 5/25/24 at 8:35 p.m. Patient 1’s EMR indicated MD 3 was notified on 5/26/24 at 10:18 a.m. that Patient 1 had Category 2 tracings with late and variable decelerations (when the FHR of the baby decreases after a contraction that can last from 15 seconds to 2 minutes) and fetal tachycardia (FHR greater than 180 beats per minute). Patient 1’s EMR indicated on 5/26/24 at 10:33 a.m. an order to withhold food and fluids from the patient was received. On 5/26/24 at 10:39 a.m. MD 3 performed an artificial rupture of membranes (the intentional rupture of the amniotic sac by an obstetrical provider) on Patient 1, which indicated clear, blood-tinged moderate amniotic fluid. Patient 1’s EMR indicated MD 3 placed a fetal scalp electrode (FSE-a spiral wire that can be placed on the scalp of the fetus to monitor their heart rate and ensure their well-being) and an intrauterine pressure catheter (IUPC-a device placed inside a pregnant woman’s uterus to monitor uterine contractions during labor) on 5/26/24 at 10:42 a.m. Patient 1 received an amnioinfusion (a procedure to replace amniotic fluid lost during labor) on 5/26/24 at 11 a.m. due to FHR decelerations. Patient 1’s EMR indicated Patient 1 was started on an oxytocin (a hormone that causes contractions of the uterus) infusion on 5/26/24 at 5:58 p.m. and was stopped on 5/27/24 at 1:40 a.m. MD 3 was notified on 5/27/24 at 1:45 a.m. of “[approximately] five minutes [deceleration] to 90 bpm, IUPC fell out earlier when pt voiding [urinated]. [oxytocin discontinued fetal heart tones] reassuring at this time...”. Patient 1’s EMR indicated she was dilated to 5 cm on 5/27/224 at 10:31 a.m. and the oxytocin was stopped on 5/27/24 at 10:48 a.m. for epidural placement (invasive pain management procedure). Patient 1’s EMR indicated MD 1 was notified on 5/27/24 at 11:42 a.m. of Patient 1’s oxytocin turned off during epidural placement and remained off due to late prolonged decelerations. Patient 1 EMR indicated the oxytocin infusion was again started on 5/27/24 at 12 p.m. and stopped at 7:31 p.m. Patient 1’s EMR indicated MD 1 performed an assessment on 5/27/24 at 9:43 p.m., MD 1 discussed with, and Patient 1 agreed to a cesarean section. Patient 1’s EMR indicated she delivered Patient 2 (baby) on 5/27/24 at 11:09 p.m. During a review of Patient 2’s (baby) “Electronic Medical Record (EMR)” the EMR indicated, Patient 2 had Apgar scores (assessment of a newborns status immediately after birth and the response to resuscitation efforts; a score of 7 or above on the test is considered in good health) of 0 at one minute, 1 at five minutes, 1 at ten minutes, 0 at fifteen minutes, and 0 at twenty minutes. Patient 2 was brought to the warming table at 30 seconds of life. Patient 2 was dusky, floppy, apneic (a condition in which a person involuntarily and temporarily stops breathing), and no had heart rate. Patient 2 was intubated (a tube inserted to provide oxygen into the lungs). Patient 2’s EMR indicated resuscitation efforts were stopped, and time of death was called by the pediatric physician on 5/27/24 at 11:44 p.m. During a review of Patient 2’s EMR, the EMR indicated an autopsy was performed on 5/31/24. The provisional autopsy (the initial medical examination of a body after death) report indicated “ ...intrauterine (inside the uterus) fetal death ... died as a result of sudden and unexpected intrauterine fetus death, pending causation ...” During a review of Patient 1’s “Tissue Pathology” report, dated 5/27/24, the report indicated “ ...acute chorioamnionitis (an infection of the placenta and the amniotic fluid) ...” During a review of Patient 1’s EMR and “Fetal Monitoring Strip (FMS)” dated 5/24/24, the FMS indicated, Patient 2 (baby) was not monitored on 5/24/24 from 7:43 a.m. to 9:27 a.m. a time lapse of 1 hour and 43 minutes. Patient 1’s EMR and FMS indicated Patient 2 not monitored on 5/24/24 from 11:12 a.m. to 2:02 p.m. a time lapse of 2 hours and 50 minutes. Patient 1’s FMS indicated Patient 2 was not monitored on 5/24/24 from 8 p.m. to 10:03 p.m. a time lapse of 2 hours and three minutes. Patient 1’s FMS indicated, Patient 2 had a deceleration when attached to the monitor at 10:03 p.m. Patient 1’s FMS indicated, another late deceleration at 10:06 p.m. Patient 1’s EMR indicated, nursing staff notified physician about a late deceleration on 5/24/24 at 10:30 p.m. Patient 1’s EMR had no documentation indicating a reason for extended time with no fetal monitoring and no physician order. During a concurrent interview and record review on 7/10/24 at 10:25 a.m. with Registered Nurse (RN) 5, the facility’s P&P titled, “Intrapartum Fetal Monitoring,” dated 10/2023 and Patient 1’s EMR dated 5/24 /24 to 5/27/24 was reviewed. RN 5 stated, she was familiar with the facility’s P&P . Patient 1’s EMR indicated, Patient 1 had an oxytocin infusion running, and fetal status was documented every 30 minutes. RN 5 verified her nursing documentation for 5/27/24 was every 30 minutes. RN 5 stated, her documentation should have been completed every 15 minutes according to policy. During a concurrent interview and record review on 7/10/24 at 10:30 a.m. with RN 5, Patient 1’s EMR and “FMS”, dated 5/27/24 from 7 a.m. to 3 p.m. were reviewed. The EMR and “FMS” indicated, Patient 1’s baby (Patient 2) had prolonged decelerations, and late decelerations. The FMS indicated the IUPC was off scale (resting uterine tone below readable level on monitor) from 6:58 a.m. to 7:43 a.m. RN 5 validated the baby had late decelerations, variable decelerations, and moments of marked (FHR rising greater than 25 bpm) and minimal variability. RN 5 verified, the IUPC did not record accurate contractions from 6:58 a.m. to 7:43 a.m. on 5/27/24. RN 5 stated, when contractions were not recorded accurately, the physician and nursing staff may not have an accurate view of labor. During a concurrent interview and record review on 7/11/24 at 9:11 a.m. with RN 4, the facility’s P&P titled, “Intrapartum Fetal Monitoring,” dated 10/2023 was reviewed. RN 4 stated she was familiar with the P&P and that she followed the policy. During a concurrent interview and record review on 7/11/24 at 9:20 a.m. with RN 4, Patient 1’s EMR and “FMS” dated 5/27/24 were reviewed. RN 4 stated, she cared for Patient 1 on the evening of 5/27/24 and was Patient 1’s delivery nurse. RN 4 stated, no oxygen was administered to Patient 1 during her shift on 5/27/24 from 7:30 p.m. to 10:45 p.m. RN 4 stated according to the facility P&P the algorithm for the FHR late decelerations interventions were not followed for Patient 1. The interventions should have been to turn Patient 1 administer a bolus to replace water and electrolytes, turning off oxytocin, and administering oxygen if necessary. These interventions were not done according to P&P. During a concurrent interview and record review on 7/11/24 at 9:25 a.m. with RN 4, Patient 1’s EMR and “FMS” dated 5/24/24 to 5/27/24 were reviewed. Patient 1’s FMS indicated, category 2 FHR tracings and documentation of interpretation of the FMS did not include category 2 tracings. RN 4 validated she documented physician at bedside on 5/27/24 at 9:43 p.m. Patient 1’s EMR indicated MD 1 performed a clinical assessment at 9:44 p.m. and Patient 1 was 6 cm dilated with significant molding (shaping of the fetal head) and caput (swelling of the scalp) in the occiput posterior (OP) (not the usual position for delivery- baby is facing the mother’s front instead of her back) position. Patient 1’s EMR indicated a C/S decision time was 5/27/24 at 9:46 p.m. Patient 1’s EMR indicated, an urgent (to be performed within 30 minutes) C/S for failure to progress. Patient 1’s FMS indicated, a prolonged deceleration at 10:15 p.m., a variable deceleration at 10:24 p.m. and a three-minute prolonged deceleration at 10:39 p.m. RN 4 validated her documented turning Patient 1 to the right side at 10:23 p.m., no additional interventions were noted. Patient 1 was moved to the Operating Room (OR) on 5/27/24 at 10:46 p.m. a one-hour time lapse from the decision for an urgent c/s was made. Patient 1’s EMR indicated, last provider notification for deceleration was at 10 p.m. RN 4 stated, she was “comfortable” in the OR and was the circulating nurse for Patient 1’s C/S. RN 4 stated, she did not obtain Fetal Heart tones in the OR per P&P. RN 4 stated, MD 1 called the C/S urgent (soon) and not emergent (immediately). RN 4 stated, an “urgent” C/S meant “not right, right now, but means soon,” within an hour. RN 4 stated, Patient 1’s FMS was a “concerning strip” and she “agreed” nursing interventions were “not working.” RN 4 validated there was no documentation where the charge nurse or physician were notified about Patient 1 baby had late and prolonged decelerations on 5/27/24. During a concurrent interview and record review on 7/11/24 at 10:03 a.m. with RN 14, Patient 1’s EMR and FMS dated 5/24/24 and 5/25/24 were reviewed. RN 14 stated she worked the p.m. shift from 7 p.m. to 7:30 a.m. RN 14 stated, she cared for Patient 1 on 5/24/24 overnight and the early morning of 5/25/24. RN 14 stated Patient 1’s first night of induction was the night of 5/24/24. RN 14 stated, Patient 1 was difficult to monitor due to her weight. RN 14 stated she found Patient 1’s baby (Patient 2) difficult to keep on the monitor. RN 14 stated, she did not inform the physician when she first determined Patient 1 was difficult to monitor per P&P. RN 14 stated on 5/24/24, she did not remember why she did not document Patient 2’s the late deceleration at 5 a.m. and validated she did not notify the physician per facility P&P. RN 14 validated she did not document any interventions during this time for the late deceleration. RN 14 stated she should document all decelerations on the FMS. RN 14 stated she did not remember why Patient 1 was off the monitor on 5/24/24 from 8 p.m. to 10:03 a.m. RN 14 validated there was no physician order documented to allow Patient 1 to be off the monitor and it was RN 14’s responsibility to ensure Patient 1 was on the monitor at all times and to notify the MD when the patient was not. During a concurrent interview and record review on 7/11/24 at 10:08 a.m. with RN 17, Patient 1’s EMR and FMS dated 5/25/25 and 5/26/24 were reviewed. RN 17 stated, she worked the p.m. shift from 7 p.m. to 7:30 a.m. RN 17 stated, she cared for Patient 1 on the night of 5/25/24 and the early morning of 5/26/24. RN 17 stated, Patient 1 was on a wireless fetal monitoring during her shift. RN 17 stated, the wireless monitoring would lose signal when Patient 1 was up to the restroom or was in certain positions. RN 17 documented signal loss in Patient 1’s EMR. Patient 1’s baby was unmonitored on 5/25/24 from 9:36 p.m. to 11:53 p.m. Patient 1’s baby was unmonitored for 2 hour and 17 minutes. RN 17 did not document the reason for extended time with no fetal monitoring. RN 17 did not notify physician about inability to monitor baby during her shift. On 5/26/24 at 2:30 a.m. RN 17 documented absent (no) decelerations, when the FMS indicated a late deceleration at 2:01 a.m. that dropped down to 100 bpm. RN 17 validated a late deceleration at 2:01 a.m. on the FMS. RN 17 stated, she did not know why she documented no decelerations at 2:30 a.m. RN 17 stated, she should have notified physician when she was unable to monitor Patient 1’s baby for an extended length of time. During a concurrent interview and record review on 7/11/24 at 10:30 a.m. with RN 13, Patient 1’s EMR and FMS dated 5/24/25 to 5/27/24 were reviewed. RN 13 stated, she worked the p.m. shift from 7 p.m. to 7:30 a.m. RN 13 stated, she admitted Patient 1 on the morning of 5/24/24. RN 13 stated, she cared for Patient 1 on the evening of 5/26/24 and early morning of 5/27/24. On 5/26/24 at 8:04 p.m. Patient 1 had a variable deceleration. RN 13 had no documentation in the EMR for a variable at 8:04 p.m. Patient 1’s FMS indicated, a late deceleration at 9:44 p.m., 9:48 p.m., and 9:52 p.m. Patient 1’s EMR indicated, no documentation of physician notification. Patient 1’s FMS indicated, Patient 1 had a five-minute prolonged deceleration at 9:56 p.m. Patient 1’s EMR indicated, no documentation of physician notification. RN 13 stated, Patient 1 had a seven-minute deceleration at 1:37 a.m. on 5/27/24. RN 13 stated, Patient 1 was sitting on a bed pan bearing down when the deceleration occurred. RN 13 stated, Patient 1 was turned to her left side, Oxytocin was discontinued, an IV bolus of Lactated Ringers begun, and the provider was notified. RN 13 stated, the FHR recovered and returned to a Category 1 tracing by 3:30 a.m. During a concurrent interview and record review on 7/11/24 at 11:05 a.m. with the Family Birth Center Director (FBCD) and RN 15, Patient 1’s EMR dated 5/27/24 was reviewed. RN 15 stated, she was the Charge Nurse on 5/27/24 the night of Patient 1’s delivery. RN 15 stated, she worked the p.m. shift, from 7 p.m. to 7:30 a.m. RN 15 stated, her role as a charge nurse was to be a resource for the other nursing staff on the floor. RN 15 stated, she helped in the OR, she attended vaginal deliveries, she watched the fetal monitoring strips and called the physician for deliveries when needed. RN 15 stated, on 5/27/24 she remembered coming on shift at 7:10 p.m. after the nursing huddle (pre shift meeting) and assessed Patient 1’s FMS with the primary nurse. RN 15 stated, Patient 1 had late decelerations, had prolonged rupture of membranes (water broken for over 18 hours), and had not made cervical change. RN 15 stated, she advised RN 4 to turn off oxytocin, reposition patient, and perform a cervical exam, and if there was no cervical change from previous cervical exam, they would discuss plan of care with the physician and a possible C/S. RN 15 stated, Patient 1’s FMS began to look “better” when oxytocin was turned off, the strip no longer had recurrent late decelerations. RN 15 stated, she became “busy” with other patients no longer focused on Patient 1. RN 15 stated, she remembered RN 4 coming to her a “couple” times about Patient 1 having prolonged and late decelerations. RN 15 had no documentation that RN 4 had informed her about any decelerations. RN 15 stated, she was not aware Patient 1 had multiple prolonged decelerations on 5/27/24 from 9:46 p.m. to 10:46 p.m. RN 15 stated, if she had known about the late decelerations and prolonged decelerations, she would have escalated the urgency of the C/S to the physician. RN 15 stated, typically nursing staff obtained fetal heart tones when a patient was moved to the OR. RN 15 stated, when a patient had an FSE, they “always” get fetal heart tones in the OR. RN 15 stated, she informed RN 4 not to remove the FSE prior to patient’s transfer to the OR. RN 15 stated, MD 1 removed the FSE when patient was moved to the OR. RN 15 stated, Patient 1’s FSE was never attached to the monitor in the OR. During an interview on 7/11/24 at 2 p.m. with Physician (MD) 1, MD 1 stated, a Laborist (physician who specializes in caring for women in labor and delivery of babies) shift was 24 hours from 8 a.m. to 8 a.m. the following day. MD 1 stated, he was Patient 1’s delivery doctor. MD 1 stated, Patient 1 delivered on 5/27/24 by C/S after a time lapse of 89 hours and 24 minutes of labor, and a time lapse of 36 hours and 50 minutes from artificial rupture of membranes. MD 1 stated, he reviewed Patient 1’s FMS throughout the day, or if the nursing staff called him with concerns. MD 1 stated, he would “glance” at the FMS in the “call room [area he stayed waiting for deliveries]”. MD 1 stated, he did not recall “offhand” if the nursing staff called him about any decelerations, late, prolonged or variables. MD 1 stated, “generally” there were no calls from nursing staff. MD 1 stated, he reviewed Patient 1’s chart on his own. MD 1 stated, he did not believe Patient 1 received enough oxytocin or misoprostol. MD 1 stated, the oxytocin was turned off due to decelerations but there was “always recovery during my shift [the FMS would have variability and accelerations].” MD 1 stated, he is available to nursing staff and they can call him with any questions or concerns. MD 1 stated, he remained on the unit and carried a cell phone. MD 1 stated, he did not remember all the details of the day. MD 1 stated, he remembered Patient 1 had two late decelerations in a row within 15 minutes. MD 1 stated, “I just know we were very, very busy”. MD 1 stated, it was possible that Patient 1 had more prolonged decelerations and late decelerations but could not remember the details. MD 1 stated, he could not comment on the three days of Patient 1’s care before he took over. MD 1 stated, he did have concerns about Patient 1 being in labor for 89 hours and 24 minutes. MD 1 stated, Patient 1’s SVE was 4 cm when he took over care from the previous physician. MD 1 stated, overall, “the strip was good.” MD 1 stated, he noted a lot of caput (swelling of the baby’s scalp) and molding (shaping of the fetal head) when he performed his vaginal exam, but there were not any acute tolerance issues at that time. MD 1 stated, he did not recall nursing staff telling him anything about late decelerations or prolonged decelerations, only that the baby had recovery and oxytocin was restarted. MD 1 stated, facility staff did not rush to do the C/S. MD 1 stated, once the C/S was called oxytocin was discontinued. MD 1 stated, obtaining fetal heart tones in the OR is routine practice. MD 1 stated, he did not recall a fetal heart tone being done in the OR and it was “news to me” that it was not done. MD 1 stated, nursing staff should have obtained a fetal heart tone in the OR. MD 1 stated, nothing “in particular” about Patient 1’s case was different in the OR. MD 1 stated, when Patient 2 (baby) was delivered he was limp, his eyes were opened, no cry, no color. MD 1 stated, he massaged the baby, stimulated the baby, clamped the baby’s cord quickly, and handed the baby to nursing staff. MD 1 stated, he did not feel he had a detailed physician sign out from the off going physician, “basically all that was said was she’s in labor”. MD 1 stated, even though Patient 1’s strip did not look “all that good”, it was a Category 1 or Category 2 it was clear to him the patient was not making cervical change. MD 1 stated, Patient 1’s C/S was performed due to arrest of dilation (Patient 1 was not making additional cervical change). During a concurrent interview and record review on 7/11/24 at 2:37 p.m. RN 16, Patient 1’s EMR and FMS dated 5/24/27 to 5/27/24 was reviewed. The EMR indicated, RN 16 assumed care of Patient 1 at 3 p.m. until 7:30 p.m. on 5/27/24. RN 16 verified Patient 1 was on oxytocin during her shift. RN 16 stated, when Patient 1 vomited on 5/27/24 at 4:12 p.m. the baby would have decelerations. RN 16 stated, Patient 1 was repositioned to her side after the deceleration. RN 16 documented Patient 1’s fetal status every 30 minutes. RN 16 stated, she should have documented every 15 minutes per P&P because her patient was on oxytocin. During a review of Patient 1’s “Physician Note (PN)”, dated 5/27/24, the “PN” indicated, “ ... I was notified by phone at [9:54 p.m.] this evening by the Laborist on duty [MD 1 name] to plan to assist with an upcoming primary cesarean section ...presented a brief SBAR (report) ...arrived to the hospital at [10:30 p.m.] ... a short while later, the patient was taken to the operating room ...” During an interview on 7/11/24 at 3:10 p.m. with MD 2, MD 2 stated, he was the assistant to the primary Physician on 5/27/24 for Patient 1’s C/S. MD 2 stated he had a “general recollection” of Patient 1 having prolonged decelerations and late decelerations. MD 2 stated, Patient 1’s FMS was not “warm and fuzzy (was not a category 1 strip)”. MD 2 stated, “it was time to call it.”. MD 2 stated, “it” was a C/S. During a concurrent interview and record review on 7/11/24 at 3:23 p.m. with the FBCD, the hospital’s P&P titled, “Intrapartum Fetal Monitoring,” revised 10/2023 was reviewed. The FBCD stated, this was a system policy, and the hospital staff should be following this policy. The FBCD stated, she expected the hospital staff to follow the policy by documenting in the EMR every 15 minutes when the patient was on oxytocin and every 30 minutes with risk factors. The FBCD stated, it was common practice to get a fetal heart tone when a patient was in the OR this was not done for Patient 1’s baby. During a concurrent interview and record review on 7/12/24 at 10:15 a.m. with the Obstetric Department Chair (OBC), the OBC stated, the event was an “unanticipated outcome” and there were some opportunities to look at the FHR tracing “differently.” The OBC stated, the cord blood gases for Patient 2 were “abnormal.” The OBC stated, there was a mixture of respiratory (when your lungs cannot remove all the carbon dioxide produced by your body) and metabolic acidosis (too much acid in your blood). The OBC stated, it was the hospital’s protocol to check fetal heart tones in the OR before a C/S procedure. The OBC stated, he recently learned the fetal heart tone was not checked for Patient 1’s baby in the OR. The OBC stated, the tracing was a not category 3 (requires immediate action, when a baby is not getting enough oxygen) so there was a 10 to15 minutes reserve of oxygen to get the baby out safely. Patient 1 had a fetal heart tone on 5/27/24 at 10:46 p.m. before moving to the OR. Patient 1’s baby did not have fetal heart tones performed by nursing staff in the OR. Patient 2 was delivered on 5/27/24 at 11:09 p.m., a time lapse of 38 minutes after last fetal heart tone was obtained. During an interview on 7/12/24 at 12:37 p.m. with the Chief Nursing Officer (CNO), the CNO stated, she expected hospital staff to obtain a fetal heart tone in the OR before the start of the C/S procedure. The CNO stated, she expected hospital staff to follow the policy for FMS documentation. During a review of Patient 1’s EMR and FMS dated 5/24/24 to 5/27/24 the EMR indicated Patient 1’s Physician decided for urgent C/S on 5/27/24 at 9:43 p.m. and the order was entered at 9:46 p.m. Patient 1’s FMS indicated, Patient 1 had a total of three prolonged late declarations from 9:45 p.m. to 10:43 p.m. Patient 1’s EMR indicated Patient 1’s physician was not notified by nursing staff of any late or prolonged decelerations after the C/S decision at 9:43 p.m. Patient 1 was moved to the OR on 5/27/24 at 10:46 p.m. Patient 1’s EMR did not have fetal heart tones performed by nursing staff in the OR. Patient 2 was delivered on 5/27/24 at 11:09 p.m., a time lapse of 38 minutes after last fetal heart tone was obtained. Patient 2 time of death was called at 11:44 p.m. During a review of the facility’s P&P titled, “Intrapartum Fetal Monitoring (FBC-206)” , dated 10/2023, indicated, “ ... The frequency and method of intrapartum fetal monitoring will be determined by the following factors ... Provider’s order ... Maternal-fetal status ... Clinical diagnosis ... Associated risk factors ... Continuous fetal monitoring is interpreted as EFM with temporary removal of monitors to accommodate the following activities, as ordered by physician: ... Bathroom privileges (BRP) ... During bedside ultrasound ... Continuous monitoring can be temporarily discontinued as ordered by the provider for a specific reason and period of time ... Electronic Fetal Monitoring Interpretation ... Decelerations: ... Determine FHR Category: ... Category 1 (Normal): ...Baseline rate of 110-160 beats per minute (bpm) ... Moderate FHR baseline variability ... Absent late or variable decelerations ... Present or absent early decelerations ...Present or absent accelerations ... Category [2] (Indeterminate): ... Bradycardia not accompanied by absent baseline variability ...Tachycardia ... Recurrent variable decelerations accompanied by minimal or moderate baseline variability ... Prolonged deceleration greater than 2 minutes but less than 10 minutes ... Variable decelerations with other characteristics ... Significant decelerations ... Category [2] FHR - clinically indicated interventions ... Physician notification ... Lateral positioning or change in maternal positioning ... O2 administration ... IV fluid bolus (500 mL) ... Discontinue or decrease oxytocin ... Cervical exam ... Consider amnioinfusion for recurrent variable decelerations ... Follow the Category [2] FHR Management Algorithm ... Moderate and/or marked variability with significant decelerations occurring with more than 50% of contractions over a 30 minute period ... Minimal and/or absent fetal heart rate variability with significant decelerations occurring with more than 30% of contractions over a 30 minute period ... Patients undergoing cesarean section ... Unscheduled Surgery: ... Continue fetal surveillance in the OR suite until the abdominal sterile preparation has begun ... The provider shall be notified when ... Category [2] FHR tracings ... Prolonged deceleration ... Moderate and/or marked variability with significant decelerations ... If the FHR tracing is abnormal, the RN will notify the provider and request that the provider review the FHR tracing ... EFM Assessment Intervals ... Latent Phase (< 4 cm) ... With Oxytocin or risk factors ... Every 15 minutes with Oxytocin. Every 30 minutes without ... Documentation of interpretation should include: ... Procedures, interventions, and evaluation of response and effectiveness ...Communication with provider ... Significant Decelerations - are defined as: o Variable decelerations >60 seconds with a nadir >60 bpm below the baseline o Variable decelerations >60 seconds with a nadir <60 bpm regardless of the baseline. o Any late decelerations of any depth o Any prolonged deceleration ...” During a review of the facility’s P&P titled, “Cesarean Section Guidelines (FBC-195)” , dated 9/2021, indicated, “ ...The Licensed Independent Practitioners (LIP) and Family Birth Center (FBC) Staff will communicate ...The LIP will communicate to FBC staff the indication for Cesarean delivery as well as the urgency/type of cesarean Section ...Schedule ...Non-emergent ... Emergent (STAT) ...In general, an unscheduled Cesarean Section should occur within approximately 30 minutes from the decision to operate ...FHR monitoring should be resumed in the OR until prep is completed ...” During a review of the facility’s P&P titled, “Cervical Ripening with Synthetic Protaglandin PGE1, e.g., misoprostol) or Prostaglandin E2 (PGE2, e.g. dinoprostone vaginal insert) (FBC-188)”, dated 07/2022, indicated, “ ...Maternal vital signs and FHR are taken every 15 minutes after administration of misoprostol tablet for 1 hour and 2 hours for dinoprostone; then per labor protocol, maternal/fetal assessment or if lack of labor every 1-2 hours while the patient is awake ... With misoprostol, after 4 hours the patient is re-evaluated by the LIP or RN ... Assessment of Fetal Heart tones and contraction pattern to determine indications for further doses. If the woman was assessed to have strong regular contractions, defined as 3 in 10 minutes with each lasting more than 30 seconds, the next dose is to be held. If the contractions space out then the next dose can be administered ...LIPs will be notified immediately for ...Fetal heart rate decelerations ...” During a review of the facility’s P&P titled, “Pitocin Augmentation/Induction (FBC-191)”, dated 7/2022, indicated, “ ...There should be documentation of the following prior to the start of all Inductions and Augmentation of labor: ... Documented estimated fetal weight (EFW) ...Documentation of moderate variability without recurrent late or variable deceleration prior to administration of Oxytocin ...Electronic fetal monitoring and uterine contraction monitoring will continue as long as oxytocin is being administered ...Following are conditions for decreasing or discontinuing the oxytocin: ... Fetal stress ... Treatment for Fetal Stress: ... Oxytocin is to be turned off ...Blood pressure and pulse every 30-60 minutes as indicated by the patient’s condition ...” During a professional reference review on The American College of Obstetricians and Gynecologists Clinical website at https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/10/the-apgar-score, “The Apgar Score”, dated October 2015, indicated, “ ...The Apgar score comprises five components: 1) color, 2) heart rate, 3) reflexes, 4) muscle tone, and 5) respiration, each of which is given a score of 0, 1, or 2. Thus, the Apgar score quantitates clinical signs of neonatal depression such as cyanosis or pallor, bradycardia, depressed reflex response to stimulation, hypotonia, and apnea or gasping respirations. The score is reported at 1 minute and 5 minutes after birth for all infants, and at 5-minute intervals thereafter until 20 minutes for infants with a score less than 7The Apgar score describes the condition of the newborn infant immediately after birth and, when properly applied, is a tool for standardized assessment ...It also provides a mechanism to record fetal-to-neonatal transition. Apgar scores do not predict individual mortality or adverse neurologic outcome. However, based on population studies, Apgar scores of less than 5 at 5 minutes and 10 minutes clearly confer an increased relative risk of cerebral palsy, and the degree of abnormality correlates with the risk of cerebral palsy. Most infants with low Apgar scores, however, will not develop cerebral palsy ....” 49884”

“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: 45977 Based on interview, and record review, the hospital failed to ensure medications were administered in accordance with the physician orders, facility policies and accepted standards of practice for one (Patient (Pt) 22) of 32 sampled patients when Pt 22’s norepinephrine (a medication used to increase blood pressure) was not titrated according to the physician orders. These failures had the potential for Patient 22 to experience excessive high blood pressure and increased risk of complications related to the medication. Findings: During a concurrent interview and record review on 7/10/24, at 9:15 a.m., with the Nurse Manager of ICU (RNM 1), Nurse Manager for Education (RNM 2) and ICU Registered Nurse (RN 12), Pt 22’s electronic health record (EHR- digital collection of medical information) was reviewed. Pt 22’s “History and Physical (H&P - the formal document that physicians produce through interview with the patient, physical exam, and the summary of testing either obtained or pending)”, dated 7/4/24, “Medications”, undated and “Flow Sheet”, undated, were reviewed. Pt 22’s H&P indicated Pt 22 was brought to the hospital “past medical history of hypertension, alcohol abuse, obesity, and depression ... He presents after suicide attempt via overdose on diphenhydramine [medication to suppress the body’s immune response] , alcohol, and lisinopril [a medication for high blood pressure]. last known well time was 1930 [7:30 p.m.] on July 3, 2024. The patients presenting blood pressure was 77/47 [mm Hg -millimeters of Mercury, normal blood pressure for men is 124/77 mm Hg]; the patient remained persistently hypotensive for the next 90 minutes or greater. Intravenous norepinephrine [mediation used to raise the blood pressure] was initiated 125 minutes after ... arrival. .... Pt 22’s “Flow Sheet” indicated, on 7/5/24 the norepinephrine was started at 2 mcg/min [micrograms/minute] when the Pt 22’s blood pressure was 100/66 mm Hg and the mean arterial pressure (MAP-average pressure in a patient’s arteries during one cardiac cycle) was 78. RNM 2 stated the nurse should not have restarted the medication as the MAP was greater than 65 and there was no indication of a new order. During a record review of Patient 22’s “Medications”, undated, the order indicated, “norEPINEPHrine ... titration Range 0 - 50 mcg/min [microgram/minute], Titrate by 2 mcg/min as often as every minute to max [maximum] 50 mcg/min. TARGET GOAL: MAP greater than 65 ... “ During an interview the Chief Nursing Officer (CNO), on 7/121/24, at 12:30 p.m., Pt 22’s care was reviewed. The CNO stated the nurse caring for Pt 22 should follow the orders as indicated in the record. The CNO stated the nurse should call the doctor if she felt there was a need to start the medication. The CNO stated nurses are expected to follow the policies for about medication administration and obtaining orders for patient care. During a review of the facility P&P titled, “Core Nursing Standards of Practice”, dated 6/2022, the P&P indicated, “ ... viii. Medication Administration ... 1. Medications should be administered according to the 6 rights of medication safety (patient, drug, dose, route, time, reason) LP [licensed provider] orders, and hospital policies ... DOCUMENTATION EXPECTATIONS ... When clarification is required or in the event of an unexpected outcome, a note should be entered by the nurse providing detail and summarization. ...” During a review of a professional reference titled “Lippincott Manual of Nursing Practice (11th ed.),” dated 2018, indicated, “Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record, administer medications as ordered, and follow physician’s orders that should have been questioned or not followed, such as orders containing medication dosage errors.””